bluuebunny/crossref_metadata_2025 huggingface dataset:
Educational opportunities in palliative care: what do general practitioners want?
Authors: Shipman Catherine , Addington-Hall Julia , Barclay Stephen , Briggs Jill , Cox Ivan , Daniels Lilian , Millar David
Published: May 2003

It is important to support general practitioners (GPs) in maintaining and developing their palliative care skills as most of the final year of a patient's life is spent at home under the care of the primary health care team. The training needs and uptake of GPs have been explored, but little is known about how GP educational preferences vary. The aim of this study was to explore the current educational preferences of GPs in different geographical locations as part of an evaluation of an educational intervention. The methods used included postal questionnaires sent to 1061 GPs. Results from 640 (60%) of GPs revealed that half (51%) wanted education in symptom control for non-cancer patients. More inner-city GPs wanted education in opiate prescribing (43%), controlling nausea and vomiting (45%), and using a syringe driver (38%) than their urban and rural colleagues (26%, 29% and 21%, respectively). Increased educational preference and increased difficulty in accessing information was associated with reduced confidence in symptom control. To maximize educational uptake it will be important for educational strategies to be developed and targeted according to variations in demand, and in particular to respond to the need for palliative care education in symptom control for patients suffering from advanced non-malignant disease.
Communication Capacity Scale and Agitation Distress Scale to measure the severity of delirium in terminally ill cancer patients: a validation study
Authors: Morita Tatsuya , Tsunoda Junichi , Inoue Satoshi , Chihara Satoshi , Oka Kiyoshi
Published: May 2003

Although valid measurement of the severity of terminal delirium is of great importance in palliative care settings, existing instruments have considerable limitations. In order to quantify patients' communication capacity and agitated behaviour, two new operational observer-rating scales, the Communication Capacity Scale (Communication Scale) and Agitation Distress Scale (Agitation Scale), were validated.

Thirty terminally ill cancer patients diagnosed with delirium were evaluated simultaneously by two palliative care physicians blinded to each other's coding using the Communication Scale and Agitation Scale. In addition, the Memorial Delirium Assessment Scale (MDAS), Delirium Rating Scale (DRS) and Sedation Scale were rated by one researcher. Both scales achieved high internal consistency and inter-rater reliability with Cronbach's alpha coefficients of 0.91 and 0.96, and Cohen's kappa values on each item of 0.72–1.00.

The principal components analysis resulted in the emergence of only one component for each scale. The total score on the Communication Scale was highly associated with that of the MDAS (= 0.78), Sedation Scale (= 0.86), and cognitive items from the MDAS and DRS (= 0.83). The whole score on the Agitation Scale was significantly correlated with that of the DRS (= 0.61) and agitation items from the MDAS and DRS (= 0.61).

In conclusion, the Communication Scale and Agitation Scale have acceptable reliability and validity to quantify patients' communication capacity and agitation symptoms of terminally ill cancer patients with delirium.
Lung cancer health care needs assessment: patients' and informal carers' responses to a national mail questionnaire survey
Authors: Krishnasamy Meinir , Wilkie Erna , Haviland Jo
Published: May 2003

The objective of this study was to describe patients' and informal carers' perceptions of care received and services offered following a diagnosis of primary lung cancer. We prepared a prospective, national, mail questionnaire survey of 466 patients with a diagnosis of primary lung cancer and a lay carer of their choice. The setting was 24 randomly chosen hospitals throughout the UK, from a range of urban ( n = 11) and rural settings ( n = 13). The majority (76%/159) of responders were recipients of care from cancer units. Two hundred and nine patients (45%) with primary lung cancer and 70 (15%) lay carers completed questionnaires. The main results that we found were that key areas of unmet need were most apparent during periods away from acute service sectors, with as few as 40% of patients reporting having received as much help as they needed from community services. The greatest onus of care for patients fell to lay carers, but only 29% of patients identified their lay carers as having needs in relation to their illness. Where patients received all their diagnostic tests in one hospital they were significantly more likely to wait less time between first seeing their general practitioner (GP) and being told their diagnosis (P = 0.0001) than patients who had to attend more than one hospital during their diagnostic work-up period. Fifty per cent of patients reported experiencing some degree of breathlessness even at rest, but only 15% reported having received any advice on living with it. Less than a quarter (23%) of hospital consultants identified anxiety as a key problem for patients with lung cancer, but 66% of patients identified it as such. Hospital staff largely overlook the needs of informal carers, who derive support from a small, mainly community oriented group of professionals, but accessing help is problematic and is dependent on local resources and a need to be proactive.

