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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.

The new Respect form- Aretha Franklin and our odd relationship with forms

17 Mar, 17 | by bbutcher

EAB2B298-BCFB-4937-967D-0C60CBDB51C5aDr Ollie Minton, Consultant in Palliative Medicine

Maybe I should not listen to BBC Radio 4 as much as I do, although it is always stimulating and often leads to debate. This is especially true of the Today program where the “vexed issue” of DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) was recently discussed. However the twist on the usual discussions is the introduction of a new form to allow people to have discussions about all aspects of their treatment. I have not been involved in the process but a large number of organisations have, and it’s been named the respect process.  I like the term process at the very least – it is not a one off event and implies complexity if nothing else. However, like all things paper or even IT based, the form completion is only really one aspect.

 

I ain’t gonna do you wrong, while you’re gone
Ain’t gonna do you wrong (ooh) ’cause I don’t want to (ooh)
All I’m askin’ (ooh)
 ”

 

Sorry, got a bit distracted there… All the fault of my esteemed colleague Dr Mark Taubert, who likes to draw parallels to life’s current news and Zeitgeist events, for example David Bowie’s death, or a recent story about a failing satellite.  So I am going to use Aretha Franklin’s anthem to discuss RESPECT. This is not a column about relationships per se, but about the new proposals from the resuscitation council and others.

 

The very sound aim is to move away from placing Do Not Resuscitate decisions in a special category and to more seamlessly incorporate them into routine practice and discussions, especially within the context of myriad other treatments, other than just the one procedure, CPR. The case for doing this has been made by many, including a recent BMJ column by Professor David Oliver.  I also would draw your attention to Mark Taubert’s excellent work in Wales around how to talk about CPR and DNACPR, especially towards the end of your life. Just google “Talk CPR”, or the website with patient co-directed videos can be found here. The videos aimed at educating professionals about the issue, featuring an affected patient and carer in them: https://www.youtube.com/watch?v=ImrfD4RbMDE

 

Ooh, your kisses (ooh)
Sweeter than honey (ooh)
And guess what (ooh)
So is my money (ooh)
All I want you to do (ooh) for me
Is give it to me when you get home (re, re, re ,re)

 

Oops, sorry, I was miles away there, please bear with me.

The lyrics of Aretha’s respect song are relevant not just for this new acronym  – “Find out what it means to me… I’ve got to have (just a little bit) of respect”. I think we can agree we all want that especially if time and prognosis is limited. However this is not simply a palliative medicine problem – patients are referred late to services and doctors are poor at prognostication and recognising dying. We need to get behind this as a speciality but as the saying goes “it’s everybody’s business”.

We cannot as professionals force people to have these conversations. Yet we are constantly being told that there are“inappropriate admissions” with extensive use of hospitals for frail elderly or complex patients.

That is way a public information website and campaign  like TalkCPR in Wales, with its hahtag campaign on Twitter (#TalkCPR)  is an important and bold strating point to educate everyone about the pros and cons of CPR, in particular in life-limiting and palliative illness.

 

Alongside this and far more important than cost, it is distressing and affects bereavement to be admitted as an emergency unnecessarily if “avoidable”. For example the increase in admissions we have all seen from nursing homes. I am sure hospital episode statistics will bear this out and the proposed new end of life metrics will allow for more nuance and detailed analysis in time.

 

This is a complex procedure and instilling the Respect ethos will take time, money and attention to detail. I think the medical research council framework  is a helpful guide as will the proposed Royal College of Physicians quality improvement hub. The fact that every relevant learned society and organisation is already involved should allow the right level of discourse to make it happen. When and how this filters through to the “shop floor” is as a best guess over some years. Whether this means trial by media around death lists and pathways it remains to be seen. I sincerely hope not.

 

But the Respect form must not merely become a ‘palliative’ for the distress symptoms of the medics (anxiety about having these conversations when the patient is actually still able to have them, for fear of making them frightened). And we shouldn’t just create a more benign piece of paper, with less hostile, nasty words (like death): this must also not become a ‘palliative’ or ‘sedative’ for the agitated media, hungry for yet more sinisterly worded forms, clandestinely used in hospitals, the ‘next LCP’.

