Palliative Medicine

The most commonly encountered clinical conditions presenting with cognitive failure (CF) are delirium, dementia and amnestic disorders. Of these, delirium is probably the most prevalent in palliative care, and it is potentially reversible. Thus, improvement in diagnostics seems warranted. The objectives of this review were to examine the methods for assessment of CF and delirium in palliative care.

Twenty-two studies were reviewed: 64% were published in 2000 or later. Twelve reports focused on delirium, six on CF, while the remaining four assessed confusion (2), hallucinations and general psychological morbidity. Median sample size was 100 (20–393). Ten different instruments were used: The Mini Mental State Exam was used in 13 studies. Five studies were validation reports of new or existing instruments.

The term CF is an imprecise description of a loss in one or more of the cognitive functions. The interchangeable use of CF as a description of specific diagnoses should be avoided, as this contributes to prevalence rates that are not representative. Assessment tools that discriminate between the different diagnostic entities presenting with CF should be used in future studies.

Intraspinal analgesia can be helpful in some patients with intractable pain. Over 15 years palliative care professionals evolved their spinals policy through a repeated series of evaluations, discussions and literature reviews. One hundred intraspinal lines were then reviewed. Notable changes in policy were the switch from epidurals to intrathecals, and the insertion of lines during working hours rather than as emergencies. Our efficacy, and frequency of adverse effects, is equal or better to published studies. Key issues in reducing adverse effects were the improved care of the spinal line exit site, a change from bolus administration to continuous infusions, and modifying line insertion techniques. Current policy is to use continuous infusions of diamorphine and bupivacaine in a 1:5 ratio through externalized intrathecal lines. The lines are effective in approximately two thirds of patients and can be kept in place for up to 18 months. The policy continues to be updated and common documentation is now in place.

Alfentanil is becoming an alternative to diamorphine when parental opioids are required, especially in the presence of renal insufficiency. Its pharmacokinetic properties suggest that tolerance may be rapidly induced, whilst concomitant administration of drugs that interfere with the cytochrome P450 system may alter its metabolism. This retrospective audit looked at the use of subcutaneous alfentanil in a palliative care setting over a 21-month period. Forty-eight out of the 81 notes identified were available for analysis. Alfentanil was used for a median of 9 days (range 1–81) with median increase in dose of 80% (range 0–1125%). No significant correlation was found between duration of infusion and dose escalation. In addition no significant correlation was found between dose escalation and concomitant drugs that either inhibited or induced the P450 system. This is the first study to investigate the use of relatively long-term use of parenteral alfentanil. The results suggest that neither tolerance nor concomitant drug administration is of clinical significance in the dose escalation.

Objective: To determine whether topical benzydamine hydrochloride 3% cream is more effective than placebo in reducing pain related to pressure areas in palliative care patients. Design: Randomized double-blind, placebo-controlled trial. Setting: Three specialist palliative care units in the north of England, with local ethical committee approval for all sites. Subjects: Hospice in-patients with pain related to pressure areas. Interventions: A single application of either benzydamine hydrochloride 3% cream or placebo cream to the painful pressure area. Main outcome measures: Pain assessed using 100 mm VAS, an 11 point numerical pain score and a five-point pain relief score. Results: There was no statistically significant difference between topical benzydamine hydrochloride 3% cream and placebo cream in reducing pain related to pressure areas in palliative care patients. Conclusions: This study does not demonstrate a statistically significant difference between the two treatments. However the study does provide reliable information with respect to the use of different pain measurement tools in late-stage palliative patients. It also provides information regarding the baseline characteristics of this group of patients which may be useful in the planning of any future similar studies.

Objectives: To determine the problems and issues of accessing specialist palliative care by patients, informal carers and health and social care professionals involved in their care in primary and secondary care settings. Data sources: Eleven electronic databases (medical, health-related and social science) were searched from the beginning of 1997 to October 2003. Palliative Medicine (January 1997–October 2003) was also hand-searched. Study selection: Systematic search for studies, reports and policy papers written in English. Data extraction: Included papers were data-extracted and the quality of each included study was assessed using 10 questions on a 40-point scale. Results: The search resulted in 9921 hits. Two hundred and seven papers were directly concerned with symptoms or issues of access, referral or barriers and obstacles to receiving palliative care. Only 40 (19%) papers met the inclusion criteria. Several barriers to access and referral to palliative care were identified including lack of knowledge and education amongst health and social care professionals, and a lack of standardized referral criteria. Some groups of people failed to receive timely referrals e.g., those from minority ethnic communities, older people and patients with nonmalignant conditions as well as people that are socially excluded e.g., homeless people. Conclusions: There is a need to improve education and knowledge about specialist palliative care and hospice care amongst health and social care professionals, patients and carers. Standardized referral criteria need to be developed. Further work is also needed to assess the needs of those not currently accessing palliative care services.

