Death of a goldfish: Social experience or medical event?

Dr Kathleen McLoughlin, National End of Life Audit and Review Co-ordinator, The Irish Hospice Foundation, reflects on the 3^rd International Public Health and Palliative Care Conference held in Ireland on 25-27 April 2013

Dr Kathleen McLoughlin

Last month I attended the 3rd International Public Health and Palliative Care Conference organised by Milford Care Centre and The University of Limerick in association with The Irish Hospice Foundation, in Limerick, Ireland.  Over three and a half days delegates reflected on the question: Death, dying, loss and care: Social experience or medical event?  Inspiring presentations from Professor Cillian Twomey and Dr Bruce Rumbold highlighted that it is indeed both. I was inspired by the stories told through the films about “Bill” and those told by Dr Frank Brennan from his practice. I was educated in the theory of ‘Health Promoting Palliative Care’ by Professor Allan Kellehear, challenged to think differently about practice by Nigel Hartley and about research by Professor Luc Deliens. I was immersed in the subject of death, dying, loss and care from the moment I woke up until the time I went to sleep. The speakers made me laugh, made me cry, made me irritated and even angry. Most importantly, they made me think. Academics and practitioners challenged us all to see things differently… to see death as part of life. They tempted us to try a new way.

On the final day of the conference, death touched my life. And yes, this is a true story ­– not an Irish yarn!  Our goldfish that we had had for four and a half years died on Saturday morning. I went into the dining room and  spotted the goldfish lying at the bottom of the

The goldfish bowl: Goldie and Silver fish spent years together in that bowl

bowl. He was struggling to breathe, he could barely move, obviously weak.

So what did I do? 
The complete opposite of everything we had considered during the conference. I picked up the bowl and rushed the fish into the kitchen and threw him into a new bowl (with his lifelong partner) into ice cold water – literally turning their world upside down – my kitchen was ER (Emergency Room) for goldfish. 

Having thrown the fish into the water and provided them with oxygen and a new environment, I put them back in their usual place. I was satisfied and proud that I had done something heroic to save his life. I could cure him.

Ten minutes later, the fish was dead.

Fear and panic started to rise.  “Why?” I hear you shout…”it’s just a bloody goldfish – you’re nuts!” True – it didn’t really matter to me – it’s not my problem.

Luke

But it’s not my goldfish… it belongs to Luke, my six-year-old son. 

Luke was staying with my parents while I was at the conference, and when  he came home, it would be to a dead goldfish. Luke would be devastated – this was his goldfish.  What could I do?  I know, I’d go  to Limerick, buy a new goldfish and pop it in the bowl before he got home and he’d never know a thing.

I looked into the bowl and there was Goldie’s friend, Silver fish. They’d spent years together in that bowl. Now, I don’t know if goldfish grieve or even notice when their little friend dies so I throw him some food and start banging on the glass, urging him to eat. Poking and prodding, working on the bereaved fish.

On the way to the conference I began to think about the morning I had had. What was I thinking of?  For three and a half days and the past 12 years I have been telling the world and hearing the words that we need to be open about death, dying, loss and care. We need to have a positive attitude and everything will be ok. We need more awareness. Yet in 10 minutes I had just about broken every principle discussed at the conference, every value of palliative care and every mantra of public health approaches in this field of end of life care. It took just 10 minutes.

I had been unwilling to recognise death as a part of life as many of the speakers had encouraged.

I’d moved a dying fish from his natural habitat, forcing him, and his lifelong soul mate to accept the emergency measures I inflicted on them to make me feel better.

I gave no consideration to the health and wellbeing of the fish’s soul mate, prodding and poking her – working on her and not with her.

I had decided to deny the truth and tell my six-year-old son a pack of lies to make things ok and to ensure that I protected him from death.

I had denied that I too was actually a little sad that Goldie was dead. 

If I reacted like this to the death of a goldfish – God only knows what will happen when I am faced with the end of life care of my parents, my husband or, god forbid, my children?

Death, dying, loss and care is a complex area. It can be difficult to apply theory and practice at these difficult times. Milford Care Centre’s work is underpinned by Mother Mary Potter, the foundress of the Little Company of Mary, who said that we all have the power within us to do good and without a vision, we perish. We, in health- promoting palliative care, have a vision and hopefully the conference last month will give us the inspiration we need to make a difference when it matters.  My wish for participants who attended, is that we take just one idea, example or action from the conference and use it to reach out to just one other person between now and the 4th International Conference in 2015, to be hosted in the UK.