 

I fundamentally believe that the form currently in its 67th version is unlikely to alter practice without significant education and training. In fact, I would rather have a really basic form without realms of information, but an extensive supporting training programme, something like a Serious Illness Conversation training project for all healthcare grades and professionals. This sort of ambitious project has already started in Wales.

 

The form itself should not be the actual training, however well it is or isn’t worded. It should not serve the purpose of assuaging those fearful of another media storm. In a sense, we should really strive for a system where the form does not matter much at all, and merely acts as an information letter from one healthcare professional to another, held by a patient or their loved-ones: “I have had a conversation about this with Mrs X. Her views are that she’d be up for any treatments doctors feel she may need, just not CPR please. Her family were there when we talked it through. Yours sincerely, Dr O M”. The qualitative text you write on a piece of paper usually trumps any tick boxes in terms of meaningfulness.

 

Yes, it’s hardly ever about the paperwork, and always about the actual ‘meat’ of these serious illness conversations. My feelings on this have not changed since August 2016.

 

Or you might walk in (respect, just a little bit)
And find out I’m gone (just a little bit)
I got to have (just a little bit)
A little respect (just a little bit)”

 

Sorry, was I singing again?

Shortcuts

4 Mar, 17 | by bbutcher

Caregivers’ Perspectives on the Use of Long-Term Oxygen Therapy for the Treatment of Refractory Breathlessness: A Qualitative Study

Aileen Collier, Katrina Breaden, Jane L. Phillips, Meera Agar, Caroline Litster, David C. Currow.

J Pain Symptom Manage. 2017 Jan;53(1):33-39.

 

A qualitative study of the perspectives of 20 caregivers in the palliative setting of patients on long-term oxygen therapy (LTOT) for the treatment of refractory breathlessness was conducted using semi-structured interviews.

The main theme reported was that caregivers felt helpless and regarded oxygen as a life sustaining for people on LTOT and was vital in managing distressing symptoms and quality of life. However it also had financial costs and burdens including equipment, the noise from the concentrator, struggling with independence and leaving the house. The authors conclude that the possible harms of LTOT are underrated and highlight the importance of providing information and education about the appropriate use of LTOT.

 

Composed by Elaine Boland.

Shortcuts

20 Feb, 17 | by bbutcher

Prevalence of cancer chemotherapy-related problems, their relation to health-related quality of life and associated supportive care: a cross-sectional survey.

Wagland, Richardson A, Ewings S, Armes J, Lennan E, Hankins M, Griffiths P.

Support Care Cancer. 2016 Dec;24(12):4901-4911.

 

This study surveyed the prevalence of 17 problems whilst undergoing chemotherapy and people’s experiences of supportive care in 363 patients from six cancer centres in the UK. The EQ5D measure was also used. The response rate was 43%. The most common problem was tiredness/fatigue with 90% responders. Over 50% reported changes in sense of taste, difficulty managing everyday tasks, trouble sleeping, constipation, low mood, feeling sick, anxious, loss of appetite and unable to concentrate/forgetful.  In a multivariate model, difficulty with everyday tasks and work was significantly associated with health-related quality of life. Patients experienced less severe problems if they received supportive care; over a fifth stated that they never received support for emotional and social problems.

 

Composed by Elaine Boland.

Palliative care in space – breaking bad news to a satellite

9 Feb, 17 | by BMJSPCblog

Fengyun, a piece of space debris orbiting Earth

by Dr Mark Taubert, Consultant in Palliative Medicine at Velindre NHS Trust, Cardiff, Wales @DrMarkTaubert

What do you do when a piece of debris in space sends out a distress message via Twitter? This particular message read as follows: “Your people predict I will burn up in Earth’s atmosphere early 2017. You’ll get messages until then. I don’t want to die.”
How poetic, I thought and then did a bit of research. ‘Fengyun’ is a piece of space junk currently orbiting Earth at 28,000 km/hr. Fengyun, and two other pieces of space debris form part of ‘Project Adrift’, devised by Cath Le Couteur and Nick Ryan. It is an artistic exploration of the secret world of space junk, and the problems with it. You can see a film about it here.

