bluuebunny/crossref_metadata_2025 huggingface dataset:
Microparticle injection effects on microwave transmission through an overly dense plasma layer
Authors: Gillman Eric D. , Williams Jeremiah , Compton C. S. , Amatucci W. E.
Published: April 2015

Microparticles injected into a plasma have been shown to deplete the free electron population as electrons are collected through the process of microparticles charging to the plasma floating potential. However, these charged microparticles can also act to scatter electromagnetic signals. These experiments investigate microwave penetration through a previously impenetrable overly dense plasma layer as microparticles are injected and the physical phenomena associated with the competing processes that occur due to electron depletion and microwave scattering. The timescales for when each of these competing processes dominates is analyzed in detail. It was found that while both processes play a significant and dominant role at different times, ultimately, transmission through this impenetrable plasma layer can be significantly increased with microparticle injection.
Low power loss and field-insensitive permeability of Fe-6.5%Si powder cores with manganese oxide-coated particles
Authors: Li Junnan , Wang Xian , Xu Xiaojun , Gong Rongzhou , Feng Zekun , Chen Yajie , Harris V. G.
Published: April 2015

Fe-6.5%Si alloy powders coated with manganese oxides using an innovative in situ process were investigated. The in-situ coating of the insulating oxides was realized with a KMnO4 solution by a chemical process. The insulating manganese oxides with mixed valance state were verified by X-ray photoelectron spectroscopy analysis. The thickness of the insulating layer on alloy particles was determined to be in a range of 20–210 nm, depending upon the KMnO4 concentration. The powder core loss and the change in permeability under a DC-bias field were measured at frequencies ranging from 50 to 100 kHz. The experiments indicated that the Fe-6.5%Si powder cores with a 210 nm-thick manganese oxide layer not only showed a low core loss of 459 mW/cm3 at 100 kHz but also showed a small reduction in permeability (μ(H)/μ(0) = 85% for μ = 42) at a DC-bias field of 80 Oe. This work has defined a novel pathway to realizing low core loss and field-insensitive permeability for Fe-Si powder cores.
Investigation on transformation of spindle-like Fe3O4 nanoparticles from self-assembling α-Fe2O3
Authors: Huang Zhaocong , Meng Hong , Yuan Shijun , Zhang Wen , Liu Er , Zhang Dong , Kou Zhaoxia , Zhai Ya , Wang Baoping , Zhai Hongru
Published: April 2015

Porous monodisperse spindle-like α-Fe2O3 nanomaterials are first synthesized successfully by a hydrothermal method, and then the as-prepared nanoparticles are annealed at different temperatures under various atmospheres to achieve the spindle-like Fe3O4 nanoparticles. The evolution of the features of nanoparticles, including the changes of the structures and microstructures as well as the magnetic properties, during the reduction process has been investigated by using the Raman spectrum and Mössbauer spectrum. Our research reveals that the α-Fe2O3 nanoparticles annealed by covering of the C powder become a mixture of α-Fe2O3 and Fe3O4 in the range of annealing temperature from 300 °C to 800 °C. With reduced atmospheric H2, spindle-like α-Fe2O3 nanoparticles are transferred to mixture of α-Fe2O3, Fe3O4 and Fe as temperature increases. They are also converted from a typical rhombohedral structure to a cubic α-Fe phase at 500 °C. Finally, with the atmosphere of H2/Ar (5%/95%), a pure Fe3O4 phase, and its excellent magnetic properties are achieved at 450 °C.
Mechanism of runaway electron beam formation during plasma disruptions in tokamaks
Authors: Abdullaev S. S. , Finken K. H. , Wongrach K. , Tokar M. , Koslowski H. R. , Willi O. , Zeng L. ,   TEXTOR Team
Published: April 2015

A new physical mechanism of formation of runaway electron beams during plasma disruptions in tokamaks is proposed. The plasma disruption is caused by a strong stochastic magnetic field formed due to nonlinearly excited low-mode number magnetohydrodynamic (MHD) modes. It is conjectured that the runaway electron beam is formed in the central plasma region confined inside the intact magnetic surface located between q = 1 and the closest low–order rational magnetic surfaces [q = 5/4 or q = 4/3,…]. It results in that runaway electron beam current has a helical nature with a predominant m/n = 1/1 component. The thermal quench and current quench times are estimated using the collisional models for electron diffusion and ambipolar particle transport in a stochastic magnetic field, respectively. Possible mechanisms for the decay of the runaway electron current owing to an outward drift electron orbits and resonance interaction of high–energy electrons with the m/n = 1/1 MHD mode are discussed.
Observation of plasma jets in a table top plasma focus discharge
Authors: Pavez Cristian , Pedreros José , Tarifeño-Saldivia Ariel , Soto Leopoldo
Published: April 2015

