• The palliative care management of a person, whatever their underlying illness, should involve consideration of:
• Appropriate communication with the person, their family and/or carers, and other healthcare professionals.
• The person's prognosis and the implications in terms of investigation and treatment.
• The monitoring and management of both physical and psychological symptoms.
• The person's social and spiritual needs.
• The needs of the person's family and/or carers.

• Health and social care professionals should have the skills to communicate effectively with the person, their carers, and each other. Those who must communicate particularly complex or distressing information should have enhanced skills, or be supported by someone who has those skills.
• Peoples' preferences regarding involvement in making decisions about their own care should be assessed on an ongoing basis.
• Peoples' and carers' needs and preferences for information should be assessed on an ongoing basis, and the provision of materials tailored accordingly.
• Suitably trained and skilled interpreters should be available for people who may otherwise find it difficult to communicate in their preferred language.
• The Gold Standards Framework also includes advance care planning and has developed an advance statement of wishes template to support discussion and recording of a person's preference for place of care. For more information, see www.goldstandardsframework.nhs.uk.

• The person should be offered the opportunity to discuss topics which are important to them at that time, for example:
• Treatment options and preferences.
• Disease status, progression and estimated prognosis.
• Social implications (e.g. work, income).
• Issues relating to those important to the person (e.g. partner, family).
• Spiritual and religious issues.
• Advance care planning issues, including preferences, hopes, and wishes (e.g. preferred place of care and issues around dying, including cardiopulmonary resuscitation, and whether they have any expressed views about organ or tissue donation). If advance care plans are made, they need to be reviewed and updated as the person's situation or views change [GMC, 2010].
• The NHS End of Life Care Programme discusses advance care planning and documentation of the wishes of people with a life-limiting condition, including advance care plans, statements of wishes and preferences, and advance decisions. For more information, see www.endoflifecareforadults.nhs.uk/eolc [End of Life Care Programme, 2007].
• The Gold Standards Framework also includes advance care planning and has developed an advance statement of wishes template to support discussion and recording of a person's preference for place of care [Gold Standards Framework, 2006b]. For more information, see www.goldstandardsframework.nhs.uk.
• The General Medical Council's guidance for doctors, Treatment and care towards the end of life: good practice in decision making has more detailed information regarding issues of advance care planning, advance requests and refusals for treatment, recording and communicating decisions, and discussions about whether to attempt cardiopulmonary resuscitation [GMC, 2010].
• Information should be given verbally to the person and their family, but written materials may be useful for some.
• It is not recommended that children be asked to interpret for parents or other family members [NICE, 2004].
• A clinician may wish to offer a palliative care patient a written record of consultations they have had with them.
• Effective communication with other healthcare professionals is also very important. This enables professionals to:
• Exchange information.
• Plan interventions.
• Share responsibility for the person's care.
• Documentation, especially using multidisciplinary records and clinic letters, facilitates communication between professionals [Doyle et al, 2004].
• An example of a multidisciplinary record is the Liverpool Care Pathway which offers a framework for caring for people at the end of life. For further information, see www.mcpcil.org.uk/liverpool-care-pathway.

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence [NICE, 2004], expert opinion from palliative care literature in a textbook [Doyle et al, 2004], and General Medical Council guidance for doctors, Treatment and care towards the end of life: good practice in decision making [GMC, 2010].
• Most people wish to know their diagnosis and what is happening with their treatment and disease [Faulkner, 1998].
• Realistic hopes and aspirations can only be achieved by honest discussions [Doyle et al, 2004].
• Attempts to protect people from the reality of what is happening to them can lead to inconsistent messages being given by different members of the healthcare team [Doyle et al, 2004].
• Establishing and documenting a management plan in advance can help to ensure that a person's wishes and preferences about treatment can be taken into account, including a Do Not Attempt CPR (DNACPR) decision, if appropriate [GMC, 2010].

