Palliative Care Department Research Articles

Gabapentin for the treatment of pain manifestations in children with severe neurological impairment: a single-centre retrospective review

Pain, irritability and feeding intolerance are common symptoms affecting quality of life in children with severe neurological impairment (SNI). We performed a retrospective study to explore the use of gabapentinoid...

Alzheimer's disease - the role of nurses in patient care

Polanska Patrycja, Galka Alexandra, Gil Roksana, Mika Katarzyna, Poleska Ewa, Sarzynska Kathie, Spodzieja Justyna, Mess Eleonora . Alzheimer's disease - the role of nurses in patient care . Journal of Education, Health and Sport. 2019;9(6):187-202. eISNN 2391-8306. DOI http://dx.doi.org/10.5281/zenodo.3241894 http://ojs.ukw.edu.pl/index.php/johs/article/view/7009 The journal has had 7 points in Ministry of Science and Higher Education parametric evaluation. Part B item 1223 (26/01/2017). 1223 Journal of Education, Health and Sport eISSN 2391-8306 7 © The Authors 2019; This article is published with open access at Licensee Open Journal Systems of Kazimierz Wielki University in Bydgoszcz, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 05.05.2019. Revised: 25.05.2019. Accepted: 09.06.2019. Alzheimer's disease - the role of nurses in patient care Patrycja Polanska 1 , Alexandra Galka 1 , Roksana Gil 1 , Katarzyna Mika 1 , Ewa Poleska 1 , Kathie Sarzynska 1 , Justyna Spodzieja 1 , Eleonora Mess 2 1 A group of nursing students under the supervision of Dr. Eleonora Mess at the Medical University of Wroclaw 2 Department of Oncology and Palliative Care, Faculty of Health Sciences, Medical University of Wroclaw mailing address: eleonora.mess@umed.wroc.pl SUMMARY Alzheimer's disease is the most common degenerative disorder of the brain resulting in dementia. It occurs most frequently among the elderly. This article presents the causes, effects and manner of developing the disease. Described above are the most important aspects of patient care. Particular attention was paid to the adaptation of housing, communication, rehabilitation, diet, forms of support for the patient and caregivers. Due to the nature of care they were also presented specific problems in health and the role of nurses has been determined. Key words: Alzheimer's disease, AD, dementia, problems, care.

ED-PALS: A Comprehensive Palliative Care Service for Oncology Patients in the Emergency Department.

The American College of Emergency Physicians has identified early palliative care referral for patients with advanced cancer as a key competent of the Choosing Wisely campaign. To study the feasibility of a new 3-way model of care between emergency department (ED), hospital palliative care department, and inpatient/home hospice. This was a prospective, descriptive study that included oncology patients who attended the hospital ED over a 3-year period from January 2015 to December 2017. The inclusion criteria were as follows: (1) presence of metastatic cancer with either; (2) any 1 of the following symptoms: pain, dyspnea, nausea and vomiting, delirium, or swelling; or (3) potential care difficulties (requiring home hospice care or inpatient hospice). A total of 340 patients were referred from the ED. Mean age was 72 years, 59% were males and 41% females, and the majority (88%) were Chinese. The most common cancers were lung 89 (26%), colorectal 71 (21%), and hepatobiliary cancer 49 (14%). The most common symptoms on Edmonton Symptom Assessment Scale scoring were pain (34%), poor appetite (31%), and dyspnea (26%). This tripartite model of palliative care, hospice, and ED collaboration allows earlier access to palliative care in the ED and direct admissions to the palliative care unit and comfort care rooms. The ED patients who did not need admission were also attended to in the palliative care "Hot Clinics" within a week with home hospice help. Patients who required inpatient hospice care were directly admitted there from the ED.

A Survey of Medical Professionals in an Apex Tertiary Care Hospital to Assess Awareness, Interest, Practices, and Knowledge in Palliative Care: A Descriptive Cross-sectional Study.

