Palliative Care and End of Life Care Explained for Medicine Interviews: Best Interests, Advance Decisions and Hospices

Palliative care is care that aims to give people with an illness that can't be cured the best possible quality of life, by controlling symptoms and supporting them and their families. It isn't only for the last days of life. For medicine interviews, know how it works, who decides when a patient can't, and the ethics.

I'm Dr Akash Gandhi, an NHS GP and the founder of TheUKCATPeople, and I've been helping students prepare for medicine interviews since 2012.

As a GP, palliative care is something I discuss with patients across the community, often during home visits. Those conversations taught me how much planning ahead matters: when a patient's wishes are written down and shared early, their family and the whole team can give them the care they want.

This guide covers how palliative care works, the law and the ethics. Other current topics are in our NHS hot topics guide.

What is palliative care?

Palliative care is an approach that improves the quality of life of people facing a life-threatening illness, and of their families. The World Health Organization describes it as care for problems that are physical, psychological, social or spiritual, not only physical symptoms.

It isn't only for cancer. People with heart failure, lung disease, dementia, motor neurone disease, kidney failure and frailty all benefit from it, and so do children with life-limiting conditions.

It isn't only for the very end of life either. Palliative care can start at diagnosis and run alongside treatment such as chemotherapy, and good palliative care early on can help people live better for longer.

Modern palliative care began in 1967, when Dame Cicely Saunders, who trained as a nurse, social worker and then doctor, opened St Christopher’s Hospice in south London. She described “total pain”: the idea that suffering at the end of life is physical, emotional, social and spiritual all at once.

Key Takeaway: Palliative care treats the whole person and their family, for any illness that cannot be cured, from diagnosis onwards.

How is palliative care different from end of life care and hospice care?

These terms overlap, and interviewers notice when you use them correctly. The NHS says someone is approaching the end of life when they are likely to die within the next 12 months, although that is often hard to predict.

A hospice is not only a building where people go to die. Most hospice care happens in people’s own homes, and many people stay on a hospice ward for a short time to get symptoms under control before going home again.

Key Takeaway: End of life care is palliative care in the last year of life; hospice care is palliative care given by a hospice team.

Who provides palliative care in the UK?

Most palliative care is given by people who are not palliative care specialists. GPs, district nurses, hospital ward teams and care home staff provide general palliative care every day.

When symptoms or situations are more complex, specialist teams help:

• Specialist palliative care teams: consultants in palliative medicine and clinical nurse specialists, in hospitals and the community
• Hospices: mostly independent charities offering inpatient beds, care at home, day services and bereavement support, free to patients
• The wider team: chaplains, social workers, physiotherapists, occupational therapists, pharmacists and counsellors

Hospices get part of their funding from the NHS and raise most of the rest through donations, shops and fundraising, so access can vary from area to area. Since the Health and Care Act 2022, integrated care boards in England have had a duty to commission palliative care services for their area.

Key Takeaway: Most palliative care is given by GPs, nurses and ward teams, with specialist teams and charity-funded hospices for more complex needs.

What does palliative care involve day to day?

Palliative care aims to keep people as comfortable and independent as possible, and to help them spend their remaining time the way they choose. It usually covers:

• Symptom control: pain, breathlessness, nausea, constipation, tiredness, anxiety and agitation
• Medicines given differently: when swallowing becomes hard, a syringe driver gives a steady dose under the skin over 24 hours
• Planning ahead: talking about wishes, preferred place of care and death, and who should make decisions if the person cannot
• Emotional and spiritual support: for fear, low mood, faith and questions about meaning
• Support for families: practical help, respite for carers and bereavement support after death

In the last days of life, GPs often prescribe anticipatory medicines, sometimes called just in case medicines. They are kept in the home so a district nurse can give them quickly for pain, sickness, breathlessness or agitation, without waiting for a doctor at night.

National guidance from NICE says people approaching the end of life should be identified early, have a named lead for their care and be offered advance care planning.

Key Takeaway: Day to day, palliative care means good symptom control, planning ahead and support for the patient and the people around them.

What does best interests mean when a patient lacks capacity?

Many people near the end of life lose the ability to make some decisions, because of illness, medicines or dementia. In England and Wales the Mental Capacity Act 2005 sets out what happens then. Our guide to assessing capacity explains the test itself.

