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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.

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.






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


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

5 Jul, 16 | by Jenny Thomas

Selected items from the News and Latest Additions sections of, 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 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, please go to our store. For enquiries regarding multiple copies please contact

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


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

Letter to Bowie read at Hay Festival by Benedict Cumberbatch

1 Jun, 16 | by BMJSPCblog


Benedict Cumberbatch reading Dr Mark Taubert’s BMJ SPC letter on the main stage at Hay Festival 2016

A letter written by Dr. Mark Taubert after David Bowie’ s death in January and originally published on our BMJ SPCare blog, was read out by the actor Benedict Cumerbatch at Hay Literary Festival on Saturday the 28th May 2016. Cumberbatch performed the reading as part of an event called Letters Live, organized by Shaun Usher and Simon Garfield. Letters Live celebrates the very best in literary correspondence, and returned to Hay Festival 2016 with a star-studded cast. The format is simple; letters of historical and cultural importance are performed by a series of stars in front of a live audience.

In the case of Saturday’s session, the performers represented a who’s who of British acting royalty, with Benedict Cumberbatch, Olivia Colman, Tom Hollander, Maxine Peake, Toby Jones, Louise Brealey and Mark Strong all taking to the stage of the Tata tent to narrate. Earlier this year, the singer Jarvis Cocker had read out Taubert’s letter at a Letters Live event in Freemason’s hall in London (video available here in this Telegraph article).

Mark Taubert‘s letter to Bowie was the last act of the evening, and Benedict Cumberbatch thanked ‘Dr Mark’, who was in attendance at the end of the reading. Speaking after the event, Dr Taubert said that it had been a magical moment, and that he had been particularly struck by audience members asking questions about palliative care and discussing care at the end of life after the event finished.

Benedict Cumberbatch descibed Letters Live as a way to pause and think: ‘Letters Live makes us pause and imagine the lives behind the letters read and the circumstances of their origin. It’s a privilege to read this most ancient of communications live to an audience. A truly inspiring event.’


CumberbatchRehearsing.jpg large

Rehearsing the letter backstage (Photo credit: Letters Live)



The Digital Legacy Conference 2016

31 May, 16 | by BMJSPCblog

By Sandy Weatherburn, ‎Founder & Director at Social Embers Digital estate management


My pledge for Dying Matters week


This weekend I attended the Digital Legacy Conference in Hackney, London, which was held at St Joseph’s Hospice.

The conference was organised by The Digital Legacy Association (DLA) to raise awareness of issues surrounding death and dying that are becoming increasingly important in society. It concluded a week of campaigning by ‘Dying Matters’ to encourage more people to talk openly about end of life issues.

The conference was opened by James Norris, founder of the DLA and of Dead Social, and James outlined some of the aims of his projects and how he got involved in this area. Chairing the event was speaker and funeral celebrant Peter Billingham, who runs Death Goes Digital, a company formed to give advice to the funeral industry about using digital technology. Peter spoke knowledgeably about some of the changes that are happening at funeral celebrations, including live stream funerals and photography, acknowledging that some are quite unusual and he gave us some interesting anecdotes.


James Norris opening the Digital Legacy Conference

Gary Rycroft was the next speaker. He is a solicitor and also works as a trustee for the National Council for Palliative Care, and the Dying Matters Coalition; both organisations promote awareness of death and bereavement issues. He told us about the Law Society Wills and Equity Committee, who produce guidelines for solicitors in relation to the law governing wills, succession and mental capacity, and he outlined how new thinking is now required with regard to digital assets.

Jane Harris Edmonds spoke to us very movingly about the death of her son Josh. She outlined how this lead to her current work ‘The Good Grief Project’. We learned from Jane how through making a film of her son’s funeral, she was able to create both a physical and a digital memorial site for him, and this is still providing comfort to her and Josh’s family and friends. ’Beyond Goodbye’ is a digital tribute to her son and ‘Postcards to Josh’ still provides an opportunity for all those who knew him to share their feelings, memories and new experiences. Music, photographs, postcards, videos and words are all used to create a way for everyone to contribute in their own preferred way.

