bluuebunny/crossref_metadata_2025 huggingface dataset:
Confusional states in advanced cancer-a flow diagram
Authors: Stedeford Averil , Regnard Claud
Published: November 2007

The many potential causes of confusion, and the difficulty of accessing a confused patient, can make this an exceptionally complicated problem to assess, manage and treat. This flow diagram outlines an approach to confusion which emphasizes the need to assess fully, treat appropriately and to realize that confusion can be managed even in the face of irreversible causes.
A clinical comparison of laxatives in a hospice
Authors: Sykes NP
Published: November 2007

Codanthramer standard strength was compared by means of a randomized crossover clinical trial with a mixture of equal proportions of lactulose and senna. Subjects were hospice inpatients who had cancer but had had no bowel diversion or evidence of intestinal obstruction. Lactulose/senna produced a significantly greater stool frequency than codanthramer in patients receiving strong opioid analgesia and reduced the usage of rectal measures. Patients' subjective assessment of bowel function indicated that lactulose/senna was more likely than codanthramer to relieve constipation or to restore normality. The incidence of diarrhoea was greater with lactulose/senna, but not significantly so when measured by patients' perceptions. Despite the difference in efficacy, patient preference was evenly divided between the agents, although there was some criticism of codanthramer's taste. It is concluded that standard strength codanthramer is less effective than the same volume of lactulose and senna in equal proportions and is more expensive. Strong codanthramer may redress the cost imbalance, but this remains to be tested. It is also suggested that a laxative dose protocol related to dose of opioid analgesia may improve the effectiveness of oral laxative therapy.
St Columba's Hospice Home Care Service: an evaluation study
Authors: Hockey Lisbeth
Published: November 2007

Between January 1988 and December 1989 a study to evaluate the Home Care Service of St Columba's Hospice (Edinburgh, UK) was undertaken. General opinions about the service were sought of patients, their carers, district nursing staff, general practitioners and the home care staff themselves. In addition, data on 66 patients were collected from their general practitioners, their district nursing sisters if applicable, the patients and/or their carers. The hospice records of the same patients were studied. It was possible, therefore, to collect information on specific patients from several sources, thereby constructing a complex and unique picture of their care seen from different perspectives. The data were assessed in relation to the hospice's declared aims of the home care service. The study also included analyses of ten years' records of all patients who had received home care within the hospice's outreach. Some weaknesses in communication were identified and there was a consistent plea by district nursing sisters and home care staff for earlier referral of patients. It is concluded that, on a general level, the home care service's aims were met.
Griefwork with children - Workshop Days at Pilgrims Hospice in Canterbury
Authors: Burroughs Alan G , Tyler Jenny , Moat Ian B , Pye Sylvia
Published: November 2007

Discussions at Pilgrims Hospice about the needs of bereaved children grieving the loss of a parent or grandparent led to a search to discover what others were doing in this field. Little appeared to have been published. We determined to tackle this problem by using a multidisciplinary approach and focusing upon the skills of the art therapist and diversional therapist backed up by the counsellor and social worker. We designed 'Childrens' Days' allowing them to bring to our attention their own feelings, fears and frustrations. The article describes how this was done and the childrens' own reactions.
AIDS related diarrhoea: a rational approach to symptomatic treatment
Authors: O'Neill William M
Published: November 2007

Diarrhoea is a common problem in patients with HIV disease. This may be caused by a variety of pathogenic organisms many of which are difficult to isolate. Specific antimicrobial treatment is limited both in availability and effectiveness. Symptomatic treatment need not be delayed. Loperamide and morphine are the antidiarrhoeal drugs of choice.
Nutritional aspects of advanced cancer
Authors: Shaw Clare
Published: November 2007

Nutritional support has an important role in enhancing quality of life in advanced cancer, whether the aim is to enhance cancer treatment, support rehabilitation or promote the enjoyment of food. There are many causes of nutritional disorders and palliation can be achieved in a variety of ways. The advice and support of a dietitian can be invaluable.
The role of intrathecal neurolysis in the treatment of cancer-related perianal and perineal pain
Authors: Lynch John , Zech Detlev , Grond Stefan
Published: November 2007

In this study of intrathecal neurolysis with phenol in nine patients with perianal or perineal cancer-related pain, we found a short duration of pain relief (17.8 days) and a significant incidence of serious side effects, with two patients having permanent urinary retention. The average daily oral morphine dose could be reduced by approximately 20% during this time but in only two out of nine patients could opioids be stopped for a period of four weeks. Conventional analgesic pain treatment based on WHO guidelines remains of paramount importance in the treatment of cancer-related perianal pain, as does the prior utilization of other lower risk techniques before considering the use of intrathecal neurolysis (ITN). Intrathecal or epidural opiates may be a preferable technique for patients with pelvic or perineal pain, and intact bladder and/or bowel function. Improved patient selection, a better understanding of the pathophysiology of the underlying pain, and appropriate timing in performing ITN during the course of the disease may result in higher success rates.
Spinal cord compression in malignancy
Authors: Kramer Jocelyn A
Published: November 2007

