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News and updates from www.palliativedrugs.com

11 Apr, 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

Desmopressin patient safety alert

NHS England has issued a patient safety alert warning (NHS/PSA/W/2016/001) on the risk of severe harm or death when desmopressin is omitted or delayed in patients with diabetes insipidus. They have identified a lack of awareness of the critical nature of desmopressin when being used for the treatment of cranial diabetes, in particular for the nasal spray, amongst medical, pharmacy and nursing staff and poor availability of the medication within inpatient clinical areas. Organizations are required to act immediately to ensure all staff are aware of this warning and action plans are put in place to reduce the risk. For more information, click here.

Hyperkalaemia with spironolactone and renin-angiotensin system drugs

The latest Drug Safety Update from the UK MHRA highlights the risk of potentially fatal hyperkalaemia with the concomitant use of spironolactone and angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). This follows a recent increase in the number of incidents reported from using these combinations. Health professionals are reminded that concomitant use of spironolactone and ACEi or ARBs is not routinely recommended. If concomitant use is essential, the lowest effective doses should be used and regular monitoring of serum electrolytes is also essential. For more information, click here.

Hot topics

NICE guidance published

  • Motor neurone disease: assessment and management (NG42). This updated version replaces NICE guideline CG105 (July 2010)
  • Transition from children’s to adults’ services for young people using health or social care services (NG43).

USA guidelines for prescribing opioids for chronic pain

The USA Centres for Disease Control and prevention (CDC) has updated a 2014 systematic review to provide 12 recommendations for prescribing opioids, in primary care, for chronic pain outside of active cancer treatment, palliative or end of life care. For more information, click here.

Drug updates

Metoclopramide 5mg/mL injection (Maxolon) batch recall

The following batches of Maxolon 5mg/mL, 2mL ampoules (metoclopramide; AMco) have been recalled due to a printing error on the outer carton regarding IV administration.

  • batch number J001 (expiry April 2020)
  • batch number J003 (expiry October 2020).

For more information, click here.

New fentanyl transdermal patient controlled system available in UK

A new fentanyl transdermal system (IONSYS), authorized for the treatment of moderate−severe post-operative pain in adults, is now available in the UK (hospital use only). The patient controlled transdermal system has an electronic controller, a drug unit and a patient activation button. Upon pressing the activation button, 40microgram of fentanyl is delivered to the patient over a 10minute period. The unit contains 80 doses and allows a maximum of 6 doses/h (240microgram/h). It is authorized for short term use for 72h. For more information, click here.

Editor’s note: An IONSYS product has previously been available in the UK but was suspended in 2008 due to a defect in the delivery system (see our news items on 30 September and 25 November 2008).

Special order ketamine capsules available in UK

Ketamine oral capsules are now available as an unauthorized product for special order. They are available as 40mg and 100mg in a pack of 100 at a cost of £199 and £189 (+VAT) from the NHS Oxford pharmacy store (01865 455909). They have a 12month shelf life. For more information, click here.

Latest additions

Survey results

Results from our survey ‘Benzodiazepines and hypnotics – What do you use?’, (January– March 2016).

Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from www.palliativedrugs.com

15 Feb, 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

CME T34 Field Safety Notices

CME T34 and leaking extension lines

Due to reports of leaking, CME has issued a Field Safety Notice recalling CME syringe extension sets (product codes 100-172S and 100-172SLL) used with CME T34/T60 syringe pumps. An alternative set (product code PN30-7100) is being supplied in the interim. However, this differs in composition, priming volume and connection to the male Luer lock (see Customer information bulletin). Further, the substitute set can only be used with syringe sizes up to 20mL within the lockbox of the T34; the female Luer prevents the lockbox lid closing with larger syringe sizes. For more information, click here.

