The Oxford Specialist Handbooks series provides readers with clear, concise information on all that is needed to successfully train in the medical sub-specialties. Each book gives an overview of clearly defined procedures, skills, guidelines, and technologies and provides practical tips and case studies to supplement hands-on experience. Where appropriate, each book complements the revised curriculum as developed by the Specialist Advisory Committees.
Dementia is a growing issue, exacerbated by improvements in health care which have led to an ageing population; currently three quarters of a million people suffer from dementia in the UK, and this is expected to rise to 1.8 million by 2050. This book concentrates on advanced disease and addresses issues such as pain management, decision-making, spiritual needs, communication, the Mental Health Capacity Act, dementia in the younger patient, and the carer's perspective.
Written by specialists, this book will be invaluable for doctors and nurses involved in palliative medicine, geriatrics, and old-age psychiatry, and the generalist who treats the patient with dementia.

Respiratory disease is the second most common cause of death worldwide. Patients with advanced non-malignant disease, such as chronic obstructive pulmonary disease, have similar or even greater health care needs than those with advanced lung cancer. Uncontrolled symptoms, distress, and social isolation contribute to the poor quality of life experienced by such patients.
This book provides practical guidance to professionals who care for patients with advanced respiratory disease. It gives evidence-based advice on a wide range of topics, including management of respiratory and non-respiratory symptoms, chronic respiratory failure, and respiratory emergencies. Recognition of when a patient may be approaching the end of life can be particularly challenging in patients with advanced respiratory disease. Ways to facilitate prognostication are covered, along with the significant communication and ethical challenges that this phase of life can present.
Written by a respiratory specialist and two palliative medicine physicians, this book will be of great value to doctors, nurses, and allied healthcare professionals working in respiratory medicine and in palliative care, both in relation to everyday clinical practice as well as meeting the requirements for postgraduate exams.

The care home sector is large, with over 400 000 residents in the UK and a similar number employed within the homes. It is therefore an area of considerable economic importance. Care home residents are often very old, and many have multiple physical and mental health needs, meaning that their care poses particular challenges. They are also a distinctly and profoundly marginalised group who are often invisible in the wider debates on quality of care including those about care homes.
Mental Health and Care Homes is a coherent and evidence-based text exploring these issues. Bringing together both clinical and research perspectives it will help those working in the care home sector to deliver high quality care and support to both residents and staff. This important, yet neglected, area is thoroughly reviewed by a range of experts including residents, family carers, staff, researchers, and clinicians.
The book has four sections: 'the inside view' which includes several first-hand accounts of care home life; 'the outside view' which discusses the regulatory, funding, and legislative context in which care homes operate; 'mental health and care', a detailed review of the major mental and other health issues that arise in care homes, as well as interventions and services to offer support; and a section exploring the 'promotion of health and wellbeing' including examples of good practice. It concludes by synthesising key themes and setting an agenda for further enquiry.
The book is written in a style that encourages engagement, with the inclusion of contemporary case studies and examples, making it topical and readable. It will be valuable for a broad professional and vocational audience across both health and social care, as well as students and researchers.

With a rapidly expanding elderly population, there has been a marked increase in the incidence of dementia, and this dreadful, debilitating illness now affects - directly or indirectly - millions of people across the world. Dementia throws up a number of particular clinical, ethical, and conceptual problems, which mostly reflect complicated evaluative decisions, for instance about diagnosis and the distinction between normal and abnormal ageing.
Different disciplines approach dementia in different ways - thus there are disease, cognitive neuropsychology, and social constructivist models of dementia, Underlying these models and approaches, each of which is clinically useful, are various and differing conceptual committments. These models carry ethical implications concerning how we ought to treat people suffereing from dementia.
Thinking through Dementia offers a critique of the main models used to understand dementia-the biomedical, neuropsychological, and social constructionist. It discusses both clinical issues and cases, together with philosophical work that might help us better understand and treat this illness. Drawing on philosophical critique of models of dementia, as well as empirical data and clinical experience, the book unifies the biological, psychological, and social accounts of illness and disease.
Highly original and thought provoking, this book will interest psychiatrists, philosophers, psychologists, and anyone involved in the care and management of those with dementia.

