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Psychology and palliative care services working together- on cultivating multi-disciplinary meetings and ensuring compassion in care

20 Nov, 14 | by makt

by Dr Katherine Regan, Clinical Psychologist, Wales, UK
Dr Regan shares her experiences working in close collaboration with a specialist palliative care team at Velindre Cancer Centre in Cardiff, Wales. She discusses why collaborative working across both areas is a useful model for the future and how both fields can learn much from one another.

Introduction

The following account is a reflection on joint working between clinical psychology and specialist palliative care services. This was in the context of weekly palliative care meetings within a multidisciplinary team (MDT) structure and also shared clinical encounters on the wards and in outpatient clinics in a large tertiary cancer centre in Wales between 2013 and 2014. At the time, I was completing my PhD thesis in clinical psychology and also working as a clinical psychology trainee and I have outlined my findings and thoughts on this experience in the following paragraphs.

Puzzle

Being a part of the Palliative Care MDT

As a clinical psychology professional having just started working in a tertiary cancer centre, I was asked whether I would like to join the weekly specialist palliative care meetings. Multi-disciplinary team (MDT) working is a fundamental cornerstone to the delivery of holistic, compassionate palliative care services (NICE, 2004), so I was keen to see this process in action, as someone who had not previously worked on a palliative team before. It provided me not only with an understanding of how palliative care as a specialty works, but a number of other reflections, too. For instance, I was someone who was experiencing this sometimes scary, daunting, even sad sounding specialty for the first time, with perhaps similar notions and preconceptions as touched on in an article by Mark Taubert (Taubert, 2013), but these were very swiftly cast aside.

From an early stage, the meetings felt like a safe space where insights into patient care were discussed refreshingly candidly and openly. All its members, independent of their professional background, contributed very actively; additional perspectives were actively encouraged. In these meetings I was able to discuss my concerns and queries from a psychology professional’s perspective, such as enquiring about patient consent, care planning, involving friends or family and offering insight into assessing psychological wellbeing and risk. Topics such as pain management, communicating with patients and families and end-of-life care-planning came up frequently. Areas of uncertainty were flagged, and the excellent Cancer Research Wales Library in Velindre Cancer Centre were sometimes able to provide same-day evidence for clinical queries, which were fed back at each palliative MDT meeting. Through enhancing my understanding of medical and palliative issues, I was better informed when supporting my own clients, having a deeper understanding of the medical and supportive healthcare context that surrounds them.

My regular MDT involvement developed into providing teaching for the team on skills in assessing and managing psychological risk and extended to developing bespoke teaching/supervision sessions for the team on issues suggested by the team (e.g. using mindfulness in practice and anxiety in cancer/palliative patients).

I was privileged to observe the team at work and witness their style of communication with palliative patients. Palliative care doctors and nurses were able to have meaningful conversations with patients about their choices, treatments, wishes, and preferences within the end-of-life context. Their communicative style appeared to enhance making shared, patient-informed decisions about end-of-life care. These conversations were happening in a very respectful and emotionally-containing way, despite the distressing context for patients and families. Topics of conversation were wide-ranging, from specifics surrounding cancer pain management to use of social media as a support mechanism through prolonged inpatient hospital stays.

The team recognised the coping strategies patients and families can rely on during times of distress and pain, and were able to normalise these responses as opposed to pathologise them. These skills in formulating/contextualising the problem, instead of placing ‘problems’ within the patient, mirrors the aim of clinical psychological assessment and intervention-planning.
In a setting where clinicians and patients are making life-changing decisions concerning the risks and benefits of proposed cancer treatments, the communication skills of palliative care professionals will be hugely beneficial if an avenue for sharing these skills with other cancer care professionals is developed.

