You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

BMJ Supportive & Palliative Care is an international peer review journal for clinicians, researchers and other healthcare workers in all clinical services where supportive and palliative care is practised. The journal aims to link many disciplines and specialties throughout the world, promoting an exchange of research evidence and innovative practice by presenting high quality scientific reports, reviews, comment, information and news of international importance.

BMJ Supportive & Palliative Care is owned by BMJ Group and is an official journal of the Association for Palliative Medicine and the Australian and New Zealand Society of Palliative Medicine.

It’s good to talk and even better to communicate effectively

24 Aug, 16 | by BMJSPCblog

EAB2B298-BCFB-4937-967D-0C60CBDB51C5aby Dr Ollie Minton, Macmillan consultant and honorary senior lecturer in palliative medicine

I remember the old British Telecom adverts moving from Maureen Lipman’s “ooh he’s got an ology” to the final incarnation of Bob Hoskins “It’s good to talk”. I’m fairly certain after this, the internet took off and the simple phone call was confined to the snapchat bin of history.
Judging by current commentary, we are even supposed to move beyond emails – not likely until we move away from being fax dependent- but my point is there are so many methods to “communicate”.

However when we talk about delivering bad news, a rapidly changing condition or the uncertainty of a changing illness a quick text or tweet status update isn’t quite sufficient. We as specialists pride ourselves on the ability to address all of these problems and more. As someone is approaching the end of life, communication really needs to be face to face. This is not an innate skill and it requires training to be done effectively.
While others invariably use the excuse of insufficient time, I believe lack of confidence is a significant driver of avoidance, or at the very least minimisation to address these areas. Perhaps more importantly, patients and families value these conversations especially around uncertainty & decision making in advanced illness.  We as professionals need to be able to meet these needs.

In the halcyon days of core MDT funding every member was funded to undertake an “advanced communication skills course”. While I am not going to debate the merits of three vs two days, multiprofessional , residential and so forth, there was ample evidence to support the course leading to sustained behavioural change. Sadly because of the costs involved and the lack of hard outcomes these have been discontinued. In part perhaps because there was no direct correlation to improvement in patient experience, for example. However there is a database (unpublished) of post course confidence scores addressing a variety of complex communication scenarios. The headline summary was that 12,000 clinicians were trained. The longer term impact has not been studied. We are left not knowing if this is a critical mass of professionals has achieved consistent change.

A recognition of lost time has been made in a Marie Curie report entitled the long and winding road.
This draws in all aspects of communication, as I alluded to at the start, but recognises the missed opportunities and the continued need to meet the expectation of sensitive tailored communication and shared decision making. Equally as it is now 2016, the report authors mention the impact of “Dr Google” and the influence of technology. They label it a call to action but acknowledge the four year hiatus and lost momentum after funding for communication training was withdrawn in 2012.

If I thought that revised medical school curricula and a cultural shift had solved these problems, I would rest easy. While we can teach these skills in the same way as prescribing they can only be developed with experience and relying on absorption through role modelling is insufficient and not in line with the ample evidence base on communication training.

Training previously has focused on experiential learning but using cancer as the model. The now defunct national cancer action team has given way to Health Education England , the GMC and other organisations who are responsible for post graduate development.
The development of simulation in medical education gives ample opportunities for flexibility in developing these skills provided the core elements of experienced facilitation, actors and video feedback are used. These can be delivered in a set way to small groups and provide training in particular areas as needed.

Outside of our speciality I observe limitations in conversations about advance care planning , uncertainty, escalation of treatment & of course DNACPR. This is addition to the development of delivering bad news, discussing complex treatment plans tailored to the individual patient need and so forth. However I would not want to see this merely added to a portfolio of more areas to be assessed. There needs to be some fluidity in how this is done to meet individual clinicians’ learning needs.
This approach is in keeping with elements of the recent independent cancer task force , albeit recommendation 60- a long way behind personalised medicine and the digital revolution.

In conclusion I can’t stress the importance of every health care professional having impeccable communication skills. While we have no control over all the methods an organisation uses to disseminate information, we all want to avoid the immortal aphorism of Cool Hand Luke: “What we’ve got here is failure to communicate”

Shortcuts

22 Aug, 16 | by Jenny Thomas

Nephrol Dial Transplant. 2016

End-of-life care for people with chronic kidney disease: cause of death, place of death and hospital costs.

