British physician Dr. Robert Twycross entered the field of end-of-life care in 1971 at the request of the preeminent pioneer in the field, Cicely Saunders, as a Research Fellow in Therapeutics. Though he is now retired, Dr. Twycross still actively promotes palliative care globally.
By Alison Ramsey
IAHPC Newsletter Editor
I interviewed Dr. Robert Twycross in late November about his experiences in palliative care during what he jokingly refers to as “my first 50 years.”
What was care of the dying like in the 1960s and 70s?
Doctors tended to neglect the dying patient, often putting them in a single room so that the ward round could bypass them.
Morphine was used only as necessary, and as meanly as possible: people had to “earn” their pain relief.
After Cicely Saunders hired you, what was your first research project?
Developed by a chest hospital in England for people dying of tuberculosis, the Brompton Cocktail was adopted by Cecily Saunders for pain control in palliative care. The recipe was:
In a carrier solution containing:
As a medical student, Cicely had met an enlightened doctor who used the Brompton Cocktail every four hours, titrated to individual patients’ needs, which gave good pain control. After she qualified, she used diamorphine—heroin—instead of morphine in the “cocktail” because she was told it was less sedative, and stimulated both mood and appetite. But it was rigidly controlled internationally; she wanted to test which ingredient was better.
What were your findings?
Despite a strong initial bias that diamorphine was better, I demonstrated clearly that there was no difference in efficacy when the two were given by mouth, in solution, every four hours, titrated to individual need.
It was great because, by then, Cecily had influenced people in a few English-speaking countries, such as the US, which didn’t have diamorphine, but morphine was available. It was a big breakthrough.
Then we looked at cocaine, and trials showed that, while it ameliorated some initial drowsiness, it had no lasting benefit. So we could make the cocktail to relieve pain much more simple: you only needed to add tap water and a bit of preservative, and warn people that they would experience drowsiness for the first few days.
How did the medical community react?
You can do research and publish papers, but it takes time for people to catch up. At a conference organized by the International Association for the Study of Pain in 1975, I said a few words about what we were doing with oral morphine, and cancer pain experts from the US laughed at me.
Twenty years earlier, they had compared a single oral dose with a single dose of injected morphine. Because it appeared to be only one-sixth as potent, they rejected its use. That reasoning was false: it doesn’t matter if it’s less potent: you just use six times as much. But, with regular dosing, the concentrations of morphine and a potent metabolite in the blood build up so that, when given regularly by mouth, it is generally necessary to give only two to three times as much by mouth as by injection.
The Brits in the audience cheered me on and, within five years, my research was accepted worldwide.
What happened next?
The idea was picked up by the cancer unit at the World Health Organization. After a few years, it became apparent that concentrating just on pain control was not enough, and the focus widened to pain relief and palliative—holistic—care.
In 2017 the Lancet reported that, each year, more than 61 million people need palliative care but most aren’t getting it. Even in the UK all is not well. One big problem is that doctors are almost exclusively taught a biomedical model, focused on the physical: the disease and cure. People haven’t been taught the ingredients of holistic care; they’ve got no role models.
Last month, the WHO released a document on assessment indictors for the development of palliative care that includes the need for formal palliative care training in medical and nursing schools. But the document adds that formal training can be optional or compulsory. I was horrified. If it’s part of universal health care, it’s got to be compulsory.
Then, of course, you can have a program, but is it any good?
You have lectured and taught in well over 40 countries. Can you imagine the desired structure of compulsory training?
My hunch is that there is far too much “chalk and talk,” feeding information but giving no time for reflection. So often, students aren’t being helped to think.
Listen, listen, listen! Let the patient tell their story. Palliative care is a partnership between the patient and the family and the caring team.
In my talks, I try to inspire. Sharing patient’s stories is one of the main ways of doing this. Among national palliative “champions” there’s an inspirational tradition that can cause others to capture the vision and inspire them too to move forward.
What are you up to now?
I’m part of PACED, a charitable foundation focusing on education and training in Eastern Europe and central Asia. We’re aiming to act as a catalyst, supporting champions and teachers in those countries. Experience has shown that it is valuable to have an overarching regional organization to support the development of palliative care.