But let me give you a bit of the past medical and social history for this particular palliative care patient, before we look at approaches to managing his or her distress:
Fengyun was once an important part of Chinese weather satellite FY1C, until it was blown into thousands of fragments by an experimental anti-satellite missile. Fenyun might burn up soon, but millions of other pieces, including Fengyun’s estimated 2840 siblings, will continue to circulate. They are potentially dangerous, too; any one of them could crash into a working satellite, currently in orbit, which poses risks for telecommunication and security.

What are this particular satellite’s main ideas, concerns and expectations? I think someone, in not too kind and compassionate a way, has broken it to Fengyun that he/she is going to die. I think the bad news was broken via electronic means, given that it is highly unlikely that a face-to-face discussion will have occurred in space. Someone dropped the bombshell that Fengyun will die by burning, quote: “I’m atmosphere intolerant, it makes me burn, and I have until early 2017, and then it’s death by close orbit“. Fengyun is now understandably frightened and distressed.

It did remind me of palliative care encounters and stories here on Earth that I hear on a monthly basis. The way news is broken about inevitable death, due to, for instance, an illness like secondary cancer, is at times insufficient. “I was told over the phone that it’s terminal.”, or “They were on a big ward round, came to my bed, one person who didn’t introduce himself spoke to me from the end of the bed, and Bang: –You’re dying!- “

 

Of course, breaking bad news is a very complex communication task. In addition to the verbal component of actually giving the bad news, it also requires other skills. These include responding to a patients’ emotional reactions, involving the patient in decision-making, dealing with the stress created by patients’ expectations for cure, the involvement of multiple family members, and the dilemma of how to give hope when the situation is bleak. The complexity of the interaction can sometimes create serious miscommunications such as patient misunderstanding about the prognosis of the illness or purpose of care. Poor communication may also thwart the goal of understanding patient expectations of treatment or involving the patient in planning next steps.

Many doctors and nurses will have heard of various forms of guidance to delivering bad news, one of which is the SPIKES mnemonic (1) and I will try to summarise what I might have done initially to help Fengyun:

STEP 1: S—SETTING UP the serious illness conversation: get the setting right and ensure privacy (no space debris should enter the palliative care space station whilst I am talking to Fengyun). Also, ensure Fengyun has significant others with him/her, in this case perhaps @VanguardAdrift another piece of space flotsam who is in the upper reaches and not at imminent risk of burning up.

STEP 2: P—Assessing the Patient’s PERCEPTION
Before discussing the aeronautical and astronomical findings, the palliative care space practitioner uses open-ended questions to create a reasonably accurate picture of how the patient perceives the situation- what it is and whether it is serious or not. For example, “What have you been told about your orbiting situation so far?” or “What is your understanding of the reasons we ran the earth re-entry probability test?”.

STEP 3: I—Obtaining the Patient’s INVITATION
While a majority of satellites may express a desire for full information about their prognosis, some may not. When a clinician hears a patient/satellite express explicitly a desire for information, it may lessen the anxiety associated with divulging the bad news. However, not wanting information is a valid psychological coping mechanism and may be more likely to be manifested as things become more serious. Discussing information disclosure at the time of ordering tests can cue the physician/NASA scientist to plan the next discussion with the patient. Examples of questions asked of Fengyun might be, “How would you like me to give the information about the results of your orbiting pathway?”