Our conclusions are that developments in service provision for patients with lung cancer and their informal carers need to focus on six key areas: development of strategies to encourage patients to present earlier to their GP; ongoing evaluation of rapid diagnostic clinics; development and evaluation of a lung cancer care coordinator role; evaluation of innovations in delivery of nursing care in the community; development of local guidelines to facilitate equitable access to palliative care and social services; and evaluation of supportive strategies targeted at lay carers.
Chaplaincy in hospice and hospital: findings from a survey in England and Wales
Authors: Wright Michael C
Published: May 2003

The purpose of this study was to identify and compare key features of spiritual care provision in hospices and acute hospitals within England and Wales. A survey by postal questionnaire was carried out on the perceptions of senior chaplains in 151 hospices and 194 hospital trusts. The overall response rate was 76%. The findings of the survey suggest (a) a trend away from establishing chapels as the spiritual focal point within hospitals and hospices, (b) the development of broader roles for chaplains, (c) a different level of service provision between hospices with funded chaplaincies and hospices with voluntary chaplaincies, (d) a wide range of non-religious spiritual care requirements on the part of patients and (e) a more frequent requirement for religious care in hospitals rather than hospices.
Use of clinical pictures in the management of nausea and vomiting: a prospective audit
Authors: Bentley Angela , Boyd Kirsty
Published: May 2003

This prospective audit aimed to evaluate a guideline for the management of nausea and vomiting in palliative care inpatients. Clinical pictures were used to guide diagnosis and treatment, with potentially reversible causes being addressed where appropriate. Over a 3-month period, 40 patient episodes occurred, all of which were included in the audit. The commonest clinical pictures were gastric stasis/outlet obstruction (35%) and chemical/metabolic (30%). Management according to the guideline was effective. Nausea was abolished in 28 of 34 cases (82%) and vomiting resolved completely in 26 of 31 cases (84%). Symptoms were totally controlled in a mean time of 3.4 days.

Nausea and vomiting, although distressing symptoms, can be controlled in the majority of cases. Multi-centre prospective audit, using a standardized tool, may prove useful in allowing larger numbers of patients to be systematically analysed and individual centres to compare outcomes.
Changes in quality of life following admission to palliative care units
Authors: Cohen S Robin , Boston Patricia , Mount Balfour M , Porterfield Pat
Published: May 2003

The primary goal of palliative care is to improve the quality of life (QOL) of people with a terminal illness. Previous studies of the impact of hospice/palliative care have documented improvement in physical and psychological symptoms, but not in overall QOL, due in part to the difficulties of measuring QOL. The McGill Quality of Life Questionnaire (MQOL) was developed to assess QOL in persons with advanced illness.

MQOL scores were determined on admission and 7–8 days later for sequential eligible and willing patients admitted to five palliative care units. These 88 patients represented 8% of those admitted to the units during the study period. Following the final MQOL completion, patients were interviewed and asked to describe the nature of the changes in QOL they had experienced since admission.

Significant improvements were found in the MQOL total score and subscale scores reflecting physical, psychological and existential well-being. In the interviews patients indicated that they had experienced changes in physical, emotional and interpersonal status, in spiritual outlook, and in their preparation for death. They also described the impact of the palliative care unit environment.

This is the first study to demonstrate that hospice/palliative care can improve existential well-being in addition to psychological and physical symptoms. It provides evidence in the patients' own words that improvements in QOL go beyond symptom control following admission to a palliative care unit. However, the study results are generalizable only to those few patients admitted who are well enough to complete a questionnaire 1 week after admission.
Attitudes towards death and dying in a representative sample of the Italian population
Authors: Di Mola Giorgio , Crisci Maria Teresa
Published: May 2003

This study investigated attitudes in Italy towards incurable disease, death and dying, and analyses the answers given to questions regarding the end of life and the care of the terminally ill patient. Of 1011 people invited to take part in this study, 829 (82%) agreed to participate. People were interviewed about the images associated with death (47% of those interviewed associated death with cancer); telling the truth to the dying patient (13% were in favour of being made aware of their impending death); the place of death (62% preferred home, 7% hospital); the attitudes of the carers (38% affirmed that pain should be alleviated, without considering the length of life, while 8% stated that they would be prepared to bear physical suffering if it meant prolongation of life) and religious faith (88% of those interviewed declared themselves Christian).

