Palliative medicine

Nature of the work

Care of dying patients and those close to them is central to this specialty. Doctors in palliative medicine also provide supportive care at earlier stages in an illness, alongside active treatments and interventions.

While most medical professionals have responsibility for good palliative and end of life care, palliative medicine physicians provide support, guidance and expertise to other teams particularly in complex situations.  They have an important role in the education of other professionals and for ensuring high standards of care in the organisations for which they work.

They encounter a range of diagnoses, although most referrals will be for patients with progressing or advanced cancer. An increasing proportion  have other progressing or end stage conditions including heart failure, renal failure, advanced chronic obstructive pulmonary disease (COPD) and neurological conditions.

An in depth knowledge of the pathology and management of these conditions is essential and forms part of the curriculum in specialist training. Some doctors will develop a sub-specialty interest depending on their post and location. In general, palliative care for patients younger than 18 years is provided through paediatric palliative care specialists.

In some care settings, such as specialist inpatient units in hospitals or hospices, the palliative care physician is responsible for the medical management of the patient. However in the community and most hospital settings, the role is one of working alongside different teams and professionals with the GP or another specialist being directly responsible for the care.

They offer care that:

• strives to achieve the best quality of life for the patient for as long as possible
• involves managing and anticipating pain and other symptoms
• addresses the psychological, social and spiritual needs of the patient
• facilitates multi-professional support in order to provide joined-up care across care boundaries, enabling care at home and fewer avoidable admissions towards the end of life
• supports anticipatory planning with patients and professionals including advance planning in the last year of life
• supports end of life care that meets the needs and wishes of the individual and family
• supports the family and significant others during the patient’s illness and their bereavement

Common procedures/interventions

The tools of the specialty are communication, clinical assessment, decision-making and in depth knowledge of pharmacology.

Some physicians will undertake paracentesis [2] (drawing off fluid form a natural cavity of the body) in hospice or home settings under guidance of portable ultrasound [3] (very high frequency sound waves). They will be familiar with specialist pain techniques including management of epidural [4] infusions (a local anaesthetic procedure for blocking pain) but this would be in conjunction with a pain specialist.

Where do doctors in palliative care work?

Consultants often work across hospice, community and hospital settings but would be based in one of these. There are posts exclusively based in a hospital, working with the multi-professional palliative care team across all wards and clinics which may include seeing patients on medical assessment units or with the acute oncology [5] team that manages malignant diseases.

Posts based in a hospice usually include sessions for home visits and/or at the local acute trust. Outpatient clinics may be provided in hospital or hospice settings. Others may be based primarily with a community palliative care team. Trainees will rotate across all of these to gain different experience. Non-training posts are more likely to be located in one setting, such as a hospice.

In any setting, the role includes provision of palliative care advice to other professionals often by telephone.

Want to learn more?

Find out more about:

• the working life [6]of someone in palliative medicine
• the entry requirements [7]and training and development [8]

• Pay and conditions

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  This section provides useful information about the pay for junior doctors (doctors in training), specialty doctors, consultants and general practitioners.

  Find out more about the current pay scales for doctors [9] and there's more information on the BMA website [10].

  NHS Employers [11] provides useful advice and guidance on all NHS pay, contracts terms and conditions.

  Medical staff working in private sector hospitals, the armed services or abroad will be paid on different scales.

• Where the role can lead

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  This specialty provides limited opportunities to work in academic medicine (though usually with some clinical input).

  Talking to consultants in the specialty and gaining experience in hospital, community and hospice settings during specialist training will help you decide whether you want to work in a hospital, in the community, in hospices or other specialist palliative care units; however as explained many roles have a foot in at least two settings.

  Working in palliative medicine offers opportunities for consultants to become involved in strategy for improving and developing palliative and end of life care services at a local level and at a national level.

• Job market and vacancies

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  This section provides useful information about the availability of jobs, finding vacancies and where to find out more.

  Job market information

  Palliative medicine had 298 consultants and 181 specialty registrars in England (NHS Digital, 2016 [12]). Women make up 73% of the consultant workforce, and  88% of the higher speciality trainees in the UK (2014/15 RCP census, 2016 [13]). Across the UK, almost as many consultants are employed by the charitable sector as by the NHS. (Across all specialties, fewer than 4% of posts are funded by the voluntary sector).

  At present there remains a shortfall in the required consultant numbers; as a specialty there has been no expansion in the last year but the number of  training posts has not been reduced.About 40 trainees complete CCT [14] training each year.

  A survey of members of the Association of Palliative Medicine in 2011-12 showed that 6.4% of consultants, SAS doctors and registrars were from ethnic minority backgrounds, 78.1% from white backgrounds and 15.5% unknown.

  In 2016 competition ratio [15] for Core Medical Training [16] (CT1), the first stage in the training (post-foundation), was 1.53 and for ST3 Palliative medicine it was 3.15 (NHS Specialty Training, 2016 [17]).

  For information regarding Scotland, Wales and Northern Ireland please click on the links below.

  NHS Scotland medical and dental workforce data [18]

  NHS Wales medical and dental workforce data [19]

  Department of Health, Social Services and Public Safety workforce information for Northern Ireland [20]

  Where to look for vacancies

  All trainees apply through the online application system Oriel [21]. You will be able to register for training, view all vacancies, apply, book interviews and assessment centres, and manage offers made to you.

  HEE offices and deaneries will have details of training vacancies. Not all areas of the UK will offer new training posts in all specialties in all years.

  All jobs will be advertised on the NHS Jobs website [22].

  The BMJ Careers website [23]also advertises vacancies.

  Vacancies are also advertised on charitable sector websites such as Charity Jobs  [24]and the websites of charities working in palliative care (eg Sue Ryder [25] and Marie Curie [26]).

• Further information

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  Organisations

  Royal College of Physicians [27]

  Royal College of Physicians of Edinburgh [28]

  Royal College of Physicians and Surgeons of Glasgow [29]

  The Association for Palliative Medicine of Great Britain and Ireland [30]

  The National Council for Palliative Care (NCPC) [31]

  Real-life stories

  A palliative medicine consultant (BMJ) [32]

  Dr Richard Berman, consultant in palliative medicine (RCP) [33]

  Dr Fiona Finlay – ST6, palliative medicine [34]