A widely adopted practitioner resource and course text, this book shows how to apply knowledge about behavior change in general -- and the stages-of-change model in particular -- to make substance abuse treatment more effective. The authors are leaders in the field who describe ways to tailor interventions for clients with varying levels of motivation or readiness to change. They draw on cutting-edge theory and research on the transtheoretical model to explain what works (and what doesn't work) at different stages of change. Rich clinical examples illustrate the "whats," "whys," and "how-tos" of using the stages-of-change model to inform treatment planning and intervention for individuals, groups, couples, and families. New to This Edition *Reflects the ongoing development of the stages-of-change model and research advances over the past decade. *Chapter on stage-based brief interventions in health care, social service, and community settings. *Group treatment chapter has been significantly revised. *Expanded coverage of the change processes relevant to each stage. See also Group Treatment for Substance Abuse, Second Edition, by Mary Marden Velasquez et al., a manual for a group-based approach grounded in the transtheoretical model.

Since the turn of the century, there has been worldwide growth in the effort to improve the quality of end of life care. Alongside these initiatives, growing interest in the international development of hospice and palliative care has created the need for an informed, in depth overview of the state of development in different world regions.
A follow-up to the successful Hospice and Palliative Care in Africa: a review of developments and challenges (Wright and Clark, OUP 2006), this book provides a detailed evidence-base of the palliative care provision in Malaysia, Thailand, and the Philippines, identifies barriers to development and how these may be overcome. The book aims to stimulate a more informed debate around these issues, to improve policy-making among intergovernmental and governmental organisations on end of life care in these regions, and to encourage further research and improved practice.
Hospice and Palliative Care in Southeast Asia: a review of developments and challenges in Malaysia, Thailand, and the Philippines includes in-depth country reports that analyse the current state of hospice and palliative care. The book is written using a template that allows effective comparison between countries and regions. Data has been gathered from multiple sources, field visits, and interviews with key activists made possible by close working relations with hospice-palliative care colleagues across the region and in particular through links with the Asia Pacific Hospice Palliative Care Network (APHN) and the national associations of each country. This book will be of relevance to anyone interested in international palliative care, including practitioners, researchers, policy-makers, social scientist, and medical historians.

Continuous sedation until death (sometimes referred to as terminal sedation or palliative sedation) is an increasingly common practice in end-of-life care. However, it raises numerous medical, ethical, emotional and legal concerns, such as the reducing or removing of consciousness (and thus potentially causing 'subjective death'), the withholding of artificial nutrition and hydration, the proportionality of the sedation to the symptoms, its adequacy in actually relieving symptoms rather than simply giving onlookers the impression that the patient is undergoing a painless 'natural' death, and the perception that it may be functionally equivalent to euthanasia. This book brings together contributions from clinicians, ethicists, lawyers and social scientists, and discusses guidelines as well as clinical, emotional and legal aspects of the practice. The chapters shine a critical spotlight on areas of concern and on the validity of the justifications given for the practice, including in particular the doctrine of double effect.

Hospital palliative care teams have been established in rapidly increasing numbers over the last 20 years, as it has been recognized that hospices can never transfer the philosophy and practice of palliative care into the acute sector by simply existing; the often work as 'stand alone units' and remain outside mainstream medicine. However, it has become apparent that improving access to palliative care for patients in acute hospitals is not as easy as employing external palliative care specialists as consultants. Even setting up a team of professionals who work solely in a hospital will often not improve the care of the great majority of patients being treated there.
Based on the extensive experiences and knowledge of three clinicians in the area who have developed palliative care services in acute settings, this book provides those facing the same challenges with practical guidance and down to earth advice on a range of problems they might encounter. Using a problem focused and practical approach, Palliative Care in the Acute Hospital Setting: A Practical Guide is filled with case-based problems to help readers identify realistic, usable, everyday solutions. It also covers the skills and knowledge needed to help teams make progress in the hospital as well as outlining the best training to help them continue to flourish.
Written in an accessible style with short and focused chapters, this clearly laid out book helps readers find the information they need to tackle particular problems easily and with confidence. With a supportive outlook and covering the non-clinical management aspects of palliative care, this book is the ideal guide for palliative care specialists making the transfer from hospice to hospital, and for those setting up palliative care teams in the acute hospital setting.

