Deans Buchanan

Dignity and patient-centred care for people with palliative care needs in the acute hospital setting: A systematic review

Background: A core concept behind patient-centred approaches is the need to treat people with, and preserve, dignity in care settings. People receiving palliative care are one group who may have particularly sensitive needs in terms of their condition, symptoms and life expectancy. Dignity is more likely to be violated in hospital settings. Given the high percentage of people with palliative care needs who are admitted to hospital during their last year of life, the provision of dignity enhancing and preserving care in that setting is of vital importance. Aim: To examine international evidence relating to dignity and person-centred care for people with palliative care needs in the acute hospital setting. Design: A systematic literature review was conducted, incorporating data extraction, analysis and quality appraisal of included papers. Data sources: MEDLINE, CINAHL, PsycINFO, ASSIA, EMBASE, Cochrane Database and Web of Science. Inclusion dates: 1 January 2000–1 April 2014. Eligibility criteria: Adult palliative care, acute care setting, dignity or person-centred care. Results: In all, 33 papers met the inclusion criteria for the review. Papers highlighted the many and varied potential threats to dignity for people with palliative care needs in acute settings, including symptom control and existential distress, approaches and models in care provision and healthcare settings and design. Conclusion: Acute hospital staff require adequate training, including symptom control, and the correct environment in which to deliver dignified and person-centred end-of-life care. Specific models/approaches to care can be beneficial, if adequate training regarding implementation is given. The needs of family members also require consideration, particularly following bereavement.

Outpatient Continuous Interscalene Brachial Plexus Block in Cancer-Related Pain

This case outlines the use of a continuous interscalene brachial plexus block to treat cancer-related pain. Using an elastomeric device, the patients previously intractable pain was controlled and he was able to return home. Furthermore, the patient developed a pragmatic and effective method of balancing loss of power and sensation against pain control using the flow restrictor. This case illustrates the potential of an integrated approach to cancer pain management to obtain rapid pain relief in the acute hospital setting.

The dignified approach to care: a pilot study using the patient dignity question as an intervention to enhance dignity and person-centred care for people with palliative care needs in the acute hospital setting

BackgroundProviding person-centred, dignity-conserving care for hospitalised patients is central to many healthcare policies and essential to the provision of effective palliative care. The Patient Dignity Question (PDQ) “What do I need to know about you as a person to take the best care of you that I can?” was designed from empirical research on patients’ perceptions of their dignity at end of life to help healthcare professionals (HCPs) understand the patient as a person.MethodsThis mixed method pilot study was designed to inform a larger multisite study in the future. It tests the hypothesis that the PDQ intervention could be used to enhance a more person-centred climate for people with palliative care needs in the acute hospital setting, and provide evidence regarding its acceptability. Outcome measures pre and post intervention Person-centred Climate Questionnaire – patient version (PCQ-P), and the Consultation and Relational Empathy (CARE) measure; PDQ feedback questionnaires were used for all participants post intervention, in addition to qualitative interviews.Results30 patients, 17 HCPs, and 4 family members participated. Results showed a positive correlation between higher PCQ-P scores and higher CARE scores, indicating that the PDQ can make improvements to a person-centred environment and levels of empathy perceived by patients. Individual results from the PCQ-P and the CARE indicated overall improvements in the majority of fields. The PDQ supported disclosure of information previously unknown to HCPs, has implications for improving person-centred care. Positive results from PDQ feedback questionnaires were received from all participants.Qualitative findings indicated patients’ appreciation of staff (Attributes and attitudes), that patients wanted staff to have awareness of them (Know me as a person), take the time to talk, and work flexibly, to allow for patient individuality (Time and place).ConclusionThe PDQ has potential to improve patients’ perceptions of care, and HCP attitudes. Furthermore, it was well received by participants. The PDQ could be incorporated into clinical practice for the care of palliative care patients in the acute setting to the benefit of personalized and dignified care.Further research using the PDQ across wider geographical areas, and more diverse settings, would be beneficial.

A role for intravenous lidocaine in severe cancer-related neuropathic pain at the end-of-life

BackgroundSystemic administration of lidocaine has been widely reported to provide effective analgesia in both cancer and non-malignant pain.Case reportWe report the use of intravenous lidocaine in the management of cancer-related neuropathic pain and its pivotal role in restoring function and facilitating end-of-life care at home.

Letter to the editor: Use Intractable nausea and vomiting successfully related with granisetron 5-hydroxtrytamine type 3 receptor antagonists in Palliative Medicine

Sir—The selective 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists, such as ondansetron and granisetron, are well accepted in the treatment of nausea and vomiting related to chemotherapy, surgery and pregnancy.1 Their use within palliative care patients is documented but uncommon.2,3 5-HT3 antagonists competitively bind receptors within gut vagal afferents and areas of the central nervous system (CNS) related to nausea, such as the chemoreceptor trigger zone and the nucleus tractus solitarii.1 This dual activity within the gut and higher vomiting centres would suggest possible utility within the palliative care population. There is observed individual variability in response to each of these drugs.1 5HT-3 antagonists differ in chemical structure, dose–response, metabolic pathways and receptor interaction.1,4,5 Individual 5-HT3 antagonists are metabolised by different components of the cytochrome P450 system. These case histories describe two patients with intractable nausea and vomiting who responded to granisetron when other anti-emetics, including ondansetron, failed to gain control.

Methadone and oedema in the palliative care setting: a case report and review of the literature.

