Palliative Medicine recent issues

Palliative sedation: welcome guidance on a controversial issue

Hauser, K., Walsh, D. — Mon, 26 Oct 2009 09:39:38 PDT

European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care

Mon, 26 Oct 2009 09:39:38 PDT

The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review.

What do patients with brain metastases from non-small cell lung cancer want from their treatment?

Dorman, S., Hayes, J., Pease, N. — Mon, 26 Oct 2009 09:39:38 PDT

Brain metastases are a common complication of non-small cell lung cancer (NSCLC). Prognosis is poor and the effectiveness of whole brain radiotherapy (WBRT) is uncertain for patients with moderate performance status. Studies on WBRT effectiveness have thus far used outcome measures, such as survival, performance status and cognitive function. The aim of this study was to study what patients with recently diagnosed brain metastases from NSCLC want from their treatment. We carried out semistructured interviews with nine patients with brain metastases from NSCLC, for whom the benefit of WBRT is uncertain. Interpretative phenomenological analysis was used. Themes identified included quality versus quantity of life, factors contributing to quality of life (including family, mobility and normality), ‘Go for it!’ — the desire to try anything, the desire for a cure or ‘magic wand’, fear and other factors (including family in decision making, information or lack of information, relationship with professionals, experience of steroids and radiotherapy including adverse effects). Quality of life is important to patients, but many are keen to try any treatment which might prolong their life. Understanding patients’ values regarding treatment and goals of treatment can help clinicians discuss these issues with patients and provide appropriate information and can aid selection of appropriate outcome measures.

Improving training in spiritual care: a qualitative study exploring patient perceptions of professional educational requirements

Yardley, S., Walshe, C., Parr, A. — Mon, 26 Oct 2009 09:39:38 PDT

Healthcare professionals express difficulties in delivering spiritual care, despite it being a core component of palliative care national policies. The patient perspective on professional training to address difficulties has not previously been sought. The aim of this study is to describe patient suggestions for development of training to deliver spiritual care. Qualitative semi-structured in-depth ‘palliative patient’ interviews (n = 20) were analysed thematically. Training suggestions encompassed practical care delivery. Patients supported staff who introduced questions about spiritual needs, and they expected opportunities to engage in spiritual care discussions. The ‘right’ attitude for spiritual care delivery was defined as being non-judgemental, providing integrated care and showing interest in individuals. Training issues included patient perspectives of boundaries between personal and professional roles. This study provides ‘palliative patient’ perspectives to strengthen recommended models of spiritual care delivery. It shows that user opinions on training can be helpful not only in deciding objectives but also how to achieve them.

Physician factors associated with outpatient palliative care referral

Ahluwalia, S., Fried, T. — Mon, 26 Oct 2009 09:39:38 PDT

Outpatient palliative care can provide significant benefits to seriously ill patients, but several barriers to appropriate referrals remain. No study has examined the physician factors associated with referral to outpatient palliative care. To determine physician factors, with a focus on physician beliefs, associated with referral to palliative care. Cross-sectional study of 170 primary care physicians at Kaiser Permanente (KP), a large non-profit Health Maintenance Organisation (HMO), using a self-administered questionnaire. Of the 145 respondents, 100 (70%) reported referring any patients to the palliative care program in the prior year, with a median of 3 referrals (interquartile range 2, 6). Factors associated with referral included working at KP between 10 and 20 years as compared to <10 years [Odds ratio [OR] 6.29 (95% confidence interval [CI] 1.38, 28.6)] and having personal experience with palliative care [OR 2.13 (95% CI 0.95, 4.976)]. None of the beliefs scales was associated with referral. Physician characteristics other than their beliefs about palliative care played a significant role in determining referral. Palliative care programs should aim to increase their visibility in the outpatient setting to increase referrals by primary care physicians. Tools that help physicians identify seriously ill patients who could benefit from palliative care may also serve to increase appropriate referrals.

End-of-life care in hospital: a descriptive study of all inpatient deaths in 1 year

Abel, J., Rich, A., Griffin, T., Purdy, S. — Mon, 26 Oct 2009 09:39:38 PDT

The objectives of this study are to ascertain how many patients who died in a district general hospital in England might have been able to be cared for at home, to obtain the cost of each inpatient stay, to make an estimate of the maximum resource implications of care packages for these patients, and to calculate the savings in hospital admissions that could be used for the development of community services. These objectives are dependant on full implementation of the End of Life Strategy. A descriptive study of all inpatient deaths in one year in a district general hospital in the south west of England was conducted. Data collection — case notes of all patients who died at the hospital from the beginning of June 2006 to end of May 2007. A total of 599 case notes of 627 patients who died in the study period were reviewed. A total of 331 patients (56%) were not assessed as being in the last year of life. Of the remaining 44%, 152 (26%) were clearly in the last year of life and 110 (18%) had significant co-morbidities and could probably have been recognised as being in the last year of life. A total of 399 (67%) of patients were appropriately admitted to hospital for their final illness, 194 (33%) could have been looked after at home. At least 119 (20%) clearly and 75 (13%) probably could have stayed at home. The mean cost of admission was £3173 per patient. A total of 77 (13%) of patients were admitted from nursing homes and 53 (69%) of these could have stayed in the nursing home to die. A total of 44% of all patients who died within the district general hospital had chronic life threatening illnesses. A maximum of one third of all hospital deaths could have been looked after at home if excellent end of life services were in place. When commissioning end of life care services, it is possible to calculate how many extra patients may need community care packages and the cost that could be redistributed from hospital to community for these services.

Prioritising drugs for single patient (n-of-1) trials in palliative care

Mon, 26 Oct 2009 09:39:38 PDT

Many of the drugs prescribed commonly to palliative care patients have potentially significant side-effects and are of unproven benefit. The acquisition of evidence to support the prescribing of these drugs has been very slow. Single patient trials (SPTs) (also known as n-of-1 trials) offer a potential means of obtaining the evidence necessary to support or refute the use of several of the drugs and interventions whose use is currently based on physician experience or anecdote alone. A list of SPTs considered "most urgent", for commonly employed treatments and for the most common and most troublesome symptoms in palliative care is presented. These are drugs for which the gap between evidence and practice is greatest, where the evidence of efficacy is most lacking, where significant side effects potentially lead to the greatest morbidity, or where cost is a major patient burden. Although not all the drugs used in palliative care are suitable, SPTs provide a potential alternative method of gathering evidence in palliative care.

