bluuebunny/crossref_metadata_2025 huggingface dataset:
Measuring the effectiveness of a fatigue and breathlessness group for palliative patients
Authors: Brookes Katie , Edwards Anne , Marshall Samantha , Williams Sarah
Published: March 2012

Background

It has long been known that fatigue and breathlessness for patients with a life limiting illness is prevalent and is frequently rated as having a greater impact on quality of life than pain (Hoekstraet al2007). It has also been shown that often it is not addressed adequately, (Coakleyet al2002). Patients believe that the symptoms are an inevitable part of their disease and patient, carers and some health professionals misguidedly use rest as a coping strategy. In 2007, in order to address these issues in a group setting, the first Fatigue and Breathlessness course commenced at St Peter's Hospice, Bristol. Topics covered on the course are fatigue, breathlessness, benefits of exercise, energy conservation, sleep, anxiety management and nutrition. Patients themselves set goals, and are encouraged to practise what they have learnt in the group at home. One of the biggest challenges has been how to measure the effectiveness of the programme. As highlighted by Pearsonet al(2007) ‘this poses significant problems in palliative care due to the declining function of clients that confounds the apparent effectiveness of the intervention’. An assessment tool has now been introduced which asks patients to measure their symptoms using a visual analogue scale (VAS), alongside a questionnaire which gives a qualitative assessment of abilities and focuses on goal achievement.

Aim

To measure the effectiveness of the course using pre and post VAS scores and qualitative assessment tools such as goal setting and questionnaires.

Conclusion

Goal setting and patient feedback proved to be the most effective tools in providing measurable and meaningful outcomes. This demonstrated a high patient satisfaction rate and improvement in quality of life. We can now provide evidence for the effectiveness of the course in a palliative setting.
Audit of the use of corticosteroids in advanced malignancy: maximising benefit and minimising harm
Authors: Hayle Catherine , Capewell Claire , Morris Debra , Brooks Lindy , Fletcher Andrew , Lowe Joanne , Sanders Dave , Harrison Sophie
Published: March 2012

Background

Corticosteroids are used within specialist palliative care for a variety of indications, from wellbeing to medical emergencies such as spinal cord compression. For benefits to outweigh toxicity, it has been suggested that they should be used according to defined guidelines.

Aim

The NorthWest Audit Group aimed to review the practice of organisations across the Northwest of England regarding corticosteroid use.

Method

This multi-centre, cross-regional, retrospective case-note audit used a standardised data collection tool to gather information on patients with advanced malignancy, known to specialist palliative care. A multi-professional steering group developed standards of good practice against which the first 2 weeks of steroid therapy was audited.

Results

Data were collected on 181 patients from 22 sites including hospital, hospice and community settings. Specialist palliative care professionals were involved in the commencement of steroids in 63%. The indication was documented in 82%, with most commonly cited reasons being anorexia, pain, fatigue and raised intracranial pressure. Previous steroid use was documented in 18%. When patients were prescribed medications that interact with corticosteroids, 4/21 (19%) had evidence of this being taken into consideration. Instructions for blood sugar monitoring were present in 24%. Where there was concurrent aspirin or NSAID use, gastro-protection was prescribed in 36/41 cases (87%). For patients remaining in the same care setting, there was evidence of a dose review in 79%. For those who were discharged from the service, there was a plan for future monitoring in 58%.

Conclusion

This audit was well received with a very positive return. It demonstrated scope for improvement in current practice. Issues highlighted include the need for improvement in documentation of previous steroid use, instructions for blood sugar monitoring and review of drug interactions. Communication is vital when a patient is transferred between services so that monitoring of safety and efficacy is on-going.
Experience of tolvaptan on patients with end stage heart failure
Authors: Broughton Caroline , Murray Andrew , Morley-Davies Adrian , Satchithananda Durwarakan Kirupanantha , Hookey Claire
Published: March 2012

Introduction

Hyponatraemia is common in end stage heart failure (ESHF). It is associated with poorer outcomes and limits the use of increasing doses of loop diuretics to alleviate congestive symptoms. Inability to reduce symptoms from hospitalised patients with ESHF can be the difference between patients dying in hospital or being discharged into the community. Tolvaptan is a vasopressin antagonist with diuretic effect with minimal effect on sodium levels. We present our current clinical experience with tolvaptan in palliative care patients with ESHF, hyponatraemia and congestive symptoms.

Method

Hyponatraemic patients with ESHF and intractable symptoms (either unresponsive to or conventionally unsuitable for further escalation of loop diuretic therapy) were considered for tolvaptan by their managing cardiologist. Seven patients were selected, 1 died on the day tolvaptan was started, notes were unavailable in 1 case.

Results

We report on 5 patients – 4 had tolvaptan started in hospital. Demographics: 4 male, mean age 71.8 years, mean number of co-morbidities was 5.6. Mean duration of treatment was 9.6 days. There were no adverse events or side effects. Loop diuretic doses were continued unchanged in 4 and increased in 1. Sodium Creatinine Weight in mmol/l in μmol/l in kg Before tolvaptan mean (SD) 122(4) 108(57) 81.1 (13.6) After tolvaptan mean (SD) 128 (4) 103 (48) 77.6 (12.4) All hospitalised patients were subsequently discharged. One patient died 3 months after treatment. The total cost of tolvaptan was £4300.80. This appears marginal compared to the total cost of hospitalisation (cumulative in patient stay of 169 days).