Comparing our data with a previous survey, carried out in 1988, we conclude that only small changes have occurred in attitudes in the intervening 11 years: a slight increase in those who said that they think ‘often' or ‘sometimes' about death (53% in 1999, 44% in 1988) and an increase in the number of people who associate the causes of death with cancer (47% in 1999, 36% in 1988). The fear has diminished of AIDS (5% versus 8%) and war (5% versus 12%) as causes of death. It is concluded that such studies will serve not simply to provide indicators of public tendencies or public interest in the problem, but will constitute a tool whereby those attitudes which merit close observation can be identified and, where necessary, changed.
Needs assessment for palliative care: three projects compared
Authors: Ingleton Christine , Skilbeck Julie , Clark David
Published: May 2003

Needs assessment remains an inexact yet evolving field of activity in palliative care. One reason for the variable quality of needs assessments in palliative care is the pragmatic orientation that comes from limited time and resources. Consequently a comprehensive approach to palliative care needs assessment is often not achieved. One route to its improvement lies in sharing experiences about techniques and methods in conducting needs assessment studies. In this paper we offer some thoughts on our own experience of conducting needs assessment for palliative care in three separate locations within a single English health region. We describe the context in which the projects were conducted; the background and origin of each study; the aims and methods used; the research process in each case; key findings; as well as the dissemination process and impact of the work. We show some of the different forms which palliative care needs assessment can take and conclude with some general principles intended to improve practice in this challenging area of health services research.
Transdermal fentanyl for pain relief in a paediatric palliative care population
Authors: Hunt Anne , Goldman Ann , Devine Tom , Phillips Marianne
Published: May 2003

This multicentre, observational study examined the efficacy of the therapeutic transdermal fentanyl system (TTS-fentanyl) in children requiring opioids for pain in life-threatening disease. Forty-one children receiving oral morphine (median dose 60 mg/day) transferred to transdermal fentanyl (median dose 25 g/h according with the manufacturer's dose conversion guidelines). Twenty-six children completed the 15-day treatment phase, seven died due to disease progression and eight were withdrawn because of adverse events, inadequate analgesia or a change to parenteral opioids. After 15 days, the median fentanyl dose was 75 g/h (range 25–250). No serious adverse events were attributed to fentanyl. There was a trend toward improved side-effects and convenience with fentanyl. Twenty-three of 26 parents (three missing) and 25 of 26 investigators considered transdermal fentanyl to be better than previous treatment. For all records available (at 15 days or on withdrawal if earlier), 75% (27/36) reported that fentanyl treatment was ‘good' or ‘very good’. The findings suggest that transdermal fentanyl is both effective and acceptable for children and their families.
Palliative care for patients with non-malignant disease: will hospital physicians refer?
Authors: Dharmasena Helen P , Forbes Karen
Published: May 2003

The objective of this research was to determine whether consultant physicians would consider referring patients with non-malignant disease to a specialist palliative care service, and if so, which patients they would refer. In addition, reasons for referral, expectations of the palliative care team and concerns about the extension of palliative care to non-malignant disease were examined.

A postal questionnaire was sent to all 100 consultant physicians, including subspecialities, working in hospitals in south-east Wales, UK.

Out of the 100 questionnaires, 78 physicians responded, of whom 94% would consider referring patients with non-malignant disease to a specialist palliative care service. The physicians would be prepared to refer patients with a wide range of conditions, for a variety of reasons.

Among the physicians surveyed there was a general enthusiasm for specialist palliative care services to be made available to patients with non-malignant disease. The most appropriate form of service was thought to be a system of shared care and responsibility and this was seen as a means of addressing concerns regarding the lack of disease-specific expertise within the palliative care team.
Improved accuracy of physicians' survival prediction for terminally ill cancer patients using the Palliative Prognostic Index
Authors: Morita Tatsuya , Tsunoda Junichi , Inoue Satoshi , Chihara Satoshi
Published: May 2003

The Palliative Prognostic Index (PPI) has recently been developed for survival prediction in terminally ill cancer patients. To clarify whether physicians' clinical prediction of survival (CPS) can be improved using this objective assessment aid, two sequential prospective studies were performed on two independent series of hospice inpatients ( n 150 and 108). In the first study, the CPS was prospectively recorded by primary physicians on the basis of their clinical experiences. In the second study, physicians estimated patient prognoses with a reference to the PPI score.

The cases where the differences between actual survival (AS) and CPS were 28 days or longer significantly decreased in the second study compared to the first study (42% vs 23%, P 0.01). Also, the cases where AS was either twice longer or half shorter than CPS significantly declined (49% vs 37%, P 0.050). As well, serious errors, defined as the cases where AS was either (a) 28 days and twice longer than CPS or (b) 28 days and half shorter than CPS, significantly decreased from 27% in the first study to 16% in the second study (P 0.028).

