La formation en soins palliatifs dans les universités européennes

José Miguel Carrasco, Eduardo Garralda, Kathrin Woitha et Carlos Centeno, du programme de recherche ATLANTES de l’Université de Navarre, en Espagne, donnent de plus amples explications sur une étude internationale réalisée en collaboration avec d’autres membres du Comité de direction pour l’éducation médicale en soins palliatifs de l’Association européenne de soins palliatifs et du groupe de travail sur le développement des soins palliatifs en Europe de cette même association.

Quelques-uns des auteurs de l’étude : (de gauche à droite) Eduardo Garralda, José Miguel Carrasco, Carlos Centeno et Kathrin Woitha

Quelques-uns des auteurs de l’étude : (de gauche à droite) Eduardo Garralda, José Miguel Carrasco, Carlos Centeno et Kathrin Woitha

Une étude réalisée à partir des données de 43 pays de la Région européenne (d’après la définition de l’Organisation mondiale de la Santé) a révélé que les étudiants en médecine ont un accès inégal à la formation en soins palliatifs. Ce travail, dirigé par des chercheurs du programme ATLANTES de l’Institut culture et société (ICS) de l’Université de Navarre, a été publié dans la revue Journal of Pain and Symptom Management.

Pour évaluer l’état de l’enseignement de la discipline, les chercheurs proposent un système de notation prenant en compte trois critères : la proportion de facultés de médecine où les soins palliatifs sont enseignés, la proportion de facultés de médecine où ils constituent une matière obligatoire et le nombre total de professeurs de soins palliatifs.

Selon cette recherche, dans 13 des pays analysés les soins palliatifs sont enseignés dans toutes les facultés de médecine ; néanmoins, ils ne sont une matière obligatoire que dans six pays. Dans 15 pays ils ne sont enseignés que dans certaines universités et dans 14 autres aucune formation particulière ne leur est dédiée. Israël, la Norvège, le Royaume-Uni, la Belgique, la France, l’Autriche, l’Allemagne et l’Irlande semblent être les lieux où l’enseignement des soins palliatifs est le plus développé.

Les auteurs concluent que si les soins palliatifs font partie d’un « nombre conséquent » de formations médicales sanctionnées par un diplôme dans les universités européennes et si une « structure d’enseignement qualifié » est en train de voir le jour, il existe toujours une différence importante entre les pays.

Nous avons réalisé une courte vidéo dans laquelle Carlos Centeno et d’autres membres expliquent plus en détail cette étude internationale et les raisons pour lesquelles l’éducation médicale en soins palliatifs est un défi auquel il faut faire face.

Télécharger un exemplaire gratuit de l’article complet
Ce billet fait référence à l’article Palliative Care Medical Education in European Universities: A Descriptive Study and Numerical Scoring System Proposal for Assessing Educational Development’ de JM Carrasco, TJ Lynch, E Garralda, K Woitha, F Elsner, M Filbet, JE Ellershaw, D Clark, y C Centeno, publicado en Journal of Pain and Symptom Management. Cet article est disponible en « libre accès » et peut être téléchargé gratuitement.

Liens et ressources

Pour en savoir plus sur les membres de l’équipe internationale de recherche…
Cette étude a été réalisée en collaboration avec d’autres membres du Comité de direction pour l’éducation médicale en soins palliatifs en Europe : Frank Elsner, Département de médecine palliative de l’Université RWTH Aachen, (Allemagne) ; Marilène Filbet, Institut Marie Curie de soins palliatifs et Hôpital académique universitaire Lyon Sud HCL (France); et John E Ellershaw, Université de Liverpool (Grande Bretagne); ainsi qu’avec des membres du Groupe de travail sur le développement des soins palliatifs en Europe: David Clark, Université de Glasgow University-campus Dumfries(Grande Bretagne) et Thomas J Lynch, du Kimmer Cancer Center de l’Université John Hopkins (États-Unis).

Nos remerciements a Léa Monsarrat et Marilène Filbet pour la traduction française de cet article.

Haga clic aquí para obtener la versión en español.

Click here to read the English version.

Posted in EAPC ACTIVITIES, EAPC Taskforces/special projects, EDUCATION & TRAINING | Tagged | Leave a comment

Supportive and Palliative Care Indicators Tool (SPICT): An international approach to identifying patients for palliative care

Dr Kirsty Boyd and Professor Scott Murray, the SPICT project leaders, explain how this increasingly popular tool is being used internationally by clinicians to identify people for integrated palliative care.