Having a serious illness can be incredibly difficult, especially when there is no cure. As your disease progresses, not only your physical health, but your entire well-being may be affected. Unfortunately, most of your medical care may only treat your body. However, there are things that you and your health care team can do to help you feel better as a whole person.
This collaborative, skill-based program will teach you practical techniques to help you cope with your illness and the stress of everyday life. You will learn strategies to improve your mood and deal with feelings of anxiety, depression, or anger. Social support is key to successful coping and you may need to strengthen your relationships, especially with caregivers. It is also important to work with your medical team and develop more effective ways to manage your symptoms. You will set goals regarding your care as well as your quality of life. In addition, you may choose to explore your spirituality and practice tools that promote personal growth.
Your facilitator will work with you to tailor the program to your individual needs. This workbook includes user-friendly forms to help you apply the content of the sessions to your personal situation. At the end of this program, you will have a new set of hands-on skills to master as you continue to grow.

Effective palliative care that rests on a sound ethical foundation requires ongoing discussions about patient and family values and preferences. This is especially important when addressing care at end-of-life including artificial nutrition and hydration, withdrawal of life-sustaining therapies and palliative sedation as well as requests for assistance in hastening death. The eighth volume in the HPNA Palliative Nursing Manuals series, Legal and Ethical Aspects of Palliative Care, provides an overview of critical communication skills and formal organizational mechanisms, such as ethics committees and interdisciplinary rounds, required for decisions in ethical dilemmas which respect diversity in the views of colleagues, as well as patients. The content of the concise, clinically focused volumes in the HPNA Palliative Nursing Manuals series is one resource for nurses preparing for specialty certification exams and provides a quick-reference in daily practice.

The first book of its kind, Resilience and Palliative Care - Achievement in adversity takes the increasing international literature on resilience and applies it to palliative and end-of-life care. The book offers an overview of all key aspects of palliative care, presented through a resilience perspective. Why do some patients and families break down while others surmounts the challenges facing them? What interventions strengthen individual, family and community coping? This book aims to facilitate change with people facing the crisis of death, dying and bereavement. Much of the existing literature has focused on risk, problems and vulnerability; the emerging concept of resilience focuses on strengths and possibilities. The 'total pain'/'total care' approach pioneered by Dame Cicely Saunders and St Christopher's Hospice now needs reinterpreting in the light of changing contexts and challenges. The realities of demographic change and resource-constrained health and social care environments have generated an increasingly risk focused approach to service delivery. A narrowly medicalised approach has inevitable limitations; professional care alone will be unable to meet need and demand in the face of ageing populations, changing patterns of illness and the need for equity. The resilience approach offers a counterbalance that harnesses the strengths of individuals and the communities in which they live and in which most of their dying will take place. Resilience thinking emphasises the importance of public health and creates a partnership between patients, professionals and community structures, seeking to build community capacity and to deliver a preventive health care that will leave future generations less afraid of the dying and bereavement that will confront all of us. This book offers insights into how, at all levels of planning and delivering palliative care, there is the opportunity to maximise coping, build an infrastructure for self-help, and increase the capacity of strengthened teams and organisations.

Health care professionals seeking to improve the quality of life for those living with serious illness and nearing the end of life will find exactly what their organization needs in the second edition of this acclaimed book by Dr. Joanne Lynn and her colleagues. Improving Care for the End of Life provides expert guidance on how to make significant improvements now, at all levels of the health care system from the bedside and the hospital to the health care policy and legislative arenas by using the rapid-cycle breakthrough approach to change. The ideas are proven, and the stories of teams that have put them to use will inspire and enlighten. New to the second edition: BL New chapters to address issues of growing interest such as continuity of care, and the special needs of dementia patients and their loved ones BL Details on trajectories of care and how these affect decisions at the end of life BL Updated and expanded information on pain management, advance care planning, ventilator withdrawal, depression and delirium, advanced heart and lung disease, and more BL Scores of new insights, measurement approaches, and tips based on the experiences of hundreds of improvement teams nationwide BL Thoroughly updated references The sourcebook speaks to all managers of health care systems serving people with serious illnesses, including doctors in offices, nurse managers on hospital units, social workers in long-term care facilities, administrators of home care and hospice agencies, hospital chaplains, directors of volunteer services, and others.

