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This issue goes to press as the first test-match gets underway and perhaps we are beginning to think of summer holidays! We are pleased to introduce a real miscellany of articles. Ethical matters are never far from the minds of those practising Palliative Medicine. The review from Drs Wasson and Cook provides a useful and timely framework which may help us to dissect the clinical dilemmas that face us every day. The article also makes mention of the now infamous case against Dr Shipman, a Manchester based GP who was convicted of murdering several of his patients.

This case has highlighted several issues of relevance for those in Palliative Medicine. Firstly, the question about appropriate doses of opioid for those with terminal illness. How often are morphine doses escalated above that really necessary in the final hours of a patients life, and how often do we attempt to reduce the dose once adequate pain control has been achieved? Secondly, this was the worst of a number of medical misdemeanours which have been richly and adversely scrutinised by the media and which have generally put the medical profession in a bad light. One article in a popular medical rag commented (or was it quoted?) that not all doctors sought to kill their patients which by implication suggests that the author thought that some did! Thirdly, what level of supervision and support is there for those who work single-handed? Who recognises when the doctor is under stress or frankly ill? Our speciality has quite a track record of psychological morbidity (acknowledged and otherwise) and do we really have access to help which is effective, non-judgemental and easy to reach. I think not.

The editor has certainly seen a number of cases (one very recently) where increasing doses of morphine have been given to relieve pain and distress in dying patients but which have failed to achieve the desired outcome. Indeed in some cases increasing morphine can cause worsening agitation particularly when renal function is compromised or if the pain is unresponsive to this drug. It needs to be remembered that pain and confusion can result from a full bladder, constipation or simply from lying in the same position for hours on end. These cases seem to occur on the “general wards” of the hospital with monotonous regularity and there are several common threads including inexperience, understaffing, absence of training, lack of awareness and inappropriate prescribing. There is often a failure to recognise when a patient is dying and, perhaps because of this, the dying patient sadly assumes a low priority against the emergency admission or the need for therapeutic intervention and monitoring. Was this not the original case put forward for the development of hospices? While I am the very last to advocate the transfer of patients in the last hours of life from their usual locus of care, it is very hard to reconcile the concept of a modern multi-speciality acute hospital with good terminal care. Perhaps these are matters that clinical governance might seek to address and which will help to establish our speciality in the acute sector.

In this issue we also focus on lymphoedema and have an article on multiple sclerosis. Karen Simpson and Lynne Rousson review their experience of intrathecal drug delivery and in addition we have an oncological perspective on the management of cervical cancer. What really interests me is the range of tools needed to assess morbidity in the treatment of cancer and the whole issue of measurements purported to assess “quality of life”(QoL). It now seems impossible to design any trial of palliative chemotherapy without some sort of QoL measure but do these really give any useful information and what happens once the study has ended? We will be looking for articles to cover this important aspect of cancer care in the future. For now I can only comment from my own experience on patients given “palliative” chemotherapy. Some patients achieve spectacularly good responses (even a “complete response”). Symptoms disappear and there is a return of well being. QoL (as measured) is good and the study ends. Unfortunately they inevitably relapse. The entire process of breaking the bad news is repeated but this time there is a high expectation that the oncologist will pull another rabbit out of the hat. Even though they may have been told that the original treatment was only “buying time” they probably didnt hear it. Second-line or even experimental treatment is offered. The patient is weakening, committed to hospital, suffers adverse effects, and dies. Symptoms during this terminal phase are often difficult to control. What would the QoL scores have told us had they been measured at this time and what influence would they have had on earlier decisions to undertake treatment? Perhaps what is needed are measures of quality of death (QoD) a challenge to us all QED!