Dr Kirsty Boyd

Dr Kirsty Boyd

Late identification of people dying with one or more advanced conditions is the main reason why most people throughout the world do not receive the palliative approach to their care, which can make such a difference. Every clinician must be able to recognise when palliative care can be of benefit. Population estimates suggest that 69%–82% of people who die in economically developed countries could benefit from integrated palliative care. About 1-2% of people living in the community and around 30% of hospital inpatients are likely to be in, or approaching, the last year of their lives. Better care of the increasing numbers of people dying with multiple advanced conditions (multimorbidity) depends on professionals in primary care teams, hospital specialists and a range of other health and social care professionals making earlier identification part of their routine clinical practice in all care settings.

Professor Scott Murray

Professor Scott Murray

The SPICT is a clinical tool developed originally in 2010 as a collaborative project between NHS Lothian and The University of Edinburgh Primary Palliative Care Research Group. It supports the professional judgement of individual clinicians and multidisciplinary teams by highlighting readily identifiable general indicators and clinical signs of deteriorating health that mean patients are at risk of deteriorating further and dying. Clinicians are prompted to consider these people for assessment of unmet holistic care needs and opportunities to talk about their health problems, the things that matter most to them and their families, and future care planning.

SPICT seeks to improve ‘prognostic awareness’ while addressing the ‘prognostic paralysis’ that sometimes means palliative care is only offered when there are no other treatment options and the patient is close to dying. An individual patient’s risk of dying is multifactorial, relative and changes over time. The SPICT approach to timely identification acknowledges this variability and does not require a decision to be made about whether a patient is likely to die within a given time frame. General indicators, such as unplanned hospital admissions and increasing care needs, are evidence of deterioration in the person’s general health. These are combined with indicators of progressive, advanced illness drawn from a wide range of disease-specific mortality scores and other prognostic tools. The SPICT is based on expert consensus about the most appropriate indicators for use in routine clinical practice. SPICT has been formally evaluated in primary care and in hospitals and is now in use in all care settings.

spictJoin the SPICT community…
Open access to the current version of the SPICT on the SPICT website has encouraged a growing community of international collaborators to contribute to ongoing peer review and refinement. Our website offers short guides to using SPICT in primary care and in hospitals and you can download the SPICT in English, French, German and Spanish. Dutch, Portuguese and Japanese translations are under way. SPICT partners around the world can post information about their projects on using SPICT in clinical practice and research. Online communities of SPICT collaborators are available in English, French and German. The EAPC Taskforce in Primary Palliative Care has recommended SPICT for use across Europe. A recent, online survey of users rated key aspects of SPICT: available on a single page (89%), uses clinical indicators (93%), applicable in community, hospital and hospice settings (81%), promotes early, integrated palliative care (83%).

‘SPICT is clear, credible and can be used in all care settings.’

Join the SPICT community, an international partnership of colleagues dedicated to getting palliative care integrated into the care of people with all chronic progressive illnesses as early as possible!

References
Highet G, Crawford D, Murray SA, Boyd K. Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): a mixed-methods study. BMJ Support Palliat Care Published Online First: 25 July 2013 doi:10.1136/bmjspcare-2013-000488.

Maas E, Murray SA, Engels Y, Campbell C. What tools are available to identify people with palliative care needs in primary care: a systematic review and survey of European practice. BMJ Support Pall Care 2013;3:444–451.

Sulistio M, Franco M, Vo A, Poon P, Leeroy W. Hospital rapid response team and patients with life-limiting illness: a multicentre, retrospective cohort study. Palliat Med 2015;29(4):302-309.

Read more on the EAPC Blog…
You can read more posts from Professor Scott Murray here.

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Pharmacological treatments for fatigue associated with palliative care

Dr Martin Mücke, Physician, Department of Palliative Medicine and Department of General Practice and Family Medicine, University Hospital of Bonn, Bonn, Germany. Dr Mochamat, Physician, Department of Anesthesiology and Intensive Care, University of Diponegoro / Kariadi Hospital, Semarang, Indonesia and Prof Dr. Lukas Radbruch, Head of Department, Department of Palliative Medicine, University Hospital of Bonn, Germany.