Kerr M, Matthews B, Medcalf JF, O’Donoghue D.

Associations between chronic kidney disease (CKD), place of death and hospital costs in adults with CKD in England in the final 3 years of life.

Using Hospital Episode Statistics data linked to Office for National Statistics mortality data, associations between place of death and hospital costs in adults with chronic kidney disease (CKD) in England was evaluated. From over 1.6 million adults, 13% had CKD. 11% of people with CKD died at home compared with 17% matched non-CKD group. CKD was associated with an increase in hospital costs of £3380 in the last year of life and a home death was associated with a reduction in hospital costs of £2811 in the CKD group in the last year of life. The most commonly recorded cause of death in people with CKD was heart disease and CKD was not on two-thirds of the death certificates.

Shortcuts are compiled by Jason Boland

News and updates from www.palliativedrugs.com

8 Aug, 16 | by Jenny Thomas

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website with over 30,000 members from 169 Countries.

Safety issues

Nasogastric tube misplacement: continuing risk of death and severe harm

A stage two (resource) patient safety alert (NHS/PSA/RE/2016/006) has been issued to help support implementation of the previous alerts on this issue (see our news item December 2013). This follows 95 incidents reported between September 2011 and March 2016, where fluids or medication were introduced into the respiratory tract or pleura, despite several patient safety alerts. A review highlighted problems with the organisational processes for implementing previous alerts. Thus this resource alert is directed at Trust boards (or equivalent) and the processes that support clinical governance. For more information, click here.

Citalopram suspected drug interaction with cocaine

MHRA has reminded prescribers to consider illicit drug use and the risk of drug interactions when prescribing. This follows a suspected fatal drug interaction between citalopram and cocaine. For more information, click here.

Thalidomide new risks

A letter has been sent to UK healthcare professionals about the risks of viral reactivation and pulmonary hypertension associated with thalidomide. For more information, click here.

Hot topics

NICE end of life care for infants, children and young people

NICE has published draft guidance for consultation on end of life care for infants, children and young people. The deadline for consultation responses is 12 August 2016. For more information, click here.

Cochrane review: oral morphine for cancer pain

The third updated version of this Cochrane review (CD003868) has been published. No new studies have been identified for inclusion in this update and the conclusions remain unchanged, i.e. oral morphine in either immediate-release or modified-release form remains the analgesic of choice for moderate or severe cancer pain. For more information, click here.

Cochrane review: hydromorphone for neuropathic pain

The previous Cochrane review on hydromorphone for acute and chronic pain has been updated and divided into more specific sub-sets. The authors have concluded that there is insufficient evidence to support or refute the suggestion that hydromorphone has any efficacy in any neuropathic pain condition (CD011604). For more information, click here.

Recognition of sepsis: NICE guideline published

NICE have published guidance (NG51) for the recognition, diagnosis and early management of sepsis in all areas. For more information, click here.

Choice in end of life care: government response

UK Department of Health has published a response to the independent review on choice in end of life care (February 2015). The government has made 6 commitments to the public to end variation in end of life care across the health system by 2020:

  • honest discussions between health professionals and dying people
  • dying people making informed choices about their care
  • personalised care plans for all
  • the discussion of personalised care plans with health professionals
  • the involvement of family and carers in dying people’s care
  • a main contact so dying people and their families know who to contact at any time.

For more information, click here.

CQC annual report: safer management of controlled drugs

The UK Care Quality Commission (CQC) has published their 2015 annual report on the safer management of controlled drugs. They make recommendations for controlled drugs accountable officers (CDAOs) and local authority public health and adult social care directors with regards to information collection and sharing in controlled drug local intelligence networks (CD LINs). For more information, click here.

Management of chronic pain in adult cancer survivors

The American society of clinical oncology has published guidelines on the management of chronic pain in survivors of adult cancer. For more information, click here.

RPS guide for pharmacists working in care homes

The UK Royal Pharmaceutical Society has developed guidance for pharmacists working in care homes. For more information, click here.

