Palliative Care Group Research Articles

Hydration management at the end of life.

The management of parenteral hydration at the end of life remains controversial. The debate centers on whether and/or how often patients should be hydrated, the volume of hydration received, and the benefit verses side effects of parenteral hydration. In order to clarify the routine practice of physicians involved in the end-of-life care in Edmonton, Alberta, Canada, we investigated the routine management of hydration by attending physicians caring for patients dying in a palliative care unit (PCU) at Norwood Capital Care, and in acute care wards at the Royal Alexandra Hospital (RAH) both while receiving and while not receiving consult advice from the Palliative Care Program. We conducted a retrospective chart review of 50 consecutive patients who died in each of the 3 sites included in the study. Data from the last 7 days prior to and including the date of death (day 0) was recorded. The majority of patients at all sites received hydration. The volume of hydration ordered in the Norwood PCU site was significantly different compared to both RAH groups on all days studied (p < 0.005). The RAH palliative care group showed a trend for lower hydration volumes compared to the RAH acute care group with significant differences on days 1 and 2 (p < 0.05). Throughout the week, for all of the hydrated patients in the Norwood PCU site, hypodermoclysis (HDC) was ordered; for nearly all of the hydrated patients in the RAH acute care group, intravenous (IV) hydration was ordered; and for approximately one third of the hydrated RAH palliative care consult group HDC was ordered, and for the remainder IV hydration was ordered. The RAH acute care group represented the largest percentage of hydrated patients receiving diuretics while the Norwood hospice site represented the lowest. The data raise the possibility that more patients in the RAH acute care group were overhydrated and may have developed symptoms such as edema, ascites, and respiratory distress. This study suggests that hydration at the end of life is managed differently in different settings of care and highlights areas for education to improve management.

Integrating Case Management and Palliative Care

Most seriously ill Americans live at home under the care of their primary physician and with the support of family caregivers. To reduce costs while simultaneously improving the quality of patient care, insurers have increasingly turned to the concept of case management. While case management is targeted to individuals with life-threatening illnesses, palliative care assessment and interventions are typically not included in the management protocols. An academic/care management/health plan partnership between Mount Sinai School of Medicine, Franklin Health, a care management organization, and South Carolina Blue Cross Blue Shield, was formed in 1998 to test the utility of integration of case management with formal palliative care assessment, feedback and recommendations to treating physicians, and ongoing support for implementation of a palliative care plan. The goal of the project was to ensure identification and optimal care of seriously ill patients' complex needs, while facilitating doctor-patient continuity, improving patient/family/physician communication, providing assistance with decision-making, ensuring quality care at home, and promoting efficient use of health care resources. Care management nurses were randomly assigned to a control (usual care) group or to the intervention (palliative care) group. Intervention nurses were trained in formal palliative care assessment and interventions, supported by treatment protocols and communication strategies with treating physicians. Measurements included symptom burden, prescribing practices, advance care planning status, satisfaction, and health care utilization. These results are pending completion of study run-out and analysis. Preliminary programmatic results indicate that combining palliative care with the case management approach is a logical, feasible, and effective strategy to improve the care of seriously ill patients living in the community. Franklin Health has offered the program to their entire client base because they feel that the integration of palliative care into their case management program improved the standard of patient care. Blue Cross Blue Shield of South Carolina has also chosen to sustain this enhanced model of care management for seriously ill patients.

Methadone for cancer pain.