Dr Martin Mücke

Dr Martin Mücke

Patrick, a 65-year-old man with prostate carcinoma, was admitted to our palliative care unit for symptom control. Patrick told us, “I’m not sure whether it’s worth it to feel like this every day. I’d like to die. I was used to taking a walk every day, that was quality of life; but now, I can’t do that. I can’t even manage visits from my friends and some days I don’t even get out of bed. I feel like I just don’t have enough energy.” This is a typical statement of palliative patients suffering from fatigue and Patrick is not alone in his battle with fatigue. Cancer-related fatigue is one of the most commonly reported cancer-related symptoms, occurring in more than 90 % of patients with this disease.

Dr Mochamat

Dr Mochamat

In an advanced disease such as cancer, fatigue can be described as tiredness, weakness or lack of energy. Fatigue can affect daily activity and quality of life and is frequently reported by palliative care patients. Fatigue is a protective response to physical or mental stress, often relieved by rest in healthy individuals. By contrast, in palliative care patients fatigue can be severely debilitating and is often not counteracted with rest, thereby impacting on daily activity and quality of life. The underlying causes of fatigue are not very well understood and fatigue is difficult to treat.

Prof Dr Lukas Radbruch

Prof Dr Lukas Radbruch

In collaboration with the Cochrane Pain, Palliative and Supportive Care Group, a team of authors from Germany, Indonesia and the United Kingdom, conducted a systematic review to evaluate the efficacy of pharmacological treatments for fatigue in palliative care. The review focused on patients at an advanced stage of disease, including those with cancer and other chronic diseases.

The team searched the literature in the electronic databases of Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO, and other resources up to April 2014 and found 45 randomised controlled trials for this update of the review. The authors analysed data from 18 drugs and 4,696 participants who received treatment for their fatigue. The trials dealt with neurological diseases (such as multiple sclerosis, post-polio syndrome and Parkinson’s disease), different types of cancer, HIV/AIDS, end-stage renal disease, multi-type advanced disease in hospice patients, amyotrophic lateral sclerosis and end-stage chronic lung disease.

Amantadine was shown to be effective in reducing fatigue in patients with multiple sclerosis. Participants with HIV/AIDS and fatigue benefited from treatment with methylphenidate or pemoline. There was some low-quality evidence from small trials that methylphenidate, a stimulant drug that improves concentration, is effective for the management of cancer-related fatigue. Previous studies have shown that erythropoietin and darbepoetin, drugs that improve anaemia (lack of iron), are also effective for cancer-related fatigue. However, due to safety concerns and side effects shown by more recent studies, erythropoietin and darbepoetin should no longer be used. Therefore, these drugs were not included in this review update. Overall, most side effects of the investigated drugs seemed to be mild.

Based on limited evidence, the authors still cannot recommend a specific drug for the treatment of fatigue in palliative care. Future trials should measure fatigue in advanced disease using comparable and standardised validated outcome instruments.

We do hope that this will give us some tools and interventions to help patients like Patrick!

Read the full Cochrane Review
This post relates to the longer article by Mücke M, Mochamat,  Cuhls H, Peuckmann-Post V, Minton O, Stone P, Radbruch L. Pharmacological treatments for fatigue associated with palliative care. Cochrane Database of Systematic Reviews 2015, Issue 5. Art. No.: CD006788. DOI: 10.1002/14651858.CD006788.pub3. Read the full Cochrane Review here.

Posted in Medicine, RESEARCH, SYMPTOM CONTROL | Tagged , | Leave a comment

Dancing to a different tune

Dr Marilyn Kendall and Professor Scott A Murray, Members of the Primary Palliative Care Group at the University of Edinburgh, Scotland, explain the background to their longer article published in the Journal of Pain and Symptom Management that looks at how we can provide good end-of-life care for everyone, whether their last dance is a fast Scottish reel, a tango or a slow waltz.

The Gay Gordons

Danse macabre: The Gay Gordons

The idea of the danse macabre, the last dance that we must all perform when death steps up and taps us on the shoulder, is well established in Western Europe since medieval times. But what will that dance be like, and who will be there to help us through it? How can we provide good end-of-life care for people dying of all conditions, not just cancer? Perhaps part of the answer to this very complex question involves better understanding of what the experience of dying is like in conditions other than cancer.