Clinical findings and recommendations made during home visits by a palliative care specialist physician

Bush, S., Wearne, H., Reilly, P., Chacko, R, Palmer, J. — Mon, 26 Oct 2009 09:39:38 PDT

Little has been reported regarding the nature of home visits by palliative care specialist physicians to assist in the management of complex cases. We determined the characteristics, actionable clinical findings and recommendations made during consecutive home visits conducted by a specialist physician for patients registered with a community palliative care service. Patient demographic information and clinical records were reviewed. Ninety-one patients received a total of 104 home and residential facility visits. Median patient age was 59 (Q1—Q3, 43—72). Ten children (under the age of 14) received a total of 15 visits. Seventy-three patients (80%) had a cancer diagnosis. Median visit duration was 60 min (Q1—Q3, 45—60). The major actionable clinical findings were pain (120), gastrointestinal (115), neuropsychiatric (58), mouth and skin (33) and respiratory (29). One-third of recommendations involved changes in analgesia regimen (opioids 67, adjuvants 44). The specialist physician home visit resulted in multiple patient care recommendations. This information may help palliative care programmes improve their care for patients and families in the community.

Barriers to advance care planning in chronic obstructive pulmonary disease

Mon, 26 Oct 2009 09:39:38 PDT

The English End of Life Care Strategy promises that all patients with advanced, life limiting illness will have the opportunity to participate in Advance Care Planning (ACP). For patients with Chronic Obstructive Pulmonary Disease (COPD), the barriers to this being achieved in practice are under-explored. Five focus groups were held with a total of 39 health care professionals involved in the care of patients with COPD. Participants reported that discussions relating to ACP are very rarely initiated with patients with COPD and identified the following barriers: inadequate information provision about the likely course of COPD at diagnosis; lack of consensus regarding who should initiate ACP and in which setting; connotations of comparing COPD with cancer; ACP discussions conflicting with goals of chronic disease management; and a lack of understanding of the meaning of ‘end of life’ within the context of COPD. The findings from this study indicate that, for patients with COPD, significant service improvement is needed before the objective of the End of Life Care Strategy regarding patient participation in end of life decision-making is to be achieved. Whilst the findings support the Strategy’s recommendations regarding an urgent for both professional education and increased public education about end of life issues, they also indicate that these alone will not be enough to effect the level of change required. Consideration also needs to be given to the integration of chronic disease management and end of life care and to developing definitions of end of life care that fit with concepts of ‘continuous palliation’.

Nurses' attitudes towards end-of-life decisions in medical practice: a nationwide study in Flanders, Belgium

Inghelbrecht, E., Bilsen, J., Mortier, F., Deliens, L. — Mon, 26 Oct 2009 09:39:38 PDT

We investigated on a nationwide level the attitudes of nurses towards end-of-life decisions (ELDs) that may hasten death and towards their role in those decisions. We took a representative random sample of 6000 nurses in Flanders, Belgium. Response rate was 62.5%. Most nurses agreed with the practice of withholding/withdrawing potentially life-prolonging treatments (93%), with decisions to alleviate symptoms with possible life-shortening side effects (96%) and with the practice of euthanasia (92%). Their support for the different decisions existed regardless of whether they had cared for terminally ill patients or not. Most nurses also thought that they have an important role to play especially in the ELD-making process. Nurses’ views on their proper role in the administration of drugs in euthanasia and continuous deep sedation showed a large dispersal. Overall, nurses’ work setting determines their opinions on nurses’ role in ELDs. In conclusion, nurses accept a wide variety of ELDs being practiced with terminally ill patients.

Reliability and validity of Japanese version of the McGill Quality of Life Questionnaire assessed by application in palliative care wards

Tsujikawa, M., Yokoyama, K., Urakawa, K., Onishi, K. — Mon, 26 Oct 2009 09:39:38 PDT

The McGill Quality of Life Questionnaire (MQOL), which consists of 16 items constructing physical, psychological, existential and support subscales and one item of overall quality of life (QOL), has been developed to assess QOL of terminal cancer patients. To examine if MQOL Japanese version (MQOL-J) is applicable, it was administered to 83 terminal cancer patients in palliative care wards several days after admission and then 7 to 10 days after the first interview. Cronbach’s coefficient for four subscales was 0.584—0.860. Sixteen items were classified into four factors by factor analysis, similar to the original English version. The results indicated that psychological and existential domains of the MQOL-J significantly related to overall QOL. Existential and support domains as well as overall QOL were significantly improved between the first and second interviews, although performance status assessed by Eastern Cooperative Oncology Group worsened. It is suggested that MQOL-J can reflect perceived health status of terminal cancer patients.

Adverse events arising from a palliative care survey

Mon, 26 Oct 2009 09:39:38 PDT

Development of evidence-based practice requires investigation of the attitudes and needs of patients, families and healthcare professionals, particularly for sensitive subject areas. Cystic fibrosis (CF) is a recessively inherited life-limiting disorder resulting in early death. Patients with this condition generally expect that lung transplantation will be an available treatment option; however, this is uncertain. A dual approach to care that involves both preparing patients for transplant assessment, while simultaneously exploring acceptable palliative care options is needed. A survey amongst patients with CF, their families and health carers was conducted to understand their attitudes and needs in relation to end-of-life care. The survey encompassed five separate domains, with a total of 60 questions requiring approximately 20 min to complete. Of the 200 surveys sent to patients, 82 (41%) completed responses were received. The Institutional Ethics Committee received six complaints from families of seven patients (3.5% of those surveyed). This article explores the nature of the adverse responses to the survey. The majority of complaints were received from family members rather than from patients. Complaints described dissatisfaction with the topic, little warning about the study and felt it to be inappropriate for their family member’s level of health. Survey instruments used to determine attitudes and needs in relation to end-of-life patient care are likely to elicit adverse responses that should be reported in a similar way to other investigational studies. Also arising from adverse responses and the complaint process, is the impact of criticism on study researchers.

Can ketamine prescribed for pain cause damage to the urinary tract?

Storr, T., Quibell, R. — Mon, 26 Oct 2009 09:39:38 PDT

Presentation of three palliative care patients who were given ketamine as an analgesic and subsequently developed significant and debilitating urological symptoms. In one patient there was resolution of symptoms following cessation of ketamine, but some symptoms persisted until death in the other two. Possible mechanisms for damage to the urothelium by ketamine are suggested.