• The National Institute for Health and Clinical Excellence has outlined key components for best practice in community palliative care.
• People needing palliative care are identified according to agreed criteria, and a management plan is discussed within the multidisciplinary team.
• These people and their carers are regularly assessed using agreed assessment tools.
• Anticipated needs are noted, planned for, and addressed.
• Patient and carer needs are communicated within the team and to specialist colleagues, as appropriate.
• Interventions which may be considered or undertaken in an emergency, such as cardiopulmonary resuscitation (CPR), are discussed and noted in advance, where appropriate.
• Preferred place of care and place of death are discussed and noted, and measures taken to comply, where possible.
• Coordination of care is orchestrated by a named person in a practice team.
• Relevant information is passed to those providing out-of-hours care, and anticipated prescribed drugs are left in the home.
• A protocol for care in the dying phase is followed, such as the Liverpool Care Pathway for the Dying Patient or the Welsh Integrated Care Pathway for the last two days of life.
• Carers are educated, enabled, and supported, which includes the provision of specific information, financial advice, and bereavement care.
• Audit, reflective practice, development of practice protocols, and targeted learning are encouraged as part of personal, practice and provider organization development plans.
• The General Medical Council provides advice and information about these issues, and also what to do if:
• The person accepts or refuses a treatment option for a reason that may seem irrational to a doctor, or for no reason at all.
• The person lacks capacity to make a decision for themselves.
• There are disagreements about treatment and care between the person, doctors, carers and/or members of the healthcare team.

• This information is based on guidance from the National Institute for Health and Clinical Excellence [NICE, 2004] which incorporated information from the Gold Standards Framework, a nationwide programme aimed at optimizing palliative care at home [Thomas, 2003].
• The information on issues of refusing treatments, assessing capacity, and disagreements regarding treatment and care, are based on the General Medical Council's guidance for doctors, Treatment and care towards the end of life: good practice in decision making [GMC, 2010].

• Attempt to estimate the person's prognosis.
• Discuss this with the person if appropriate.

• The Prognostic Indicator Guidance (pdf) can be used to help assess prognosis. It is part of the Gold Standards Framework, which aims to optimize the care of people nearing the end of life who are looked after by primary care teams in the community. It includes the question 'Would you be surprised if this patient were to die in the next 6 to 12 months?' to try to identify people nearing the end of their lives [Gold Standards Framework, 2005a; Gold Standards Framework, 2006a].
• Risks associated with assessing the prognosis include:
• Overestimating the length of survival — families may feel 'robbed' of time with their relative.
• Underestimating the length of survival — the person and their family may question the credibility of the source of information.
• It is therefore important to emphasize that an estimate of the person's prognosis is not a guarantee of what will happen.

[Gold Standards Framework, 2005b]

• A discussion of prognosis should involve:
• Identifying the person's own thoughts regarding their prognosis.
• Explaining the difficulty of providing an accurate prognosis.
• Providing a rough estimate only (e.g. days, weeks, months, years).
• Some people may request not to know their prognosis. This should be respected and they should be given the opportunity to discuss it again at a later date.

• This recommendation is based on the Prognostic Indicator Guidance from the Gold Standards Framework, the development of which involved collaboration with the Royal College of Physicians, the Royal College of General Practitioners, GPs with a special interest in palliative care, and national disease associations [Gold Standards Framework, 2005a; Gold Standards Framework, 2005b; Gold Standards Framework, 2006a]. Expert opinion from textbook literature was also considered [Doyle et al, 2004]:
• Estimating the prognosis helps in the planning of appropriate treatment and care [Gold Standards Framework, 2006a].
• If prognosis is not discussed, or predictions are inaccurate, people may make inappropriate treatment decisions, or inadequately prepare for death [Doyle et al, 2004].
• Doctors may lack confidence when predicting how long someone might live, but if the discussion is avoided, people may be less likely to discuss their own fears and worries, resulting in increased anxiety [Doyle et al, 2004].

• It is essential to recognize the signs of dying in order to appropriately care for people at the end of life.
• People are likely to be in the terminal phase of their illness when they:
• Deteriorate day by day or faster because of their underlying condition.
• Express a realization that they are dying.
• Have reduced cognition, and are drowsy or comatose.
• Are bed-bound.
• Take little food or fluid, and have difficulty taking oral medication.
• Are peripherally cyanosed and cold.
• Have an altered breathing pattern.
• For further information, see the Prognostic Indicator Guidance (pdf), which is part of the Gold Standards Framework.

• The terminal phase starts a median of 23 hours before death and may last hours to several days [Morita et al, 1998].
• It is important to recognize the terminal phase so that appropriate management pathways, such as the Liverpool Care Pathway (which offers a framework for caring for people at the end of life), can be utilized. For further information, see www.mcpcil.org.uk/liverpool-care-pathway.