Drug updates

FDA authorizes dronabinol oral solution

A dronabinol oral solution (Syndros; Insys Therapeutics) has been authorized in the US for treating anorexia associated with weight loss in patients with AIDS, and nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional anti-emetic treatments. It is currently awaiting scheduling by the US Drug Enforcement Administration. For more information, click here.

Glycopyrronium oral solution authorized for severe drooling in the UK

European Medicines Agency has authorized a glycopyrronium 320microgram/mL oral solution (Sialanar; Proveca) for the treatment of severe drooling in children >3 years and adolescents, with neurological conditions. The Committee for medicinal products for human use had previously issued a negative opinion for wider use in patients with mild‒moderate drooling, however following re-application, authorization has been granted for severe drooling. For more information, click here.

Latest additions

PCF updated monographs summary (July 2016)

The on-line Palliative Care Formulary is being continually updated. The following monographs have been updated during July and supersede those in the print publication of the 5th edition of the Palliative Care Formulary (PCF5) and PCF5+ 2015 PDF. They can be accessed from the formulary section of the website.

Chapter 01: PPI (minor change)

For a full list of all the monographs updated since the print publication of PCF5, click here. Follow us on twitter @palliativedrugs for the latest updates.

Prepared by Sarah Charlesworth and Andrew Wilcock

Shortcuts

8 Aug, 16 | by Jenny Thomas

Support Care Cancer. 2016

Patient and health care provider perceptions of cancer-related fatigue and pain.

Williams LA, Bohac C, Hunter S, Cella D.

Surveys were used to determine the impact of fatigue and pain and compare perceptions of patients with cancer and oncologists/oncology nurses. From a random sample of adult patients from the general US population with a non-hematologic tumour treated with >2 months of systemic anticancer therapy, 550 of 1122 (49%) completed a survey. This was along with 400 of 533 oncologists (75%), and 400 of 617 oncology nurses (65%), who had to spend >75% of their work time in patient care and >50% providing direct care for adult patients with solid tumours receiving chemotherapy. 98% of patients reported fatigue; 72% of oncologists and 84% of oncology nurses thought this was the case.

From the patients, 58% reported that fatigue affected them more than pain during chemotherapy compared with 29% of oncologists and 25% of oncology nurses. 86% of patients reported pain while undergoing chemotherapy; 36% of oncologists and 51% of oncology nurses thought this. Oncologists/oncology nurses underestimated fatigue and pain for patients with cancer during chemotherapy, showing the importance of assessing symptoms by direct patient reporting.

Shortcuts are compiled by Jason Boland

Knowledge translation & impact at the end of life

4 Aug, 16 | by BMJSPCblog

EAB2B298-BCFB-4937-967D-0C60CBDB51C5aby Dr Ollie Minton, Macmillan consultant and honorary senior lecturer in palliative medicine

2004 was a long time ago (not quite in a galaxy far, far away), but sufficient time has passed for the highly lauded NICE supportive and palliative care guidance to have been enacted. ( https://www.nice.org.uk/guidance/csg4 )

The clearly stated aim was 7 day services – forgive me if you’ve heard that one before- yet the recent Royal College end of life care audit showed this was achieved in only one third of hospitals. So by my reckoning it’s been 12 years to achieve what was mandated with limited success.

 

I use this as an example of the lack of perceived progress to move the health infrastructure forward. We provide care in a variety of settings and hospitals are only one aspect of that. Again the same themes emerged from the James Lind Alliance priority settings  . No one was focused on complex symptom management or which interventional pain methodology was best. On the contrary everything in the top 10 (and significantly beyond) was focused on health service delivery, continuity and communication across care settings.

One of the frustrations of these efforts is how this is “translated” to provide impact on the ground. We are very able now to identify unmet need, where palliative care is likely to be beneficial and evidence to support our involvement both with economic  and, yes, even possible survival benefit . I have quoted these studies and evaluations at every local CCG or network meeting.

 

I wonder if it is our own introspection that defeats us or over complicating the methods of assessments without an explicit link to finances. If there is no incentive to translate this knowledge into practice this is perhaps one reason that exemplars of best practice are not more widely adopted or replicated. Equally we should not adopt a new initiative without the supported evidence base and an implicit tension arises. Are we as a speciality less likely to adopt new practice, do we aspire to a higher standard on the evidence hierarchy or is the knowledge not being disseminated? It is likely as in all areas of medicine to be a mixture and accepting the time required to alter practice.