The prevalence, pathophysiology and clinical features of spinal cord compression are reviewed, with particular emphasis on the diagnostic challenge presented by the patient with metastatic disease, back pain and normal neurological findings. Methods of investigation and treatment options are reviewed. Interdisciplinary collaboration is essential in formulating treatment decisions and evaluating outcomes. Palliative medicine physicians need to be aware of the possible benefits available to patients from a positive approach to the diagnosis and treatment of spinal cord compression.
Quality of care of the terminally ill: the carer's perspective
Authors: Sykes Nigel P , Pearson Sally E , Chell Susan
Published: November 2007

The experience and opinions of carers of 106 patients dying of cancer in Pontefract Health District were obtained by semistructured interview approximately six months after bereavement. A balanced population of patients who had died either at home or in hospital was selected by quota sampling. The interview investigated the perceived quality of key areas of care and also collected carers' spontaneous comments about the service. These comments were grouped into the following categories related to dimensions of satisfaction with health care: organization of care; interpersonal relationships with health care professionals; communication of information; and the hotel services and environment in hospital.

A total of 106 carers, 63% of those contacted, were interviewed and there was no significant difference in response rate between patient categories. Despite general satisfaction with medical treatment, 65% of carers cited inadequate control of symptoms; 58% of patients had not applied for any financial benefits, despite almost universal eligibility. Nearly 60% of patients had died in hospital, but a carer was present at the time of death in only 40% of these cases. Over half the carers had received no support since bereavement. Spontaneous comments about palliative care and relationships with staff were generally favourable, but were highly critical of communication with professionals and of the organization of care, although no carer had lodged any formal complaint. A smaller, local hospital was preferred to the district general hospital.

It is concluded that informal carers provide a perspective on the quality of palliative care which complements that of health professionals. Methods of gathering carers' views which do not restrict comment to those areas perceived as important by health professionals should be an integral component of the

monitoring and evaluation of all services involved in the provision of palliative care. The results of this study have already proved highly influential in directing the attention of the health authority to areas of service provision where deficiencies had not previously been recognized.
A Master's degree and graduate diploma in palliative care
Authors: Maddocks Ian , Donnell Janet
Published: November 2007

The development, structure and curriculum of a multidisciplinary academic course in palliative care leading to awards at graduate diploma and Master's level is outlined. Offered by the Flinders University of South Australia, the course is open to foreign students through distance education.
The use of chemotherapy in palliative care
Authors: Pagnoncelli Dante , Vianna Lena Bulcao
Published: November 2007

Cytotoxic chemotherapy can have a role in palliating the symptoms of advanced cancer. A case is described where chemotherapy provided appropriate palliation.
Terminal care in the community- an evaluation of residential workshops for general practitioner/district nurse teams
Authors: Nash Ann , Hoy Andrew
Published: November 2007

This paper describes the development and content of palliative care residential workshops for general practitioner/district nurse pairs from the same practice. Pre- and post-testing self-rating scales were completed by the participants of five workshops. A retrospective questionnaire identified perceived effects on practice in terms of patient and family care, and the impact of having attended with a professional colleague. Demographic data are presented followed by respondents' perceived changes in practice following the workshop. These are supported by clinical examples. Respondents were able to identify specific effects of having attended with a colleague and offered supporting examples from their practice. The difficulties and limitations in the use of self-rating scales are discussed along with the possible effects of such methods on course content and development. Recommendations are made for further study.
The organization of hospital-based home care for terminally ill cancer patients: the Motala model
Authors: Beck-Friis Barbro , Strang Peter
Published: November 2007

In 1977, the first palliative home care programme in Sweden, the Motala hospital-based home care, was established to provide a high level of medical care on a 24-hour basis, as an alternative and a replacement to hospital care. The current study summarizes the care and organizational needs of 179 consecutive terminally ill cancer patients treated during a 10-year period. Of the patients, 70% came from acute clinics. The median time of care was 36 days. The need for help with activities of daily living was a significant predictor of the length of survival, with the greatest difference between four or less compared to five or six items ( p = 0.0006). Analgesics were needed by 96% of the patients, and 78% were provided with various facilities such as hospital beds. The input of family members as primary caregivers was essential for successful care, as were security factors such as easy availability of a nurse or doctor, at any time day or night, and an immediate, guaranteed hospital bed, if needed. As many as 89% of the patients who wished to live at home until death actually did so. We conclude that hospital-based home care according to the Motala model can replace hospital care for selected patients, but only if both the patient and the family approve.
Domiciliary care: a comparison of the views of terminally ill patients and their family caregivers
Authors: Spiller Juliet A , Alexander David A
Published: November 2007

