bluuebunny/crossref_metadata_2025 huggingface dataset:
Estimate of the maximum absorption rate of microscopic arterial air emboli after entry into the arterial circulation during cardiac surgery
Authors: Dexter Franklin , Hindman Bradley J , Marshall Jeffrey S
Published: November 2007

Some clinicians place patients in the Trendelenburg position during aortic unclamping to decrease the incidence of microscopic cerebral air embolism. Experimental studies have shown that use of the Trendelenburg position does not prevent air emboli from reaching the brain. Nevertheless, the position can decrease the velocity at which bubbles approach the brain, giving more time for nitrogen in the bubbles to be absorbed. We applied a validated mathematical model to estimate that the maximum rate of absorption of microscopic air emboli in blood during and after cardiopulmonary bypass (CPB) equals 1.57 μm/s. This rate is very small, since clinically relevant microbubbles have radii 50-1500 μm, and travel from the aorta to the brain within seconds. The result holds for all usual conditions of CPB. We conclude that absorption does not affect the disposition of air introduced into the arterial circulation. Use of the Trendelenburg position cannot decrease neurologic injury from cerebral air embolism by permitting greater bubble absorption.
Low extracorporeal priming volumes for infants: a benefit?
Authors: De Somer F. , Foubert L. , Poelaert J. , Dujardin D. , Van Nooten G. , François K.
Published: November 2007

An extracorporeal circuit consisting of an oxygenator especially designed for neonatal use and appropriately sized tubing, with an average total priming volume of 205 ml, was used on 80 infants undergoing cardiac surgery for congenital heart-disease. The priming volume and foreign surface area of the circuit were determined. The influence of low priming volumes on the use of blood products and the management of cardiopulmonary bypass was studied. No whole blood or platelets were used in this study. The mean volume of packed red blood cells used over the hospital stay was 202 ± 67 ml. The mean volume of fresh frozen plasma (FFP) used until the second postoperative day was 62 ± 72 ml. The mean total blood loss until the second postoperative day was 15.8 ± 9.2 ml/kg.

The priming volume of the extracorporeal circuit was 62% lower than values commonly reported in the literature. The low priming volume had a strong influence on the use of platelets and FFP and to a lesser extent on the use of packed red blood cells.
Clinical evaluation of the oxygenation capacity and controllability of 15 commercially available membrane oxygenators during alpha-stat regulated hypothermic cardiopulmonary bypass
Authors: Stinkens D. , Himpe D. , Thyssen P. , De Bakker A. , Smets W. , Borms S. , Muylaert Ph , Van Hove M. , Suy M. , Van Cauwelaert Ph
Published: November 2007

Oxygenation performance was tested in 15 membrane oxygenators by calculating the resistance for oxygenation (R) and the calculation of oxygen transferred versus FiO2. The clinical data reveal that the SARNS Turbo 440 (36.7-51.9%), the AFFINITY (37.2-50.1 %) and the HF 5400 (37.5-52.3%) are the oxygenators with the lowest FiO2 settings for comparable amounts of oxygen transferred during hypothermia and during normothermia followed by MAXIMA Plus (39.1-55.8%), MAXIMA Plus PRF (39.1-56.2%), CAPIOX SX 18 (39.7-61.2%), MONOLYTH (43.0-61.3%), OXIM 11-34 (44.1-63.9%), COBE Duo (44.7-64.9%), COBE Optima (47.4-66.4%), COMPACTFLO (48.3-65.3%), SAFE II (49.0-67.6%), UNIVOX (49.8-71.3%), MAXIMA (50.2-70.1 %) and the CM 50 (58.6-77.0%). Similar results were found by calculation of R. HF 5400 (2.41-1.87 mmHg/min/ml O2), AFFINITY (2.63-1.87 mmHg/min/ml O2), OXIM II-34 (2.72-2.45 mmHg/min/ml O2), MAXIMA Plus PRF (2.75-2.07 mmHg/min/ ml O2), COBE Optima (2.83-2.13 mmHg/min/ml O2), UNIVOX (2.84-2.17 mmHg/min/ml O2), MONOLYTH (2.89-2.24 mmHg/min/ml O2), SARNS Turbo 440 (3.03-2.12 mmHg/min/ml O2), MAXIMA Plus (3.09-2.28 mmHg/min/ml O2), SAFE 11 (3.19-2.50 mmHg/min/ml O2), CAPIOX SX 18 (3.27-2.44 mmHg/ min/ml O2), COMPACTFLO (3.41-2.50 mmHg/min/ml O2), MAXIMA (3.53-2.72 mmHg/min/ml O2), COBE Duo (3.57-2.71 mmHg/min/ml O2) and the CM 50 (3.53-2.72 mmHg/min/ml O2). As a measure of controllability of oxygenation, the coefficient of variation on the FiO2 ordered on the normothermic blood samples was used, giving as a result CAPIOX SX 18 (2.9-2.5%), AFFINITY (3.6-3.5%), COBE Duo (4.3-2.9%), HF 5400 (5.7-4.7%), MAXIMA Plus (8.1- 5.4%), COMPACTFLO (8.2-5.0%), MONOLYTH (8.3-4.0%), MAXIMA (8.7- 3.4%), COBE Optima (9.6-6.8%), SARNS Turbo 440 (10.1-7.3%), MAXIMA Plus PRF (10.9-8.7%), CM 50 (11.9-2.4%), UNIVOX (13.3-8.9%), OXIM 11-34 (15.5-17.3%) and the SAFE II (16.1-9.8%). The low FiO2 settings and the lower resistance for oxygenation are an indication of the reserve capacity of the oxygenators whose importance is proven by clinical data of emergency perfusions on patients under full resuscitation.
Including children in family-focused acquired brain injury rehabilitation: a national survey of rehabilitation staff practice
Authors: Webster Guinevere , Daisley Audrey
Published: November 2007

