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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.

News and updates from www.palliativedrugs.com

3 Feb, 17 | by bbutcher

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

Hot topics

Association for Paediatric Palliative Medicine (APPM) Master Formulary 2017

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

 

Cochrane review: fentanyl for neuropathic pain

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

 

Cochrane review: hydromorphone for cancer pain

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

 

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

This updated review (CD007354) confirmed the previous conclusions:

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

For more information, click here.

 

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

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

Drug updates

Gabapentin oral solution and enteral feeding tubes

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

Latest additions

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

 

Prepared by Sarah Charlesworth and Andrew Wilcock

Shortcuts

31 Jan, 17 | by bbutcher

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

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

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

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

 

Composed by Elaine Boland

Shortcuts

15 Jan, 17 | by bbutcher

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

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

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

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

 

Composed by Elaine Boland

News and updates from www.palliativedrugs.com

28 Dec, 16 | by James Smallbone, Publishing Assistant

22/12/16

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

Safety updates

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

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

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

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

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

 

Drug updates

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

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

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

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

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

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

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

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

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

 

Latest additions

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

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

To purchase a licensed copy, and help support palliativedrugs.com, please go to our store. For enquiries regarding multiple copies please contact hq@palliativedrugs.com

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

Chapter 02: Systemic local anaesthetics

For a full list of all the monographs updated since the print publication of PCF5, click here. Follow us on twitter @palliativedrugs for the latest updates.

 

Prepared by Sarah Charlesworth and Andrew Wilcock

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

22 Dec, 16 | by James Smallbone, Publishing Assistant

It’s eponymous my dear Watson!

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

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

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

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

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

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

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

Yours,

Minton (of the lesser kinky hair)

 

By Ollie Minton

News and updates from www.palliativedrugs.com

14 Oct, 16 | by Jenny Thomas

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

Hot Topics

Updated Do Not Attempt Cardiopulmonary Resuscitation policy

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

British guideline on management of asthma updated

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

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

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

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

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

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

NICE guidance on multimorbidity

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

Drug updates

Palladone (hydromorphone) SPC updated

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

Authorized glycopyrronium oral solution now available in UK

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

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

SMC accepts diamorphine nasal spray

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

Latest additions

PCF5+ 2016 pdf available soon!

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

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

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

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

Results from our survey (August-September 2016).

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

 Prepared by Sarah Charlesworth and Andrew Wilcock

Palliative or supportive? A rose by any other name

22 Sep, 16 | by Jenny Thomas

by Dr Ollie Minton, Macmillan consultant and honorary senior lecturer in palliative medicine.

I do not assume everyone has an intricate knowledge of Shakespeare but most will be familiar with the balcony scene in Romeo & Juliet. The inference is that the name of something does not affect how it functions. I won’t extrapolate that any perceived speciality conflict is on a par with the Montagues & Capulets. Although there is an on-going debate about how we should best work together & within that how best to name ourselves.

However, if the plural of anecdote does not equal data then I am left wondering what the technical term is for the extrapolation of a single trial result. We can all accept the evidence hierarchy mantra (with some qualitative side bars) & that meta-analysis is “king”.

It is why I need to question the need to alter the word palliative to supportive.

The evidence, such as it is, comes from a 2009 trial in an American cancer centre. This was a survey of medical oncologists & while I won’t argue with the conclusions that renaming the service resulted in more referrals, I do wonder if it clouds a more nuanced issue.   Attempts to address this subsequently focus on broader working relationships and less on the specific terminology of the service. However these approaches are open to wide local variation depending on staff and organisational setup- the name of the service is one aspect. The demand for all our services is increasing year on year regardless.

I am aware the journal is called supportive and palliative care and the two words are a powerful combination. All health care professionals provide “supportive care” or at least they should, as the reports of care of the dying patient make it clear “it’s everybody’s business”. This is further complicated by regulatory guidance from e.g. the UK General Medical Council which refers to end of life care. This is probably akin to other speciality terminology – geriatricians debating frailty, deconditioning & the impact of multiple co-morbidity. We all have some understanding of these terms but the exact definition & interpretation will differ amongst professionals. We are probably all guilty of speciality specific blinkering but I’d like to think just because I have a hammer in my toolbox… A debate about the rights and wrongs of specific words is not necessarily relevant to patient care.