• This recommendation is based on expert opinion from palliative care resources that were developed from clinical experience [Regnard and Hockley, 2004].

• The terminal phase requires a careful discussion with the person, family, and carers regarding the following issues. This may involve discussing and weighing up the benefits, burdens and risks for the person:
• Stopping any unnecessary drug treatments and continuing other drug treatments by an appropriate route.
• Having commonly required medication available in the house (e.g. cyclizine, diamorphine, hyoscine hydrobromide, and midazolam), so that new or developing symptoms can be treated without delay.
• Control of physical symptoms.
• Realistic goals (e.g. in terms of treatment and resuscitation issues).
• Religious and spiritual care.
• Providing an appropriate environment (e.g. one which is comfortable and has an appropriate level of noise and activity for the person).
• If the person is likely to require care out of normal surgery hours, ensure that the local on-call service has been informed and given an effective handover.
• Provide emergency contact numbers and information on what to do when death occurs.

• The Liverpool Care Pathway for the Dying Patient provides a national framework caring for people in the terminal phase. It integrates professional communication and documentation, putting national guidelines into clinical practice. For more information, see www.mcpcil.org.uk/liverpool-care-pathway.

• These recommendations are based on guidance from the National Institute for Health and Clinical Excellence [NICE, 2004], expert opinion from palliative care resources [Twycross and Wilcock, 2001; Regnard and Hockley, 2004], and the General Medical Council guidance for doctors, Treatment and care towards the end of life: good practice in decision making [GMC, 2010].

• Assessment of the person's needs for physical support should be repeated at key points during the course of the illness, including:
• At the time of diagnosis.
• Around treatment episodes.
• As treatments end.
• At the time of a relapse.
• When death is approaching.
• As symptoms are often multiple and interrelated, a systematic approach to assessment and management is necessary. The following is suggested:
• List symptoms, assess their severity, and prioritize them with the person.
• Diagnose the cause of symptoms as accurately as possible.
• Elicit the person's understanding of the diagnosis.
• Set goals for treatment with the person and their carers.
• Review and reassess changing symptoms regularly.
• Keep nutrition and hydration status under review.

• Enquire about symptoms, rather than waiting for the person to report them [Regnard and Tempest, 1998].
• Determine the impact of each symptom on the person's life by enquiring about time of onset, exacerbating factors, effects on everyday life (e.g. sleep disturbance).
• Even if cancer is the underlying cause, different mechanisms may be responsible for the symptom (e.g. vomiting from hypercalcaemia or gastric outflow obstruction).
• Bear in mind that all symptoms may be made worse by insomnia, exhaustion, anxiety, and depression.
• Keep drug treatment as straightforward as possible [Twycross and Wilcock, 2001]:
• Do not delay starting treatment, as symptoms become more difficult to manage the longer they are left untreated.
• If a symptom is persistent, regular prophylactic treatment is preferable to the use of drugs on an 'as required' basis.
• Achievable goals should be discussed and agreed with the person.
• Nutrition and hydration provided by tube or drip are regarded in law as medical treatments and should be treated in the same way as other medical interventions. They would usually be considered of overall benefit if the aim is to prolong life and/or provide symptom relief [GMC, 2010].
• Refer to a specialist if a problem occurs which is outside the expertise of the primary care team [Twycross and Wilcock, 2001].

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence [NICE, 2004], expert opinion from the literature based on clinical experience [Regnard and Tempest, 1998], and the General Medical Council guidance for doctors, Treatment and care towards the end of life: good practice in decision making [GMC, 2010].
• A qualitative study found that doctors tend to underestimate the severity of symptoms (e.g. dyspnoea), and this is associated with under-treatment of those symptoms [Roberts et al, 1993].

• Assessment of the psychological state of the patient should be repeated at key points during the course of the illness, including:
• At the time of diagnosis.
• Around treatment episodes.
• As treatments end.
• At the time of a relapse.
• When death is approaching.
• All staff directly responsible for patient care should offer general emotional support based on skilled communication, effective provision of information, courtesy, and respect.
• People and carers found to have significant levels of psychological distress should be offered prompt referral to services able to provide specialist psychological care.