Background:Medical discipline in India focuses on cure rather than comfort care. Palliative care is concerned with improving quality of life and relieving sufferings in patients with advanced incurable terminal diseases. Palliative care in India is still in infancy stage due to lack of knowledge, attitude and skills among health care providers. The reason being lack of training in under graduate as well as postgraduate teaching curriculum and lack of sensitization among policy makers.Aims and Objectives:To assess the awareness, interest, practices and knowledge in palliative care among medical professionals working in a tertiary care hospital.Materials and Methods:All participants were mailed proforma to be filled in a fixed format including details of their qualification, demographic data, their field of work, their training in palliative care and multiple choice questions regarding awareness interest, practices and knowledge of palliative care.Results:Out of 186 respondents, 56% had not received any basic training in palliative care. 81% wanted palliative care education to be included in undergraduate curriculum. Poor program was identified as the most common barrier in learning palliative care. 77% respondents had no idea about home based palliative care services. 50.8% patients dies in hospital in their terminal stage. 88% were interested in learning safe opioid practices. Although 89.8% were aware of the need of palliative care in metastatic cancer but less than 50% were aware of the fact that palliative care is also required in MDR-TB and mental illness.Conclusion:This study reflects data of an apex cancer institute of the country. The result of awareness is not very encouraging despite a dedicated palliative care department. So, we can assume what will be the palliative care status in other parts of India where there is no palliative care at all.Recommendation:We strongly recommends that palliative care teaching should be incorporated in undergraduate curriculum to sensitize the students from the beginning. Budding residents in their learning phase can play an important role by learning and providing palliative care as the first person to come into contact with the patients are residents. There is a strong need of spreading palliative care awareness all over the country.

Developing a Delphi survey in MD/APP’s for distress level after supportive care inpatient consults.

125 Background: Physicians caring for patients with terminal cancer are at particular risk for compromised well-being due to the nature and intensity of the clinical stresses they face. The factors contributing to professional burnout severity included younger age, working in isolation, and working longer hours a shown by a survey conducted by Kamal et al. For patient encounter distress multiple factor have been mention as a source of distress for providers including patient factors, physician factors and environmental factors. No documented evidence of the distress level in palliative care (PC) providers after patient encounter is available. We intend to identify the most common predictors for high distress level after patient encounter in order to identify ways to support our staff. Methods: A group of 28 PC faculty physicians and mid-level providers in the Department of PC at the M. D. Anderson Cancer Center were invited to participate in the study by email with Qualtrics link e-online questionnaire. The questionnaire seek their opinion on the most important interaction or situations that increase their distress level during a PC consult. A 5-point Likert scale of agreement was used, ranging from “strongly disagree” to “strongly agree”. We will conduct the procedure to generate the question prompt sheet with 3 Delphi rounds. Results: After the first round of the Delphi the situations that could cause distress after a consult with more than 80% agreement were identify as: difficult family, manipulative family/patient, angry patient/family, primary team in denial, time of the consult, and number of consults. Situations like patient's terminal diagnosis, patient/family religious beliefs, cultural background, or presence of observer or trainee were less likely consider as source of distress with a less than 20% agreement. Conclusions: For PC specialists situations that affect the communication or rapport with patients as well as amount/burden of clinical work seems to be more a source of distress. Other situations related to uncontrolled symptoms, EOL issues or patient background were less likely a source of distress what could be explain by the expertise of the specialist with these EOL discussions and symptom management.