This study compares terminally ill patients and their family caregivers in terms of the physical and emotional status of the patients, the adequacy of the support provided for the patients and where the patients would be most appropriately placed during the last stage of their lives. Patients and caregivers shared similar views about the latter, but there was a lack of concordance between them regarding the patients' physical and emotional state. Patients generally reported a much more favourable view of their outlook and emotional state than did their caregivers. Caregivers may need help to review their assumptions about the patients' emotional welfare, and caution should be used in accepting caregivers' views about how patients are coping emotionally.
Audit of neural blockade for palliative care patients in an acute unit
Authors: Boys L. , Peat S.J. , Hanna M.H. , Burn K.
Published: November 2007

During the period from September 1990 to March 1992, 155 nerve blocks were performed for 125 patients as part of the clinical management of pain due to malignant disease. The efficacy, in terms of pain score reduction, and spontaneously reported side effects secondary to these procedures were prospectively audited. Neural blockade was undertaken in accordance with strict clinical criteria, and medication was optimized with the aim of achieving maximum analgesia with minimum side effects at all times. Pain was assessed before the block, 24 hours after the block and at follow-up (two to six weeks) using visual analogue scores or verbal rating scales. All patients were audited. The total (all patients, all blocks) median (lower-upper quartile) pain score dropped from 8 (6-10) cm before the block to 2 (0-4) cm at 24 hours after the block (p< 0.05) and to 1 (0-4) cm at follow-up (p <0.005). A concomitant reduction in analgesic requirements was observed. The incidence of serious side effects was low (two patients in this series). The results indicate the usefulness of these techniques for patients in the palliative care setting.
Validity of the support team assessment schedule: do staffs' ratings reflect those made by patients or their families?
Authors: Higginson Irene J. , McCarthy Mark
Published: November 2007

This study aimed to assess the validity of the Support Team Assessment Schedule (STAS), a measure of the outcome of palliative care, through comparisons with the views of patients and family members. STAS ratings completed by two support teams were compared with (1) patients' ratings and (2) family member/carer ratings of seven (of the total 17 STAS) items, collected by independent interviewers. Of 183 patients referred to the teams, 84 (46%) were interviewed and 99 (54%) could not be contacted. Sixty-seven patients had family members or carers, all of whom were interviewed. Tests for agreement between team and patient were high for four items, and showed moderate correlations (Spearman's rho ranged 0.45-0.66) for five items, excepting two items including family needs. The summed scores for seven items were correlated, rho = 0.66, p < 0.0001. Where differences were found, team members identified more problems than patients' self-ratings, except for one item, 'pain control', where team members identified fewer problems. Team ratings were usually closer to those of the patients than to those of the family member; a team rating often lay between the patient's and family member's rating. The STAS is a measure of professional assessment which is independent from, although based on, the patient and family. The results support the validity of STAS as a measure of the outcome of palliative care from the perspective of a palliative care team.
Spinal surgery in the treatment of metastatic back pain: three case reports
Authors: Fallon Marie T. , O'Neill William M.
Published: November 2007

Back pain resulting from spinal instability in metastatic bone disease can be difficult to alleviate by pharmacological methods and surgical intervention is frequently required. This paper discusses the treatment options with three illustrative case reports.
Managing the anxious patient with advancing disease- a flow diagram
Authors: Maguire Peter , Faulkner Ann , Regnard Claud
Published: November 2007

Anxiety can be one aspect of the psychological reaction to cancer and may be present at a clinical level. It can hinder or even prevent the diagnosis and management of other problems and when it develops into an anxiety state it can be disabling. This flow diagram describes the key clinical decisions involved in diagnosing and helping a patient troubled with anxiety.
Octreotide in relieving gastrointestinal symptoms due to bowel obstruction
Authors: Mercadante Sebastiano , Spoldi Elio , Caraceni Augusto , Maddaloni Salvatore , Simonetti Maria Teresa
Published: November 2007

Gastrointestinal obstruction is a common problem in advanced malignant disease, but its management remains controversial. In those patients for whom surgery is not appropriate, medical intervention is the only remaining option. We present a series of 14 patients with intestinal obstruction who were managed with subcutaneous injections of octreotide, a somatostatin analogue which reduces the volume of gastrointestinal secretions. Good control of vomiting was achieved in 12 patients, and no major side effects were observed. Octreotide would appear to be a useful drug in this clinical situation.
Bereavement support: evaluation of a palliative care memorial service
Authors: Foulstone Sarah , Harvey Brian , Wright Judy , Jay Margaret , Owen Fran , Cole Roger
Published: November 2007