P.S Yes, I told Luke about the fish. He was sad. He cried. He said, “I loved that fish.” We buried him and planted a strawberry plant to mark his grave. And everyone is fine…

Useful resources

• The Irish Hospice Foundation has produced a range of resources on bereavement and end of life care. 
• Milford Care Centre has designed a series of useful leaflets for use with people living with death, dying, loss and care in the community. 

Fostering hope through palliative rehabilitation

Caroline Belchamber, Physiotherapy Lecturer, Bournemouth University, and Senior Physiotherapist at Lewis-Manning Hospice, Poole, Dorset, UK, explains the background to her longer article, which is published in the May/June edition of the European Journal of Palliative Care.

Caroline Belchamber

The open and supportive environment of palliative rehabilitation ‘fosters a sense of hope and helps people regain a sense of connectedness, enabling them to live rather than just existing.’

What is palliative rehabilitation?
When the quantity of life can no longer be increased, the quality of life must be maximised.¹ The aim of palliative care is to reduce the degree to which disabilities become permanent or interfere in everyday life irrespective of how long that life may be,² paralleling rehabilitation, which promotes a kind of wellness to exist even at point of death, such as the experience of a good death.³ Therefore palliative rehabilitation is essential in enhancing the lives of people with cancer. (See also http://ncat.nhs.uk/sites/default/files/Gateway_11008_DEC_rehab_20081117_0.pdf )

My research explored palliative rehabilitation,⁴ within a specialist palliative day care centre which included: group work ⁵ (social, exercise and diversional therapy); non-pharmacological approach to breathlessness, (breathing techniques, relaxation, pacing, lifestyle changes, anxiety and fatigue management); lymphodema management and aromatherapy, all seen as important components within palliative rehabilitation and delivered by a multidisciplinary palliative care team. I was involved in the exercise group and non-pharmacological approach, where I brought a number of skills to palliative rehabilitation including respiratory and knowledge of human function and movement, enabling me to maximise the person’s potential no matter how long they had left to live. Using physical approaches I promoted, maintained and restored physical, psychological and social wellbeing, while continually assessing the person’s changing health status.⁶ Through semi-structured interviews using interpretative phenomenology I captured the meaning of my participant’s lived experience of palliative rehabilitation. A key factor identified was ‘fostering a sense of hope,’ described in my article.⁷ 

Read the full article in the May/June issue of the European Journal of Palliative Care

Does the following statement sound familiar to you?

‘The beginning was devastating, it is difficult to cope with, it is difficult to take in when they say, you know, there is nothing they can do, and you have not got very long left to live, and you think of death and you know, I was frightened, I was terrified of dying. To be honest it is very hard to accept when they turn up and tell you what you’ve got. It’s like a cardboard shutter coming down.’

Do you wonder when faced with this situation how you can help foster hope?

Remember that the deepest prison, sealed off from light and sound, cannot hold the human spirit if hope endures. It is a window to the wider world. It is the link to love.⁸

Are we as professionals bringing ‘spirituality and compassion’ to those living with cancer? Do we ‘bring hope and consolation to the end?’ Are we enabling people with cancer ‘to live until they die?’ Are we providing ‘good medical practice and humanity?’ as spoken by Dame Cicely Saunders in this BBC Radio 4 recording.

Does palliative rehabilitation have a place in cancer survivorship?
The term ‘palliative’ brings with it unfortunate connotations, which doesn’t do justice to the concept of palliative care. Palliation relieves a variety of distressing symptoms, but is not the sole prerogative of hospice carers. Palliative care should begin at diagnosis and be an integral part of the cancer journey,⁹ meaning that it could last from a few days to months and in some cases years.¹ Palliative care is now starting to be recognised as an integral part of care delivered alongside cancer treatment services,¹⁰  consequently palliative rehabilitation is an appropriate inclusion within the Cancer Survivorship Agenda.  (For an international perspective see http://jco.ascopubs.org/content/24/32/5166 and for research see http://www.wcrf.org/blog/tag/cancer-survivorship/ ).

What are your thoughts and experiences of palliative rehabilitation?
Please contact me for more information on palliative rehabilitation either at Bournemouth University or Lewis-Manning Hospice.

To find out more…
The article to which this post relates, ‘Fostering hope through palliative rehabilitation’, by Caroline Belchamber, Mamood Gousy and Caroline Ellis-Hill, is published in the May/June 2013 edition of the European Journal of Palliative Care, (Vol. 20, no. 3).