In the last years, medium size Z-pinch experiments operating at tens of kJ are being used to create supersonic plasma jets. Those experiments are produced with wire arrays and radial foils, and they are conducted in generators based on water-filled transmission lines. Also plasma jets have been observed in small X-pinch experiments operating at 1 kJ. In this work, observations of plasma jets produced in a table top plasma focus device by means of optical and digital interferometry are shown. The device was operated at only ∼70 J, achieving 50 kA in 150 ns. The plasma jets were observed after the pinch, in the region close and on the anode, along the axis. The electron density measured from the jets is in the range 1024–1025 m−3. From two consecutive plasma images separated 18 ns, the axial jet velocity was measured in the order of 4 × 104 m/s.
3D, wideband vibro-impacting-based piezoelectric energy harvester
Authors: Yu Qiangmo , Yang Jin , Yue Xihai , Yang Aichao , Zhao Jiangxin , Zhao Nian , Wen Yumei , Li Ping
Published: April 2015

An impacting-based piezoelectric energy harvester was developed to address the limitations of the existing approaches in single-dimensional operation as well as a narrow working bandwidth. In the harvester, a spiral cylindrical spring rather than the conventional thin cantilever beam was utilized to extract the external vibration with arbitrary directions, which has the capability to impact the surrounding piezoelectric beams to generate electricity. And the introduced vibro-impacting between the spiral cylindrical spring and multi-piezoelectric-beams resulted in not only a three-dimensional response to external vibration, but also a bandwidth-broadening behavior. The experimental results showed that each piezoelectric beam exhibited a maximum bandwidth of 8 Hz and power of 41 μW with acceleration of 1 g (with g=9.8 ms−2) along the z-axis, and corresponding average values of 5 Hz and 45 μW with acceleration of 0.6 g in the x-y plane.
Improving the use of available feed resources to overcome sheep feeding deficits in western China
Authors: Philp Joshua , Komarek Adam M. , Pain Sarah J. , Li Xueling , Bellotti William
Published: April 2015

Socioeconomic and agro-ecological circumstances often compel smallholder livestock farmers in the developing world to maintain livestock over winter, and this can incur production penalties due to insufficient feed quality and availability. Recent policy efforts in western China have attempted to address this issue through the promotion of lucerne production to support growing livestock numbers with its high nitrogen content, however lucerne is underutilised by farmers and rarely maintained beyond harvest. The potential benefits to production of storing enough lucerne to meet the minimum nitrogen requirements of rumen function during the winter deficit were explored in an experiment in Qingyang Prefecture, Gansu Province, P.R. China. Tan weaner sheep (mean weight 15.4 kg) were fed corn straw, corn grain and lucerne hay in respective ratios of 80 : 20 : 0 [metabolisable energy (ME) = 7.4 MJ/kg DM, crude protein = 40 g/kg DM; ‘R1’] or 55 : 20 : 25 (ME = 8.2 MJ/kg DM, crude protein = 65 g/kg DM; ‘R2’). Rations were offered daily in a constant quantity that supplied ~80% maintenance energy requirements at the start of the experiment. Sheep fed R2 retained 0.7 kg more on average than those fed R1 (P < 0.01) after 20 days under experimental conditions with a mean weight change of –0.089 kg/day for R1 and –0.055 kg/day for R2 (P < 0.01). Sheep fed R1 experienced a sustained loss in digestive function over time, with ration DM digestibility decreasing by 0.56% per day (P < 0.01, R2 = 0.65), and MJ of ME per kg of ingested DM (M/D) decreasing by 0.06 MJ/kg DM per day (P < 0.001, R2 = 0.98). The mean M/D of R1 had fallen to 6.1 after 20 days (P < 0.01). The mean DM digestibility and M/D observed in R2-fed animals remained comparatively stable, with no statistically significant differences between starting and finishing values (P > 0.05). The results indicate that the capacity for underfed Tan weaner sheep to absorb energy from low protein rations typical of winter rapidly degrades and that the lucerne hay in the diet prevented this decline. Furthermore, these findings demonstrate that conserving lucerne for inclusion in winter rations is a potential strategy for smallholder farmers to maintain the digestive efficiency of Tan sheep during sustained underfeeding contributing to greater retention of liveweight on restricted diets.
Phenotypic Shifts in Life History Traits Influence Invasion Success of Goldfish in the Yarlung Tsangpo River, Tibet
Authors: Liu Chunlong , Chen Yifeng , Olden Julian D. , He Dekui , Sui Xiaoyun , Ding Chengzhi
Published: April 2015

Goldfish Carassius auratus have been established in myriad ecosystems outside of their native ranges, and part of their successful establishment in new ecosystems might be attributed to the shift in life history traits. To explore the role of phenotypic shifts in Goldfish invasions, we quantified and compared spawning times and growth rates in the early life history of nonnative Goldfish from Chabalang and Chongdui wetlands in the Yarlung Tsangpo River basin. Spawning of nonnative Goldfish began on March 20 and April 14 for the Chabalang and the Chongdui populations, respectively, and both were considerably earlier than native populations despite the cold environments in the Yarlung Tsangpo River basin. Growth rates for the Chabalang population were significantly higher than those for the Chongdui population during the first 14 d posthatch; however, growth rates for the Chongdui population became higher after the 37th day. Within the Chabalang population, Goldfish hatching later had faster growth rates than individuals hatching earlier. Consequently, it seems that shifts in the timing of spawning and growth rates play an important role in the invasion success of Goldfish in extremely cold climates.
Shortnose Sturgeon and Atlantic Sturgeon in the Kennebec River System, Maine: a 1977–2001 Retrospective of Abundance and Important Habitat
Authors: Wippelhauser Gail S. , Squiers Thomas S.
Published: April 2015