A memorial service providing bereavement support in a palliative care unit is evaluated. Results indicate that respondents found it to be a positive experience, particularly in relation to its formality and content. One-fifth of respondents experi enced distress during the service, but this was evaluated as appropriate, being related to personal thoughts, feelings of loss and sadness, and remembrance.
Dental care of patients in a hospice
Authors: Walls Awg , Murray ID
Published: November 2007

This paper describes the dental care provided at an English hospice. Dental care is felt to be important because the ability to enjoy food is an important element in the quality of life. Over a three-year period, 67 patients were referred for dental advice of whom all but four were edentulous. The commonest complaint was of ill-fitting dentures, and the causes and possible solutions to this problem are reviewed.
Palliative home care and place of death among cancer patients: a population-based study
Authors: Costantini Massimo , Camoirano Erica , Madeddu Liviana , Bruzzi Paolo , Verganelli Elisa , Henriquet Franco
Published: November 2007

This population-based study of all cancer deaths (n = 12 343) occurring in Genoa, Italy, from 1986 to 1990 investigated the relation between place of death and age, sex, marital status, education, cancer site and provision of palliative home care (PHC). The proportion of home deaths significantly increased from 27.9% (1986) to 33.0% (1990) and was twice as frequent among PHC users (60.8%) than among nonusers (29.3%). The number of patients dying of cancer who received PHC increased from 41 in 1986 (1.6% of cancer deaths) to 191 in 1990 (8.0% of cancer deaths). PHC users, when compared to nonusers were younger, more frequently married, had a higher level of education and were more frequently affected by cancers of the lung, breast or prostate. Multivariate analysis shows that the probability of home death increased with increasing age and education level and was higher in females and in married patients. The provi sion of PHC was the strongest predictor of home death (OR = 4.00; 95% Cl = 3.33-4.81), while the temporal trend almost disappeared. These results suggest that most of the increase in home deaths from 1986 to 1990 is attributable to the PHC and that expansion of the PHC services may enable about 60% of cancer patients to die at home. These results appear to be desirable from the individual patient's viewpoint and in a public health perspective.
Handling the withdrawn patient- a flow diagram
Authors: Maguire Peter , Faulkner Ann , Regnard Claud
Published: November 2007

The withdrawn patient challenges effective communication. Some patients are naturally introverted or quiet, but for others the withdrawal represents a change with many possible causes. This flow diagram describes the approach to a withdrawn patient and outlines management.
Palliative care services in Britain and Ireland - update 1991
Authors: Eve Ann , Smith Anthony M
Published: November 2007

The objective of this study was to repeat part of a survey carried out the previous year and to describe and quantify the hospice and palliative care inpatient units throughout Great Britain and Ireland for the year 1991, this also to include a survey of palliative care day centres and hospital support services.

Questionnaires were sent to 346 hospice and palliative care services in Great Britain and Ireland. Replies were analysed by the Hospice Information Service.

A total of 293 replies were received (84% response). The report details bed usage, length of stay and admissions, deaths and discharges in inpatient units. It also describes provision of day centre places and type of services offered. An initial assessment is made of the different types of hospital palliative care support services available. An estimate of the number of patients receiving palliative care in inpatient units and in day care centres is made.
A self-evaluated assessment suitable for seriously ill hospice patients
Authors: Rathbone GV , Horsley S. , Goacher J.
Published: November 2007

Current quality of life (QOL) assessments, whilst being suitable for patients undergoing active treatment, are often too cumbersome for patients who are in the terminal phase of their illness, and may themselves produce distress.

In an attempt to measure QOL in these patients a simple assessment was piloted (PEPS - patient evaluated problem score) in which patients were asked to identify and grade major problems as they perceived them and also to grade problems previously identified by the medical and nursing staff. A global QOL score and a self-administered WHO score completed the assessment.

Of 70 patients admitted to the unit over a seven-month period, 44 completed questionnaires, 38 in full. Subsequently, uptake has been far greater (due to establishment of the method as part of routine care) with 73% of all patients admitted to our unit completing PEPS. Overall, a mean of 5.6 problems per patient were identified, of which 14% were psychosocial. Of those patients who completed questionnaires, 58% identified problems not picked up by the nursing and medical staff; 52% of these were psychosocial problems. Of 28 patients who died having previously completed questionnaires 22 had done so in the previous three weeks including eight in the previous seven days.

