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Palliative care aims to give the best quality of life for patients with incurable life-threatening diseases. It provides relief from pain and other distressing symptoms associated with these diseases. Palliative care also aims to provide a support system to aid the family in coping with the patient's illness and their bereavement. One of the most significant phases of palliative care is the terminal care that takes place in the last days of life and which aims to provide a dignified death for the patient. This chapter discusses the challenges faced by the primary care teams in providing palliative care within the home setting. Among these are communication problems; continuity of care; competency of the multidisciplinary specialist palliative care teams; team work within the multidisciplinary teams; ethical issues and dilemmas; investment of time by the health care providers; needs of the relatives and carers; and partnership between the family, patients, and professionals.

This chapter focuses on the final days of the patients and the transition from palliative care to terminal care. Despite advances in the treatment of haematological malignancies, many patients face death due to their disease. In these moments, families encounter profound sadness, and clinicians experience inadequacy for not being able to change the course of death. Although death is inevitable and cannot be averted, there is much that can be done to improve the last days of the patient and to assure dying with a sense of dignity. Good terminal care plays a prominent role in achieving good death and in creating positive memories for the families and the healthcare professionals. One of the keys to good terminal care is the admission that death is inevitable and that the focus of care has changed. In the chapter, the focus is on the terminal care of haematological patients who face a short terminal phase after intensive treatment, whose palliation requires high-tech and invasive interventions, who are taken care of in regional centres, and who are often young. Also discussed are the creation of decisions and the ethical issues within the context of terminal care.

This chapter examines the training needs of carers of dying older people in nursing and residential care homes in Great Britain. It focuses on establishing the need for training to improve the quality of terminal care available to dying residents and argues that bringing in the basic principles and practices of palliative care is one factor that has the potential to improve the quality of dying in care homes. It endorses the Modernising the Social Care Workforce (TOPSS 1999) proposal that training should be resourced as a tripartite approach between employers, employees, and government to fund the necessary training to fill the knowledge, skills, and qualifications gap.

Cicely Saunders was the first modern doctor to devote her entire professional career to caring for those at the end of life. Her approach was forged in clinical practise, research, and teaching at St Joseph’s Hospice. It was significantly influenced by the writings of authors such as C.S. Lewis, Viktor Frankl, and Teilhard de Chardin. Emerging ideas about religious community, found in the work of theologians such as Olive Wyon, were also significant. She set out to re-invent older traditions of terminal care into a new, modern guise, drawing on medical innovations in pain and symptom control, and emerging ideas of personhood, suffering, and identity. Her aims were given added authenticity through a series of personal bereavements in the early 1960s. This chapter also describes the detailed process by which St Christopher’s Hospice became a reality and opened its doors in July 1967, when Cicely Saunders was forty-nine years old.

This chapter examines the growing importance of diagnosis and treatment of depression and other psychiatric disorders in patients with terminal cancer. Depression is a common complication among patients receiving end of life care that continues to be under-recognized and remains a source of considerable suffering. The amelioration of depression is essential in order to provide effective and comprehensive palliative care, as it will minimize prolonged suffering, maximize the potential for a meaningful existence, and help provide a higher quality of life for patients near the end of life.

This is a paper originally presented in 1961 to the Congress of the Royal Society of Health and which had an important role in disseminating Cicely Saunders' developing ideas at that time, particularly to officials in the Ministry of Health who were beginning to take an interest in her work. It considers more personal aspects of terminal care. In this work, people are made to face their attitudes to death, emotions, fears and also faith. A nurse can be so overwhelmed with sympathy that she loses her steadiness and her efficiency; it is not to be suggested that common sense or professional standing be left on one side. However, they will fail their dying patients if they always remain hidden behind technical functions and avoid the true personal contact for which so often patients are longing.

The year 1978 saw the publication of the textbook which, over a long period, so many had been encouraging Cicely Saunders and her colleagues to produce. In this chapter, she opens up a discussion on the relationship of terminal care to the ‘cure’ and ‘care’ systems. However it is also noted that ‘no patient should become locked in what is for him the wrong system’. The discussion outlines a broad definition of terminal care, drawing on the work of Weismann — an absence of suffering, preservation of important relationships, an interval for anticipatory grief, relief of remaining conflicts, belief in timeliness, exercise of feasible options and activities, and consistency with physical limitations, all within the scope of one's ego ideal.

This chapter examines the problems of doctors in responding to patients' requests for physician-assisted death. It explores the potential meaning of such requests through a series of case vignettes and identifies acceptable responses that are tailored to the needs of the individual patient. The chapter discusses the clinical criteria that have been proposed as a guide for physicians who find assisted suicide a morally acceptable last-resort option for terminally ill patients with relentlessly progressive medical illnesses.