If the name of the service was important to patients then I would be less recalcitrant. A trial attempted to address this issue, but I am still left wondering. The design is overly complex (2x 2 factorial) in a small number of patients and the wording was combined with differing descriptions of the service.  At a time when openness and transparency to enable decision making is paramount, I don’t think a statistically significant change with a 0-10 scale is the outcome measure of choice. 

I come back to the fact we do not solely deal with cancer; any proposed name changes are as a result of at most 50% of our referrals. Anecdotally our relationship locally with oncology is clear – oncologists refer to  my colleagues in palliative care in order to develop, highlight and/or augment the serious illness conversations that palliative patients need and of course deal with their symptoms. They may emphasise certain aspects of our role – such as a focus on symptom control rather than end of life care, but I have never been aware of anyone not referred to palliative care, for fear of what our service name may do to the patient. We, for our part, minimise any obstacles to seeing appropriate patients and while there are a variety of models we can adopt, we need to be resolute in the approach and service we offer. We should be proud that a palliative ( & supportive) approach does not discriminate about diagnosis/ stage but is based on need and the name does not alter that.

News and updates from www.palliativedrugs.com

8 Sep, 16 | by Jenny Thomas

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

Hot topics

Cochrane review: codeine versus placebo for cough in children

In this review the authors conclude that codeine (or its derivatives) should not be used for cough in children <12 years, because:

  • there is no published RCT evidence of benefit in this age group
  • children may have a greater risk of undesirable effects
  • the high degree of variability in the metabolism of codeine to morphine in children, may negate a therapeutic effect or, conversely, risk opioid toxicity and respiratory depression
  • the underlying aetiology should be defined, rather than the cough empirically treated.

For more information, click here.

 Cochrane review: oxycodone for neuropathic pain

A previous Cochrane review on oxycodone for neuropathic pain and fibromyalgia has been split into separate reviews and the use of oxycodone for neuropathic pain has been updated (CD010692). The authors concluded that there was very limited evidence that oxycodone (as oxycodone m/r) provides moderate benefit (30% reduction in pain) in painful diabetic neuropathy or postherpetic neuralgia. There was no evidence for other neuropathic pain conditions. For more information, click here.

 NICE- Call for evidence for End of Life Care service delivery

NICE are requesting information for the guideline they are developing on End of Life Care for adults in the last year of life, specifically, on service delivery models to:

  • identify people who may be entering the last year of their life
  • support people to stay in their preferred place of care (e.g. out of hours services)
  • facilitate smooth transitions between care settings (e.g. discharge planning teams)
  • facilitate continuity and coordination of care (e.g. multidisciplinary team working)
  • reduce inappropriate/avoidable hospital admissions (e.g. community health services and telehealth)
  • facilitate discharge back to the community from other settings (e.g. rapid discharge pathways).

The deadline for submission is 19 September 2016. For more information, click here.

Latest additions

PCF updated monographs summary (August 2016)

The on-line Palliative Care Formulary is being continually updated. The following monographs have been updated during August 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 01: Quick Clinical Guide: Death rattle (noisy rattling breathing), Quick Clinical Guide: Opioid-induced constipation, Laxatives (minor change), H2-receptor antagonists (minor change)

Chapter 02: Haemostatics

Chapter 04: Antihistaminic antimuscarinic anti-emetics (minor change)

Chapter 05: Paracetamol, Morphine (minor change)

Chapter 06: Helicobacter pylori gastritis monograph discontinued

Chapter 07: Corticosteroids (minor change), Danazol, Demeclocycline, Desmopressin

Chapter 10: Skeletal muscle relaxants (minor change)

Chapter 13: Propofol

For further details of minor changes, see the individual notifications in the Latest additions section of http://www.palliativedrugs.com/latest.html.

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.

Parenteral NSAIDs – Which one do you use?

Results from our survey (June-July 2016).

Prepared by Sarah Charlesworth and Andrew Wilcock

Shortcuts

31 Aug, 16 | by Jenny Thomas

JAMA Neurol. 2016 May 16. doi: 10.1001/jamaneurol.2016.0383. [Epub ahead of print]

The Association of Chemotherapy-Induced Peripheral Neuropathy Symptoms and the Risk of Falling.