There is a growing debate about the question of equity of access to hospice and palliative care services. Even countries with relatively well developed palliative care systems are considered to have problems of access and inequity of provision. Despite these concerns, we still lack a relevant evidence base to serve as a guide to action. We present an analysis of access to adult hospice inpatient provision in the north-west region of England that employs Geographical Information Systems (GIS). Measures of the possible demand for, and supply of, hospice inpatient services are used to determine the potential accessibility of cancer patients, assessed at the level of small areas (electoral wards). Further, the use of deprivation scores permits an analysis of the equity of access to adult inpatient hospice care, leading to the identification of areas where additional service provision may be warranted. Our research is subject to a number of caveats–it is limited to inpatient hospice provision and does not include other kinds of inpatient and community-based palliative care services. Likewise, we recognise that not everyone with cancer will require palliative care and also that palliative care needs exist among those with nonmalignant conditions. Nevertheless, our methodology is one that can also be applied more generally.

Background: Palliative sedation therapy is often required in terminally ill cancer patients, and may cause emotional burden for nurses. The primary aims of this study were 1) to clarify the levels of nurses' emotional burden related to sedation, and 2) to identify the factors contributing to the burden levels. Methods: A questionnaire survey of 3187 nurses, with a response rate of 82%. Results: Eighty-two percent of the nurses (n=2607) had clinical experience in continuous-deep sedation. Thirty per cent reported that they wanted to leave their current work situation due to sedation-related burden (answering occasionally, often, or always). Also, 12% of the nurses stated that being involved in sedation was a burden, 12% that they felt helpless when patients received sedation, 11% that they would avoid a situation in which they had to perform sedation if possible, and 4% that they felt what they had done was of no value when they performed sedation. The higher nurse perceived burden was significantly associated with shorter clinical experience, nurse perceived insufficient time in caring for patients, lack of common understanding of sedation between physicians and nurses, team conference unavailability, frequent experience of conflicting wishes for sedation between patient and family, nurse-perceived inadequate interpersonal skills, belief that it was difficult to diagnose refractory symptoms, belief that sedation would hasten death, belief that sedation was ethically indistinguishable from euthanasia, nurse-perceived inadequate coping with their own grief, and nurses' personal values contradictory to sedation therapy. Conclusions: A significant number of nurses felt serious emotional burden related to sedation. To relieve nurses' emotional burden, we encourage 1) management efforts to reduce work overload, 2) a team approach to resolving conflicting opinions, especially between physicians and nurses, 3) co-ordination of early patient-family meetings to clarify their preferred end-of-life care, 4) education and training about sedation specifically focused on interpersonal skills, systematic approaches to diagnosing refractory symptoms, minimum life-threatening potency in sedation, and ethical principals differentiating sedation from euthanasia, and 5) exploring nurses' personal values through the patient-centered principle.

Depression is a common symptom in patients with advanced cancer and patients who are depressed may also have physical symptoms which are difficult to palliate and which improve as their depression is appropriately treated. This study was carried out to determine if there was an association between depression and physical symptoms in patients with advanced cancer and to establish whether a seven-item verbal rating scale asking patients to verbally rate the severity of physical symptoms together with low mood could be used to screen for depression. The scale was validated against a semi-structured clinical interview according to DSM IV criteria. Seventy-four patients participated with an age range of 28–92 years. All patients had an ECOG performance status of two or three. The prevalence of major depression in this study was found to be 27% (95% C.I. 17–37%). The mean score on the verbal rating scale was 28.77 (median score 29.5) (95% C.I., 26.23–31.31; range 0–65). A cut-off of ≥30 gave a sensitivity of 65% and specificity of 59%, with positive and negative predictive values of 37% and 82% respectively. The verbal mood item alone had an optimal cut-off point of 3, with a sensitivity of 80% and specificity of 43%. Patients diagnosed as being depressed according to psychiatric interview rated each symptom higher than nondepressed patients. The verbal mood item and total verbal rating score correlated with a high significance (rs=0.607, P<0.01), implying a relationship between a patient's subjective mood state and other symptoms. Both using the verbal scale and asking patients to verbally rate their mood alone had poor efficacy as a screening tool. However, there is a close association between physical symptoms and the presence of depression in palliative care patients.

Objective: To explore, over a one-year period, the ideas and attitudes of patients with end-stage cardiac failure concerning dying. Design: Prospective longitudinal multiple case study using qualitative interview techniques. Participants: Thirty-one patients from two hospitals who fulfilled one or more of the following criteria: NYHA III or IV, ejection fractionB >25%, at least one hospitalization for heart failure. Main outcomes: Statements of patients with advanced heart failure, expressed in semi-structured interviews, concerning the quality of dying and medical decisions at the end of life. Results: Many respondents only thought about death during exacerbations. Mentioned aspects of appropriate dying include: a degree of usefulness, prognostic knowledge, appropriate duration and mental awareness. Few respondents were in favour of euthanasia or suicide, but all wanted life-prolonging treatment to be withheld or withdrawn when appropriate. Conclusions: Our study found some elements of ‘appropriate dying’ that differ from other studies and that are relatively specific for advanced heart failure. The tendency of patients not to think about death raises ethical concerns.

Inferior vena caval obstruction (IVCO) is an occasional cause of lower limb oedema in palliative care patients with metastatic malignancy. We present five cases who underwent IVC stenting for symptomatic relief. Four of the five cases had significant reduction in their oedema but three of these four patients died within two weeks of the procedure. The procedure itself is described and the appropriateness of this intervention in patients with end-stage disease is discussed.