Claud Regnard

Breaking bad news - a flow diagram:

Breaking bad news is neither an easy nor a popular task. Properly handled, however. it can be given in a positive way that the individual can both accept and understand. There may be a range of emotions and concerns following the telling of bad news. These need to be explored and worked through with each individual. This flow diagram describes the steps in this important process.

Evolving spinal analgesia practice in palliative care

Intraspinal analgesia can be helpful in some patients with intractable pain. Over 15 years palliative care professionals evolved their spinals policy through a repeated series of evaluations, discussions and literature reviews. One hundred intraspinal lines were then reviewed. Notable changes in policy were the switch from epidurals to intrathecals, and the insertion of lines during working hours rather than as emergencies. Our efficacy, and frequency of adverse effects, is equal or better to published studies. Key issues in reducing adverse effects were the improved care of the spinal line exit site, a change from bolus administration to continuous infusions, and modifying line insertion techniques. Current policy is to use continuous infusions of diamorphine and bupivacaine in a 1:5 ratio through externalized intrathecal lines. The lines are effective in approximately two thirds of patients and can be kept in place for up to 18 months. The policy continues to be updated and common documentation is now in place.

Managing the anxious patient with advancing disease. A flow diagram

Anxiety can be one aspect of the psychological reaction to cancer and may be present at a clinical level. It can hinder or even prevent the diagnosis and management of other problems and when it develops into an anxiety state it can be disabling. This flow diagram describes the key clinical decisions involved in diagnosing and helping a patient troubled with anxiety.

Pain and distress in advanced dementia: choosing the right tools for the job.

Objective: There is a concern that pain is under-recognized in dementia. However, there may be other causes of distress. We wished to evaluate the utility of a distress tool and a pain tool. Methods: Nursing home residents with advanced dementia were observed using pain (Pain Assessment in Advanced Dementia scale (PAINAD)) and distress (Disability Distress Assessment Tool (DisDAT)) assessment tools. Those in pain were treated. Reassessment occurred at one and three months. Results: From 79 participants, 13 were assessed as being in pain. Psychosocial factors explained the behaviour of a false positive group. Both tools showed a significant decrease in pain following intervention (p = 0.008). Behaviours were similar in both groups. Conclusions: Both tools are useful. However, the pain tool also picks up distress, which is not caused by pain. It could potentially lead to false ascriptions of pain. The distress tool picks up a broader array of signs, which may be useful both in practice and in research.

Using videoconferencing in palliative care

Recent technological advances and reducing costs have meant that videoconferencing is a possible new medium for health-care teams. The IMPaCT (Interactive Multimedia Palliative Care Training) project began in 1997 with the aims of assessing the practicalities of videoconferencing in palliative care and assessing its educational effectiveness. The use of videoconferencing was closely evaluated during the first 2 years of the project and this paper presents the results of that monitoring. Twenty-two sites were linked worldwide, reaching 136 professionals without the costs or time needed to travel. The savings on travel and time within the UK alone would have paid for the equipment in 1 year. Sites only continued with videoconferencing if they reached a point where their organization saw the advantages of videoconferencing. Links were easy to establish and rarely failed regardless of distance. Users rapidly adapted to the new medium, and links could be used in a variety of settings and audiences, including journal clubs and expert workshops. Videoconferencing offers a new and unique way of supporting palliative care professionals while reducing time and costs for both tutors and learners.

Gastrostomies in dementia: bad practice or bad evidence?