CME T34 and use in direct sunlight

CME has issued a Field Safety Notice recommending that the CME T34 is protected from sunlight by covering with a bag/dedicated syringe pump pouch. This is a precaution following problems reported for T60 syringe pumps, where infusions have stopped and alarms activated when exposed to direct sunlight. The issue is related to a change in the material used for the pump housing from June 2013 onwards, which is also used in T34 syringe pumps. For more information, click here.

Hot topics

NICE palliative care guidelines

NICE are starting the process of updating the 2004 clinical guidance ‘Improving supportive and palliative care for adults with cancer’. The draft scope for the updated guidance has been published for consultation. NICE are also recruiting health professionals, and lay members, to join the guidelines committee. The deadline for both consultation responses and applications to join the committee was 29 January 2016. For more information, click here.

Drug updates

Haloperidol, cyclizine and levomepromazine UK supply updates

Haloperidol 5mg/mL injection

We reported in October 2015 (News item 6 October 2015) that there were supply difficulties with haloperidol injection 5mg/mL. We understand that this is now out of stock. Amdipharm Mercury have reported that there is an issue with the raw ingredient, and they do not expect this to be resolved until the end of 2016. There is no other UK authorized product available. We understand that alternative haloperidol injection formulations from other Countries, unauthorized in the UK, are available for import via special order.

Cyclizine 50mg/mL injection

We reported in December 2015 (News item 9 December 2015) that there were supply difficulties with cyclizine injection 50mg/mL. We understand that although there is no known manufacturing issue, the supply and demand situation is currently unstable.

Levomepromazine 25mg/mL injection

They have been some local reports of supply difficulties, however, Sanofi have confirmed that their product (Nozinan) is in stock and available to order; they are unaware of any wholesaler restrictions.

Latest additions

PCF updated monographs summary (January 2016)

The on-line Palliative Care Formulary is being continually updated. The following monographs have been updated during January 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.

Note there were no changes to the on-line PCF during December 2015.

January 2016

Chapter 04: Benzodiazepines (correction)

Chapter 06: Cellulitis in a lymphoedematous limb, Quick Clinical Guide: Cellulitis in lymphoedema

For further details of corrections, see the individual notifications in the Latest additions section of www.palliativedrugs.com. 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

The Liverpool Care Pathway – are patients suffering unnecessarily due to media criticism?

1 Mar, 13 | by Assistant Editor

 

The overwhelming majority (89%) of senior palliative care doctors who responded to a survey carried out for the BMJ and Channel 4’s Dispatches think the Liverpool care pathway (LCP) is the right approach for caring for patients in their final hours, and they would choose it for themselves.

However, almost three quarters (74%) think that recent criticism in the media and elsewhere has led to less use of the LCP. Of these, two-thirds (67%) said patients and relatives had asked them not to use it and 84% said staff were apprehensive about relatives’ complaints.

The results, published on bmj.com today (http://press.psprings.co.uk/bmj/march/Finalresults.xls) – and due to be aired on Channel 4 Dispatches on Monday 4 March – support concerns already made by palliative medicine leaders.

One specialist said the controversy around the LCP “has caused additional distress for relatives at an already distressing time when their loved one is dying.” Another said that that it was “putting end of life care back about twenty years, where dying patients were hidden inside rooms and not seen by a consultant.”

The Liverpool care pathway was introduced to help doctors and nurses provide quality care for patients during their final hours and days of life, but it has recently been criticised after accounts of patients having food and fluids withdrawn and the use of financial incentives. Some families are claiming that their relatives could, and should, have lived longer.

As a result, the Department of Health and the NHS National End of Life Care Programme are currently reviewing the pathway.

In February, in conjunction with Channel 4 Dispatches, the BMJ emailed 3,021 hospital doctors for an anonymous online survey of the Liverpool care pathway. The results are based on answers from 563 doctors who responded and had used the pathway in their practice (185 palliative medicine consultants, 168 in other grades in palliative medicine, and 210 doctors in another specialty). The respondents included about 40% of all palliative medicine consultants in the UK.