STEP 4: K—Giving KNOWLEDGE and Information to the Patient
It is important to warn patients/satellites that bad news is imminent and this may lessen the shock that can follow the disclosure of bad news. Examples include, “Unfortunately I’ve got some bad news to tell you” or “I’m sorry to tell you that…”.
It is vital to start at the level of comprehension and vocabulary of an individual patient. Importantly, try to avoid technical words like ‘atmospheric drag’, ‘biopsy’, or ‘aerodynamic heating’. Ideally try to give information in small chunks and check periodically as to the satellite’s understanding. And avoid phrases like “There is nothing more we can do for you.” This attitude is inconsistent with the fact that satellites and patients often have other important therapeutic palliative goals such as good pain control, listening to good music including ‘Satellite of Love’ by Lou Reed and of course being listened to and understood.

STEP 5: E—Addressing the Patient’s EMOTIONS with Empathic Responses
This one seems obvious, but there are a few things to bear in mind. Responding to the individual’s emotions is one of the most difficult challenges of breaking bad news. Emotional reactions may vary from silence to disbelief, crying, denial, or anger.
When we get bad news the emotional reaction is often an expression of shock, isolation, and grief. For instance, Fengyun posted the following on 09/02/2017: “I’ve gone 4,290,595,779 km since I was born and still have no purpose other than speed and mass.” In this situation the good palliative space physician can offer support and solidarity to the patient by making an empathic response. For instance, after you have given the satellite a brief period of time to express his or her feelings, let it know that you have connected the emotion with the reason for the emotion by making a connecting statement, such as “I can see that this is upsetting news for you”.

STEP 6: S—STRATEGY and SUMMARY
Satellites with a clear plan for the future are less likely to feel anxious and uncertain. Before discussing a plan, it is important to ask them if they are ready at that time for such a discussion. Clinicians are often very uncomfortable when they must discuss prognosis and treatment options with the patient, if the information is unfavorable. The reasons for this can vary but are often down to uncertainty about expectations, fear of destroying hope, fear of their own inadequacy in the face of an uncontrollable course of action, not feeling prepared to manage the anticipated emotional reactions, and sometimes embarrassment at having previously painted too optimistic a picture.

In summary, it is vitally important to keep in touch and follow things up. Sometimes, Fengyun, when the patients I see know that time may be short, they initially react with shock, but many take solace in the fact that we all must face death at some point in our lives, and that others have gone through similar experiences. And that there is always something else that can be done. There is nothing new under the Sun.

 

Ref:

(1) Bailea W, Buckman R, Lenzia R, Globera G, Bealea E, Kudelkab AP SPIKES- A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer doi: 10.1634/theoncologist.5-4-302 The Oncologist August 2000 vol. 5 no. 4 302-311 http://theoncologist.alphamedpress.org/content/5/4/302.full

News and updates from www.palliativedrugs.com

3 Feb, 17 | by bbutcher

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.

Hot topics

Association for Paediatric Palliative Medicine (APPM) Master Formulary 2017

The 4th edition of the APPM Master Formulary is now available. It is available to download from the APPM website or from our Document library under the topic Paediatric (prescribing guidelines).

 

Cochrane review: fentanyl for neuropathic pain

The authors concluded that there is insufficient evidence to support or refute the suggestion that fentanyl has any efficacy in any neuropathic pain condition (CD011605). For more information, click here.

 

Cochrane review: hydromorphone for cancer pain

The authors found a lack of evidence to support a preference for hydromorphone over other opioid analgesics such as morphine and oxycodone. The treatment effect of hydromorphone appeared to be similar to that of the comparator drugs for adults with moderate to severe cancer pain, However, most of the outcome data were based on single randomised controlled trials with a small sample size (CD011108). For more information, click here.

 

Cochrane review: benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases

This updated review (CD007354) confirmed the previous conclusions:

  • there is no evidence for a beneficial effect of benzodiazepines in the relief of breathlessness in people with advanced cancer and COPD. There is a non-significant beneficial effect, but the overall effect size is small. Benzodiazepines caused more drowsiness as an adverse effect compared to placebo but less compared to morphine. These results justify considering benzodiazepines as second- or third-line treatment, when opioids and non-pharmacological measures have failed to control breathlessness
  • there is currently not enough evidence to support the use of benzodiazepines in the prevention of episodic breathlessness in people with cancer. There are no data from controlled trials for the treatment of episodic breathlessness with benzodiazepines
  • there are no differences regarding the type of benzodiazepine, dose, route and frequency of administration, and duration of treatment.