Methadone is an opioid used in the management of cancer pain both in opioid naïve patients and in rotation from other opioids. A particular role in neuropathic pain has been suggested. The quest for evidence based palliative care prompted a formal appraisal of methadone in comparison with other analgesics. To determine the effectiveness and safety of methadone analgesia in cancer pain patients. MEDLINE (1966 to August 2002), EMBASE (1980 to August 2002), CancerLit (1993 to August 2002), CINAHL (1982 to August 2002) and Cochrane databases were searched using a strategy developed with the Cochrane Pain, Palliative and Supportive Care Group. Assiduous efforts were made to identify unpublished or current trial work. Randomised controlled trials of methadone against active or placebo comparator in patients with cancer pain were included. Outcome measures sought were reduction in pain intensity measured by an appropriate scale, adverse effects, attrition, patient satisfaction and quality of life. There were no language restrictions. Absence of patient reported data was an exclusion criterion. Eligible studies were selected with independent collaboration from a colleague in Bristol (AND). Full text was retrieved if any uncertainty about eligibility remained. Non-English texts were screened by Cochrane contacts aware of the eligibility criteria. Quality assessment and data extraction were conducted using standardised data forms. Drug and placebo dose, titration, route and formulation were compared and detail of all outcome measures (if available) recorded. Eight randomised controlled trials (five double blinded, two crossover) with 356 recruits and 326 completing patients were included. All involved active placebo (five morphine, one dextromoramide or pethidine, one diamorphine with cocaine mixture). All employed different starting doses, titration regimens and pain scoring scales. Few presented complete pain data sets and no meta-analysis has been possible. No differentiation by cancer pain syndrome was made. Complete adverse events data were recorded in every study, and were similar in incidence and severity to those experienced with morphine. There is evidence to suggest that methadone is an analgesic with similar efficacy to morphine and a comparable side effect profile. However, the majority of studies involved single dose comparisons or short term use. This methodology fails to reproduce clinical practice. Therefore there is a very significant danger that the effects of methadone accumulation leading to delayed onset of adverse effects which occurs with chronic administration has not been represented. Fixed interval dosing schedules conducted over several days are associated with a high risk of serious morbidity and mortality. There is no trial evidence to support the proposal that methadone has a particular role in neuropathic pain of malignant origin. Conclusions have been limited by the variations in trial design, dosing regimens and limited presentation of primary outcome data. The complex and highly individual pharmacokinetics of methadone require that experienced clinicians take responsibility for initiating, titrating and monitoring this drug.

Single dose oral paracetamol (acetaminophen) for postoperative pain.

Paracetamol (acetaminophen) and non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for the relief of mild and moderate pain arising from headache, musculoskeletal conditions and dysmenorrhoea. A prior Cochrane systematic review concluded that paracetamol is also effective for postoperative pain, but additional trials have since been published. This review sought to evaluate the efficacy and safety of paracetamol using current data, and to compare the findings with other analgesics evaluated in the same way. To assess the efficacy of single dose oral paracetamol for the treatment of acute postoperative pain. We searched the Cochrane Library (Issue 3, 2002), the trials register of the Cochrane Pain, Palliative and Supportive Care group (November 2002); MEDLINE (1966 to May 1996); PubMed (1996 to August 2001); EMBASE (1980 to 1996); the Oxford Pain Relief Database (1950 to 1994); and reference lists of articles in order to update an existing version of the review. Randomised, double-blind, placebo-controlled clinical trials of paracetamol for acute postoperative pain in adults. Two reviewers independently assessed trial quality and extracted data. The area under the 'pain relief versus time' curve was used to derive the proportion of patients with paracetamol or placebo experiencing least 50% pain relief over four to six hours using validated equations. The number-needed-to-treat (NNT) was calculated using 95% confidence intervals. Information on adverse effects was also collected. Forty-seven reports that enrolled 4186 patients (2561 patients were treated with a single oral dose of paracetamol and 1625 with placebo) met the inclusion criteria and were included in the analyses. The NNTs for at least 50% pain relief over four to six hours following a single dose of paracetamol were as follows: 325 mg NNT 3.8 (2.2 to 13.3); 500 mg NNT 3.5 (2.7 to 4.8); 600/650 mg NNT 4.6 (3.9 to 5.5); 975/1000 mg NNT 3.8 (3.4 to 4.4); and 1500 mg NNT 3.7 (2.3 to 9.5). Sub-group analysis showed no significant differences between smaller and larger trials, or lower and higher quality trials. Drug-related study withdrawals were rarely reported. Studies reported a variable incidence of adverse effects that were generally mild and transient. There were no statistically significant differences in the frequency of reported adverse effects between paracetamol 975/1000 mg and placebo. Single doses of paracetamol are effective analgesics for acute postoperative pain and give rise to few adverse effects.

Feverfew for preventing migraine.

