bluuebunny/crossref_metadata_2025_split huggingface dataset:
Therapeutic and postmortem opioids levels
Authors: Siddiq Ibrahim , Noble Bill , Morley Stephen 
Published: March 2012

BackgroundThe range of opioid dose in patients receiving palliative care is wide and not directly related to response. The levels of opioids in therapeutic and postmortem, population group studies and forensic studies have been studies in published data.AimTo describe the results of studies of opioids levels in living patients receiving palliative care treated for pain, and in postmortem studies between 1970 and 2009.MethodLiterature review of studies concerning five of the opioids; Diamorphine, Morphine, Oxycodone, Fentanyl and Methadone, by using: Hand Search, Cochrane library (systematic Review) and Medline OvidSP, in english language. The level of evidence on each clinical study or review is determined and the evaluation focuses on the relationship between doses and opioids levels, in overdose and therapeutic use.ResultsThe authors found few studies in palliative care describing fatal events and blood levels in opioid overdose with variation in level, due to differences in drug metabolism. Overall 300 papers were reviewed, 251 of studies were reviewed in therapeutic and postmortem. Number of papers 71 of Studies of ante-mortem/population Group studies/therapeutics (pharmacokinetics, overdose addiction (maintenance),postoperative,cancer pain, tolerance, respiratory depression,withdrawal and data collection(dose finding)). Number of papers 180 of studies of postmortem/cadaver group studies/plasma levels (Fatal suicides, trauma victim, and accident death, coincidental and other conditions). The remaining 49 of studies were concerned with (mechanisms, switching, drug monitoring and controversy over drugs use).ConclusionsMeasurement of the relationship between fatal events and opioid blood levels is difficult, due to laboratory error, blood contaminants and variations between individual subjects. It does not appear to be wise to infer opioid levels in life from postmortem evidence in cases of therapeutic opioid use.
Quality end of life care
Authors: Johnstone Ros , Fowell Andrew 
Published: March 2012

Implemented on an all-Wales basis in 2000 the Welsh Integrated Care Pathway (ICP) for the last days of life has gone from strength to strength. Starting with 38 sites there are now over 100 sites using the ICP to deliver quality end of life care in a variety of settings including: hospitals hospices specialist in-patient units and in the community. Centrally collecting and analysing the ICP variance sheets has permitted quality monitoring and benchmarking exercises facilitating feedback and informing the on-going development of the ICP tool Variance monitoring shows that the incidence of goal variances associated with the management of pain, agitation and excess respiratory secretions or rattle have decreased over time, indicating a higher proportion of goal achievement and improvement in optimum care. The same tool is used for cancer and non-cancer patients with no differences between the two patient groups on length of time on the pathway or frequency of goal related reported variances. The ICP has recently undergone a thorough overhaul and the new pathway has been taken up and used throughout the principality.ConclusionIt is possible to implement, sustain and maintain the use of the ICP over a wide geographical area and for different patient groups, ensuring that quality end of life care can be delivered in different care settings. Currently there is a strong move to develop and implement an ICP for end of life care in intensive care units, adopting the same model of implementation therefore facilitating a Wales wide implementation monitoring and feedback process.
Palliative medicine and smartphones: an opportunity for innovation?
Authors: Nwosu Amara , Curi Stephen Mason Marie 
Published: March 2012

BackgroundThe use of smartphones and their applications are providing health professionals with opportunities to integrate technology into clinical practice. The number of work-related applications available to health professionals is increasing. Certain specialities have a large number of resources available for health professionals; however, the availability of applications specific to palliative medicine is, as yet, limited.AimTo review all smartphone applications available to the five most popular operating systems (iPhone, Blackberry, Android, Palm and Windows) which are targeted to health professionals within palliative medicine.MethodsEach smartphone app store was queried with a combination of the following keywords: palliative, pain, cancer, symptoms and medicine. The applications were purchased and tested if their title and/or description showed relevancy to palliative care.FindingsSix applications specific to palliative medicine were identified across all five operating systems. These consisted of blog orientated applications (Pallimed and Geripal), an app containing guidelines from eight cancer networks (PalliApp), an education based app (Palliative Care) and opioid dose converter applications (eOpioid and PalliCalc).ConclusionThere is a lack of palliative medicine specific resources available for smartphones. No literature currently exists to examine the potential benefits of mobile technology on learning, clinical practice and professional development. This is an opportunity for further research and development. Academic institutions could partner with technological developers to improve access to, and dissemination of information. Considered development of mobile technology has the potential to improve patient care, data sharing and education within the speciality.
Pain from subcutaneous injections: myth or reality
Authors: Srivastava Leena , Robson Peter 
Published: March 2012

