Several medical options in palliative care can have complex moral, religious, cultural, medical and legal issues. These treatment options, such as assisted suicide, rehydration, parenteral nutrition and cardiopulmonary resuscitation have been heavily debated in the literature. Physician-assisted suicide is a controversial topic for debate, with growing pressure from advocacy groups for legalisation in regions that have yet to decide. Currently, there is substantial opposition from concerned medical professionals. However, a school of medical professionals acknowledges that physician-assisted suicide may have a role in terminal care. The debate over the use of artificial nutrition and hydration (ANH) in terminal illness is also contentious despite extensive ethical and empirical research. Advocates for and against ANH both agree that the most compassionate and humane option for patients near the end of life is hospice and/or palliative care. However, many of those who support ANH do not seem to appreciate that the standard palliative practice is to avoid the use of ANH in almost all instances. These topics remain heavily disputed in the medical community. In formulating a satisfactory answer, we need to remind ourselves that we cannot generalise a treatment as a correct or incorrect option. Rather, we need to consider each case individually, weigh the risks and benefits of each treatment, and individually consider treatment options in a multidisciplinary care model.

In early stages of cancer, patients are often presented with treatment options and encouraged to have shared treatment decisions with their oncologists. Shared decision making becomes particularly important, as several treatment options with different possible outcomes and adverse events exist. For example, women with early breast cancer are counseled on the options of mastectomy versus lumpectomy and radiation. The same principle should also apply in late stages of cancer, where cure is usually not possible in patients with widespread metastases. In these cases, the aim of treatment should be to relieve symptoms and suffering. Improving quality of life (QOL) rather than tumor control takes priority in palliative care. QOL has also been identified as an important endpoint for new cancer drugs, as determined by the Food and Drug Administration (FDA); as such, cancer drug approval can be based on improvement of QOL. The use of patient-reported QOL instrument tools help clinicians determine if certain treatments improve QOL. The research of palliative interventions should have QOL assessment to assist clinicians, patients and their family members in shared decision making.

Many cancer patients experience a variety of distressing symptoms, adversely affecting their functional status and quality of life (QOL). Subjective symptoms such as pain, fatigue and depression are common among cancer patients, with approximately 33-55% of cancer patients experiencing pain during the course of their illness. Previous literature commonly examined a single symptom and its effect on patients' functional status and QOL, but patients often experience multiple symptoms simultaneously. Since individual symptoms are often associated with decreased QOL, the assumption that symptom clusters might have a greater effect on QOL is logical. The coexistence of symptoms provides an insight into the importance of assessing clusters of symptoms rather than focusing on individual symptoms. Although the focus of single symptoms has advanced the understanding of those particular symptoms, it may not be as helpful to health care professionals in guiding practice when patients present several concurrent symptoms. It is important for clinicians to address and ultimately treat all concurrent symptoms. Symptom cluster research will help our understanding and treatment of multiple symptoms.

In Canada over the past fifteen years, there has been a 39% rise in new cancer patients, necessitating the expansion of current oncological facilities. The population is getting older and larger, which in turn is translating into more cases of cancer. Other reports projecting cancer growth across different countries found similar results. With the prevalence of cancer expected to increase in the future, it is important to properly allocate resources towards cancer research to better serve the population. Patients with cancer continue to live longer; as such, more elderly individuals will live with cancer. In fact, cancer has been classified as a chronic illness alongside diabetes, hypertension, and heart disease. This may translate to an increased demand for oncologists, specialist-trained nurses, diagnostic services, cancer centres, cancer therapies and palliative care. More importantly, this will translate to an increased necessity for cancer research to decrease the mortality and morbidity associated with cancer while improving the quality of care.

With effective systemic therapy and comprehensive supportive care, patients with metastases can live longer. Breast cancer patients with only or predominantly bone metastases have a median survival of 2.3 years following diagnosis, while metastatic prostate cancer patients have a median survival time of 11.3 months. With recent advances in research, the overall survivorship of metastatic patients has increased. The improved quality of care for metastatic cancer patients has resulted in longer survivorship. Living longer can lead to a higher chance of development for skeletal-related events (SREs), which are defined as either spinal cord compression, hypercalcemia, pathological fractures or a need for palliative radiation therapy or surgery for bone pain. To try to reduce pathological fractures, it is important to detect impending fractures earlier and to administer prophylactic surgery as needed. Longer survivorship also allows time for the development of brain metastases. Recent advances incorporating stereotactic radiosurgery (SRS) have been favored over conventional whole-brain radiation therapy (WBRT) in the preservation of neurocognitive functions and survival benefit in patients less than 50 years of age. Multidisciplinary clinics for brain metastases are again desirable with the joint input of the radiation oncologists and neurosurgeons.

Bone metastases are a common event for cancer patients. We have developed an innovative and unique clinical research program dedicated to palliative radiation oncology at the Odette Cancer Centre, Sunnybrook Health Sciences Centre and specifically a multidisciplinary clinic for bone metastases. The development of this program introduces an effective strategy to conduct research in palliative radiation oncology. Symptom control is very important for the quality of life for bone and brain metastases patients. This is an evolving active field of research as greater emphasis is being placed into understanding the goals of improving not only a patient's survival, but the ability for therapies to improve the quality of a patient's life. In this book we present the EORTC QLQ-C30 questionnaire, which was used in a multi-center study with patients recruited from Edmonton, Alberta, Canada; Kaohsiung, Taiwan; Kerala, India; Nicosia, Cyprus; Sao Paulo, Brazil; Taipei, Taiwan; Tanta, Egypt; and Toronto, Ontario, Canada, with brain and bone metastases. It was found that the difficulties bone and brain metastases patients experience are different in several ways. Patients with bone metastases have more pain and reduced physical functioning. However, patients with brain metastases have more severe role functioning deficits. With use of the QLQ-C30, it was also found that there is ambiguity regarding the root of patient issues. Future studies that require more comprehensive disease-specific findings should include disease-specific assessment modules such as the QLQ-BM22 and QLQ-BN20. Important domains such as the minimal clinically important difference should also be established in individual subgroups of patients to assist in clinical trial design.