If you already have a web-based subscription to the European Journal of Palliative Care you will be able to download this issue plus all articles in the journal archive.  You can also browse the archive and download articles by taking a 10-minute or 30-minute subscription. Members of the EAPC receive discounted subscription rates to the journal – click here to subscribe online.

References

1. Hill D, Hart K, A. practical approach to nutritional support for patients with advanced cancer. International Journal of Palliative Nursing 2001; 7 (7): 317-321.
2. Robinson D. The contribution of physiotherapy to palliative care, European Journal of Palliative Care 2000; 7 (3): 95-98.
3. Michael K. A case for rehabilitation in palliative care. Rehabilitation Nursing; 2001.26 (3): 84 & 113.
4. Belchamber CA, Gousy MH, Ellis-Hill C. Fostering a sense of hope through palliative rehabilitation. European Journal of Palliative Care 2013; 20 (3): 136 – 139.
5. Belchamber C. Participant’s perception of Group work in the management of cancer symptoms in older people. Groupwork 2009; 19 (2): 79 – 100.
6. Rankin J, Robb K, Murtagh N, Cooper J, Lewis S. Rehabilitation in cancer care. London: Wiley-Blackwell: 2008.
7. Belchamber, CA, Gousy MH. Rehabilitative care in a specialist palliative day care centre: A study of patient’s perspectives. International Journal of Therapy and Rehabilitation 2004; 11 (9): 425-34.
8. Brown PB, 1928. In Exley H. A special gift of hope and courage, Watford: Exley publications Ltd: 2003.
9. Gillham L. Physiotherapy-palliative care, Physiotherapists in Oncology and Palliative Care 1992; 78: 3. 
10. Department of Health (DH). National Health Service (NHS) Cancer Plan. Executive summary, London: HMSO: 2000.

Social media, palliative care and me: a personal view

MORE HIGHLIGHTS FROM THE 13^TH EAPC WORLD CONGRESS IN PRAGUE…

Sean Hughes, Research Associate (InSup-C), International Observatory on End of Life Care, Lancaster University, UK

Dr Sean Hughes

One of the more interesting aspects of this year’s EAPC Congress was the emerging importance of social media in the palliative care arena. The topic was the subject of a few formal sessions and presentations, but was prominent in casual conversations in the corridors and coffee breaks and at stands in the market place.

‘#EAPC’ enabled Twitter feeds with comment and announcements on congress activity and mobile devices were in constant use around the venue. As a relative novice with an interest in how to get the most out of what social media might offer, I was keen to find out more.

Jim Cleary speaking in the Meet the Experts session

Things did not start well. A clash in the programme meant that I did not get to the workshop on the first day of Congress. With that disappointment behind me, I made it to the Meet the Expert presentation by Jim Cleary and Frank Ferris in the early hours of the next day. What impressed (and perplexed) was the range of social media platforms. These included the usual suspects: Facebook ™, Twitter ™, YouTube ™ and the like, but many that I had never heard of, let alone used. We learned that Google+ ™ with its hangout and document-sharing facilities is amongst the fastest growing in a rapidly advancing scene.

Tips on how to manage information overload using filtering techniques and careful time allocation were helpful. It was clear just how useful social media could be in increasing general awareness of palliative and end of life care. Jim told how an older relative in rural Australia was able to comment on the state of services in rural Ukraine through following his social media posts without leaving her armchair!

But what of the pitfalls? Aside from the issue of how to efficiently handle and filter large amounts of information, a critical eye is required as to what to trust and what to ‘share-on’. As with all advances, unintended consequences and the permanence of a digital footprint need to be considered. As Jim and Frank put it: ‘what happens in Las Vegas, stays on the internet’, or words to that effect.

At a later session, Jacob Strand, a palliative care physician, sensitively explored the professional dilemmas inherent in social media contact with clients. Just how far can you go in these connections and what of professional boundaries? On the other hand, Jim pointed to the potential benefits in using social media in patient and family discussions and other consultations. Some create two social media profiles to separate personal and professional lives in the digital sphere.

Social media was a prominent topic in casual conversations and at stands in the market place: delegates talking to members of EAPC social media team, Avril Jackson (centre) and Anthony Greenwood (second left)

For me, only more questions. Prominent among these is how social media could be used as a research tool. In particular, how I might use it for our study on integrated palliative care (InSup-C)? Any answers out there?

Find out more…
PowerPoint presentations from the 13^th EAPC World Congress will soon be available to view on the EAPC website. Please follow the blog, Facebook,  and Twitter @EAPCOnlus feeds for further announcements.  