Conclusion

Tolvaptan is safe, well tolerated and reduces congestion without significantly worsening either hyponatraemia or (in our patients) renal function. It can aid discharge from hospital to facilitate patient's palliative care choices. Tolvaptan adds to strategies for symptom relief in ESHF by palliative care specialists and cardiologists alike.
Regional audit on the symptomatic management of nausea & vomiting in the medical management of malignant bowel obstruction
Authors: O'Brien Elizabeth , Edwards Laura , Sutherland Aaron , Mitchell Kath , Concannon Maxine , Murray Yvonne , Sanders Dave , Waterman David , Twomey Feargal , Harrison Sophie
Published: March 2012

Background

Malignant bowel obstruction is a recognised complication of advanced malignancy. Surgery is not always suitable therefore antiemetics are the mainstay of symptomatic management. There is little evidence for any specific antiemetic. NWAG was initiated to co-ordinate audits across palliative care settings within the north-west.

Aims

To review the assessment and management of nausea and vomiting in medically managed malignant bowel obstruction. To audit against six standards set following a literature review.

Method

Retrospective, multi-centre review of case notes.

Results

Thirteen organisations returned 101 data collection sheets (5 hospices 8 hospitals). Ninety-nine of these were used (41 from hospices and 58 from hospitals). The presence or absence of nausea, vomiting and colic was documented at initial assessment in 80%, 91%, 80% respectively (n=99). Antiemetics were prescribed via non-oral routes in patients with nausea and/or vomiting regularly in 90% (n=252) and PRN in 97% (n=236). Regular or continuous medications via non-oral routes were prescribed within 48 h of a documented episode of nausea and/or vomiting secondary to malignant bowel obstruction in 68%. Consideration was given to reviewing management of nausea and vomiting in patients requiring two or more PRN medications for nausea and vomiting in the preceding 24 h. Day 2 82% (n=22), Day 4 88% (n=19). Metoclopramide was stopped if colic was present in 27% (n=11). 6. The co-prescription of cyclizine and metoclopramide should not occur – regular 100% (n=99) Regular +PRN 93% (n=99)

Conclusion

Regular assessment of symptoms is crucial in patients with medically managed bowel obstruction. Frequency and route of administration should be considered. Regular review is required to establish effectiveness of management and the need for change. PRN and regular medication combinations need assessment.
‘Dead-tired’ – a novel MDT approach to fatigue management for patients with advanced disease
Authors: Bowler Emily , Malik Farida
Published: March 2012

Introduction

Fatigue is a common and distressing symptom for patients with malignant and non-malignant disease.1 The importance of specific training programmes for managing fatigue have been cited.2 The authors describe an innovative multi-professional fatigue clinic for patients with advanced disease.

Methods

A palliative care occupational therapist/physiotherapist-led fatigue clinic was developed in the day therapy unit in St Wilfrid's Hospice, Eastbourne. The clinic involves 4 weekly sessions; topics include breathing techniques, graded exercise, energy conservation (pacing, prioritising), energy restoration (nutrition, sleep, relaxation) and a complimentary therapy led session. Data collected as part of the service included patient self-reported fatigue (brief fatigue inventory (BFI)) collected at start, 4 weeks & 5-week follow-up) and demographics. Patients also completed a fatigue diary and service evaluation. Descriptive statistics were used to describe service findings. A paired t test was used to describe difference in global BFI score at start and at 4 weeks.

Results

Twenty-seven patients were referred to the clinic (25 internal hospice referrals) 18 started the service. Nine patients were unable to start (seven unwell, one died, one declined). Results are available on 17 patients (mean age 64.6 years (SD 10.7), 71% female,) 16/17 had a cancer diagnosis (5/16 had breast cancer, 5/16 colo-rectal cancer). Mean global BFI at start=69.1 (range 48–85) and at 4 weeks=54.9 (range 40–72). Mean improvement in global BFI score=14.2, t=3.3, p=0.02, n=10. Patients positively evaluated the service. Further data for 5-week follow-up, to follow.

Conclusion

Findings suggest the fatigue clinic appears beneficial in managing patient fatigue. Early referral is recommended, so patients are seen before their disease has progressed too far.
Assessing healthcare professionals knowledge and improving mouth care within a palliative care unit
Authors: Smith Louise , Gale Sue , Newberry Leanne
Published: March 2012

Introduction

Mouth care is essential to provide comfort for the dying patient. Good oral care (assessment, planning and delivery) is underpinned by healthcare professionals' (HCPs) knowledge and utilisation of appropriate tools and care plans. A multi-phase study was commenced within a 16 bed inpatient unit to ascertain factors impeding nursing practice, which staff had felt to be suboptimal.