Little was known about the populations of Shortnose Sturgeon Acipenser brevirostrum and Atlantic Sturgeon A. oxyrinchus in the Kennebec, Androscoggin, and Sheepscot River estuaries (the Kennebec system) in Maine, prompting a series of field studies spanning the years 1977–2001. Although the impetus for these studies varied, common objectives were to estimate population abundances and locate habitat important to the conservation of both species. During 16 years of gill‐net sampling, we caught 3,372 Shortnose Sturgeon and 403 Atlantic Sturgeon. On the basis of two mark–recapture studies, the adult Shortnose Sturgeon population in the Kennebec system was estimated to be 5,117 (95% confidence interval, 4,206–6,279) for the period 1977–1981 and 9,436 (7,542–11,888) for the period 1998–2000. Gill‐net sampling led to the identification of two spawning areas in the Kennebec system. One was an approximately 0.7‐km‐long reach immediately downstream of Brunswick Dam in the Androscoggin estuary, and the other was an approximately 26‐km‐long reach immediately downstream of Edwards Dam in the upper Kennebec estuary. Shortnose Sturgeon were caught at both locations, while Atlantic Sturgeon were documented only in the upper Kennebec estuary. Acoustic telemetry was used to identify a wintering site in Merrymeeting Bay that was used by Shortnose Sturgeon.
Mappings of finite distortion between metric measure spaces
Authors: Guo Chang-yu
Published: April 2015

We establish the basic analytic properties of mappings of finite distortion between proper Ahlfors regular metric measure spaces that support a(1,1)(1,1)-Poincaré inequality. As applications, we prove that under certain integrability assumption for the distortion function, the branch set of a mapping of finite distortion between generalizednn-manifolds of typeAAhas zero Hausdorffnn-measure.
International progress in creating palliative medicine as a specialized discipline and the development of palliative care
Authors: Payne Sheila , Lynch Tom
Published: April 2015

This chapter provides an overview of the development of palliative medicine as a specialized discipline, and seeks to trace the development of international initiatives that have promoted and facilitated the growth of palliative care services. The focus is on palliative care services for adults with life-limiting conditions and advanced disease. A chronological narrative is traced from the first hospices developed in Dublin, Ireland, to the emergence of the modern hospices in the United Kingdom in the 1960s. The global spread of the principles of palliative care is traced in the formation of national and regional organizations. The chapter offers evidence on the progress of educational initiatives, both within medicine and for other members of the multidisciplinary team, at undergraduate and post-qualification level. The proposal for ten core common interdisciplinary competencies defines the essential foundations of palliative care. Finally, the chapter considers what areas of palliative medicine require further development.
The epidemiology of death and symptoms: planning for population-based palliative care
Authors: Sands Megan B. , O’Connell Dianne L. , Piza Michael , Ingham Jane M.
Published: April 2015

Despite the advances of modern medicine, many illnesses continue to evade cure. Chronic, progressive, incurable illness is a major cause of disability, distress, suffering, and, ultimately, death. This is true for many causes of cancer, progressive neurological disorders, AIDS, and other disorders of vital organs. Progressive chronic diseases of this ilk are most common in late adulthood and old age, but they occur in all ages. When cure is not possible, as often it is not, the relief of suffering is the cardinal goal of medicine. The clinical imperative to relive suffering requires a nuanced understanding of the factors that contribute to suffering and the interaction between the distress of the patient, family members, and health-care providers. This chapter reviews those concepts and offers an approach to the evaluation of suffering for patients requiring palliative care.
Predicting survival in patients with advanced disease
Authors: Glare Paul , Sinclair Christian T. , Stone Patrick , Clayton Josephine M.
Published: April 2015

Worldwide there are over 50 million deaths per year. In considering the goal of fostering optimal care towards the end of life for these individuals, high-quality population-based data about disease and symptom occurrence as well as health-care needs are essential. Such data are important so that informed planning can underpin policy, service development, and patient care. This chapter discusses epidemiology as it relates to the ‘human experience’ towards the end of life with an emphasis on diseases, symptoms, psychosocial experiences, and access to health services. Some of the methods by which such data are collated in various parts of the world are described. The dramatic variability in experiences towards the end of life across regions and nations is also highlighted. Examples of where information is available that may inform planning for populations are discussed, as are areas where data may be helpful or needed but lacking.
Palliative care in the emergency department
Authors: DeSandre Paul L. , May Karen
Published: April 2015

