Palliative care is active total care of patients whose disease is not responsive to curative treatment.

Control of pain, of other symptoms and of psychological, social and spiritual problems is paramount. The goal of palliative care is the achievement of the best quality of life for patients and their families1. Palliative care therefore requires a multidisciplinary team approach with doctors, nurses, social workers, rehabilitation professionals and chaplains, all playing an important role. 

Although palliative care exists as a specialty, it only deals with a small proportion of dying patients and mainly those with cancer. The majority of patients in the final stages of chronic life limiting illness will be cared for by generalist medical staff including: general practitioners, physicians, surgeons and geriatricians. Patients with cancer spend on average 90% of their last year of life at home2 and more than 50% die in hospital3. A higher proportion of patients with non-cancer diagnoses will die in hospital. Patients with non-cancer diagnoses are also more likely to be older, have multiple co-morbidities and have a more unpredictable disease trajectory4. This compounds the problem of delivering effective palliative care to this group of patients5. Although the majority of patients die in hospital, evidence suggests that care for the dying in hospital is often poor6. Even when technical aspects of care are adequate, bereaved relatives complain of lack of care and compassion from hospital staff7.  

Poor training in palliative care
Whilst all practitioners dealing with dying patients should be skilled in the “palliative care approach”8 teaching of palliative care is generally poor in medical school and for junior medical staff in hospitals9, perpetuating the problem of poor palliative care skills amongst generalist medical staff. Training in palliative care should include training in communication skills, psychological and social aspects of care and end of life ethics, as well as control of physical symptoms10.  

Since palliative care is a multidisciplinary specialty, training in a multidisciplinary setting with professionals from varying backgrounds facilitating each others’ learning provides a potentially enhanced learning experience. Experience at the University of Warwick of the multidisciplinary MSc course in palliative care, which has a flexible modular structure (including a core module in non-cancer palliative care) has demonstrated these benefits, with students from specialist medical, general practice, nursing, and allied health professional backgrounds evaluating the course highly. If you are interested in getting to know more about this course please contact Mrs Carmel Parrot on tel. 02476 524 625 or visit www.warwick.ac.uk/primary_care/

Dr Peter Ferry
Senior Clinical Lecturer and Honorary Consultant Physician/
Geriatrician Warwick Medical School and Warwick Hospital

Dr Dan Munday
Consultant in Palliative Care and
Honorary senior Clinical Lecturer,
North Warwickshire PCT and Warwick Medical School

References
 

1. Cancer Pain Relief and Palliative Care: Technical Report Series 804. Geneva: World Health Organisation, 1990.
   
2. Seale C, Cartwight A. The year before death. Aldershot, Hants: Avebury, 1994.
   
3. Addington-Hall J, McCarthy M. Dying from cancer: results of a national population-based investigation. Palliative Medicine 1995; 9:295-305.
   
4. Murray SA, Boyd K, Kendall M, Worth A, Benton TF, Clausen H. Dying of lung cancer or cardiac failure: prospective qualitative interview study of patients and their carers in the community. BMJ 2002; 325(7370): 929.
   
5. Kafetz K. What happens when elderly people die? Journal of the Royal Society of Medicine 2002; 96:536-8.
   
6. Mills M, Davies HTO, Macrae WA. Care of dying patients in hospital. BMJ 1994; 309(6954):583-6.
   
7. Rogers A, Karlsen S, Addington-Hall J. ‘All the services were excellent. It is when the human element comes in that things go wrong’: dissatisfaction with hospital care in the last year of life. Journal of Advanced Nursing 2000; 31(4):768-74.
   
8. A policy framework for commissioning cancer services: A report by the expert advisory group on cancer to the Chief Medical Officers of England and Wales. London: DOH, 1995.
   
9. Barclay S, Todd CJ, Grande G, Lipscombe J. How common is medical training in palliative care? A postal survey of general practitioners. British Journal of General Practice 1997; 47:800-5.
   
10. Edmonds P, Rogers A. ‘If only someone had told me...’ A review of the care of patients dying in hospital. Clinical Medicine 2003; 3:149-52.