Objective: To establish whether rehabilitation staff work regularly with child relatives of adults with acquired brain injury to involve them in their family member's rehabilitation. To explore factors influencing rehabilitation staff's decisions about involving child relatives.

Design: A cross-sectional postal survey design was used for the main study. Questionnaire packs were sent to rehabilitation staff, followed by a reminder letter one week later. Non-responders received a follow-up pack after three weeks.

A prospective design was used with a subsample of participants who re-completed the questionnaire one month later.

Subjects: Participants were 393 multidisciplinary staff working in rehabilitation services for adults with acquired brain injury throughout the UK.

Main measures: A questionnaire based on the theory of planned behaviour was designed specially for the purposes of the study.

Results: A response rate of 67% (n = 263) was obtained. Few respondents (19%, n = 50) reported carrying out work with child relatives. Perceived behavioural control (e.g. access to training, resources and support) significantly predicted staff's intention to work with child relatives, and whether they carried this out. Staff's attitudes towards work with child relatives also significantly predicted intentions. Other influential factors were anxiety, training, work setting and perceptions of colleagues' attitudes.

Conclusions: Little work is carried out with child relatives by acquired brain injury rehabilitation staff, influenced by several factors. A priority in addressing this is to provide staff training.
Patterns of postural deformity in non-ambulant people with cerebral palsy: what is the relationship between the direction of scoliosis, direction of pelvic obliquity, direction of windswept hip deformity and side of hip dislocation?
Authors: Porter David , Michael Shona , Kirkwood Craig
Published: November 2007

Objective: To investigate: (a) associations between the direction of scoliosis, direction of pelvic obliquity, direction of windswept deformity and side of hip subluxation/ dislocation in non-ambulant people with cerebral palsy; and (b) the lateral distribution of these postural asymmetries.

Design: Cross-sectional observational study.

Setting: Posture management services in three centres in the UK.

Subjects: Non-ambulant people at level five on the gross motor function classification system for cerebral palsy.

Main measures: Direction of pelvic obliquity and lateral spinal curvature determined from physical examination, direction of windswept hip deformity derived from range of hip abduction/adduction, and presence/side of unilateral hip subluxation defined by hip migration percentage.

Results: A total of 747 participants were included in the study, aged 6—80 years (median 18 years 10 months). Associations between the direction of scoliosis and direction of pelvic obliquity, and between the direction of windswept hip deformity and side hip subluxation/dislocation were confirmed. A significant association was also seen between the direction of scoliosis and the direction of the windswept hip deformity (P<0.001) such that the convexity of the lateral spinal curve was more likely to be opposite to the direction of windsweeping. Furthermore, significantly more windswept deformities to the right (P = 0.007), hips subluxed on the left (P = 0.002) and lateral lumbar/lower thoracic spinal curves convex to the left (P = 0.03) were observed.

Conclusions: The individual asymmetrical postural deformities are not unrelated in terms of direction and not equally distributed to the left/right. A pattern of postural deformity was observed.
Tilted seat position for non-ambulant individuals with neurological and neuromuscular impairment: a systematic review
Authors: Michael S.M. , Porter D. , Pountney T.E.
Published: November 2007

Objective: To determine the effects of tilt-in-space seating on outcomes for people with neurological or neuromuscular impairment who cannot walk.

Data sources: Search through electronic databases (MEDLINE, Embase, CINAHL, AMED). Discussions with researchers who are active in field.

Review methods: Selection criteria included interventional studies that investigated the effects of seat tilt on outcome or observational studies that identified outcomes for those who had used tilt-in-space seating in populations with neurological or neuromuscular impairments. Two reviewers independently selected trials for inclusion, assessed quality and extracted data.

Results: Nineteen studies were identified which fulfilled the selection criteria. Seventeen of these were essentially before—after studies investigating the immediate effects of tilting the seating. All studies looked at populations with neurological impairment, and most were on children with cerebral palsy (n = 8) or adults with spinal cord injury (n = 8).