ARRANGEMENT OF WORK AT PALLIATIVE CARE DEPARTMENT IN ALMETYEVSK BRANCH OF THE REPUBLICAN CLINICAL ONCOLOGICAL DISPENSARY OF THE MINISTRY OF HEALTH OF TATARSTAN REPUBLIC

In the Russian Federation, the incidence of cancer diagnosed at an advanced stage still remains high. A majority of patients (75 %) present with an advanced disease. The goal of palliative care is achievement of the best quality of life and relief of suffering of cancer patients. However, today there is no single model of palliative care.The aim of the studywas to analyze the activities of the Department of Palliative Care of Almetyevsky Branch of the Republican Clinical Oncology Center of the Republic of Tatarstan.Material and methods.The Palliative Service of the Republic of Tatarstan is unites several institutions, including the Almetyevsky branch of the Republican Clinical Oncological Dispensary, which was organized in 2015. Based on the population of Almetyevsky region, there are two medical outreach teams.Results.Between 2016 and 2017, 1 025 patients received palliative care at home, and 6 625 visits were made. Pain syndrome was the most common reason for admission (more than 80 %) followed by depression (more than 80 %), disability disorders (more than 40 %), insomnia (25 %), dyspnea (22 %), and impaired consciousness (5 %). As a result of the creation of this service, a decrease in the number of ambulance visits to patients was recorded: from 92 to 12 % for the reason of severe intolerable pain, from 75 to 6.6 % due to moderate pain and from 6.7 to 0, 3 % due to mild pain. The incidence of unjustified hospital stay decreased by 28 %.Conclusion.Organization of the team of professionals invoplved in providing high-quality cancer care in Almetyevsk helped to improve the quality of palliative care for incurable cancer patients.

366P - Socioeconomic status and demographic assessment of advanced cancer patients in palliative care department of a tertiary care centre: Observational study

366P - Socioeconomic status and demographic assessment of advanced cancer patients in palliative care department of a tertiary care centre: Observational study

Acupuncture in Palliative Care

Background: Acupuncture is an innovative and scientific supported option to treat oncological patients and seems to be an effective palliative care option. In the region of Tuscany, at the Palliative Care Department of “Misericordia” Grosseto Hospital a real integration of acupuncture in Palliative Medicine has been started. The objective of this work is to retrospectively evaluate the effects of the integrated medical approach in a palliative care unit. Methods: Medical records of the cancer patients belonging to the palliative care unit who voluntarily underwent integrated therapy with acupuncture were retrospectively analyzed. For each patient, an innovative and personalized treatment was used that included the use of - Points based on Traditional Chinese Medicine (TCM) - Points based on Microsystems Acupuncture Technique - Points with a psychic action (Shen Ling) Codified evaluation indexes have been collected at the beginning and after 1-2 months of the integrated therapies. Edmonton Symptoms Assessment Scale (ESAS) and SF-12 questionnaire were used for oncological patients while in palliative care were used well-being subjective criteria and the Tarlowski Scale. Results: More than 900 sessions of acupuncture in about 320 outpatients and their families, 45 residents in the hospice facility and 8 palliative care operators were performed in 2 years; 92.4% of patients reported some improvement in their symptoms on the ESAS, with 36.8% reporting a good or remarkable improvement or complete resolution. Examination of the items on the SF-12 questionnaire showed a remarkable improvement in perceived health two months after the start of the integrated therapy. Conclusions: Acupuncture is a promising adjunctive therapy for those patients nearing the end of life in the home hospice setting. Acupuncture is safe and clinically cost-effective for the management of common symptoms in palliative care and hospice patients.

COMPARISON OF DOCUMENTED PATIENT CARE BEFORE AND AFTER IMPLEMENTATION OF END OF LIFE CARE PATHWAY FOR TERMINALLY ILL PATIENTS AT SHAUKAT KHANUM MEMORIAL CANCER HOSPITAL AND RESEARCH CENTRE