Challenges and hurdles facing Palliative Care and Psychology Teams in Cancer Settings

The intuition about a patient’s experience of distress was very genuinely displayed in many of our MDT discussions. However this skill may also represent a barrier to clarifying patients’ understanding, expectations and wishes in end-of-life care, for both psychology and palliative care professionals. It is well understood that when professionals identify, or strongly empathise, with patients it can feel even more difficult to see those patients struggle with their life-limiting condition. This level of identification with patients may inadvertently influence our assumptions, or conclusions, about what these patients may be thinking, frightened of, or hope for, as we start to imagine how we would be coping in those circumstances. Discussing death and dying is uncomfortable, and even the best communicators can fall victim to psychological defences that arise in order to deal with this discomfort e.g. avoiding asking difficult questions in order to rescue the patient from their existential anxieties, or interrupting silences that may feel uncomfortable but should be left to give the patient time to formulate their distress.

During my work with the team I became aware of the teams interest in self-care, especially within the context of receiving frequent referrals for patients who had become distressed while admitted on the wards. It could be easy to feel that palliative care’s role was to ‘fix’ patients when they become upset, through medication and support. This is often a shared experience for psychological services, where an influx of referrals can occur in the context of a patient’s distress over diagnosis, prognosis or end of curative treatment.

If both psychology and palliative care are thought of as services that can ‘rescue’ patients from their (understandable) distress, joint-working may have an impact on improving a wider understanding of our services. Sharing our professional goals, values and skills in managing distress and communication has been beneficial between palliative and psychology services; therefore it may prove beneficial to share this understanding, jointly, with other professionals within cancer services.

However, challenges for maintaining and developing a clinically effective working relationship between psychology and palliative care exist. Finding the time and space for palliative care professionals to develop psychologically-informed techniques in managing distress and pain, and feel confident about them, is difficult. Perhaps continuing to cultivate a reciprocal relationship between psychological services and palliative care is one solution, where a venue to discuss and learn from cases can be developed. Creating opportunities for psychology to model or share their clinical practice with palliative care colleagues may also normalise the use of psychologically informed communication skills and strategies.

Cultivating Compassionate Care through MDT working

The experience of being ‘assimilated’ into the palliative care MDT leads to a conclusion that a pre-requisite to delivering compassion in care is cultivating compassionate care within multidisciplinary relationships. As a professional outside of the palliative care team I was welcomed into a team that values being proactive, emphasizes active participation, agency and being collaborative– which is what psychologists recognize as key facets to developing clinically effective therapeutic relationships for psychological interventions (e.g. Cognitive Analytic Therapy, Ryle and Kerr, 2002).

Self-care within cancer services is a challenge in itself. Cultivating a MDT that cares for its team members, as well as its patients may enhance delivering compassionate care, as it is thought that compassionate role models can energise staff and enhance others’ ability to be compassionate. (Chellel et al, 2013) Having strategies for promoting self-care can increase personal and professional wellbeing and improve patient care. Sanchez-Reilly and Morrison et al (2013) describe validated methods for enhancing self-care for professionals when caring for patients with life-limiting cancer. These strategies include:

1) create a network of peers and co-workers and stay connected with them on an ongoing basis,

2) improve communication and management skills by seeking additional training,

3) practice meaning-based coping by sharing personal and professional sources of meaning and incorporating into daily practice.

Upon reflecting on the working relationship established between psychology and palliative care, it was apparent that the MDT itself embodied these strategies intuitively. Compassion is a value recognised by healthcare professionals, patients and the public yet it can be difficult to describe it. It is represented in many ways; a word, a smile, an act of kindness, or by listening to another person. The evidence shows that compassion is seen in small things that make a big difference to one’s comfort (Compassion in Practice, 2013). Compassion makes people – patients and professionals- feel cared for, and can be embodied within an MDT that makes one feels proud to be a part of.

References

Chellel, A, Ramage, C and Watters, P (2013) A Theory of Compassion as Revealed by the Narratives of Nurses, Patients and Relatives. Brighton: Brighton and Sussex University Hospitals Trust.
NHS England (2013).Compassion in Practice – One year on. http://www.england.nhs.uk/wp-content/uploads/2013/11/comp-pract-1yr-on.pdf (accessed on September 30th, 2014).

National Institute for Clinical Excellence (NICE) (2004). Improving Supportive and Palliative Care for Adults with Cancer. http://www.nice.org.uk/guidance/csgsp (accessed on September 30th 2014).

Ryle, A. and Kerr, I.B. (2002) Introducing Cognitive Analytic Therapy: Principles and Practice. Chichester, Wiley.

