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OBJECTIVE: Medical education can be described as a socialization process that has a tendency to produce doctors who struggle to convey to patients that they care. Yet, for people who are suffering, to enjoy the quality of life they are entitled to, it is important that they feel cared for as people, rather than simply attended to as patients. METHOD: This article addresses how we teach medical students the art of caring for the person rather than simply treating the disease--a question particularly relevant to end-of-life care where, in addition to the physical needs, attention to the psychosocial, emotional, and spiritual needs of the patient is paramount. Following an overview of what it is to care and why it is important that patients feel cared for, we investigate how we learn to care and develop caring human relationships, describing the development and display of empathy in adulthood and the developmental impact of human interaction. RESULTS: We outline evidence of situational barriers to effective education about care in medicine including role models, ward culture, and the socialization process. SIGNIFICANCE OF RESULTS: We then propose a model for medical education based on patient contact, reflection, self-care, role model development, and feedback that will see students learn the art of human care as well as the science of disease management. [ABSTRACT FROM AUTHOR]

Humane care is an essential component of the doctor's role at the end of life. Over the last 20 years, there has been a steady global increase in the extent and variety of medical teaching about the care of people who are dying. In some countries, palliative medicine is now recognised as a discrete medical specialty. Rightly, much emphasis has been placed on symptom management, communication skills and ethical issues. But rarely does the concept of care, or how doctors learn to care, emerge in the medical literature. The concept of 'care' is usually defined as a professional behaviour: attending to a patient's needs. Yet, the concept of care also requires a professional commitment on a more holistic level. To care is to be receptive to and responsible for others. This is care motivated by true empathy: a concern for the patient's well-being that comes from a sensitive identification with the patient's situation. This paper reports some of the findings from an interpretive phenomenological study involving 10 doctors and their experiences of learning to care for people who were dying. The doctors came from differing medical disciplines and had varying levels of experience. During the interviews the doctors retrospectively identified 'turning points' at which they first perceived some notion of what it means to care for someone who is dying. The doctors often used poignant language when recollecting the strong feelings associated with these critical incidents. They felt that their training had been inadequate in preparing them for such care. The article asks whether their medical education had adequately prepared these doctors for this key element of their work. It recommends ways in which practitioners may be better prepared to care for people who are dying. [ABSTRACT FROM AUTHOR]

Context Palliative medicine education has been undertaken in a number of clinical schools for over 20 years, but systematic education in this subject area is still not common. During the last five years at the Mary Potter Hospice, Wellington, New Zealand, in partnership with the University of Otago, Wellington School of Medicine, we have been developing a longitudinal experience for our students. Goal: In this paper we summarise our experiences with the intention of providing some ideas and guidance for schools that have not yet begun including this important area in their regular curriculum. Approach: In each of their clinical years, students have an opportunity to explore aspects of the care of people who are dying. Didactic learning in the classroom is reinforced by clinical exposure in the hospice in-patient unit. Findings: Students state that their confidence in providing palliative care and their ability to communicate with people who are dying are improved and that they would value more exposure to this aspect of medical practice. This programme provides an opportunity for a closer liaison between the hospice and the University. More formal links are being developed. [ABSTRACT FROM AUTHOR]

There are few studies on interment preferences and practices for people in remote and rural regions of developed countries. This mixed methods study in rural Australia collated data on funeral and interment practices with an ethnographic exploration of the post-death preferences of terminally-ill rural residents. In the region, between February 2015 and May 2016, 44% of decedents were cremated. Burial preferences reflected family traditions, generational connections to historic cemeteries, and the wish to instantiate belonging to people and place. Cremation provided the opportunity for ashes to be scattered at personally-significant places. Funeral planning was important for patients and family caregivers, and funerals are valued rural community rituals.