Reviewer's conclusion: Posterior tilt can reduce pressures at the interface under the pelvis.
The palliation of cerebral tumours with high-dose dexamethasone: a review
Authors: Kirkham SR
Published: November 2007

The historical use of corticosteroids for cerebral oedema due to malignancy is reviewed. The mechanisms for the formation and treatment of cerebral oedema are discussed and advice is given as to the clinical use of dexamethasone, including mention of adverse effects and drug interactions.
Truth telling with dying cancer patients
Authors: Gilhooly Mary LM , Berkeley John S , McCann Kathy , Gibling Felicity , Murray Keith
Published: November 2007

Awareness of condition and frequency of discussion of diagnosis were examined in two studies on place of care for terminally ill cancer patients. Approximately one-third of the patients died without having discussed their diagnosis with their general practitioners. Age, perceived social class and type of cancerwere found to be associated with patients' awareness and discussions with GPs. Interestingly, place of death was not associated with awareness; patients dying in hospices were not significantly more likely to be aware or to have discussed the diagnosis with their GPs. Lack of awareness of diagnosis was reported as affecting decision making about place of care and, to a certain extent, to carers' emotional response. The main reason given for not discussing the diagnosis with the patient was relatives' wishes.
Intralesional methylprednisolone for rib metastases: an alternative to radiotherapy?
Authors: Rowell NP
Published: November 2007

Twenty-two patients with rib metastases or involvement of the ribs by multiple myeloma underwent infiltration of the tender areas with methylprednisolone (Depo-Medrone) under intercostal block by a previously described technique.1 Of 20 assessable patients, 11 became painfree in under 10 days with recurrence of pain in only one, and in three the pain was considerably improved. The procedure was well tolerated and there were no complications. This technique offers an alternative to irradiation in certain situations.
Review article : Hypercalcaemia of malignancy
Authors: Heath DA
Published: November 2007

This article reviews the incidence and clinical features of hypercalcaemia caused by malignancy. The pathogenesis is examined, looking at recent evidence on endocrinological processes, particularly parathyroid hormone related protein. Finally the article reviews current thinking on treatment.
The cost-effectiveness of the Citymission Hospice Programme, Melbourne
Authors: Dunt David R. , Cantwell Annie M. , Temple-Smith Meredith J.
Published: November 2007

A quasiexperimental study evaluating the Citymission Hospice Programme, Melbourne, a demonstration programme funded by the WK Kellogg Foundation and the Federal Australian government, is described. Its cost-effectiveness is compared with the best available programme of care, as traditionally delivered. Sixty-five hospice and 55 control patients, and/or their family caregiver, were interviewed monthly until the patient's death, generating 271 patient and 195 caregiver interviews. Patients in the hospice group experienced a small but statistically significant reduction in pain, variously assessed at the first and last assessment. They also suffered similarly small but significant reductions in dyspnoea, insomnia and dissatisfaction with the care at the last assessment before death. Patients in the two groups did not differ in their level of other physical and emotional symptoms or in a number of quality-of-life measures. Relatives and other individuals caring for patients in the hospice group experienced somewhat greater difficulties in their role as caregivers than those in the control group. The care of hospice patients was no less expensive and did not produce a shift to noninstitutional care. It is concluded that the cost and effectiveness of this programme of hospice care is at least equivalent to the best traditional care.
Management of malignant ulcers — a flow diagram
Authors: Saunders J. , Regnard C.
Published: November 2007

A malignant ulcer is defined here as a break in epidermal integrity because of infiltration by malignant cells. This may be due to primary skin malignancy, metastatic deposits or extension of malignancy from deeper structures. The flow diagram does not deal with decubitus ulcers, ulcers due to antitumour therapy, (e.g. apthous ulcers after chemotherapy or extravasation of irritant drugs), or malignant ulcers of the mucous membranes, (e.g. oral malignancies).
Nonmetastatic manifestations of malignancy: neurological
Authors: Grant R.
Published: November 2007

More than 20% of patients with systemic neoplasia will develop neurological symptoms and signs (Figure 1)1 and between 7-15% of these are due to nonmetastatic complications. If diagnosed early, many nonmetastatic manifestations are reversible, but if not, they impair quality of life and are potentially rapidly fatal.
Oedema in advanced disease: a flow diagram
Authors: Badger Caroline , Regnard Claud
Published: November 2007

In this flow diagram, oedema is defined as an excessive accumulation of tissue fluid resulting in a measurable swelling. This may be a low protein oedema, a high protein oedema or a mixed picture. Clearly treatment of the disease will improve the oedema, but this flow diagram assumes the progression of the disease is irreversible. Treatment of the oedema therefore comprises exercise, skin care and compression, with or without truncal massage.
Pressure sores in advanced disease: a flow diagram
Authors: Bale Susan , Regnard Claud
Published: November 2007

The management of a patient with a pressure sore is a complex and difficult problem. Even with excellent nursing care, pressure sores can develop in the severely debilitated patient with malignancy. To reduce the likelihood of this happening three issues need to be considered: pressure relief, nutritional status and local management.
Training in and knowledge of terminal care in medical students and junior doctors
Authors: Oliver David
Published: November 2007

A survey of medical students and junior doctors shows a lack of training and knowledge in the care of dying patients and symptom control. The need for an increased emphasis on this training is identified.
The education and training of Scottish clergy in the care of the dying
Authors: Murray Derek B
Published: November 2007

