Consultant physicians working with patients - Royal College of ...

2 Specialties Palliative medicinePalliative medicineDr Bee Wee MBBCh MRCGP FRCP PhD Consultant and senior clinical lecturer inpalliative medicineDr Stephanie Gomm MBChB FRCP MD Consultant palliative medicine1 Description of the specialtyPalliative medicine, recognised in the UK as a medicalspecialty in 1987, is defined as ‘the study of patientswith active, progressive, far-advanced disease, for whomthe prognosis is limited and the focus of care is thequality of life’. Palliative physicians work withinspecialist palliative care teams, assessing and treatingpatients with difficult symptoms and complexpsychosocial and spiritual problems. The specialistsociety for palliative medicine physicians in the UK isthe Association for Palliative Medicine of Great Britainand Ireland (APM) (www.apmonline.org).Traditionally, most patients referred for palliative carehave advanced cancer. 1 More patients with end-stageprogressive non-malignant diseases are now beingreferred to specialist palliative care, from 13.6% in2006–7 2 to 17% in 2010–11. 1 Since 2000, the moststriking increases are in outpatients (8% to 24%),hospital support (6% to 20%) and day therapy (5% to17%). For specialist palliative care inpatient units, theproportion of patients with a diagnosis other thancancer has increased from 3% to 11%, and the lowestincrease is for community settings from 4% to 10%.Inequity of access to specialist palliative care bydiagnosis, geography, age and ethnicity remains.2 Organisation of the service and patternsof referralA typical serviceSpecialist palliative care services include some or all ofthe components shown in Table 1. These are delivered bymultiprofessional teams who may come from differentorganisations within the National Health Service(NHS) or voluntary sector. These services are usuallypart of supportive and palliative care networks (withincancer networks) and/or end-of-life care networks.Arrangements vary to reflect local structures andneeds. Relationships between palliative care networksand cardiac and renal networks are developing.Table 1 Components of specialist palliative careservicesClinicalInpatient specialistpalliative careCommunity palliative careteamsHospital palliative careteamsDay therapy servicesOutpatient clinicsAcademicEducation and trainingprogrammes/centresResearch groups anddepartmentsSources of referralIn 2007–8, 3 referrals to specialist palliative care camefrom: GPs or district nurses (28%) hospital doctors (34%) other specialist palliative care teams (16%).Patients are referred when specialist palliative careexpertise is needed in: symptom management management of complex psychosocial and spiritualissues terminal care decision making in uncertain progressive situations.Sometimes one-off consultations are required. Moreoften, ongoing shared care is helpful. Referrals may betriggered by patients, families or other professionals.3 Working with patients: patient-centredcareA patient-centred focus is fundamental to palliative carepractice: helping patients to express their wishes andachieve their preferences in relation to symptommanagement and end-of-life care, within amulticultural context.C○ Royal College of Physicians 2013 189