BackgroundThe use of the subcutaneous route is well established in Palliative Care. It is the most commonly used parenteral route for administering drugs when the oral route is not suitable. Based on ‘clinical experience’, it is often taught that subcutaneous injections are less painful; however, there is a paucity of evidence.AimThe aim of this survey was to evaluate the incidence of pain from subcutaneous injections and explore the factors likely to influence pain.MethodA prospective survey was carried out at St Benedict's Hospice, Sunderland, UK in 2010 over a 1 month period. Data were collected for 50 consecutive injections, either given singly or via a subcutaneous cannula.Results76% of injections were not painful, 18% caused discomfort and 6% caused pain. 100% of injections causing pain were given singly. 45% of injections which were not painful were through subcutaneous cannulas. The insertion of subcutaneous cannulas did not cause pain.LimitationsPain from subcutaneous injections is influenced by various concomitant factors and as our sample size was small, it was difficult to evaluate the specific role of individual factors. Moreover, all commonly prescribed drugs in Palliative care were not used. Discussion: This survey shows that most patients do not experience pain from subcutaneous injections. There was also a lower incidence of pain when a subcutaneous cannula was used for injections. There are currently no guidelines on the insertion of such cannulas. From our data, patients who need repeated injections will benefit from them early on.ConclusionOur survey has shown that the majority of patients do not experience pain from subcutaneous injections. Further multicentre studies are needed to clarify the role of individual factors which may cause pain.
The management of malignant ascites in Palliative care: An audit of clinical practice and development of standards and guidelines
Authors: Johney Leslie , Chapman Laura , Allsopp Leslie , Curie Marie , Gray Dawn , Griffiths Anne 
Published: March 2012

BackgroundMalignancy is the underlying cause in approximately 10% of all cases of ascites. About 15–50% of patients with malignancy will develop ascites. Cancers commonly associated with the development of ascites include breast, colorectal, endometrial, gastric, ovarian and pancreatic cancer. Several pathophysiological mechanisms are implicated in the development of malignant ascites. Management should be aimed at maximising patient comfort and quality of life. Management options include diuretic therapy, therapeutic paracentesis and peritoneovenous shunts. Oncological interventions maybe helpful for patients with ovarian malignancy and lymphoma. Hormonal treatments maybe useful for management of receptor positive cancers like breast cancer.AimsA supra regional re-audit of palliative care network practice was performed which established compliance with regional guidelines. Two questionnaires were developed. The first questionnaire gathered information on individual anonymised patients with ascites. The second questionnaire focused predominantly on clinical practice when carrying out paracentesis.MethodsA prospective case-note audit of patients with ascites within specialist palliative care services in the network. Data were collected over 6 months from hospice, community, hospital advisory palliative care teams. Collected data included management of ascites with drugs, paracentesis and the use of permanent indwelling catheters for the management.ResultsMore than 50% of patients had an Ultrasound prior to drainage of ascites. 30% of patients had paracentesis at the Hospice. Only 40% of staff had access to units where permanent indwelling catheters was being inserted. Most units did not have a scanning device in house.ConclusionExamination of current practise in the Merseyside and Cheshire Cancer Network shows that management of ascites is predominantly using diuretics and paracentesis as per previous standards and guidelines. However there are units who now insert permanent indwelling catheters. Some units also have their own ultrasound device for diagnosing ascites and marking out the site of needle insertion.
Audit on documentation of steroid usage in palliative care patients in a UK inpatients' hospice
Authors: Subramaniam Sivakumar , Newens Paula , Vellaturi Krishna , Caio Bettini , Marshall Jane , Fisher Simon 
Published: March 2012