A practical, empowering guide to navigating your partner's diagnosis of a terminal or life-limiting illness, or death. Receiving the news that your partner has a terminal or life-limiting illness, or has died unexpectedly, is among the worst experiences in life. At a time when you are least able to cope, you are faced with a multitude of difficult decisions, some of which must be made quickly. What you need is a friend who has experienced everything you are about to face, who can support you as you navigate some tough, important choices. This book is that friend. There is plenty of information out there but where to start looking? What information is needed and how can it be accessed? What decisions are essential in the immediate term and what can be left until later? Throughout the book, the emphasis is on protecting and supporting those left behind by presenting almost every choice you may need to make and the possible implications of each decision. You will learn: - The importance of creating a will, arranging power of attorney, organising advanced decisions of treatment, and even getting married or entering a civil partnership - What you are entitled to from the state, the NHS and your employer - How to stabilise your finances and prepare to run a household alone - Where your partner ought to be during treatment and/or palliative care, and how to go about achieving this - Which decisions need to be made after death, from planning the funeral to accessing your partner's estate - How to navigate the grieving process and take control of a happy future No matter where you are in the process, How to Survive Losing a Loved One is a comprehensive, practical and empowering guide to coping with your partner's terminal illness and death, and building the next chapter in your life.

Despite the fact that most palliative care educators are involved in teaching, there is little literature devoted to education specifically within palliative care. This book bridges that gap, giving a wide-ranging, global view of palliative care education. It offers theoretical and practical insights, along with specific suggestions for developing knowledge and skills for teaching. It also contains extensive accounts of important contextual matters which influence the range and quality of palliative care education, including: interprofessional learning; continuing professional development; evaluation; and educational leadership. The development of palliative care as a clinical speciality is increasingly conducted at an international level, and a special feature of this book is the inclusion of chapters reviewing palliative care education in each continent. This enables practitioners and teachers to share knowledge across diverse healthcare systems and cultures. There is also an acknowledgement of the multi-professional team involved in palliative care, as education and training are looked at from the perspectives of doctors, nurses, and allied health professionals. The book is split into three distinct parts: Part 1 - sets the scene for existing palliative care education, both in the UK and internationally. Part 2 - focuses on the theory underpinning each aspect of teaching, learning and assessment, and then examines the practicalities of delivering these in the clinical setting. Part 3 - explores ways of building and nurturing a culture of learning in palliative care, whether as an individual or as an organization.

The idea of a philosophy of palliative care emerged with Cicely Saunders' vision for 'a good death', and was developed further with the WHO definition of palliative care. It is now being applied not only to cancer patients, but to all patients in end of life situations. As this 'palliative care approach' advances, it is important to pause and comment on its effectiveness. It is a philosophy of patient care, and is therefore open to critique and evaluation. Using the Oxford Textbook of Palliative Medicine, 3rd edition as their basic reference, Randall and Downie present their argument that the palliative care approach has become too busy and over-professionalised, and that it therefore has significant weaknesses. They examine the framework of the specialty - quality of life, autonomy, dignity, patient-centredness, and the priority assigned to relatives in the remit of care - and the moral problems associated with implementing such a philosophy. The resource implications of various health care policies are also discussed in relation to the WHO definition. Whilst the authors defend the achievements of palliative care and those who work in the profession, they present suggestions for an alternative philosophy. Their philosophy prompts many ethical and philosophical questions about the future of palliative care.

All long-term illnesses, whatever their diagnosis, have much in common. The difficulties and challenges that come with illness, and the strategies to overcome them, are shared by most patients. Managing an illness effectively and tackling the difficulties it causes can greatly improve how you feel and your quality of life. This book identifies the challenges posed by illness and suggests a wide variety of ways in which you might meet them. Key to this is the idea of becoming expert in managing your own illness and learning how best to deal with it. The authors accept that you know more than them about how you experience it, so that rather than telling you what to do, they offer a tool box from which you may pick the strategies that best suit you. The two authors, one a person with a long-term illness and one a doctor, combine their expertise and experience to offer a practical and comprehensive guide along your own unique journey. If you have a long-term illness, or if you care for someone who does, then this is a book for you.