I was really enthused by the discussion at the recent Hospice UK attempts to revitalise research in hospices. Naturally there was reference to the origins of an evidence based approach by Dame Cicely with recognition that this was broader than doing more RCTs.

In the current parlance: asking the right questions & taking into account the local networks. The aim being to achieve maximum impact and relating evidence and data obtained to promote innovative & best practice. However there was an appreciation that supporting clinical research – including for example which is the best sub lingual fentanyl formulation and dose titration – is needed.

This is born out in the lack of consistent guidelines which on the face of it nationally reach broad consensus. However one recent example locally has been the treatment of hypercalcaemia – which drug, what dose, how often – and not a Cochrane review in sight. There are other examples we all will have but as a hospital specialist attempting to influence a clinical pharmacist without a meta-analysis- you can imagine your argument is neither strong nor compelling. Within the speciality you only need to attend a conference to see the fixed beliefs and biases we all have to appreciate how liberally guidelines are interpreted.

I make one plea to use the short cuts on the website and digested studies from the APM science committee – we’ve done the hard work so you don’t have to.

No one wants a minimum standard to be marked against but as the NHS constitution states it aspires to highest standards of excellence and professionalism through the   “conduct and use of research to improve the current and future health and care of the population”. If we cannot achieve this at the end of life wherever the setting is, we are not having the impact we are capable of doing at one of the most important times to do so.

Kate Granger

27 Jul, 16 | by BMJSPCblog

by Dr Mark Taubert, Consultant in Palliative Medicine, Velindre Cancer Centre, Cardiff

On  July 23, 2016, Dr. Kate Granger died at St Gemma’s Hospice.

Goodbye  Kate.

Some words. Where can we live, but days? A message you sent me in October 2013 read, “I have high expectations of myself & what I can achieve – I know these are set a little high but I do like a challenge!”

And what you have achieved. There are many wonderful tributes to you, and they are all filled with gratitude and admiration at what you have been able to change. We thought amongst the many posts, blogs and articles, this particular one from Ali Cracknell was notably poignant.

So, to remain brief but to the point: here at BMJ Supportive& Palliative Care, you will be remembered and we, too, are amongst the many who marvel at what you have created. Your presence in life and on social media, your sense of humour, coupled with that plain-speaking honesty and directness, were humbling. Extraordinary.

Images say more than a thousand words, so we have collated some of them here. Lastly, we think you may have liked this poem by Philip Larkin.

So long, Kate.

 

Days – Philip Larkin

What are days for?

Days are where we live.

They come, they wake us

Time and time over.

They are to be happy in:

Where can we live but days? Ah, solving that question

Brings the priest and the doctor

In their long coats

Running over the fields.

 

 maxresdefault

 

 Kate-Granger
UntitledJS37880592granger-campaign_2839469bCnmLgegWAAAYfcrCnGgWN1XgAAhPkk2374602002_90507708_kgtweet_80675198_kategranger-image1_80675196_kategranger

Shortcuts

25 Jul, 16 | by Jenny Thomas

Int J Geriatr Psychiatry. 2016 Mar 27. doi: 10.1002/gps.4463. [Epub ahead of print]

The management of behavioural and psychological symptoms of dementia in the acute general medical hospital: a longitudinal cohort study.

White N, Leurent B, Lord K, et al

A longitudinal cohort study of 230 patients with dementia admitted to two UK hospitals assessed behavioural and psychological symptoms and documentation of non-pharmacological and pharmacological management. 75% of patients with dementia had behavioural and psychological symptoms (especially aggression and activity disturbance). Non-pharmacological management was used in 55% of patients, 36% had psychosocial interventions with little evidence of effectiveness monitoring. Patients were prescribed antipsychotics (12%), benzodiazepines (12%), antidepressants (16%), or sedatives (3%). Patients prescribed antipsychotics were nearly 6 times more likely to die, compared to those who were not.

Shortcuts are compiled by Jason Boland

Shortcuts

11 Jul, 16 | by Jenny Thomas

Palliat Med. 2016 Mar 24. pii: 0269216316640421. [Epub ahead of print]

Perspectives of people with mild intellectual disabilities on care relationships at the end of life: A group interview study.