Steroids are commonly used medications in palliative care patients. It is well known that inappropriate or prolonged prescribing of steroids could be harmful for patients. An Audit of documentation of steroid usage in in-patients was completed in 2007 at three hospices with 90 patients. This recommended (1) every patient on steroids must have indication, dose, response and planned length of treatment documented. It may be feasible to record this in both case notes and drug chart. (2) All patients on steroids and NSAIDs should be on a PPI. (3) All patients discharged on steroids should have a management plan documented.AimTo evaluate our current practice against the recommendations from the 2007 audit.MethodologyRetrospective, case notes &drug chart review of all the patients discharged from two inpatients' units from November 2010 to May 2011 with 32 beds in total.ResultsTotal patients: 133, patients discharged on steroids: 60 (30%). Indication documented: 52/60; Response clearly documented: 37/60.Planned duration documented: 40/60.Patient on steroids and NSAIDs not on PPI: 2/5. No documented plans about steroids in discharge letter: 28/60.ConclusionA significant number of patients are discharged on steroids from inpatients' units. However, the documentation of indications, planned length of use, response to the treatment and reduction plans needs further improvement. One of the main findings from the audit is that the documentation regarding steroid prescription and planned reduction in discharge summaries needs to be significantly improved. It is recommended that a separate box be added to the discharge letters regarding steroids and plans of reduction and introduce steroid card for the patients to carry to alert the professionals. To re-audit in 2 years time to check progress.
The clinical and strategic impact of generic documentation for end of life anticipatory prescribing
Authors: Wenham Sarah , Smith Kathryn , Taylor Chris , Atcheson Lynn , Greenall Melanie , Haythornthwaite Cherith 
Published: March 2012

BackgroundThe End of Life (EoL) Care Strategy (2008) recommends that consistent ‘co-ordination of care’ and ‘delivery of high quality services in all locations’ is essential across a healthcare economy. Due to historical development and redesign of community services within a large healthcare economy in the north-west of England, we found ourselves with three different community policies for anticipatory medication at the EoL and five different prescription and authorisation forms. Cross-organisational collaborative working is essential to develop consistent standards that provide the high quality of EoL care and minimise potential risk.AimTo assess the clinical impact of generic documentation for ‘Just in Case 4 Core Drugs’ (JiC4CD) anticipatory prescribing at the EoL across a healthcare economy.MethodA multi-disciplinary group of clinical experts from all the key stakeholder organisations within the healthcare economy reviewed the existing processes and documentation, and an ideal clinical pathway was agreed. A Task and Finish group designed and implemented new documentation in line with this pathway, including: • prescribing guidance • single prescription and authorisation booklet • JiC4CD pack (issued from community, hospital and hospice pharmacies) • audit form Audit forms were completed by the primary healthcare team and returned for analysis using simple statistical methodology.ResultsThe clinical impact of the JiC4CD booklet and pack was demonstrated with regard to: • EoL symptom control • prescribing and administration clinical incidents • crisis domiciliary visits and unplanned hospital admissions • place of death • carer satisfaction • healthcare professional satisfaction Facilitating factors and barriers to implementation will be discussed.ConclusionSingle generic documentation for JiC4CD anticipatory medications across a healthcare economy not only has a positive impact on individual patients, but the process also demonstrated benefits of cross-organisational partnership collaboration to achieve ‘high quality care for all adults at the EoL’.
Radiology imaging in the hospice setting
Authors: Beggan Shane , Rayment Clare , Ward Jason 
Published: March 2012