In conclusion, the PPI can contribute to improvement in physicians' ability to predict survival of terminally ill cancer patients.
Moral problems in palliative care journals
Authors: Hermsen Maaike A , ten Have Henk A M J
Published: May 2003

With the growth of palliative care services, interest in moral issues also seems to be growing. However, we need to know which moral issues are specific to palliative care. The first step in answering this is to consider the moral concerns raised and discussed by the palliative care community itself. This article presents a bibliographical analysis of moral problems, first by selecting the problems identified as moral problems in the leading palliative care journals, and then by classifying these into different types.
How many inpatients at an acute hospital have palliative care needs? Comparing the perspectives of medical and nursing staff
Authors: Gott C Merryn , Ahmedzai Sam H , Wood Claire
Published: May 2003

The primary aim of this prospective face-to-face interview survey was to identify the proportion of inpatients at an acute hospital (Royal Hallamshire Hospital, Sheffield, UK) considered to have palliative care needs by medical and nursing staff directly responsible for their care. During the 1-week period of the survey (6–10 September 1999), 452 inpatients were present in the hospital. Nursing staff were interviewed for 99% of patients; medical staff for 81%. Staff interview data were supplemented by case note review. Overall, 23% of the total inpatient population were identified as having palliative care needs and/or being terminally ill by staff and 11% were considered suitable for referral to a specialist palliative care bed. However, there was a low level of concurrence between medical and nursing staff as to which individual patients had palliative care needs (although this increased with perceived increased proximity to death), including which would be suitable for referral to a specialist palliative care bed. A need for further palliative care education for medical and nursing staff working within acute hospital settings was identified to ensure that the best use is made of hospital-based specialist palliative care services.
Provider perspectives on palliative care needs at a major teaching hospital
Authors: Llamas K J , Llamas M , Pickhaver A M , Piller N B
Published: May 2003

Jericho Metropolitan Hospital (JMH) is a major Australian teaching hospital which lacked a designated palliative care service at the time this study was conducted. A questionnaire addressing palliative care service needs, and educational and support needs of staff, was sent to 267 multi-disciplinary oncology staff at JMH. A response rate of 83% was achieved. Staff identified a number of palliative care needs that were being particularly poorly addressed by existing services. These included: spiritual support, cultural needs, grief and bereavement support, pleasant surroundings, adequate privacy and facilities for families. The majority of respondents identified the following issues as critical problems in palliative care provision: lack of a designated palliative care service, lack of palliative care education of staff, unmanageable caseloads and inadequate physical facilities for the provision of care. Only 24% of respondents reported having had any palliative care education, and 92% of respondents expressed a need for further education. The majority of respondents (79%) expressed a need for improved staff support. There was a significant association between perceived need for improved support and professional discipline (2 31.33, P 0.002), with medical staff being significantly less likely than other staff groups to report a need for improved support. Overall, the health providers surveyed identified major deficiencies in the provision of palliative care to cancer patients at JMH and in the palliative care education and support for staff caring for terminally ill cancer patients. The findings support the need for a designated palliative care service at JMH to improve the standard of care of dying cancer patients, and the need for improved palliative care education and support for staff.
The emergence of Medicare hospice care in US nursing homes
Authors: Miller S C , Mor V
Published: May 2003

Although Medicare-financed hospice care has been provided in nursing homes in the USA for over 10 years, very little is known regarding the use of this government health care benefit in nursing homes. Using resident assessment data and hospice and inpatient Medicare claim data from five US states, we were able to identify and describe nursing home residents receiving hospice care between 1992 and 1996, and their hospice utilization patterns. Six per cent of all dying nursing home residents received hospice care at some point in time and, in 1996, an estimated 24% of all Medicare hospice patients in the five study states received hospice while in a nursing home. Of those residents beginning hospice care after nursing home admission, 48% were 85 years or older, 70% were female, 94% were white, 76% were unmarried and 62% had a non-cancer principal diagnosis. The average length of stay in the hospice programme for residents receiving hospice care while in the nursing home was 90.6 days, the median 35 and the mode 2. Hospice care in US nursing homes is a prevalent model of care that appears further to extend the Medicare hospice benefit to older adults who are female and to those with non-cancer diagnoses. Lengths of stay in the programme are similar to those observed in the community and the average length of stay is substantially shorter than previously estimated by an influential government study.
The concept of palliative care in the Netherlands
Authors: Janssens Rien J P A , ten Have Henk A M J
Published: May 2003

Palliative care in the Netherlands is growing and the climate for further development is favourable. Although there is a great deal of consensus on the current debates within palliative care, important disagreements persist. These disagreements relate to the history of palliative care within the country, the scope of palliative care, its values, the appropriate institutional context, and the moral acceptability of euthanasia in palliative care. In this paper, the consensus and the disagreements are described and discussed. It is concluded that many disagreements emerge from so-called external goals of palliative care. It is recommended that the debate should refocus on the internal goal of palliative care, which is the quality of life of the patient and his or her loved ones.
Patients' perceptions of visiting: a phenomenological study in a specialist palliative care unit
Authors: Thomas R
Published: May 2003

It is assumed that visiting increases peace of mind and patient's well-being, but this assumption has not yet been formally studied from the patient's viewpoint. The family and close friends are seen as an integral part of the care team for patients receiving palliative care, yet the perception of their contribution in the experiences of the patients has been rarely recorded. This study uses qualitative methods to investigate patients' perceptions of visiting, by using a phenomenological approach. Six patients took part in semi-structured interviews; these were thematically analysed for common experiences, and highlighted two themes: coping and control. Whilst being different themes, they are inextricably linked, as an element of control will usually help coping. Methods of increasing patient control over visiting may, therefore, enhance coping mechanisms.
Euthanasia: moral paradoxes
Authors: ten Have H A M J
Published: May 2003