Bekkema N, de Veer AJ, Hertogh CM, Francke AL.

Seven group interviews including 33 people with mild intellectual disabilities in the Netherlands explored care relationships at the end-of-life. The main themes were a) dealing with wishes and b) ‘being there’. it was important for the wishes of the ill person to be ascertained (including preferences relating to personal care, end of life and funeral),that these are recorded and honoured; there was an emphasis on control and respecting autonomy. They need people who are there, practically (providing help and care if needed), emotionally (listening and providing empathy, especially from familiar people), socially (including social activities) and spiritually (providing existential guidance and support), with an emphasis on providing positive experiences. The authors conclude that there is added value and potential of involving people with intellectual disabilities in studies on end-of-life care.

Shortcuts are compiled by Jason Boland

News and updates from www.palliativedrugs.com

5 Jul, 16 | by Jenny Thomas

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website with over 30,000 members from 169 Countries.

Safety issues

Topical miconazole interaction with warfarin

MHRA has highlighted the risk of serious bleeding events in patients taking warfarin and using cream, ointment, powder or oral gel formulations of miconazole. The potential for a drug interaction between oral miconazole and warfarin is well documented due to miconazole inhibiting the CYP2C9 enzyme involved in the metabolism of warfarin. The MHRA are now receiving a large number of reports of potential drug interactions involving topical miconazole (particularly the oral gel formulation) and warfarin, and are now reviewing whether further measures are needed to minimise the risks to patients. In the meantime, their advice is to carefully monitor the anticoagulant effect and reduce the dose of warfarin if necessary. As some topical formulations of miconazole are available without prescription, patients taking warfarin should be warned not to use topical miconazole without consulting their doctor. For more information, click here.

Hot topics

RPS guidance for the prescribers of Specials

The Royal Pharmaceutical Society (RPS), has published guidance for the prescribers of specials. The document can be downloaded from the RPS website, or from here. This document was produced at the request of NICE and following consultation in 2015 (see our news item 10 November 2015). It complements the RPS professional guidance for the procurement and supply of specials which was published in December 2015.

Neuropathic pain: pregabalin and gabapentin prescribing

The latest PrescQIPP bulletin discusses dose optimisation of pregabalin and cost effectiveness in line with authorized indications and guidance from NHS England and NICE. For more information, click here.

 e-learning Indian palliative care course

eCancer has launched a text only version of the palliative care e-learning course for health professionals in India. For more information, click here.

Drug updates

Epistatus 10mg/mL oromucosal solution batch recall

MHRA has issued a class 2 medicines recall for a specified batch of Epistatus (midazolam) 10mg/mL oromucosal solution (unauthorized buccal liquid; Special products). The incorrect size of neck adaptor has been fitted and they are not compatible with oral syringes (Batch: 73234 Expiry: Oct 2017 Size: 1 x 5ml First issued: 24 Feb 2016). For more information, click here.

NICE evidence summary for fentanyl transdermal patient controlled system

NICE has published an evidence summary for the new fentanyl transdermal system (IONSYS) that was launched earlier this year in the UK (see our news item 28 March 2016). It is authorized for the treatment of moderate−severe post-operative pain in adults (hospital use only).

NICE conclude that the fentanyl transdermal system has comparable efficacy to IV morphine patient-controlled analgesia (PCA). Its undesirable effect profile is as expected for an opioid used in post‑operative pain, and is similar to that of IV morphine PCA. They report a better patient satisfaction than IV morphine PCA but a higher drug cost. For more information, click here.

New naproxen suspension available in UK

A new authorized naproxen oral suspension 125mg/5mL (Orion Pharma) is now available. The NHS indicative cost is £110 for 100mL. This is significantly more expensive than the tablets or the effervescent tablets and the previously unauthorized special order product. The effervescent tablets are now accepted by the Scottish Medicines Consortium (SMC) for use in NHS Scotland for patients with swallowing difficulties. For more information, click here.

Naproxen (generic)

Tablets 250mg, 500mg, 28 days @ 500mg b.d. = £2.75.