The emergency department provides immediate access to medical care for patients and families in crisis. As the proportion of elderly in our populations increases, complications related to advanced illness will likely drive increasing numbers of patients with palliative care needs into emergency departments. In addition to immediately life-threatening situations, severe physical symptoms, psychological distress, social upheaval, or even an unrecognized spiritual crisis near death can overwhelm patients or their caregivers, who come to the emergency department hoping for relief from their suffering. Emergency clinicians must rapidly assess these complex needs while negotiating interventions with effective and efficient communications. This chapter addresses several of these essential clinician skills for effective primary palliative care in the emergency department. These include rapid assessment of patients with palliative care needs, titration of opioids for pain emergencies, efficiently establishing goals of care, skilful and empathic death disclosure, and a structured approach to involving family presence during cardiopulmonary resuscitation.
The core team and the extended team
Authors: Faksvåg Haugen Dagny , Nauck Friedemann , Caraceni Augusto
Published: April 2015

Interdisciplinary teamwork is an inherent feature of palliative care. A team is defined as a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable. Efficient teams are characterized by good leadership, efficient communication, a strong sense of cohesion, and good decision-making and conflict resolution skills. A palliative care team usually consists of core and extended members. The team needs to be named and defined, but must also be flexible and integrate the professionals and skills needed in the individual case, as well as the patient and family members. The palliative care consult team has a unique role as the interface between palliative medicine and other medical specialties in the acute hospital, and has several levels of intervention. Every team should audit its own performance with respect to structure, processes, and outcomes.
Social work in palliative care
Authors: Altilio Terry , Laing Nina
Published: April 2015

The early link of palliative social work clinicians in the United Kingdom and the United States provided a foundation for the evolving specialty of social work in palliative care which continues to be enriched by social work practitioners across the world. Social workers practise in diverse settings and have the opportunity to move palliative care values and processes beyond hospitals and hospices to nursing homes, prisons, and senior centres. This chapter discuss how palliative care social work skills are a rich opportunity to serve patients, families, teams, and institutions. It begins with a section introducing social work in palliative care and moves on to discuss the convergence and synergy of social work with palliative care. Issues such as assessment and intervention (including confidentiality, assessment, culture, and family meetings) are then introduced and roles and responsibilities in social work teams are discussed. Finally a patient family narrative is presented.
Occupational therapy in palliative care
Authors: Cooper Jill , Kite Nina
Published: April 2015

Occupational therapy in palliative care aims to help patients achieve their optimum independence in activities that are important to them. The specific functional difficulties may include extreme fatigue, anxiety and shortness of breath due to advanced disease including metastatic spinal cord compression, fractures, or peripheral neuropathies. Patients may have problems with cognition and perception, body image, life role, and spiritual issues as well as physical disabilities. This chapter describes the broad range of areas in which the occupational therapist works in palliative care together with the interprofessional team. They take a key role in organizing and facilitating safe discharge and care at home, with the aim of achieving best quality of life and avoiding re-admission to hospital wherever possible. The occupational therapist analyses and assesses specific problems and provides a treatment programme or solution to help the patient remain as independent as possible, using clinical reasoning and evidence-based practice.
The contribution of the dietitian and nutritionist to palliative medicine
Authors: Richardson Rosemary , Davidson Isobel
Published: April 2015

Management of the nutritional consequences of disease and its treatment are now acknowledged as a key component of palliative care provision. Factors affecting the ability to eat and the consequent changes in body composition which occur with disease progression often initiate concern in patients and relatives alike. The role of the dietitian is to provide dietary counselling in partnership with the patient where realistic goal setting can be achieved. The evidence base for improvement in nutritional status is equivocal which may be expected in this heterogeneous population. However, achieving recommended energy intakes is viewed as achievable using this strategy but is resource intensive. Nutritional assessment allows for appropriate monitoring of sequential changes in nutritional status and should be the cornerstone of a dietitian’s role. Classifying a patient’s stage of cachexia appropriately may prove useful in identifying when dietetic interventions are likely to be of greatest benefit.
Palliative care needs assessment tools
Authors: Girgis Afaf , Waller Amy
Published: April 2015

The delivery of appropriate and equitable care is a challenge facing many areas of health care, including palliative care. This chapter discusses the concept of needs assessment, which is inherent in the World Health Organization definition of palliative care, and considers strategies for assessing people’s needs and experiences, with a focus on the tools developed specifically for this purpose (including generic needs assessment tools for patients with any chronic disease, and needs assessment tools for patients with advanced cancer, dementia, heart failure, chronic obstructive pulmonary disease, or HIV/AIDS. It reiterates the importance of needs assessment tools being implemented as part of routine care to facilitate the right care being offered to people at the time they most need it, by the people or service which is most appropriate to meet identified needs.
Opioid therapy: optimizing analgesic outcomes
Authors: Fallon Marie T. , Cherny Nathan I.
Published: April 2015