Reporting end-of-life practice: can we trust doctors to be honest?

Draper, H., Ives, J., Pall, H., Smith, S., Damery, S., Wilson, S. — Mon, 26 Oct 2009 09:39:38 PDT

Methodological review: measured and reported congruence between preferred and actual place of death

Bell, C., Somogyi-Zalud, E, Masaki, K. — Tue, 04 Aug 2009 06:40:43 PDT

Congruence between preferred and actual place of death is an important palliative care outcome reported in the literature. We examined methods of measuring and reporting congruence to highlight variations impairing cross-study comparisons. Medline, PsychInfo, CINAHL, and Web of Science were systematically searched for clinical research studies examining patient preference and congruence as an outcome. Data were extracted into a matrix, including purpose, reported congruence, and method for eliciting preference. Studies were graded for quality. Using tables of preferred versus actual places of death, an overall congruence (total met preferences out of total preferences) and a kappa statistic of agreement were determined for each study. Twelve studies were identified. Percentage of congruence was reported using four different definitions. Ten studies provided a table or partial table of preferred versus actual deaths for each place. Three studies provided kappa statistics. No study achieved better than moderate agreement when analysed using kappa statistics. A study which elicited ideal preference reported the lowest agreement, while longitudinal studies reporting final preferred place of death yielded the highest agreement (moderate agreement). Two other studies of select populations also yielded moderate agreement. There is marked variation in methods of eliciting and reporting congruence, even among studies focused on congruence as an outcome. Cross-study comparison would be enhanced by the use of similar questions to elicit preference, tables of preferred versus actual places of death, and kappa statistics of agreement.

Symptoms and problems in a nationally representative sample of advanced cancer patients

Johnsen, A., Petersen, M., Pedersen, L, Groenvold, M — Tue, 04 Aug 2009 06:40:43 PDT

Little is known about the need for palliative care among advanced cancer patients who are not in specialist palliative care. The purpose was to identify prevalence and predictors of symptoms and problems in a nationally representative sample of Danish advanced cancer patients. Patients with cancer stage 3 or 4 from 54 hospital departments (n = 1630) received the EORTC QLQ-C30 questionnaire. Mean scores were calculated according to the scoring manual and in addition a ‘symptom/problem’ and a ‘severe symptom/problem’ was defined and calculated. Multiple logistic regression was used to identify predictors. In total, 977 (60%) patients participated. The most frequent symptoms/problems were fatigue (57%; severe 22%) followed by reduced role function, insomnia and pain. Age, cancer stage, primary tumour, type of department, marital status and whether the patient had recently been hospitalized or not were associated with several symptoms and problems. This is probably the first nationally representative study of its kind. It shows that advanced cancer patients in Denmark have symptoms and problems that deserve attention and that some patient groups are especially at risk.

An evaluation of the implementation of a programme to improve end-of-life care in nursing homes

Badger, F, Clifford, C, Hewison, A, Thomas, K — Tue, 04 Aug 2009 06:40:43 PDT

The Gold Standards Framework in Care Homes programme aims to improve the quality of end-of-life care for residents. The impact of introducing phase 2 of the programme to homes in England was evaluated. A pre–post survey design was adopted, focusing on indicators identified as markers of good end-of-life care. The 95 homes in phase 2 of the programme were invited to participate in the evaluation. Homes completed a baseline survey of care provision and an audit of the five most recent resident deaths. The survey and audit were repeated post programme completion. Forty-nine homes returned completed pre- and post-surveys, 44 returned pre- and post-data on deaths. Although some staff found completion of the programme challenging, homes that returned pre- and post-data demonstrated improvements in aspects of end-of-life care. There were statistically significant increases in the proportion of residents who died in the care homes and those who had an advanced care plan. Crisis admissions to hospital were significantly reduced. This evaluation indicates that appropriately funded structured programmes have the potential to assist nursing homes improve the provision of end-of-life care to older adults, in line with government health policy.

An integrated model of provision of palliative care to patients with cystic fibrosis

Bourke, S., Doe, S., Gascoigne, A., Heslop, K, Fields, M, Reynolds, D, Mannix, K — Tue, 04 Aug 2009 06:40:43 PDT

Palliative care of patients with cystic fibrosis (CF) is often undertaken by CF teams rather than palliative care teams because of the specialist nature of the disease and the potential role of lung transplantation. We developed an integrated model of provision of palliative care whereby most care is delivered by the CF team using palliative guidelines and pathways, with additional support available from the specialist palliative care team when needed. We report our experience of the terminal care of 40 patients with CF with regard to the circumstances of death, lung transplantation status, specific symptoms and provision of palliative treatments. The transition from disease modifying treatments to palliative care was particularly complex. Patients had a high level of symptoms requiring palliation and most died in hospital. Palliative care is a crucial component of a CF service and requires the specialist skills of both the CF and palliative care teams.

An evaluation of two decision-making scales for children with life-limiting illnesses

Knapp, C, Huang, I., Madden, V, Vadaparampil, S, Quinn, G, Shenkman, E — Tue, 04 Aug 2009 06:40:43 PDT

Purpose

Annually, about 500,000 children are coping with life-limiting illnesses. Many of these children could benefit from pediatric palliative care which provides supportive services. These services can also aid parents in decision making. In order to measure the effect of pediatric palliative care programs on decision making, a valid and reliable tool must be identified. This study aims to validate the psychometric properties of the Decisional Conflict Scale (DCS) and the COMRADE instruments for children with life-limiting illnesses.

Methods

Analyses were conducted using survey data collected from 266 parents whose Medicaid enrolled children have life-limiting illnesses.

Results

Results of the analyses suggest that the DCS has better psychometric properties for measuring decision making within the population of children with life-limiting illnesses than the COMRADE.

Conclusion

Pediatric palliative care programs should use the DCS to measure the effectiveness of services aimed at supporting families with high levels of decisional conflict.

The supportive and palliative care needs of Australian families of children who die from cancer

Monterosso, L, Kristjanson, L., Phillips, M. — Tue, 04 Aug 2009 06:40:43 PDT

Objective

To identify the perceptions of parents of children who died from cancer regarding the palliative and supportive care they received in hospital and in community settings.

Method

Face-to-face or telephone questionnaires. Setting Tertiary paediatric oncology centres in Western Australia, New South Wales, Queensland and Victoria.