A randomized selection of Scottish clergy were sent questionnaires on the education and training they had received, before and after ordination, in the care of the dying. The results suggest that in recentyears such training has increased, but is still seen as inadequate, and the implications of these findings are discussed.
A study of the relative frequency and importance of gastrointestinal symptoms, and weakness in patients with far advanced cancer: student paper
Authors: Dunlop GM
Published: November 2007

In this study 50 hospice and hospital patients with far advanced cancer were asked to select, from a series of cards describing symptoms, those symptoms which they had, and to rank in order the five most distressing to them. Using a scoring system it was possible to assess the frequency of all symptoms nominated and to assess which symptoms were most distressing to the patient. Weakness was the most frequent and distressing symptom overall, according to the patients. Gastrointestinal symptoms such as dry mouth, anorexia, constipation and nausea were also common and were considered to be distressing, dry mouth and anorexia more so than pain. Differences were evident between patients in various subgroups: recent versus long admissions; hospice versus hospital patients; and male versus female patients. However it is important to note that weakness was the most frequent and the most distressing symptom for all patient groups.
The ethics of euthanasia
Authors: Wilkinson John
Published: November 2007

Types of euthanasia are described, and active, voluntary euthanasia defined. Arguments for active, voluntary euthanasia and the assumptions upon which these are based are presented. Counter arguments are also presented, with suggested alternatives to active, voluntary euthanasia in modern health care provision.
The control of diarrhoea in advanced cancer-a flow diagram
Authors: Regnard Claud , Mannix Kathryn
Published: November 2007

Diarrhoea is here defined as a soft or fluid stool, usually (but not invariably) accompanied by increased frequency of defecation in patients with advanced cancer. This flow diagram looks at decisions required in diagnosing the cause, and briefly discusses some approaches to treatment.
The role of oral controlled-release morphine for pain relief in children with cancer
Authors: Goldman Ann , Bowman Angela
Published: November 2007

Effective pain control is a key part of the care of children with cancer. We report our experience with controlled-release morphine tablets (MST Continus, NAPP) given as analgesia to 60 children who were terminally ill from a range of malignant diseases. MST was given over periods ranging from 1-165 days (median 14 days). We found that the appropriate initial dose was 1 mg/kg/dose for children whose pain was not controlled by mild analgesics or weak opioids. Maximum doses up to 41.6 mg/kg/dose were needed to maintain analgesia. Provision of a short-acting opioid is essential for breakthrough pain. The main side-effects were temporary drowsiness and constipation. Careful education of parents and health-care professionals in the correct use of MST is important. MST proved an effective and acceptable strong analgesic for children, particularly convenient for the terminally ill at home.
Forgiveness in the hospice setting
Authors: Clark Ramona
Published: November 2007

Many people reach the end of their lives needing to forgive themselves or others. The resolution of personal and family conflicts can contribute to a peaceful death and a more healthy grieving period for those who remain. There are phases in the forgiveness process that need to be worked through if resolution is to be achieved. By being aware of these phases and by establishing a trusting relationship with patients and their families, hospice staff can facilitate forgiveness.
How much of a problem is dyspnoea in advanced cancer?
Authors: Heyse-Moore Louis H , Ross Vernon , Mullee Mark A
Published: November 2007

Dyspnoea in advanced cancer has been little investigated. We studied 303 patients admitted to Countess Mountbatten House to discover how common and how severe this symptom is, and in whom it occurs. Of these patients, 55.5% were dyspnoeic on admission. The prevalence of dyspnoea was 78.6%, however, in those surviving for less than a day after admission. The mean age was 65.9 years. Dyspnoea was more likely to be present in those with carcinoma of the bronchus and breast, and those with lung metastases. Of patients admitted, 11.4% were rated as severely dyspnoeic (3 on a scale of 0-3). Survival was significantly shorter as severity of dyspnoea increased.
Symptoms of HIV disease
Authors: Welch JM , Barlow D. , Richardson PH
Published: November 2007

Forty patients with symptomatic HIV disease were asked to complete a questionnaire at the end of an outpatient consultation. They reported the presence and intensity of their symptoms and ranked them by the distress caused. The doctor who had seen each patient completed a parallel questionnaire. Significantly more symptoms were reported by patients than by the doctors. Doctors seemed to have the best general awareness of symptoms that were either overt (e.g. skin problems, weight loss) or suggestive of serious conditions (e.g. cough). Patients appeared more aware of, and distressed by, other symptoms (e.g. anorexia, insomnia). The correlations between doctor and patient ratings of the same symptom were generally poor; the symptoms most accurately identified were usually either overt or suggestive of serious disease. Although many symptoms reported by people with HIV disease are not life-threatening, they cause distress and are treatable. When patients have many problems doctors focus on the most urgent, but increased awareness of other symptoms may improve the quality of life of these patients.
Features of Judaism for carers when looking after Jewish patients
Authors: Abeles Margaret
Published: November 2007

This article hopes to be an aid to doctors, nurses, social workers and other carers involved with, or having close contact with, Jewish people and families who are facing terminal illness and approaching death. It approaches this from an orthodox point of view as this is the basis for the laws, customs and practice which carers may encounter.
Dying from cancer: the views of bereaved family and friends about the experiences of terminally ill patients
Authors: Addington-Hall JM , MacDonald LD , Anderson HR , Freeling P.
Published: November 2007

Objective: To investigate current experiences of dying cancer patients and to identify areas where improvements in care are needed.