Russian court sentences physician over providing pain relief to terminally ill patient

Adri Nieuwhof, Human Rights Advocate, Switzerland

Adri Nieuwhof

On 29 May, I received information from a Russian physician calling for support to Dr Alevtina Petrovna Khorinyak who was sentenced in court for performing her professional duties by providing care to a terminally ill cancer patient. Dr Khorinyak has 50 years’ experience as a general practitioner. She worked in the Polyclinic No. 4′s group practice in the Siberian town of Krasnoyarsk, Russian Federation.

On 27 April 2009, Dr Khorinyak wrote two tramadol prescriptions to relieve the intolerable pain of Victor Sechin, a terminally ill cancer patient who did not reside in the service area of Khorinyak’s polyclinic. She decided to help Sechin because she had known him for more than 20 years as a friend of the family. Moreover, she was the physician who had diagnosed Sechin with a malignant neoplasm in 2006.

Dr Alevtina Khorinyak (Photo: Change.org http://chn.ge/1bdEcnd)

By the end of March 2009, Sechin was suffering unbearable pain that prevented him from sitting, lying down, or sleeping. The attending physician from ‘his’ polyclinic prescribed stronger fentanyl patches of 100 mcg/h (instead of 75 mcg/h) to relieve the pain. However, the pharmacy had no 100 mcg/h patches in stock. Sechin continued to receive the old dosage fentanyl patches but now in combination with tramadol tablets.

Problems arose on 18 April 2009 when Sechin’s pharmacy had no tramadol in stock. Only this pharmacy could deliver free tramadol to Sechin and have his prescription paid for from his federal benefits. Although tramadol tablets could be bought in another pharmacy, the attending physician of Sechin’s polyclinic refused to write the required prescription. More than one month later, on 22 May 2009, Sechin’s physician wrote a new prescription for tramadol.

In the days following 18 April, Sechin suffered severe pain while asking for relief. His relatives were unable to witness his suffering and asked Dr Khorinyak for help. In response, on 27 April 2009 Dr Khorinyak wrote two prescriptions for tramadol to relieve the patient’s unbearable pain. Another friend of the family bought the tramadol in the pharmacy and brought the tablets to the patient.

Criminal prosecution
In 2011, the Russian Federal Drug Control Service noticed the prescriptions in the local pharmacy and referred the case to the state prosecutor who brought the case to court. On 20 May 2013, the Court found Dr Khorinyak guilty of “forgery of documents in order to facilitate the commission of another crime” (Article 327 of the Criminal Code of the Russian Federation), and “trafficking potent substances in large quantities by prior agreement with the intent to sell as an organized group” (Article 234). The judge did not send Dr Khorinyak to prison because of her advanced age. Instead, she was sentenced to a fine of 15,000 Rubles (Euros 363).

In her verdict, Judge Nonna Markova gave no weight to the arguments of the defence that medical indications for tramadol treatment were confirmed by numerous documents; there was a medical necessity for tramadol prescriptions for pain management; the prescription forms had been certified by a personal signature and a personal seal of Dr Khorinyak and by the seal and the stamp of the Polyclinic No. 4, and that the lack of attachment of Sechin to Polyclinic No. 4 had no legal value. She did not commit a crime, but conscientiously performed her professional duties by providing the requested and needed assistance to manage the pain of a terminally ill cancer patient.

Moreover, the World Health Organization does not recommend controlling tramadol as a drug, and neither is it included in the international drug control conventions.

On June 4, I heard that Khorniyak’s attorney had now appealed against the Court’s ruling.

Support the Prague Charter
The Prague Charter: Palliative care a human right demonstrates how we can all work together to advocate access to palliative care as a human right.

Please support the Prague Charter by signing the petition.

Memorable moments: the 13th EAPC World Congress

Dr Corinne Cohen Peimer shares her personal highlights from the 13^th EAPC World Congress held in Prague on 29 May to 2 June 2013.

Dr Corinne Cohen Peimer

I am an American family medicine physician who recently moved to Switzerland, and I’ve worked in a hospice in the town of Blonay since December 2012. I was invited to attend the 13^th EAPC World Congress in Prague by my good friend and nurse colleague, Esther Schmidlin, who also happens to sit on the EAPC board. Having heard much about the EAPC from Esther over the years, I was eager for my own hands-on discovery of the organisation and its biennial congress. As a ‘first-timer’, I will share some of my impressions, perhaps reinforcing what many of you have experienced several times, and hopefully enticing those of you who have not yet had the opportunity to attend to come along to the next EAPC congress.