Treatment with analgesic drugs is the mainstay of cancer pain management. The major group of drugs used in cancer pain management is the opioid analgesics. During the last 30 years, there has been a dramatic increase in our knowledge of the sites and mechanism of action of the opioids. The development of analytical methods has also been of great importance in facilitating pharmacokinetic studies of the disposition and fate of opioids in patients. More recently, advances in genomic research have indicated the potential importance of pharmacogenetic factors in the response to opioid analgesics. These studies have begun to offer us a better understanding of some of the sources of variation between individuals in their response to opioids and to suggest ways of minimizing some of their adverse effects. This chapter presents a comprehensive discussion of the pre-clinical pharmacology and clinical aspects of opioid analgesia and the principles of opioid administration.
Opioid therapy: managing risks of abuse, addiction, and diversion
Authors: Price Julie R. , Hawkins Alric D. , Passik Steven D.
Published: April 2015

Given the complex and chronic medical problems that are seen in the palliative care setting, there is an ever increasing need for awareness of prescription drug abuse. Providers must balance the potential for abuse of prescribed opioids with the need to provide appropriate analgesia for patients in the palliative care setting. In addition, the presence of aberrant drug use amongst patients with advanced illness represents a major impediment to appropriate care. In order to maximize patient outcomes and to prescribe needed medication both safely and fairly, the clinician should work to develop appropriate controls and monitoring. Aberrant drug-related behaviour is a complex phenomenon that can occur in the chronic medically ill patient and needs to be approached in an empathetic manner that allows for recognition of the biological, chemical, psychological, and social aspects, with the ultimate goal of safely managing patients’ pain, while addressing other issues that are leading to their distress and perpetuating their aberrant drug use.
Non-opioid analgesics
Authors: Sjøgren Per , Elsner Frank , Kaasa Stein
Published: April 2015

Non-opioid analgesics encompass the non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol (acetaminophen). The NSAIDs include acetylsalicylic acid (ASA, aspirin), dipyrone (metamizole), and numerous other drugs in diverse classes. The NSAIDs have potent anti-inflammatory, analgesic and antipyretic activity, and are among the most widely used drugs worldwide. In palliative medicine, they represent the first step of the World Health Organization’s analgesic ladder used for mild pain and they are an important supplement to opioids and adjuvant drugs at higher steps of the ladder. The disadvantages of non-opioid analgesics include a ceiling effect for pain relief and the risk of side effects. NSAIDs are also associated with an increased risk of adverse gastrointestinal, renal, and cardiovascular effects and hepatotoxicity can result from overdosing with paracetamol. This chapter describes the clinical pharmacology of NSAIDs, their classification, molecular mechanisms of action and adverse effects, as well as some recent developments aimed at designing effective anti-inflammatory agents with improved safety and tolerability profiles.
Adjuvant analgesics
Authors: Lussier David , Portenoy Russell K.
Published: April 2015

In the management of pain associated with serious illness, ‘adjuvant analgesics’ usually are administered in concert with opioid therapy in an effort to improve outcomes when an opioid does not provide satisfactory relief with tolerable side effects. They may be divided into categories, including multipurpose drugs, and drugs used selectively for neuropathic pain, bone pain, pain due to bowel obstruction, or musculoskeletal pain. These drugs are selected for a trial based on limited data available and clinical experience; sequential trials may be undertaken when pain is refractory. Multipurpose drugs may be considered for any type of pain. The most useful include corticosteroids and analgesic antidepressants. For neuropathic pain, conventional first-line agents are gabapentinoids, analgesic antidepressants, and corticosteroids. Corticosteroids and bisphosphonates, are used commonly for bone pain. The indications and dosing strategies for these drugs are evolving as scientific evidence and clinical experience accumulate.
Interventional approaches for chronic pain
Authors: Swarm Robert A. , Karanikolas Menelaos , Rao Lesley K. , Cousins Michael J.
Published: April 2015

Severe, uncontrolled pain remains common in populations with serious or life-threatening illness. Despite the availability of oral opioid therapy in most developed countries, an estimated 10-30% of people with advanced cancer have inadequate pain control. Published guidelines endorse the view that these patients should be considered for procedural, or so-called interventional, pain therapies. Generally accepted indications for interventional pain therapies include (a) uncontrolled pain despite systemic analgesics and (b) unacceptable systemic analgesic adverse effects. This chapter describes these therapies and discusses how they are best used within a multimodal strategy for symptom management. Interventional pain therapies are now incorporated into best practices for cancer pain management. These therapies, especially spinal analgesics, neurolytic coeliac plexus block, and vertebroplasty, have become essential components of palliative care, to control pain that cannot be safely and effectively managed with systemic analgesics.
Confidentiality
Authors: Kirk Timothy W.
Published: April 2015

