I moved from general medicine into hospice-palliative care 50 years ago – in March1971 – when, at the invitation of Cicely Saunders, Founder and Medical Director of St Christopher’s Hospice in London, I accepted the post of Research Fellow in Therapeutics.
Later, in 1976, I moved back to Oxford (my alma mater) to a new free-standing palliative care unit on the campus of one of the University Teaching Hospitals. After I retired in 2001, I have continued writing with younger colleagues and teaching ‘on request’.
My professional life has been immeasurably rich and rewarding: I have been privileged to care for thousands of people with end-stage disease, taught countless medical students, doctors and others and, in the early years, conducted research mainly into the use of morphine by mouth for cancer pain. Thus my career has comprised a trinity of patient care, education, and research.
Since 1971 the world of palliative care has changed beyond recognition. [Gomez-Batiste & Connor 2017] Palliative Medicine is now a recognized specialty in an increasing number of countries, and university departments have been established. The fact that palliative care is now seen by both the World Health Organization and the United Nations as an essential component of ‘universal health coverage’ should facilitate development in countries where palliative care is still virtually non-existent. [Global Atlas 2020]
The present pandemic has led to even greater recognition of the need for high quality end-of-life care, and it has seen the involvement of palliative care teams in Intensive Care and other specialist care units. The President of the Association for Palliative Medicine here in the UK recently wrote that ‘Palliative care really came to the fore during 2020 and moved to a new space and a new thinking and my hope is that that movement continues. We have to continue to evolve and grow as a specialty.’ However, although palliative care has spread enormously and diversified considerably over the last half century, should we be aiming to evolve even further?
As a ‘dinosaur’ from the last Century, this is not for me to say. On the other hand, I think it most important to remember our roots, namely holistic partnership-based care for those approaching the end of life focused on comfort and quality of life We must also not forget the many challenges which we will continue to face. Inevitably, there will be never-ending financial ones. In addition, the values of the wider ‘Health Industry’ – competition, rationalism, productivity, efficiency, and profit – are essentially incompatible with compassion and caring. [Youngson & Blennerhassett 2016].
Further, there is still antagonism within the medical profession in some countries. This is partly fuelled by the distaste which many doctors feel when confronted with end-stage disease, and the reluctance to change the focus of care from disease control to comfort. Communication skills are still often distressingly poor. Linked with this is the inability of many doctors to engage sensitively in discussions about impending death. ‘Attention to detail’ in relation to pain and symptom management is often lacking.
Thus the challenge of providing high quality palliative care long-term should not be under-estimated. It requires determination, resilience, and high level clinical skills, sustained by a positive attitude toward our patients as people of worth, as verbalized by Cicely Saunders:
‘You matter because you are you. You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but to live until you die.’
Global Atlas of Palliative Care, 2nd Edition (2020): available at https://bit.ly/3dESF4h
Gomez-Batiste X & Connor S (2017). Building Integrated Palliative Care Programs and Services. Worldwide Hospice and Palliative Care Alliance. https://www.thewhpca.org/resources/category/building-integrated-palliative-care-programs-and-services
Youngson R and Blennerhassett M (2016) Humanising healthcare. BMJ. 355:466–467.
Robert Twycross is Emeritus Clinical Reader in Palliative Medicine, University of Oxford, UK, and one of the early pioneers within the specialty. From 1988–2005 he was Head of the WHO Collaborating Centre for Palliative Care. He is co-author of several widely acclaimed textbooks, notably the Palliative Care Formulary (up to 6th edition 2017) and Introducing Palliative Care (6th edition 2021). He has received numerous awards from professional organizations. Since 2017, he has been a Trustee of the Palliative Care Education Foundation (PACED; www.paced.org.uk)