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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.


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

Department of Health in England launches end of life survey

27 Oct, 11 | by Assistant Editor

A new survey commissioned by the Department of Health aims to gauge the quality of end of life care in England. The project, which is being administered by the Office for National Statistics (ONS) will involve sending a postal survey to 49,000 individuals who registered the death of a loved one between November 2010 and June 2011.

Questions will relate both to the quality of care that the loved one received and also the support available to the respondents themselves. The results of the survey will inform the DoH End of Life Care Strategy which aims to improve the care available to people dying from long-term illness.

The results of the survey should be made available in March 2012.

Read the 2008 End of Life Care Strategy here.

British GPs urged to “find their 1%”

25 Oct, 11 | by Assistant Editor

A new campaign by the Dying Matters Coalition is encouraging GPs to identify the 1% of their patients who are entering their last year of life.

The Find Your 1% project aims to promote discussion of end-of-life care in order to increase the number of people dying at home. A report released last year by the National End of Life Intelligence Network showed that whilst over 60% of people would prefer to die in their own home, only around 20% actually are.

A key goal of the campaign is to encourage people to think about where they would like to die, as well as to empower them to tell their carers and loved-ones where they would like to spend their final days.

In order to recognise individuals who may benefit from the scheme, GPs are urged to ask themselves the question “Would I be surprised if this person were to die in the next 12 months?” during routine consultations with patients.

However, accurately predicting someone’s life expectancy at any given age is generally very difficult (particularly if they haven’t been diagnosed with a serious illness) and some commentators, including Northumberland LMC secretary Dr Jane Lothian, have suggested that the ‘somewhat arbitrary’ selection of patients may be ethically unsound.

Find out more about the campaign here.

Increase in admissions to palliative care in Australian hospitals

21 Oct, 11 | by Assistant Editor

A new study by the Australian Institute of Health and Welfare (AIHW) shows that over the last decade the number of hospital admissions for palliative care services has increased by over 50%.

This news was well received by Palliative Care Australia (PCA), an organisation which promotes the provision of quality end of life care. Dr Yvonne Luxford, PCA Chief Executive said “This is a fantastic indicator that our hospital system is gaining an understanding of the need to refer people to palliative care. What we need to make sure, however, is that people are receiving high quality care, and one way to do this is by ensuring that education about palliative and end of life care is a standard provision for all health professionals.”

Maintaining quality of care is especially important in light of the study’s other main finding – that the average length of hospital stay for palliative care patients in Australia is 12.5 days – almost four times longer than the average for all admissions (3.2 days). With palliative care provision and utilisation on the rise, more funding may well be needed to keep care quality at a premium.

The study also showed that people with cancer are overwhelmingly referred to palliative care (69% of cancer patients in the study), but that only 21% of individuals suffering from heart failure and 20% from COPD were admitted to palliative care services, highlighting a discrepancy in the types of serious illness which are considered to benefit from palliation.

Read the full report here.

Access to palliative care in the US is improving but further work is needed.

14 Oct, 11 | by Assistant Editor

The US-based Center to Advance Palliative Care has issued a national ‘Report Card’ which upgrades the overall level of palliative care accessibility in the country to a B grade, up from C in 2008.

But whilst the number of hospitals with specialist palliative care units has increased significantly in recent years (more than doubling since 2000), there is still room for improvement, with Diane Meier, director of the Center, stating that “millions of seriously ill Americans still do not have access.”

As well as an overall national grade, the report marked states individually, with seven states (including Minnesota, Vermont and Washington) scoring an A – up from just three in 2008. Most states received a B grade, with only two – Delaware and Mississippi – given an F.

Read the full report and view the interactive map here.

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