Overall, 91% (514) thought that the pathway represented best practice for care of the dying patient, including 89% (164) palliative care specialists. If used properly, 98% (551) thought it allowed patients to die with dignity, with only two respondents (0.4%) disagreeing.

When asked if they would want the pathway during a terminal illness, 90% (509) said yes and 3% (16) said no. And despite media reports, almost all (98%) did not think that pressure on beds or other resources had influenced decisions to use the pathway.

However, only 13% (75) respondents agreed that hospitals should be offered financial incentives for using the pathway, with over half (58%) disagreeing.

Concerns about lack of training in the use of the pathway were also raised, in particular around recognising a dying patient and communicating this to patients and relatives.

Other respondents pointed to “damaging misconceptions” about the pathway, such as it precludes nutrition, hydration or antibiotics, that it is a one way process with no further patient review, and that it is an active intervention to hasten death.

Dr Fiona Godlee, BMJ Editor in Chief, said: “This survey gives overwhelming support for the LCP from doctors who have experience in using the pathway when caring for patients in the last few days of life. The fact that most of these doctors said they would choose the LCP for themselves is doubly reassuring. The recent adverse media coverage of the LCP has been misleading and has damaged patient care. I hope this survey goes some way to restoring public confidence in the LCP as a reasonable and compassionate choice for patients and their families when making decisions about end of life care.”

Death on the Ward: Channel 4 Dispatches (Monday 4 March, 8pm) interviews leading specialists, terminally ill patients and families to explore the simple question at the heart of this controversy: can doctors accurately tell when someone is dying?

Proposal for the development of community end of Life Care: A guest post by Julian Abel

12 Feb, 13 | by Assistant Editor

 

Background

Over the last 45 years the hospice movement has set the standard for caring for people who are approaching the end of life.  The levels of services have been developing steadily and the quality of care has been of the highest standard.  An unintentional consequence of the development of end of life services has been that the care has become professionalised.  Families naturally look for professional care as their loved one becomes increasingly unwell.  In addition, although healthcare professionals look to see what care the family can deliver, the main focus of supporting people at home is the addition of a variety of professional care.  Culturally, we have lost something of the traditional role of the community caring for people who are dying.

Proposal

There are two components to this proposal.  The first part relates to involving the network of family and friends supporting the dying person and carer at home.  The second part aims to build compassionate communities who can help to support end of Life Care in their own community.

 

  1. Developing family and friends networks

 

Caring for the terminally ill relies heavily on the support of family and friends.  Often there is a very natural reluctance to ask for help from even close family members.  Even if people offer to help, it is not always clear whether help can be given.  Furthermore close carers may feel a sense of value in maintaining their role without asking others to help.

There are a wide variety of tasks that need to be completed in order to keep someone at home.  These include cooking, cleaning, shopping, washing, dressing, visits to clinics, feeding, medication, collecting prescriptions, and toileting.  Some of these tasks may be small in themselves part in combination add up to a large burden for one person.

We propose that developing a network has two phases.

Firstly, for each patient a map is drawn of close family members and friends.  If possible a person who would be prepared to be the main coordinator is identified on this map.

The second phase is that a chart of the week is drawn up with all the tasks listed down one side.  The coordinator then decides with the main carer and the patient of the acceptability of asking people for help, in a regular and organised fashion.  An explanation that can work well in this circumstance is that caring for somebody with a terminal illness is more of a marathon rather than a sprint.  Keeping the carer has supported as possible is a key component to maintaining the patient at home. Even small amount of input can help significantly.  For example the lift to the shops once a week may be very helpful.  Somebody sitting with the patient whilst the shopping is done can help to give the carer a break.  Sharing the tasks out in an agreed way can help to spread the load of care.  The coordinator maps family and friends on to the chart.

The ideal time to start thinking about these kind of arrangements is when the discussion of advance care planning is started.  At the hospice, advance care planning discussions are usually started by the specialist palliative care community nurse. Planning for care fits easily into thoughts about the future.  The advantage of starting at this point is that care can be increased as the patient becomes less well.

