Doreen Oneschuk

Framework for Continuous Palliative Sedation Therapy in Canada

BACKGROUND Canada does not have a standardized ethical and practice framework for continuous palliative sedation therapy (CPST). Although a number of institutional and regional guidelines exist, Canadian practice varies. Given the lack of international and national consensus on CPST, the Canadian Society for Palliative Care Physicians (CSPCP) formed a special task force to develop a consensus-based framework for CPST. OBJECTIVE Through a preliminary review of sedation practices nationally and internationally, it was determined that although considerable consensus was emerging on this topic, there remained both areas of contention and a lack of credible scientific evidence to support a definitive clinical practice guideline. This led to the creation of a framework to help guide policy, practice, and research. METHODS This framework was developed through the following steps: 1) literature review; 2) identification of issues; 3) preparation of a draft framework; 4) expert consultation and revision; 5) presentation at conferences and further revision; and 6) further revision and national consensus building. RESULTS A thorough literature review, including gray literature, of sedation therapy at the end of life was conducted from which an initial framework was drafted. This document was reviewed by 30 multidisciplinary experts in Canada and internationally, revised several times, and then submitted to CSPCP members for review. Consensus was high on most parts of the framework. CONCLUSION The framework for CPST will provide a basis for the development of safe, effective, and ethical use of CPST for patients in palliative care and at the end of life.

Assessment and knowledge in palliative care in second year family medicine residents

Inadequate physician knowledge, particularly in areas of pain assessment and use of analgesics, has been identified as a major factor contributing to poor pain management in cancer patients. In most medical schools, teaching in Palliative Care at both the undergraduate and postgraduate levels is limited or nonexistent. Baseline knowledge and changes in knowledge in areas relevant to Palliative Care were assessed by the use of 2 16-question examinations (Exams A and B) in 78 second-year Family Medicine Residents from the University of Alberta Family Medicine Residency Program. The residents participated in a two-week rotation on the Acute Palliative Care Unit at the Edmonton General Hospital or Grey Nuns Community Health Centre between September 1991 and February 1996. The residents were randomly assigned on their first day (Time 1) to complete either Exam A or B and were subsequently crossed over on their final day of the rotation to complete the alternate Exam (Time 2). Six domains were represented in the Exams as follows: pain assessment, opioid use, adjuvant medications, delirium, urinary catheterization, and hydration. Improvements were noted in the mean percentage results in Time 2 compared with Time 1 for Exams A, B, and A and B combined. Mean global percentage results were 53 +/- 15 versus 73 +/- 13 (p < 0.001) at Times 1 and 2, respectively. There were significant improvements for domains in Time 2 compared to Time 1 (p < or = 0.05) for combined A and B Exam except for urinary catheterization. Despite these documented improvements in scores, serious deficiencies were identified particularly in the areas of pain assessment and opioid use, namely opioid sude effects and issues involving dependence, addiction, and tolerance. Examinations, such as the two used in this study, can be a useful aid in assessing physician knowledge in addition to structuring teaching in Palliative Care. Examination content will require updating as knowledge in Palliative Care evolves.

Black cohosh (Cimicifuga racemosa [L.] Nutt.): safety and efficacy for cancer patients.

Goals of workBlack cohosh is commonly used to treat hot flashes and other symptoms associated with menopause. It is thought to have multiple mechanisms of action, including potential phytoestrogenic properties. This has caused some concern about its use by patients with hormone-sensitive cancer. This paper will present the results of a systematic review of the safety and efficacy of black cohosh (Cimicifuga racemosa [L.] Nutt.) in patients with cancer.Materials and methodsA critical assessment of clinical (n = 5) and preclinical (n = 21) studies of black cohosh and cancer (breast and prostate) to treat hot flashes and other related symptoms is presented. In addition, clinical studies, case reports, animal studies, and in vitro assessments of the safety of black cohosh for patients with hormonally sensitive cancers is summarized and interpreted.Main resultsIn general, the research assessing efficacy of black cohosh for the treatment of hot flashes in women with breast cancer is inconclusive. There is laboratory evidence of antiproliferative properties but no confirmation from clinical studies for a protective role in cancer prevention. Black cohosh seems to have a relatively good safety profile. Concerns about liver toxicity are inconclusive. With relevance to cancer patients, black cohosh also seems not to exhibit phytoestrogenic activity and is in fact possibly an inhibitor of tumor growth.ConclusionsThe use of black cohosh appears to be safe in breast cancer patients without risk for liver disease, although further research is needed in this and other populations.

Consensus Recommendations for the Management of Constipation in Patients with Advanced, Progressive Illness

Constipation is a highly prevalent and distressing symptom in patients with advanced, progressive illnesses. Although opioids are one of the most common causes of constipation in patients with advanced, progressive illness, it is important to note that there are many other potential etiologies and combinations of causes that should be taken into consideration when making treatment decisions. Management approaches involve a combination of good assessment techniques, preventive regimens, appropriate pharmacological treatment of established constipation, and frequent monitoring. In this vulnerable patient population, maintenance of comfort and respect for individual preferences and sensitivities should be overriding considerations when making clinical decisions. This consensus document was developed by a multidisciplinary group of leading Canadian palliative care specialists in an effort to define best practices in palliative constipation management that will be relevant and useful to health care professionals. Although a wide range of options exists to help treat constipation and prevent its development or recurrence, there is a limited body of evidence evaluating pharmacological interventions. These recommendations are, therefore, based on the best of the available evidence, combined with expert opinion derived from experience in clinical practice. This underscores the need for further clinical evaluation of the available agents to create a robust, evidence-based foundation for treatment decisions in the management of constipation in patients with advanced, progressive illness.

Access to palliative medicine training for Canadian family medicine residents.