Purpose: Shaukat Khanum Memorial Cancer Hospital and Research Cancer primarily deals with cancer patients and has various departments which provide best-integrated lifesaving care. However, when patients who have been given all possible medical and oncological treatment still progress their disease, they are then referred for best supportive care to palliative care department. The aim of this paper was to audit documented care for palliative patients before and after implementation of end of life care (ELC) pathway.Materials and Methods: We used a retrospective method to audit 45 terminally ill patients over a period of 3 months. Then, a re-audit was done over a period of 3 months and data were collected for patients who were started on SKM-ELC pathway.Results: Results show that the implementation of ELC pathway, 67% of the patients were not prescribed PRN medications for symptom control, 20% of the patients were not reviewed for the need of assisted nutrition and for 20% of the patient’s primary team were not even notified that the patient is dying. After the ELC pathway implementation, it was found that 100% of patients were reviewed for PRN medications and assisted nutrition. Oncologists were timely notified that the patient is dying.Conclusion: In summary, we can say that implantation of ELC pathway has significantly improved documented patients care in all aspects.Key words: Cancer, care for dying, end of life care, goals of care pathway

Integration of Palliative Care into the Comprehensive Cancer Center of Germany - Consultation Hours and Fellowship Rotations of the Specialized Palliative Care

Comprehensive Cancer Centers are characterized by interdisciplinary exchange for meeting increasingly complex care needs during the course of the disease. Tumor consultations hours and fellowship rotations build hereby bridges between the subjects and disciplines. In order to be able to provide support in the Comprehensive Cancer Center Network for the further integration of specialized palliative medicine, it was highlighted to what extent consultation hours and fellowship rotations for the palliative care are integrated into the centers. Information about the spS and fellowship rotation of the Comprehensive Cancer Center (n = 16), which had previously been funded by the Cancer Aid, was paper-based collected with a survey questionnaire. For this purpose, the heads of the palliative care departments of the centers were interviewed from July to August 2017. The evaluation was performed by SPSS (frequency, mean value, median, range). 15 from 16 centers responded to the survey (93.75 %). Nine centers (60 %) have a consultation hour for palliative care. Four from nine centers can submit this offer for ≥ 4 hours (44.4 %). Fellowship rotations in the palliative care occur primarily in all centers from oncology / hematology (n = 11, 73.3 %) and anaesthesia (n = 6) and often for a twelve months (n = 11) period of time. Outpatient structures of the palliative care have been insufficiently implemented to a consultation hour within Comprehensive Cancer Centers. The existing effort to integrate palliative care into the oncological course of disease requires further structuring in order to increase the visibility of palliative care services. Fellowship rotations in the palliative care department are regularly implemented in the network even if only for some of the subjects in order to raise awareness of the possibilities of the palliative care.

Characteristics and Outcomes of Psychology Referrals in a Palliative Care Department

ContextPsychologists can provide unique contributions to interdisciplinary palliative care. Despite research indicating high distress in palliative care cancer patients, little has been reported regarding the feasibility and practice of psychology in this setting. ObjectivesTo review the integration of clinical psychology practice in a palliative care department at a major comprehensive cancer center. MethodsRetrospective chart review of 1940 unique cancer patients (6451 total patient contacts) referred for psychology services provided by clinical psychologists in palliative care from September 1, 2013 to February 29, 2016. ResultsPsychologists provided services to 1644 inpatients (24% of palliative care inpatients) and 296 outpatients (19% of palliative care outpatients). Most of them (85%) received services in the inpatient setting. Most patients were females (57%) and white (68%) with a variety of cancer diagnoses. Adjustment disorders were the most prevalent in both settings with significant differences in other Diagnostic and Statistical Manual of Mental Disorders (5th Edition) diagnoses by service location (P < 0.0001). Psychological assessment (86%) and supportive expressive counseling (79%) were the most frequent services provided in the initial consult. Duration of initial visit was significantly longer in outpatient (median 60 minutes) compared with inpatient setting (median 40 minutes) (P < 0.0001). No significant differences were noted between settings regarding the median number of counseling sessions per patient; however, most (70%) only received one or two sessions. Over time, total patient encounters increased in the inpatient setting (P < 0.0001), whereas session lengths in both settings significantly decreased (P < 0.0001). ConclusionPalliative care psychology services successfully integrated into an interdisciplinary palliative care department and rapidly grew in both inpatient and outpatient settings.