Feverfew (Tanacetum parthenium L.) extract is a herbal remedy used for preventing attacks of migraine. To systematically review the evidence from double-blind randomised controlled trials (RCTs) assessing the clinical efficacy and safety of feverfew versus placebo for preventing migraine. Publications describing (or which might describe) double-blind RCTs of feverfew extract for migraine were sought through the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2003); PREMEDLINE/MEDLINE (1966 to July 2003); EMBASE (1974 to July 2003); the trials register of the Cochrane Pain, Palliative and Supportive care group (July 2003); and AMED (1985 to July 2003). Manufacturers of feverfew were contacted and the bibliographies of identified articles checked for further trials. Randomised, placebo-controlled, double-blind trials assessing the efficacy of feverfew for preventing migraine were included. Trials using clinical outcome measures were included. Trials focusing exclusively on physiological parameters were excluded. There were no restrictions regarding the language of publication. Data on patients, interventions, methods, outcome measures, results and adverse events were extracted systematically. Methodological quality was evaluated using the scoring system developed by Jadad and colleagues. Two reviewers independently selected studies, assessed methodological quality and extracted data. Disagreements concerning evaluation of individual trials were resolved through discussion. Five trials (343 patients) met the inclusion criteria. Results from these trials were mixed and did not convincingly establish that feverfew is efficacious for preventing migraine. Only mild and transient adverse events were reported in the included trials. There is insufficient evidence from randomised, double-blind trials to suggest an effect of feverfew over and above placebo for preventing migraine. It appears from the data reviewed that feverfew presents no major safety problems.

The last forty-eight hours of life in a Portuguese palliative care unit: does it differ from elsewhere?

The last few days of life have received significant attention in the literature. Reports have shown similarities and differences between programs. As a palliative care service in a cultural context that has not been reported on, we thought that an audit of our own experience in the care of patients in the last 48 hours of life and a comparison with other programs would be important. A prospective audit was designed to record data for four general domains: general demographic information, symptom prevalence, patient performance status, and perceived level of comfort. The inclusion criteria of patients were: older than 15 years of age (an admission criterion for patients of the unit), diagnosis of cancer, no active cancer-direct treatments, and patients who were on the unit for longer than 48 hours. The audit was completed when the 300th eligible patient died in the unit. Twenty-nine of 300 patients (9.6%) required sedation and the most common cause was delirium. Morphine was the most widely prescribed medication (85% of patients). The subcutaneous route was utilized extensively. Only 12% of the patients received parenteral fluids, usually via hypodermoclisis. Death was considered by staff to have been peaceful in 86% of cases. Our practice appears to mirror that of other palliative care groups.

The Cochrane Pain, Palliative and Supportive Care Group: life history of a Cochrane review.

The Cochrane Pain, Palliative and Supportive Care Group: life history of a Cochrane review.

Oral morphine for cancer pain.

Morphine has been used to relieve pain for many years. Oral morphine in either immediate release or sustained release form remains the analgesic of choice for moderate or severe cancer pain. To determine the efficacy of oral morphine in relieving cancer pain. To assess the incidence and severity of adverse effects. The following databases were searched: The Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Library, Issue 4, 2002; the trials register of the Cochrane Pain, Palliative and Supportive Care group (February 2002); MEDLINE 1966 to December 2002; EMBASE 1988 to December 2002; and the Oxford Pain Relief database 1950 to 1994. Published randomised controlled trials (full reports) reporting on the analgesic effect of oral morphine in adults and children with cancer pain. Any comparator trials were considered. Trials with fewer than 10 subjects were excluded. One reviewer extracted data, and the findings were checked by two other reviewers. There were insufficient comparable data for meta-analysis to be undertaken, or to produce numbers-needed-to-treat (NNT) for the analgesic effect. Forty five studies (3061 subjects) met the inclusion criteria. Fourteen studies compared oral sustained release morphine (MSR) preparations with immediate release morphine (MIR). Eight studies compared MSR and MSR in different strengths. Nine studies compared MSR with other opioids. Five studies compared MIR with other opioids. Two studies compared oral MSR with rectal MSR. One study was found comparing each of the following: MSR tablet with MSR suspension; MSR with MSR at different dose frequencies; MSR with non-opioids; MIR with non-opioids; oral morphine with epidural morphine; and MIR with MIR by a different route of administration. Morphine was shown to be an effective analgesic. Pain relief did not differ between MSR and MIR. Sustained release versions of morphine were effective for 12 or 24 hour dosing depending on the formulation. Adverse effects were common but only 4% of patients discontinued treatment because of intolerable adverse effects. The randomised trial literature for morphine is small given the importance of this medicine. Most trials recruited fewer than 100 participants, and did not provide appropriate data for meta-analysis. Trial design was frequently based on titration of morphine or comparator to achieve adequate analgesia, then crossing subjects over in crossover design studies. It is not clear if these trials are sufficiently powered to detect any clinical differences between formulations or comparator drugs.