The authors conducted a nine-item mail questionnaire of the 16 Canadian family medicine teaching programme directors to determine the accessibility and operation of palliative care education for their respective family medicine residents. All 16 faculties of medicine responded (100%). The survey revealed that while all universities offer elective time in palliative care only five out of 16 (31%) have a mandatory rotation. The median durations of the mandatory and elective rotations are limited to two and three-and-a-half weeks, respectively. The majority of the universities offer formal lectures in palliative care (12/16, 75%) and educational reading material (13/16, 81%), with the main format in 14/16 (87%) of the sites being case-based learning. The two most common sites for teaching to occur for the residents are the community/outpatient environment and an acute palliative care unit. Fifty-six per cent (9/16) of the universities have designated faculty positions for palliative medicine with a median number of two positions per site. Only one centre offers a specific palliative medicine examination during the rotation. Feedback from the residents regarding their respective palliative medicine programmes were positive overall. Findings from our survey indicate an ongoing need for improved education in palliative medicine at the postgraduate level.

The status of complementary therapy services in Canadian palliative care settings.

Goal of workLittle is known about complementary therapy services (CTs) available in Canadian palliative care settings.Materials and methodsAn online survey was e-mailed to multiple Canadian palliative care settings to determine the types and frequency of CTs provided and allowed, who are the CT providers, funding of CT services, and barriers to the provision of CTs.Main resultsThe response rate was 54% (74/136). Eleven percent of surveyed palliative care settings provided CTs, and 45% allowed CTs to be brought in or to be used by patients. The three most commonly used CTs were music (57%), massage therapy (57%), and therapeutic touch (48%). Less than 25% of patients received CTs in the settings that provided and/or allowed these therapies. CTs were mostly provided by volunteers, and at most settings, limited or no funding was available. Barriers to the delivery of CTs included lack of funding (67%), insufficient knowledge of CTs by staff (49%), and limited knowledge on how to successfully operate a CT service (44%). For settings that did not provide or allow CTs, 44% felt it was important or very important for their patients to have access to CTs. The most common reasons not to provide or allow CTs were insufficient staff knowledge of CTs (67%) and lack of CT personnel (44%).ConclusionsOverall, these findings were similar to those reported in a US-based hospice survey after which this survey was patterned. Possible reasons for these shared findings and important directions regarding the future of CT service provision in Canadian palliative care setting are discussed.

Palliative management of brain metastases

The development of brain metastases in patients with advanced cancer is associated with increased morbidity and diminished longevity. Palliative treatment modalities focus predominantly on improving quality of life. Well-established beneficial treatments include the use of corticosteroids, radiotherapy, and surgery. Management issues that require further exploration and clarification include the dosages of glucocorticoids, the prophylactic use of anticonvulsants and the indications for radiosurgery.

Comparison of the Constipation Assessment Scale and Plain Abdominal Radiography in the Assessment of Constipation in Advanced Cancer Patients

CONTEXT Constipation is a distressing condition for advanced cancer patients and is frequently underdiagnosed. OBJECTIVES The primary objective of this study was to determine if a strong correlation existed between the use of the Constipation Assessment Scale (CAS) and a plain abdominal radiograph in the interpretation of constipation in patients with advanced cancer. The secondary aim of the study was to compare the plain film radiographic constipation scores among three palliative medicine physicians. METHODS The study was a prospective cross-sectional study of 50 advanced cancer patients admitted to a tertiary palliative care unit. These patients completed the CAS shortly after their admission to the unit. Around the same time, they underwent a flat plate of abdomen that was scored from 0 to 12, based on the amount of stool in the colon, by three palliative medicine physicians who were blinded to the CAS results and each others radiographic interpretations. Kendall Tau correlation coefficient was used to estimate and test the correlations between the CAS and radiographic constipation scores. RESULTS There was no concordant correlation between the CAS scores and each physicians radiographic constipation score. There also was no concordant correlation between the CAS score and the combined radiographic constipation scores of the three palliative medicine physicians (Kendall Tau coefficient=0.04; P=0.72). The degree of correlation between the radiographic constipation scores from the three palliative medicine physicians was moderate. CONCLUSION Our study failed to yield a strong correlation between the CAS and the plain abdominal radiographic scores for constipation completed by three palliative medicine physicians. It is advisable that constipation in advanced cancer patients be assessed both clinically and radiographically.

Undergraduate Medical Palliative Care Education: A New Canadian Perspective

Prior to 1 year ago, undergraduate medical palliative medicine education at the University of Alberta in Edmonton, Alberta, was limited to a 1-hour didactic session and one-half day patient visit. A new integrative curriculum has allowed for increased educational exposure to palliative care for medical students. Topic content has expanded and different teaching modalities are used to aid learning. A highlight of the program is Bus Rounds where small groups of students visit terminally ill patients in either a hospice or home setting. After their training, the students performed well on two examination questions dealing with palliative care issues.

Acupuncture in palliative care

Goals of workAcupuncture involves the insertion of needles into designated acupuncture points to aid in the treatment of symptoms and to improve health.Materials and methodsA survey was conducted in a tertiary palliative care unit where 50 patients with advanced cancer were surveyed to determine their understanding of, use of, and interest in acupuncture.Main resultsTwenty-seven (54%) patients provided an accurate understanding of acupuncture. Although only 30% of patients had previously used acupuncture to treat noncancer medical conditions and only 10% had used it for cancer related symptoms, 80% of patients were interested in seeing an acupuncture practitioner on the care unit if one was made available.ConclusionsAlthough few advanced cancer patients on a tertiary palliative care unit had previously received acupuncture, many had a general understanding of this complementary therapy, and expressed an interest in seeing an acupuncture practitioner.