Prof Nathan Cherny presents results from The International Collaborative Project to evaluate the availability and accessibility of opioids for the management of cancer pain

The Prague Congress has been striking in its breadth and impact. I have attended lectures, discussions, presentations and videos with topics ranging from the ethics of euthanasia to the gifts of grief; from technological advances in pain management to the importance of ensuring basic access to morphine; from the inclusion of spirituality in palliative care to the inclusion of palliative care in public health; and from dealing with dementia to dealing with patients who have external cardiac defibrillators. Some sessions have been eye opening, some reconfirming, some humbling, some gut wrenching, and some grounding.  I have shed a few tears with my colleagues, but also a few giggles. I have been stunned by the scope of research – not only in the extent of topics covered, but also in the number of countries represented. And, most importantly, I have been struck by the other conference attendees. Perhaps the most memorable moments will be those passed during the coffee breaks, hashing out the impact that the flood of information will have on our individual practices, sorting out what we will take home with us, interpreting and incorporating the dilemmas into our own daily approaches to palliative care.

Memorable moments in coffee breaks: delegates from Cameroon and France talking to plenary speaker, Prof René Schaerer, and Amelia Giordano from EAPC head office

Stepping away from my clinical practice into a world of research and discussion has been enlightening. But the power of the information learned has been equalled only by the power of being surrounded by so many individuals who share a common passion, heightened by the presence of a myriad of backgrounds. The interdisciplinary emphasis on communication that exists at my hospice is taken to a new level and new importance here, amidst 2,000+ attendees from dozens of countries and a wide variety of professions. I feel privileged to have participated in such a gathering, and look forward to bringing at least a couple of pearls from this sea of wisdom back to my colleagues at home.

I offer my sincere thanks for an excellent experience, especially to all of you who spent countless hours making this weekend not only possible, but also incredible.

Find out more…

• PowerPoint presentations from the 13^th EAPC World Congress will soon be available to view on the EAPC website. Please follow the Blog, Facebook,  and Twitter @EAPCOnlus feeds for further announcements.  
• The 8^th EAPC World Research Congress will be held in Lleida, near Barcelona, Spain on 5-7 June 2014.
• The 14^th World Congress of the EAPC: Building Bridges will be held in Copenhagen, Denmark, on 8-10 May 2015.

Coming up…
We’ll be publishing more stories from the Prague Congress during the next days and weeks.

Talking about palliative care at the World Health Assembly

Lukas Radbruch, Incoming Chair of the International Association for Palliative Care

Professor Lukas Radbruch

The 66^th World Health Assembly was held at the Palais des Nations in Geneva, Switzerland, just two weeks ago. I went there for the day on 22 May and had some time to listen to the plenaries, where the health ministers of one country after the other explained in about five minutes what their country’s healthcare system had managed to achieve, and what were the major barriers and problems it was facing. All of them talked about prevention and cure; I did not hear anything about palliative care.

Palais des Nations, Geneva: site of the World Health Assembly

So why did I go there?

Actually, for a very good reason. On 22 May a side event was sponsored by the permanent missions of Panama, Uganda and the United States, together with the International Association for Hospice and Palliative Care (IAHPC), the Union for International Cancer Control (UICC), the Worldwide Palliative Care Alliance (WPCA), the World Medical Association, the African Palliative Care Association (APCA), the Asociación Latinoamericana de Cuidados Paliativos (ALCP), Hospice Africa Uganda, Kenya Hospice and Palliative Care Association, Open Society Foundations and Human Rights Watch.

This side event was on strengthening palliative care as a component of integrated treatment throughout the life course. It started out with Dr Javier Diaz, the Minister of Health of the Republic of Panama, explaining about the role and responsibility of the World Health Organization and the World Health Assembly in promoting palliative care. He explained that worldwide about 50 million people require palliative care every year, but that in 100 countries no palliative care is available at all. He also stated that this problem could be resolved, as access to palliative care should be established for every patient who needs it.

Side event on strengthening palliative care as a component of integrated treatment throughout the life course

Prof Onyebuchi Chukwu, the Minister of Health of the Federal Republic of Nigeria, described how palliative care is being developed in Africa’s most populous nation, with huge needs and scarce resources. He talked about the barriers that have to be faced, for example misconceptions about opioid analgesics that have to be overcome.