• The appropriate psychological intervention will depend on the person's current psychological problem and previous history, as well as the level of support available and their prognosis:
• Psychological assessments and interventions should be undertaken somewhere that is quiet, comfortable, and private.
• Staff providing psychological care should be adequately trained and supervised, and mechanisms to ensure support for staff should be available.
• Emergency psychiatric services should be available for people with severe mental health problems.

[NICE, 2004]

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence [NICE, 2004].
• Around 50% of people with cancer experience anxiety and depression around the time of diagnosis which is significant enough to adversely affect their quality of life.
• In the year after diagnosis, 10% of people have symptoms that require specialist intervention by psychiatric or psychology services.
• Around half of people with advanced disease experience anxiety and depression.
• Professional psychological support is likely to benefit people with cancer and their carers, whatever the severity of their psychological distress.
• Psychological symptoms are often not recognized, so services may not be offered.
• Health and social care professionals often lack appropriate assessment skills and may underestimate the benefits of psychological support.

• Assessment of the person's social needs should be repeated at key points during the course of the illness, including:
• At the time of diagnosis.
• Around treatment episodes.
• As treatments end.
• At the time of a relapse.
• When death is approaching.

• Needs for social support should be elicited as part of routine assessment, ideally including social care professionals.
• Social care and support needs include:
• Emotional support.
• Help with personal care (e.g. bathing and dressing).
• Advice on work and employment issues and help with benefit claims.
• Help with housework and shopping.
• Practical aids (e.g. wheelchairs).
• Help caring for dependents (e.g. children or elderly relatives).
• The person and their carers should be offered informed professional assistance to obtain benefits for which they are eligible.
• Support may be provided by family and friends.
• Local authorities, NHS, or voluntary organizations may provide respite or day care, support groups, volunteer visitors, assisted transport, and bereavement care.
• Be aware that assessment of need can be difficult because some people and their carers may be reluctant to ask for help.

[NICE, 2004]

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence [NICE, 2004].

• Assessment of the person's spiritual needs should be repeated at key points during the course of the illness, including:
• At the time of diagnosis.
• Around treatment episodes.
• As treatments end.
• At the time of a relapse.
• When death is approaching.

• Spiritual need relates to a person's search for meaning within his or her life. Religion is a means of expressing underlying spirituality, but spiritual belief may not always be expressed in a religious way.
• The level of support people need may range from an informal sharing of ideas about life, death, and the ultimate purpose of our existence, to the provision of formalized religious ritual.
• Key issues in delivering effective spiritual and existential support to people who are receiving treatment or at the end of life include:
• Listening to the person's experience and discussing their questions.
• Affirming the person's humanity.
• Protecting the person's self-worth, dignity, and identity.
• Ensuring that spiritual care is offered as part of a holistic approach to health that also includes psychological, social and emotional care.
• The person and their carers should have access to staff who are sensitive to their spiritual needs.
• Multidisciplinary teams should have access to suitably qualified, authorized, and appointed spiritual care givers and should also be aware of local community resources for spiritual care.

[NICE, 2004]

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence [NICE, 2004].

• Family members and carers should be offered the opportunity for their needs (e.g. for support and information) to be assessed separately from those of the patient.
• Whenever possible and appropriate, family members and carers should be invited to accompany the person during clinical encounters and should be involved in decisions about treatment and care, in accordance with the individual's wishes.
• Family members and carers should be made aware of, and have easy access to, local sources of information, advice, and support designed to meet their own needs.

• The needs of the family and/or carers should particularly be addressed at stages in the patient pathway acknowledged as especially demanding, and when extra help may be needed. Consider that people of different ethnic backgrounds or cultures may have specific preferences regarding family involvement [NICE, 2004].
• Sources of support include patient and carer support and advocacy services, counselling and chaplaincy services, and ethics support networks [GMC, 2010].
• Family members caring for their relative at home may experience a number of concerns [Doyle et al, 2004]:
• Fear of the person dying.
• Anxiety about an emergency occurring (e.g. what constitutes an emergency and how to deal with it).
• Feelings of inadequacy with regard to caring for the person at home (e.g. lack of knowledge about how to make the person comfortable or appropriate lifting techniques).
• Suppression of their true emotions in order to protect the person they are caring for.
• Financial worries.
• Altered role and lifestyle.
• The demands of being a carer can sometimes present as physical symptoms (e.g. fatigue, weight loss) [NICE, 2004].
• Interventions to help the family include [Doyle et al, 2004]:
• Facilitating communication between the person and their family and healthcare professionals.
• Recognizing stress in other areas (e.g. work, coping with children).
• Education to teach them the skills and knowledge to provide the care necessary to enhance the person's comfort.
• Discussion of their relative's pain management, to reduce anxiety regarding potential addiction or tolerance.
• Encouragement of expression of fears, concerns, uncertainty, and emotional strain.
• Provision of information regarding the person's death and what to expect.