Design: Interviews with principal carers eight weeks after the death of cancer patients who had been routinely notified by hospital staff and had entered a district wide trial of a new service for terminally ill cancer patients.

Setting: An inner London health district.

Subjects: Eighty carers of cancer patients who died between 1987 and 1989. Results: Anorexia, breathlessness, pain, insomnia and depression were all experienced by over 50% of patients in the last week of life. Twenty per cent of patients in pain were reported to have had no effective treatment. Carers of patients dying at home were significantly more likely to feel that the place of death had been right for the patient (97% versus 53%) than carers of patients dying in hospital. Half (36) of carers were dissatisfied with hospital care: the main reason given was that nurses were too busy to provide adequate care (24). Thirty-nine per cent of carers were dissatisfied with information they received from the hospital and eight had wanted to know more about the timing of death. Twenty-seven per cent of 64 carers who had had contact with the general practitioner during the final illness were dissatisfied with care provided by the GP. Twenty per cent of 56 carers who had had contact with district nurses were dissatisfied because of the lack of continuity of care or because nurses appeared rushed. Twenty-nine per cent had had a home help and 10% had had meals on wheels. Fifty-two per cent of carers needing equipment to help them nurse the patient, and 15% of carers who had needed help during the night, had been unable to obtain such help without difficulty, if at all.

Implications: More attention should be paid to ensuring that good symptom control is achieved for all patients. More support from general practitioners, community nursing and social services is needed to enable patients to remain at home when desired. Improvements are needed in the care provided for dying patients on acute wards.
Interpleural infusion with bupivacaine for intractable cough
Authors: Marsh Chris R , Hardy Paul AJ
Published: November 2007

In a postpneumonectomy patient an interpleural catheter was inserted for chest-pain control. The patient's intractable cough was controlled during the period of infusion of local anaesthetic
Art therapy as part of a palliative care programme
Authors: Connell Camilla
Published: November 2007

The principle aim in art therapy is to assist patients towards a better understanding of their situation. A case study shows how the role of the therapist is less that of a teacher and more one of questioning companion. It is hoped that this approach will be increasingly recognized as having a valuable part to play in palliative care.
Bed occupancy, patient throughput and size of independent hospice units in the UK
Authors: Kirkham Stephen , Davis Michael
Published: November 2007

There are few published figures relating to clinical activity of inpatient hospice units. Aquestionnaire was circulated to 60 independent hospices in the UK asking about number of beds, bed occupancy and number of admissions; 45 units responded. It is concluded that bed occupancy is an unreliable measure which can give significantly different figures depending on how it is calculated, and the number of admissions per bed per year (the throughput) may be the most informative single measure. Formulae for calculating maximum and average throughput for hospices of different size are provided.
Referral to a Liaison Psychiatrist from a palliative care unit
Authors: Ramsay Noren
Published: November 2007

All referrals to a psychiatrist from a palliative care unit, during a one year period, were reviewed. The reasons for referral of patients from the unit, the psychiatric diagnosis on assessment, the intervention by the psychiatrist and the results of the intervention are discussed. Depressive illness was the commonest diagnosis in the 26 patients referred (50%). Sudden immobility due to a hemiplegia or paraplegia was noted to be a risk factor for the development of depression (17%). Family factors played a role in the presentation of 14 patients. In the majority of cases intervention by the psychiatrist was in the form of a diagnostic consultation, which led to guidelines for further management by the palliative care team. In four of the cases, intervention by the psychiatrist was more prolonged (greater than three interviews). Forty per cent of the patients referred showed an improvement in their mental state. The conclusion of the paper is that psychiatric assessment can be useful to the palliative care team, in the assessment and management of psychological disorder in patients with a terminal illness.
Cancer pain: the US responds
Authors: Professor June L Dahl , Joranson David E
Published: November 2007

The increasing public and professional interest in the United States concerning effective cancer pain control, has led to the development of state cancer pain initiatives. However, the understandable pressure to reduce drug abuse has paradoxically made effective pain control more difficult. It is hoped that the combined impetus of state initiatives and various national groups will lead to improved pain management. Achieving better relief of cancer pain goes some way to meeting the current debate on euthanasia.
The working patterns of hospice based home care teams
Authors: Boyd Kirsty J
Published: November 2007

In 1990, a survey of the structure and working arrangements of 12 urban, hospice-based home care teams in the UK was carried out. The main areas of interest were staff numbers and training, visiting patterns for assessment and follow-up, workload including out-of-hours cover, and relationships with primary care teams. The role of home care services and two possible models, participatory and advisory, for provision of such services are presented and discussed.
Nausea and vomiting in advanced cancer-a flow diagram
Authors: Regnard Claud , Comiskey Mary
Published: November 2007

