Palliat Med Research Articles

Origin and development of the family carers’ movement in the United Kingdom in the 20th century

The history of the carers’ movement in the United Kingdom began in the second half of the 20th century. Demographic, social, and cultural changes in the UK made it necessary to define the role of a family carer in light of the needs of an ageing population. The Carers UK organisation, together with government representatives and researchers, fought for recognition and understanding of the challenges faced by carers, recognition of the rights for carers, as well as adoption and dissemination of the term ‘carer’ in social awareness. The main purpose of the essay is to show the origin of the family carers’ movement in the UK in the 20th century, and the integration process of different entities. The presented information can be an example for other countries facing similar challenges with informal care of those who are dependent due to age or illness. Palliat Med Pract 2020; 14, 1: 26–34

Ethical Considerations About Clinician Reimbursement for Advance Care Planning

Ethical Considerations About Clinician Reimbursement for Advance Care Planning

WHAT'S YOUR STATUS? RESUSCITATING A DYING DISCUSSION IN PSYCHIATRY

Although the Patient Self-Determination Act of 1991 required that all Medicare/Medicaid-certified institutions inform patients about their right to refuse life sustaining treatments like CPR, the medical literature consistently documents a deficit in code status assessment and documentation for patients admitted to the hospital (1). A 2011 study showed that only 9.3% of over 11000 patients had a code status documented within 24 hours of admission to a medical floor (2). While the literature is limited, this deficit appears to be even greater in psychiatric units: a study of about 600 psychiatric and medical inpatients found the rates of code status documentation among psychiatric patients was significantly lower compared to patients admitted to the medical floor (65 vs 96%, p<0.001) (3). As the population continues to age, the appropriate assessment and documentation of code status becomes particularly relevant for older psychiatric patients. Specific challenges relevant to older adults on inpatient psychiatric units include higher cardiac risks due to self-injurious behaviors, neurocognitive deficits and communication barriers. Common psychiatric conditions that may affect capacity in hospitalized psychiatric patients including psychosis, catatonia, delirium, suicidality. Clinicians should be aware that even in the presence of severe psychiatric burden, capacity may be preserved and should not be presumed absent. A resident-driven quality improvement project at Stanford Hospital aimed to improve code status documentation practices will be described. As many trainees lack formal training in these discussions and report underutilization of capacity determination, it is particularly important that the ethical and legal implications of code status assessment and documentation practices are considered. This session will illustrate the clinical relevance of assessing code status in older adults with psychiatric illnesses and provide an overview of the literature on this topic. Strategies for improved code status assessment and documentation practices will be discussed. 1. Yuen JK, Reid MC, Fetters MD. Hospital do-not-resuscitate orders: why they have failed and how to fix them. J Gen Intern Med. 2011;26:791–7. 2. Anderson WG, Pantilat SZ, Meltzer D, Schnipper J, Kaboli P, Wetterneck TB, et al. Code status discussions at hospital admission are not associated with patient and surrogate satisfaction with hospital care: results from the multicenter hospitalist study. Am J Hosp Palliat Med. 2011;28:102–8. 3. Warren MB, Lapid MI, McKean AJ, Cha SS, Stevens MA, Brekke FM, et al. Code status discussions in psychiatric and medical inpatients. J Clin Psychiatry. 2015;76:49–53.

Correction to: Collaboration Makes Us Better: Time to Increase Equity in the Science of Hospice and Palliative Care by Candrian C, Furuno JP, Kavalieratos D, and Harrison KL. J Palliat Med 2019;22(12):1492. (DOI: 10.1089/jpm.2019.0348)

Correction to: Collaboration Makes Us Better: Time to Increase Equity in the Science of Hospice and Palliative Care by Candrian C, Furuno JP, Kavalieratos D, and Harrison KL. J Palliat Med 2019;22(12):1492. (DOI: 10.1089/jpm.2019.0348)

Lévy noise-induced near-death spikes and phase transitions of a biological neural network