Over recent decades, tremendous advances in the prevention, medical treatment, and quality of life issues in children and adolescents surviving cancer have spawned a host of research on pediatric psychosocial oncology. This important volume fulfills the clear need for an up-to-date, comprehensive handbook for practitioners that delineates the most recent research in the field--the first of its kind in over a decade. Over 60 renowned authors have been assembled to provide a thorough presentation of the state-of-the art research and literature, with topics including:
-Neuropsychological effects of chemotherapy and radiation therapy
-Bone marrow transplantation
-Important issues about quality of life during and following treatment
-Collaborative research among child-focused psychologists
-Standards of psychological care for children and adolescents
-Stress and coping in the pediatric cancer experience
-The role of family and peer relationships
The Comprehensive Handbook of Childhood Cancer and Sickle Cell Disease represents both multidisciplinary and international efforts, an alliance between physicians and parents, and a combination of research and service. With a wealth of information of great interest to patients and their families, this volume will also be a welcome resource to the psychologists, psychiatrists, pediatricians, oncologists, nurses, and social workers who confront these issues as they help children and their families through the treatment, recovery, and grieving processes.

Cicely Saunders is universally acclaimed as a pioneer of modern hospice care. Trained initially in nursing and social work, she qualified in medicine in 1958 and subsequently dedicated the whole of her professional life to improving the care of the dying and bereaved people. Founding St. Christopher's Hospice in London in 1967, she encouraged a radical new approach to end of life care combining attention to physical, social, emotional and spiritual problems, brilliantly captured in her concept of "total pain." Her ideas about clinical care, education and research have been hugely influential, leading to numerous prizes and awards in recognition of her humanitarian achievements. This book includes a selection of Cicely Saunders' most important writings throughout a period of over forty years.
Full articles, chapters, editiorials, reviews, and commentaries include important clinical themes relating to the care of dying people such as pain and symptom management, issues of communication and truth telling, and the needs of particular patient groups, such as those with cancer and other diseases. The book includes pieces that reflect on the wider development of the palliative care field and on policy and organizational issues. Some of the papers take up the theme of spiritual care at the end of life, as well as the question of euthanasia, raising in turn issues of a wider theological and philosophical nature.
The articles are written for a multi-disciplinary audience and will be of enormous interest to many professionals now working in palliative care. The collection will become a key work of reference for those interested in the evolution of hospice and palliative care and will serveas an important sourcebook of many currently hard to obtain publications by the acknowledged founder of the modern hospice movement. This book will also stand as a remarkable testimony to the personal contribution of Cicely Saunders and the influence she has had upon the modern field of palliative and end of life care.

This is the fourth volume in a new international, multi-contributed series aimed at providing practical, clinical guidance on how to deal with difficult symptoms related to specific cancer sites. In this volume the Editors bring together first-rate palliative care with oncological treatment for patients with advanced breast cancer. The book is presented in a user-friendly handbook format, with use of tables and algorithms to ensure that it is portable, accessible and can be read and referred to on, or before going to, the ward, or before a domiciliary visit. Specialists in palliative care and oncology settings, working in the acute sector and in hospices, will find the book invaluable. It will also appeal to consultants as well as specialist registrars, clinical nurse specialists and nurse practitioners in palliative care and oncology. The Palliative Care Consultations series is primarily aimed at those individuals working in an acute hospital cancer centre and/or tertiary referral centre. Books are designed to give the busy clinician advice on clinical problems, both those rarely encountered and those that are very common, but difficult. The volumes are site specific and each volume encompasses a review of the current oncological or haemato-oncological management of advanced disease with symptom control advice. These volumes will give clinicians excellent advice on symptom control in the context of palliative care. The books will also be of use and interest to other professions working in acute hospitals.

Since the publication of the first edition of "The Medical Care of Terminally Ill Patients," the field of palliative care has progressed significantly, both socially and scientifically. In this new edition, Dr. Robert Enck reviews the results of clinical studies devoted to the care of dying patients. Special attention is given to pain management, management of symptoms, care of advanced cancer patients, and care of patients with nonmalignant diseases. More than 100 new references, a new list of abbreviations, and tables with new drugs and dosages provides valuable information.

Dr. Enck places great emphasis on enhancing the quality of life while addressing the most common symptoms of terminal illness.

In most patients, pain medication, along with physical therapy and supportive counselling, adequately controls the pain of terminal disease, but in some cases pain medication fails or produces unacceptable side effects, and other more invasive interventions may be used. This practical book provides comprehensive and easy-to-follow guidelines on nerve blocking and neuromodulation techniques to help patients and professionals make choices in pain management. Patients selection and appropriate referral are discussed as well as ethical issues and consent. This book will be an invaluable source of information for a variety of professionals working with patients with advanced disease, including palliative care doctors and specialist nurses, as there is a scarcity of consultants in pain management in the field of palliative care. Some healthcare professionals may not have experience of the full range of techniques that may benefit their patients, therefore limiting the choices available to patients with uncontrolled pain in the context of palliative care. This book will ensure that the full range of techniques are considered to provide excellent care for patients with pain that is difficult to manage.

