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The changing landscape of palliative care : a universal imperative
Taylor, Amy Davies, Andrew Saravanan, Ponnusamy
Taylor, Amy
Davies, Andrew
Saravanan, Ponnusamy
Affiliation
Trinity College Dublin, Ireland; Our Lady's Hospice & Care Services, Dublin, Ireland; University College Dublin, Ireland; University of Warwick, Coventry; George Eliot Hospital NHS Trust, Nuneaton
Other Contributors
Publication date
2025-07-23
Subject
Collections
Research Projects
Organizational Units
Journal Issue
Abstract
I am excited to introduce the latest issue of Clinical Medicine, which features an outstanding collection of articles on common topics in palliative care. I am thankful for the thoughtful curation of the invited topics by my editorial colleague Prof Davies and guest editor Dr Taylor for this issue’s CME section. This issue offers valuable learning insights for clinicians and academics across all fields of medicine. I have included summaries of these articles from the section editors, along with highlights of two original research papers and the thought-provoking Harveian Oration article – my picks for this issue.
The basic principles of palliative care have been around for centuries. However, palliative medicine is still a relatively new medical specialty and, like other medical specialties, has evolved somewhat over the last decade or so. The basic tenet of palliative care involves a patient-centred, holistic approach (addressing physical, psychological, social and spiritual issues), which is not unique to the specialty, and indeed is the ‘norm’ in many other medical specialties. Nevertheless, a holistic approach is of little use, without the evidence to support relevant interventions, or the resources to deliver these interventions.
The World Health Organization estimates that 56.8 million people, including 25.7 million people in the last year of life, require palliative care, although only 14 % of these individuals actually receive such care.1 Inadequate training and resources are major issues, worsened by a lack of effective regional and national policies. Importantly, although the evidence base for palliative care has improved, much clinical practice is only supported by expert opinion, which is often inconsistent, and often based on historical teachings.2
Given the universal relevance of palliative care, this CME series provides a specialist palliative care perspective (with supporting evidence wherever possible) on some of the most common scenarios encountered in routine clinical practice:
❖ Palliative care or supportive care?3 Increasingly, palliative care services are rebranding themselves due to negative connotations relating to the term ‘palliative’. Taylor and Davies discuss this issue, while highlighting the ongoing evolution of palliative care and palliative medicine.
❖ Palliative care: what’s the evidence?4 Pask et al review the available evidence, and highlight that both non-specialist and specialist palliative care services can improve outcomes and reduce costs. However, palliative care is not a panacea, and further research is needed to determine the role of specialist palliative care services in specific cohorts of patients (eg patients with dementia, ‘cancer survivors’).
❖ Cancer pain – all change please?5 Recently, the World Health Organization updated their cancer pain guidelines, and removed the so-called ‘three-step analgesic ladder’. Yri and Laird explore the challenge of managing cancer-related pain, particularly given that many more people are now living longer with such pain, and advocate for an individualised, multimodal approach (ie pharmacological, non-pharmacological).
❖ Opioid analgesics: managing the predictable:6 Opioid analgesics remain an essential component of cancer pain management. Barnes et al discuss the common/predictable adverse effects of opioid analgesics, and how to mitigate and manage these often troublesome clinical problems.
❖ Advance care planning:7 Advance care planning is becoming a standard of care in many areas of clinical practice. Robinson and Paes discuss the processes and challenges around advance care planning, and the evidence relating to patient-related clinical outcomes (eg place of death).
❖ Clinically assisted nutrition and hydration at the end of life:8 Decisions about withholding or withdrawing of medical interventions at the end of life are often challenging. Davies reviews the limited evidence relating to clinically assisted nutrition and hydration, emphasising the need for an individualised approach supported by relevant international guidance.
❖ Clinical problems in the last days of life:9 Wadee and Noble discuss three major end-of-life problems (ie terminal delirium, audible secretions / ‘death rattle’, terminal haemorrhage), and how to manage these distressing problems given the limited evidence to guide clinical practice.
❖ Palliative sedation at the end of life: practical and ethical considerations:10 ‘Palliative sedation’ is a controversial end-of-life medical intervention. Barry et al explore the complex practical, ethical and cultural aspects pertaining to palliative sedation in clinical practice.
Specialist palliative care services will never be able to provide palliative care to all those who would benefit from its implementation. Hence, it is imperative that all healthcare professionals understand the principles of palliative care, and have a basic understanding of the up-to-date management of common palliative care clinical problems.
❖ EIC’s choices:
Collett et al11 report useful insights from a UK-wide study on an important, rapidly growing crisis of burnout among healthcare professionals — and offer promising strategies to support their mental health. While the evidence remains far from clear, they do highlight practical tools that could improve our workplaces today. With an ageing population, the challenges of early Alzheimer’s diagnosis and rapidly evolving newer therapies, the network meta-analysis by Su et al12 on the comparative efficacy and safety of current immunotherapies provides timely guidance for clinicians. Finally, Prof Sayer, last year’s Harveian Orator, eloquently argues the need for a ‘fourth shift’ in her article;13 a must, in my opinion, for providing holistic and individualised care, as well as faster translation of new research evidence into clinical practice. This is relevant not just for ageing research and palliative care, but across all disciplines of medical practice.
Citation
Taylor A, Davies A, Saravanan P. The changing landscape of palliative care: a universal imperative. Clin Med (Lond). 2025 Jul;25(4):100492. doi: 10.1016/j.clinme.2025.100492. Epub 2025 Jul 23.
Type
Article