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence [NICE, 2004], and the General Medical Council's guidance for doctors, Treatment and care towards the end of life: good practice in decision making [GMC, 2010].
• Cancer can affect the whole family, who often provide vital support for the person who is receiving palliative care [NICE, 2004].
• Carers can feel helpless and frustrated when they are unable to provide comfort to their relative, but often do not express their own needs [Doyle et al, 2004; NICE, 2004].
• Healthcare providers may not always teach specific care-giving skills, which would be valuable to families [Doyle et al, 2004].

• Ongoing day-to-day care of people with advanced cancer, by health and social care professionals, should be based on locally agreed protocols and guidelines, delivered within the context of a managed system or pathway.
• Health and social care professionals providing day-to-day care should know when to seek advice from, or refer to, specialist palliative care services.
• Discussion with the local specialist palliative care service (community, hospice, or hospital-based, as appropriate) should allow joint decisions to be made on whether further involvement by the specialist team is required at this point in the patient pathway.

• The multidimensional nature of problems in palliative care requires a multidisciplinary approach.
• Both the GP and district nurse should be involved as early as possible after diagnosis and can contact their local specialist palliative care team for support or advice.
• After clinical assessment, if there is a specialist need, referral to the specialist palliative care team may be necessary.
• The palliative care team may include any or all of the following specialities:
• Palliative medicine consultants and doctors
• General practitioner
• Palliative care nurses, including:
• Palliative care nurse specialist/Macmillan nurse
• Marie Curie nurse
• Palliative care pharmacist
• Physiotherapist
• Occupational therapist
• Counsellor (particularly bereavement counsellors) or psychologist
• Dietitian
• Social worker
• Spiritual adviser
• Benefits adviser
• Complementary therapists
• Macmillan nurses provide support and information to people with cancer and their families [Macmillan Cancer Relief, 2004].
• They do not usually provide 'hands-on' care, but give advice to the primary care team, including advice regarding medication for symptoms (e.g. pain, nausea, vomiting).
• The person and their family can self-refer to the Macmillan nursing team.
• Marie Curie Cancer Care provides nurses who care for terminally ill people and give them the choice of dying at home supported by their families [Marie Curie Cancer Care, 2007].
• Marie Curie nurses can provide hands-on care at home through the day or night.
• Marie Curie and Macmillan nursing services are free of charge to the person and their family and their services can be accessed via the person's GP or district nurse.
• Communication between professionals within multidisciplinary teams and other service providers caring for the person is important. Continuity of care should be achieved, possibly by nominating a 'key-worker' for individual people [NICE, 2004].
• The Gold Standards Framework in the community supports good communication and coordination of care, with a practice Supportive Care Register [Gold Standards Framework, 2005c]. For further information, see www.goldstandardsframework.nhs.uk.
• The Liverpool Care Pathway offers a framework for caring for people at the end of life. For further information, see www.mcpcil.org.uk/liverpool-care-pathway.

• This recommendation is based on guidance from the National Institute for Health and Clinical Excellence [NICE, 2004].