For more information, click here.

 

End of life care for infants, children and young people with life-limiting conditions: planning and management

This NICE guideline (NG61) has now been published in full on-line. For more information, click here.

Drug updates

Gabapentin oral solution and enteral feeding tubes

The UK Summary of Product Characteristics (SPC) for Gabapentin Rosemont 50mg/mL oral solution (Rosemont Pharmaceuticals) has been updated to include information about administration via nasogastric and percutaneous endoscopic gastrostomy feeding tubes. Section 6.6 of the SPC contains information on the specific type of tubes suitable for use (including the material, bore size, internal diameter and maximum length) and the procedure to be followed when administering the oral solution via these routes. For more information, click here.

Latest additions

The on-line Palliative Care Formulary is being continually updated. For a full list of all the monographs updated since the print publication of PCF5, see the Latest additions section of the website or follow us on twitter @palliativedrugs for the latest updates. Over the next few months we will be working hard in the background on the technical side of the website in preparation for the publication of PCF6 print edition later this year. Part 2 of PCF (which contains the general topics) is being reorganised to make it more user-friendly. The new PCF format will be launched first on the website in March/April 2017 and will also contain multiple monographs that have been updated during the interim period.

 

Prepared by Sarah Charlesworth and Andrew Wilcock

Shortcuts

31 Jan, 17 | by bbutcher

Association Between Palliative Care and Patient and Caregiver Outcomes: A Systematic Review and Meta-analysis.

Kavalieratos D, Corbelli J, Zhang D, Dionne-Odom JN, Ernecoff NC, Hanmer J, Hoydich ZP, Ikejiani DZ, Klein-Fedyshin M, Zimmermann C, Morton SC, Arnold RM, Heller L, Schenker Y.

JAMA. 2016 Nov 22;316(20):2104-2114. doi: 10.1001/jama.2016.16840.

A narrative meta-analysis of randomized clinical trials (RCT) of palliative care interventions in adults with life-limiting illness was performed. 43 RCTs were included and involved 12,731 patients and 2479 caregivers (cancer and non-cancer). 23 RCTs were included in the meta-analysis. Palliative care interventions were associated with statistically and clinically significant improvements in physical symptoms and quality of life at 1 to 3 months. There was no association between palliative care and survival. There were improvements in patient and caregiver satisfaction with care, advance care planning and lower health care utilization with palliative care. When only the low risk of bias RCTs were meta-analysed, no statistically significant and clinically important associations remained.

 

Composed by Elaine Boland

Shortcuts

15 Jan, 17 | by bbutcher

Relationship between Opioid Treatment and Rate of Healing in Chronic Wounds.

Shanmugam VK, Couch KS, McNish S, Amdur RL.

Wound Repair Regen. 2016 Nov 16. doi: 10.1111/wrr.12496. [Epub ahead of print]

450 people participated in this longitudinal observational study to investigate the relationship between opioids and wound healing.  Using fixed-effects models and time-to-event analysis, opioid dose was significantly associated with total wound surface area (p<0.0001); subjects with mean opioid dose ≥10mg were significantly less likely to heal than those with no opioid (HR 0.67 [0.49-0.91], p=0.011) after adjusting for wound size. People who never had opioids healed faster than those who received opioids (p=0.0009). The authors plan to correlate the exposure of opioids and clinical outcome data with tissue mRNA expression array data which might help understand the molecular mechanisms that may contribute to delayed wound healing.

 

Composed by Elaine Boland

News and updates from www.palliativedrugs.com

28 Dec, 16 | by James Smallbone, Publishing Assistant

22/12/16

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 updates

Medical device alert: insulin delivery devices
UK MHRA have issued a Medical Device Alert (MDAS/2016/020) informing health professionals that they should warn patients not change their insulin delivery device without first checking with their diabetes specialist. This relates to disposable patch pumps, reusable ambulatory infusion pumps, handsets and insulin cartridges. Patients should contact their diabetes specialist if they are invited by a manufacturer or other organisation to try a new device, e.g. via social media, to avoid risk of hyperglycaemia, hypoglycaemia or diabetic ketoacidosis.

