Fiona Hicks

Clinical Pharmacokinetics of Ondansetron. A Review

5−HT3 receptors are ubiquitous in the enteric, sympathetic, parasympathetic and sensory nervous systems and in the central nervous system (CNS) (Kilpatrick et al 1990). In man 5−HT3 receptors are mainly situated on enterochromaffin cells in the gastrointestinal mucosa, which are innervated by vagal afferents (Reynolds et al 1989), and the area postrema of the brain stem, which forms the chemoreceptor trigger zone. Ondansetron is a selective antagonist at 5−HT3 receptors. It is 100 times more potent than metoclopramide at this site (Tyers 1992). It shows limited binding to other receptors and has a wide therapeutic window. Ondansetron is a useful antiemetic which probably has both central and peripheral actions in patients undergoing radiotherapy, cytotoxic chemotherapy or general anaesthesia (Naylor & Rudd 1992). This paper reviews the pharmacokinetics of ondansetron in health and disease to provide information for clinicians; it might alter prescribing and alert them to possible drug interactions.

Nerve Blocks in Palliative Care

1. Philosophy behind the use of interventional pain management techniques in palliative care 2. Defining the problem 3. Assessment of pain 4. Pain syndromes 5. Choice of technique 6. Simple peripheral nerve blocks and injections 7. Regional nerve blocks 8. Spinal drug delivery 9. Electrical stimulation techniques 10. Ethical issues

An innovative development programme for consultants to improve patient care in the last months of life

> Knowing is not enough: we must apply. Being willing is not enough, we must don> n> Leonardo Da VincinnAround half the annual 600,000 deaths in England occur in hospital, with an average of 30xa0days spent as inpatients during the last year of life, over several admissions.[1][1] Forty per cent of

Rethinking priorities: experience of an educational initiative to change attitudes, behaviours and clinical practice in end-of-life care

To implement the National End of Life Care strategy and enable more people to express and achieve their preferences about care at the end of life, senior clinicians outside palliative medicine need to make it a routine part of their practice. However, it is acknowledged that recognising that people are entering the last phase of their illness is not always straightforward, and having conversations about aims of treatment and planning for future care may not be easy. In order to begin to address these challenges, funding was sought from the Yorkshire and the Humber Strategic Health Authority (SHA), and subsequently Health Education England, Yorkshire and the Humber (HEEYH), to pilot a development programme in 2 acute trusts. 2 palliative medicine consultants shared the trainer role at each site, supporting hospital consultants from a range of specialties, with a GP to give a community perspective. The programme involved individual clinicians identifying their own learning needs and specific issues for end-of-life care in their patients. The group met together monthly in action learning sets to discuss issues in a safe yet challenging environment. Following evaluation using a combination of training needs analyses, feedback questionnaires, audits and service evaluations, it was modified slightly and repiloted in 2 further trusts as ‘Rethinking Priorities’. This paper describes the programme and its outcomes, especially in relation to participants learning, service development and leadership. It also highlights the challenges, including different learning styles, the concept of action learning, obtaining funding and dedicated time, and how to evaluate the effectiveness of a programme. Overall, it suggests that an educational initiative based on clinicians identifying their own learning needs, and using an action learning approach to explore issues with other colleagues, with the addition of some targeted sessions, can result in positive change in knowledge, behaviour and clinical practice.

Improving end-of-life communication between primary and secondary care within respiratory medicine

We read with interest the editorial about “Improving palliative care for patients with COPD” [1] and the subsequent article by Meffet et al. [2]. We would like to highlight the results of our study looking at the impact of initiatives to improve communication with primary care in relation to end-of-life care (EoLC). Improving end-of-life care for respiratory and COPD patients through better communication from secondary care http://ow.ly/U3ecw