In the past, palliative care services were developed largely based on assumptions about patient need from the health professionals' points of view. Palliative care services are now adapting to changing demands upon them consequent upon changing patterns of disease and the introduction of new therapies, and ultimately to the challenge of providing care for patients with other chronic conditions. Assessment of the palliative care needs of the whole population is therefore essential for need, supply, and demand to overlap. Epidemiological data and analysis of existing health services can inform needs assessment. In the UK health service, need is defined as the ability to benefit from health care. The purpose of needs assessment is to determine the levels of need and of existing service provision within the community in order to facilitate the planning of future services.

This chapter discusses the components of total pain in terminal care. These are mental pain, social pain, spiritual pain, and staff pain. It is important to explore these problems in order for palliative care staff to better understand the suffering of each patient and to help both the patients and their families. Terminal care staff must not be trapped into thinking that pain only demands the immediate use of appropriate drugs.

This chapter examines the challenge for and the changing role of palliative care, particularly with respect to venous thromboembolism (VTE). There are several factors that have driven the expansion of palliative care beyond just the provision of terminal care for cancer patients. These include the advances in the management of metastatic diseases which means that patients with incurable diseases may live longer and receive palliative therapies for several years. This chapter suggests that the challenge for palliative care in VTE is to ensure that patients receive appropriate management that maximizes their quality of life and is in accordance with their wishes.

This chapter discusses the transition from palliative care in the hospital setting to terminal care in the home setting. After the decision to stop chemotherapy or aggressive treatment, families and patients often seek the comfort of their homes in the hopes of finding familiar surroundings. In instances such as this, rapid hospital discharge is a must; however, adequate support must be provided to avoid emergency situations. This chapter covers: how to determine if the patient and their families want a home-care setting; guidelines on creating good communication with the patients and the families, particularly on difficult issues; symptom management for patients with advanced haematological malignancies; how to plan a smooth and efficient hospital discharge; and how to determine risk factors associated with complicated bereavement.

This paper is widely cited as a landmark contribution in the discussions about terminal care that were beginning to take place in the United Kingdom in the early 1960s. Published in 1963 and based on a talk given to its members, it sees Cicely Saunders entering the heartlands of the Royal College of Physicians, and the Section of Surgery at that. Her paper draws on research work at St Joseph's and compares problems and treatments in some 900 patients. The paper concentrates not on the drugs used with these patients, but rather the methods of their deployment. The ‘cardinal rules’ are set out: careful assessment of the symptoms that trouble the patient, assessment of the nature and severity of pain, and the regular giving of drugs.

This chapter explains the interrelationship between a clearly formulated philosophy of hospice care and the possibility of ethical reflection and analysis in hospice care. In so doing, it proposes that the reader consider the care given by hospices to be a special kind of practice that contains and infers its own ethics. Terminal care given by hospices is also situated in a larger society, and therefore its internal values interact with a broad set of social values; the practice of hospice care interacts with many other social practices, some that support hospice and some that are in tension with it. This situation of internal ethical coherence within a context of social and cultural plurality provides an important orientation and framework for ethical decision making in, and about, hospice care.

This chapter begins with the words of David Tasma, spoken to Cicely Saunders in 1948: ‘I only want what is in your mind and in your heart’. She describes St Christopher's Hospice, which grew from the inspiration of David Tasma, as ‘a medical foundation whose research reaches out widely in writing and teaching’ and as ‘a community in which the patients are the central members’. This sophisticated and reflective paper containing quotations from poems by T. S. Eliot and William Blake, is the first by Cicely Saunders in which the term ‘palliative care’ is used to denote the entire field of activity, rather than simply to signify the palliation of symptoms which may precede terminal care — a nomenclature recently introduced at that time by Balfour Mount himself.

This chapter aims to present the Tibetan Buddhist perspective that offers a rationale, experiential richness, and understanding in the area of death and dying, explaining the underlying principles of Tibetan Buddhism, which serve as the basis of death and dying practices. It also explores different practices during the various phases of death and evaluates how they can be incorporated into present-day end-of-life care.

Inpatient care is one of four Medicare-required levels of hospice care in the United States. This chapter explores the ethics embedded in administrative and clinical aspects of delivering hospice care to inpatients. It offers a broad overview of the most common ways that hospice organizations provide inpatient terminal care. In so doing, it highlights the strengths and drawbacks of each operational setting as they inform ethical aspects of care. The chapter also explores ethical challenges in the inpatient hospice care setting and offers guidance on how to address them in keeping with the specific values and culture of the particular hospice organization.

This chapter introduces readers to the aims and scope of the book. Readers are given the social and scholarly context in which the book emerges. The introduction suggests that the history and philosophy of hospice care contain moral values that can be resonant or dissonant with larger social values, giving those who work in hospice organizations an important place in the national discussion about terminal care. Finally, it offers a brief explanation of the goals of each chapter in the book.