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Palliative care seeks to improve the quality of life for patients suffering from the impact of life-limiting illnesses. Palliative care encompasses but is more than end-of-life care, which is defined as care during the final hours/days/weeks of life. Although palliative care policies increasingly require all healthcare professionals to have at least basic or non-specialist skills in palliative care, international evidence suggests there are difficulties in realising such policies. This study reports on an action research project aimed at developing respiratory nursing practice to address the palliative care needs of patients with advanced chronic obstructive pulmonary disease (COPD). The findings suggest that interlevel dynamics at individual, team, interdepartmental and organisational levels are an important factor in the capacity of respiratory nurses to embed non-specialist palliative care in their practice. At best, current efforts to embed palliative care in everyday practice may improve end-of-life care in the final hours/days/weeks of life. However, embedding palliative care in everyday practice requires a more fundamental shift in the organisation of care.

The primary goal of medical education is to foster development of clinical competence in trainees at all levels. Variable clinical experience, inconsistent methods of instruction, and ambiguous evaluation criteria undermine this goal. Standardized patients, trained to consistently portray a wide variety of clinical cases, can help overcome many of these educational problems. This article describes the development and application of standardized patients throughout medical training at The University of Texas Medical Branch, Galveston, in the freshman interviewing course, the second-year physical diagnosis course, third-year clerkships, a fourth-year final exercise, and residency training. Development of this program is discussed in the context of a broader literature in medical education, and investigation of variables affecting standardized patient and student performance is reported. Future directions for use of standardized patients in monitoring and promoting the development of clinical competence are discussed.

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