“Thank you very much for your letter of 5th April. I am most interested in your thought that perhaps this will eventually be your own field” [2] — this is what Dame Cicely Saunders wrote to the then 25-year-old Robert Geoffrey Twycross, a medical graduate from Oxford, whom she had met two years earlier while still a student. It was then that Twycross established the Radcliffe Christian Medical Society at his University so that he could invite Dame Cicely Saunders to give a lecture on her plans to organize modern care for the dying. The idea of Robert Twycross, which Saunders eagerly picked up, became a reality. He could write about himself at the end of his life: “I am one of the pioneers of hospice and palliative care in the UK” [3].
Just a few weeks ago, on 20th October 2024, Robert G. Twycross passed away peacefully at his home, surrounded by his loved ones. The funeral took place on 15th November at All Saints’ Church in Headington. In addition to his family and friends, it was attended by colleagues and students of Dr. Twycross, and probably hundreds of doctors and nurses involved in palliative care in many places around the world watched it broadcast via the Internet. Dr. Robert G. Twycross was another representative of the outgoing generation of palliative and hospice care pioneers. His special relationship with Poland deserves commemoration [4].
When Robert G. Twycross came to Milan for the first Congress of the newly established European Association for Palliative Care (EAPC) in 1988, he met there three Polish doctors: the already known to him Dr. Zbigniew Żylicz, working in the Netherlands, Dr. Grażyna Zengteler from an informal voluntary home hospice (the third in Poland) established by the parish of St. John Cantius in Poznań, and Prof. Jacek Łuczak, a cardiologist and anesthesiologist who was just starting his palliative journey. In 1987, he succeeded in setting up the first Polish pain clinic for cancer patients — at the University Hospital in Poznań, where he worked, and then a palliative care team to provide multidisciplinary palliative care to patients and their families at home [1, 5, 6]. Two doctors from Poznań were able to come to Milan thanks to scholarships from the International School for Cancer Care established by Dr. Twycross a year earlier [1]. This was the beginning of a long friendship and very fruitful years of cooperation.
In 1988, Dr. Robert G. Twycross was already well-known in the world of palliative medicine, mainly as a researcher and a colleague of Dame Cicely Saunders. In the first half of the 1970s, he worked at St Christopher’s Hospice in London established by Cicely Saunders in 1967 — the first modern hospice in the UK, which became the model for the worldwide hospice movement. Inspired by her, Dr. Robert Twycross conducted scientific research comparing the analgesic effectiveness of morphine and diamorphine (heroin) [7, 8]. The results of his studies led to the introduction of orally administered morphine to international standards for the treatment of pain in cancer patients. When, on the initiative of Jan Stjernswärd, the Working Group for the development of cancer pain relief standards at the WHO was established, Robert Twycross played a key role in that project. He is considered the author of the key principles in the recommendations first published in 1986 [9], which still form the basis of pain management theory today, not only in cancer patients but also in patients with chronic pain of non-cancer origin. The next 1990 edition was the basis of the Polish version — Cancer Pain Relief and Palliative Care. Report of the WHO Expert Committee, Geneva 1990, Polish edition Kraków, 1994.
In 1976, one of the first NHS-funded hospices in the UK — Sir Michael Sobell House — was established in Oxford. Dr. Robert Twycross was initially the Medical Director of the unit (until 1987), and from 1988 to 2005, he was the Director of the World Health Organization’s Collaborating Centre for Palliative Care established at the Oxford Hospice. Dr. Robert Twycross was a tireless lecturer in the field of palliative care in Oxford, as well as in over 40 countries around the world, including Poland. He made Sir Michael Sobell House one of the most important centers of education in the field of palliative care and medicine at that time. Over the following years, palliative care pioneers from most European and many non-European countries would come to Oxford. In the mid-1990s, Dr. Robert Twycross organized pioneering international courses for palliative care leaders from all over the world. In line with the idea of multidisciplinary team work, nurses, physicians, psychologists, and other staff underwent joint theoretical and practical training at the patient’s bedside, under the watchful eye of Dr. Twycross and his team. The lecturers from Sir Michael Sobell House Hospice were not only physicians but also nurses, psychologists, sociologists, and clergymen.
The cooperation between Dr. Robert Twycross and Prof. Jacek Łuczak, initiated at the meeting in Milan, lasted more than 20 years. In November 1988, Dr. Twycross came to Poznań for the First National Congress of Palliative Care, organized by the newly formed team led by Prof. Jacek Łuczak [5, 10]. In 1989, the first Palliative Care and Intensive Oncological Therapy Department was established in Poland, within the structure of the Chair of Oncology of the Poznań University of Medical Sciences. Education of medical students began in 1990, and it was one of the first pre-graduate programs of that type in the world [11, 12]. Twycross and Łuczak signed a cooperation agreement between Sir Michael Sobell House and the Poznań University of Medical Sciences. This resulted in a series of post-graduate courses in palliative care (Advanced Courses in Palliative Care). From 1990 to 2002, they were organized in Ślesin, Ląd, Krasnobród, Olcza, and from 1994 in Puszczykowo [5, 10, 13].