A common experience for many people once the patient has died here is that everyone disappears after the funeral, leaving the care and feeling lonely and unsupported.  However, in this arrangement regular contact can be maintained and gradually withdrawn as the sense of loss and loneliness lessens.  The Healthcare professionals involved in which support the coordinator in drawing up a plan and look to see where there are gaps.  These gaps could then be filled by existing professional Care Services.

  1. The second phase of the project is the development of compassion in communities.  Each time a family network looks after their terminally ill loved-one, they develop skills and expertise on how to do this.  These skills are a resource for communities.  The closest Health Care professional to the patient could ask the developed network if individuals would like to volunteer to help other people in their locality who may be in a similar situation either now or in the future.  For those people who are prepared to do this the details could be kept as a resource and they could be offered more formal training as a volunteer.  For people who have a small network, it is much easier to ask whether they would accept help from somebody who lives in the locality who has been through a similar experience.  They may well be a neighbour who already knows the family concerned.

Over a period of time, communities could build up a large network of you who are prepared to support their neighbours in the end of Life Care.  In this way, end of Life Care is handed back to the community in which it belongs, supported and aided by Health Care professionals.

 

Project proposal

We propose that Weston Hospicecare run a project on developing compassionate communities.  We think that the community specialist palliative care nurse is the ideal person to start the process of identifying the key coordinator and providing supportive documentation.  This would follows naturally from starting advance care planning discussions.  We know from our records that these take place on average three months before the patient dies.  If there is no obvious person to do the coordinating, the palliative care nurse could fulfil this role.

We think that there will be, particularly initially, a significant time input which will have an impact on the palliative care nurses job.  For this reason we would like to employ another specialist palliative care nurse who can act as backfill.

We think that the volunteer carer programme would be ideal in developing volunteers for particular neighbourhoods.  We intend to start the project apply targeting the small number of GP practices so that we can build up a neighbourhood resource.  When a new patient within that locality needs support, the hospice could then use the resources held by the volunteer carer programme.

 

Julian Abel

Do ‘humorous’ references to murder and euthanasia reflect societal beliefs about palliative care?

13 Sep, 12 | by Assistant Editor

A recent survey of palliative care doctors published in the Mayo Clinic Proceedings investigates the role that gallows humour plays in the relationships between palliative care physicians and their patients and colleagues.

The online survey, developed by Lewis Cohen MD and colleagues from Tufts University School of Medicine, found that nearly three-quarters of doctors interviewed have been ‘humorously’ accused of promoting death. Most of the comments came from fellow physicians and health care workers.

Parallel to this, results indicated that 25 out of the 633 respondents reported having been formally investigated for hastening a patient’s death. One third of cases were initiated by fellow health care workers.

The study concludes that whether real or in jest, accusations of murder are part of a wider issue. The survey highlights that the presence of gallows humour into the medical environment is representative of conflicting beliefs about end-of-life care, specifically hastening death. The article cites global examples of palliative care cases that have been brought to court, emphasising the international scale of the issue.

Although caring for dying patients is always a serious matter, it would be a mistake to suggest that physicians ought to cease joking about death with their colleagues. Cohen reiterates that, “Levity must remain an acceptable defense mechanism in medicine for coping with the weightiest of medical duties: helping patients to die with grace and dignity”. In Cohen’s opinion, rather than curbing humorous references, it is more important for medical professionals to address the underlying conflicts that exist both globally and within their own community. Accusations from health care professionals clearly indicate that there are strong disagreements over end-of-life care that must be discussed.

Should palliative care play a role in the management and treatment of diabetes?

8 Aug, 12 | by Assistant Editor

New research published this week in the Journal of General Internal Medicine indicates that palliative care could play an important role in the management of type 2 diabetes.

The study, conducted by a team of researchers in California, analysed the symptom burden and survival times of over 13,000 diabetic adults aged 30-75. The results indicated high prevalences of pain and discomfort, with 42% of participants reporting acute pain and 40% reporting chronic pain.