Sanchez-Reilly, S., Morrison, L. J., Carey, E., Bernacki, R., O’Neill, L., Kapo, J., … & deLima Thomas, J. (2013). Caring for oneself to care for others: physicians and their self-care. The Journal of Supportive Oncology, 11(2), 75.

Taubert M   Palliative Care- A depressing specialty? BMJ blog  http://blogs.bmj.com/bmj/2013/10/14/mark-taubert-palliative-care-a-depressing-specialty/  (accessed on 06/11/2014)

News and updates from www.palliativedrugs.com

16 Jun, 14 | by James Smallbone, Publishing Assistant

9th June 2014

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.

 

Hot topics

NICE Evidence Update: Opioids in palliative care
The UK National Institute for Health and Care Excellence has produced a summary of the selected new evidence relevant to the use of opioids in palliative care since the NICE clinical guideline: Opioids in palliative care (CG140) was published in 2012. The new evidence identified in this Evidence Update (58) is not expected to have any impact on the existing guidance. For more information, click here.

 

Drug updates

Tramadol to become Schedule 3 Controlled Drug
Tramadol, currently a Prescription Only Medicine (POM) will become a Schedule 3 Controlled Drug as from 10 June 2014 in England, Wales and Scotland. Controlled Drug prescription requirements will apply, but it will be exempt from safe custody requirements. This follows a consultation by the advisory Council on the Misuse of Drugs (see our news article 14 March 2014). For more information, click here.

Zopiclone and zaleplon to become Schedule 4 (Part 1) Controlled Drugs
Zopiclone and zaleplon currently both Prescription Only Medicines (POM) will become Schedule 4 (Part 1) Controlled Drugs as from 10 June 2014 in England, Wales and Scotland. This brings them under the same category as zolpidem and the benzodiazepines (except temazepam and midazolam). For more information, click here.

Ketamine injection supply problems
Pfizer UK has confirmed that it is currently out of stock of ketamine (Ketalar) 10mg/mL and 100mg/mL injection and that the 50mg/mL injection is very low. There have been supply problems with ketamine injection since November 2012 (see our news article 21-09-2012). The ketamine 10mg/mL and 100mg/mL are not expected to be back in stock until March 2015. There are currently no further details on the 50mg/mL injection. For enquiries please contact Pfizer customer services (01304 616161).

 

Latest additions

PCF updated monographs
The following monographs of the on-line Palliative Care Formulary (PCF) have been updated during April 2014 and supersede those in the publication of the 4th edition of the Palliative Care formulary (PCF4) and PCF4+2013 epdf. They can be accessed from the formulary section of the website:

Chapter 01: Loperamide
Chapter 02: Haemostatics (new merged monograph)
Chapter 04: Melatonin, Anti-epileptics (new merged monograph), Gabapentin and pregabalin (new merged monograph), Carbamazepine, Oxcarbazepine, Levetiracetam, Valproate
Chapter 05: Paracetamol, Nefopam, Celecoxib (minor update), Ibuprofen (minor update), Diamorphine, Alfentanil, Quick Prescribing Guide: Management of procedure-related pain
Chapter 06: Helicobacter pylori gastritis
Chapter 07: Progestogens
Chapter 09: Ferrous sulfate
Chapter 10: Rubefacients and other topical products
Chapter 20: Quick Clinical Guide: Setting up a CME McKinley T34 syringe pump for CSCI

For a full list of all the monographs updated since the publication of PCF4, click here. Follow us on twitter @palliativedrugs for the latest updates.

Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from www.palliativedrugs.com

11 Mar, 13 | by Assistant Editor

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.

 

Drug updates

 

DTB Sativex in multiple sclerosis

The latest Drug and Therapeutics Bulletin (DTB) examines the place of the cannabinoid product, Sativex (GW Pharma, UK) in multiple sclerosis. For more information click here.

 

Glycopyrronium bromide inhaler launched in UK

A glycopyrronium bromide hard capsule powder inhaler (Seebri Breezhaler, Novartis) has been launched in the UK as a maintenance bronchodilator treatment to relieve symptoms in adult patients with chronic obstructive pulmonary disease (COPD). The recommended dose is 50microgram once daily. The NHS cost of an inhaler plus 30 capsules = £28. The Scottish Medicines Consortium (SMC) has accepted Seebri Breezhaler for use within NHS Scotland. For the SPC, click here.