Participants

69 parents.

Results

Parents indicated the need for clear and honest information about their child’s condition and prognosis throughout the trajectory of illness. Parents also required access to, and advice from, multidisciplinary health professionals when caring for their child at home. Parents preferred to care for their child at home wherever possible throughout the palliative care trajectory of their child’s cancer and were well supported by immediate and extended family and friends. However, many families were affected emotionally and financially by the burden of caring for their child with incurable cancer. Families required financial and practical assistance with providing care from their child. Parents wanted and needed more practical resources and information to assist with the management of their child’s nutrition and pain, as well as for the support of their other children.

Conclusion

Care for children and their families should be coordinated by a multidisciplinary team in consultation with children and their families, and should be linked and integrated with the treating hospital in collaboration with community services.

"We will remember them": a mixed-method study to explore which post-funeral remembrance activities are most significant and important to bereaved people living with loss, and why those particular activities are chosen

Vale-Taylor, P — Tue, 04 Aug 2009 06:40:43 PDT

In an increasingly secular age in which society no longer offers a code of behaviour for those who are bereaved as in Victorian times, the majority of people do not seek support from church-based rituals of remembrance. Most hospices provide religious Services of Remembrance and Thanksgiving or non-faith remembrance gatherings for families and friends, and although these are usually well attended, the average number of families represented is usually less than 20% raising the question of whether alternative support should be offered to the remaining majority of families. This study explored which post-funeral remembrance activities are most significant and important to people living with death-related loss, and why those particular activities are chosen. A total of 43 participants took part in a mixed-method study using 2 different data sets: a self-report questionnaire and semi-structured interviews. To add further contextual data to support the study, a third dataset was created when six hospice bereavement counsellors met as a Focus Group. Results indicated that although formal remembrance events are valued, informal rituals created by the bereaved are more important and significant to them. Results could be divided into four different categories: rituals to maintain a ‘direct link’, or those undertaken ‘for’ the deceased, rituals that remember the deceased within the community and those viewed as an act of remembrance. The most common reason for choosing a ritual was to keep a bond with the deceased or ensure that the deceased was remembered by others. Remembrance and ritual is personal to each individual and is dynamic, altering from day to day. Remembrance appears to be a journey made up of many small daily rituals, some of which are generic to bereaved people and some of which are highly individualistic. For the majority of people, their informal rituals are far more important than the large planned events that hospices offer because the informal rituals occur and serve to sustain people in the context of their daily lives.

Are end-of-life patient education materials readable?

Ache, K., Wallace, L. — Tue, 04 Aug 2009 06:40:43 PDT

Although established guidelines for developing low-literacy patient education materials are available, poorly designed material continue to be disseminated. We evaluated the readability and layout of English-language end-of-life patient education materials available on the Internet. Internet websites of five national palliative care organizations were searched to identify patient education materials for review. A convenience sample of 15 patient education materials per palliative care organization (n = 75) was downloaded and printed. The Simplified Measure of Gobbledygook (SMOG) was used to calculate the reading grade level (readability) of the text, while the layout features was assessed using criteria from the User-Friendliness Tool (UFT). The reading grade level of patient education materials ranged from 7^th to 12^th grade (mean ± SD = 11.1 ± 1.9). None of the patient education materials scored high on all UFT criteria. In particular, the greatest need was increasing the amount of white space and improving the way in which information was organized visually. Healthcare providers can only aid in the decision process, patients and their loved ones are ultimately responsible for making these choices. These decisions are important as choices need to be made about end-of-life care while patients are still cognitively able to do so. Well designed end-of-life patient education materials can offer a wealth of knowledge to assist and guide decision making. On the basis of these results, end-of-life patient education materials should be revised so that the average adult is able to understand the message presented, thereby enhancing his/her ability to make informed decisions.

'They're part of the team': participant evaluation of the ACTIVE intervention

Oliver, D., Washington, K., Wittenberg-Lyles, E, Demiris, G, Porock, D — Tue, 04 Aug 2009 06:40:43 PDT

This study used participant feedback to qualitatively evaluate an intervention (Assessing Caregivers for Team Intervention through Videophone Encounters [ACTIVE]) that used videophone technology to include patients and/or their family caregivers in hospice interdisciplinary team meetings. Data were generated during individual interviews with hospice staff members and family caregivers who participated in ACTIVE intervention. Modified grounded theory procedures served as the primary analysis strategy. Results indicated that ACTIVE intervention enhanced team functioning in terms of context, structure, processes and outcomes. Participants discussed challenges and offered corresponding recommendations to make the intervention more efficient and effective. Data supported the ACTIVE intervention as a way for hospice providers to more fully realise their goal of maximum patient and family participation in care planning.

The use of artificial nutrition among cancer patients enrolled in palliative home care services

Orrevall, Y, Tishelman, C, Permert, J, Cederholm, T — Tue, 04 Aug 2009 06:40:43 PDT

In this study, patients’ views and experiences of using home artificial nutrition, and factors associated with use of home parenteral nutrition (HPN) were investigated. Structured telephone interviews with 620 cancer patients enrolled in 21 palliative home care services were analysed. HPN was more common (11%) than home enteral tube feeding (HETF, 3%). Home artificial nutrition (including HPN and HETF) was usually introduced more than four months before death. Three of four HPN recipients also had oral food intake. HPN use was associated with eating difficulties, nausea/vomiting, and fatigue rather than gastrointestinal problems per se. HETF was generally used for patients with problems related to oesophagus and head and neck tumours. In conclusion the results suggest that, contrary to existing guidelines, HPN is used to supplement oral intake, and not only for patients with a non-functioning gastrointestinal tract.