Calcitonin for metastatic bone pain.

Pain is the most frequent symptom experienced by cancer patients, its intensity dependent on the site of the tumour. Tumours that compromise bone or nervous structures due to the bone destruction process are the most painful. There are several treatments to deal with pain (and other symptoms) caused by bone metastasis. The hormone, calcitonin, has the potential to relieve pain, and also retain bone density, thus reducing the risk of fractures. To assess the effectiveness of calcitonin in controlling metastatic bone pain and reducing bone complications (hypercalcemia, fractures and nervous compression) in patients with bone metastases. Electronic searches were performed in MEDLINE (1966-2001), EMBASE (1974-2001), the Cochrane Central Register of Controlled Trials (Issue 2, 2001), specialised registers of the Cochrane Cancer Network and of the Cochrane Pain, Palliative and Supportive Care Group. Registers of clinical trials in progress were also searched. Studies were included if they were randomised, double-blind clinical trials of patients with metastatic bone pain, treated with calcitonin, where the major outcome measure was pain, assessed at four weeks or longer. Study selection and data extraction were performed by two independent reviewers. Only two studies (90 patients) were eligible for inclusion in the review and therefore meta-analysis of the data was not possible. Intention-to-treat analysis was performed by imputing all missing values as adverse outcomes. Of the two small studies included in the review, one study showed a non-significant effect of calcitonin in the number of patients with total pain reduction (RR 2.50; CI 95%, 0.55 to 11.41). The second study provided no evidence that calcitonin reduced analgesia consumption (RR 1.05; CI 95%, 0.90 to 1.21) in patients with painful bone metastases. There was no evidence that calcitonin was effective in controlling complications due to bone metastases; for improving quality of life; or patients' survival. Although not statistically significant, a greater number of adverse effects were observed in the groups given calcitonin in the two included studies (RR 3.35, CI 95%, 0.72 to 15.66). The limited evidence currently available for systematic review does not support the use of calcitonin to control pain from bone metastases. Until new studies provide additional information on this treatment, other therapeutic approaches should be considered.

Use of ISDN video-phones for clients receiving palliative and antenatal home care.

We examined the use of ISDN video-phones by health professionals and two types of home care clients: those receiving palliative care and those receiving antenatal care. In the palliative care group, there were four female clients and 15 health professionals; these clients on average had the video-phones at home for six weeks and made 12.5 calls per week. The antenatal care group consisted of six female clients and eight female registered nurses; these clients on average also had the video-phones at home for six weeks and made 12.5 calls per week. Exit interviews were conducted with three clients and eight staff in the palliative care group, and with six clients and three staff in the antenatal care group. Palliative care clients and their families commented that the visual feature of the phone enhanced the care that they received. In the antenatal group, the video-phone was used mainly for booking appointments and arranging home visits. In general, the technology was well received by clients and care providers.

The Cochrane Pain, Palliative and Supportive Care Group: scope and challenges.

The Cochrane Pain, Palliative and Supportive Care Group: scope and challenges.

Topical agents or dressings for pain in venous leg ulcers.