Palliative Chemotherapy Near the End of Life in Oncology Patients

Although palliative chemotherapy during end-of-life (EOL) care is used to relieve symptoms in patients with metastatic cancer, chemotherapy may lead to more aggressive EOL care. We evaluated the use of and variables associated with chemotherapy at EOL. This study included data from patients who died from advanced cancer and underwent palliative chemotherapy between April 2007 and May 2017 at the Department of Palliative Care of Fudan University, Shanghai Cancer Center. Data were collected from hospital medical records. Univariate and multivariate analyses were conducted to identify the variables that independently predicted the use of palliative chemotherapy. Among the 542 patients in the study, 85 (15.7%) underwent palliative chemotherapy during the last month and 28 (5.2%) underwent it during the last 2 weeks of life. Age <59 years (odds ratio [OR] = 1.82, 95% confidence interval [CI]: 1.51-2.61), performance status <3 (OR = 3.73, 95% CI: 1.46-4.67), and cardiopulmonary resuscitation (OR = 3.88, 95% CI: 3.01-5.34) were independently associated with the use of chemotherapy. The use of palliative chemotherapy during the last year of life differed significantly by patient age ( P < .001). The observed chemotherapy rates of 15.7% during the last month of life and 5.2% during the last 2 weeks of life are in line with international recommendations. This study showed that palliative chemotherapy is associated with more aggressive EOL care and indicates that younger patients and those with lower performance status are more likely to receive palliative chemotherapy. Significant variations in EOL treatment strategies among different age groups during the last year of life were also identified.

Unspoken Words: Overcoming Head and Neck Silencing Tumors

Research in Medical & Engineering Sciences Unspoken Words: Overcoming Head and Neck Silencing Tumors Noura Y AlSalloum1, Balaji P Duraisamy2 and Sami A AlShammary2* 1Department of Family Medicine and Employee Health, King Fahad Medical City, Saudi Arabia 2Department of Palliative Care, King Fahad Medical City, Saudi Arabia *Corresponding author: Sami A AlShammary, Department of Palliative Care, King Fahad Medical City, Riyadh, Saudi Arabia Submission: December 18, 2017; Published: February 26, 2018 DOI: 10.31031/RMES.2018.03.000575 ISSN: 2576-8816Volume3 Issue5

Current Status and Issues of Home Palliative Care Introduction in Department of Chemotherapy and Palliative Care

Current Status and Issues of Home Palliative Care Introduction in Department of Chemotherapy and Palliative Care

Treatment practices for metastatic pancreatic cancer: Can we deliver an appropriately efficacious and safe regimen in Indian patients?

The median overall survival (mOS) in metastatic pancreatic cancers (PCs) hovers between 6 months to 11 months. The study is a retrospective analysis of metastatic PC patients who were evaluated from August 2013 to August 2016 in the Department of Gastrointestinal (GI) Medical Oncology, Tata Memorial Hospital (TMH). Out of 218 patients, 24 patients (11%) were not planned for chemotherapy and referred to the Department of Palliative Care for further supportive care. One hundred and fifty-three patients received palliative chemotherapy in TMH with median age of 56 years (range: 23-79), male (60.1%), and nonresident in Maharashtra (60.1%). Regimens used most commonly were gemcitabine-nab-paclitaxel in 60 patients (39.2%), gemcitabine-erlotinib in 25 patients (16.3%), and modified FOLFIRINOX in 21 patients (13.7%). A total of 58 patients (43%; n = 135) had Grade 3/4 toxicities. As of cutoff date for the analysis of outcomes, 139 patients (90.8%) patients had ceased first-line chemotherapy, due to radiologically proven progressive disease (PD) in 89 patients (64%), repeated Grades 3 and 4 adverse events in 26 patients (18.7%), and clinically PD in 18 patients (12.9%). With a median follow-up of 278 days, the mOS was 217 days (95% confidence interval [CI]: 175-258), and the median event-free survival was 125 days (95% CI: 107-122). Dose modifications for chemotherapy are required commonly when treating metastatic PC, with common reasons for dose reduction being toxicities, Eastern Cooperative Oncology Group performance status >=2, and low albumin levels. Studies evaluating logistic and financial aspects of treating metastatic PC with chemotherapy in India are warranted.