Near-death spikes or near-death surges are a sudden increase in neuron activity in the human brain before neurons end their firings. Just before a person is clinically dead, such spikes are observed in certain cases, so the name is near-death spikes. The reason for this behavior is the lack of oxygen in brain (Chawla et al. in J Palliat Med 12(12):1095–1100, 2009). In this study, it is demonstrated that a particular type of noise called Levy noise can generate such activity in the neural network of the worm Caenorhabditis elegans. The study identified different parameter regions of noise at which the network makes transitions from one synchronous state to another and the mechanism behind them. Such transitions are already reported in cortical regions of brain (Canavero et al. in Surg Neurol Int 7(Suppl 24):S623–S625, 2016). During the transition period between asynchronous and synchronous firing states, network is more susceptible to changes in firing pattern of individual neurons (Zandt et al. in PLoS ONE 6(7):e22127, 2011; Uzuntarla et al. Neural Netw 110:131–140, 2019). In this work, it is demonstrated that the recognized parameter regions can be used to control the network dynamics. The study also identified Levy noise values at which the network displays generation of waves of different frequencies. This result suggests a new method for neurostimulation in the case of traumatic brain injury. The study reveals that the characteristic exponent ($$\alpha $$) of the noise has better influence on the network dynamics than the scale parameter of noise (D) and the synaptic coupling constant (Gsyn) of the network. The neuronal network even displayed Gamma oscillations for large values of $$\alpha $$. If the parameters of the neurons are made chaotic, the network firing rate is diminished and it displayed Delta and Theta oscillations.

PC-FACS

PC-FACS

Serotonin syndrome in advanced cancer patient treated with tramadol and antidepressants

Serotonin syndrome is potentially life-threatening syndrome associated with excessive serotonergic activity within the central nervous system. Serotonin syndrome is associated with medication use, drug interactions, and overdose. While serotonin syndrome is often associated with the use of selective serotonin inhibitors (SSRI), an increasing number of reports are being presented involving the use of tramadol. With tramadol increasing popularity, the goal of this article is to make physicians more alert and aware of this potential side effect. Serotonin syndrome may be difficult to diagnose. A case of serotonin syndrome caused by the combination of tramadol and antidepressants in a patient with advanced cancer is presented and discussed. The importance of early diagnosis of this syndrome is emphasized. Palliat Med Pract 2019; 13, 3: 161–164

Neuropathic pain: new mechanisms of action of old drugs

Approximately 7–10% of the general population and 30% of cancer patients suffer from neuropathic pain, which is induced by the damage or disease of the neurologic structures. Sometimes neuropathic pain is caused by the pressure on a nerve but more often pain is due to the sensitization of the centers in the spinal cord and brain. Some structures become so sensitive to the peripheral pain impulses that they become totally independent of them. Recently neuropathic pain is seen as an activation process of the innate immunologic system. In this area the Toll-like receptors seems to play an important role and many drugs are able to inhibit their activation. Treatment of neuropathic pain depends on the possibility of nerve decompression. However, in many cases, the sensitization is the target for treatment. For this purpose, most useful are gabapentinoids that inhibit influx of calcium across the membrane. Antidepressants (SNRI) such as duloxetine and venlafaxine are also useful as well as tricyclic antidepressants, although the latter are characterized by significant adverse effects. In some types of neuropathic pain 8% capsaicin, as well as 5% lidocaine plasters or different opioids, are successfully used although there is still a lack of sufficient, good quality controlled clinical trials. The description of the role of Toll-like receptors in the pathophysiology of neuropathic pain is a breakthrough in thinking and hope for the future to elaborate new, more effective treatment methods. Palliat Med Pract 2019; 13, 3: 123–128

An overview of the use of drugs in palliative care settings worldwide

Introduction: To provide an overview of drug use in palliative care worldwide and to identify the most commonly used medicines in palliative care settings. Methods: Quasi–systematic review. Search strategy: Medline/PubMed, Embase, SCOPUS and Google Scholar were searched utilizing the selected MeSH terms: palliative care, hospice, drug utilization, and prescription patterns. Results: Overall, it is apparent that there is a significant lack of published literature outlining drug usage in palliative care settings. Twelve sources of information were reviewed from 9 different countries including Austria (n = 1), Brazil (n = 1), Canada (n = 1), Germany (n = 1), Italy (n = 2), Netherlands (n = 2), Norway (n = 1), Switzerland (n = 1) and USA (n = 3), as well as a multinational study comparing 11 European countries. Medication use between countries was similar. The most commonly prescribed classes of medicines included non-opioid analgesics, opioids, laxatives, sedatives and antipsychotics and the most commonly prescribed individual drugs comprised morphine, haloperidol, laxatives and paracetamol. Conclusions: The literature identifies that there is insufficient evidence to describe and compare what drugs are currently used in palliative care settings worldwide. This is attributed to the lack of recently published articles leading to a large gap in knowledge in understanding drug utilization practices in palliative care. Further research is required to address these gaps in knowledge, and identify medication management issues in palliative care and determining whether there are significant differences in drug management practices. Palliat Med Pract 2019; 13, 3: 134–141