Method

In phase 1, qualitative data were collected from 42 HCPs in a survey comprising 14 open questions and thematic analysis applied. The survey asked HCPs' knowledge, current practice and ideas on improving oral care. Following this an assessment tool, care plan and a purposefully designed product guide were introduced. In phase 2, a second survey reanalysed HCPs' knowledge acquired after implementation of the tools. The Royal Marsden Manual (2008) was used as a point of reference during both phases.

Findings

Phase 1 found that 95% of respondents understood the aims of good mouth care, factors leading to poor oral health (reduced oral intake (75%), poor oral hygiene (65%) and medication (45%)) and actions to be taken if problems were suspected (70%). However procedural knowledge of oral assessment was poor and use of assessment tool/s deficient. 90% of respondents failed to identify half the recommended equipment for assembling an oral care tray. Following introduction of the tools, phase 2 survey showed HCPs' knowledge had increased, and patients had benefitted.

Conclusion

Although collectively some responses in phase 1 appeared good, on an individual basis findings showed HCPs' knowledge was suboptimal. Phase 2 showed that the introduction of the assessment tool, care plan and product guide, had increased HCPs' knowledge and confidence. Consequently patients routinely experienced higher quality care, now evidenced in the revised documentation.
An audit of opioid prescribing at a teaching hospital
Authors: Chhana Sital , Dickman Andrew
Published: March 2012

Background

After receiving reports of 5 deaths and over 4200 dose-related patient safety incidents concerning opioid medicines up to June 2008, the UK National Patient Safety Agency issued a rapid response report.1The NPSA issued guidance that should be applied when prescribing, dispensing or administering opioids.

Aims and objectives

The aim of this project was to assess the current prescribing of schedule 2 and 3 opioids in teaching hospital and identify preventable errors over a 2-week period.

Method

Over a 2-week period, pharmacists on medical wards identified patients receiving schedule 2 or 3 opioids for chronic pain, whether the patient was admitted on treatment or it was newly prescribed. This generated a list of inpatient charts that were audited prospectively against local and national guidelines.

Results

Seventy patients who had been prescribed opioids for chronic pain were identified. The majority of prescriptions (56%) were written by FY1 doctors. Most of the patients (83%) were already prescribed regular opioids on admission; 81% were prescribed the correct opioid dose as per admission drug history, while the 19% were purposefully changed to new treatment. Dose changes were performed correctly in 80% of the cases, with increases being within 30–50% of the previous dose. Two thirds of ‘as required’ doses were prescribed inadequately, either not being prescribed at all, or the dose had not been calculated as 1/6 of the background dose. Almost three-quarters (73%) of patients were not co-prescribed a laxative.

Discussion/conclusion

During this audit two main areas of error with opioid prescribing were highlighted: prescription of ‘as required’ medication and appropriate co-prescription of a laxative. The results suggest that prescribers are not familiar with certain aspects of opioid treatment. Since the majority of prescribing was performed by junior doctors, this study has highlighted the need for additional education and training.
Comparison of management of noisy breathing at the end of life in two Hospices in the UK
Authors: Subramaniam Sivakumar , Thiru Thirukumaran , Cawley Declan , McGee Helen , Parker Georgina , Fisher Simon
Published: March 2012

Background

Excessive respiratory secretions are common at the end of life. A Cochrane review concluded that there was no current evidence of effectiveness of current interventions but it is a symptom that relatives find distressing in end of life care. Therefore clinicians need to balance the available evidence with the distress remarked on by relatives.

Aim

To compare audits on the management of ‘death rattle’ in two hospices against national guidelines.

Methodology

Retrospective, case note review of inpatients who died over a 5 month period in 2010 (Unit 1) and in 2011 (Unit 2). Results Unit 1: 73 patients: 66 had antisecretory medication prescribed. Twenty-four patients needed the medication. 27/66 had incorrect doses prescribed. 21/24 had response assessed/documented. 18/24 patients documented benefit from the antisecretory drug. Non-Pharmacological measures, 2/24 patients had evidence of re-positioning only with no documentation of communication with the family (0/24). 20/24 patients died within 48 h of the first dose of antisecretory medication. Results Unit 2: 72 patients: 65 had antisecretory medication prescribed. 36 patients needed the medication. 16/65 had incorrect doses prescribed.29/36 response assessed/documented. 24/29 patients had documented benefit from the antisecretory drug. Non-Pharmacological measures, 3/36 patients had evidence of re-positioning with 4/36 documentation of communication with the family. 22/36 patients died within 48 h of the first dose of antisecretory medication.

Conclusion

Patterns of antisecretory medication appears very similar pattern in both hospices. In the majority of cases, documentation supported adherence to the national guidelines. Of note is the considerable dose variation in the drugs prescribed. This has been highlighted as an education and training issue. The supporting documentation to evidence the use of non-pharmacological measures but also in communicating with the relatives about the ‘death rattle’ needs further work.
Cross purposes? Challenges of providing palliative care to frail older people in a community service
Authors: Skilbeck Julie , Arthur Antony , Seymour Jane
Published: March 2012

Background

Providing palliative care to frail older people in the last years of life is challenging. Increasingly this is becoming a focus of Community Matrons (CM) work. Effective communication between CMs and frail older people is vital, ensuring that palliative care needs are identified, responded to and met; a key requisite of the End of Life Care Strategy (DOH 2008).