The National Institute for Health and Clinical Effectiveness (NICE) has produced a new medicine evidence summary for this product which can be accessed from the here.

 

Carbamazepine, oxcarbazepine and eslicarbazepine risk of serious skin reactions

The December Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update has highlighted the risk of serious skin reactions, including Stevens-Johnson syndrome, with carbamazepine, oxcarbazepine and eslicarbazepine in patients with European descent or Japanese origin who have the HLA-A*3101 genetic marker. The risk of serious skin reactions with these drugs is known to be associated with patients of Asian origin who have the genetic marker HLA-B*1502, and screening is recommended for patients of Han Chinese or Thai origin before treatment with these drugs.

There are currently insufficient data to support screening for the HLA-A*3101 genetic marker before treatment. Current advice is that patients of European descent or Japanese origin who are known to have the genetic marker HLA-A*3101 should only receive carbamazepine, oxcarbazepine or eslicarbazepine after careful consideration of the benefits and risks.

 

NICE evidence summary of oral magnesium glycerophosphate use

The National Institute for Health and Clinical Excellence (NICE) has published its evidence summary for the use of unauthorized (unlicensed) oral magnesium glycerophosphate for preventing recurrent hypomagnesaemia.

 

Prepared by Sarah Charlesworth and Andrew Wilcock

News and updates from www.palliativedrugs.com

8 Mar, 13 | by Assistant Editor

Selected items from the News and Latest Additions sections of www.palliativedrugs.com, the world’s leading palliative care website.

Hot topics

Haloperidol for psychosis-induced aggression or agitation

A Cochrane review has been published on the use of haloperidol for rapid tranquilisation of psychosis-induced aggression or agitation. For more information click here.

 

BNF palliative care section updated

The online BNF (December 2012) palliative care section has been reorganised and now includes new tables for opioid conversions. The new pain management with opioids section has been organised to provide guidance on specific routes for pain management. The equivalent doses of opioid analgesics table has been expanded to include more drugs and routes; also included is a new buprenorphine table and updated fentanyl patch conversion table. For more information click here.

 

Guide on advance decisions to refuse treatment

The National Council for Palliative Care and the NHS National End of Life Care Programme have produced a guide for health professionals on Advance Decisions to Refuse Treatment (ADRT). This guide supersedes the 2008 version and can be downloaded from the NHS National End of Life Care website.

 

Prepared by Sarah Charlesworth and Andrew Wilcock

New study finds that UK breast cancer patients receive insufficient pain management and palliative care

22 Nov, 11 | by Assistant Editor

A study conducted by researchers at Breast Cancer Care and the University of Southampton indicates that over a third of female breast cancer patients are in unnecessary discomfort – despite recent advances in medical management of the disease.

The cross-sectional survey was carried out in two cancer centres in the UK and assessed a wide-range of quality of life indicators amongst 235 women with metastatic breast cancer. Over a quarter of the sample reported experiencing shortness of breath (27%) and nausea (26%). Additionally, 34% of participants reported high levels of pain or other uncontrolled symptoms.

Most notably, only 7% of respondents stated that they were being treated by local palliative care services and just 6% by their GP, indicating that there may be an unmet need in terms of access to palliative care amongst the study population.

The study highlights the fact that although palliative care services in the UK are amongst the most extensive in the world, their use is still generally confined to the very end of life and they are often not used alongside curative interventions.

Survey shows US doctors are strongly in favour of palliative care

17 Nov, 11 | by Assistant Editor

A poll released this week by The National Journal and Regence Foundation found that doctors in the US are overwhelmingly supportive of palliative care interventions for seriously ill patients.

Of the 500 doctors who completed the survey, 96% believed that enhancing the quality of life of seriously ill patients was more important than extending their lives for as long as possible. Another 96% of respondents agreed that making palliative care available to all patients who need it should be a higher priority for American healthcare providers.