End-of-life decisions in the United Kingdom

Tue, 04 Aug 2009 06:40:43 PDT

End-of-life decisions in the UK: a response to van der Heide and colleagues

Seale, C — Tue, 04 Aug 2009 06:40:43 PDT

End-of-life decisions in the United Kingdom involving medical practitioners and legalisation of euthanasia or physician-assisted suicide: survey of doctors' attitudes

Tue, 04 Aug 2009 06:40:43 PDT

UK doctors' attitudes to the legalisation of assisted suicide

Lee, W, Price, A, Rayner, L, Hotopf, M — Tue, 04 Aug 2009 06:40:43 PDT

Liverpool care pathway carers survey

Tue, 04 Aug 2009 06:40:43 PDT

Suffering and healing - our core business

George, R — Mon, 15 Jun 2009 03:31:27 PDT

On dying and human suffering

Kellehear, A — Mon, 15 Jun 2009 03:31:27 PDT

This review compares and contrasts the major reoccurring themes in two sources of research literature – social studies of dying and human suffering. The purpose of such a comparison is to employ the major insights of each field as a useful method of critically evaluating the insights of the other. Critical exchanges and comparisons between the research area of dying studies and on human suffering have been modest to date. This article will explain that the experience of dying benefits from being situated and analysed in a broader context of cultural experience, as suggested by the theory and study of human suffering. Conversely, the theory and methods involved in studies of human suffering can gain from a mortal view of vulnerability, grief, social ambiguity and identity changes characteristic of experiences at the end of life.

Prioritisation of future research topics for children's hospice care by its key stakeholders: a Delphi study

Malcolm, C, Knighting, K, Forbat, L, Kearney, N — Mon, 15 Jun 2009 03:31:27 PDT

The Delphi process, widely used in health research to seek consensus on key issues amongst large stakeholder groups, was adopted to allow families, hospice staff/volunteers and linked professionals to identify and prioritise future research priorities for children’s hospice care. In the qualitative Round 1, interviews with families (n = 5), linked professionals (n = 18) and focus groups with hospice staff and volunteers (n = 44) led to the generation of 56 research topics categorised within 14 broad themes. To give a larger number of stakeholders (n = 621) (including families n = 293; hospice staff/volunteers n = 216 and professionals n = 112) the opportunity to rate the importance of each research topic and seek group consensus on the future research priorities for children’s hospice care, subsequent Rounds 2 and 3 involved the use of postal questionnaires. Response rates to questionnaires were 44% in Round 2 (274/621) and 83% in Round 3 (204/247). Participants prioritised research topics relating to 1) hospice and respite care needs of young people (aged 16 +), 2) pain and symptom management and 3) bereavement and end-of-life care. There was wide acknowledgement by those took part in the process of the difficulty in rating the topics, and emphasis on the fact that all of the topics raised during the project are of high importance and merit further research. The current salient issues perceived by key stakeholders as being the research priorities for children’s hospice care were identified. Addressing these priority topics for research would further contribute to the development of a much needed evidence base in children’s hospice and palliative care research and optimise the delivery of children’s hospice services that are underpinned by valid and robust research.

Assessment of iron status and the role for iron-replacement therapy in anaemic cancer patients under the care of a specialist palliative care unit

Robertson*, K., Hutchison, S. — Mon, 15 Jun 2009 03:31:27 PDT

Anaemia is common in advanced cancer, may develop for several reasons, and is not always symptomatic. Our observations of the seemingly indiscriminate prescription of iron-replacement therapy (IRT) for anaemic palliative care patients, and our practice of discontinuing IRT in patients with normal red-cell indices, prompted a study to determine (1) the prevalence of anaemia in our patients, (2) what proportion had iron deficiency, (3) the prevalence and benefits of IRT and (4) the prevalence of side effects attributable to IRT. The prevalence of anaemia was 65%. We found a 9% prevalence of iron deficiency, and suggestive but inconclusive evidence of iron deficiency in a further 41%, but only three (27%) of these patients had typical iron deficiency red-cell indices. Only two patients within the study population were taking IRT. Haemoglobin increased significantly in one, but fell in the other, and both experienced side effects attributable to iron. IRT should neither be indiscriminately prescribed nor withheld for anaemic palliative care patients, and the decision should not be based on red-cell indices alone. When symptomatic anaemia is found in patients whose general condition indicates that IRT would be acceptable, iron status should be fully assessed. A therapeutic trial of IRT may be justified where ferritin is elevated, but other parameters suggest iron deficiency.

Deciding about continuous deep sedation: physicians' perspectives: A focus group study

Mon, 15 Jun 2009 03:31:27 PDT

Although guidelines restrict the use of continuous deep sedation to patients with refractory physical symptoms and a short life-expectancy, its use is not always restricted to these conditions. A focus group study of physicians was conducted to gain more insight in the arguments for and against the use of continuous deep sedation in several clinical situations. Arguments in favour of continuous deep sedation for patients with a longer life-expectancy were that the overall clinical situation is more relevant than life-expectancy alone, and that patients’ wishes should be followed. Continuous deep sedation for patients with predominantly emotional/existential suffering was considered appropriate when physicians empathize with the suffering. Further, some physicians indicated that they may consider the use of sedation in the context of a euthanasia request. Arguments were that the option of continuous deep sedation is a better alternative; it may comfort some patients when their thoughts about potential future suffering become unbearable. Further, some considered continuous deep sedation as less burdening or a bother to perform. We conclude that physicians’ decision-making about continuous deep sedation is characterized by balancing the interests of patients with their own feelings. Accordingly, the reasons for its use are not unambiguous and need further debate.

Paediatricians' perceptions on referrals to paediatric palliative care

Knapp, C, Thompson, L, Madden, V, Shenkman, E — Mon, 15 Jun 2009 03:31:27 PDT

Children have traditionally been referred to palliative care when curative treatments were exhausted. Recently, experts have suggested that children could benefit from palliative care early in their courses of illness. Using survey data from 303 paediatricians in Florida and California, this study assesses if paediatricians would refer children to palliative care early in their course of illness. Results showed that more years in practice were associated with decreased odds of referring children to palliative care. Academic practice setting and more Medicaid patients were associated with greater odds of referral prior to the end of life. Hispanic paediatricians, those with more experience and those who practice in a hospital setting were associated with decreased odds of referral prior to the end of life. Results suggest that health planners who wish to implement or refine integrated paediatric palliative care programs should consider outreach strategies targeted at paediatricians with specific characteristics.

Multiple sources: mapping the literature of palliative care

Tieman, J., Sladek, R., Currow, D. — Mon, 15 Jun 2009 03:31:27 PDT

Palliative care is an increasingly important area of clinical practice and health service delivery. The heterogeneity of the patient population and the multidisciplinary nature of care draw on knowledge from many fields of clinical practice and academic enquiry. This has implications for the retrieval of evidence and literature and the spread of new knowledge in palliative care. This study shows that the CINAHL, Embase and PsycINFO bibliographic databases hold sizeable repositories of palliative care articles not indexed on Medline. It also highlights the number and range of journals publishing palliative care content. In 2005 alone, 1985 journals published 6983 items. These findings show the challenges for palliative care professionals in managing the complex evidence base for this diverse field of care and the importance of mechanisms that facilitate the identification of palliative care information. Dissemination strategies that ensure that new knowledge reaches the many audiences implicit in the range of journals publishing palliative care are also critical in supporting improvements in clinical practice and service delivery.