Aim

To explore interactions between CMs and frail older people towards the last year of life.

Study design

A prospective, longitudinal case study design, using ethnographic data collection methods. Ten participants aged 75 years and over, receiving care from a CM, were recruited. Participants followed up approximately monthly for 6 months or until death. In total, 49 interviews were conducted with older people; 49 CM visits were observed. Medical documents were reviewed for 10 participants. Data were audio-recorded and transcribed verbatim. Analysis involved theme identification, with cross case comparison.

Findings

A feature of the interaction between the older person and CM was ‘being at cross purposes’. This occurred when: the older person's concerns were discussed; changes were proposed to their routine; end of life conversations were initiated; role expectations differed. The outcome of these interactions led to the older person's concerns not being identified, and at times a lack of trust. These interactions typically occurred during transitions in health status.

Discussion

How care is organised contributes to CMs and older people unintentionally being at cross purposes. CMs work is framed by a policy of Risk and Clinical Assessment, which can be at odds with a palliative approach. Assumptions underpinning the label of frailty, and the impact of transition on the older person, compound this further. Commissioners of community services for frail older people need to consider these competing demands so that CMs can engage more effectively in palliative care provision.
Identifying and managing the emotional support needs of nurses delivering paediatric palliative care in the community
Authors: Reid Fiona
Published: March 2012

Background

The death of a child is a rare phenomenon in the western world, being a highly emotive and subjectively distressing event. There is a misconception surrounding the level of nursing expertise, and an underestimation of the degree of emotional work required to undertake the delivery of end-of-life care to children and young people (CYP).1 Exposure to repetitive episodes of stress and psychological dysfunction influences nurses grief, relationships, personal health, professionalism, decision-making and ultimately, future care delivery.

Aim

To identify the stressors, obstacles, emotional demands, and support needs of nurses delivering paediatric palliative care in the community setting.

Methodology

A qualitative design was used, involving indirect purposive sampling of relevant nurses. Seventeen 1:1 semistructured interviews were conducted, and the data analysed using a thematic approach, with defined topics extrapolated.

Results

Interrelated factors emerged that influenced the stressors for nurses, and coping mechanisms that they utilised: organisational structure, relationships and team working, community context, self-efficacy, coping strategies and support systems. shared and/or discrete issues could be distinguished between the various nurses dependent on qualification, care context, rurality, education and numbers of paediatric palliative care episodes delivered.

Conclusion

The delivery of palliative care to CYP is complex and multifaceted. This qualitative exploration serves to provide insight into nurses previously undocumented feelings. It highlights the private, professional and work-related variables that impact on the stressors, challenges, rewards and support systems for those nurses working in this field. New findings and areas for further research are identified, and recommendations made regarding comprehension of rural healthcare, team-working, support platforms and education for this group of nurses.
Comparing the use of Edmonton symptom assessment system (ESAS-r) in hospice & oncology outpatients
Authors: Subramaniam Sivakumar , Burcombe Russell , Cawley Declan
Published: March 2012

Current guidance, nationally and internationally, would suggest within oncology and hospice outpatient settings holistic assessment be completed. However how this should occur and what assessment tool be used, there is no agreed consensus.

Aim

To explore the use of a validated patient reported symptom assessment tool within a lung oncology and hospice outpatient setting.

Methodology

An exploratory study looking at patient reported ESAS-r assessment form completion prior to attending their clinic review with an oncology and hospice setting and the data collected, analysed for comparison.

Results

Total number of Hospice patents: 22 (male13: female 9), age: 42–80 versus total number of Oncology out patients: 26 (male14: female 12), age: 54–91. The median total symptom score for hospice outpatients was 34.5/100 versus median total score for Oncology outpatients was 23.5/100. Tiredness (6.5/10) and drowsiness (5/10) were the high scoring symptoms within hospice outpatients while tiredness (5/10) and wellbeing (5/10) were in the lung cancer outpatient setting. The median score for pain and shortness of breath was 3/10 & 0/10 in Hospice patients versus 1/10 & 1.75/10 in Oncology clinic patients.

Conclusion

The symptom scores were comparable and not surprisingly the median scores were higher in the hospice outpatient setting. The physical and psychological symptoms scored significantly higher in the hospice outpatient population. The authors acknowledge the small sample size and this was an exploratory piece of work. However, clinicians found the ESAS-r tool to be clinically useful and helped focus discussions about what was important from a patient's agenda but helped in the disclosure of commonly ignored symptoms such as fatigue. This then prompted further assessment for eligibility for clinical trials specifically directed at fatigue management. Therefore the use of a patient, self-reported holistic assessment tool is a useful addition to oncology and hospice outpatient clinics.
The management of breakthrough cancer pain (BTCP) and the use of immediate release fentanyl products
Authors: Nwosu Amara , Marley Kate , Sulaivany Esraa , Dickman Andrew , Curie Marie , Littlewood Clare
Published: March 2012

Background

Breakthrough pain is a common problem for people with cancer, and is associated with significant morbidity in these individuals. The association of palliative medicine (APM) has produced guidelines for the management of breakthrough cancer pain (BTcP). Immediate release fentanyl products are licensed for the management of BTcP; however, some practical concerns exist about their safety and routine use in clinical practice.