This book offers healthcare professionals, academics and anyone affected by cancer a fresh and original approach to the supportive care of people with cancer. It looks at the underlying reasons why cancer so often leads to high levels of distress and, more importantly, it suggests many practical ways distress can be minimised and prevented. The actual experiences of cancer patients, as recorded in their personal diaries, are combined with theory, research and practical clinical advice. In each of its seven chapters Cancer in Context takes a different perspective towards supportive care in cancer. It begins by considering how people in general manage and adjust to massive changes in their lives and, in particular, how they react to the threat of cancer. It goes on to examine the "lived experience" of people with cancer as they negotiate the many changes and challenges that follow their diagnosis. Of course cancer doesn't only affect the person who has the disease, it also impacts on families, partners and carers. One chapter explores these and other issues, such as sexual difficulties, the needs of older people, single people, and gay and lesbian couples. Chapter 4 shows that the social and cultural context of a person's life is critical to understanding their resources, the way the are treated, and the responses the make to serious illness. However, it is in the clinical context that professionals have an opportunity to minimise disruption to their patients' quality of life as they endure the notorious demands of oncology treatments. The book offers practical clinical advice on psychosocial aspects of conventional cancer treatments, common treatment difficulties, cancer rehabilitation and palliative care. Chapter 6 provides a summary of the burgeoning area of information and communication skills within healthcare and, finally, the book ends by considering how doctors, nurses, radiographers and other healthcare professionals can maintain their supportive care in light of such high levels of stress and burnout among these staff groups.

This is the third book in a new international, multi-contributed series aimed at providing practical, clinical guidance on how to deal with difficult symptoms related to specific cancer sites. There are few more distressing problems for patients and families than the development of a primary or secondary brain tumor. Treatment is often palliative, though intensive, from the start. Little firm evidence exists to guide the physician in caring for patients with seizures refractory to standard treatment. Most of the work is based on case reports or personal experience. This book draws the information together in an easily accessible form so that the book can be read and referred to on the ward, or before a domiciliary visit.
Specialists in palliative care and oncology settings, working in the acute sector and in hospices, will find this book invaluable. It will also appeal to consultants as well as specialist registrars, clinical nurse specialists and nurse practitioners in palliative care, oncology and neurology.

Patients with degenerative neurological disorders are among the most handicapped patients in medicine. Many of these diseases are incurable. Expert palliative care is the duty of every neurologist: however, to date, this has not been a standard feature of neurological practice or training. This book helps define a new field, namely palliative care in neurology. It brings together all necessary information for neurologists caring for a patient with advance disease. Palliative care is an approach to the management of patients with life-threatening illness that attempts to enhance comfort, relieve psychosocial and spiritual distress, assure respect for decision making, provide support for the family, and prepare the patient and family for the end of life. This unique book covers each of the many dimensions of palliative care as they relate to patients with advanced neurological disorders. Basic principles of palliative care and specific ethical issues (such as euthanasia, food and hydration and advance directives) are covered. The needs of populations with specific neurological disorders are described and the management of symptoms that are common to all is explored in detail. Each chapter introduces its topic using a case report which may be used directly for teaching purposes. The authors have put together an invaluable resource, which lays the foundation for further research in the field.

This is the second book in a new international, multi-contributed series aimed at providing practical, clinical guidance on how to deal with difficult symptoms related to specific cancer sites. In gynaecology there are a number of symptoms which cause great distress to the individual and their families, and perplexity to the physicians and nurses caring for them. This volume covers the management of incurable disease for each of the most common cancers followed by a review of the most difficult symptoms that are encountered in this tumor group. Contributors provide scientific background to symptom-control chapters, with an indication of the sources and evidence for their advice.
Specialists in palliative care and oncology setings, working in the acute sector and in hospices, will find this book invaluable. It will also appeal to consultants as well as specialist registrars, clinical nurse specialists and nurse practitioners in palliative care, oncology and gynaecology.