Background: In rural settings, relationships between place and self are often stronger than for urban residents, so one may expect that rural people would view dying at home as a major feature of the 'good death'., Aim: To explore the concept of the 'good death' articulated by rural patients with life-limiting illnesses, and their family caregivers., Design: Ethnography, utilising open-ended interviews, observations and field-notes., Participants: In total, 12 rural (town and farm) patients with life-limiting illnesses, 18 family caregivers and 6 clinicians, in the Snowy Monaro region of New South Wales, Australia, participated in this study over the course of the deaths of the patients. Interviews were transcribed and analysed with observational data using an emergent thematic process., Results: A 'safe death' was central to a 'good death' and was described as a death in which one could maintain (1) a connection with one's previous identity; (2) autonomy and control over decisions regarding management of end-of-life care and (3) not being overwhelmed by the physical management of the dying process. For all participants, the preferred place of death was the 'safe place', regardless of its physical location., Conclusion: Safety, in this study, is related to a familiar place for death. A home death is not essential for and does not ensure a 'good death'. We all have a responsibility to ensure all places for dying can deliver the 'safe death'. Future research could explore the inter-relationships between safety and preference for home or home-like places of death.

Residential aged care (RAC) is a significant provider of end-of-life care for people aged 65 years and older. Rural residents perceive themselves as different to their urban counterparts. Most studies describing place of death (PoD) in RAC are quantitative and reflect an urban voice. Using a mixed-methods design, this paper examines the PoD of 80 RAC residents (15 short-stay residents who died in RAC during respite or during an attempted step-down transition from hospital to home, and 65 permanent residents), within the rural Snowy Monaro region, Australia, who died between 1 February 2015 and 31 May 2016. Death data were collected from local funeral directors, RAC facilities, one multi-purpose heath service and obituary notices in the local media. The outcome variable was PoD: RAC, local hospital or out-of-region tertiary hospital. For the permanent RAC residents, the outcome of interest was dying in RAC or dying in hospital. Cross tabulations by PoD and key demographic data were performed. Pearson Chi squared tests and exact p-values were used to determine if any of the independent variables were associated with PoD. Using an ethnographic approach, data were collected from 12 face-to-face, open-ended interviews with four RAC residents, with a life expectancy of ≤6 months, and six family caregivers. Interviews were audio-recorded, transcribed and analysed thematically. Fifty-one (78.5%) of the permanent residents died in RAC; 21.5% died in hospital. Home was the initial preferred POD for most interviewed participants; most eventually accepted the transfer to RAC. Long-term residents considered RAC to be their "home"-a familiar place, and an important part of their rural community. The participants did not consider a transfer to hospital to be necessary for end-of-life care. Further work is required to explore further the perspectives of rural RAC residents and their families, and if transfers to hospital are avoidable., (© 2018 John Wiley & Sons Ltd.)

The 'good death' is one objective of palliative care, with many 'good death' viewpoints and research findings reflecting the urban voice. Rural areas are distinct and need special consideration. This scoping review identified and charted current research knowledge on the 'good' rural death through the perspectives of rural residents, including rural patients with a life-limiting illness, to identify evidence and gaps in the literature for future studies. A comprehensive literature search of English language articles (no date filter applied) was conducted in 2016 (2 January to 14 February) using five library databases. Reference lists of included articles, recent issues of eight relevant journals and three grey literature databases were also hand-searched. Twenty articles (for 17 studies and one systematic review) were identified after a two-phase screening process by two reviewers, using pre-determined inclusion criteria. Data from each study were extracted and charted, analysed using a thematic analysis of the included articles' content, and with a quantitative analysis of the scoping review. These papers revealed data collected from rural patients with a life-limiting illness and family caregivers, rural healthcare providers, the wider rural community, rural community leaders and rural health administrators and policy makers. Rural locations were heterogeneous. Residents from developed and developing countries believe a 'good death' is one that is peaceful, free of pain and without suffering; however, this is subjective and priorities are based on personal, cultural, social and religious perspectives. Currently, there is insufficient data to generalise rural residents' perspectives and what it means for them to die well. Given the extreme importance of a 'good death', there is a need for further studies to elicit rural patient and family caregiver perspectives., (© 2016 John Wiley & Sons Ltd.)

