Carol Douglas

The efficacy of haloperidol in the management of nausea and vomiting in patients with cancer.

CONTEXT Haloperidol is used commonly for the control of nausea and vomiting (N/V) in palliative care patients, but there is very little evidence to support its use. OBJECTIVES To assess the efficacy of haloperidol as an antiemetic in patients with cancer and N/V not related to cancer treatment. METHODS Patients with an N/V score of at least 1 on a 4-point scale were prescribed either oral or subcutaneous haloperidol. N/V and toxicity were assessed daily for the duration of the study (maximum five days) by both the patient and an observer (health professional). RESULTS At Day 2, 33 of 42 (79%) treated patients were assessable for response. Eight (24%; 95% confidence interval [CI]: 10%-39%) patients had complete control of N/V and 12 (36%; 95% CI: 20%-53%) had partial control, giving an overall response rate of 61% (95% CI: 44%-77%). At Day 5, 23 patients were assessable for response. The overall response rate was 17 of 23 (74%; 95% CI: 56%-92%). If all patients are included in the response analysis, the overall response rates at Days 2 and 5 were 47% and 40%, respectively. CONCLUSION Haloperidol has some efficacy in the treatment of N/V in this patient group. The results from this uncontrolled study provide pilot data from which to plan future controlled trials of antiemetics in the palliative care population.

Palliative care in the emergency department: An oxymoron or just good medicine

In 2006, the American Board of Emergency Medicine co‐sponsored hospice and palliative medicine as a recognized medical subspecialty. There is recognition of the need for these skills to be available in EDs in the USA. This article discusses the rationale for integrating a palliative approach in the ED. We need to engage our palliative care colleagues to increase clinical support to meet the needs of these vulnerable patients and to foster collaborative educational opportunities.

The Value of Expert Opinion in Guiding Policy Development To Support Better Care of the Dying in Australasia: A Response to the Letter by Chan and Webster

Dear Editor: Australia New Zealand Society of Palliative Medicine (ANZSPM) Clinical Indicators Working Group is committed to the development of a Clinical Indicator (CI) for the care of the dying. As part of the development of such a CI, a Care-of-theDying Pathway (CODp) workshop was convened at the 2010 ANZSPM Conference. This brought together clinical leaders from Australia and New Zealand in Palliative Medicine to specifically examine the evidence for and relevance of pathway use for supporting terminal care. Scoping of prevalence of pathway use indicated that throughout all states of Australia and throughout New Zealand CODp development and implementation was widespread. The majority of CODps were modified versions of the Liverpool Care Pathway. There is recognition that a CODp is based on previously identified gaps in care and evidence of poor quality care. We wish to emphasize that the CODp guides appropriate and proactive diagnosis of dying, rational deprescribing and relevant prescribing, removes the burden of unnecessary clinical interventions that may be construed as futile treatment, and prompts communication with patient and family. The pathway is supported by evidence-based symptom control. Palliative medicine specialists, through their unique multiple experiences as engaged clinicians, recognise dying and do not view death as a failure, unlike much of the rest of medicine. This aspect is an important component of any CODp. Such recognition and acceptance allows for truthful, realistic and timely endof-life discussions with patients and their caregivers or families. Chan and Webster understand the pathway as a single clinical intervention, rather than a framework that guides the clinician. The danger of applying a reductionist approach, thereby subjecting a quality framework of care for a population of patients (terminal phase) to the rigors of pure randomized control clinical trial research, reduces the individual care of a dying person to ‘a one size fits all’ approach. No two ‘‘pathways’’ look the same on scrutiny, just as no two patients make the same ‘‘journey into the night.’’ As such the argument in the letter by Chan and Webster raises issues profound around the best research methodology to use for investigating the impact of complex multidisciplinary care plans, and the impact of health system changes brought about by care pathways for improving the care of the dying. The limitations of randomized controlled trials as a research methodology are made more obvious when we try to use them to investigate questions around: quality of care provision, health systems design changes, and their impact on evidence. Currently there is debate raging within the Cochrane Collaboration itself with the development of the qualitative methods research group and the effective practice and organization of care subgroups. There was unanimous agreement at the aforementioned ANZSPM workshop that there was no evidence of harm with the use of a pathway. If the CODp was a prescribed medication (thus applying a ‘‘one size fits all’’-reductionist approach) the number needed to harm (NNH) would imply low level of risk to the prescriber. Importantly the ANZSPM Clinical Indicators Working Group was able to determine that there was consensus through expert opinion that the use of a CODp provides current best practice care of the dying. The ANZSPM Clinical Indicators Working Group are progressing the development of the care of the dying CI. We in the Antipodes are grateful that compassionate and rational care can be afforded to the dying.

Risk of 12-month mortality among hospital inpatients using the surprise question and SPICT criteria: a prospective study

Objectives People with serious life-limiting disease benefit from advance care planning, but require active identification. This study applied the Gold Standards Framework Proactive Identification Guidance (GSF-PIG) to a general hospital population to describe high-risk patients and explore prognostic performance for 12-month mortality. Methods Prospective cohort study conducted in a metropolitan teaching hospital in Australia. Hospital inpatients on a single day aged 18 years and older were eligible, excluding maternity and neonatal, mental health and day treatment patients. Data sources included medical record and structured questions for medical and nursing staff. High-risk was predefined as positive response to the surprise question (SQ) plus two or more SPICT indicators of general deterioration. Descriptive variables included demographics, frailty and functional measures, treating team, advance care planning documentation and hospital utilisation. Primary outcome for prognostic performance was 12-month mortality. Results We identified 540 eligible inpatients on the study day and 513 had complete data (mean age 60, 54% male, 30% living alone, 19% elective admissions). Of these, 191 (37%) were high-risk; they were older, frailer, more dependent and had been in hospital longer than low-risk participants. Within 12 months, 92 participants (18%) died (72/191(38%) high-risk versus 20/322(6%) low-risk, P<0.001), providing sensitivity 78%, specificity 72%, positive predictive value 38% and negative predictive value 94%. SQ alone provided higher sensitivity, adding advanced disease indicators improved specificity. Conclusions The GSF-PIG approach identified a large minority of hospital inpatients who might benefit from advance care planning. Future studies are needed to investigate the feasibility, cost and impact of screening in hospitals.

My Life—My Death

and family perspectives. For the patient, they note that the suffering motivating VSED is sometimes “acute, severe, physical, and graphic.” Other times, the motivating suffering is “more anticipatory and immediate or more psychosocial than physical.” Like Menzel, they note that “VSED can be very difficult to complete.” And the optimal timing can be hard to determine. For the clinician, Horowitz, Sussman, and Quill emphasize: (a) the challenges in assessing decisional capacity, (b) how and when the option should be shared, as well as (c) the benefits and risks of consultative support. For the family, they emphasize, on the one hand, how the process offers the opportunity for family reconciliation and, on the one hand, the risk of harm, if family members disagree. Mark Corbett is a geriatric and palliative medicine physician at Wake Forest School of Medicine. He challenges prevailing assumptions and misconceptions about VSED by assessing two central counterarguments. First, Corbett argues that VSED is consistent with the physician’s role and integrity. Indeed, he concludes that patients are even “entitled” to a willing physician’s assistance, because physicians have a “duty and obligation” to relieve suffering. Second, Corbett outlines the safeguards necessary to prevent error and abuse, concluding that they are sufficient to mitigate slippery slope risks.