Over the past 30 years, euthanasia has been under continuous debate in the Netherlands. This contribution aims to provide a moral assessment of this debate. It is argued that euthanasia should be understood within a historical context, as a protest against medical power and as a way to bring about good death. Within the euthanasia debate, two paradoxes are identified which make the issue inherently complex and hard to regulate. The first paradox results from the dialectical relation between individual autonomy and relief of suffering as the major justifications of euthanasia. Although euthanasia represents an ultimate effort to give the individual patient control over his dying, the result of the debate is an increase of medical power. The second paradox is that although euthanasia emerged from a commitment to good death, it is resulting in a reduced range of options to bring about good death.
The development of clinical guidelines on paracentesis for ascites related to malignancy
Authors: Stephenson J , Gilbert J
Published: May 2003

Malignancy-related ascites gives rise to troublesome symptoms and carries a poor prognosis. Abdominal paracentesis is a widely used and effective procedure for symptom relief, but practice with regard to the procedure itself may vary considerably. Evidence obtained in the context of liver disease probably influences practice in malignancy, although the pathophysiology involved is different. Anecdotal evidence suggested a difference in practice between the Exeter and District Hospice and the adjoining hospital, and this was confirmed by a review of case notes. Patients undergoing paracentesis in the hospital were more likely to have prior ultrasound assessment and to be given intravenous fluids, and had longer drainage times and longer inpatient stays. It seemed that some practices were placing unnecessary burdens on patients whose life expectancy was short. A set of clinical guidelines for the procedure was drawn up, based on the limited evidence available and the practice within the hospice. These guidelines emphasise performing ultrasound investigations only in cases of diagnostic uncertainty, allowing up to 5 L of fluid to drain without clamping, leaving drains in for no more than 6 h and giving intravenous fluids only when specifically indicated. These guidelines were introduced on the oncology ward of the adjoining hospital. The impact on practice was assessed by means of a retrospective case note review of all procedures carried out on the ward in the 6 months before and after the guidelines were introduced. The introduction of guidelines resulted in significant reductions in prior ultrasound assessment, mean length of time drains were left in and mean length of inpatient stay for planned procedures. There were no cases of symptomatic hypotension in the postguidelines group.
Defining patients as palliative: hospital doctors' versus general practitioners' perceptions
Authors: Farquhar M , Grande G , Todd C , Barclay S
Published: May 2003

There appears to be a lack of consensus on the classification of individual patients as ‘for palliative care’, although the extent of this is unknown. General practitioners (GPs) of 213 patients with a palliative diagnosis of lung or colo-rectal cancer were sent a one-page questionnaire to assess information sent by hospital doctors, and to establish the GPs' perception of patients' palliative status. A total of 185 questionnaires were returned (87% response rate). Of those GPs receiving information from the hospital, one in four rated the adequacy as less than positive; 26% reportedly received no information or received it ‘too late’. In 20% of cases, GPs did not perceive patients as palliative, although hospital records suggested that they were, and death certificates received later potentially confirmed this. There was, however, no significant difference between GPs allocating a patient to palliative status or not, in terms of the promptness or adequacy of information received from the hospital, as rated by the GP. There was a significant difference in survival between patients whom GPs perceived as for palliative care and those they did not (‘palliative’ patients died, on average, 117 days earlier). Possible explanations of the differing perceptions of patients' palliative status are discussed. The findings have implications for patient care in the community, patients' informed choices, and palliative care research.
Evaluation of the effectiveness of UK community pharmacists' interventions in community palliative care
Authors: Needham D S , Wong I C K , Campion P D
Published: May 2003