Objective: To describe the place of death of residents in a rural region of New South Wales., Design: Cross-sectional quantitative study using death data collected from local funeral directors (in person and websites), residential aged-care facilities, one multipurpose heath service and obituary notices in the local media (newspapers/radio)., Setting: Snowy Monaro region (New South Wales Australia)., Participants: Residents, with advanced frailty or one of 10 conditions amenable to palliative care, who died between 1 February 2015 and 31 May 2016., Main Outcome Measure: Place of death., Results: Of 224 deaths in this period, 138 were considered amenable to palliative care. Twelve per cent of these deaths occurred in a private residence, 38% in the usual place of residence and 91% within the region., Conclusion: Most rural residents with conditions amenable to palliative care died in the region. Most did not die in their usual place of residence. Further qualitative work is needed to determine palliative care patients' and family caregivers' preferences for, and the importance placed on, place of death. While there may be a need to support an increase in home deaths, local rural hospitals and residential aged-care facilities must not be overlooked as a substitute for inpatient hospices., (© 2017 National Rural Health Alliance Inc.)

Background: End-of-life care must be relevant to the dying person and their family caregiver regardless of where they live. Rural areas are distinct and need special consideration. Gaining end-of-life care experiences and perspectives of rural patients and their family caregivers is needed to ensure optimal rural care., Aims: To describe end-of-life care experiences and perspectives of rural patients and their family caregivers, to identify facilitators and barriers to receiving end-of-life care in rural/remote settings and to describe the influence of rural place and culture on end-of-life care experiences., Design: A systematic literature review utilising the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines., Data Sources: Four databases (PubMed, CINAHL, Scopus and Web of Science) were searched in January 2016, using a date filter of January 2006 through January 2016; handsearching of included article references and six relevant journals; one author contacted; pre-defined search terms and inclusion criteria; and quality assessment by at least two authors., Results: A total of 27 articles (22 rural/remote studies) from developed and developing countries were included, reporting rural end-of-life care experiences and perspectives of patients and family caregivers. Greatest needs were informational (developed countries) and medications (developing countries). Influence of rural location included distances, inaccessibility to end-of-life care services, strong community support and importance of home and 'country'., Conclusion: Articulation of the rural voice is increasing; however, there still remain limited published rural studies reporting on patient and family caregivers' experiences and perspectives on rural end-of-life care. Further research is encouraged, especially through national and international collaborative work.

Men with prostate cancer experience many side effects and symptoms that may be improved by a physically active lifestyle. It was hypothesized that older men with prostate cancer who were physically active would report significantly higher levels of quality of life (QOL) as assessed by the WHOQOL-BREF and the WHOQOL-OLD. Of the 348 prostate cancer survivors who were invited to participate in the present postal survey, 137 men returned the questionnaires. Those who were physically active had significantly lower prostate specific antigen (PSA) scores and higher social participation than those insufficiently active. These findings offer some support for the benefits of physical activity (PA) within the prostate cancer population in managing the adverse side effects of their treatments on aspects of their QOL. Future research should more closely examine what types of PA best promote improvements in varying aspects of QOL and psychological well-being for prostate cancer survivors.