Nausea and vomiting are common in advanced cancer and can have many causes. Successful treatment is possible in most patients when the clinician combines the history, symptoms, clinical examination and information about the patient's tumour, with existing knowledge about the mechanisms of nausea and vomiting. In this way antiemetics can be targeted at specific causes.
Imagework in a case of intractable pain
Authors: Kearney Michael
Published: November 2007

The psychotherapeutic skill of imagework is defined and discussed in terms of its historical background and different forms. The potential value of imagework in a palliative care context is described by presentation of a case of intractable malignant pain in which this approach was used.
Organ donation: the hospice perspective
Authors: Peters Deidre , Sutcliffe Jayne
Published: November 2007

Organ donation following asystole in hospice patients is a relatively recent development. This paper looks at the development of organ donation in a hospice and considers the criteria and contra-indications for corneal, heart valve and kidney donation. A series of 12 asystolic kidney donors is presented; at the time of writing, 12 of the 24 grafted kidneys are functioning.
Drug management of pain caused by cancer: a study of general practitioners' treatment attitudes and practices
Authors: Lang Chim C , Beardon Paul HG , Ladlow Myles , Macrae William
Published: November 2007

This study assesses the treatment attitudes and practices of general practitioners in the management of pain caused by cancer. The study consisted of two parts: (1) a questionnaire survey of 328 GPs (including trainees) in Tayside, Scotland and (2) an analysis using duplicate prescriptions of all opioid analgesic prescribing over a five-year period among the doctors in a primary health care centre (population 11500). In the questionnaire survey, 63% (206) of the GPs replied. Of these respondents, 80% were prepared to manage malignant pain on their own and 17% would refer 'frequently' to the local hospice. Only 19% of respondents work in collaboration with the pain clinic and, if so, the pain clinic undertakes most of the decisions made on pain management. Co-proxamol (paracetamol plus dextropropoxyphene hydrochloride preparation) was the preferred analgesic for mild to moderate pain due to cancer and controlled-release morphine sulphate was preferred for severe pain. Duplicate prescription monitoring showed that 24% (2722) of patients received one or more prescriptions for opioid analgesics over the study period. Forty-five per cent of the patients were prescribed co-proxamol. When morphine sulphate or diamorphine was prescribed (3% and 1 % of patients respectively), laxatives were frequently coprescribed (64% and 58% respectively), as were anti-emetics (57% and 32% respectively). This study therefore shows that most GPs manage pain caused by cancer without help from hospital specialists. This study also shows a degree of awareness concerning good prescribing practice in cancer pain.
Weakness and fatigue in advanced cancer — a flow diagram
Authors: Regnard Claud , Mannix Kathryn
Published: November 2007

Weakness and fatigue are common complaints in patients with advanced cancer and have a wide variety of causes. This flow diagram describes the decisions required to assess the cause, and outlines treatment.
A clinical trial of chlorhexidine oral spray in terminally ill cancer patients
Authors: Jobbins J. , Addy M. , Bagg J. , Finlay I. , Parsons K. , Newcombe RG
Published: November 2007

One hundred and ninety-seven patients with advanced cancer admitted to Holme Tower Marie Curie Centre, Penarth, Wales entered a double blind, single phase placebo-controlled clinical trial of 0.2% chlorhexidine gluconate mouth spray for the control of oral symptoms. The sprays were administered by nursing staff twice daily for two weeks. A detailed questionnaire was completed and the mouth examined at entry and after one and two weeks of spray usage. Oral rinses and imprint cultures were collected at the same time intervals to monitor the effects of each spray on oral carriage of yeasts, coliforms, Staphylococcus aureus and Streptococcus mutans. The results suggested possible limited activity of a chlorhexidine mouth spray after two weeks of use in decreasing oral yeasts, although the difference from placebo did not reach statistical significance. In addition, both active and placebo sprays provided some patients with relief from oral dryness. Overall there was no evidence for efficacy of a chlorhexidine oral spray in patients with advanced cancer.
Managing pain in advanced cancer - a flow diagram
Authors: Thompson John , Regnard Claud
Published: November 2007

The complex nature of pain in cancer should not deflect the carer from the need to assess the precipitating cause of each pain. This flow diagram describes the clinical decisions required in assessing pain, suggests likely causes and outlines treatment.
Unfinished business - grief repression affecting adaptation and acceptance in terminal breast cancer
Authors: Cole Roger M
Published: November 2007

Unfinished business includes long held repression of negative emotions such as grief, anger and guilt. This paper discusses the effects of repression on adaptation and acceptance in terminal cancer using an illustrative case study.
'Good palliative care' orders
Authors: Maddocks Ian
Published: November 2007

A Select Committee of the Parliament of South Australia, considering revisions to legislation governing care of the dying, did not support allowing doctors to assist suicide. They recommended that no liability attach to the provision of reasonable palliative care which happens to shorten life. The Committee affirmed the suggestion that positive open orders to provide 'good palliative care' should replace 'do not resuscitate' orders.
Managing family problems in advanced disease-a flow diagram
Authors: Smith Nick , Regnard Claud
Published: November 2007