Introduction: In 1997, the Royal Pharmaceutical Society of Great Britain Working Party reported that UK community pharmacists had a crucial role in effective medicines management and effective symptom control for those receiving palliative care in the community. However, prior to the integration of community pharmacists into the community palliative team, it is necessary to evaluate the effectiveness of their pharmaceutical interventions. Aim: To assess the effectiveness of community pharmacists' clinical interventions in supporting palliative care patients in primary care using an independent multidisciplinary panel review. Methods: Patients with a life expectancy of less than 12 months were each registered with a single pharmacy and their consent was obtained for the community pharmacists to access their general practitioner (GP) case records. The community pharmacists received training in palliative pharmaceutical care and documenting interventions. The trained community pharmacists provided palliative pharmaceutical care to the recruited patients. At the end of a 10-month period, the clinical interventions were reviewed by an independent multidisciplinary expert panel consisting of a palliative care consultant, a Macmillan nurse (community palliative care nurse) and a hospital pharmacist with special interest in palliative care. Results: Fourteen community palliative care teams (including community pharmacists, GPs and community nurses) took part in the study and 25 patients were recruited over the 10-month recording period. All but one patient had a diagnosis of cancer; the other patient had chronic obstructive pulmonary disease. By the end of the project, 14 patients had died. Community pharmacists recorded a total of 130 clinical interventions. Thirty interventions were excluded as insufficient information had been documented to allow review by the panel. Eighty-one per cent of the interventions were judged by the expert panel likely to be beneficial. However, 3% were judged likely to be detrimental to the patients' well-being. Conclusions: Most of the clinical interventions made by the community pharmacists for palliative pharmaceutical care were judged by the expert panel as being likely to be beneficial. The result supports the view that when community pharmacists are appropriately trained and included as integrated members of the team, they can intervene effectively to improve pharmaceutical care for palliative care patients.
Integration of acupuncture into the oncology clinicy
Authors: Johnstone Peter AS , Polston Gregory R , Niemtzow Richard C , Martin Peter J
Published: May 2003

Purpose/Objective: Patients with cancer or symptoms referable to cancer therapy were offered acupuncture as potential palliation of their symptoms. This paper describes the physical integration of the discipline into the Oncology Clinic, and patient perspectives on its availability and efficacy. Patients and methods: Between August 1999 and May 2000, 123 patients with varying symptoms received acupuncture in our Center's Radiation and Medical Oncology Clinics and Breast Health Center. These patients had 823 visits during this time period. A practice outcome analysis was performed on patients receiving therapy between 1 January 2000 and 30 April 2000. The 89 patients treated during this interval had 444 total visits. In June and July 2000, a questionnaire was administered by phone to 79 of these patients (89%). Standard allopathic care continued while patients were receiving acupuncture. Results: Major reasons for referral included pain (53%), xerostomia (32%), hot flashes (6%) and nausea/loss of appetite (6%). Patients had a mean of five acupuncture visits (range 1– 9). Most patients (60%) showed at least 30% improvement in their symptoms. About one-third of patients had no change in severity of symptoms. There were no untoward effects reported related to the acupuncture. When analysed by diagnosis, these values persist. Irrespective of response to therapy, 86% of respondents considered it ‘very important' that we continue to provide acupuncture services. Conclusion: Acupuncture may contribute to control of symptoms for cancer patients. Expansion of providers, continued patient follow-up, optimization of techniques and prospective objective measurement of response continue in our clinic.
Patient-held records in cancer and palliative care: a randomized, prospective trial
Authors: Cornbleet Michael A , Campbell Phyllis , Murray Scott , Stevenson Margaret , Bond Senga
Published: May 2003

Objectives: To evaluate prospectively the introduction of a patient-held record (PHR) in the management of patients with advanced cancer and palliative care needs. Design: a) A prospective, parallel group, randomized controlled trial. b) A postal survey of the opinions of health professionals whose patients had a PHR. Setting: Out-patient oncology centres in Glasgow and Edinburgh, hospice home-care services across the central belt in Scotland. Participants: A total of 244 patients with advanced cancer recruited either from oncology out-patient clinics or hospice home-care services. The baseline interview was completed by 231 patients and 117 were randomized to receive the PHR. Between 4 and 6 months later, 80 patients with the PHR and 97 without were interviewed. Of the 83 health professionals caring for patients known to have received the PHR 63 replied to a postal questionnaire. Main outcome measures: Subjective views of patient satisfaction with communication and perception of communication between patient and health care professionals as determined by structured interview at baseline and after 4– 6 months. Results: We could identify no improvement in the provision of information to patients, or patients' satisfaction with information provided by out-patient doctors, GPs, practice and community nurses and hospice or palliative home care staff. Overall, patients' perception of communication between all staff involved in their care with and without PHRs was excellent in 24% and 21%, respectively, or very good in 56% and 58% (P=0.89). The PHR made no difference to information passing between health professionals, or to the degree of family involvement. Most of those who had a record found it of some use and benefit. Conclusion: This study provides no evidence on which to base the widespread promotion of PHRs, although local projects with committed clinicians and patients may well prove popular and effective.
Plasma concentrations of morphine, morphine-6-glucuronide and morphine-3-glucuronide and their relationship with analgesia and side effects in patients with cancer-related pain
Authors: Quigley Columba , Joel Simon , Patel Naina , Baksh Amina , Slevin Maurice
Published: May 2003

Morphine, the recommended drug for the management of moderate to severe cancer pain, is metabolized predominantly to the glucuronides morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G). The quantitative clinical importance of these metabolites following the administration of oral morphine is unclear. This study investigates the relationship between plasma concentrations of morphine (M), M6G, M3G and clinical effects in patients receiving sustained release oral morphine for cancer-related pain.