Ms Kathy Greenlee, the Assistant Secretary of Health for Ageing of the United States of America, discussed the importance of palliative care in a time of ageing populations. Public awareness is all about active ageing, and nobody is talking directly about death, as it is felt to be just too depressing. People want to die peacefully in their sleep, but not many will. A change is necessary, discussing preferences for the end of life. She also stated clearly that the new framework on noncommunicable diseases (NCD) would not be complete without considering palliative care. John Beard, representing the WHO Department of Ageing and Life- course, emphasized this position and explained WHO’s efforts to promote a public health approach to palliative care.

John Beard (WHO Department of Ageing and Life-course) and Kathy Greenlee, (Assistant Secretary of Health for Ageing of the United States of America)

Other speakers included Dr Mary Cardosa, President of the Malaysian Medical Association, and Prof Claude Moreira, head of pediatric oncology at Hôpital Aristide le Dantec in Senegal.

The meeting had an interested audience, which participated very actively in the discussion, and it may well have raised awareness in a number of participants. However, the main goal of the side event was not only to discuss successful palliative care models from different regions of the world, but also to initiate a discussion about a potential resolution to promote access to palliative care for those in need at the next World Health Assembly in 2014.

We hope that this side event will be the first step towards putting palliative care on the political agenda of a major global healthcare organisation!

Please support the Prague Charter…
The Prague Charter: Palliative care a human right demonstrates how we can all work together to advocate access to palliative care as a human right.

Please support the Prague Charter by signing the petition.

News from Prague – the 13th World Congress on palliative care

Lukas Radbruch, Chair of the Scientific Committee and past president of the EAPC

Sitting in the hotel room, I wonder whether I am really in Prague.

Professor Sheila Payne at the congress opening on Thursday

The congress opened on Thursday with short notes from Ladislav Kabelka (Chair of the Local Organising Committee), Sheila Payne (President of the EAPC), myself as Chair of the Scientific Committee, Vaclav Hampl (Rector of Charles University Prague) and by the Czech Minister of Health Leos Heger. The support from both the local academic setting as well as the political support from the minister of health was most reassuring, and made participants feel at home in the ‘Golden City’ of Prague.

Even before the opening some serious work had been done in a number of workshops. The Workshop on the Role of Volunteers in Palliative Care brought together volunteers from different countries in Europe and discussed the different perceptions, roles and barriers encountered in volunteer work. This exchange was an important step towards setting up an EAPC Task Force on Volunteers.

Workshop on volunteers

The first plenary session highlighted the history of palliative care, and the lessons to be learned as well as challenges we face today, told by one of the pioneers of palliative care, former EAPC board member, René Schaerer. He managed to span the time from the early days of the EAPC to the future in his Floriani Award lecture.

Australian researcher, Meera Agar, presented her research results on treatment of delirium in palliative care patients, for which she had received the Early Researcher Award of the EAPC.

Early Researcher Award presented to Meera Agar

Following the plenaries a number of parallel sessions with a wide range of topics made for a difficult choice. In the parallel session on ethics and end-of-life decisions, Paul van den Berghe and Friedemann Nauck discussed the relationship of euthanasia and palliative care. Paul van den Berghe described the problems faced in a country that has a legislation permitting euthanasia, and Friedemann Nauck explained the problems and incompatibilities of euthanasia and palliative care, and emphasized the normative standpoint of the EAPC, that euthanasia should not be part of palliative care.

The parallel session on leadership attracted a larger number of participants, indicating that palliative care seems to be growing out of the phase where individual pioneers work in isolated places, and that leadership in teams, services and networks is of growing importance. Agnes Czikos gave the example of her own journey in the Leadership Development Initiative (chaired by Frank Ferris), and Carl-Johan Fürst explained the framework for mentorship. David Currow explained how to set up clinical networks, and Stein Kaasa gave some highlights from the Palliative Care Research Network of EAPC.

With such a full programme and strong content participants need to take a break – another opportunity to network and share experiences

A congress is not only shaped by the invited speakers, but also the participants, who enjoyed discussing the lectures, and many of whom presented posters or free communications on their own research or clinical experiences.

Meeting point: EAPC booth

The EAPC booth saw a lot of visitors, offering information on the EAPC social media activities; EAPC taskforces or other EAPC activities. Participants could also pick up a copy of the brand new Atlas of Palliative Care (2^nd edition) released at the congress by the EAPC Taskforce on Development of Palliative Care in Europe chaired by Carlos Centeno.

We hope that the participants enjoy the congress, and will enjoy it until the closing ceremony later this morning!