Therapeutic challenge: severe dyspnea in a patient with metastatic breast cancer and lymphangitis carcinomatosis syndrome

Introduction. Dyspnea, regardless of etiology (pulmonary, neuromuscular or caused by other factors), remains a significant challenge. There is still a lack of effective methods of the treatment of severe dyspnea associated with intensifying anxiety which is the most common indication for intensification of causative and symptomatic treatment or palliative sedation. Case report. A 48 year-old woman diagnosed with relapsed breast cancer with bone, pleural, hepatic and pulmonary metastases with lymphangitis carcinomatosis syndrome confirmed by lung biopsy. In 2011 the patient underwent breast conserving surgery followed by teletherapy, brachytherapy and tamoxifen hormone therapy for 5 years. Comorbidities included chronic obstructive pulmonary disease, diabetes mellitus type 2, depression and nicotine addiction. The patient was urgently admitted to the Department of Oncology and Radiotherapy from Clinical Emergency Department due to rapidly aggravating dyspnea and respiratory failure. Chest X-ray showed massive bilateral pleural effusion and threatening cardiac tamponade. Treatment involved thoracentesis and pericardiocentesis with concurrent symptomatic management. After temporary stabilization of the patient and due to rapid progression of the disease salvage, paclitaxel chemotherapy was started. Despite the features of potential chemosensitivity (chemotherapy–naive, rapid progression, visceral metastases) the applied treatment was ineffective. After careful evaluation of clinical situation and possible treatment strategies, and after obtaining patient’s consent, sedation with midazolam and morphine was applied. Conclusions. This case demonstrated ineffective salvage chemotherapy used in the patient with severe dyspnea induced by a rapid progression of metastatic breast cancer and difficulties in obtaining effective symptomatic treatment. Palliat Med Pract 2019; 13, 3: 156–160

The role of naldemedine in the treatment of patients with opioid-induced constipation

Opioid-induced bowel dysfunction (OIBD) and opioid-induced constipation (OIC) significantly decrease patients’ quality of life (QoL), lead to complications and opioid non-compliance resulting in pain exacerbation. Traditional laxatives are first-line preventive and therapeutic measures, although they display limited efficacy and several adverse effects (AE). Non-pharmacology measures, prokinetics, opioid switch, all have little evidence and do not target OIBD and OIC pathophysiology both associated with activation of predominantly μ-opioid receptors mostly peripherally in the gastrointestinal (GI) tract. A combination of prolonged-release (PR) oxycodone with PR naloxone in one tablet with a ratio of 2:1 is available, although limitations include maximal daily dose of 160 mg/80 mg, respectively, and normal liver function. Peripherally acting μ-opioid receptor antagonists (PAMORA) block opioid receptors in the GI tract without compromising analgesia as they do not cross the blood–brain barrier. Currently three drugs are available: methylnaltrexone, naloxegol and naldemedine. Naldemedine has proven efficacy superior to placebo in the treatment of OIC in both cancer and non-cancer patients while improving patient-reported constipation symptoms and patients’ QoL. It is well tolerated with mostly mild to moderate intensity GI adverse effects such as abdominal, pain, nausea, and diarrhea, without compromising analgesia. Naldemedine dosing is convenient as it is administered once daily by an oral route. Moreover, naldemedine may be safely used in patients with renal failure and mild to moderate hepatic impairment. Effective prevention and treatment of OIC is of paramount importance in patients receiving long-term opioid therapy. Palliat Med Pract 2019; 13, 3: 113–128