Peak and trough plasma concentrations of morphine and its metabolites were determined by high-performance liquid chromatography (HPLC). At corresponding time points, pain [Visual Analogue Scales (VAS), Verbal Rating Scales (VRS), Pain Relief Scores (PRS)] and toxicity (VAS and VRS) were assessed. Renal and liver function tests were performed.

Forty-six patients were included in the study. There was a significant correlation between dose and both peak and trough plasma M, M6G and M3G (r>0.60, P<0.001 for each). Differences between peak and trough M, M6G, M3G, M / M6G, M6G:M, M3G:M and M3G:M6G were all significant (P<0.001 for each). Pain was generally well controlled in the group, with a median VAS of 15 mm at the peak blood sampling time point. The differences between peak and trough values for VAS pain, VAS nausea and VAS drowsiness were not statistically significant (P = 0.078, 0.45 and 0.099, respectively).

There were no differences in peak or trough morphine and metabolite concentrations or ratios between patients with low (< median) or high pain scores. Similarly, there was no significant relationship between high and low plasma concentrations and clinical effect.

This study did not identify a simple relationship between plasma concentrations of morphine, morphine metabolites or metabolite ratios and clinical effects in patients with cancer and pain who were receiving chronic oral morphine therapy. Although overall pain control was good, there was marked interpatient variability in the dose of morphine and the plasma concentrations necessary to achieve this degree of analgesia.
Proxy reporting in after-death interviews: the use of proxy respondents in retrospective assessment of chronic diseases and symptom burden in the terminal phase of life
Authors: Klinkenberg M , Smit J H , Deeg D J H , Willems D L , Onwuteaka-Philipsen B D , van der Wal G
Published: May 2003

This study evaluates the quality of data obtained from after-death interviews with significant others of deceased older persons regarding the prevalence of chronic diseases and symptoms in the terminal phase of life. These data are compared with reports from physicians and earlier self-reports from the deceased person. There were significant increases in nonresponse and nonavailability of significant others for decedents who had been divorced or had never been married, thus introducing some selection bias. At the level of the total sample, significant others seem to give accurate information about the prevalence of chronic diseases when compared with self-reports and reports from physicians. At the level of the individual sample member, after-death interviews with significant others provide valid information for the assessment of the prevalence of malignant neoplasms, diabetes mellitus, chronic obstructive pulmonary disease and cerebrovascular disease, but not for osteo- and rheumatoid arthritis and artherosclerotic disease. At the level of the total sample, the prevalence of symptoms assessed by significant others did not differ greatly from the assessment made by physicians. However, at the level of the individual sample member, the validity of symptom assessment by significant others could not be supported by data obtained from the physicians. With regard to the type of significant others interviewed, children reported more symptoms than partners. The use of significant others in after-death interviews can be a valid method with regard to the assessment of chronic diseases and symptoms on a group level. On an individual level this can be concluded only for chronic diseases with clearly observable consequences.
Which depression screening tools should be used in palliative care?
Authors: Lloyd-Williams Mari , Spiller Juliet , Ward Jason
Published: May 2003

Depression is a significant symptom for many palliative care patients, but is difficult to diagnose and therefore treat. In an effort to improve detection, there has been increasing interest in the use of screening tools. Many tools, however, have been developed for physically well patients and it is important that tools are validated for the populations in which they are used. The present study was carried out on behalf of the Association of Palliative Medicine, Science Committee, to assess the available evidence for using screening tools in palliative care. The single question ‘Are you depressed?’ was the tool with the highest sensitivity and specificity and positive predictive value. Where the Hospital Anxiety and Depression Scale and the Edinburgh Depression Scale are used, the validated cut-off thresholds for palliative care patients should be employed. Patients who report thoughts of self-harm or suicide need prompt assessment and evaluation.
The experiences of donor families in the hospice
Authors: Carey Irene , Forbes Karen
Published: May 2003

Objectives: This study explored the experiences, attitudes and feelings of relatives who consented to donation of corneas of a loved one who had died of cancer. Design: Semistructured interviews were conducted by a single researcher and qualitatively analysed for systematic identification of themes. Setting and participants: Two specialist palliative care units in Southern England participated. The names of donor families were obtained via transplant coordinators, the local eye bank and hospice records. Ten donor families were interviewed, four to 12 months after their relative's death. Results: The majority of interviewees had thought the deceased was ineligible for donation due to cancer or old age. Approaches regarding donation were generally made by nurses and described as sensitive by relatives. Very few family members would otherwise have considered or raised the subject. Almost all were glad they had agreed to donation although few felt it directly affected their bereavement. A range of motivations for consent was encountered but decisions were very much easier if the deceased's wishes were already known. Most favoured an opt-out system or the right of the family to decide if the deceased's wishes were not known. Conclusions: Corneal donation is possible for patients dying from cancer. This study indicates that it is generally regarded positively by donor family members. Education of the public and health professionals is necessary to highlight both the eligibility criteria and the need for donation. Families should be encouraged to discuss donation to facilitate respecting individuals' wishes. In the absence of a known decision from the deceased, health professionals should be aware of their responsibility to discuss the issue with the family.
Intravenous morphine for rapid control of severe cancer pain
Authors: Harris J T , Kumar K Suresh , Rajagopal M R
Published: May 2003