Characteristics and implications of attrition in health-related quality of life studies in palliative care

Ahlner-Elmqvist, M, Bjordal, K, Jordhoy, M., Kaasa, S, Jannert, M — Mon, 15 Jun 2009 03:31:27 PDT

In a longitudinal study of 297 palliative care patients, 280 patients were followed from inclusion to death. Characteristics and health-related quality of life (HRQL) of the participants and those who later dropped out were compared at inclusion, and 3 and 2 months before their death. At inclusion, the dropouts were older (P = 0.001), had reduced Karnofsky performance score (P < 0.001), received more help from the local authority (P = 0.004) and had reduced HRQL compared with patients who continued in the study and completed the next questionnaire. There were no differences in any of the HRQL parameters between participants and dropouts 3 months before death. Two months before death, differences in HRQL were found, but in favour of the dropouts. Data from patients close to death may be representative of a larger group of patients, whereas initial dropouts may lead to a positive bias of reported HRQL.

Palliative day care - a study of well-being and health-related quality of life

Andersson Sviden, G, Furst, C., von Koch, L, Borell, L — Mon, 15 Jun 2009 03:31:27 PDT

Aim

The aim of the study was to study the outcomes of palliative day care, in terms of health-related quality of life and the emotional well-being of cancer patients participating in a palliative day care programme for a period of five weeks, compared with a group of palliative cancer patients not participating in day-care.

Methods

The day care sample comprised of patients in a palliative day care programme delivered in two different day care facilities. Participants in the comparison group were recruited from a palliative home care service facility. All patients had a cancer diagnosis. The participants were invited to respond to two questionnaires once a week for a period of five weeks; the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30) and the Mood Adjective List (MACL).

Results

The participants in the day care group and the comparison group reported similar levels of perceived functioning and symptoms, as measured by the EORTC QLQ-30, with no significant differences between the groups. However, the day care group reported higher levels of emotional well-being as measured by the MACL than the comparison group reported, although these differences were not statistically significant.

Resource utilisation and costs of palliative cancer care in an interdisciplinary health care model

Johnson, A., Abernathy, T, Howell, D, Brazil, K, Scott, S — Mon, 15 Jun 2009 03:31:27 PDT

This paper presents a detailed description of health care resource utilisation and costs of a pilot interdisciplinary health care model of palliative home care in Ontario, Canada. The descriptive evaluation entailed examining the use of services and costs of the pilot program: patient demographics, length of stay broken down by disposition (discharged, alive, death), access to services/resources, use of family physician and specialist services, and drug use. There were 434 patients included in the pilot program. Total costs were approximately CAN$2.4 million, and the cost per person amounted to approximately CAN$5586.33 with average length of stay equal to over 2 months (64.22 days). One may assume that length of stay would be influenced by the amount of service and support available. Future research might investigate whether in-home palliative home care is the most cost effective and suitable care setting for those patients requiring home care services for expected periods of time.

Hospital staff attributions of the causes of physician variation in end-of-life treatment intensity

Larochelle, M., Rodriguez, K., Arnold, R., Barnato, A. — Mon, 15 Jun 2009 03:31:27 PDT

Discrepancies between patient wishes and end-of-life treatment decisions have been documented, and the determinants of end-of-life treatment decisions are not well understood. Our objective was to understand hospital staff perceptions of the role of acute care hospital medical doctors in end-of-life treatment intensity. In 11 purposively sampled Pennsylvania hospitals, we completed 108 audiotaped semistructured interviews with key informants involved in decision making or discharge planning. Using grounded theory, we qualitatively analysed transcripts using constant comparison to identify factors affecting end-of-life treatment decisions. A predominant theme identified was that end-of-life treatment intensity depends on the doctor. Communication with patients and families and collaboration with other care team members also were reported to vary, contributing to treatment variation. Informants attributed physician variation to individual beliefs and attitudes regarding the end-of-life (religion and culture, determination of when a patient is dying, quality-of-life determination and fear of failing) and to socialization by and interaction with the healthcare system (training, role perception, experience and response to incentives). When end-of-life treatment depends on the doctor, patient and family preferences may be neglected. Targeted interventions may reduce variability and align end-of-life treatment with patient wishes.

An unusual cause of insomnia

Dando, N, England, S, Ford-Dunn, S — Mon, 15 Jun 2009 03:31:27 PDT

We report the case of a patient with tonsillar carcinoma, presenting with insomnia and symptoms of obstructive sleep apnoea/hypopnea syndrome (OSAHS), which were exacerbated following an increase in benzodiazepine dose. There is a growing body of evidence describing OSAHS in patients treated for head and neck cancer. However, to our knowledge, there are no reports relating to the population of patients with progressive disease, whose management is palliative. We would advise consideration be given to the possibility of OSAHS in a patient presenting with an oropharyngeal tumour and sleep disturbance and would also suggest caution in the prescription of benzodiazepines and other sedative medication to this group of patients.

The use of thalidomide in the management of bleeding from a gastric cancer

Lambert, K, Ward, J — Mon, 15 Jun 2009 03:31:27 PDT

Medical management of severe gastrointestinal bleeding can present a therapeutic challenge. We describe a case of bleeding secondary to gastric cancer that failed to settle, despite treatment with tranexamic acid, etamsylate and sucralfate. Thalidomide was prescribed for its antiangiogenic properties. Bleeding settled within 1 week of starting 300 mg of thalidomide nocte. The effect appeared to be dose dependant, with bleeding recurring only when the dose was reduced to 100 mg of thalidomide nocte.