Background: There have been many studies on the actual and preferred place of care and death of palliative patients; however, most have been whole population surveys and/or urban focused. Data and preferences for terminally ill rural patients and their unofficial carers have not been systematically described., Aim: To describe the actual place of death and preferred place of care and/or death in rural palliative care settings., Method: A systematic mixed studies review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines., Data Source: PubMed, PsychINFO, Scopus and CINAHL databases were searched (September to December 2014); eligible quantitative and qualitative studies included preferred and/or actual place of death/care of rural, regional or remote residents; rural data that are clearly identifiable; death due to palliative condition (malignant and non-malignant) or survey of participants with current or hypothetical life-limiting illness., Results: A total of 25 studies described actual place of death; 12 preferred place of care or death (2 studies reported both); most deaths occurred in hospital with home as the preferred place of care/death; however qualitative studies suggest that preferences are not absolute; factors associated with place are not adequately described as rurality was an independent variable; significant heterogeneity (rural setting and participants), however, many areas had a greater chance of home death than in cities; rural data are embedded in population reports rather than from specific rural studies., Conclusion: Home is the preferred place of rural death; however, more work is needed to explore influencing factors, absolute importance of preferences and experience of providing and receiving palliative care in rural hospitals which often function as substitute hospice., (© The Author(s) 2016.)

While physical activity is beneficial for men with prostate cancer, too few perform sufficient activity for such benefit. This study examined perceptions of men with prostate cancer of their barriers and facilitators to physical activity, and how androgen deprivation therapy (ADT) may influence these perceptions. Two focus groups were conducted, involving six ADT and eight non-ADT patients respectively. Data were transcribed verbatim and themes developed using a general inductive thematic approach. Facilitators to physical activity common to both groups of cancer survivors included clinician and spousal involvement, with pre-existing co-morbidities and increased age cited as barriers by both groups. The ADT subgroup cited personal involvement as a facilitator to physical activity, with fatigue, reduced motivation and a relative lack of specific advice from their clinician as additional barriers. The non-ADT subgroup had no additional facilitators to physical activity but cited time constraints as a barrier. These results highlight the important role that cancer clinicians and spouses play in promoting physical activity for men with prostate cancer and how ADT may influence their other facilitators and barriers. As physical activity is beneficial for prostate cancer survivors, especially those on ADT, cancer clinicians should regularly discuss physical activity with their patients., (© 2013 John Wiley & Sons Ltd.)

Background: The experiences of young people who have siblings with life-limiting illnesses are not well understood., Aim: The study proposed to identify the concerns of siblings of pediatric palliative care (PPC) patients., Design and Measurement: Semistructured interviews were administered to participants and analyzed using qualitative inductive thematic analysis., Setting and Participants: Study subjects were 18 siblings of PPC patients aged 9 to 22 living in the Auckland area., Results: The siblings of PPC patients held concerns about their siblings' impending death and desires to be involved in their lives and care., Conclusions: Siblings may benefit from opportunities to be involved in conversations about mortality and the care of their ill sibling. They are able to express their concerns and help provide care to PPC patients.

Objective: The primary aim of this study was to examine the perceptions of older men with prostate cancer regarding their quality of life and physical activity post-diagnosis, and the potential benefits and risks associated with being physically active. A secondary aim was to gain some preliminary insight into how these perceptions may differ as a function of androgen deprivation therapy (ADT)., Methods: Two focus groups were conducted, consisting of six ADT and eight non-ADT men, respectively. The probe questions used assessed the link between quality of life and physical activity as well as the benefits and risks associated with physical activity. Data were transcribed verbatim and themes identified using a general inductive thematic approach., Results: The primary themes identified were sexual health, 'plumbing' and non-urogenital side-effects, return to and increased levels of physical activity post-diagnosis, physical health/function and psychological benefits of physical activity as well as over-doing it and age-related risks of excessive physical activity. However, not all themes were present in both the ADT and the non-ADT sub-groups., Conclusions: These results further highlight the link between physical activity and quality of life in prostate cancer survivors and how they use physical activity as a part of their survivorship process. Of particular interest was how several men on ADT used resistance training to counteract ADT-related side-effects affecting their masculinity. As the evidence for physical activity for prostate cancer survivorship is increasing, cancer clinicians and service providers should consider ways to better assist these men, especially those on ADT become more active., (Copyright © 2013 John Wiley & Sons, Ltd.)