Introduction Methadone is a synthetic opioid which is being used with increased frequency in the palliative care setting for management of complex pain. There have been cases published reporting the development of oedema with methadone maintenance therapy but no cases on the association with methadone and peripheral oedema in the palliative care setting. As yet, the underlying mechanisms are unclear. Case presentation This case report describes a gentleman with ependymoma and difficult-to-control lower back pain and scrotal pain. This pain had failed to respond to other strong opioids. He was prescribed methadone and then subsequently developed bilateral peripheral oedema. Case management Peripheral oedema resolved following cessation of methadone. Conclusions This highlights an important potential adverse effect of methadone in a society of increased methadone prescription for pain control. The published literature to date is reviewed and possible underlying mechanisms explored.

Sinus bradycardia related to methadone in a patient with myeloma receiving thalidomide therapy

A 47-year-old man with malignant myeloma, responding to thalidomide treatment (100mg once daily), was admitted to a specialist palliative care unit to undertake an opioid switch from fentanyl to methadone. He had previously been treated with several opioids (morphine, oxycodone, diamorphine and hydromorphone) and anti-neuropathic agents (gabapentin, amitriptyline, ketamine and venlafaxine) for severe neuropathic pain related to complete destruction of the 10th thoracic vertebra. The radicular pain was only partially sensitive to opioids. There was a large incident component to the pain, managed with sublingual fentanyl, but his background analgesic requirements also remained high. With effective analgesic doses of fentanyl (250 mg/h) and pregabalin (300mg twice daily), intolerable side effects occurred (drowsiness, reduced concentration, myoclonus and hallucinations). Downward titration of either medication was limited by increasing background pain. After discussion it was agreed to admit the patient to convert to methadone to attempt to achieve analgesia with less toxicities. Utilizing a modified Morley and Makin conversion method, the patient was started on oral methadone 15mg twice daily and 10mg as needed (up to every 8 hours). Further rescue opioids were available within the lock out periods. By day three, although pain was better controlled and less drowsiness was present, the patient complained of light-headedness and described an episode of pre-syncope on standing. Observations revealed a pulse rate of 40 beats per minute (bpm) but normal blood pressure. A 12-lead electrocardiogram documented a sinus bradycardia of 32 bpm. Methadone was discontinued and breakthrough opioids were left in place to provide analgesia and prevent opioid withdrawal. Cardiac monitoring was instituted and myocardial infarction was ruled out by troponin testing. There were no electrolyte abnormalities. The thalidomide was discontinued under haematology advice. Atropine was given on four occasions over the course of the next 3 days, either for symptomatic bradycardia or absolute bradycardia of less than 40 bpm. The bradycardia resolved over 4 days from methadone discontinuation. We were able to provide ongoing analgesia through titration of oral hydromorphone and ketamine. After a period of cardiac stability his thalidomide was reintroduced.

USING THE “PATIENT DIGNITY QUESTION” AS A PERSON-CENTRED INTERVENTION FOR PATIENTS WITH PALLIATIVE CARE NEEDS IN AN ACUTE HOSPITAL SETTING

Background The aim of palliative care is to improve the quality of life of patients who are living with a progressive, life threatening illness. In order to achieve this, the patient needs to be cared for as a person. However, current research indicates that this is not always achieved in the acute hospital setting. Aim This feasibility study set out to determine the practicalities and effectiveness of using the ‘Patient Dignity Question’, (Chochinov 2010) an intervention derived from extensive, empirical research on dignity near the end of life, in order to enhance person-centred care. Methods A mixed methods feasibility study using both patient reported outcomes measures (person centred climate questionnaire PCCQ; Patient Dignity Question questionnaire (developed by Chochinov et al), and semi-structured interviews was adopted underpinned by pragmatic theory. The study was conducted in a large teaching hospital with a purposive sample of nine patients and five healthcare professionals. Results The results of indicate that is feasible to carry out this type of study for people with palliative needs in the acute care setting. Adopting a mixed methods approach was effective in answering the research questions and meeting the study aims. The primary outcome measure was effective in determining the person-centred nature of the hospital climate. However, it was unable to determine if the ‘Patient Dignity Question’ had a direct influence on this. Conclusion Study participants were willing and happy to take part in this study despite their illness and environment. Participants found the ‘Patient Dignity Question’ and summary both useful and practical. They described it as an intervention that can help to improve the care patients receive and help them feel valued as an individual. A funded study with 30 patient, 30 family members and 30 health professionals is now being undertaken with a before and after trial design.

What’s dignity got to do with it? Patient experience of the dignity care intervention: a qualitative evaluation study

The delivery of palliative care in the community setting has been recognized as a valued and challenging aspect of nursing care. To this end, care pathways have been shown to support nurses in a variety of settings to deliver individualized patient care. This study provides a qualitative evaluation of an end-of-life intervention known as the Dignity Care Intervention (DCI) based on patients’ perspectives. The DCI consists of four sections: a manual, the Patient Dignity Inventory, reflective questions, and evidence-based care actions. A qualitative design underpinned by the philosophy of Merlau-Ponty was employed for the evaluation of the DCI. Data collection included individual interviews with participants (n = 25). Interview data were analyzed using framework thematic analysis. Four theme categories were identified: “experience of DCI,” “responding to my illness concerns,” “how illness affects me as a person,” and “how illness concerns affect my relationships.” The DCI was found to enable patients to discuss openly important issues with community nurses that they might not otherwise have raised. Participants conveyed satisfaction with the support they received through the DCI. The use of care pathways detailing interventions to manage clinical problems and ensure systematic integration of the best available evidence into care delivery can improve end-of-life care.