Psychosocial symptoms were also common amongst those surveyed, with a quarter reporting experiencing either fatigue, depression or insomnia. Interestingly, younger individuals (aged under 60) were more likely to report psychosocial symptoms, whilst those over 60 were more likely to experience painful symptoms.

The American Diabetes Association estimates that over 25 million people have diabetes in the US alone. The global prevalence of the disease is thought to be over 285 million and rising. With palliative care being incorporated more and more often into the management of non-cancer diseases including heart disease and kidney failure, this study highlights an important issue – could palliative care be used to alleviate painful symptoms amongst diabetic patients, and is there a place for palliative medicine in standard diabetes care?

Results of the UK’s first National Bereavement Survey released

3 Jul, 12 | by Assistant Editor

Today saw the publication of the results from the UK’s first National Bereavement Survey. The questionnaire, which was administered in November 2011, aimed to establish what the standard of end-of-life care was, as seen through the eyes of people who had lost a loved-one.

The responses of over 22,000 people were collated and the results highlight geographical disparities in perceived quality of care. Residents of Bournemouth, Poole and Dorset gave the highest ratings for end-of-life care, whilst the quality of care in Bedfordshire and Luton was considered the worst.

Overall, 75% of respondents rated the quality of care as good or better. People were more likely to rate the quality of care as outstanding if their loved-one died in a hospice or at home as opposed to in a hospital. In fact, hospice care was considered the best setting for end-of-life care, with 92% of respondents who had experienced hospice care rating it as good or better.

There was a large disparity between the numbers of people reporting ‘complete pain relief’ according to setting, with 62% of hospice deaths reporting this but only 17% of home deaths.

Care quality for people who died of cancer was more likely to be perceived as outstanding than care for people who died from cardiovascular disease – indicating that there are ongoing problems with integrating palliative care services into cardiovascular disease management.

Only 44% of respondents reported that the person had expressed a wish about where they would like to die. This is at odds with other surveys which have suggested that the majority of people would like to die at home.

The report highlights several causes for concern in terms of the provision of end-of-life care in the UK. Most notably, it appears that people who die at home are still not receiving adequate pain relief, that people dying from non-cancer disease continue to be neglected by the end-of-life care services and that the wishes of people who are dying are not being adequately communicated to their loved ones.

 

The transition from childhood to adult palliative care: A time for action

27 Jun, 12 | by Assistant Editor

Young people with palliative care needs from across the UK are today lobbying the government to change the way that the transition from childhood to adult palliative care services is handled.

Currently, support for children with life-limiting conditions comes to an abrupt end at the age of either 16 or 18. Services for adults – provided jointly by the National Health Service and other government bodies – are far less extensive, and the sudden loss of support leaves many families in a state of shock.

The issue is particularly timely as, due to rapid medical advancement in the last few decades, more and more people born with life-limiting conditions are surviving to 18 and beyond. In the last ten years alone in the UK the number of young people living with long-term health conditions which may require palliative care has risen by 30%.

Over the next two days a group of young people facing this difficult transition are gathering in London to meet with ministers and other healthcare professionals. Their aim is to explain the major failings of the current system and encourage policy-makers to take action. Today the issue is being raised in the House of Lords, and tomorrow it will be discussed at a conference at the Oval Cricket Ground.

The event is accompanied by a report entitled ‘Don’t Let Me Down’ by Marie Curie, which outlines how the current system could be improved and urges the Prime Minister to spearhead the new initiative.

The BMJ’s new stance on assisted dying

18 Jun, 12 | by Assistant Editor

The BMJ recently expressed its support for the notion that the UK’s leading medical bodies, including the BMA and Royal Colleges, abandon their opposition to assisted dying in favour of a neutral stance.

The move comes as a recent poll undertaken by Dignity in Dying revealed that of 1000 GPs surveyed, 62% supported a shift to neutrality. This, accompanied by the finding that over 80% of the general public support the legalisation of assisted dying, means that the BMJ’s stance had become increasingly untenable.