This randomized controlled trial compared intravenous route with oral route for initial dose titration of morphine in 62 patients with end-stage cancer and severe pain. Patients in the intravenous group received 1.5 mg intravenous bolus doses of morphine every ten minutes till pain relief was total or until they became drowsy. After that they got oral morphine at a dose equal to the total initial intravenous requirement four-hourly. Patients in the oral group got oral morphine 5 mg doses (if opioid-naÖve) or 10 mg (if already on weak opioid) four hourly. Patients in both groups had the option to receive rescue doses of their regular oral dose as and when needed, if necessary hourly. Twenty-seven of 31 in the intravenous group had either total or satisfactory pain relief by the end of one hour, whereas only eight of 31 in the oral group had a similar result. After 24 hours and later both groups had similar results. There was no immediate serious side effect in any of the patients. The late side effects were similar in the two groups. In the intravenous group, the ratio of initial intravenous dose requirement to the subsequent regular single oral dose after two days centred around 1:1 (range 1:0.5-1:3.3). This study found the intravenous method to be safe, effective and superior to the traditional method in providing immediate relief to severe cancer pain.
A stakeholder evaluation of the impact of the palliative care clinical nurse specialist upon doctors and nurses, within an acute hospital setting
Authors: Jack Barbara , Oldham Jackie , Williams Anne
Published: May 2003

There has been an expansion in the number of palliative care teams based in the acute hospital setting. Although organization of these teams varies both in structure and approach, the clinical nurse specialist is one of the key members. The last decade has seen an escalation in the UK of clinical nurse specialists, and following the Calman-Hine Report and the more recent NHS Cancer Plan, it is anticipated that the number of clinical nurse specialists in palliative and cancer care is likely to grow.

This paper presents the qualitative findings of an evaluation study designed to investigate the impact of the clinical nurse specialist within a palliative care team based in an acute hospital setting. A stakeholder evaluation that encompassed 31 tape-recorded semi-structured interviews with senior nurses, consultants, junior doctors and nurses representing different grades were performed. The data was analysed for emerging themes utilising a case and cross case analysis methodology.

The results suggested the presence of the clinical nurse specialists is seen as beneficial to both medical and nursing staff. This paper will focus upon exploring these potential benefits, included providing support, advice and education.
Octreotide for palliative treatment of hepatic metastases from non-neuroendocrine primary tumours: evaluation of quality of life using the EORTC QLQ-C30 questionnaire
Authors: Pistevou-Gombaki Kiki , Eleftheriadis Nikos , Plataniotis Georgios A , Sofroniadis Ioannis , Kouloulias Vassilis E
Published: May 2003

Background and aim: While octreotide has been used in palliative treatment of hepatocellular carcinoma and neuroendocrine tumours with good results, little is known about the possible role of this in palliative treatment of hepatic metastases. Material and methods: We present our experience from the use of octreotide in palliative treatment of symptomatic liver metastases in 16 patients (11 males, five females, age ranged 43-69 years) with proven hepatic metastases from different primary tumours (six with non-small lung cancer, four with colon carcinoma, two with primary pancreatic head carcinoma, two with prostate cancer and two with adenocarcinoma of the stomach). All patients were administered 20 mg long-acting octreotide IM (octreotide LAR) once the first day, octreotide SC 0.5 mg three times daily on days 2-14 and then 20 mg long-acting octreotide IM every month. Quality of life was assessed by using the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30). Tumour response was evaluated by using ultrasonography. Results: One month after baseline, octreotide resulted in significant (P>0.01, Wilcoxon test) improvement and stabilization of all major related EORTC QLQ-C30 parameters such as global quality of life, pain, fatigue, insomnia, appetite loss as well as physical, emotional, cognitive, social and role functioning. Except for mild hyperglycaemia in six out of 16 patients and mild gastrointestinal complications in one patient, no other severe side effect due to octreotide was reported. Two patients died two months after the initiation of the study due to generalized metastatic disease, while the remaining 14 patients were still alive seven months after the initiation of the study. The hepatic metastases were stabilized and no new lesions were detected by ultrasonography. Conclusions: Although further studies are warranted, we consider the use of octreotide a good alternative in palliative treatment of symptomatic liver metastases in patients with end-stage malignant disease.