The interaction between patient, family and professional team can sometimes make difficult situations worse rather than better. This flow diagram attempts to clarify the process by which a professional assesses situations and suggests ways in which people can gain understanding about their difficulties. Once everyone has a greater understanding of what is or is not happening, the diagram points to ways in which professionals can use questions to help patient and family create a solution that is workable both for them and for the professionals.
General practitioners and palliative care
Authors: Wakefield Melanie A , Beilby Justin , Ashby Michael A
Published: November 2007

A randomly selected sample of 158 South Australian general practitioners (GPs) were sent a questionnaire which assessed opinions and management practices in the palliative care of terminally ill patients. A total of 117 responses (74%) were received. Most GPs were at least moderately satisfied with the care they were able to give their terminally ill patients, although a substantial number reported difficulties in pain and other symptom control, dealing with relatives' emotional distress and attending to patients' psychosocial needs. There was considerable support for continuing education in these aspects of palliative care. More than half were at least somewhat concerned by opioid side effects and impairment of cognitive function, although opioid dependence was not a concern. Considerable dissatisfaction was expressed with public hospital care for the terminally ill and most felt excluded from decision-making once their patients were admitted. The findings suggest that continuing education is required for GPs and that palliative care should become an integral part of undergraduate education. There is also a need to enhance communication and co-ordination between hospital and community-based services for the terminally ill.
Communicating with people who request euthanasia
Authors: Cole Roger M
Published: November 2007

The subject of euthanasia is widely debated in the medical literature and lay press in terms of morals, anecdotes and medical or legal ethics. This paper approaches the issue from a patient-centred perspective, giving four case histories to demonstrate widely varied motives or hidden agendas for requesting euthanasia. It concludes with guidelines in an approach to communication which may empower the caregiver when confronted with a patient requesting assisted death or suicide.
Pneumothorax and palliative pleural aspiration - an audit of technique
Authors: Thomas Robert , Maher Jane
Published: November 2007

The incidence of pneumothorax following a review of 55 single-sitting bedside pleural aspirations of malignant effusions over an 18-month period in the clinical oncology departments of the Middlesex and Mount Vernon Hospitals was assessed and two groups were compared. Group 1 (29 aspirations in 16 patients) involved a technique using an 8 ch (French) gauge trocar and cannula, a three-way tap and a sealed bag system, resulting in no pneumothoraces. Group 2 (26 aspirations in 18 patients) involved a variety of other techniques with a pneumothorax rate of 19.2% ( p = 0.0189 using Fisher's Exact Test). The small trocar/sealed bag system was complication-free, relatively painless, quick to perform, cheap, gave the option of draining to dryness and was easily learnt by the junior doctors who most often perform this procedure at the bedside. This technique is described in detail in the text. A reduction in the risk of pneumothorax minimizes the need for a postaspiration chest radiograph, facilitating aspiration in an outpatient, hospice or domiciliary setting. A domiciliary study is to be planned using the procedural standard described.
Diabetes mellitus in hospice patients: some guidelines
Authors: Boyd Kirsty
Published: November 2007

Diabetes is a relatively common medical condition in hospice patients. Management should be aimed at maintaining quality of life and the views of patients and families should be taken into consideration.
Euthanasia: the word and the act in palliative medicine
Authors: Di Mola Giorgio
Published: November 2007

The word 'euthanasia' has been used with a variety of meanings, all of which refer to one precise action: the killing of a suffering person. A moral evaluation of such an act can lead us either to condemn it a priori, shutting the door upon any argument, or to allow further discussion. But the issue must be discussed, starting with an analysis of the meaning of the word and then examining both whether it is justifiable or not in palliative care, and whether it is acceptable within a general medical context. This paper supports the assumption that a correct and clear-cut analysis of the word euthanasia and of the act to which the word refers can be carried out only through a debate which separates the various levels of reasoning (medical, ethical, religious, political, legal) and keeps them distinct from one another.
Two lawyers and a technician
Authors: Randall Fiona
Published: November 2007

The major arguments used to support the legalization of euthanasia are that such a move would increase autonomy both for individuals and for society as a whole, and would diminish suffering. This paper examines these two points from several angles, and concludes that, from the standpoint of society as a whole, the legalization of euthanasia would be likely to achieve the complete opposite: a reduction in autonomy and an increase in overall suffering. The involvement of doctors in euthanasia is seen as a separate debate. The medical ethic of beneficence and its importance are discussed, together with the consequent dilemmas produced if this ethic is to be retained at the same time as requesting doctors to perform euthanasia. Consequences for the doctor-patient relationship in terms of loss of trust are described. To resolve these dilemmas it is suggested that, if euthanasia were legalized, initial assessment should be by two lawyers, and the act itself performed by a technician, suitably vocationally trained.
Suitable screening tests for cognitive impairment and depression in the terminally ill- a prospective prevalence study
Authors: Power David , Kelly Sheila , Gilsenan Joan , Kearney Michael , O'Mahony Denis , Walsh J. Bernard , Coakley Davis
Published: November 2007

