Palliative medicine
Palliative medicine was recognised as a specialty in 1987, when specialist medical training programmes were established. This coincided with the rapid development of specialist palliative care services, which included new links between community, hospice and hospital care and between the NHS and the voluntary sector. Since 1995, the development of cancer services following the publication of the Calman-Hine Report has given further impetus to specialist palliative care integrated with cancer services. In particular, this has led to a rapid and continuing expansion in consultant posts. As a consequence of these continuing developments, many consultants in previously established posts are playing a key role in the strategic development of local services, and those taking up new appointments may be doing so without a fully developed or resourced service infrastructure.
Palliative care is the active total care of patients and their families by a multiprofessional team when the patient's disease is no longer responsive to curative treatment (World Health Organisation, Technical Series 804, Geneva 1990). The majority of palliative care in the UK is provided within the clinical setting in which the patient is routinely managed, particularly primary care, rather than by specialist services. However, specialist palliative care services are needed by a significant minority of people whose deaths are anticipated, and may be provided directly by specialist services or indirectly by means of professional advice to those caring for the patient. Referral is usually prompted by the presence of severe uncontrolled symptoms, major difficulties in adjusting to a terminal illness, or the need for inpatient terminal care.
Consultants in palliative medicine work within multiprofessional specialist care teams and services. Traditionally, the vast majority of patients referred for specialist care have had advanced cancer. Although that remains the case for many services, the need for palliative medicine is not diagnosis - specific but is defined by the patient's and family's needs. An increasing proportion of patients with advanced HIV disease or end-stage organ failure is now referred to specialist palliative care services, particularly in acute hospitals. Across the UK there is wide variation in the proportion of people dying from cancer who are seen by specialist palliative care services. In 1985 the range was 25-60%. Just under 20% of all cancer deaths occur in hospices or specialist palliative care inpatient units. The proportion of patients seen is determined partly by the availability of services, and rises as services expand. Referrals come equally from hospital services and primary care.