Erratum

Mon, 15 Jun 2009 03:31:27 PDT

Key stakeholders' experiences and views of the NHS End of Life Care Programme: findings from a national evaluation

Kennedy, S, Seymour, J, Almack, K, Cox, K — Mon, 11 May 2009 01:33:05 PDT

This article reports on the qualitative interview component of a national evaluation of the NHS End of Life Care Programme. It describes and discusses the views and experiences of 37 stakeholders of the Programme in relation to its development and implementation, impact and sustainability. The sample comprises individuals holding different roles in, and contrasting views and experiences of the Programme, and from various locations in England. Overall, the aims, approach and impact of the Programme were described positively, although concerns about achieving sustainability were widespread. The extent of support for the Programme's primary aim to extend and improve end of life care, and the contribution of the hardworking and skilled individuals involved with its implementation, were highlighted as key influences on its successes. The authors conclude that many of the views and experiences highlighted in the stakeholder enquiry are reflected in the development and detail of the recently announced End of Life Care Strategy.

Classification of pain in cancer patients - a systematic literature review

Mon, 11 May 2009 01:33:05 PDT

One of the aims of the European Palliative Care Research Collaborative (EPCRC) is to achieve consensus on a classification system for cancer pain. We performed a systematic literature review to identify existing classification systems and domains/items used to classify cancer patients with pain. In a systematic search in the databases Medline and Embase, covering 1986–2006, 692 hits were obtained. 92 papers were evaluated to address pain classification. Six standardised classification systems were identified; three of them systematically developed and partially validated. Both pain characteristics and patient characteristics relevant for cancer pain classification were included in the classification systems. All but one of the standardised systems aim at predicting treatment response or adequacy of treatment. Several domains and items used to describe cancer pain but not formally described as part of a classification system were also identified and systematised. The existing approaches to pain classification in cancer patients are different, mostly not thoroughly validated, and none is widely applied. An internationally accepted classification system for cancer pain could improve research and cancer pain management. This systematic review suggests a need for developing an international consensus on how to classify pain in cancer patients.

Does palliative home oxygen improve dyspnoea? A consecutive cohort study

Currow, D., Agar, M, Smith, J, Abernethy, A. — Mon, 11 May 2009 01:33:05 PDT

Palliative oxygen for refractory dyspnoea is frequently prescribed, even when the criteria for long-term home oxygen (based on survival, rather than the symptomatic relief of breathlessness) are not met. Little is known about how palliative home oxygen affects symptomatic breathlessness. A 4 -year consecutive cohort from a regional community palliative care service in Western Australia was used to compare baseline breathlessness before oxygen therapy with dyspnoea sub-scales on the symptom assessment scores (SAS; 0–10) 1 and 2 weeks after the introduction of oxygen. Demographic and clinical characteristics of people who responded were included in a multi-variable logistic regression model. Of the study population (n = 5862), 21.1% (n = 1239) were prescribed oxygen of whom 413 had before and after data that could be included in this analysis. The mean breathlessness before home oxygen was 5.3 (SD 2.5; median 5; range 0–10). There were no significant differences overall at 1 or 2 weeks (P = 0.28) nor for any diagnostic sub-groups. One hundred and fifty people (of 413) had more than a 20% improvement in mean dyspnoea scores. In multi-factor analysis, neither the underlying diagnosis causing breathlessness nor the demographic factors predicted responders at 1 week. Oxygen prescribed on the basis of breathlessness alone across a large population predominantly with cancer does not improve breathlessness for the majority of people. Prospective randomised trials in people with cancer and non-cancer are needed to determine whether oxygen can reduce the progression of breathlessness compared to a control arm.

Ratings of symptoms and comfort in dementia patients at the end of life: comparison of nurses and families

van der Steen, J., Gijsberts, M., Knol, D., Deliens, L, Muller, M. — Mon, 11 May 2009 01:33:05 PDT

After-death reporting by proxies on end-of-life outcomes is used in research and can also be used to target institutions directly to improve practice. We compared the scores of family caregivers and nurses on two End-of-Life in Dementia Scales (EOLD) scales: Symptom Management (SM; range 0–45) over the last 3 months of life and Comfort Assessment in Dying (CAD; range 14–42). Higher scores represent better outcomes. Four Dutch nursing homes retrospectively enrolled 48 decedents with dementia. Total mean scores for family caregivers and nurses were 28.7 (SD 9.6) versus 25.2 (SD 12.7) for the SM and 31.7 (SD 5.5) versus 32.8 (SD 8.2) for the CAD. Mean item scores also did not differ much. Concordance Correlation Coefficients were 0.42 (SM) and 0.04 (CAD). Mean evaluations of end of life with dementia corresponded reasonably well between family and professional caregivers, but correspondence of individual observations was poor to moderate, suggesting serious differences in individual ratings but little systematic difference.

Modafinil for the treatment of fatigue in lung cancer: a pilot study

Spathis, A, Dhillan, R, Booden, D, Forbes, K, Vrotsou, K, Fife, K — Mon, 11 May 2009 01:33:05 PDT

Cancer-related fatigue is the most prevalent and distressing symptom experienced by patients with advanced cancer. Central nervous system stimulants have been shown to relieve fatigue in nonmalignant disease. Modafinil is a stimulant with a selective site of action in the brain that is better tolerated than traditional stimulants, such as methylphenidate. The aim of this study was to determine the feasibility of conducting a randomised controlled trial to assess the efficacy and safety of modafinil for the treatment of fatigue in patients with lung cancer. Twenty patients with non-small cell lung cancer were recruited to this open-label study. Modafinil was taken in a fixed dose-titration schedule of 100 mg daily for 7 days followed by 200 mg daily for 7 days. Fifteen patients completed the study. During the study period, there was a rapid and statistically significant reduction in the primary outcome, fatigue (P = 0.001) and the secondary outcomes of daytime sleepiness and depression/anxiety. This improvement in fatigue was also clinically significant. Ten patients chose to continue modafinil after the study and the drug was well-tolerated. It would be both feasible and worthwhile to conduct a definitive randomised controlled trial to determine the role of modafinil in the treatment of cancer-related fatigue.

Advance care planning in care homes for older people: an English perspective

Froggatt, K, Vaughan, S, Bernard, C, Wild, D — Mon, 11 May 2009 01:33:05 PDT

Advance care planning (ACP) as a process of discussing and recording wishes for future care and treatment is increasingly being promoted and discussed in the UK, reflecting recent changes in legislation. This study describes current ACP practice in care homes for older people drawing on data from a questionnaire survey (n = 213) of, and interviews (n = 15) with, care home managers. Whilst consultation about general care is taking place in the majority of homes surveyed using both formal and informal processes, the number of residents that have completed any ACP processes varies. Managers face intrinsic and extrinsic challenges related to the ascertaining of, and the implementing of wishes as they address ACP in the care home context. Until these wider contextual factors are addressed it will be difficult for staff in care homes to effectively undertake and implement ACP in care homes.