Communication about death is often a sensitive topic in families with children. The present studied compared answers of 141 school children aged 5-7 to questions about death, and their caregivers' predictions. Children were interviewed, and caregivers answered on paper, questions on inevitability, applicability, irreversibility, cessation, causation, and personal mortality. For causation, cessation, and irreversibility, children were significantly more correct than caregivers expected, and girls were more correct on applicability. Communicating with children about death may not always be as caregivers expect.

The perspectives of young New Zealanders receiving pediatric palliative care (PPC) are not well understood. A qualitative study of the perceptions of 16 PPC patients and their siblings, aged 9 to 18, was conducted through audio and written diary accounts. Inductive thematic analysis revealed several concerns. of participants, including special treatment that patients had received, spending time with their families, their feelings of being judged or discriminated against, their sense of being understood themselves and of understanding others, and mortality. A nonjudgemental, open approach is recommended when consulting with patients and their siblings in order to determine their needs.

Assisting or hastening death is a dilemma with many ethical as well as practical issues facing healthcare practitioners in many countries worldwide now. Various arguments for and against assisted dying have been made over time but the call from the public for legalisation of euthanasia or assisted suicide has never been stronger. While many studies have documented the reluctance of medical and other health professionals to be involved in the practice of assisted dying or euthanasia, there is still much open debate in the public domain. Those who have the most experience of palliative care are strongest in their opposition to assisted death or euthanasia. This paper explores salient practical and ethical considerations for healthcare practitioners associated with assisted death, with a focus on examining the concepts of autonomy for patients and healthcare practitioners. The role of the healthcare practitioner has clearly and undoubtedly changed over time with advances in healthcare practices but the duty of care has not changed. The dilemmas for healthcare practitioners thus who have competent patients requesting hastened death extends far beyond acting within a country's laws as they go to the very heart of the relationship between the practitioner and patient.

Context: Prostate cancer patients, especially those on androgen deprivation therapy (ADT), experience many symptoms that make it difficult to maintain their independence and quality of life. Because ADT acts by means of reducing testosterone production, exercise may offset many of the ADT side effects and those of the cancer itself., Objectives: This systematic review of the literature evaluates whether exercise could reduce symptoms and improve quality of life for prostate cancer patients., Methods: Using relevant databases and key words, 12 training studies were found meeting the inclusion and exclusion criteria., Results: Grade A level evidence was observed for the benefits of exercise in improving muscular endurance, aerobic endurance, and overall quality of life, as well as reducing fatigue in prostate cancer patients. Grade B evidence also suggested that exercise may improve prostate cancer patients' muscle mass, muscular strength, functional performance (walking and sit to stand speed), as well as health-related, social and physical quality of life. These effects appeared greater for group-rather than home-based-exercise, especially if these programs included resistance training., Conclusion: It is recommended that most prostate cancer patients be encouraged to exercise regularly by their clinicians and significant others. Where possible, this exercise should be group-based and include some resistance training. Future research in this area should directly compare group- and home-based, as well as resistance, aerobic, and combined resistance and aerobic training to better elucidate the most effective forms of exercise for this population and what factors affect initiation and adherence to such programs., (Copyright © 2012 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Background: Cancer cachexia is a syndrome of progressive weight loss. Non-small cell lung cancer patients experience a high incidence of cachexia of 61%. Research into methods to combat cancer cachexia in various tumour sites has recently progressed to the combination of agents.The combination of the anti-cachectic agent Eicosapentaenoic acid (EPA) and the cyclo-oxygenase-2 (COX-2) inhibitor celecoxib has been tested in a small study with some benefit. The use of progressive resistance training (PRT) followed by the oral ingestion of essential amino acids (EAA), have shown to be anabolic on skeletal muscle and acceptable in older adults and other cancer groups.The aim of this feasibility study is to evaluate whether a multi-targeted approach encompassing a resistance training and nutritional supplementation element is acceptable for lung cancer patients experiencing cancer cachexia., Methods/design: Auckland's Cancer Cachexia evaluating Resistance Training (ACCeRT) is an open label, prospective, randomised controlled feasibility study with two parallel arms. All patients will be treated with EPA and the COX-2 inhibitor celecoxib on an outpatient basis at the study site. In the experimental group patients will participate in PRT twice a week, followed by the ingestion of essential amino acids high in leucine. A total of 21 patients are planned to be enrolled. Patients will be randomised using 1:2 ratio with 7 patients enrolled into the control arm, and 14 patients into the treatment arm. The primary endpoint is the acceptability of the above multi-targeted approach, determined by an acceptability questionnaire., Discussion: To our knowledge ACCeRT offers for the first time the opportunity to investigate the effect of stimulating the anabolic skeletal muscle pathway with the use of PRT along with EAA alongside the combination of EPA and celecoxib in this population., Trial Registration: Netherlands Trial Register (NTR): ACTRN12611000870954.