We have worked together for more than 16 years as members of the Primary Palliative Care Group at the University of Edinburgh, a social scientist and a doctor. During that time we have conducted various serial interview studies looking at the experiences of patients, and their family and professional carers, as they approach the last year of their lives. The studies have spanned the three main trajectories of physical decline – cancer, organ failure and frailty. This has given us a large and unique data set of narrative accounts of living with, and dying from advanced cancers (lung, brain and bowel), chronic obstructive pulmonary disease (COPD), liver failure, heart failure, and frailty.

Prof Scott Murray

Prof Scott Murray

Dr Marilyn Kendall

Dr Marilyn Kendall

In 2014, we gathered together all the researchers who worked on these studies to synthesise their findings and reflect on what we have learned. In our paper, ‘Different Experiences and Goals in Different Advanced Diseases: Comparing Serial Interviews with Patients with Cancer, Organ Failure or Frailty and Their Family and Professional Carers’, we have integrated the findings by each trajectory of decline to understand if there are typical beginnings, middles or ends in the last year or so of life. We have shown that patients have very difference experiences, hopes and needs and that death as a character is more prevalent in cancer narratives than the other trajectories, where people tend to have other more pressing concerns, such as to avoid hospital admission or admission to a care home.

By comparing and contrasting these complete narratives, from diagnosis to death and beyond, we have shown that these experiences are so different that service providers could consider how hospices and palliative care can be remodelled in person-centred ways. This is different from the current rather formal configuration, and could provide support and reassurance for patients and families whatever form that final dance takes – whether it is a fast Highland reel, a rather syncopated up-and-down tango or a slow last waltz!

Editor’s note
Scott Murray and friends have been taking part in this year’s Death on the Fringe, part of the Edinburgh Festival Fringe. Snippets from the dances were well received! See below for links.

Download a free copy of the full article
This post relates to a longer article, ‘Different Experiences and Goals in Different Advanced Diseases: Comparing Serial Interviews with Patients’, by Dr Marilyn Kendall et al, published in Journal of Pain and Symptom Management 50 (2015), pp. 216-224 DOI information: 10.1016/j.jpainsymman.2015.02.017. (You can download the full-text article for personal use until 22 September 2015 – it’s on the Primary Palliative Care Group website in the News and events – blog).

Links

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Social media and palliative medicine: An opportunity for community and professional engagement

This week, Dr Amara Nwosu, Marie Curie Palliative Care Institute Liverpool (MCPCIL), University of Liverpool, UK, talks about the use of Twitter in end of life care.

 

I find technology fascinating.

Dr Amara Nwosu

Dr Amara Nwosu

This interest has been present for a long time. As a child I remember coding graphics on my first computer (the ZX Spectrum) and building a radio from scratch (it was big, ugly and bulky but I loved it!).

I am captivated by anything that can be plugged in and/or switched on. Furthermore, I am keen to explore opportunities to incorporate technology into my clinical-academic life. Examples include my review of palliative care smartphone apps,1 the ‘MyPal’ podcast (a podcast about technology, innovation and palliative care)2 and my PhD research (a study which involved the use of bioelectrical impedance analysis to evaluate hydration in advanced cancer).3 4

Social media is another of my interests. Social media has become commonplace in society; platforms such as Facebook, Twitter and YouTube continue to grow in prevalence and influence.5 Twitter (a social media micro-blogging service), since its creation in 2006 has amassed 302 million monthly active users (who send approximately 500 million tweets per day). I was interested to use Twitter to evaluate how palliative care issues are discussed on social media.

My article entitled ‘Social media and palliative medicine: a retrospective 2-year analysis of global Twitter data to evaluate the use of technology to communicate about issues at the end of life’ was published in BMJ Palliative & Supportive Care. (See link below). The aim of this study was to determine the frequency, sentiment and trend of Twitter ‘tweets’ containing palliative care related hashtags (for example, #palliative) and/or phrases sent by users over a two-year period. TopsyPro, a social media analytics tool, was used to conduct the analysis. TopsyPro provides several metrics about tweets, such as the volume, frequency, the overall tone (sentiment) and change in use over time (acceleration). In total, 13 palliative search terms were identified and analysed.