An Observational Study to Assess the Socioeconomic Status and Demographic Profile of Advanced Cancer Patients Receiving Palliative Care in a Tertiary-Level Cancer Hospital of Eastern India.

Introduction:Socioeconomic status (SES) comprises of not just gross income but also educational qualification, financial security and individual perceptions of social status and class. It has been observed that people with low SES have less access and utilization of palliative care services. With this background, this observational study was carried out at SGCCRI to assess and evaluate the SES of patients attending the palliative care department and analyse the major social concerns of patients in the last days of life.Objectives:Assessment of socio- economic status and demographic profile of patients with advanced cancer receiving palliative care.Materials and Methods:From May 2017 to October 2017 we assessed the demographic features and socio-economic status of 80 advanced cancer patients receiving palliative care by interviewing them face to face with the help of a self designed social assessment sheet.Results:A total of 80 patients consented to be interviewed with regards to assessment of their socio-economic conditions. Majority were male patients (64%) with the highest percentage in the age group of 60-70years (33%). 38% of the patients interviewed were from rural surroundings. Only 38% of the patients had completed their basic education. Approximately 30% of the patients interviewed had income less than 1lakh/month while majority (>60%) had income in the bracket of 1lakh- 2lakh. In 30% of cases, the patient was the sole earner in the family.Conclusion:It was observed that majority of patients and their family were constrained with regards to financial resources and large percentage of patients had social insecurity with respect to future of family members.

Reducing radiotherapy waiting times for palliative patients: The role of the Advanced Practice Radiation Therapist.

IntroductionPalliative radiotherapy is effective in reducing symptom burden and improving quality of life in patients with symptomatic metastatic cancer and should be delivered in a timely manner. The aim of this study was to determine whether referring patients directly to a Palliative Advanced Practice Radiation Therapist (APRT) improves access to palliative radiotherapy and reduces time from referral to treatment.MethodsAt Radiation Oncology Mater Center (ROMC) in Brisbane, Australia a new referral pathway was developed which involved patients requiring palliative radiotherapy, being referred directly to the APRT from a single external hospital medical oncology and palliative care departments. Over a 5 months period, patient demographics and time in working days from referral to treatment were compared for consecutive palliative patients seen within our department. Patients were stratified by method of referral i.e. via the new referral pathway (NP) or via standard referral pathway (SP).ResultsBetween October 2014 and March 2015, a total of 150 patients were referred for palliative radiotherapy. Of these patients, 48 were referred and processed via the NP. There was a significant reduction in the number of days from referral to treatment for patients referred through the NP. Patients referred through the NP via the APRT had a mean and median wait time of 3.5 and 3 days respectively compared with 8.1 and 5 days for patients referred through the SP (P = <0.001). Patients were also more likely to have the treatment completed with less visits to the hospital (P < 0.001).ConclusionsThe new referral pathway utilising a dedicated palliative APRT decreased waiting times for patients receiving palliative radiotherapy and improved timely access to the radiotherapy service for both referrers and patients.