Venous leg ulcers affect up to 1 per cent of people at some time in their life. These ulcers are often painful and some clinicians choose dressings and topical treatments (analgesia/ local anaesthetic) to reduce the pain both during and between dressing changes. To assess the effectiveness of dressings, local anaesthetics or topical analgesia for pain relief in venous leg ulceration. Cochrane Wounds Group Register and the Cochrane Collaboration Field in Complementary Medicine were searched in June 2002. Cochrane Pain Palliative and Supportive Care Group and Cochrane Wounds Group strategy were combined and used. All randomised controlled trials which evaluated local interventions used to relieve venous leg ulcer pain were considered. Pain was defined as either persistent pain or pain at dressing changes or debridement. Eligibility for inclusion was confirmed by two reviewers who independently assessed the potential trials. Details of eligible studies were summarised using a data extraction sheet which was checked by the second reviewer. No trials evaluating interventions for persistent pain were identified for the initial review in 1999 nor the update in 2002. Three trials were included in the 1999 review comparing a eutectic mixture of local anaesthetic (EMLA) versus placebo for pain at debridement. In 2002 a further 3 trials were available (6 trials in total with 317 patients). The studies were considered sufficiently similar to pool and meta analysis found a statistically significant reduction in debridement pain scores with EMLA 5% cream. EMLA was associated with a reduction in pain scores (measured on a 100 mm scale) of 20.6 mm (95% Confidence Interval 29.11-12.19). One small trial measured healing as an outcome and found no difference in numbers of ulcers healed at the end of the study. EMLA provides effective pain relief for venous leg ulcer debridement however, the effect of the product on ulcer healing is unknown. Research is required to determine the impact of debridement and of EMLA on ulcer healing. There were no trials addressing the treatment of persistent pain (between and at dressing changes) and further research is warranted.

Communicating with Dying Patients and their Relatives

Jean Lugton is a nurse with long experience of research and training in palliative care. As such she has excellent understanding of the stresses and pressures that professionals feel when faced with dying patients and their relatives. It is appropriate therefore that, after a brief chapter defining terminal illness, she talks about the needs of staff caring for terminally ill people. Not many authors would have the courage to focus on our personal needs as professionals before addressing the practicalities of communication. The need to reflect on our personal concerns, approaches and abilities is brought out further by the questions and exercises at the end of each chapter. These are often of the nature of ‘How can this be achieved in your clinical area?’. In the final chapter Lugton brings out the fact that patients may need different levels of communication and support and relates this to different levels of competence in palliative nursing, with further encouragement to reflect on personal capabilities. This personal approach throughout implies a concern for the nurses for whom she is writing and a desire to encourage readers to provide their best in their own individual situation in the difficult area of palliative care. This is not a book of high-blown theory or of distant guidelines. Lugton provides a practical book made up of different insights and illustrated by many examples from the real world as she takes us through the breaking of bad news, assessment of needs, planning of support and preparation of relatives for bereavement. All of us who have worked in this sphere will have benefited as much from the support of a peer (of whatever profession) as from knowing what we should do. The approach of this little book should encourage us to be more active in providing this support to each other. Here are questions that we should be looking at together as healthcare teams, especially when we lack the full support of a palliative care group or a hospice. That is how the book came over to me, but at the same time I was often worried by the structure. The foreword tells us that research and theory have been woven together but the link between theory and practical advice is sometimes hard to find. Chapter headings do not always relate well to content. In the chapter on ‘Breaking Bad News’ the first three-quarters is given over to considering reactions and support after the news has been given rather than the actual process. Whilst the breaking of bad news is normally a medical responsibility, there is little input on how the different members of the team (including the nurses) might be involved: nurses often have to pick up the pieces after a bad experience, but this is addressed only by advice that ‘if one member of staff is continually untactful when breaking bad news to patients, it is a clinical governance issue.’ The area of spiritual care is limited to four pages; although this is seen as a communication problem, no real guidance is offered on how to open up the issue and see if help is needed. At times one feels that the author's desire to mention principles and theory is battling against the desire to make the book practical and helpful to the reader. Although this book is intended for nurses, it would help all professions in the team to support one another. It offers many helpful insights—but look elsewhere for a clear exploration of the underlying theory.

Bisphosphonates for the relief of pain secondary to bone metastases.