The action deadline for putting systems into place to inform diabetic patients of this is 21 December 2016. For more information, click here.

Hydrocortisone 100mg/mL injection batch recall
MHRA has issued a class 3 medicines recall for the specified batch of hydrocortisone 100mg/mL solution for injection (AmdiPharm UK Limited). The solution in some ampoules has a yellow appearance. The batch should be quarantined and returned to the original supplier. For more information, click here.

pH testing for nasogastric tube positioning
A National Institute for Health Research (NIHR) Signal has been published highlighting research which concluded that pH testing was the best initial approach for confirming the position of a nasogastric tube in adults. For more information, click here.

Patient Safety Alert: Risk of death and severe harm from error with injectable phenytoin
A warning alert NHS/PSA/W/2016/010 has been issued highlighting the risks associated with the prescribing, preparation, administration and monitoring of injectable phenytoin. It asks providers to consider if more can be done to strengthen local procedures to reduce the risks of error with this complex medicine. For more information, click here.

 

Drug updates

Hydromorphone injection now authorized in the UK
Hydromorphone solution for injection or infusion is now available as an authorized product (Palladone, Napp) in the UK as 2mg/mL, 10mg/mL, 20mg/mL and 50mg/mL. It is authorized for the relief of severe cancer pain in patients >12 years old by either intravenous injection/infusion or by subcutaneous injection/infusion.

When converting from oral hydromorphone to parenteral hydromorphone, the SPC recommends a 3:1 conversion ratio, i.e. dividing the total daily oral dose by 3 to give the total daily parenteral dose. (Note. This is a more conservative estimate than the traditional 2:1 dose conversion ratio as recommended in PCF).

The formulation can be diluted with WFI or 0.9% saline. The SPC states that no evidence of incompatibility was observed between Palladone injection and representative brands of the following drugs, when stored in high and low dose combinations in polypropylene syringes over a 24h period at ambient temperature:

  • dexamethasone sodium phosphate
  • glycopyrronium bromide
  • haloperidol
  • hyoscine butylbromide
  • hyoscine hydrobromide
  • ketamine hydrochloride
  • levomepromazine hydrochloride
  • metoclopramide hydrochloride
  • midazolam hydrochloride

(Note. Incompatibility has been observed with dexamethasone or haloperidol, at some higher concentrations, see PCF Appendix 3 compatibility charts and the SDSD for more details).

The NHS cost per 1mL ampoule of 2mg/mL, 10mg/mL, 20mg/mL and 50mg/mL is £1.60, £13.20, £26 and £34 respectively. (Note. Hydromorphone injection is ≤5 times more expensive than the equivalent dose of morphine injection). For more information, click here.

Hydrocortisone 100mg/mL injection batch recall
MHRA has issued a class 3 medicines recall for the specified batch below of hydrocortisone 100mg/mL solution for injection (AmdiPharm UK Limited). The solution in some ampoules has a yellow appearance. The batch should be quarantined and returned to the original supplier.

Batch: 039268 Expiry: Aug 2017 Size: 1 x 5 First issued: 27 May 2016. For more information, click here.

IV carbamazepine authorized in the US
The FDA has authorized a parenteral formulation of carbamazepine (Carnexiv; Lundbeck) for short-term replacement therapy for oral forms of the drug in adults with certain seizure types when oral administration is temporarily not feasible. The IV carbamazepine total daily dose is 70% of the PO carbamazepine total daily dose, and should be divided equally into four infusions to be administered q6h. Each dose should be diluted in 100mL of diluent and infused IV over 30 minutes. The company has not yet filed for a marketing authorization in Europe. For more information, click here.

 

Latest additions

PCF5+ 2016 PDF now available for only £25
We are pleased to announce that the September 2016 PDF version of the Palliative Care Formulary (PCF5+ 2016) is now available to purchase from our store and that we have been able to keep the cost at £25.