BackgroundThere is little literature available regarding the use of radiology services within the hospice setting. St Gemma's Hospice in Leeds has a 32-bed inpatient unit with around 600 admissions per annum and a day unit and outpatient service reviewing 400 patients a year. It accesses the local hospital trust for imaging.AimsTo collate all radiology requests over a year to determine the frequency of different imaging modalities and what proportion detected the anticipated result or an alternative explanation for symptoms. Secondary aims included the proportion of patients who died within 2 weeks of imaging and examining the cost of imaging.MethodData were collected retrospectively from the radiology IT department at Leeds Teaching Hospitals NHS Trust. It included details of all imaging requested for inpatients and outpatients between 1/1/10 and 31/12/10 by Doctors within the hospice.Results51 patients had 62 scans: 21 CTs, 18 MRIs, 10 Ultrasound scans, 4 CXRs, 4 AXRs, 3 Nuclear bone scans and 1 barium swallow. The most common reasons for imaging were for possible brain metastases (13), or spinal cord compression (12), 29% and 25% respectively were positive. Imaging for venousthromboembolism (11), and disease progression (6), were the next most common reasons for scanning, 27% and 67% respectively were positive. Scans showed an explanation for symptoms in 5/12 (42%) for SCC, 5/13 (38%) for brain mets, 5/5 (100%) for PE and 5/6 (83%) for disease progression. 11% of patients died within 2 weeks of having their scan. The approximate total cost based on NHS average reference costs was just under £10,000.ConclusionMost scans were appropriately requested. Depending on the imaging between 25 and 100% showed some abnormality. Most imaging was avoided in the 2 weeks prior to a patient's death. The costs associated with imaging are significant.
Intravenous cannula care in the inpatient hospice setting
Authors: Newens Paula , Rowlstone Theresa , Butler Claire 
Published: March 2012

BackgroundThere is little data on the subject of practical procedures in hospices. The Minimum Data Set, collected annually by the National Council for Palliative Care, recorded clinical interventions for the first time in 2008–2009. Response rates remain too few to draw conclusions. Anecdotally, there has been an increase in practical procedures with growth of the modern hospice movement. Bloodstream infections account for 7% of all healthcare associated infections (HCAI) in England and are associated with high level of patient mortality. Around 44% of these infections are directly attributable to invasive devices. It has been estimated that each HCAI costs the NHS £4,300 totalling at least £1 billion.AimsTo assess current practice of insertion and ongoing care of intravenous cannulae in the inpatient hospice setting. To develop new strategies to promote best practice guidelines.MethodsThe documentation relating to 10 consecutive intravenous cannula insertions was recorded prospectively at an inpatient specialist palliative care unit. Ward staff were blinded to this to minimise observation bias. Documentation for each cannula was assessed retrospectively against NHS guidelines and standards. New documentation was developed. Following a trial period, the insertion and ongoing care of cannulae were reaudited across the organisation, comprising three inpatient specialist palliative care units. Twenty consecutive cannulae were recorded and assessed retrospectively.ResultsThe initial audit showed an average of 14.7% compliance with the national guidance which increased to 68.6% after the introduction of the new documentation. The Mann–Whitney test suggested a statistically significant (p=0.0006) improvement in recording of cannula care.ConclusionIt is important that evidence-based guidance is used across all areas of healthcare to improve patient care. Introduction of a quick, simple, self-contained recording system can produce a significant increase in the evidence of good cannula care.
Ambulatory epidurals: an innovative alternative
Authors: Thompson Anthony , Coackley Alison , Levshankov Kosta , Haywood Chris , Barton Greg , McConaghy Margaret 
Published: March 2012

BackgroundContinuous epidural infusions are often delivered by pumps that require changing every 24 h. This limits patient independence and quality of life and provision in the community can be difficult. Alternatives can be extremely expensive with limited availability for example, implantable devices.MethodsThe Accufuser Elastomeric Vacuum Pump device delivers a near linear infusion with a patented piston over 5.7 days. The infusion can be prepared aseptically in the Pharmacy department.Discussion/ResultsThis report describes the challenges and benefits of implementing a new approach to delivering epidural infusions in four patients. The device has been tolerated well, and used on four separate occasions. Longest duration of use was 14 weeks and is on-going. Robust device which is lightweight, easy to manage and does not depend on batteries. Good evaluation from patients. Easy, flexible drug titration. Combination of drugs can be varied according to compatibility studies. Change of device is managed easily by staff following appropriate training. The device is cost effective and allows patients to maintain mobility and independence. It has been accepted by community staff. This device has no significant safety issues or complications.
Use of intravenous bolus doses of ketamine for acute refractory pain
Authors: Ahamed Ashique , Spawton Vanessa , Wells Lynne , Newell Elizabeth , Ahmedzai S H 
Published: March 2012