The key principles are worth knowing in plain words:

• Assume capacity: every adult is presumed able to decide unless it is shown they cannot
• Help them decide: use simple language, pictures or a better time of day before concluding they cannot
• Unwise is not incapable: a decision others disagree with does not mean someone lacks capacity
• Best interests: if they cannot decide, the decision must be in their best interests
• Least restrictive: choose the option that limits their rights and freedom the least

Best interests is not what the doctor thinks is medically best, and it is not what the family wants. It means working out what the person would have wanted, using their past and present wishes, beliefs and values, and talking to the people who know them well.

Families must be consulted, but they do not make the decision unless they hold a lasting power of attorney. If someone has nobody to speak for them, an independent mental capacity advocate is appointed. Scotland and Northern Ireland have their own laws built on similar ideas.

Key Takeaway: Best interests means deciding as the patient would have wanted, using their wishes and values, after talking to the people who know them.

What is the difference between an advance decision and an advance statement?

Both let a person plan ahead for a time when they cannot decide for themselves, but they work very differently. This is one of the most useful distinctions to know for an interview.

Advance decision to refuse treatment

An advance decision, sometimes called a living will, lets someone aged 18 or over refuse specific treatments in advance. If it is valid and applies to the situation, it is legally binding and doctors must follow it.

To refuse life-sustaining treatment, such as ventilation or CPR, it must be written down, signed by the person and a witness, and say clearly that it applies even if their life is at risk. An advance decision can only refuse treatment: nobody can use one to demand a treatment.

Advance statement

An advance statement is a wider record of what matters to someone: where they would like to be cared for, their religious beliefs, who they want with them, even the music they like. It is not legally binding, but anyone making decisions about their care must take it into account.

Lasting power of attorney

A lasting power of attorney for health and welfare lets someone choose a trusted person to make decisions for them if they lose capacity. It must be registered before it can be used, and the attorney can only refuse life-sustaining treatment if the document gives them that power.

Key Takeaway: An advance decision refuses treatment and is legally binding; an advance statement records wishes and must be taken into account but is not binding.

Where do DNACPR and ReSPECT fit in?

A DNACPR decision means that if the person’s heart stops, CPR will not be attempted. It is a clinical decision, made because CPR would not work or would cause more harm than benefit, and it covers CPR only: every other treatment and all care continue.

Patients cannot demand CPR that will not work, but they have a right to be involved. In the Tracey case in 2014, the Court of Appeal ruled that doctors must normally discuss a DNACPR decision with the patient, unless that would cause them physical or psychological harm.

Many areas now use ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment. It records which emergency treatments a person would or would not want, including CPR. Our DNACPR guide goes into the ethics in detail.

Key Takeaway: DNACPR covers CPR only, is a clinical decision that should normally be discussed with the patient, and is often recorded on a ReSPECT form.

What ethical issues come up in palliative care?

End of life care brings the four pillars of medical ethics into sharp focus.

The doctrine of double effect

Strong painkillers and sedatives are sometimes given to relieve severe suffering near the end of life. The doctrine of double effect says this is acceptable even if it could, in theory, shorten life, as long as the intention is to relieve symptoms and the dose is proportionate.

Used carefully, these medicines are not thought to shorten life, and this is very different from giving a drug in order to end someone’s life.

Withholding and withdrawing treatment

Doctors are not obliged to give treatment that will not help, and a patient with capacity can refuse any treatment. Stopping a treatment that is no longer helping is treated in law and ethics the same as not starting it, although families often find withdrawal much harder.

Food and drink offered by mouth are basic care and are always offered. Feeding through a tube or a drip is treated as medical treatment, so decisions about it follow the same rules as other treatments.

Telling patients the truth

Families sometimes ask doctors not to tell a patient they are dying. A patient with capacity has a right to information about their own health, though some people choose not to know, and that choice should be respected. Our guide to breaking bad news covers how doctors handle these conversations, and confidentiality covers what can be shared with relatives.

Fair access

People with conditions other than cancer, people from deprived areas, and people from some ethnic minority groups are less likely to receive specialist palliative care.

Palliative care and assisted dying

Assisted dying is not legal in England and Wales, and palliative care does not aim to hasten death. Many palliative care doctors argue that better access to good palliative care should come first in this debate, while others support a change in the law. Our assisted dying guide has the latest position.

