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This chapter begins with a discussion of the changing aims of medicine, from the originally simple purpose of making a diagnosis, followed by attempting a cure and if that were not possible, then trying to palliate the consequences, into broader and more humanistic objectives. The first of these modern objectives is the increasing investment into prevention and earlier detection of disease, reflecting the current view that earlier intervention with many diseases may result in a better chance of disease eradication. The discussion then covers the factors determining symptom perception and the success of palliation, care of dying patients; models of palliative care; palliative medicine as a specialty; implementing a comprehensive supportive care network; who could benefit from comprehensive supportive care; constituents of a supportive care network; the relationship between supportive care and palliative care; end of life care; and assisted dying and euthanasia.

The educational challenge for palliative care was recognized in Australia a decade ago, in other words, better education in cancer pain and palliative care at undergraduate and postgraduate levels needed to be achieved, through an enhancement of existing education, the introduction of new programmes, and better integration throughout Australia of disparate efforts. Real advances have been made, in particular by the development of the Chapter of Palliative Medicine and the development of new programmes to enhance the palliative approach. However, palliative care education has been diverse and imaginative, at times highly focused and specific, at others more wide-ranging and all-encompassing. Creative and culturally specific responses to the challenges of education are more likely to succeed than imposed formulae and concepts. Teaching has taken many forms: bedside teaching and modeling of the palliative approach, participation in national conferences in the region, and conducting or participating in courses as well as hosting palliative care visitors to Australia and New Zealand.

Medical education in the UK is undergoing radical change. Against a background of similar changes in the National Health Service (NHS) and in the public perception of professionals, this chapter tries to provide a snapshot of this rapidly changing landscape in medical education. In the UK, palliative medicine was established as a medical specialty within the Royal College of Physicians in 1987. Since 1993, under the reforms brought in by the then Chief Medical Officer, Sir Kenneth Calman, to comply with European regulations, those aiming to become specialist physicians in palliative medicine must undergo four years of higher specialist training. This chapter provides a basic understanding of how doctors are currently trained in the UK; the pathway from trainee to specialist physician in palliative medicine; and key issues and recent developments in medical education in the UK.

This chapter discusses the structure of training in palliative medicine in Great Britain and describes the various bodies that oversee it. Under the Modernising Medical Careers (MMC), postgraduate training in Palliative Medicine follows core medial training (CMT), with entry to Palliative Medicine at Specialty Training level 3 (ST3), following a minimum of two years CMT and the achievement of membership of the Royal Colleges of Physicians (MRCP) or membership of the Royal Colleges of General Physicians (MRCGP). Some of the bodies that oversee palliative medicine include the Postgraduate Medical Education Training Board (PMETB), the London Deanery, and the Joint Royal Colleges of Physicians Training Board (JRCPTB).

This chapter discusses the ideal structure and function of a palliative care team in an acute hospital. According to ‘The 2004 Manual for Cancer Services’, the core team should include, as a minimum, a palliative medicine specialist, a palliative care nurse specialist, and a multi-disciplinary team coordinator/secretary. This chapter also provides recommendations concerning the setting up of a new team or developing an established team, operational policies, and the management of the team.

This chapter begins with a discussion of why concerns about informed consent are warranted in palliative medicine research and why procedures for informed consent should be considered a key methodological challenge. Next, it discusses procedures for assessing decision-making capacity, followed by an outline of provisions that can be made for patients who lack capacity. The chapter concludes with recommendations to guide the judicious use of these procedures in the design of palliative care studies. The goals of good end-of-life care are to relieve suffering and to improve quality of life. However, access to palliative care is poor, and standards to guide palliative care have not been clearly established. At least in part, these deficiencies exist because of a lack of solid evidence on which to base clinical decisions. Therefore, there is an urgent need for a standard of care and increased access to quality care.

This chapter presents the 2004 foreword to the third edition of the Oxford Textbook of Palliative Medicine. Here, Cicely Saunders gathers up much of these influences and thoughts about development touched on in so many of her later writings. This chapter is a good reading for anyone new to and learning about the field of palliative care and the mode of its development. Characteristically, she gives the final word to a patient: ‘Loneliness is not so much a matter of being alone as of not belonging’.

Farr Curlin takes up Latham’s argument from chapter 3 that not all deaths can be considered “good.” Curlin explores current practices of hospice and palliative medicine and shows how they both recover an art of dying and undermine the spirit of the Ars moriendi. Curlin warns that hospice and palliative medicine, as a professionalized form of caring, has adopted some practices that don’t necessarily allow for the achievement of higher values in dying—values that, as Latham shows, are necessary for the articulation of a new art of dying. Rather, Curlin suggests that hospice and palliative medicine is best practiced within medicine and under the constraints of that profession; despite a more limited role, it is within the context of medicine and its associated telos that hospice and palliative medicine can best help patients engage in the tasks of dying well.

This chapter identifies the ways in which technology operates in people's conceptions and experience of death, drawing from the author's clinical work with terminal patients, their families, and a palliative-care team and ethics committee at the Massachusetts General Hospital. It notes the ways in which technologies can extend and produce suffering, showing that palliative medicine addresses the aspects of suffering which have been excluded or left behind, such as the feelings of loss about the ability to function.

This chapter presents a lengthy 1992 editorial on ‘voluntary euthanasia’ that appeared in the journal Palliative Medicine. It is among the first articles to explore an issue that subsequently generated a great deal of debate — the extent to which it is possible to endorse both the attempt to expand palliative care and the call for the legalisation of euthanasia. For Cicely Saunders, this was anathema, since euthanasia cannot ever be construed as an aspect of palliative care. In referring back to her original 1959 article on euthanasia, published in Nursing Times, she reiterates her considered view that euthanasia should be opposed on moral grounds and at the same time every effort should be made to eliminate the suffering that causes it to be requested.

This chapter discusses neurosurgical palliation. Some of the topics it covers – movement disorders, gamma knife, vertigo, etc. – are also discussed in detail in other surgical textbooks. A working definition of palliative medicine and surgery is provided, followed by the skill sets required in palliative surgery and the various dimensions of suffering. The relationship between patients and their physician, how to offer hope when there is nothing more to be done, and providing incurable patients with comfort are discussed. Guiding principles to pain and suffering are provided, and the chapter ends with a comprehensive discussion on pain and various disorders, presenting several case studies on neurological palliation.

Nephrology and palliative medicine are on the verge of discovering each other, and when this occurs they will find several areas of commonality and mutual benefit. Nephrologists are now vigorously deliberating over issues related to discontinuation of dialysis. Palliative medicine has much to offer the end-stage renal disease population, which is increasingly elderly, suffers from multiple diseases and symptoms, and has a greatly reduced life expectancy. This chapter emphasizes the practice of nephrology in the US, and focuses on patients who are maintained with either haemodialysis or peritoneal dialysis. Despite being hampered by the absence of a discrete medical literature that synthesises palliative care and nephrology, the chapter is propelled by the growing convergence and potential synergy of these evolving specialties.