Bisphosphonates form part of standard therapy for hypercalcemia and the prevention of skeletal events in some cancers. However, the role of bisphosphonates in pain relief for bony metastases remains uncertain. To determine the effectiveness of bisphosphonates for the relief of pain from bone metastases. MEDLINE (1966-1999), EMBASE (1980-1999), CancerLit (1966-1999), the Cochrane library (Issue 1, 2000) and the Oxford Pain Database were searched using the strategy devised by the Cochrane Pain, Palliative and Supportive Care Group with additional terms 'diphosphonate', 'bisphosphonate', 'multiple myeloma' and 'bone neoplasms'. (Last search: January 2000). Randomized trials of bisphosphonates compared with open, blinded, or different doses/types of bisphosphonates in cancer patients were included where pain and/or analgesic consumption were outcome measures. Studies where pain was reported only by observers were excluded. Article eligibility, quality assessment and data extraction were undertaken by both reviewers. The proportions of patients with pain relief at 4, 8 and 12 weeks were assessed. The proportion of patients with analgesic reduction, the mean pain score, mean analgesic consumption, adverse drug reactions, and quality of life data were compared as secondary outcomes. Thirty randomized controlled studies (21 blinded, four open and five active control) with a total of 3682 subjects were included. For each outcome, there were few studies with available data. For the proportion of patients with pain relief (eight studies) pooled data showed benefits for the treatment group, with an NNT at 4 weeks of 11[95% CI 6-36] and at 12 weeks of 7 [95% CI 5-12]. In terms of adverse drug reactions, the NNH was 16 [95% CI 12-27] for discontinuation of therapy. Nausea and vomiting were reported in 24 studies with a non-significant trend for greater risk in the treatment group. One study showed a small improvement in quality of life for the treatment group at 4 weeks. The small number of studies in each subgroup with relevant data limited our ability to explore the most effective bisphosphonates and their relative effectiveness for different primary neoplasms. There is evidence to support the effectiveness of bisphosphonates in providing some pain relief for bone metastases. There is insufficient evidence to recommend bisphosphonates for immediate effect; as first line therapy; to define the most effective bisphosphonates or their relative effectiveness for different primary neoplasms. Bisphosphonates should be considered where analgesics and/or radiotherapy are inadequate for the management of painful bone metastases.

The Cochrane Collaboration Pain, Palliative Care and Supportive Care Collaborative Review Group

The Pain, Palliative and Supportive care group is one of 50 collaborative review groups that make up the Cochrane Collaboration, an international organization with the task of preparing, maintaining and disseminating systematic reviews of the effects of healthcare. Cochrane reviews are published cumulatively four times a year on the Cochrane library (CD-ROM and Web-based), along with other useful material such as a register of some 300,000 randomized controlled trials. The group has identified some 20,000 randomized trials in pain and 1,200 in palliative care. Reviews in progress are also published on the library as protocols. Full peer-review is undertaken for protocols and reviews. The Pain, Palliative and Supportive care group is an informal international team involving some 100 people from some 18 countries. The group has published 26 protocols and 17 full reviews with a further 50 reviews in progress. The task is huge and there is scope for further volunteers to help with the various tasks of writing reviews, peer reviewing and literature searching.

The Cochrane Collaboration Pain, Palliative Care and Supportive Care Collaborative Review Group

The Pain, Palliative and Supportive care group is one of 50 collaborative review groups that make up the Cochrane Collaboration, an international organization with the task of preparing, maintaining and disseminating systematic reviews of the effects of healthcare. Cochrane reviews are published cumulatively four times a year on the Cochrane library (CD-ROM and Web-based), along with other useful material such as a register of some 300,000 randomized controlled trials. The group has identified some 20,000 randomized trials in pain and 1,200 in palliative care. Reviews in progress are also published on the library as protocols. Full peer-review is undertaken for protocols and reviews. The Pain, Palliative and Supportive care group is an informal international team involving some 100 people from some 18 countries. The group has published 26 protocols and 17 full reviews with a further 50 reviews in progress. The task is huge and there is scope for further volunteers to help with the various tasks of writing reviews, peer reviewing and literature searching.

A Quebec Survey of Issues in Cancer Pain Management

We report the results of a cancer pain survey mailed to Quebec hematologist-oncologists and palliative care physicians in 1999. The survey was designed to sample views on the current status of pain management and on obstacles to the provision of adequate pain relief for patients. The survey, formulated by an ethics network centered at the Clinical Research Institute of Montreal, was distributed to all members of the Association of Hematologist-Oncologists of Quebec and to all physician members of the Quebec Palliative Care Association. Responses were obtained from 138 Palliative Care Association members (response rate 61%) and 76 hematologist-oncologists (response rate 45%). Major obstacles reported included inadequate assessment of both contributory psychosocial issues and severity of pain, patient reluctance to take opioids, and inadequate access to non-drug techniques for pain relief. Access to opioids was not regarded as a problem. Both groups felt generally competent in their ability to manage various aspects of cancer pain therapy. They gave little credit to their formal medical school or residency training. Fifty-six percent of the palliative care group and 57% of the hemato-oncologists rated their medical school experience as only “poor” or “fair” on a 4-point scale. Residency ratings were modestly better. We conclude that medical faculties should assign a high priority to teaching health professionals patient assessment techniques. Simple symptom assessment scales should be routinely used in oncology/palliative care practice. Medical school training in pain management is not highly regarded and should be enhanced. We also note that, based on response to the scenario of a patient presenting with severe pain, many physicians, while feeling competent in the use of opioids, may be overly conservative in their initial use.