Objective: This project sought to better understand the nature of medical care from the perspective of people approaching the end of life., Method: We asked 13 people who were dying (and a family member for each) to describe their care and the ways in which doctors' behavior fosters or inhibits the feeling that they were cared for as individuals. Interviews took a phenomenological approach. Data analysis was thematic., Results: Examples used by participants as evidence of care varied widely and showed the potentially complex nature of quality care. Participants' descriptions reflect the many ways people can impart and experience care as unique individuals in the medical context. They also provide clear examples of what uncaring behaviour looks and feels like., Significance of Results: The importance of care was clearly illustrated through descriptions of the benefits of caring behavior and the negative consequences of uncaring behavior. In order to demonstrate the empathy and compassion expected and assumed of medical graduates and engender a feeling of being cared for among their patients, doctors need to invite and develop a relationship with those they are caring for. There needs to be a focus on each member of the caring relationship primarily as individual human beings.

Objective: This study sought to hear what patients approaching death had to say about doctor-patient interactions and care in order that doctors can learn how to demonstrate care more effectively so that each patient feels cared for as an individual., Methods: In semi-structured interviews, 13 people dying of cancer shared their experiences and perspectives on care within the patient-doctor relationship., Results: Participants' recollections of experiences with doctors showed that genuine demonstration of care begins with doctors seeking common ground with the patient as a fellow human being and individual. The psychological and physical suffering that results from allowing stereotypical assumptions and behaviours to shape doctor-patient interaction was clear., Conclusion: The consequences of allowing the stereotypes and power of the primary context in which patients and doctors interact challenge the process of building a caring doctor-patient relationship. Caring doctors overcame this by exploring and carefully attending to the individual characteristics and needs of patients as people first and foremost., Practice Implications: To demonstrate genuine care doctors must learn to recognise and question the social expectations and inherent assumptions of medical contexts and roles of patient and doctor and allow unique characteristics of patient and context to guide their interactions., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

End of life care or palliative care has been acknowledged as important over the last 30 years and it is essential that doctors have core training in palliative care during their undergraduate training. There is little knowledge of the nature of teaching of palliative care within the undergraduate curriculum. This review was undertaken to determine the evidence to create an effective and appropriate undergraduate curriculum in palliative care. All relevant databases were electronically searched from 1966 until 2001 and selected contemporary work included. Key authors were contacted and grey literature and conference abstracts were searched. Efforts were made to quality grade any evaluation studies of teaching, learning and assessment. Two hundred and eighty abstract citations were obtained--192 papers were excluded due to lack of relevance to this study. Eighty-eight abstracts were obtained and forty-nine papers included in the review. There were no randomized controlled trials of educational interventions or open effect studies. All studies included were descriptive and were graded as level of evidence C. The main findings include lack of consistency in what undergraduates are taught about palliative care. Teaching tends to be fragmented, ad hoc and lacks co-ordination. There are difficulties in recruiting appropriate teachers. Palliative care is rarely formally assessed. Teaching focused more on the acquisition of knowledge and skills rather than attitudes. It is suggested that guidelines should be established within each medical school to develop an integrated curriculum for palliative care with due reference to the multidisciplinary nature of palliative care.