• Within each Cancer Network, commissioners and providers (statutory and voluntary) of cancer and palliative care services, working with service users, should oversee the development of services in line with the recommendations of this Guidance. Key personnel will need to be identified to take this forward.
• Assessment and discussion of patients' needs for physical, psychological, social, spiritual, and financial support should be undertaken at key points (such as at diagnosis; at commencement, during, and at the end of treatment; at relapse; and when death is approaching). Cancer Networks should ensure that a unified approach to assessing and recording patients' needs is adopted, and that professionals carry out assessments in partnership with patients and carers.
• Each multidisciplinary team or service should implement processes to ensure effective inter-professional communication within teams and between them and other service providers with whom the patient has contact. Mechanisms should be developed to promote continuity of care, which might include the nomination of a person to take on the role of 'key worker' for individual patients.
• Mechanisms should be in place to ensure the views of patients and carers are taken into account in developing and evaluating cancer and palliative care services. Cancer Partnership Groups provide one potential mechanism. Systems should be devised to support patients and carers to participate in their own care, featuring a range of informal support opportunities such as self-help activities and peer support schemes within community settings.
• Communicating significant news should normally be undertaken by a senior clinician who has received advanced level training and is assessed as being an effective communicator. As this is not always practical, all staff should be able to respond appropriately to patients' and carers' questions in the first instance before referring to a senior colleague.
• The outcome of consultations in which key information is discussed should be recorded in patients' notes and communicated to other professionals involved in their care. Patients should be offered a permanent record of important points relating to the consultation.
• Policies should be developed at local (Cancer Network/provider organization/team) level detailing the information materials to be routinely offered at different stages to patients with particular concerns. These policies should be based on mapping exercises involving service users.
• Commissioners and provider organizations should ensure that patients and carers have easy access to a range of high quality information materials about cancer and cancer services. These materials should be free at the point of delivery and patients should be offered appropriate help to understand them within the context of their own circumstances.
• Commissioners and providers of cancer services, working through Cancer Networks, should ensure that all patients undergo systematic psychological assessment at key points and have access to appropriate psychological support. A four-level model of professional psychological assessment and intervention is suggested to achieve this.
• Explicit partnership arrangements should be agreed between local health and social care services and the voluntary sector to ensure that the needs of patients with cancer and their carers are met in a timely fashion and that different components of social support are accessible from all locations.
• Patients and carers should have access to staff who are sensitive to their spiritual needs. Multidisciplinary teams should have access to suitably qualified, authorized, and appointed spiritual care givers who can act as a resource for patients, carers, and staff. They should also be aware of local community resources for spiritual care.
• Mechanisms need to be implemented within each locality to ensure that medical and nursing services are available for patients with advanced cancer on a 24-hour, 7 days a week basis, and that equipment can be provided without undue delay. Those providing generalist medical and nursing services should have access to specialist advice at all times.
• Primary care teams should institute mechanisms to ensure that the needs of patients with advanced cancer are assessed, and that the information is communicated within the team and with other professionals as appropriate. The Gold Standards Framework provides one mechanism for achieving this.
• In all locations, the particular needs of patients who are dying from cancer should be identified and addressed. The Liverpool Care Pathway for the Dying Patient provides one mechanism for achieving this.
• Commissioners and providers, working through Cancer Networks, should ensure they have an appropriate range and volume of specialist palliative care services to meet the needs of the local population, based on local calculations. These services should, as a minimum, include specialist palliative care inpatient facilities and hospital and community teams. Specialist palliative care advice should be available on a 24-hour, 7 days a week basis. Community teams should be able to provide support to patients in their own homes, community hospitals and care homes.
• Commissioners and providers, working through Cancer Networks, should institute mechanisms to ensure that patients' needs for rehabilitation are recognized and that comprehensive rehabilitation services and suitable equipment are available to patients in all care locations. A four-level model for rehabilitation services is the suggested model for achieving this.
• Commissioners and NHS and voluntary sector providers should work in partnership across a Cancer Network to decide how best to meet the needs of patients for complementary therapies where there is evidence to support their use. As a minimum, high quality information should be made available to patients about complementary therapies and services. Provider organizations should ensure that any practitioner delivering complementary therapies in NHS settings conforms to policies designed to ensure best practice agreed by the Cancer Network.
• Provider organizations should nominate a lead person to oversee the development and implementation of services that specifically focus on the needs of families and carers during the patient's life and in bereavement, and which reflect cultural sensitivities.
• Cancer Networks should work closely with Workforce Development Confederations (the Workforce Development Steering Group in Wales) to determine and meet workforce requirements and to ensure education and training programmes are available.
• Provider organizations should identify staff who may benefit from training and should facilitate their participation in training and ongoing development. Individual practitioners should ensure they have the knowledge and skills required for the roles they undertake.

[NICE, 2004]

• These are the key recommendations of guidance from the National Institute for Health and Clinical Excellence on 'Improving Supportive and Palliative Care for Adults with Cancer' [NICE, 2004].