The analysis revealed that over a two-year period (2011–2013) the discussion of palliative care on Twitter was frequent (683.5K tweets) and increasing (a rise of 62.3% over the two years). The majority of tweets were positive about palliative care, demonstrated by a sentiment score of 89% (meaning that 89% of tweets were more positive than all other tweets sent on Twitter during this period).

Overall this study demonstrates that a lot of discussion about palliative care is taking place on Twitter, and the majority of this is positive. Consequently, social media presents a novel opportunity for engagement and on-going dialogue with public and professional groups about palliative care.

Read the full article…
This post relates to a longer article, ‘Social media and palliative medicine: a retrospective 2-year analysis of global Twitter data to evaluate the use of technology to communicate about issues at the end of life’ by Nwosu AC, Debattista M, Rooney C, et al published in BMJ supportive & palliative care 2015;5(2):207-12. You can view the abstract free of charge; the full text article is available at a charge or on subscription to the journal.

References

  1. Nwosu AC, Mason S. Palliative medicine and smartphones: an opportunity for innovation? BMJ Supportive & Palliative Care 2012;2(1):75-7.
  2. Nwosu AC. MyPal: a podcast about technology, innovation and research relevant to palliative care 2015. 
  3. Nwosu AC, Mayland CR, Mason SR, et al. Hydration in advanced cancer: cn bioelectrical impedance analysis improve the evidence base? A systematic review of the literature. Journal of Pain and Symptom Management 2013;46(3):433-46.e6.
  4. Nwosu AC, Mayland CR, Mason S, et al. Patients want to be involved in end-of-life research, BMJ Supportive & Palliative Care 2013;3:(4):457.
  5. Taubert M, Watts G, Boland J. et al. Palliative social media. BMJ Supportive & Palliative Care. 2014;4(1):13-8.

Links

 

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With great power comes great responsibility: Using Facebook to explain palliative care

Dr Leeroy William is a Consultant in Palliative Medicine at Monash Health and Eastern Health/Adjunct Senior Lecturer in Palliative Medicine at Monash University, Victoria, Australia. Here, Dr William explains the background to a longer article in the July/August edition of the European Journal of Palliative Care.

Dr Leeroy William

Dr Leeroy William

In 2010, I was lucky enough to hear Dr Alejandro Jadad deliver a plenary session at the International Congress of Palliative Care in Montreal. It was a memorable lecture, full of humour and insight into palliative care’s engagement with technology. Dr Jadad not only poked fun at our hesitancy to use email, but also challenged the fears we had of electronic patient communication. Fortunately, times have changed and we seem to be embracing technology – including the world of social media.1

Our team’s use of Facebook as a teaching tool occurred from a chance observation. It was the prevalence of laptops in the audience that prompted my colleagues (Drs Michael Franco and Peter Poon) and me to think of engaging with students differently. The Facebook page (see link below) has become very relevant to the growing interest in palliative and end-of-life care observed in society. There seems to be a greater openness to discuss death and dying, in the context of an ageing population and the limitations of medical care.1, 2 Furthermore, Twitter (see link below) has become a portal to new research and conference updates from around the globe.

Dr Atul Gawande suggests our job in medicine is to enable wellbeing, and that palliative care provides the kind of thinking required to achieve this task.3 Although palliative care is a growing specialty, Dr Gawande recognises that all clinicians need to “apply such thinking to every person they touch”.3 I would certainly agree. After all, finding the balance between the knowledge of the disease, the beliefs of the patient and what we should do in the face of this information, describes the art of medicine. So, how can we achieve better integration of palliative care into mainstream medicine? How far have we come and how much further do we need to go?

Over the years, I have witnessed the misperceptions about palliative care from healthcare professionals, patients and their families. Despite decades of palliative care education, bridging the knowledge gap has been a challenge. However, social media affords us the opportunity to disseminate the palliative care message to a global audience. We have used the connectivity of social media to engage inter-professional and societal awareness about palliative care. Our Facebook page may spark an interest, challenge beliefs or change practices. However, with such power comes the responsibility to meet the demand generated. Palliative care services will need to prepare to deliver care both directly and indirectly. In so doing, perhaps we may achieve a culture of care in mainstream medicine that truly does cure sometimes, relieve often, but comforts always.

References and resources
1. Taubert M, Watts G, Boland J, et al. Review: Palliative social media. BMJ Support Palliat Care 2014; 4(1): 13-18.