PEPS has proved very useful in the management of patients, enabling the identification of previously unrecognized or underrated problems, particularly of a psychosocial nature, and also as a means of evaluating progress. It is readily acceptable to patients, even those close to death.
Safety and efficacy of nebulized lignocaine in patients with cancer and breathlessness
Authors: Wilcock A. , Corcoran R. , Tattersfield AE
Published: November 2007

Although anecdotal reports suggest nebulized lignocaine may help breathlessness in patients with cancer this has not been examined formally. We report a pilot study comparing nebulized lignocaine 100 mg and 200 mg with saline in six patients with cancer who were breathless at rest. Nebulized lignocaine was well tolerated apart from mild bronchoconstriction in two patients after the 200 mg dose and the unpleasant taste; serum concentrations were below levels at which toxicity has been reported. The effort of breathing (measured on a visual analogue scale) did not differ between treatments, whereas the distress of breathing was less after saline than after either dose of lignocaine. These findings do not support the reported benefits of nebulized lignocaine.
Nasogastric feeding in the management of severe dysphagia in motor neurone disease
Authors: Scott Amanda G , Austin Helen E
Published: November 2007

This paper reviews the experience of managing 31 patients with severe dysphagia in motor neurone disease. Thirteen patients were fed nasogastrically and the remaining 18 were managed conservatively without a nasogastric tube. The introduction of nasogastric feeding led to the development of new problems in some patients, without any significant differences in survival times or relief of distressing symptoms.
The efficacy of choline magnesium trisalicylate (CMT) in the management of metastatic bone pain: a pilot study
Authors: Johnson JR , Miller AJ
Published: November 2007

Twenty-six patients with painful, bony metastases were recruited into a randomized, double-blind, single dose, two-treatment, three-part crossover study of choline magnesium trisalicylate (CMT) and placebo. Assessments were made prior to and at one, two, three and four hours after dosing.

Bone pain caused by metastatic cancer was significantly relieved one hour after the administration of 1500 mg CMT ( p = 0.04). At all four time points the pain was less than baseline with CMT and at three time points greater than baseline with placebo but these results did not reach statistical significance. The summed pain intensity difference for patients was greater with CMT than with placebo, but this also did not reach significance. The incidence of volunteered side-effects was similar for both treatments. The results suggest that a nonacetylating, nonsteroidal anti-inflammatory drug may have a role complementary to that of an opioid in the management of metastatic bone pain.
Successful use of methadone in nociceptive cancer pain unresponsive to morphine
Authors: Leng G. , Finnegan MJ
Published: November 2007

Morphine is the mainstay of pain control in cancer patients. We describe three patients in whom adequate analgesia was not obtained with morphine, and discuss the role of morphine metabolites and the use of methadone as an alternative strong opioid analgesic.
Tube feeding in palliative care: benefits and problems
Authors: Boyd Kirsty J , Beeken Linda
Published: November 2007

Percutaneous endoscopic gastrostomy techniques are becoming more widely available and will be considered increasingly for patients with head and neck or upper gastrointestinal malignancies, and for neurological dysphagia, as occurs in motor neurone disease. This case history illustrates some of the practical and ethical issues raised by their use.
Plasma concentrations of midazolam during continuous subcutaneous administration in palliative ca re
Authors: Bleasel Martin D , Peterson Gregory M , Dunne Paul F
Published: November 2007

We have investigated the steady-state plasma concentrations of midazolam during continuous subcutaneous administration in palliative care. Using a sensitive gas chromatography with electron capture detector assay, plasma concentrations of midazolam were measured in 11 patients (median age 68 years; range 47-82 years; six females) receiving the drug by continuous subcutaneous infusion (median rate 20 mg/day; range 10-60 mg/day). While not significant, the infusion rate tended to decrease with increasing age of the patient (Spearman's p = —0.51; p = 0.11). The steady-state plasma concentration range was 10-147 ng/ml, with a median of 30 ng/ml. Infusion rates and plasma concentrations of midazolam were correlated (Spearman's p = 0.71 ; p < 0.05). No other significant relationships were found between plasma concentrations and the variables of age, sex and liver function.
Epidural infection associated with epidural catheterization in a cancer patient with back pain: case report
Authors: Yap Keng Bee , Finlay Ilora G
Published: November 2007

Single epidural injections of local anaesthetic/steroid mixtures and epidural catheterization are useful in controlling pain when other measures fail. However, epidural infection is a recognized risk of these procedures, but can be difficult to diagnose.