Tablets e/c 250mg, 375mg, 500mg, 28 days @ 500mg b.d. = £9.

Oral solution 125mg/5mL, 28 days @ 500mg b.d. = £1,232.

Stirlescent® (Stirling)

Tablets effervescent 250mg, 28 days @ 500mg b.d. = £44.

With esomeprazole

Tablets m/r naproxen 500mg e/c + esomeprazole 20mg, 28 days @ 1 tablet b.d. = £15. Note this product is cheaper than prescribing both drugs separately.

Latest additions

Levomepromazine for anti-emesis – How do you use it?

Results from our survey (April– May 2016).

 Introducing Palliative Care 5th edition (IPC5) now available.

We are pleased to announce that IPC5 is now available to purchase from our store for £25 (including p&p in the UK).

IPC5 has moved from a single authorship to a collaborative project between palliativedrugs.com editorial team and eight new contributors. Updates include:

  • covering the Association for Palliative Medicine of Great Britain and Ireland recommended curriculum for medical undergraduates
  • expanded sections on ethics, law, children, symptom management
  • the Essential Palliative Care Formulary, and a synoptic table of drug doses for common symptoms.

IPC5 has already received the following high praise:

We all need one book that we know, thumb often, trust and refer to. This palliative care book fills all these roles for staff at every grade. End of life care is everyone’s business; if used to the full, this book can and will improve patient care in all settings.’ Professor Ilora Baroness Finlay of Llandaff

This new collaborative edition is the best of the best. Its clear, concise, balance of theory and application is admirable and is replete with practical wisdom. This is required reading for anyone serious about caring for the dying well, for it is long enough to be useful and short enough to be digestible.’ Professor Rob George, President of the Association for Palliative Medicine

The holistic and multimodal approach of this book, which builds on the total pain model of Dame Cicely Saunders, is particularly to be commended.’ Professor Irene Higginson, Director of the Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London

This book is not just a symptom control handbook, it covers all aspects of holistic care in an easy to read and navigable format. It will become an old friend – get to know it!Dr Fiona Rawlinson, Programme Director, Palliative Care Education, Cardiff University.

To purchase a licensed copy, and help support palliativedrugs.com, please go to our store. For enquiries regarding multiple copies please contact hq@palliativedrugs.com

PCF updated monographs summary (May/June 2016)

The on-line Palliative Care Formulary is being continually updated. The following monographs have been updated during May/June and supersede those in the print publication of the 5th edition of the Palliative Care Formulary (PCF5) and PCF5+ 2015 PDF. They can be accessed from the formulary section of the website.

Chapter 02: Furosemide

Chapter 05: Opioid antagonists (minor change)

Chapter 24: Prolongation of the QT interval in palliative care (minor change)

For a full list of all the monographs updated since the print publication of PCF5, click here. Follow us on twitter @palliativedrugs for the latest updates.

 

Prepared by Sarah Charlesworth and Andrew Wilcock

Shortcuts

27 Jun, 16 | by Jenny Thomas

PLoS One. 2016 Mar 24;11(3):e0151435. doi: 10.1371/journal.pone.0151435. eCollection 2016.

Patient Perspectives of Dignity, Autonomy and Control at the End of Life: Systematic Review and Meta-Ethnography.

Rodríguez-Prat A, Monforte-Royo C, Porta-Sales J et al

In a systematic review and meta-ethnography to explore the relationship between perceived dignity, autonomy and sense of control in patients at the end of life, 21 studies (400 participants) were included. There were three broad themes: a) dignity mediated by the loss of functionality, linked to the loss of control and of the value ascribed to one’s life; b) dignity as identity, which related to self-identity and the impact of social factors; and c) autonomy as a determining factor of perceived dignity, was linked to the desire for self-determination and control over dying. The authors suggest that dignity and autonomy are interconnected, multidimensional and dynamic concepts, similar to personal identity. Patients with an intrinsic sense of dignity maintained a positive view of themselves despite their illness, thus it is central to care to address the areas of life on which a patient’s dignity is based.

Shortcuts are compiled by Jason Boland

BMJ Supportive & Palliative Care blog

BMJ Supportive
& Palliative Care

BMJ Group's first dedicated supportive and palliative care journal.
Visit site



Creative Comms logo