Although confusional states and depression are common accompaniments of advanced cancer, few objective data are available concerning the prevalence of these clinical states or what methods are most suitable for their accurate detection. We decided that a 10-question Abbreviated Mental Test Score (AMTS) and a semistructured application of modified DSMIII-R (Diagnostic and Statistical Manual of Mental Disorder, third edition - revised) criteria for a major depressive illness were the most suitable screening tests for a terminally ill population. Thirty of 87 patients (34%) displayed significant cognitive impairment. The AMTS rating declined with approaching death and also correlated negatively with age. Of 81 patients, 21 (26%) were depressed when screened using DSMIII-R criteria for depression. One-third of patients with impaired AMTS scores also satisfied DSMIII-R criteria for depression. Of cognitively impaired patients, 90% had at least two possible causes for their confused state. We have found that both the AMTS and semistructured interview using DSMIII-R criteria for depression are useful routine screening tests in the terminally ill.
Survivor focus groups: a quality assurance technique
Authors: Woodward Christel A. , King Bernice
Published: November 2007

The use of a total quality management frame work by the palliative care team (PCT) at the Chedoke-McMaster hospitals has led to a standardized method of obtaining feedback from some of the hospitals' customers. Every three months, a focus group is convened of randomly chosen significant others who were most involved in a nonprofessional caregiving role for the deceased patients. The participants are invited to discuss their perceptions of the quality of care provided by the PCT and how it could be improved. This paper describes the procedures used and feedback received in the first year of this audit procedure. The lessons learned during implementation of this audit procedure and how this feedback has affected the PCT's functioning are discussed. This process can provide information for continuous improvement of the care provided by the PCT.
Attitudes to some aspects of death and dying, living wills and substituted health care decision-making in South Australia: public opinion survey for a parliamentary select committee
Authors: Ashby Michael , Wakefield Melanie
Published: November 2007

This study aimed to provide evidence on community attitudes to certain death and dying issues in South Australia for a state parliamentary committee on the law and practice relating to death and dying. The following areas were studied: truth-telling, pain control, level of treatment, preferred place of death, rights of patients to refuse treatment, opinion about living wills and substituted health care decision making. A representative population survey of 625 households in metropolitan Adelaide and three major rural centres was made in August 1991, using personal interviews administered at home with one adult in each house hold aged over 18 years. A total of 462 (74%) adults completed the interviews. There was strong support for truth-telling by doctors about incurable cancer and impending death, although this was not universal. Fears of potential addiction, habituation, tolerance and impaired cognitive function as a result of analgesia for cancer pain were strongly expressed, particularly amongst those who reported least formal education. Those with experience of a death in the last eight years were most likely to consider the level of treatment offered to patients with incurable cancer to be inadequate, but 53% considered the level to be about right. Nearly 60% of respondents favoured death at home, but there was a trend for older people to favour death in hospital. Despite the existence of the Natural Death Act (1982), only 20% were aware that living wills were legal in South Australia. There was strong support for a medical power of attorney.
Living wills in English law
Authors: Stern Kristina
Published: November 2007

There is considerable debate surrounding the provision of life-sustaining treatment to those unable themselves to give consent. This article examines the issues involved from a legal perspective, and discusses two proposed solutions: the 'advance directive' and the 'health care proxy'. It is concluded that a legislative framework should be set up in order to give advance directives a legal status.
Short terminal admissions to a hospice
Authors: Boyd Kirsty J
Published: November 2007

Over a six-month period, 47 patients (9.8% of admissions) died within 48 hours of admission to St Christopher's Hospice and were included in this study. There was a high prevalence of symptoms on admission but many were amenable to treatment, even in the short time available. Respiratory symptoms were commonest and the most difficult to control. The majority of the patients required an opioid. although only low doses were needed. Almost all the relatives had no regrets about the place of death. Hospice staff felt that a number of patients transferred from hospital should not have been moved. The study confirmed the value of short terminal admissions to patients and families and suggested areas for further action.
How to assess thinking skills in cancer patients
Authors: Nelson-Jones Richard , Cosolo Walter
Published: November 2007

This article emphasizes the importance of health care professionals assessing and working with the way cancer patients think. Health care professionals can help cancer patients think more effectively about the organic manifestations of their disease, problems that arise from the cancer experience, and problems unrelated to cancer, but which negatively influence their lives. Nine thinking skills areas are identified and described. Skills that health care professionals can use to assess patients' thinking, and to gain insight into their own thinking, are reviewed. In addition, suggestions are made for how patients can be helped to overcome thinking skills weaknesses and build their strengths so that they can optimize their chances of quality life.
The effect of transfer from a palliative care unit to nursing homes - are patients' and relatives' needs met?
Authors: Maccabee Joyce
Published: November 2007

The constant demand on hospice inpatient services has led to an increasing use of nursing home beds for patients requiring longer-term nursing care, once their symptoms have been controlled and if care at home is not feasible. The effect of such a transfer on the patient has not previously been examined. The results of this study suggest that the transfer of a patient from a palliative care unit to a nursing home may lead to a shortfall in meeting the needs of patients and relatives. Strategies that might improve this practice in the current social services climate are suggested.