This case report illustrates the complexity of diagnosis and management of epidural infection.
The use of nebulized opioids for breathlessness: a chart review
Authors: Farncombe Margaret , Chater Susan , Gillin Andrée
Published: November 2007

Breathlessness secondary to both cancer and non-malignant disease is a distressing, exhausting symptom which, to date, has been difficult to control. This paper reports a chart review undertaken on patients referred to the Ottawa Civic Hospital's Palliative Care Service over the 18-month period from 1 January 1992 to 30 June 1993. The intent of the review was to assess the recorded efficacy and safety of nebulized opioid use on patients with complaints of dyspnoea. Fifty-four patients were treated and subjective data have been compiled. The treatment was found to be effective, safe and convenient for the majority of the patients studied. In addition, nebulized opioids have been demonstrated as a treatment modality which is feasible for self-administration by the patient at home.
Regional Study of Care for the Dying: methods and sample characteristics
Authors: Addington-Hall Julia , McCarthy Mark
Published: November 2007

The Regional Study of Care for the Dying (RSCD) was established in 1990 with the dual aims of providing district health authorities with an audit of local services for the dying, and of addressing questions about experiences of people dying from cancer, effectiveness of hospice care, and needs of, and appropriate service provision for, people dying from causes other than cancer. The survey methods are described in this paper, together with the characteristics and representativeness of the sample.

An interview survey was conducted of family or others who knew about the last year of life of a random sample of people who died in 1990. It was based upon methods used in nationally representative surveys by Cartwright in 1969, and Cartwright and Seale in 1987.

The setting was 20 district health authorities, who paid for local data collection. Approximately 270 deaths were randomly sampled in each district: 5375 deaths were sampled in total. As cancer patients are the focus of most services for the dying, cancer deaths were sampled disproportionately (54%).

Interviews were obtained for 69% (3696) of the sample. The response rate varied significantly by cause of death, age and social class of deceased, and the degree of deprivation of the district. There were small, but statistically significant, differences in cause of death and age between those deaths for whom interviews were obtained and national figures for deaths occurring in 1990.

The discussion addresses key issues in the study, including responses from ethical committees, response rate and quality of data. The survey has been successful, both in providing districts with information on local services, and in obtaining a large, broadly representative, sample of deaths, thus enabling many outstanding questions about the needs of dying patients and their families, and about appropriate service provision, to be addressed.
Professional needs of palliative care nurses in New South Wales
Authors: Redman Selina , White Kate , Ryan Ellen , Hennrikus Deborah
Published: November 2007

A survey of 108 palliative care nurses practising in New South Wales, Australia, was undertaken to explore their professional needs and clinical knowledge. Opportunity for improved training was the most frequently nominated professional need. Only 12% of the sample had postgraduate qualifications in palliative care and fewer than 20% were currently undertaking postgraduate training. Sixty-three per cent of nurses indicated that a lack of opportunity for formal study was a problem for them. The results of the knowledge survey revealed a need for additional training. Many nurses did not have the clinical knowledge identified as minimal by an expert committee. Those nurses who had a postgraduate qualification in oncology scored more highly on the knowledge questionnaire than did those whose general nursing training was undertaken outside Australia. The implications of these findings for training and other professional support are discussed.
Lymphangiosarcomata - experience in a lymphoedema clinic
Authors: Mulvenna Paula M , Gillham Lydia , Regnard Claud FB
Published: November 2007

Two cases of patients attending a lymphoedema clinic and developing lymphangiosarcomata are described. The epidemiology, natural history and management of this uncommon malignancy are discussed and the pertinent features that should be sought by professionals involved in routine follow-up of patients prone to lymphoedema outlined.
The WHO objectives for palliative care: to what extent are we achieving them?
Authors: Johnston Gail , Abraham Charles
Published: November 2007

This paper examines recent research in palliative care in the light of the guiding principles set out by the World Health Organization. It outlines the gaps in the literature and suggests priorities for future research. Areas of unmet need are documented and it is argued that research comparing outcomes across care settings and relating particular care practices to outcome measures would help to set care targets. Further definition of the expected outcomes of psychological and spiritual care, as well as care for carers, is recommended. Available measures are reviewed and suggestions made for the development of additional measures. Finally, some key methodological problems are discussed, including making cross-setting comparisons, identifying appropriate outcome measures, prioritizing patients' own identification of outcomes, using different methodologies as death approaches, and combining different perspectives offered by patients, lay carers and professional carers. The role of qualitative data as an indicator of rating scale validity is discussed in this context.
The changing face of paediatric oncology
Authors: Foot Annabel BM
Published: November 2007

Childhood malignancies differ from those encountered in adult life not only in tumour type but also in their response to treatment. There have been major advances in the use of combined modality and combination chemotherapy regimens over recent years. High-dose therapy with bone marrow and peripheral stem cell transplantation procedures are being increasingly incorporated into specialized treatment regimens, particularly in the management of 'high-risk' and relapsed patients who were previously incurable. Overall, cure rates for children with cancer now exceed 60%. Despite this, the progress in the treatment of some tumour groups remains poor. This paper summarizes recent advances but also highlights some of the problem areas that still exist or are expected to be encountered in the near future.
An extra care sheltered housing complex for frail ambulant cancer patients
Authors: Sherry Kathleen L
Published: November 2007