Key Takeaway: Know double effect, withholding versus withdrawing, truth telling, fair access and how palliative care differs from assisted dying.

What happened to the Liverpool Care Pathway?

The Liverpool Care Pathway was a framework for care in the last days of life, used widely across the NHS. Families reported that it was sometimes applied like a checklist, with poor communication and fluids stopped without explanation, and it was phased out in 2014.

It was replaced by One Chance to Get it Right, which set five priorities for care of the dying person: recognise that someone may be dying, communicate sensitively, involve the person and their family in decisions, support the family, and agree an individual plan of care.

Our Liverpool Care Pathway guide tells the full story.

Key Takeaway: The Liverpool Care Pathway was replaced in 2014 by five priorities that put individual care and communication first.

How can I talk about palliative care in my medicine interview?

Palliative care questions come in three main forms: a knowledge question, an ethical scenario, or a role-play with an actor playing a patient or relative. Some medical schools now run a whole station on terminal illness.

Hospice volunteering, care home work and time with a GP or district nurse all give you real examples. Think about one patient you met and what helped them.

Interviewers look for:

• Compassion: you see the patient as a person with their own priorities
• Respect for autonomy: you put the patient’s wishes at the centre, including their right to refuse
• Accurate knowledge: you know the difference between an advance decision and an advance statement
• Teamwork: you recognise the nurses, carers and families who provide most of the care

For scenario practice, our guide to MMI role-play stations shows how to structure a conversation with an upset relative, and our medicine interview coaching gives you mock stations with personalised feedback.

Key Takeaway: Use a real example, keep the patient’s wishes at the centre and show you understand the law well enough to explain it clearly.

Example interview questions on palliative care

You are unlikely to be asked any of these word for word, and you do not need a prepared answer to each one. Use them to check your understanding: if you could speak for a minute on most of them, you know this topic well enough for whatever the interviewer actually asks.

Questions to get you thinking

1. What is palliative care, and who is it for?
2. What is the difference between palliative care and end of life care?
3. What does a hospice do?
4. What is the difference between an advance decision and an advance statement?
5. What does acting in a patient’s best interests mean?
6. What did you learn about death or dying from your work experience?

Harder questions to stretch you

1. A family asks you not to tell their father that he is dying. What would you do?
2. A patient with capacity wants to stop all treatment and go home. Their daughter disagrees. What should happen?
3. Is there a moral difference between withholding and withdrawing treatment?
4. Should more NHS money go to palliative care before the law on assisted dying is changed?

Model answer: "A patient has an advance decision refusing antibiotics, and now has pneumonia. Their son asks you to treat it. What should happen?"

The first thing I would want to know is whether the patient can make this decision now. If they have capacity, the advance decision does not apply: I would ask them directly, and their current wishes would decide what happens.

If they lack capacity, I would check that the advance decision is valid and applies to this situation. That means it covers antibiotics, describes circumstances like these, and the patient has not done anything since that suggests they changed their mind.

Pneumonia can be life-threatening, so for the refusal to apply it would need to be written, signed and witnessed, and say it applies even if their life is at risk. If it meets those conditions, it is legally binding, and the team would have to follow it, even though the son disagrees.

I can understand why the son is asking. He is probably frightened of losing his parent. I would want a senior doctor to talk with him, explain what the advance decision says and why it must be respected, and listen to his worries.

Following the advance decision doesn't mean stopping care. The patient would still have their symptoms treated, with oxygen, medicines for breathlessness and fever, and support for the family.

If there were real doubt about whether the document was valid, the team would get legal advice, and in an emergency could treat while that was resolved.

Why this answer works:

• It starts with capacity: which decides whether the advance decision applies at all
• It knows the law: valid, applicable, and the extra rules for life-sustaining treatment
• It cares for everyone: the son’s fear and the patient’s comfort, not only the legal answer

Practise more with our medical school practice interview questions and our guide on how to answer medical ethics interview questions.

Key Takeaway: For any end of life scenario, check capacity first, then the patient’s known wishes, then best interests, and keep caring for the family throughout.

The one thing to take into the room

Palliative care is about helping people live as well as possible until they die, in the way they would choose. If you remember that the patient’s own wishes come first, and you can explain best interests, advance decisions and advance statements in plain words, you are well prepared.

Key Takeaway: Put the patient’s wishes at the centre of every answer, and show you know how the law protects them when they can no longer speak for themselves.