This chapter offers an explanation of, and approach to, respecting confidentiality as an ethical obligation in the practice of hospice and palliative medicine. Understood in the context of coincident ethical obligations to maximize clinical benefit, avoid preventable harm, and restore moral agency, respecting confidentiality is embedded in the most basic philosophical precepts that define hospice and palliative care. As such, following a brief conceptual framework, the chapter explores ways to employ the framework in the service of patients and families in clinical practice. While various regions and nationalities will have legal and regulatory requirements informing the definition and practice of respecting confidentiality, this chapter focuses instead on respecting confidentiality as an ethical value. Readers are encouraged to supplement the content of this chapter with the relevant requirements that apply in their practice location.
Neuro-palliative care and disorders of consciousness
Authors: Fins Joseph J. , Pohl Barbara
Published: April 2015

Neuro-palliative care is an important resource for patients and families confronting severe brain injury. Although many clinicians equate brain injury with certain death or futility, survivors have substantial needs that might be met by palliative care expertise. This chapter suggests that the boundaries of palliative medicine include those with severe brain injury, most notably those in the minimally conscious state, and that with this nosological expansion practitioners of palliative care reflect carefully on often nihilistic attitudes directed towards patients with disorders of consciousness. This chapter establishes how to better meet the needs of these patients and their surrogates, reviewing definitional criteria for the vegetative and minimally conscious states, highlighting advances in diagnostic and therapeutic interventions (such as neuroimaging, drugs, and deep brain stimulation) and considering what neuroprosthetic devices tell us of the capacity of patients to experience-and functionally communicate-pain, distress, and suffering.
Truth telling and consent
Authors: Emanuel Linda L. , Johnson Rebecca
Published: April 2015

Truth telling and informed consent are relatively recently established legal and ethical norms in end-of-life health care. This chapter provides an exploratory guide to the evolution of both norms, highlighting some of the benefits, problems, and issues associated with both terms. It also presents a selection of the stepwise protocols and practices which Western medicine has developed in order to deliver patient-centred palliative care which comforts and relieves. In addition, the chapter discusses the impact that constant adjustment to loss can have on patient psychology and decision-making in end-of-life care scenarios and the value of framing that experience in terms of continuous reintegration. Finally, the chapter discusses the lessons which can be learned from the contested place of family within health-care systems where decision-making depends on truth telling and informed consent, and the lessons which can be learned from familism across the globe.
Ethics in paediatric palliative care
Authors: Hain Richard D.W.
Published: April 2015

Professional competence is a necessary but insufficient representation of how an individual health-care professional should properly behave in relation to a patient. Medical ethics addresses the further question of the basis on which actions taken by professionals in the context of that relationship are morally right. Children are distinct from adults in ethically relevant ways. They lack autonomy, both in practice and in principle, and their interests are easily ignored or annexed to others. In practice, ethical questions in children are currently addressed using the ‘four-principles’ or by appealing to rights-based arguments. Behind both are ethical theories (particularly deontology, utilitarian consequentialism, and virtue ethics) that are important, but problematic, in children. This chapter reviews existing ways of looking at ethics in end-of-life care for children, considering three specific contemporary debates in medical ethics in children’s palliative care: the principle of double effect, euthanasia, and withholding or withdrawal of life-sustaining treatment.
Dignity and palliative end-of-life care
Authors: Chochinov Harvey Max , McClement Susan E. , Kredentser Maia S.
Published: April 2015

The concept of dignity continues to receive attention in health care, with particular implications for end-of-life care. This chapter reviews current conceptualizations of dignity, integrating medical, philosophical, and ontological perspectives. The centrality of dignity to palliative care is discussed, exploring empirical findings, which examine what dignity means to patients and families in the context of illness and end-of-life care. The chapter provides an overview of validated tools, evidence-based therapies, and practical ‘everyday’ communication skills that health-care providers in diverse clinical settings can use to enhance patient dignity. Suggestions are provided for extending existing research into the notion of dignity as it relates to vulnerable groups, and how interventions aimed at supporting patient dignity can impact family members. Dignity subsumes many key aspects of comprehensive care, which can guide health-care providers towards improving end-of-life experiences for patients and families.
Skin problems in palliative care
Authors: Grocott Patricia , Gethin Georgina , Probst Sebastian
Published: April 2015

Nursing aspects of palliative wound care are driven by patient and family goals integrated with three components of wound management: the management or palliation of the underlying cause of the wound, management of wound-related symptoms, and management of the wound and peri-wound skin. Wounds most commonly found include pressure ulcers, fungating malignant wounds, and fistulae. Patients with blistering skin conditions, inherited and acquired, have extensive longstanding wounds and palliative care needs. In addition, meticulous skin care for patients of all ages with debilitating long-term conditions is crucial to prevent unnecessary skin breakdown. The symptoms and local problems associated with broken skin and wounds include odour, exudate, excoriation, maceration, bleeding, pain, and pruritus, and key clinical interventions include the application of wound dressings and skin care products. Unless these are managed effectively and consistently, body image and feelings of self-worth are affected together with the ability to socialize and maintain employment.
Lymphoedema
Authors: Keeley Vaughan
Published: April 2015