BackgroundKetamine is used in palliative care to help relieve refractory pain that does not respond to conventional opioids or adjuvant analgesics. It is commonly administered via subcutaneous or the oral route. This however has its limitations since ketamine infusion can cause skin irritation and result in its reduced absorption and intolerable adverse effects We demonstrate our experience in the use of intravenous (IV) bolus doses of ketamine to help control acute pain as well as to help assess adverse effects which can predict the appropriateness of commencing a subsequent infusion of ketamine.AimProspective review of patients receiving IV bolus ketamine in a tertiary cancer hospital from August 2010 to September 2011.MethodAdministration of Slow IV bolus doses of ketamine. Titration of ketamine depending on improvement in pain relief or advent of intolerable adverse effects. Assessment of extent of pain relief following administration of ketamine. Patients were asked to rate pain from 0 (no pain) to 10 (worst pain) The pain scores were taken prior to and during and post administration of ketamine.ResultsEleven patients received IVbolus doses of Ketamine during this period.All patients received haloperidol 1.5 mg s/c prior to IV ketamine. The average age of patients 47 Mean pain score prior to initiation of ketamine 8/10 Background opioids in morphine equivalent doses (MEQ)ï¿½Mean MEQ=330 mg average dose of ketamine administered=20 mg(range7.4–40 mg). Average pain score post administration=2/10 adverse effects: drowsiness 63%, intoxicated feeling 18% severe visual hallucination 9%. One patient required administration of IV midazolam to counter the adverse effects. Nine out of 11 patients conitnued with either s/c or IV infusions of ketamine.ConclusionAdministration of IV ketamine is an effective and safe method in managing acute pain in palliative care
End of life care in the district general: are we making the most of every opportunity?
Authors: Procter Lucy , Lightfoot Jennifer , Wilson Jo , Lisney Fiona , Russell Richard 
Published: March 2012

BackgroundHeatherwood and Wexham Park NHS Foundation Trust manages 1200 deaths per year. Of these, an unknown percentage is expected, and appropriate for the Liverpool Care Pathway (LCP), a national tool designed to optimise care in the terminal phase. In a busy District General Hospital, our challenge is to accurately select dying patients for management on the LCP.AimsOn an acute medicine and respiratory ward, we aimed to establish: The quality of care provided for dying patients. The percentage of deaths managed on the LCP. The number and reasons for missed LCP opportunities. Method: All deaths on an acute medicine and respiratory ward during November and December 2009 were retrospectively analysed by an interdisciplinary panel using a locally developed data collection tool.ResultsFor 22 deaths, 20 case notes were available. Cause of death was divided into three categories: acute illness (36%), long-term condition (41%) and malignancy (23%). For all deaths, inappropriate medications were discontinued, feeding and hydration issues were addressed, and DNACPR documentation completed. 32% of deaths were managed on the LCP. Anticipatory comfort prescribing (86%), documented communication with relatives (86%), and evidence of patient comfort (71%) were superior in this group. LCP was inappropriate in the remainder because of active treatment (69%), unanticipated cardiorespiratory arrest (23%) and patient refusal to accept terminal diagnosis (8%). The panel concluded that two of these could have been managed on the LCP.ConclusionOn an acute respiratory/medical ward, 40% of deaths were appropriate for the LCP. Only two LCP opportunities were missed. Evidence of patient comfort and communication with relatives was superior for patients managed on the LCP. For gravely ill patients deteriorating despite active management, the implementation of ceilings of treatment and parallel palliative interventions such as anticipatory comfort prescribing may enhance care.