AN INNOVATIVE DEVELOPMENT APPROACH FOR ACUTE HOSPITAL SENIOR CLINICIANS TO IMPLEMENT THE NATIONAL EOLC STRATEGY 2008

Background Approximately half the annual 600,000 deaths in England occur in acute hospitals although research indicates that most would choose to die elsewhere. The National End of Life Care Strategy encourages senior clinicians outside the speciality of palliative medicine to engage with end-of-life care and make it a routine part of their practice. Aim To pilot a programme enabling consultant colleagues from other specialties to identify their own learning needs, engage with the issues, undertake specific technical/clinical learning about palliative and end-of-life care, and identify improvements in their own practice. Having increased their own expertise, they would share and spread learning to clinical colleagues within their departments. Method Funding for the pilot was obtained from Yorkshire and Humber Strategic Health Authority (SHA) for a group (approximately 6) of motivated hospital consultants, and a GP to provide a community perspective, in two trusts – one large Teaching Hospital and one small District General. The programme was led by consultants in palliative medicine who had been trained in facilitating action learning, supported by a small steering group. It included joint clinics and ward rounds, one-to-one meetings and bespoke training as identified by participants. Work was progressed through Action Learning Sets. Evaluation included Training Needs Analyses, questionnaires and audit of practice. Results In addition to improved knowledge about palliative care in general, participants identified increased openness in discussing end-of-life issues and confidence in provision of community services. Service improvements include changes in content of outpatient and discharge letters, development of guidelines, implementation of the AMBER care bundle and Rapid Discharge, and addressing DNACPR practices in their departments. Participants have opted to continue meeting quarterly and act as champions for end-of-life care. Discussion Trust “buy-in” to the programme is essential to its success. Innovations have been different in each Trust. A proposal has been submitted to extend the programme to two other trusts before national roll out.

WHO RESPONDS TO A BEREAVED FAMILY SURVEY ABOUT ACUTE HOSPITAL CARE AT THE END OF LIFE

Aim To explore who responded to the Leeds Teaching Hospitals Trust (LTHT) bereaved family survey. Background The LTHT Specialist Palliative Care Team (SPCT) locally adapted a bereavement survey for families (Worcestershire Acute Hospital NHS Trust, 2012). This was developed to give bereaved relatives the opportunity to provide feedback on their experience of the care their relative received at the end of life in the acute setting. The LTHT SPCT Bereaved Carers Service User (BCSU) group contributed to the design of the survey at the outset. Method Over a 10 week period, March to May 2013, the survey was given to bereaved relatives of adult patients when they collected medical cause of death certificates from the bereavement office. Patients who died in A&E were excluded. Results There were 146 respondents (response rate 23%).Trends identified from the demographics were that respondents tended to be from children of the deceased (son 23%, daughter 40%) and most responses came from older peoples services (27%). The most prevalent age of death was 86–90. There was a low response rate from oncology wards (1%). Results were presented to the BCSU group. Conclusion The highest response was from daughters of older adults. Further exploration is needed into the low response rate from oncology, and spouses of the deceased. The timing of the survey may have influenced the group of respondents. It may have been too early on in their bereavement. Delaying the time that the survey is sent to bereaved relatives/carers may help increase the response rate. Opinions from the BCSU group and experience from other hospital trusts will be considered to inform changes to the next survey to gain feedback from a more representative population and improve the care patients receive at the end of life.

SURVEY OF POTENTIAL DRUG INTERACTIONS IN ACUTE HOSPITAL INPATIENTS RECEIVING SPECIALIST PALLIATIVE CARE (SPC)

Aim Polypharmacy is common in palliative care and is associated with an increased risk of potentially harmful drug interactions. In order to identify common interactions and explore the SPC approach to polypharmacy we surveyed hospital inpatients receiving input from an SPC advisory service. Methodology The notes and drug charts of 50 consecutive patients referred to the SPC team between May and August 2012 were retrospectively reviewed. Potential interactions were identified and classified according to their clinical significance as minor, moderate or major using the website http://www.drugs.com/ Results The median number(range) of medications per patient at the time of initial assessment was 12 (5–23). In total, there were 628 potential interactions, 53 major, 505 moderate and 70 minor. Potential interactions were seen in 90% of patients and 62% had a major potential interaction. The median number (range) of major, moderate, and total potential interactions per patient was 1 (0–5), 8 (0–28), and 11 (0–32) respectively. There was a positive correlation between the number of medications and the number of potential interactions (p<0.0001). Common interactions in the major group were: QT interval prolongation (26%), enhanced serotonergic activity (18%), cytochrome P450 inhibition (16%), increased bleeding risk (12%), and reduced seizure threshold (5%). Common drugs implicated include haloperidol, cyclizine, levomepromazine, metoclopramide, opioids, benzodiazepines and ondansetron. Although at risk, none of the patients included in the study had evidence of major or moderate adverse events due to drug interactions. In only 14% (5/37) of patients taking potentially unhelpful medication, like antihypertensive, antiplatelet, and cholesterol lowering agents had SPC advised the medicines to be stopped. Conclusion This study demonstrates that majority of acute hospital inpatients receiving SPC are at risk of clinically significant drug interaction although the clinical importance is less clear. The study highlights the need for SPC teams to be vigilant for common interactions and to minimise polypharmacy by stopping medications of little benefit.