The courses were run by Prof. Łuczak's Department and Robert Twycross was their scientific director, later with the assistance of Prof. Łuczak, Dr. Michael Minton, and Prof. Zbigniew Żylicz. The participants of the courses were physicians, nurses, psychologists, and healthcare managers, not only from Poland but also from many other countries, especially from Central and Eastern Europe (e.g. Lithuania, Slovakia, Hungary, Serbia, and Romania). Today, it is difficult to determine the exact number of international participants in these tiraining courses, which were meticulously prepared by Robert. The “paper” records have not survived. Approximately 40–80 people attended each course and many of them established the first palliative and hospice care units in their cities and countries in the following years. The training program was developed jointly by Dr. Twycross and Prof. Łuczak. New themes and educational plans for the following years were determined at each conference. Current topics that were addressed during the courses were based on first studies that were published in this developing field.
Particular attention was paid to difficult cases of pain treatment (“intractable pain”). During the courses, participants shared the experiences in the use of opioids (e.g. tramadol) and analgesic adjuvants (e.g. ketamine) in the treatment of cancer and non-cancer pain, which was a novelty at that time. Further experience gained by participants was discussed in consecutive years.
During the courses, Dr. Twycross took on the roles of scientific director, lecturer, discussion moderator, and… inquisitive student. He thoroughly analyzed every topic covered, paying attention to the smallest details. He was guided by the ”attention to detail” principle — a basic rule in pain treatment. There was no place for inaccuracy. He was regarded by most participants as an excellent teacher. His lectures were systematic and clear. During informal discussions, he asked course participants for their opinions on the topics of his lectures. He encouraged undertaking research. He was truly respected. Thanks to him, the world’s best experts in the newly emerging specialty were invited to lecture on the courses (e.g. Prof. Vittorio Ventafridda, Prof. Kathleen Foley, Prof. Irene Higginson, Prof. David Clark, Prof. Sam Ahmedzai, Prof. David Oliver, Dr. Michael Minton, Prof. Zbyszek Żylicz, Dr. Steven Passik, Prof. Ruben Bild, and Dr. Phyllis R. Silverman). Robert’s enthusiasm for developing of palliative care was “contagious”, inspiring, and energizing. Robert encouraged educating healthcare professionals, hospice staff, and students in the field of symptom management and palliative care. The courses organized in Puszczykowo were followed by local or wider-range programs managed by hospice associations and emerging palliative care teams. The subject “palliative care”/“palliative medicine”, first taught at the University in Poznań, found its way to other universities where both physicians and nurses were educated. One can say that the current expertise in palliative care and education in palliative medicine in Poland would not be possible without Dr. Robert Twycross [12, 14, 15].
Dr. Robert Twycross spread the idea of palliative care, continuing and developing the work of Dame Cecily Saunders, lecturing at many international conferences in Europe, America, and Asia (e.g., he participated in palliative care training courses in India for many years). In his late years, he supported the development of palliative care in the former Soviet Union countries. He visited Poland several times in the last decades of his life, including as a guest of honor at the conferences of the Polish Society of Palliative Medicine (PTMP) in 2008 and 2012; he was awarded the title of Honorary Member of the PTMP in 2011. In June 2016, Dr. Robert Twycross was a speaker at the 9th conference of the journal Palliative Medicine in Practice combined with the 20th Anniversary of the Department of Palliative Care of Collegium Medicum in Bydgoszcz. He was a Member of the Scientific Council of Palliative Medicine in Practice for several years.
Dr. Robert Twycross played a key role in the recognition of palliative medicine as a medical specialty in the UK (1987), and other countries (Poland was the third country to introduce a medical specialty in palliative medicine, in 1999, and the first specialists passed the exam in 2003) [16]. He developed the first curricula for medical students. He was the author of many books and articles on palliative care and pain management published in the years 1968–2024. The first publications on the treatment of patients with advanced cancer that appeared in Poland were translations of Dr. Robert Twycross’s works. His lectures were translated by Prof. Zbigniew Żylicz [17], and the textbook of which Dr. Twycross was a co-author (together with Sylwia Lack), the first one in that field on the Polish market, was translated by the physicians from the Hospice Pallotinum in Gdańsk — Mr. and Mrs. Stolarczyk [18]. The most important collective work, initiated in 2000 and still being developed by the Doctor’s colleagues — Dr. Andrew Wilcock and Dr. Sarah Charlesworth, seems to be the compendium of pharmacotherapy in palliative care — Palliative Care Formulary (latest 8th edition, 2022) [19].
Dr. Twycross, consequently, throughout his life, opposed euthanasia and decriminalization of the so-called assisted dying [3] — from his earliest articles written while still a student, through statements submitted to the British Parliament, to positions developed in hospice care communities. The last article written by Robert on the issue of assisted dying was published in April 2024 [20]. Robert was a very religious person, living according to the principles of the Bible. It is a little-known fact that after his retirement as a physician, he was involved in preaching in the Anglican Church for a few years [21].
Robert had an interesting view on the unique role that palliative care should have in medicine. He believed that, despite the significant development, there should remain the original enthusiasm and freshness: “In palliative care, the number of followers is no longer small, and routinization has already occurred in countries where palliative care has become established. However, palliative care continues to need the creative and disruptive influence of charisma. Most palliative care programs have not yet reached the goal of truly holistic care. If palliative care is to continue to develop, an ongoing creative tension between charisma and routinization is necessary. Otherwise, the palliative care movement of the late 20th century will degenerate, like so many other movements before it…” [22] — these words of Dr. Robert Twycross, written over twenty years ago, remain relevant today.
Dr. Robert Twycross never sought titles or honors. He approached each successive project with commitment and English sense of humor. Privately, he was a warm, understanding, and very hospitable man, a friend to many, husband to Deidre for 60 years, father to five children, and grandfather. The reminiscences and thanks published after his death prove how much he was appreciated and loved.
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