The history and development of an extra care sheltered housing complex, specifically designed and built for frail, ambulant, cancer patients is reviewed. Consideration is given to diagnosis, length of stay, place of death, family and social background. Problems are highlighted and the need for future research is discussed.
Use of nonsteroidal anti-inflammatory drugs in cancer
Authors: Pace Victor
Published: November 2007

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used in cancer, yet they are also responsible for many, often serious, adverse effects. This review examines the various mechanisms through which NSAIDs work. It looks at the experience built up in using NSAIDs in cancer pain in general, but then particularly examines whether the evidence available supports the claim often made that these drugs have a specific role in relief of pain from bony metastases. Criteria for choosing one NSAID over another, including adverse effect profiles, efficacy and tolerability, are considered, as are methods for improving the safe use of these drugs.
Interventional radiology in a palliative care setting
Authors: Jones Simon N
Published: November 2007

Interventional radiology is becoming both more common and more complex. It is tending to replace many conventional surgical procedures because it is less costly and also carries low rates of morbidity and mortality. A minority of patients with solid tumours will develop conditions that are amenable to improvement with these techniques, especially obstruction of the urinary or biliary tracts, or of the oesophagus. This paper describes these procedures, and also discusses situations in which this kind of intervention is appropriate. In addition to the relief of obstruction of a hollow viscus, various techniques are being developed to allow percutaneous tumour ablation; it is likely that these will become more widespread in the future.
Undergraduate education and palliative care
Authors: Coles Colin
Published: November 2007

The undergraduate education of health professionals has legitimately broad but ultimately conflicting aims. There is a need to reformulate how professionals work, think and learn, and for this analysis to inform undergraduate programmes. Palliative care is not strongly placed politically to influence these developments, yet the contribution it can make is enormous, through allowing students the opportunity to experience what it does and to reflect on that experience.
Postgraduate research training: the PhD and MD thesis
Authors: Higginson Irene , Corner Jessica
Published: November 2007

Higher research degrees, such as the PhD, MPhil and MD, have existed within universities for 80 years or more, although the differences between the MD and PhD remain confused. A higher research degree training provides individuals with greater research knowledge and skills, and benefits the specialty. Concern exists about the levels of supervision sometimes provided, failure to complete degrees, and the variable levels of research knowledge and skills attained. We propose that higher research degrees in palliative care have four functions: extending personal scholarship, generating knowledge, training for the individual and contributing to the growth of the specialty. Such an approach may include: a formalised first year with taught components such as in research MSc programmes, formal supervision and progress assessment. In palliative care, clinical and academic approaches need greater integration. Multiprofessional learning is essential. To allow individuals to undertake higher research degree programmes, fellowships or specific funding are needed.
An investigation of the ability of oral naloxone to correct opioid-related constipation in patients with advanced cancer
Authors: Sykes NP
Published: November 2007

A dose-ranging study of the use of oral naloxone in opioid-related constipation in patients with far-advanced cancer is reported. Naloxone doses were calculated as a percentage of the morphine dose each patient was receiving. Seventeen patients entered the first phase of the study, which had a randomised, double-blind design. Outcome measures were small bowel transit time (SBTT) measured by the lactulose/hydrogen breath test, pain scores and the occurrence of adverse events.

One subject was excluded before receiving naloxone. No significant difference between placebo and naloxone occurred in the 14 remaining patients receiving total daily doses of naloxone 10% or less of the 24 h dose of morphine. Two further patients experienced a marked laxative effect with naloxone at 20% of the 24 h dose of morphine. In one of these, SBTT was available and was unchanged from placebo. The other declined to continue with SBTT measurement.

Phase two of the study had an open design, in which laxative effects were determined clinically. Naloxone at a maximum dose level of 20% was given to seven patients, up to 40% to two patients and up to 80% to one patient. Four out of the seven patients in the 20% dose level group, and all of the remainder, experienced laxative effects. Two patients experienced symptoms of opioid withdrawal, one of whom also had return of pain.