Dr Fiona Godlee, Editor-in-Chief of the BMJ, highlighted similarities with prior opposition to the legalisation of abortion and suggested that whilst doctors would have to carry out the procedure, the decision regarding the concept ‘rests with society and its representatives in parliament.’ In order for society’s views to be expressed adequately, the Healthcare professionals for Assisted Dying (HPAD) ask for the BMA and certain opposing Royal Colleges to move their position to neutrality. At the BMA’s annual conference later this month, a debate on whether to assume a neutral position will ensue.

The proposition of neutrality is supported by HPAD’s Chair and Emeritus Professor of Geriatric Medicine, Raymond Tallis who states that opposition to assisted dying hinders the principle of specific patient-centred care. This view is – at least in part – an acknowledgment of the fact that medical bodies’ opposition to assisted dying is in conflict with the wishes of the general public, the overwhelming majority of whom seem to support it. Thus he states that ‘the proper stance of healthcare professional bodies is one of neutrality’.

In response to the BMJ’s new bearing, Dr Peter Saunders, director of the pro-life group Care Not Killing stated that the call “is a carefully orchestrated move by a small minority of doctors with extreme views aimed at neutralising medical opposition and softening up public and parliamentary opinion in advance of new pressure to change the law.”

He maintains that a change in the law on assisted dying “would place pressure on vulnerable sick, elderly and disabled people to end their lives for fear of being a financial or emotional burden on loved ones” which is “the very last thing we need” at a time when scores of families “are already under considerable financial pressure”.

Whilst this shift towards neutrality may not actively support a case for legal reform on the matter, some have speculated that it may lay the foundations for the legalisation of assisted dying in the UK. However, the case of Belgium shows that in order for legal reform to occur, there must be overwhelming public, as well as institutional, support for it. The fundamental question is whether or not this is currently the case in the UK.

 

__________________________________________________

 

Medical bodies’ stances on assisted dying

Opposed

BMA

Royal College of Physicians of London

Royal College of Surgeons of England

Royal College of General Practitioners

Association of Palliative Medicine

No position

General Medical Council

Royal College of Anaesthetists

Royal College of Obstetricians and Gynaecologists

Royal College of Paediatrics and Child Health

Royal College of Physicians of Edinburgh

Royal College of Surgeons Edinburgh

Neutral

Royal Society of Medicine

Royal College of Nursing

Royal College of Nursing Scotland

Royal College of Psychiatrists

New NICE guidelines aim to address patient concerns about the use of opioids in advanced disease.

24 May, 12 | by Assistant Editor

The UK’s Institute for Clinical Excellence has released new guidelines which aim to standardize the use of opioids in advanced disease pain management.

It is estimated that each year in the UK some 300,000 people are diagnosed with cancer and 900,000 have heart failure. As well as this, thousands live with long-term chronic conditions such as kidney disease and COPD.

Despite the fact that opioids offer the most effective pain control in advanced disease, both patients and doctors seem unwilling to use them.

Often, it seems, patients worry about the side-effects of opioid painkillers, as well as the possibility of becoming addicted. According to Dr Damien Longson, Chair of the Guideline Development Group,  “Because opioids are powerful medicines people worry they can become addicted, particularly if opioids are prescribed over an extended period of time”.

As well as this, many doctors seem unsure about when strong opioids are an effective and appropriate treatment option.

The new guidelines aim to combat both patient and doctor aversion to opioid prescribing.

The guidelines recommend more clear and effective communication with patients, including asking them about their concerns and discussing these with them. Also, NICE recommends that patients be given access to out of hours contacts and frequent reviews of pain control and side effects.

Regular oral sustained-release or immediate-release preparations are recommended for patients beginning strong opioid treatment for chronic disease, with rescue doses of oral immediate-release preparations for breakthrough pain.

Read the full guidelines here: http://www.nice.org.uk/CG140

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