Lymphoedema is a chronic oedema developing as a result of failure of the lymphatic system to drain fluid and other substances, such as proteins, from the tissues. It typically affects the limbs but can involve any part of the body. The management of all types of lymphoedema is largely palliative in nature in that there are no surgical or other treatments which offer a cure for the problem in the vast majority of cases. This chapter focuses on oedema associated with advanced cancer and other diseases, encountered towards the end of life with some reference to cancer treatment-related lymphoedema, as this may also be present in people with advanced disease.
Radiotherapy in symptom management
Authors: Hoskin Peter J.
Published: April 2015

Radiotherapy has a major role in symptom control and over 40% of all radiation treatments are given with palliative intent. In the palliative setting, radiotherapy will usually be delivered using high-energy external beam treatment from a linear accelerator. Bone metastases may be treated with intravenous systemic radioisotopes and dysphagia with endoluminal brachytherapy. A general principle of palliative radiotherapy is that it should be delivered in as few treatment visits as possible and be associated with minimal acute toxicity. The main indications for palliative radiotherapy are in the management of symptoms due to local tumour growth and infiltration. These include pain from bone metastases, visceral pain from soft tissue metastases, and neuropathic pain from spinal, pelvic, and axillary tumour. Local pressure symptoms are particularly onerous and potentially dangerous when they affect the nervous system; thus spinal canal compression remains one of the few true emergency situations in which radiotherapy is indicated. Similarly brain, meningeal, or skull base metastases require urgent assessment and can be helped with local radiotherapy. Obstruction of a hollow tube or drainage channels can lead to significant symptoms and again local radiotherapy can be valuable in addressing this scenario. Such indications would include dysphagia, bronchial obstruction, leg or arm oedema, vena cava obstruction, or hydrocephalus. Finally haemorrhage can be distressing if rarely life-threatening. Local radiotherapy to bleeding tumours in the lung, bronchus, bowel, genitourinary tract, and skin is very effective at control of bleeding.
The role of general surgery in the palliative care of patients with cancer
Authors: Badgwell Brian , Krouse Robert S.
Published: April 2015

Palliative surgery is defined as surgical intervention in patients with incurable malignancy for symptoms attributable to their cancer. A considerable percentage of consultations at major cancer centres are palliative in nature, resulting in 13-21% of all operations meeting the criteria for palliative surgery. Common symptom groups for evaluation include gastrointestinal obstruction, wound problems/infections, gastrointestinal bleeding, and obstructive jaundice. This chapter outlines the indications, treatment options, and outcomes for these diagnoses and a few less common indications for surgical consultation. Clinical trials are infrequent in this population and there is a paucity of prospective studies with quality of life outcomes measures. Most studies focus on morbidity and mortality as palliative surgery has long been recognized as having increased risk for complications, although recent studies suggest an improvement in this regard. The benefits of palliative surgery should focus on quality of life, symptom control, and symptom prevention. Future studies will be needed to determine the definitions of success and hopefully include patient-reported outcomes assessment.
Orthopaedic surgery in the palliation of cancer
Authors: Healey John H. , McKeown David
Published: April 2015

Metastatic spread of cancer to bone is frequent and causes pain, disability, and functional limitation. New understanding of the homing method of cancer cells to bone and the mechanism of cancer production of pain raise possible new treatment strategies. Non-surgical treatments such as chemotherapy and hormone therapy are effective in early disease. Bisphosphonates and inhibition of osteoprotegerin prevent progression of bone lesions and avoid pain, radiation, and surgery. Radiotherapy arrests disease and relieves pain in many cases. Surgery is needed when the bone is weak or fractured. It effectively relieves pain and preserves function. It usually requires replacing or bypassing the deficient bone with site-specific reconstructive surgery. Surgery should be selected based on projections of patient survival. New tools to make these projections have been validated and are now available. New targeted drug therapies appear to be changing metastatic bone disease into a more chronic condition. This will alter the management of local disease in many histological subtypes of metastatic cancers.
Interventional radiology in the palliation of cancer
Authors: Sabharwal Tarun , Fotiadis Nicos I. , Adam Andy
Published: April 2015

Over the past four decades, a variety of invasive diagnostic and therapeutic procedures have been developed by radiologists. The term ‘interventional radiology’ most appropriately refers to therapeutic procedures performed under imaging guidance. Interventional radiological procedures have virtually replaced several more invasive and hazardous surgical alternatives. Other interventional techniques offer completely new therapeutic options. Some diagnostic radiological procedures are frequently followed by therapeutic manoeuvres. Interventional radiology can make a significant contribution to the palliation of patients with irresectable malignant tumours, as many of the procedures can relieve symptoms without the need for general anaesthesia, a prolonged stay in hospital, or the discomfort associated with recovery from a surgical operation. The vast majority of procedures are performed using local anaesthesia and mild sedation. The emphasis in this chapter is on the indications, contraindications, and likely outcomes, rather than on detailed technical descriptions.
Cancer pain syndromes: overview
Authors: Cherny Nathan I.
Published: April 2015