Aims

(1) To identify the multi-disciplinary team (MDT) experience in managing BTcP in relation to APM guidance. (2) To identify the MDT experience of using immediate-release Fentanyl products in the management of breakthrough cancer pain. (3) To develop new regional guidelines to help health professionals manage breakthrough cancer pain.

Methods

A literature review informed the development of two audit surveys which examined the health professional's experience of: (1) Managing a patient with BTcP. (2) Using short acting Fentanyl products. Electronic surveys were distributed to multidisciplinary members of four integrated cancer networks during the month of August 2011.

Results

Twenty-eight BTcP surveys and 29 fentanyl products surveys proformas were completed. BTcP was identified correctly in most instances (80.8% of individuals had their background cancer pain controlled). Oxynorm was the most popular short-acting opioid (32% of occasions); Abstral was the most popular immediate-release Fentanyl preparation across hospice, hospital and community settings. Most episodes of BTcP were relieved in 30 min (56%). Concerns about storage and disposal (45%), delay in accessing medicines (45%), prescribing issues (62%) and education of generalists (62%) were highlighted by respondents.

Conclusion

Most episodes of BTcP were correctly identified and pain tended to resolve within 30 min of receiving analgesia. Concerns around prescribing and the education of generalists were highlighted by respondents. The findings were presented and discussed at the Regional Specialist Palliative Care Audit Group Meeting. Local guidelines and standards were agreed for publication.
The potential role of wicking fabric for the management of sweating in advanced malignant disease
Authors: Brooks Simon , Harris Dylan
Published: March 2012

Background

Sweating is an underreported and frequently distressing symptom that can occur in cancer patients. Treatment options are varied and often unsuccessful and patients may not want to try new medication that has adverse effects or increases their tablet load. Non-pharmacological interventions such as cotton T-shirts can be tried but patients may find that they quickly become wet and cold and require frequent changing. There may be a role for garments made from wicking fabric which draw sweat away from the body.

Aim

To explore the potential role of wicking fabric for the management of sweats in advanced malignant disease through a case study.* A 54-year-old lady with multiple myeloma experienced frequent drenching sweats, mainly at night. There was no associated fever. Paracetamol, non-steroidal anti-inflammatory drugs and corticosteroids were not helpful. She found that cotton T-shirts became uncomfortably wet, making her feel cold, and they often needed changing overnight leading to lack of sleep. By using wicking fabric T-shirts instead, she was able to enjoy undisturbed nights for several weeks and awoke feeling refreshed and relatively dry. She also found the wicking T-shirts helpful in the management of her daytime sweating. Overall she felt that the wicking garments significantly improved her quality of life at that time.

Conclusion

This case study, in the context of the available evidence, suggests a potential useful role of wicking fabric. A randomised crossover study comparing cotton T-shirts with those made from wicking fabric in the management of malignant sweating is now being developed to explore this theme further. *Verbal consent was obtained from the patient who sadly passed away before written consent could be obtained. Written assent provided by patient's husband.
An audit into the knowledge of pain control among medical staff in a Ugandan teaching hospital
Authors: Royston Rachel , Morgan Willoughby
Published: March 2012

Uganda was the first African country to make palliative care part of its National Health Policy, in 1999. But provision remains patchy and consequently the awareness of important palliative care principles among general healthcare staff is also variable. Mbarara Regional Referral Hospital (MRRH) in South-West Uganda has no resident palliative care team, but services are provided by three times-weekly visits from the charity Hospice Africa who prescribe and dispense oral morphine. The hospital pharmacy, despite having access to morphine, has filled no prescriptions for it from hospital clinicians between September 2010 and March 2011. The question was raised whether non-prescribing of morphine reflects deficient knowledge of pain control among medical staff. This audit therefore aimed to explore knowledge and attitudes toward pain control among medical staff in MRRH and then target an intervention to improve awareness. In addition, current analgesia prescribing practices were audited. A questionnaire was distributed to doctors and students within the medical department to assess baseline knowledge against eight audit standards. After an education programme, the questionnaire was then re-distributed to evaluate any change in understanding. In addition, ‘snapshot’ audits of all analgesic prescriptions on the medical wards were conducted before and after the educational intervention. Initial knowledge of analgesia and attitudes towards its use showed deficiencies in a number of areas. These gaps in understanding showed universal improvement after the educational sessions. However, the audit of prescribing demonstrated only a small increase in correct prescriptions over the audit period. These results demonstrate that targeted education was successful in improving physician's knowledge of pain control, however in order to maximise correct prescribing an alternative intervention seems to be required.
An audit of the multidisciplinary management of malignant bowel obstruction on an oncology ward in an acute tertiary hospital
Authors: Ryan Richella , Bruce Emma , Leithead Jane
Published: March 2012

Background

Malignant bowel obstruction is common in advanced cancer. It is frequently associated with a poor prognosis. Management is complex and requires multidisciplinary input. Though management decisions need to be individualised, the assessment process leading to such decisions should be systematic.