When a similar survey was carried out on a random sample of adults earlier this year, only 71% said that quality of life was more important than length of life, indicating a difference of opinion between medical professionals and the general public.

The results also showed that whilst a large proportion of doctors believed that palliative care is important, a quarter stated that they were not sufficiently prepared to discuss options for end of life care with patients; highlighting a possible gap in expertise and training and perhaps also an unwillingness to tackle what is seen as a very sensitive subject.

Read an overview of the results here.

US project aims to integrate palliative care and emergency medicine

15 Nov, 11 | by Assistant Editor

A newly launched national initiative in the US entitled Improving Palliative Care in Emergency Medicine (IPAL-EM) will promote access to palliative medicine for seriously ill patients presenting at emergency departments.

The project, which was supported in part by the Centre to Advance Palliative Care, aims to increase referral rates for seriously ill patients from emergency wards to more appropriate care settings and also to improve control of physical symptoms.

It has become increasingly apparent over recent years that the fields of emergency medicine and palliative care are inter-linked in terms of patient experience. Many people suffering from serious and long-term illnesses will attend an emergency department at some point, often in need of pain relief. There is also more recognition of the general role which palliative care can play in the emergency room, where it can be used to decrease both physical pain and stress experienced by patients and their loved ones.

IPAL-EM aims to provide palliative and emergency physicians with the tools and evidence necessary to integrate the two therapeutic areas.

Tearfund to launch palliative care services in Zimbabwe

8 Nov, 11 | by Assistant Editor

The relief and development agency Tearfund is to launch a palliative care initiative in Manicaland, Zimbabwe. The project, funded by the Princess of Wales Memorial Fund, will focus on training palliative care professionals in the region, improving access to pain-relieving drugs and developing referral systems.

The population of Manicaland, which is located in the West of the country, has a high prevalence of HIV/AIDS and over 9000 deaths from cancer a year, only 1% of whom receive morphine.

Tearfund was awarded the grant after a pilot project in Tanzania was deemed successful.

The news is sure to be welcomed by advocates of palliative care provision in lower-income countries.

Does the legalisation of euthanasia affect palliative care?

2 Nov, 11 | by Assistant Editor

A new report by the European Association for Palliative Care (EAPC) may challenge the notion that the legalisation of euthanasia negatively affects the growth of palliative care services.

The study, which was originally requested by the Commission on Assisted Dying, compared palliative care indicators in countries with legalised euthanasia (Belgium, The Netherlands,  Switzerland and Luxembourg) and some without (Spain, Germany and France). This was supplemented by a review of the scientific literature on the subject.

The report concluded that there were well-developed palliative care services in countries with legalised euthanasia and that there was no detectable influence of euthanasia legislation upon the development of palliative care.

These results run contrary to the opinion that palliative care services in a country suffer as a result of assisted dying becoming legal.

However, the authors recommended that any country considering legalising euthanasia should also ensure that there is an equitable, accessible and affordable palliative care framework in place.

Read the full report here.

SHORT CUTS

2 Nov, 11 | by Assistant Editor

Articles of interest in other scholarly journals

Click on the article headings to view abstracts

Antagonistic effects of ondansetron and tramadol? A randomised placebo and active drug controlled study.

Rauers NI, Stüber F, Lee EH, Musshoff F, Fimmers R, Barann M, Stamer UM.

This postoperative randomised, double-blinded study assessed if ondansetron and tramadol had opposing effects and if co-administration decreased their efficacy. It showed that using both drugs together did not increase tramadol use or emesis.

Undocumented alcoholism and its correlation with tobacco and illegal drug use in advanced cancer patients.

Dev R, Parsons HA, Palla S, Palmer JL, Del Fabbro E, Bruera E.

In this retrospective study of 665 patients, the frequency of undiagnosed alcoholism among patients with advanced cancer and its relationship to alcoholism, smoking and use of illegal drugs was assessed. 598 patients had completed the Cut Down, Annoyed, Guilty, Eye Opener (CAGE) questionnaire. The frequency of CAGE-positive results was 17%, of which only 13% had been identified before their palliative care consultation. These patients were more likely to have a current and past history of smoking, and illegal recreational drug use. Pain and dyspnea were worse in patients who had a history of nicotine use. Both CAGE-positive patients and patients who had a history of tobacco use more frequently were receiving strong opioids at the time of their palliative care consultation.