2. Gawande A. BBC: 2014 Reith Lectures. [Internet]. London; 2014 Dec. Available from the BBC website.

3. Gawande A. Being Mortal: Medicine and what matters in the end. Metropolitan Books; 2014. P. 259.

EJPC224coverRead the full article in the European Journal of Palliative Care
This post relates to a longer article, ‘Facebook helps to get the palliative care message across to future doctors’ by Leeroy William, Michael Edward Franco and Peter Poon published in the July/August 2015 issue of the European Journal of Palliative Care  (vol. 22.4). If you have a web-based subscription to the journal you’ll 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.

Coming up…
On the EAPC Blog next week, Dr Amara Nwosu will be talking about his research on the use of Twitter to discuss end-of-life care.

Posted in EAPC-LINKED JOURNALS, European Journal of Palliative Care | Tagged | 1 Comment

Palliative stories – turning the negative into a positive

Palliative Stories – the EAPC’s blog series from the perspective of patients and family carers

Today, Jennifer Fox shares her story.  Jennifer recently completed a PhD exploring the transition to palliative care at Institute of Health and Biomedical Innovation and School of Nursing, Queensland University of Technology, Brisbane, Australia.

“We must turn this negative into a positive.” My husband of 26 years said these simple, optimistic words on the day he was diagnosed with melanoma and was informed he might only have months to live. These words were an unexpected source of strength and guidance for me during his illness and continue to inspire me now, almost 10 years on from his death.

Jenny Fox with her husband, Murray, three months before he died

Jenny Fox with her husband, Murray, three months before he died

In 2004 my husband was diagnosed with melanoma. Five months after diagnosis the surgeon delivered the news, “go home and get your affairs in order, it is only a matter of months.”  In the coming months my husband’s condition deteriorated. We had to make decisions about where he would spend the final weeks and days of his life. As a family we chose to care for him at home. This was made possible with the support of local community hospice and palliative care nurses. The compassion and understanding of these nurses in the provision of care was the inspiration that enabled me to ‘step outside my comfort zone’ at a time when my life was at a turning point…

Following my husband’s death in 2005, I was devastated, wondering if there was any purpose to my life. I was an accountant with a 25-year background in small business taxation, however, that position then seemed meaningless. Upon reflection I was struck by the privilege inherent in the role of palliative and hospice nurses in the provision of care to those nearing the end of life. I made the decision to study nursing.

My nursing career has allowed me to follow my passion and give voice to those impacted by the need for palliative care. In hindsight, my husband could have been considered for palliative care when he was advised, “go home and get your affairs in order.” However, palliative care was not mentioned and if it had been, I would have ‘run a mile’. At that time my husband had no symptoms from what the surgeon considered a terminal diagnosis. In my view he was not dying; he did not need palliative care.

TransitionWhy was this my reaction and how would I react now, 10 years later, if given the same situation? This is an interesting and complex question and one that was the basis of a PhD I recently completed exploring the transition to palliative care. My PhD research identified a complex interaction between acute care services and palliative care. 1 It highlighted many social, structural and cultural factors that impinge upon the patient and family journey in the transition to palliative care.

There are no easy answers; however, my research provides knowledge and insight into the complexities of the transition process, and for me both the personal and professional journeys continue. I have heeded my husband’s advice. I have turned a negative into a positive by finding a more satisfying and rewarding direction in my life journey.

Reference
1. Fox, J.A. (2015). ‘The transition to palliative care: A critical exploration in the context of metastatic melanoma’, PhD thesis, Queensland University of Technology, Brisbane, Australia.

Read more ‘Palliative Stories’ on the EAPC Blog
If you missed the previous posts in this series, please click here. A new story will be published each month.

If you have a patient, or a family member or friend, who would like to contribute to the series please contact the editor.

A message from the EAPC
We would like to thank everyone who has kindly contributed to this series of ‘Palliative Stories’. In publishing patients’ and families’ stories we are aware that content may sometimes focus only on one side of the story but we hope that the stories will help us all to better understand people’s palliative and end of life care experiences. Unfortunately, we are not able to give advice or comment on individual cases but we share in the distress that our contributors have experienced.

Posted in Palliative Stories, PATIENT & FAMILY CARE | Tagged | 2 Comments