Sedation for Delirium and Other Symptoms in Terminally Ill Patients in Edmonton

The use of sedation and the management of delirium and other difficult symptoms in terminally ill patients in Edmonton has been reported previously. The focus of this study was to assess the prevalence in the Edmonton region of difficult symptoms requiring sedation at the end of life. Data were collected for 50 consecutive patients at each of (a) the tertiary palliative care unit, (b) the consulting palliative care program at the Royal Alexandra Hospital (acute care), and (c) three hospice inpatient units in the city. Patients on the tertiary palliative care unit were significantly younger. Assessments confirmed the more problematic physical and psychosocial issues of patients in the tertiary palliative care unit. These patients had more difficult pain syndromes and required significantly higher doses of daily opioids. Approximately 80% of patients in all three settings developed delirium prior to death. Pharmacological management of this problem was needed by 40% in the acute care setting, and by 80% in the tertiary palliative care unit. The patients sedated varied from 4% in the hospice setting to 10% in the tertiary palliative care unit. Of the 150 patients, nine were sedated for delirium, one for dyspnea. The prevalence of delirium and other symptoms requiring sedation in our area is relatively low compared to others reported in the literature. Demographic variability between the three Edmonton settings highlights the need for caution in comparing results of different palliative care groups. It is possible that some variability in the use of sedation internationally is due to cultural differences. The infrequent deliberate use of sedation in Edmonton suggests that improved management has resulted in fewer distressing symptoms at the end of life. This is of benefit to patients and to family members who are with them during this time.

Launching a palliative care homepage: the Edmonton experience.

The Internet, with its graphical subdivision, the World Wide Web (WWW). has become a powerful tool for the dissemination of information and for communication. This paper discusses the authors' experiences with creating, launching and maintaining an official publication on the Internet by the Edmonton Regional Palliative Care Program and the Division of Palliative Medicine, University of Alberta, Canada. It describes the content and format of the homepage and the process of publication. Over a six-month period there were 892 visits to the site and 84 separate items of correspondence to the site's editors. Of these correspondence items, 36 were requesting further information regarding clinical and other programme information. Sixty-nine of the 84 communications came from North America and Europe. The pattern of readership is briefly discussed as are some of the potential advantages and challenges when utilizing this electronic medium. To promote the dissemination of reliable information on the Internet, the authors encourage other palliative care groups and organizations to publish on the WWW. The URL is http:/(/)www.palliative.org (previously http:/(/)www.caritas.ab.ca/approximately palliate).

When to treat dehydration in a terminally ill patient?

The need to treat dehydration in terminally ill patients has become a very controversial topic. Numerous reports in the literature illustrate opposing view-points from both clinical and ethical perspectives. Arguments for the maintenance of hydration in terminally ill patients have tended to come from "the traditional medical model". Many health care professionals looking after terminally ill patients have reacted to the generalized use of intravenous fluids in dying patients and the perceived negative effects of this management. Our palliative care group has argued that the viewpoint that dehydration in dying patients is not a cause of symptom distress overlooks commonly reported problems, such as agitated delirium, that can be prevented or reversed by the management of dehydration. This review presents a summary of the traditional arguments, a different perspective on the controversy, biochemical parameters reported in terminally ill cancer patients, recent dehydration research, and the use of hypodermoclysis and rectal hydration. We conclude that the data reported to date are insufficient to allow a final conclusion on the benefit or harm of dehydration in terminally ill patients. Nevertheless, it is worth considering that while some dying patients may not suffer any ill effects from dehydration, there may be others who do manifest symptoms, such as confusion or opioid toxicity, that might be alleviated or prevented by parenteral hydration.