The use of crisis medication in the management of terminal haemorrhage due to incurable cancer: A qualitative study.

Harris D, Finlay I, Flowers S, Noble S.

The practice of relieving patient distress through sedative doses of anxiolytics or opioids in terminal haemorrhage was evaluated through Semi-structured interviews with 11 specialist nurses. This showed that anxiolytics and opioids rarely benefit the patient who is having a terminal haemorrhage as it is so rapid that patients died before it could be administered. Furthermore, it may remove nurses from giving patient care, as staying with and supporting the patient, as well as using dark-coloured towels to camouflage blood was reported to be of more practical use. The focus on administering medications was often to the detriment of these non-pharmacological approaches.

Unidirectional Cross-Activation of GRPR by MOR1D Uncouples Itch and Analgesia Induced by Opioids.

Liu XY, Liu ZC, Sun YG, Ross M, Kim S, Tsai FF, Li QF, Jeffry J, Kim JY, Loh HH, Chen ZF.

Spinal opioids can cause itch, which has previously been thought to result from pain inhibition. This study separates the sensation of itch from analgesia, demonstrating that morphine directly induces itch in a subset of spinal neurons by signalling through a heterodimer of opioid (μ-opioid receptor isoform 1D) and gastrin-releasing peptide receptors. In addition, blocking MOR1D-GRPR association attenuates itch but not analgesia. This study also evaluated the downstream effectors of GRPRs and suggests potential pharmacological targets.

Non-steroidal anti-inflammatory drugs and risk of pulmonary embolism.

Biere-Rafi S, Di Nisio M, Gerdes V, Porreca E, Souverein P, Boer A, Büller H, Kamphuisen P.

In a case-control study (of 4433 cases and 16,802 controls) using a Dutch registry the population based effect of non-steroidal anti-inflammatory drugs (NSAIDs) on pulmonary embolism (PE) was assessed. Current use of NSAIDs was associated with PE, with the overall risk for NSAIDs being highest in the first 30 days of use. Use of acetaminophen and tramadol also increased the risk of PE with a similar time trend. Although NSAIDs are associated with an increased risk of PE, this might be due to the underlying medical condition for which they are prescribed, as suggested by a similarly increased thrombotic risk in patients receiving paracetamol and tramadol.

Comparative clinical effects of hydromorphone and morphine: a meta-analysis.

Felden L, Walter C, Harder S, Treede RD, Kayser H, Drover D, Geisslinger G, Lötsch J.

In this meta-analysis of eight studies the analgesic effects of morphine and hydromorphone were compared. It suggested that hydromorphone (494 patients) provides slightly better (P=0.012) clinical analgesia than morphine (510 patients). The effect-size was small although the advantage of hydromorphone was more evident in studies of better quality. Nausea, vomiting and itching were similar. This suggests some advantage of hydromorphone over morphine for analgesia. The authors suggest that hydromorphone’s safety in renal failure or during acute analgesia titration, are based on limited evidence and require substantiation by further studies.

Methadone toxicity due to smoking cessation–a case report on the drug-drug interaction involving cytochrome P450 isoenzyme 1A2.

Wahawisan J, Kolluru S, Nguyen T, Molina C, Speake J.

To report the potential clinically significant pharmacokinetic interaction that may result from smoking cessation in patients on methadone maintenance therapy.

This case report describes a 46-year-old man with decreased respirations and altered mental status related to methadone toxicity, despite being on a stable dose of methadone for chronic back pain. These toxicities resolved by withholding and then reducing the methadone dose. It was subsequently noted that he had recently stopped smoking, which was thought to be the precipitating factor. The explanation for this effect is that tobacco smoke contains polycyclic aromatic hydrocarbons which induce the cytochrome P450 CYP1A2 enzymes which partly metabolise methadone and decreased smoking can lead to a reduction in methadone metabolism, resulting in higher serum concentrations

By Jason Boland, Consultant in Palliative Medicine, Barnsley Hospice, United Kingdom

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