Palliative medicineBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7204.2 (Published 24 July 1999) Cite this as: BMJ 1999;319:S2-7204
It is a fact of life that we all must die, hopefully as peacefully and comfortably as possible. The specialty dedicated to achieving this is expanding, writes Marie Williams
- Mari Lloyd-Williams, specialist registrar in palliative medicine
Although a young specialty, palliative medicine is now the 11th largest and one of the fastest growing, but still many people shrug their shoulders when asked what we do. After three and half years in post, I still get letters from the university addressed to me at the “Department of Palaeontology Medicine.” The word palliative is derived from the Latin “pallium,” which means to cloak or hide. Palliative medicine is the specialist care of patients who have a life threatening, incurable illness, with the aim of treating their symptoms so that they can live their remaining life as comfortably as possible. Despite many changes in medical education we still do not train new generations of doctors to deal with the reality of progressive chronic illness.
What is it?
Palliative medicine encompasses a wide range of skills, both intellectual and people centred - the palliation of physical symptoms is a large part of the work, but the holistic care of patients includes their psychological, social, and spiritual wellbeing. This care often extends after the death of a patient to the bereaved relatives and friends. It provides an opportunity to work with medical colleagues in all specialties and with general practitioners and a wide range of paramedical staff. These close working relationships are often fostered by the shared care of individual patients and by the sharing of knowledge and skills. Some of the most challenging aspects of the work involve supporting patients and families in ethical decision making, often in highly charged emotional situations, and there is a need for considerable diplomacy.
Historically, specialists in palliative medicine largely worked in hospices - independent units often funded by the local community - but consultants now have an increasing role in hospital symptom control teams and in the community, although most continue to have a hospice base. As clinical nurse specialists and general practitioners increase their knowledge of palliative medicine, the patients who are referred to palliative medicine are often those with more complex physical symptoms or psychological needs. The management of these patients often involves working closely with other medical colleagues such as anaesthetists and psychiatrists. Palliative medicine has traditionally treated patients with cancer, AIDS, and motor neurone disease, but many people believe that the principles of palliative care need to be extended to patients with other diseases, such as end stage renal failure or cardiorespiratory diseases. Consultants in palliative medicine also have a role in the strategic development of local services and a commitment to providing education to other groups on aspects of palliative care.
Palliative medicine is based firmly on the multidisciplinary team - it is not the specialty of choice for those with the attitude that “I'm the doctor, and make I all the decisions around here.” Doctors who feel that they have to make everything right for their patients will also have difficulties: although pain and other physical symptoms can usually be effectively and speedily palliated, emotional and spiritual problems are not always remediable despite the best efforts of all team members. Multidisciplinary teams usually work extremely well, with the skills of each team member contributing to the overall care of the patient. However, working in this environment, especially as a single consultant or in an isolated hospice unit, can lead to a feeling of professional isolation and a failure to appreciate one's role as a doctor.
General professional training
As in all other medical specialties, a minimum of two years general professional training is required before entry to higher specialist training. The two years' must be spent in approved posts with direct involvement in patient care and include a range of specialties. Eighteen months of the two years must be in posts providing experience in admission and early follow up of acute emergencies, and six of these 18 months must be in a specialty admitting patients from an acute unselected medical take. Entry to palliative medicine is by higher diploma, usually MRCP or MRCGP. Those wishing to enter higher training in palliative medicine from a vocational training scheme may find that they have to undertake further senior house officer posts. There are senior house officer posts in palliative medicine, usually hospice based, and competition for these posts is intense as those wishing to enter other specialties (such as geriatric medicine, stroke medicine, and general practice) also want to gain some experience in palliative medicine at senior house officer level. It is recommended and almost mandatory that those wishing to enter higher training in palliative medicine spend at least six months at senior house officer level first.
Currently, training in palliative medicine lasts four years and will be spent in a variety of settings, including hospices, hospitals, and the community, with some schemes rotating to other hospice units and hospitals. The Joint Committee of Higher Medical Training specifies that two years must be spent in units offering a full range of services - inpatient, day care, home care, and so on. All training is under the guidance of a supervising consultant, and there are named education supervisors for each section of the programme. Locally, palliative medicine training is under the auspices of a programme director. In addition to palliative medicine, experience is gained in allied specialties - oncology, haematology, neurology, acute pain management, psychiatry, general practice, etc - depending on the previous experience of the trainee.
All training in palliative medicine is generic, and, although there are no recognised sub- specialties, many trainees develop a special interest during their training. Up to one year may be spent in supervised research, although opportunities and funding for this in palliative medicine are limited, but some trainees develop their own academic interests. Trainees in palliative medicine are automatically members of the Doyle club, which meets twice a year and provides links with other trainees to give support and enable the sharing of ideas and experience. At all times, there is opportunity for training flexibly: women trainees outnumber men, and this is reflected in the sympathetic approach to part time training.
Palliative medicine is an expanding specialty, and there are currently many more posts available than there are people qualified to fill them. In a bid to ease this shortfall, the Specialist Advisory Committee is increasing the number of specialist registrars, with an increase of about 20 in the national training numbers negotiated until the year 2001-2. As new consultants are appointed, the current shortfall may be reduced, but career prospects are likely to remain good for some time.
Pros and cons of palliative medicine
Ability to retain a large amount of patient contact during training and at consultant level
Benefit of integrating with all hospital disciplines and general practitioners
Working as part of a supportive multidisciplinary team
Well structured training
Opportunities for flexible training and careers
Opportunities to influence service development
Good quality of life
Emotionally challenging and demanding
Constantly dealing with great uncertainty
Can be professionally isolating
Few opportunities to develop a research or academic career
The workload of consultants varies according to the nature of the post, but much palliative medicine is provided by consultants themselves. Many have a remit to provide inpatient care at a hospice unit, outpatient consultations, domiciliary consultations, and sessions in hospitals for assessing patients and for providing support and education for specialist nurses and other staff. The workload of most consultants in palliative medicine is very demanding. On-call commitments vary according to the service provision - many consultants work one in two rota because of the small number of consultants based in any one area. The academic structure in palliative medicine has been slow to develop, but there are now six chairs in palliative medicine and a further three academic centres.
There are good opportunities for part time working. Also, there are opportunities for hospice clinical assistantships in palliative medicine on a sessional basis, and many general practitioners find this rewarding and fulfilling. The role of Macmillan facilitator, a general practitioner with an interest in palliative medicine and a remit to provide education and support for general practitioner colleagues, also provides an opportunity for those in general practice to develop and maintain an interest in palliative medicine.
How to stay sane
Excellent communication skills, the ability to look at problems from all angles, and a calm, pragmatic approach are generally needed if one is to remain in the specialty for a lifetime. Considering the emotionally demanding nature of the work, the burnout rate is relatively low. Many find the nature of team working to be supportive, and the Association for Palliative Medicine has set up a mentoring scheme for new consultants. As with all medical careers, it is essential to have a full life outside work and, above all, a well developed sense of humour.
Further information from
Association for Palliative Medicine, 11 Westwood Road, Southampton, SO17 1DL