The right of a close person to access medical data after the death of a patient

Maintenance of medical confidentiality is a fundamental duty of a physician. It is derived from the right to privacy, which, as a constitutionally protected value, can only be restricted under exceptional circumstances. Medical law provisions should therefore precisely define exceptions to discretion. One of these exceptions is the ability to disclose confidential information after the death of a patient, if a person close to that patient has given consent to that effect. This regulation was introduced in 2016. However, it was highly imperfect and generated many dogmatic and practical problems. For that reason, the legislator decided to change it. The amended regulations entered into force on 9 February 2019. Their aim was to remedy existing ambiguities and subject the procedure related to violation of confidentiality under such circumstances to greater control. This article shows the evolution of this regulation and discusses its current structure. Accordingly, the article presents the notion of a close person, the possibility of making use of a judicial procedure in case of doubts as to whether the person who gives the consent is authorised to do so, as well as to resolve disputes between close persons. In addition, rules for making medical records of a patient available after that patient’s death were also described. Palliat Med Pract 2019; 13, 3: 142–148

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Medical cannabis: prescribing and research developments

Journal of Prescribing PracticeVol. 1, No. 6 NewsMedical cannabis: prescribing and research developmentsAysha MendesAysha MendesE-mail Address: [email protected]Freelance Journalist, specialising in healthcare and psychologySearch for more papers by this authorAysha MendesPublished Online:12 Jun 2019https://doi.org/10.12968/jprp.2019.1.6.272AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View article References Clinical Pharmacist. Cannabis composition alters effects of drug on brain. 2019. https://www.pharmaceutical-journal.com/news-and-analysis/research-briefing/cannabis-composition-alters-effects-of-drug-on-the-brain/20206551.article (accessed 28 May 2019) Google ScholarGodlee F. Medical cannabis on the NHS. Br Med J. 2018;362:k3357. https://doi.org/10.1136/bmj.k3357 Google ScholarKim A, Kaufmann CN, Ko R et al.. Patterns of medical cannabis use among cancer patients from a medical cannabis dispensary in New York state. J Palliat Med 2019. https://doi.org/10.1089/jpm.2018.0529 Google ScholarRobinson J. DHSC commissions ‘rapid’ evaluation of medical cannabis prescribing. 2019. https://www.pharmaceutical-journal.com/20206409.article?utm_campaign=2482_PJ_daily_alert&utm_medium=email&utm_source=Pharmaceutical%20Journal&firstPass=false (accessed 22 May 2019) Google ScholarSpring M, Bingham H, Bryant SL. Prescribing cannabis drugs: response from NICE and Health Education England. Br Med J. 2018; 363:k4940. Google ScholarTorjesen I. Medical cannabis will be available on prescription in UK from autumn. Br Med J. 2018; 362:k3290. https://doi.org/10.1136/bmj.k3290 Google ScholarWall MB, Pope R, Freeman TP. Dissociable effects of cannabis with and without cannabidiol on the human brain's resting-state functional connectivity. J Psychopharmacol. 2019; https://doi.org/10.1177/0269881119841568 Google Scholar FiguresReferencesRelatedDetails 2 June 2019Volume 1Issue 6ISSN (print): 2631-8385ISSN (online): 2631-8393 Metrics History Published online 12 June 2019 Published in print 2 June 2019 Information© MA Healthcare LimitedPDF download

Undiscovered morphine. The effects of the long-term use of the opioids

Morphine and other opioids are used much more often and for a longer time than before. This causes many relatively unknown adverse effects, which become apparent only after a while. One of them is opioid-induced hyperalgesia and abnormal magnesium metabolism. The adverse effect that negatively influences the quality of life is opioid-induced hypogonadism. Morphine can have a profound immunosuppressive and tumour-promoting effect. It is probably responsible for the increased rate of heart infarctions. Very interesting are suggestions that morphine and other opioids are changing the large bowel microbiome. All of these phenomena do not concern only few patients but are generalized in this population and the severity of the phenomenon depends only on the treatment period. Jet none of these adverse effects are mentioned in drug leaflets. All of these phenomena are treatable providing that the diagnose is made accurately and timely. It is very well possible that in the future we shall be able to prevent most of these adverse effects. Palliat Med Pract 2019; 13, 1: 22–26