Mark Taubert, an NHS Consultant Physician in Palliative Medicine, spoke next. He started his talk by observing how Jane had demonstrated that both physical and digital spaces can be used simultaneously and creatively to remember someone. He went on to tell us about an open letter he had written in a BMJ Supportive and Palliative Care blog post to David Bowie about the late singer’s death and last months. His letter thanked Bowie for the awareness he had raised by what must have involved meticulous preparation for the last weeks of his life, knowing that his illness was terminal. He spoke about the profound effect the album Blackstar and Bowie’s music more generally had had on him and many people that he worked with, and referred to it as a ‘a work of death art’. His letter became widely talked and blogged about on social media, in the press and on TV, after being shared by David Bowie’s son Duncan and highlighted the work of palliative care professionals.

We were also pleased to connect with many others who attended the conference. St Joseph’s Hospice made us feel very welcome and this very poignant memory tree at the bottom of the stairs reminded us of how many different ways we can remember those who’s lives have now ended.

The Digital Legacy Conference is an annual, not for profit conference by the Digital Legacy Association. To find out more click here


Memory Tree at St Joseph’s Hospice

News and updates from

16 May, 16 | by Jenny Thomas

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

Safety issues

FDA enhances warnings for opioids

US Food and Drug Administration (FDA) has announced class-wide enhanced labelling warnings for:

  • immediate-release opioid pain medications, in relation to risks of misuse, abuse, addiction, overdose and death; these are similar to those added to modified-release formulations in 2013 (see our news item 24 September 2013) and
  • both immediate-release and modified-release formulations, in relation to the undesirable effects on the endocrine system, and also the potential for interaction with other medicines resulting in serotonin syndrome.

The updated indication for immediate-release opioids states that they should be reserved for pain severe enough to require opioid treatment and for which alternative treatment options (e.g. non-opioid analgesics or opioid combination products) are inadequate or not tolerated. The dosing information also provides clearer instructions regarding patient monitoring and drug administration, including initial dosage, dosage changes during therapy and a warning not to abruptly stop treatment in a physically dependent patient. In addition, a precaution that chronic maternal use of opioids during pregnancy can result in neonatal opioid withdrawal syndrome, has been added.

Safety measures for immediate-release opioids

Safety issues for all opioids

MHRA reminder of fire risk with paraffin-based emollients

UK Medicines and Healthcare products Regulatory Agency (MHRA) has reminded health professionals to warn patients using paraffin-based emollients, not to smoke or use naked flames (or be near people smoking or using naked flames) due to the risk of clothing or dressings catching fire. The risk is greatest when these preparations are applied to large areas of the body, or when dressings or clothing become soaked with emollient. Patients should also be advised to change clothing and bedding regularly. For more information, click here.

Hot topics

Safe use and management of controlled drugs: NICE guideline published

NICE have published the final guideline for the safe use and management of controlled drugs (NG46) that was available for consultation in October 2015 (see our news item 28 October 2015). The guideline covers prescribing, obtaining, supply, administration, handling, recording and monitoring of controlled drugs in all NHS settings in England, except care homes. Managing and using controlled drugs in care homes is included in the separate NICE guideline (SC1).

Controlled drugs: safe use and management (NG46)

Managing medicines in care homes (SC1)

Administration of medicines in care homes by care assistants

UK Department of Health has published evidence-based guidance for care home providers on the administration of medicines in care homes (with nursing) by care assistants. For more information, click here.

 SIGN publishes CHF patient information booklet

Scottish Intercollegiate Guidelines Network (SIGN) has published a patient booklet based on SIGN clinical guideline 147: management of chronic heart failure (CHF). For more information, click here.

RCGP End of Life Care toolkit

The Royal College of General Practitioners (RCGP) has launched a Palliative and End of Life Care toolkit for health professionals, patients and carers in general practice. We are pleased to note that is listed as one of the clinical resources providing best practice guidance for the treatment of patients at the end of life. For more information, click here.

 Cochrane review: Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness

This new Cochrane review (CD011008) has been published in full on-line. The authors concluded that there was some low quality evidence that showed a benefit of using oral or injectable opioid drugs for the treatment of the symptoms of breathlessness. There was no evidence for opioids by nebulizer.

 Methadone for pain in palliative care

A one-hour on-line course on the use of methadone for pain in palliative care has been launched by Canadian Virtual Hospice. It is accredited as a Royal College Accredited Group Learning Activity (free for those in Canada). For more information, click here.

Drug updates

New buprenorphine transdermal patches available

Lower strength

Qdem pharmaceuticals has launched a branded generic buprenorphine transdermal patch (Butec) in strengths of 5, 10 and 20microgram/h.

Napp pharmaceuticals has launched an additional buprenorphine transdermal patch (BuTrans) of 15microgram/h to add to its current range of 5,10 and 20microgram/h.