Supporting lay carers in end of life care: current gaps and future priorities

Mon, 11 May 2009 01:33:05 PDT

Informal carers are central to the achievement of end of life care and death at home and to policy aims of enabling patient choice towards end of life. They provide a substantial, yet hidden contribution to our economy. This entails considerable personal cost to carers, and it is recognised that their needs should be assessed and addressed. However, we lack good research evidence on how best to do this. The present position paper gives an overview of the current state of carer research, its gaps and weaknesses, and outlines future priorities. It draws on a comprehensive review of the carer literature and a consensus meeting by experts in the field. Carers’ needs and adverse effects of caregiving have been extensively researched. In contrast, we lack both empirical longitudinal research and conceptual models to establish how adverse effects may be prevented through appropriate support. A reactive, "repair" approach predominates. Evaluations of existing interventions provide limited information, due to limited rigour in design and the wide variety in types of intervention evaluated. Further research is required into the particular challenges that the dual role of carers as both clients and providers pose for intervention design, suggesting a need for future emphasis on positive aspects of caregiving and empowerment. We require more longitudinal research and user involvement to aid development of interventions and more experimental and quasi-experimental research to evaluate them, with better utilisation of the natural experiments afforded by intra- and international differences in service provision.

Information disclosure to terminally ill patients and their relatives: self-reported practice of Belgian clinical specialists and general practitioners

Michiels, E, Deschepper, R, Bilsen, J, Mortier, F, Deliens, L — Mon, 11 May 2009 01:33:06 PDT

Objective of this study is to examine physicians’ practices regarding information disclosure to terminally ill patients and to their relatives, without informing the patient. A questionnaire had been sent to a random sample of 3014 Belgian physicians from different specialties frequently involved in end-of-life care. Responses were analysed using weighted percentages, Chi-square, Mann–Whitney U-tests and a multivariate ordinal logistic regression. Response rate was 58%. Both clinical specialists and general practitioners (GPs) discuss most topics related to terminal illness with their patients except end-of-life hastening options, spirituality, life expectancy and options to withhold/withdraw life-sustaining treatment. The topics which most physicians always discuss with relatives without informing the patient are the aim of treatment, palliative care and incurability. There is a significant difference between clinical specialists and GPs. Clinical specialists and GPs discuss most end-of-life topics with the patient but omit important issues such as end-of-life hastening options and life-expectancy.

Illness awareness in terminal cancer patients: an Italian study

Corli, O, Apolone, G, Pizzuto, M, Cesaris, L, Cozzolino, A, Orsi, L, Enterri, L — Mon, 11 May 2009 01:33:06 PDT

The amount and quality of information and awareness in cancer patients’ is a topic frequently debated, but few studies have focussed on terminal patients. This is the objective of the present study that involved two different palliative home-care units in Italy, which recruited 550 terminal cancer patients. Data from patients and their caregivers was prospectively collected with special attention to information patients were provided with when their cancer was diagnosed and patients’ awareness of their current health condition. In the case of the information, 67.0% of patients reported they were previously informed about their diagnosis, but only 58.0% seemed to be aware of their terminal condition. The comparison between the caregivers opinions about the level of information provided to the patients and their present awareness and what the patients really know about their own disease shows a high degree of correspondence. Some variables such as age and education level of patients were associated with patient’s awareness.

Improved competence after a palliative care course for internal medicine residents

Mulder, S., Bleijenberg, G, Verhagen, S., Stuyt, P., Schijven, M., Tack, C. — Mon, 11 May 2009 01:33:06 PDT

Residents report that they received inadequate teaching in palliative care and low levels of comfort and skills when taking care of dying patients. This study describes the effects of a problem-based palliative care course on perceived competence and knowledge in a representative Dutch cohort of residents in internal medicine. Before and after the course, we carried out a questionnaire survey and knowledge test in 91 residents. The results show that many residents felt they had limited competence or were incompetent when taking care of patients in the palliative care phase. This was particularly true with respect to communication concerning euthanasia and physician-assisted suicide or hastened death (86% and 85% respectively reported limited competence or incompetence). Participants reported that they received inadequate training in palliative care and believed that specific education would make them feel more competent. The number of times that residents were engaged in palliative care situations and the years of clinical experience had a positive influence on perceived competence. Participating in the course improved perceived competence and knowledge in palliative care. No correlation was found between perceived competence and knowledge of palliative care.

Treatment of palliative care emergencies by prehospital emergency physicians in Germany: an interview based investigation

Wiese, C., Bartels, U., Ruppert, D, Marung, H, Luiz, T, Graf, B., Hanekop, G. — Mon, 11 May 2009 01:33:06 PDT

Palliative care medical emergencies as a consequence of advanced cancer account for approximately 3% of all prehospital emergency cases. Therefore, prehospital emergency physicians (EP) are confronted with ‘end of life decisions’. No educational content exists concerning palliative medicine in emergency medicine curricula. Over the course of 6 months, we interviewed 150 EPs about their experiences in ‘end of life decisions’ using a specific questionnaire. The total response rate was 69% (n = 104). Most of the interviewed EPs (89%, n = 93) had been confronted with palliative care medical emergencies and expressed uncertainties in dealing with these difficult situations, especially in the area of psychosocial care of the patients (50%). The emergency treatment of palliative care patients can become a particular challenge for any EP. A large percentage of interviewed EPs felt uncertain about aspects of social care and in the assessment of decisions at the end of life. Further information and training are necessary to amenable EPs to provide adequate patient-oriented care to palliative care patients and their relatives in emergency situations.

A UK hospice's position on assisted dying

Stephenson, J. — Mon, 11 May 2009 01:33:06 PDT

Corrigendum to "The management of constipation in palliative care: clinical practice recommendations" by PJ Larkin, NP Sykes, C Centeno, JE Ellershaw, F Elsner, B Eugene, JRG Gootjes, M Nabal, A Noguera, C Ripamonti, F Zucco, and WWA Zuurmond; On behalf of The European Consensus Group on Constipation in Palliative Care: Palliative Medicine 2008; 22: 796-807. DOI: 10.1177/0269216308096908.

Mon, 11 May 2009 01:33:06 PDT

Book reviews

Mon, 11 May 2009 01:33:06 PDT