Aims

The primary aim was to provide baseline information on key areas of malignant bowel obstruction management for future auditing purposes. A secondary aim was to assess compliance with the current hospital guidelines for the medical management of this condition.

Methods

The medical notes for 32 admissions to the oncology ward of an acute tertiary hospital between 31 July 2009 and 1 August 2010 were reviewed. Data was entered onto a proforma. Descriptive statistical analysis was performed using SPSS.

Results

The majority of patients had advanced cancer with peritoneal metastases (28.88%). Ovarian was the most common primary site (17.57%). 15 (47%) patients were committed to a course of chemotherapy at presentation. The majority of patients had symptoms of nausea (26.81%), vomiting (26.81%), abdominal pain (26.81%) and altered bowel habit (27.78%). Medications were administered via a continuous subcutaneous infusion in 19 (60%) cases. A nasogastric tube was inserted in 10 (31%) cases. Cyclizine was the most commonly used first-line antiemetic (57%). Octreotide was rarely used (3.9%). Treatment of persisting bowel obstruction included: chemotherapy (13.41%), surgery (3.9.4%), radiotherapy (1.3%), stenting (5.15%) and venting gastrostomy (1.3%). 7 (22%) patients were commenced on parenteral nutrition. Twenty-seven patients (84%) survived to discharge and, of these, 20 (74%) were discharged home.

Conclusion

The results indicate that the presentation and nature of malignant bowel obstruction is heterogeneous and that treatment decisions vary widely. The current local guidelines are under review to promote more consistent management and to guide referral to important disciplines.
Pictorial prescribing reduces error in administration of fentanyl for breakthrough pain
Authors: Booth Stephen , Gloag Maria , Kinna Sara , Wheble Andrew Bell Jo , Wheeler Daniel
Published: March 2012

Objectives

Fentanyl is commonly used in patients with transient exacerbations of cancer pain due to its rapid transmucosal absorption. Intranasal sprays, sublingual tablets, and buccal tablets or lozenges are available. The preparations are not interchangeable, with varying bioavailability, creating potential for opioid prescribing errors. This study aimed to demonstrate a reduction in opioid medication errors via a novel and low cost strategy: the use of printed stickers for prescription charts with a pictorial cue illustrating the preparation.

Methods

Fifty-four nurses from our institution were shown 10 handwritten or printed pictorial sticker prescriptions for fentanyl for breakthrough pain. They were asked to indicate which preparation and dose they would administer from boxes of Instanyl (Nycomed), Abstral (ProStrakan), Effentora and Actiq (Cephalon), and to indicate the ease with which they understood the prescription on four-point Likert items. The authors measured the frequency with which nurses selected the wrong preparation or dose. Likert items were analysed categorically as positive or negative responses. Results are reported as OR with 95% CI, and were compared using the χ2test.

Results

Nurses were more likely to choose the correct fentanyl preparation when using pictorial printed stickers compared to handwritten prescriptions: errors were significantly reduced from 20 to 6 (OR 3.52, 95% CI 1.39 to 8.90, p<0.005). Also, dose errors were non-significantly reduced from 27 to 19 (OR 1.47, 95% CI 0.80 to 2.70, p=0.057). Analysis of Likert items showed a significant improvement in understanding of which preparation to administer: positive responses increased from 227 of 267 responses with handwritten prescriptions to 247 of 266 responses with pictorial printed stickers (p<0.0005). Conclusion: Using pictorial printed stickers is an effective strategy for reducing errors in choice of rapid-onset fentanyl preparations. There may be a wider use for pictorial prescribing where many non-interchangeable preparations of the same drug exist.
Malignant bowel obstruction: current practice in an inpatient specialist palliative care unit
Authors: MacKay Helen , Isherwood Ruth
Published: March 2012

Background

Malignant bowel obstruction (MBO) is a distressing complication of many advanced cancers, notably those of ovarian or colorectal origin. Most patients with advanced disease are managed medically to improve their symptoms, however variation exists in how this is achieved.

Aims

The audit aimed to establish current practice in the management of MBO within a hospice inpatient unit, prior to writing evidence-based guidelines for use locally.

Methods

Cases were identified by reviewing letters written for the last 100 patients who had died in the inpatient unit. Records were retrieved for patients with: MBO as certified cause of death; symptoms suggesting obstruction (nausea, vomiting, colic, abdominal distension, constipation); or cancers with a propensity to cause obstruction at any level. Case notes were reviewed and a database created to collate information including; primary diagnosis, presence of metastatic disease, likely cause of MBO, symptom response, pharmacological agents used and outcome of obstructive episode.