PCF5+ 2016 contains all the updates made to the on-line PCF over the last 12 months and reflects the content of the on-line PCF as of the 1 September 2016. It therefore supersedes both the printed version of PCF5 and the PCF5 September 2014 and 2015 PDF.

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 (Nov 2016)
The on-line Palliative Care Formulary is being continually updated. The following monograph has been recently updated and supersedes that in the print publication of the 5th edition of the Palliative Care Formulary (PCF5) and PCF5+ 2016 PDF. It can be accessed from the formulary section of the website.

Chapter 02: Systemic local anaesthetics

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

Menkel’s Kinky Hair versus Dilnott Fairer Care – Journeys through Nuncupation

22 Dec, 16 | by James Smallbone, Publishing Assistant

It’s eponymous my dear Watson!

Eponymous
adjective
1. (of a person) giving their name to something.
“the eponymous hero of the novel”

2. (of a thing) named after a particular person or group.
“their eponymous debut LP”

Medical students of a certain vintage will have used the Oxford Handbook of Clinical Medicine. There was a section at the end devoted to eponymous syndromes. At the time these were originally described, this was significant innovation and rightly they have lived on. Cushing’s syndrome for example has its own page on NHS choices. Obviously the wider relevance of these conditions depends on their prevalence – Menkel’s kinky hair syndrome stayed with me from medical school but I have never knowingly seen a case. As you would expect, it is becoming harder and harder to generate your own syndrome. This may change with the 100,000 genome project  but the best you can probably hope for is a single nucleotide polymorphism attributed to you & your collaborators!

The same cannot be said for eponymous reports sadly. Are such reports becoming a bit of a career aim for the ‘establishment’? The usefulness of said reports is invariably inversely proportional to the length of the document. I do not arrive at this conclusion lightly and am not going to debate report structures. I discussed knowledge translation in a previous blog  and I firmly believe that less is more.

However, in case it has passed anyone by we have reached something of a crisis in health and social care. Not a Blackadder Goes Forth type crisis, no, this is in fact having a serious impact on all of our roles. This is definitely a time for action, not a measured debate on the Dilnott report as heard on the Radio 4 today program, for instance. Whilst our eponymous hero Cushing made his observations some time ago in 1932 – along with Addison, these do have clinical relevance today.  I am not sure an 82 page report alongside hundreds of supporting documents archived on the government website in 2011 will have the same relevance, now or in 80 years time.

It is difficult to make a direct comparison between syndromes and reports but: here goes. There are over 200 eponymous syndromes  & many redundancies where historical substitutions have been made. It is an honour that a vanishingly rare number of doctors will achieve. The same cannot be necessarily said for parliamentary output  but, while weighty tomes (literally and metaphorically), not every one bears an actual name. For those in the establishment, the usual health and social care suspects include Dilnott, Barker, Altmann amongst others going back in time – no doubt to the inception of the health and social care systems post the second world war. There are also linked reports around pensions/ageing and other aspects that feed in to health. I would hesitate to give a definitive number of reports. If the number is not approaching 200 then the reduction in relative frequency compared to eponymous syndromes is more than compensated by the length. The honour, if there is one, is usually awarded in advance with ennoblement of the lead author whereas the usefulness of most eponymous syndromes are/were often only fully recognised posthumously.

Although the chances of either is approximately zero, I would hope if I ever got the call to add to the metaphorical paper pile of PDF archives, I would find inspiration from one of my medical heroes and channel rule 13 of The House of God.

Yours,

Minton (of the lesser kinky hair)

 

By Ollie Minton

News and updates from www.palliativedrugs.com

14 Oct, 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.

Hot Topics

Updated Do Not Attempt Cardiopulmonary Resuscitation policy

The Scottish government has published an update to NHS Scotland’s Do Not Attempt Cardiopulmonary Resuscitation policy for adults. For more information, click here.