Selected aspects of nutrition in palliative care

Proper nutrition in palliative care is essential to achieve a good quality of life of patients and better treatment results. The diet should include the proper amount of calories and nutrients such as proteins, omega 3 fatty acids, dietary fibre, vitamin D and vitamin C. The meals must be balanced, tasty, diverse and appetizing. In this paper, an example of one-day diet for adult palliative care patients is proposed. Palliat Med Pract 2019; 13, 1: 17–21

The use of opioid analgesics in chronic pain therapy — a retrospective, single-center study

Introduction: The use of opioids is fundamental in moderate and severe pain management. There is an increase in opioids use in highly developed countries, while at the same time in other countries, difficulties in access to appropriate pain treatment are observed. The aim of the study was to determine the use of opioids in the treatment of chronic cancer-related and non-cancer pain. Material and methods: The study covered the medical documentation of patients under the care of the Pain Medicine Clinic, Palliative Medicine Clinic and Hospice in the period 01.01.2017–30.04.2017 which reported: sex, age, duration of medical services, primary diagnosis, opioid treatment — pharmacological substances, a form of supply and side effects. Results: In the study, 634 medical consultations of 196 patients were analyzed and 32 (16%) of them were cancer patients. The predominant cause of pain were degenerative diseases, disorders of the spinal nerves and nerve plexuses. Oxycodone was most often used as a monotherapy for cancer and non-cancer pain. Transdermal buprenorphine was significantly more frequently used in non-cancer pain and transdermal fentanyl was more frequently administered in cancer-related pain. In the group of cancer patients, the principles of multi–modal therapy were more often applied and no adverse effects were noted. Conclusions: Opioids are the primary method in pharmacotherapy at the specialist level. Oxycodone is widely used in monotherapy of cancer-related and non-cancer pain. Various forms of the supply of opioids in the therapy of chronic cancer pain is not associated with the risk of side effects. Palliat Med Pract 2019; 13, 1: 11–16

What can nurses do to manage incontinence challenges in end-of-life care?

What can nurses do to manage incontinence challenges in end-of-life care?

Application of dignity therapy in an advanced cancer patient — wider therapeutic implications

Aim: Dignity therapy is a short-term, individualized, patient-focused form of therapy reducing stress and helping both the patient and his family appreciate the end-of-life situation. The present study describes the impact of dignity therapy on an advanced cancer patient within a Polish hospital setting. Methods: MH. Chochinov’s dignity therapy protocol was applied. A session was conducted during which an interview with the patient was recorded; subsequently subjected to a statistical analysis. The competent judges’ approach was used to effectively preclude subjective interpretation of the patient’s statement by an investigator. The judges’ appraisal was then checked for concordance (W Kendall). The patient was also asked to complete a survey questionnaire designed to assess the therapeutic effectiveness of dignity therapy in the intervention. Results: The patient indicated that family epitomized the most crucial values. He also highlighted othe issues, i.e. his work and life’s passion — playing the drums. The survey questionnaire indicated that by far the greatest benefit consisted in an overall improvement of his mental well–being (4.67). Benefits for the family followed (4), including his hope for recovering family ties (4). An unexpected therapeutic effect consisted in re–establishing a broken relationship with his daughters. Conclusions: Dignity therapy proved effective not only as a method of enhancing the patient’s own sense of dignity in the face of impending death but also tangibly instrumental in overcoming a dramatic communication break within a family. Palliat Med Pract 2018; 12, 4: 218–223

Hospice and Palliative Care volunteering in the Netherlands. Practices of Being There

Hospice and Palliative Care (HPC) volunteering is not easily comparable through European countries. Comparison of practices in different countries helps to acknowlegde, protect and improve the core of this unique source in palliative care. To this end this contribution describes volunteering practices at the end of life in The Netherlands. It presents quantitative characteristics about numbers of volunteers, type of hospices and hours worked and a qualitative description of the volunteering work guided by the concept of ‘ Being There’. Some reflections on education of volunteers is added. The satisfaction of relatives with services is discussed and some thoughts on quality assurance of volunteering are shared. All information and data in this publication is retrieved from several ‘grey’ documents like mission statements, year reports or registration fact sheets. All describe the Dutch situation of HPC volunteering and are written in the Dutch language. Palliat Med Pract 2018; 12, 4: 193–197