Kolb NA, Smith AG, Singleton JR, et al

A secondary analysis of a prospective study was performed to determine the association between the symptoms of taxane/platinum chemotherapy-induced peripheral neuropathy (CIPN) and the risk of falls. From 116 patients with breast, ovarian, or lung cancer, 32 had CIPN symptoms. Seventy-four falls or near falls were reported over an average follow-up of 2 months. Those with CIPN were nearly 3 times more likely to report a fall or near fall than those without, with 8/32 (25%) with CIPN obtaining medical care for falls, compared to 6/84 (7%) without CIPN. The authors suggest education and monitoring of patients receiving neurotoxic chemotherapy may facilitate fall prevention strategies.

Shortcuts are compiled by Jason Boland

It’s good to talk and even better to communicate effectively

24 Aug, 16 | by BMJSPCblog

EAB2B298-BCFB-4937-967D-0C60CBDB51C5aby Dr Ollie Minton, Macmillan consultant and honorary senior lecturer in palliative medicine

I remember the old British Telecom adverts moving from Maureen Lipman’s “ooh he’s got an ology” to the final incarnation of Bob Hoskins “It’s good to talk”. I’m fairly certain after this, the internet took off and the simple phone call was confined to the snapchat bin of history.
Judging by current commentary, we are even supposed to move beyond emails – not likely until we move away from being fax dependent- but my point is there are so many methods to “communicate”.

However when we talk about delivering bad news, a rapidly changing condition or the uncertainty of a changing illness a quick text or tweet status update isn’t quite sufficient. We as specialists pride ourselves on the ability to address all of these problems and more. As someone is approaching the end of life, communication really needs to be face to face. This is not an innate skill and it requires training to be done effectively.
While others invariably use the excuse of insufficient time, I believe lack of confidence is a significant driver of avoidance, or at the very least minimisation to address these areas. Perhaps more importantly, patients and families value these conversations especially around uncertainty & decision making in advanced illness.  We as professionals need to be able to meet these needs.

In the halcyon days of core MDT funding every member was funded to undertake an “advanced communication skills course”. While I am not going to debate the merits of three vs two days, multiprofessional , residential and so forth, there was ample evidence to support the course leading to sustained behavioural change. Sadly because of the costs involved and the lack of hard outcomes these have been discontinued. In part perhaps because there was no direct correlation to improvement in patient experience, for example. However there is a database (unpublished) of post course confidence scores addressing a variety of complex communication scenarios. The headline summary was that 12,000 clinicians were trained. The longer term impact has not been studied. We are left not knowing if this is a critical mass of professionals has achieved consistent change.

A recognition of lost time has been made in a Marie Curie report entitled the long and winding road.
This draws in all aspects of communication, as I alluded to at the start, but recognises the missed opportunities and the continued need to meet the expectation of sensitive tailored communication and shared decision making. Equally as it is now 2016, the report authors mention the impact of “Dr Google” and the influence of technology. They label it a call to action but acknowledge the four year hiatus and lost momentum after funding for communication training was withdrawn in 2012.

If I thought that revised medical school curricula and a cultural shift had solved these problems, I would rest easy. While we can teach these skills in the same way as prescribing they can only be developed with experience and relying on absorption through role modelling is insufficient and not in line with the ample evidence base on communication training.

Training previously has focused on experiential learning but using cancer as the model. The now defunct national cancer action team has given way to Health Education England , the GMC and other organisations who are responsible for post graduate development.
The development of simulation in medical education gives ample opportunities for flexibility in developing these skills provided the core elements of experienced facilitation, actors and video feedback are used. These can be delivered in a set way to small groups and provide training in particular areas as needed.

Outside of our speciality I observe limitations in conversations about advance care planning , uncertainty, escalation of treatment & of course DNACPR. This is addition to the development of delivering bad news, discussing complex treatment plans tailored to the individual patient need and so forth. However I would not want to see this merely added to a portfolio of more areas to be assessed. There needs to be some fluidity in how this is done to meet individual clinicians’ learning needs.
This approach is in keeping with elements of the recent independent cancer task force , albeit recommendation 60- a long way behind personalised medicine and the digital revolution.

In conclusion I can’t stress the importance of every health care professional having impeccable communication skills. While we have no control over all the methods an organisation uses to disseminate information, we all want to avoid the immortal aphorism of Cool Hand Luke: “What we’ve got here is failure to communicate”

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