Cancer pain syndromes are defined by the association of particular pain characteristics and physical signs with specific consequences of the underlying disease or its treatment. The recognition of cancer pain syndromes and the ability to distinguish between them is a critical skill for palliative care clinicians since syndromes are associated with distinct aetiologies and pathophysiologies, and they often have important prognostic and therapeutic implications. Pain syndromes associated with cancer can be either acute or chronic. Whereas acute pains experienced by cancer patients are usually related to diagnostic and therapeutic interventions, chronic pains are most commonly caused by direct tumour infiltration. Adverse consequences of cancer therapy, including surgery, chemotherapy, and radiation therapy, account for 15-25% of chronic cancer pain problems, and a small proportion of the chronic pains experienced by cancer patients are caused by pathology unrelated to either the cancer or the cancer therapy.
Visceral pain
Authors: Chang Victor T.
Published: April 2015

Visceral pain is pain that arises from, in, or around internal organs. Common examples include chest pain and functional abdominal pain. In palliative medicine, well-known visceral pain syndromes include pain from pancreatic cancer and bowel obstruction. Recent advances have increased our understanding of the diagnostic challenges and therapeutic possibilities for patients with visceral pain syndromes. Understanding the basis of referred pain is a key component of patient assessment. The complexity of visceral nociception and pain signalling is being unravelled through anatomical, immunohistochemical, and functional studies. On a molecular level, families of receptors and signalling proteins have now been described that will lead to a future with innovative therapies. This knowledge has developed within the paradigms of pain pathways, peripheral activation and peripheral and central sensitization, thereby linking and distinguishing visceral pain from somatic and neuropathic pain. Treatment options for visceral pain in palliative care encompass a wide variety of medical, interventional, and psychological approaches. With appropriate diagnostic measures and careful consideration of therapeutic options, most patients can achieve satisfactory relief.
Management issues in chronic pain following cancer therapy
Authors: Chasen Martin , Giddings Gordon
Published: April 2015

With improved surveillance, diagnoses, and treatment of patients with cancer, an increased life expectancy, and specifically an increased number of ‘cancer cured’ patients, is noted. However, the long-term effects of the disease and treatment have a bearing on obtaining optimal physical, psychological, and cognitive functioning for cancer survivors. Pain impacts on all dimensions of quality of life and is one of the most distressing symptoms for patients. Patients often under-recognize pain and are unsure if optimum pain control is achievable. In addition, members of the interdisciplinary team often fail to assess the patient’s pain adequately, due to a lack of knowledge of the principles of pain relief and side effect management. Treatment requires an interprofessional approach that details a comprehensive assessment, with ongoing reassessment, utilizing both pharmacological and non-pharmacological measures. Empowerment of the cancer survivor, respect for survivors’ individuality and collaboration among team members are key elements of any successful strategy to optimize a patient’s quality of life.
Skin problems in oncology
Authors: Merims Sharon , Lotem Michal
Published: April 2015

The skin may be adversely affected by any serious medical illness, often as a secondary process related to infection, trauma, nutritional deficiencies, and other factors. Disease-specific skin involvement occurs commonly in some conditions, and is best characterized in cancer. Skin of the patient with advanced cancer is unique compared to other organs of the body. While the sequela of metastatic spread to internal organs often is replacement of normal tissue and resultant organ failure, widespread replacement of skin with a neoplasm is uncommon. Yet, even a local disruption of skin integrity can cause deterioration in the quality of life, debilitation, and even mortality. Other aspects of neoplastic disorders affecting the skin discussed in this chapter include accumulation of abnormally produced metabolites, adverse effects to treatment, and paraneoplastic syndromes. It is important to give dermatological aspects of disease their appropriate attention, because these can be the ones that may be dealt with efficiently and improve the patient’s quality of life.
Palliative issues in the care of patients with cancer of the head and neck
Authors: Murphy Barbara A. , Zatarain Lauren A. , Cmelak Anthony J. , Bayles Steven , Dowling Ellie , Billante Cheryl R. , Ridner Sheila , Haman Kirsten , Bond Stewart , Marie Flores Anne , Panarut Wisawatapnimit , Andrews Bethany M.
Published: April 2015

Head and neck cancer (HNC) refers to tumours arising from the epithelial lining of the upper aerodigestive track, including the oral cavity, larynx, pharynx, paranasal sinuses, and salivary glands. There are 50,000 cases of HNC diagnosed annually within the United States. The majority of tumours (> 90%) are squamous cell carcinomas. Risk factors include tobacco, alcohol, and areca nuts; human papilloma virus (HPV) or Epstein-Barr virus; and mucosal irritation. Previously considered to be a disease of older adults, the epidemic of HPV-associated oropharyngeal cancers has led to a striking increase in HNC among middle-aged adults. Symptoms are usually present at the time of diagnosis and remain problematic through the terminal phase. For those patients who are cured, long-term biopsychosocial sequelae may persist for years. Thus, assessment and treatment of palliative issues is an intrinsic and vital component of care for the HNC patient.