Utilisation de la voie sous-cutanée en soins palliatifs néonatals : revue de la littérature et enquête de pratique en France

Subcutaneous hydration (hypodermoclysis) and drug administration is a widely used method of analgesic therapy in adult palliative care medicine. Very little is known about its use in neonatal medicine. Evidence-based guidelines do not exist due to a lack of data. In this study, the advantages of subcutaneous analgesic therapy in terms of comfort in neonatal palliative care situations were investigated. This report details the results of a systematic review associated with a survey in neonatal intensive care units (NICUs) and pediatric palliative care departments (PPCTs) in France. No article was available in the Medline database. In Google®, we found six guidelines that described the use of the subcutaneous route in the pediatric palliative population. The participation rate in the survey was approximately 83% for French NICUs and 74% for PPCTs. Eleven percent of NICUs and 27% of PPCTs had already used subcutaneous drug administration for palliative care, mainly for analgesia and terminal sedation. Limiting factors of its use were mainly alternative options and the lack of data. Nevertheless, 76% of NICUs and 73% of PPCTs expressed an interest in the use of the subcutaneous route in NICUs. Ninety-one percent of French NICUs and 80% of PPCTs were interested in elaborating a protocol using the subcutaneous route for analgesia, anxiolysis, or terminal sedation. The subcutaneous route can be advantageous for comfort care in the neonatal palliative population. Studies are needed to define the modalities, pharmacodynamics, and pharmacokinetics of therapeutics in this population.

Palliative Care Development in Mongolia

ContextSince the year 2000, Mongolia has established the foundation measures for a national palliative care program and has made several significant achievements. MethodsSystematic reviews and observational studies on palliative care development in Mongolia have taken place over the past 16 years. ResultsMongolia began palliative care development in 2000 with the creation of the Mongolian Palliative Care Society and the Palliative Care Department. Palliative care is included in the Mongolia's Health Law, Health Insurance Law, Social Welfare Law, National Cancer Control Program, and the National Program for Non-Communicable Diseases, and has approved Palliative Care Standards and Pain Management Guidelines. Palliative care education is included in the undergraduate and postgraduate curriculum in all medical universities. Six hospice units in Ulaanbaatar have 50 beds; each of the nine districts and all 21 provinces have up to four to five palliative beds, and there are 36 palliative care units, for a total 190 beds for three million people. In 2014, a pediatric palliative care inpatient unit was established with five beds. Essential drugs for palliative care have been available in Mongolia since 2015. The pharmaceutical company IVCO produces morphine, codeine, pethidine, and oxycodone in Ulaanbaatar. ConclusionMongolia has made real progress in integrating palliative care into the health system.

A New Approach to the Investigation of Sudden Unexpected Death.

* Abbreviations: OCME — : Office of the Chief Medical Examiner SIDS — : sudden infant death syndrome SUDP — : sudden unexplained death in pediatrics Sudden unexplained death in pediatrics (SUDP) is an inclusive term for sudden deaths in children that remain unexplained by standard autopsy and death scene investigation, including sudden infant death syndrome (SIDS), sudden unexpected infant death, sudden unexplained death in childhood, and undetermined deaths. Mortality from SUDP is significant and exceeds that from either cardiac disease or cancer in children <19 years of age.1 Its diagnostic considerations overlap with sudden unexpected death in epilepsy and unexplained sudden cardiac death in youth, also occurring predominantly during sleep, although salient findings in such cases include a history of epilepsy or notable cardiac results. Among children ultimately diagnosed with SUDP, those dying unexpectedly who are <3 years of age are the least likely to have explanations found with the current standard approach to investigation.2 Pediatricians have focused largely on preventive measures in the child’s sleep environment and the detection of child abuse in SUDP. Achievements in research and new approaches in medical care have created possibilities for understanding unapparent biological vulnerabilities in a small child that may become lethal. Research continues to find evidence for a biological basis in SUDP,3 including abnormalities in the hippocampus seen both across the age ranges of SUDP4 and epilepsy. The epidemiology of SIDS is predicted by general trends in infant mortality that are themselves attributed to biological risk reduction and medical care.5 Undiagnosed diseases programs, where living patients undergo extensive clinical evaluation to … Address correspondence to Richard D. Goldstein, MD, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Ave, D2008, Boston, MA 02115. E-mail: richard.goldstein{at}childrens.harvard.edu