Background: The nature of medical care at the end of life and, in particular, the way in which caring is learned remain problematic for medical educators and the profession. Recent work has indicated that doctors learn to care, in an emotional and intimate way, from people who are dying., Methods: This paper reports on the development of a programme designed for medical students in their first clinical year who spend time with a person who is dying and their family. The students are required to produce a portfolio assignment that includes a personal reflection of the experience. The findings from a phenomenological study undertaken using these personal reflections are reported. These reflections and comments are interpreted as being embedded in five key themes., Results: The actual encounters differed from the medical students' anticipation of them. Students identified an emotional component to the experience; they explored their own and the patient's understandings of spirituality; they reflected on personal meanings of the encounter and they suggested ways in which they might learn to care more effectively for people who are dying., Discussion: The way in which many of these students approach end-of-life care has been altered through a transformative educational experience that encouraged them to draw on their own experiences and skills. Their learning was facilitated by the writing of accounts and the discussion that each group held with teaching staff at the conclusion of the programme.

This paper illustrates the evaluation of some of the effects of a 3-day workshop for principals and trainees in general practice on a number of aspects of palliative care, using pre-, immediate and late post-tests. Further qualitative evaluation is attempted by including a questionnaire with the late post-test. The evaluation is to demonstrate significant shifts, or differences, in confidence in dealing with physical and psychosocial symptoms, and in participants' perceived ability to cope, and to support these findings with qualitative data where appropriate.

As the need for palliative care increases, palliative care is emerging as a field of medical care in its own right. At the same time there are many aspects of palliative care that are problematic, particularly in palliative care education. The aspects reviewed here include: (a) the lack of a long tradition and adequate conceptualization of palliative care; (b) the significance of psychological, emotional, and spiritual aspects; (c) the importance of but inadequate understanding of symptom control; (d) the fact that palliative care is not curative in the accepted sense; (e) its multiprofessional nature; (f) the range of different settings of palliative care; and (g) the fact that palliative caregivers have to perform their duties in situations where the emotional and psychological demands on them may be immense. A number of general issues relevant to palliative care education are also reviewed.

The development of the specialty of palliative medicine has produced variable activity in the field of medical education. This article reviews published papers (primarily from Europe but with reference to other countries) identifies the extent of activity, and notes the absence of evaluative work. Undergraduate and postgraduate activity is identified.

This paper outlines the development of a medical education programme within the existing programme of the Macmillan Education Centre of the Dorothy House Foundation, Bath, England, between 1989 and 1992. A review of some of the significant contributions to the literature in this area is followed by a description of the initial research that was instrumental in designing these courses. A review of activities of the Centre is reported. A more detailed description of a course specifically designed for family doctors is made. A natural development from that course was one for all disciplines involved in caring for the terminally ill--this is described--along with some of the difficulties of such a method of education. Reference is made to evaluative work undertaken with reporting of initial data and work still in progress. Conclusions are drawn about the nature of such workshops and comment made on the role of facilitation.

Cell doubling time was determined in several ways in the apical mm of newly emerged, 0·2, 1 and 4 cm long lateral roots of Vicia faba L. and in every case it tended to decrease with increase in root length. Similar values were obtained in the roots of each length investigated when cell doubling time was calculated from the rate of passage of cells into the period of DNA synthesis (S) in both control and colchicine treated roots and from the rate of accumulation of cells in metaphase in the presence of colchicine, assuming cell number increased exponentially, i.e. colchicine had not affected the rate of entry of cells into mitosis or S during the 3 to 6 h period over which measurements were taken. A discrepancy was found, however, between the values determined for cell doubling time obtained from these rates and those calculated on the basis of the method devised by Evans and his co-workers (Evans, Neary and Tonkinson, 1957). Possible reasons for such a discrepancy are discussed.