British guideline on management of asthma updated

The 2016 update to the BTS/SIGN British guideline on the management of asthma is now available. It includes a complete revision of the sections on diagnosis and pharmacological management of asthma, and updates to the sections on supported self-management, non-pharmacological management of asthma, acute asthma, difficult asthma, occupational asthma, and organisation and delivery of care.

A summary and the full guideline can be downloaded from both the BTS and the SIGN website. Additional supporting material are also available on the SIGN website

 NICE Consultation: Care of dying adults in the last days of life

NICE has published a draft quality standard for consultation on the care of dying adults in the last days of life. There are four quality statements listed:

  • adults who have signs and symptoms that suggest they may be in the last days of life are monitored for further changes to help determine if they are nearing death, stabilising or recovering
  • adults in the last days of life are given care that is in accordance with their stated preferences and responsive to their changing preferences
  • adults in the last days of life who are likely to need symptom control are prescribed anticipatory medicines with individualised indications for use and dosage
  • adults in the last days of life have their hydration status assessed daily, and a discussion about the risks and benefits of clinically assisted hydration.

The deadline for consultation responses is 27 October 2016. For more information, click here.

NICE guidance on multimorbidity

NICE guideline (NG56) multimorbidity: clinical assessment and management is now available.

Drug updates

Palladone (hydromorphone) SPC updated

Both immediate-release and modified-release Palladone (hydromorphone) capsules are now authorized to be opened and the granules sprinkled onto soft food for administration where necessary. However, the granules of the modified-release formulation must be swallowed whole and not crushed, broken or chewed as this can lead to a rapid release and absorption of a potentially fatal dose of hydromorphone. For more information, click here.

Authorized glycopyrronium oral solution now available in UK

A glycopyrronium 200microgram/mL (1mg/5mL; Colonis Pharmaceuticals) oral solution is now available, costing £91 for 150mL. It is authorized for the treatment of peptic ulceration, thus use in indications in palliative care, e.g. drooling would be off-label. However, a glycopyrronium 320microgram/mL oral solution, authorized for severe drooling, is expected to be launched soon (see our news item 28 July 2016). For more information, click here.

Glycopyrronium 200micorgram/ml (1mg/5mL) oral suspension, although cheaper (when comparing 28 days’ cost @ 1mg t.d.s.), remains an unauthorized product via special order.

SMC accepts diamorphine nasal spray

The Scottish Medicines Consortium has accepted diamorphine nasal spray (Ayendi; Wockhardt) for the treatment of acute severe nociceptive pain in children and adolescents in a hospital setting. It should be administered in the emergency setting by practitioners experienced in the administration of opioids in children and with appropriate monitoring. For more information, click here.

Latest additions

PCF5+ 2016 pdf available soon!

PCF5+ 2016 pdf version is anticipated to be available in November 2016. We are pleased to announce that we will be able to keep the cost of this version at £25.

This annual version of the PCF will contain the updates made to the on-line PCF over the last 12 months since the last pdf version (PCF5+ 2015 pdf), and will reflect the content of the website as of 1st September 2016.

The on-line formulary will still be continually updated, providing the most up to date version. The more members subscribe, the more we can reduce the cost of subscription. We would like to thank you for your support over the last 12 months. Please note if you require bulk purchases of the pdf format please contact hq@palliativedrugs.com to discuss your requirements.

Survey results: Withdrawal of ventilation at the request of a patient

Results from our survey (August-September 2016).

The Association of Palliative Medicine (APM) produced guidance for professionals on the withdrawal of assisted ventilation at the request of patients with motor neurone disease in 2015, and is now collating experiences for ventilator-dependent patients with a broader range of conditions who request that their assisted ventilation be stopped. It is hoped that this may inform guidance for other groups of patients in future editions of the guidelines. UK health professionals involved in supervising ventilator withdrawal are encouraged to complete the audit of process and outcomes which is available, alongside the current guidance, on the APM website.

 Prepared by Sarah Charlesworth and Andrew Wilcock

BMJ Supportive & Palliative Care blog

BMJ Supportive
& Palliative Care

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