Tube feeding in dementia remains controversial as evidenced by recent responses to the Royal College of Physicians (RCP) report on oral feeding [1]. Criticisms of non-oral feeding are based on a failure to show a favourable outcome [2] or to lengthen survival [3, 4], a worsening of prognosis [5] and a higher mortality rate in hospitalised patients [6]. When dysphagia become severe, nasogastric tubes are often the first recommendation [1], with gastrostomies inserted once the patient is well enough to tolerate the procedure. However, there are many unanswered questions about tube feeding in general and gastrostomies in particular with respect to dementia: (i) What causes weight loss in dementia? The cytokinemediated cachexia syndrome is well recognised in cancer, chronic infection and cardiac disease, but is not seen in dementia. Weight loss in dementia is not an inherent part of the disease process but due to insufficient nutritional intake for the individual’s metabolic needs [7]. (ii) Is dysphagia a terminal symptom? In Alzheimer’s dementia, dysphagia can occur early in the disease process [8] and is not always a terminal symptom as is often believed [1]. Dysphagia often presents at an advanced stage having been missed because of poor screening [9], atypical presentations (e.g. in people with Down’s syndrome) and carer adjustment to its presence. There is little research exploring the extent of dysphagia in early to mid-stage dementia [10, 11], and until this is done a blanket ‘no gastrostomy’ policy cannot be justified. (iii) Are gastrostomies inserted too late? Delay in identifying dysphagia risks malnutrition. Patients with low albumin levels do worse than those with normal levels post-gastrostomy and the risk of pneumonia due to severe dysphagia is increased [12, 13]. (iv) Is survival a relevant outcome measure? The evidence on survival is unclear varying from no effect on survival [16], a post-gastrostomy median survival of 6 months [14], and both increased [15] and reduced survival [13] with nasogastric feeding. A failure to improve survival has often been the central argument against tube feeding in dementia [1]. This observation suggests that tube feeding does not increase the risk of unnecessarily prolonging a patient’s life and is a point in favour of tube feeding. (v) Are refeeding syndrome or gastric stasis being recognised? Refeeding syndrome results in severe electrolyte imbalances and a risk of death [17, 18]. Gastric stasis is common in patients with malnutrition and advanced disease, but is often overlooked in people with impaired cognition and increases the risk of aspiration if a standard feed rate is used. There is no mention of these problems in the gastrostomy– dementia literature. (vi) What method of tube feeding is being assessed? It has been noted [14] that some papers do not specify whether gastrostomies or nasogastric tubes are being assessed [3, 19]. The paper by Mitchell et al. [3] describes ‘feeding tube placement’ without specifying the type, and yet the recent RCP report [1] quotes this source as applying to gastrostomy feeding. (vii) Are the most appropriate outcomes being assessed? We lack data on outcomes more relevant to palliative care: Eating for survival or eating for pleasure: the shift from struggling to eat for survival to eating for pleasure with supplementary feeding via gastrostomy can be achieved gradually according to the patient’s swallowing ability and wishes. Gastrostomy feeding does not have to mean the end of enjoyable eating. Patient distress: a tool to document distress in people with severe communication difficulties such as dementia [20–22] allows us to better understand the distress caused by prolonged oral meals, repeated admissions for pneumonia and fatigue caused by malnutrition. Symptoms of malnutrition: taste changes, anorexia, fatigue, poor wound healing, susceptibility to infections and gastric stasis due to autonomic insufficiency are rarely mentioned in the gastrostomy–dementia literature. Reducing hospital admissions: infections can be managed in the patient’s own setting because antibiotics can be administered via the gastrostomy rather than requiring intravenous routes. Administration of medications: the gastrostomy allows patients to continue drugs such as anticonvulsants independent of oral feeding ability. Distressing mealtimes: we strongly support enabling patients to maximise their oral intake. However, the insistence of ‘oral only’ results in prolonged mealtimes of an hour or more to ensure adequate intake, begging the question of whether anyone benefits from this process. Exhaustion and distress caused by prolonged mealtimes have not been studied, and there seems to be no consideration of the stress felt by staff concerned about worsening or precipitating aspiration-related problems.

Re: Update on Cancer Pain Guidelines

To the Editor: Caraceni et al. draw attention to a much needed discussion about the use of opioids in the management of cancer pain, and the work that is being currently undertaken to update the World Health Organization’s (WHO) and European Association for Palliative Care’s guidelines is timely. Morphine, for instance, one of the most traditional and commonly used opioids, has held a fundamental role in managing cancer pain, yet confusion around starting doses, titration, and maintenance in its use is still widespread. Morphine prescribing has been benchmarked for many years and guidelines produced, which formed the basis of other opioid prescribing advice. Despite this, prescribing errors and criminal overdoses have been responsible for deaths in the UK. This prompted us to review published guidance and identify discrepancies and variations in these texts.

Cervical intrathecal analgesia for head and neck/upper limb cancer pain: six case reports

We describe six cases of head and neck or upper limb cancer palliative care patients with refractory pain, treated with an intrathecal catheter placed at cervical or upper thoracic spinal levels with a non-implanted, externalized and tunnelled delivery system. In these cases, this system was safe and effective. Palliative Medicine 2007; 21 : 543—545

Eliciting the current problems of the patient with cancer - a flow diagram

The assessment of a patient is an integral part of clinical management. It should be conducted in a way which maximizes the likelihood of patients disclosing all their main problems, whether physical, social or psychological in nature. Unfortunately, professional carers can be uncertain of their ability to do this. This flow diagram leads the carer through key points in the assessment interview.

Dealing with anger in a patient or relative: a flow diagram

Anger from any cause can block effective interaction between the patient and the carer. It has many possible causes, which may be rational, irrational (i.e. inappropriate or misdirected) or pathological. This flow diagram suggests strategies for handling anger in patients with advanced disease.