Results

Fifty-one case records were consulted after screening. Twenty-three patients had clinical presentations suggestive of MBO. The majority (n=17) were female. Ages ranged from 50–89 years. Colorectal and gastric cancers were the commonest primaries. Eighteen patients received an antisecretory agent; nine were prescribed octreotide alone, two hyoscine butylbromide alone and seven a combination of both agents. Octreotide doses ranged from 200 mcg–1200 mcg/24 h. Indications for adding hyoscine butylbromide (20 mg 180 mg/24 h) were persisting large volume vomiting and the development of colic. Symptom improvement was recorded for all patients. The episode of obstruction resolved clinically in only two cases.

Conclusion

This audit suggests that octreotide is the first line antisecretory agent in use within the Hospice. Hyoscine butylbromide was added for patients with on-going symptoms. Inclusion of hyoscine butylbromide as an additional antisecretory appeared of value in achieving symptom control, which the forthcoming guidelines will reflect.
Use of intravenous drugs in palliative care
Authors: Ahamed Ashique , Richardson Sian , Newell Julia , Ahmedzai Sam H
Published: March 2012

Background

The use of oral and subcutaneous medications is well established in palliative care. There are however certain situations where these routes may not be appropriate or effective in symptom control of patients. Below we illustrate three recent cases where intravenous administration of drugs helped relieve intractable symptoms and thus improve quality of life of patients. Case 1) 26-year-old male. Diagnosis Acute promeylocytic leukemia. Developed severe nausea and vomiting following chemotherapy. Symptoms not controlled on Metoclopramide, cyclizine or ondansetron. Patient very distressed by the symptoms. Commenced on IV Levomepromazine infusion. Significant improvement in symptoms after 3 hours. Nausea completely resolved after 4 days. Case 2) 55 year old male. Diagnosis :Advanced metastatic prostate cancer. Developed Intracerebral haemorrhage and splenic infarcts secondary to DIC. Severe pain, vomiting and in distress. Symptoms not well controlled on oral/s/c or transdermal medications. Also developed severe bruising at syringe driver sites. Commenced on Intravenous infusion of Oxycodone, Midazolam and Levomepromazine. Significant improvement in symptoms within a few hours. Further titration according to PRN requirements. Patients condition deteriorated after a few days but remained symptomatically well controlled. Case 3) 57-year-old male. Sickle cell disease. Chronic painful bilateral leg ulcers, oral analgesics ineffective. Commenced on s/c ketamine infusion. Initial mild improvement in symptoms but developed severe site reactions which persisted despite addition of steroids and frequent site changes. Commenced on intravenous ketamine infusion. Significant improvement in pain within 24 h.

Conclusion

Intravenous administration is an effective way of managing symptoms and should be considered in management of refractory symptoms where other method have been unsuccessful.
Achieving preferred priorities for care (PPC): an audit of hospital to home discharges
Authors: Wigmore Nicola , Brennan Tracie
Published: March 2012

Introduction

Increasingly more patients wish to die at home. However it has been identified patients and their carers experience poor hospital discharges as a result of fragmented communication and inadequate co-ordination of services. The anticipated outcome of this audit was to identify areas for improvement for patients and their carers.

Aim

The aim of this audit was to highlight both positive and negative aspects of hospital to home discharges and its emotional impact on patients and their carers. While identifying ways in which Hospice at Home (H@H) can improve the transition from hospital to home.

Methods

The audit contained a two part questionnaire, completed on 30 referrals to the H@H team. The questionnaire identified areas of particular interest for example district nurse involvement, medications and transport, including patients and carers perspective.

Results

Not all patients arrived home therefore did not achieve their PPC. For those that arrived home there were various contributing factors leading to patients encountering a fractured discharge, for example, medication, transport and time of arrival home. Overall, patients and their carers reported negative experiences of their discharges, however despite this carers agreed their decision to bring the patient home was the right one.

Conclusion

Significant changes are needed to improve discharges from hospital to home. Services need to be more co-ordinated with an improvement in communication between the acute and primary setting. Delayed or unsupported discharges are memorable and have a long term impact on patients and their carers.

Recommendations

A large number of recommendations were derived from the audit incorporating various areas, for instance, education, communication, transport and the extension of services like H@H. The recommendations from the audit can be applied nationally to any discharge regardless of setting.
A service development to educate healthcare assistants about physical rehabilitation which focusses on independence in an inpatient hospice unit
Authors: Atkinson Rachel
Published: March 2012