It is concluded that oral naloxone at a daily dose of 20% or more of the prevailing 24 h morphine dose is a potentially valuable therapy for opioid- related constipation. However, opioid withdrawal was observed and it is suggested that initial individual naloxone doses should not exceed 5 mg. Further research is needed into the oral absorption of naloxone, as well as further studies of clinical efficacy and dosing.
Quality of life assessment in advanced cancer
Authors: Donnelly S. , Walsh D.
Published: November 2007

Our purpose is to examine how applicable current quality of life instruments are in advanced cancer. Quality of life (QOL) is difficult to define and measure; it is a multidimensional, dynamic and subjective concept. An acceptable QOL instrument for advanced disease should be simple to administer and easy to explain, complete and analyse. In our view, the present instruments used in oncology do not serve the needs of advanced cancer patients. Based on our review, we believe a single question posed on a linear or categorical scale should be used to assess QOL in advanced cancer in preference to other available methods.
A study of animal companionship in a day hospice
Authors: Phear David N
Published: November 2007

Attitudes to companion animals were surveyed among 50 patients and staff at a day care hospice. Dog visits were welcomed by all but two. Of the 37 patients studied, only seven had a companion animal, often their closest companion. Many more would like to keep an animal, but were prevented by age, frailty or accommodation restriction.
A comparison of hospice and hospital care for the spouses of people who die
Authors: Seale Clive , Kelly Moira
Published: November 2007

To compare the quality of care for spouses of dying people in St Christopher's Hospice, London and nearby hospitals in 1994 and to make comparisons with earlier studies of the same setting, interviews were undertaken with spouses of people who had died from cancer in these settings, matched by the deceased's age and sex.

The subjects comprised 66 people whose spouses had died in 1994, 33 of whom had died in the hospice, 33 in local hospitals. The mean age was 69.3; 61 % were female.

No significant differences between groups were found on the outcome measures (adjustment to bereavement, anxiety and psychosomatic symptoms at the time of the final admission), largely replicating earlier studies in the same setting. In various respects hospitals have moved closer to hospice practice: in contrast to earlier studies, there were no differences in visiting patterns or in spouses helping with inpatient care. Bereavement follow-up is now initiated in some cases by hospitals. Liberal visiting hours could be stressful, however, and spouses sometimes helped with care to remedy staff shortcomings. Regret at not being present at the death was more common in the hospital group.

Bereavement interventions may have more effect on subsequent adjustment if targeted on high-risk individuals. Other benefits than adjustment, however, may be achievable. Steps to create a calm atmosphere on hospital wards where people can be with their relatives near the time of death are desirable.
The effects of the clinical characteristics of dying cancer patients on informal caregivers' satisfaction with palliative care
Authors: Fakhoury Walid KH , McCarthy Mark , Addington-Hall Julia
Published: November 2007

To assess associations between informal caregivers' satisfaction with services delivered to their dying cancer patients and their perceptions of the duration of functional limitation and the duration of various symptoms experienced by these patients, a secondary analysis was conducted on a subsample of the Regional Study of Care for the Dying (RSCD). The RSCD is a retrospective interview survey of family members or others who knew about the last year of life of a random sample of people who died in 20 health districts in the UK in 1990. The subsample consisted of 1858 informal caregivers of people who died from cancer (ICD codes 140-208).

More than half (52%) of informal caregivers were highly satisfied with community nurses, compared to 39% and 35% of those who reported high satisfaction with services provided by general practitioners and hospital doctors respectively. Informal caregivers of patients who died from a lymphatic or haematopoietic tissue cancer were more likely than others to report high satisfaction with hospital doctors (47%), while least satisfaction was reported by those who cared for patients who had a neoplasm of the genito-urinary or respiratory/intrathoracic organs (30%). The duration of pain was not significantly related to any of the satisfaction measures.

The results suggest the need to take patient clinical characteristics into account in population-based evaluations of palliative care. They also indicate the need for more research to be carried out to assess the reasons behind the dissatisfaction of informal caregivers of patients with respiratory or genito-urinary cancers with services provided by hospital doctors and to detect whether these patients have unmet needs that should be addressed. More research is also needed into the management of symptoms by the general practitioners, especially symptoms pertaining to respiration and incontinence.
HIV infection: the spectrum of symptoms and disease in male and female patients attending a London hospice
Authors: Kelleher Peter , Cox Sarah , McKeogh Maeve
Published: November 2007

To delineate the demographic features and clinical profile of male and female individuals utilizing a respite, rehabilitation and hospice centre in London, a retrospective study of patient notes was undertaken. The subjects were 59 male and 59 female HIV patients at first admission to the hospice.

The study revealed clinically important differences between men and women and also identified special problems for African women and intravenous drug users. Women experienced more constipation, headache and musculoskeletal pain than men. Men suffered more neuropathic pain and visual loss. Lower respiratory tract infections were more common in women, especially in those with a history of injection drug use. Gynaecological morbidity was common. There was no difference in AIDS diagnoses between men and women. HIV encephalopathy developed in 23% of the cohort during the follow-up period which has implications for provider units.

There are increasing numbers of HIV-positive women and injection drug users being referred for palliative care services. Multidisciplinary teams should be aware of the particular symptom profile of these groups.