Higher strength

Two types of generic buprenorphine transdermal patches in the higher strengths of 35, 52.5 and 70microgram/h are now available in addition to the branded generic (Hapoctasin; Actavis) and the original brand (Transtec; Napp).

Sufentanil sublingual tablet patient-controlled system

NICE has published an evidence summary for a new sufentanil sublingual tablet system (Zalviso; Grunenthal) which is due to be launched in September 2016. The new tablet system is programmed to dispense a single 15microgram sufentanil tablet on a patient-controlled basis to manage moderate-severe post-operative pain. The tablets are contained within a cartridge which must be used with the Zalviso administration device. This controls the dispensing of the tablet in response to patient activation with a lockout period of 20minutes. The cost of the system has not yet been released. For more information, click here.

Latest additions

Free access to the on-line Palliative Care Formulary renewed for NHS Scotland for fourth year

We are delighted to report that NHS Education for Scotland has subscribed to the on-line Palliative Care Formulary (PCF) for a fourth year! The on-line PCF is hosted on the Palliative Care portal of the NHS Scotland Knowledge Network website and is available free of charge to those with an NHS Education Scotland ATHENS user name and password. The content is continually updated and represents the most current PCF version. HON code accreditation extended

We are delighted to report that has been re-accredited for the fifteenth year running by the Health on the Net (HON) foundation and complies with the HON code standard for trustworthy health information.

The Health on the Net (HON) certificate serves as a guarantee that our website, at the date of its certification, complies with and pledges to honor the 8 principles of the HON Code of Conduct as drawn up by the HON foundation. For more information, click here.

PCF updated monographs summary (March & April 2016)

The on-line Palliative Care Formulary is being continually updated. The following monographs have been updated during March & April 2016 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 05: QPG: Use of transdermal buprenorphine (minor change)

Chapter 07: Progestogens

Chapter 15: Opioid dose conversion ratios (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



27 Apr, 16 | by Jenny Thomas

Cancer. 2016 Mar 28. doi: 10.1002/cncr.29844. [Epub ahead of print]

Multicenter cohort study on the survival time of cancer patients dying at home or in a hospital: Does place matter?

Hamano J, Yamaguchi T, Maeda I et al

In a prospective cohort study in 58 Japanese specialist palliative care services, potential differences in the survival time of adults (≥20 years old) with cancer receiving palliative care dying at home or in a hospital were explored. Patients were enrolled consecutively with 2426 recruited and 2069 analysed. Of these, 1582 received palliative care in hospital (1507 died in a hospital and 75 died at home); 487 received palliative care at home (100 died in a hospital and 387 died at home). Adjusting for background prognostic factors and stratified by a prognostic model into days’ and weeks’ and months’ prognosis groups, patients who died at home survived longer than those who died in a hospital in the days’ (estimated median survival 13 vs. 9 days) and weeks’ (36 vs. 29 days) but not the months’ prognosis group. Place of death had a significant influence on the survival time.

Shortcuts are compiled by Jason Boland


13 Apr, 16 | by Jenny Thomas

J Pain Symptom Manage. 2016 Apr 1. pii: S0885-3924(16)30012-4. doi: 10.1016/j.jpainsymman.2015.12.338. [Epub ahead of print]

Comparing Unmet Needs to Optimize Quality: Characterizing Inpatient and Outpatient Palliative Care Populations.

Hochman MJ, Wolf S, Zafar SY et al

A cross-sectional descriptive secondary database analysis of a 10 organization registry of initial palliative care patient consultations was used to compare the unmet symptom, advance care planning and functional needs of 633 patients receiving hospital (n=216) and outpatient (n=417) palliative care. Inpatients were older than outpatients (73 vs. 64 years), were twice as likely to have a primary diagnosis of cancer (81% vs. 43%) and had a with a lower performance status (38% of inpatients and no outpatients had a Palliative Performance Score ≤30%), with twice as many inpatients thought to be in the last 6 months of life (88% vs. 46%). The vast majority of both groups indicated they were ‘at peace’, but 39% of inpatients and 21% of outpatients rated their quality of life as poor. At their first palliative care encounter 4% of inpatients and 59% of outpatients had pain, however more inpatients had anorexia and dysphagia compared to outpatients. In view of the differences in these population, the authors conclude that different clinician skillsets and assessments are needed depending on the setting of palliative care consultation.

Shortcuts are compiled by Jason Boland

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