Rehabilitation is a specialty in its own right, with a powerful emphasis on inter-professional working to help patients improve their independence. Due to medical advances people with life limiting illnesses are living longer and even though they will not be cured rehabilitation has a vital role in improving their lives over the time they have ahead. This concept may seem strange in the context of palliative care but the goals of rehabilitation and palliative care are the same in helping a person to become as active and independent as possible. The aim of this service development is to educate Health Care Assistants (HCAs) to promote a physical rehabilitation approach in a 31 bedded in-patient hospice unit that focuses on independence. A series of education and practice interventions were developed. They were implemented through group tutorials, display boards and clinical facilitation, with an evaluation of all of these strategies. It has shown that the HCAs who participated found that their knowledge and confidence around the techniques increased. The impact of this service development however was difficult to measure due to poor uptake and evaluation of the educative strategies employed. This service development has demonstrated that the education of HCAs has the potential to improve the rehabilitation of palliative care patients but that this needs to be delivered in a way that ‘fits around’ the daily work of HCAs and has to be recognised as an important part in the culture of the hospice. Those who participated in the service development evaluated it positively, feeling that they were in the position to carry out the techniques and practice with the patients. A further outcome of the development is to consider different ways to provide the classroom teaching and clinical facilitation within the organisation to allow greater participation from staff.
Survivorship of the specialist palliative care team
Authors: Waldock Joy , Lambert Kath
Published: March 2012

Background

MYSPC community team consists of six WTE CNSs supported by three consultants, covering a population of 360, 000. Long term sickness in the team and difficulties recruiting became an acute crisis with additional sickness in spring 2011. At most times from May 2011 we had less than 1/3 of our nurses. After discussion within the team a difficult decision was reached and we issued the following: It is with regret that the Mid Yorkshire Macmillan specialist palliative care team have to inform you that we are unable at this time to accept referrals for face to face consultations/domiciliary visits for community patients in Wakefield and North Kirklees. This is due to unprecedented sickness in the team and the decision has not been taken lightly. Please continue to send in referral forms and these will be reviewed each day by a consultant who will liaise with you by telephone to offer advice. Please accept our apologies for any inconvenience this causes and we will return to normal service as soon as we are able.

Aims

The authors compare a 3 month period of staffing shortage with 3 months in the previous year demonstrating impact on the clinical service. Areas: • Referral numbers • Level of intervention • Face-to-face contacts • Re-referrals • Triage methods • Use of other services • Impact on non-clinical work • Emotional impact on the team.

Conclusion

The impact has been significant and has resulted in changes in the way the team responds to referrals. Although this has been a difficult time it has ensured we reflect on the way we work with primary care colleagues. The authors have to utilise our skills and time to maximise effectiveness. The authors will be able to make recommendations for future models of working, not just at times of crisis.
Delivering palliative care in a rural setting
Authors: Jones Angela , Johnstone Ros , Cadwalader Betsi
Published: March 2012

Palliative care delivery in rural settings requires a flexible multidisciplinary team approach, drawing on various levels of knowledge and expertise to optimally support the patient, and their relatives/carers. The model evolved and successfully implemented across a wide rural area in North Wales, consists of palliative care consultants, Macmillan nurses, hospice at home nurses and allied health professionals, all providing input into the care of terminally ill patients. Linking with healthcare professionals in acute and primary care settings including residential care, the team deliver clinical and non-clinical care 7 days a week. Clinical work entails direct patient contact involving assessment, planning, implementation, evaluation and review of care. This involves liaison between palliative care consultants, GP's, pharmacy, district nursing teams, allied health professionals, private/charitable agencies and travelling time. The provision of specialist palliative care education is tailored according to need, and delivered locally also, a wider concurrent programme of educational sessions is systematically delivered to enhance continuing professional development. Operating in the West of a large NHS organisation the multidisciplinary team funding is four-fold and includes contributions from statutory and voluntary sectors. These factors, introduce specific management challenges shaping the model of service provision. This model has been 10 years in development, a time of change within the NHS. Lessons learnt highlight communication, forward planning and an entrepreneurial approach. The model reflects best-practice and as it continues to mature the authors are confident in offering our experiences to others wishing to explore exemplary models of palliative care service provision in a rural setting.
Mind the gap: do tertiary cancer centres need 24 hour access to specialist palliative care services?
Authors: Pooley Owen , Coackley Alison , Noble Agnes , Griffiths Ann , Arundell Donna
Published: March 2012

Background

The National Institute for Clinical Excellence recommended that Cancer Networks should provide 24 h access to specialist palliative care telephone advice. The Manual of Cancer Services 2004 suggested that a telephone advice service should be available to core members of cancer MDTs. Clatterbridge Centre for Oncology is a tertiary cancer centre with more than 7000 new patients every year. A specialist palliative care service is available 7 days per week 9–5 but the 24 h access is provided by an informal arrangement with a single clinician. Healthcare professionals working in tertiary cancer centres often have an increased knowledge of palliative care and it has been suggested that 24 h access to specialist advice may not be as important as for district general hospitals.

Aim

To explore the views of healthcare professionals working in a tertiary cancer centre about the need for 24 h access to specialist palliative care advice.

Method

A questionnaire was distributed to healthcare professionals in a tertiary cancer centre asking for their views on: areas of concern use of current informal advice provision impact of advice on patient care.

Results

The questionnaire was distributed to 129 staff. The response rate was 47%. In the previous 4 weeks advice had been required on 46 occasions. 54% of staff had requested advice. 97% found the advice very helpful.100% felt that the advice had a positive impact on patient care.

Conclusion

This survey demonstrated that staff in a tertiary cancer centre had palliative care educational needs and valued access to specialist palliative care advice believing that it had a positive impact on patient care.