Peter Poon

Hospital rapid response team and patients with life-limiting illness: A multicentre retrospective cohort study

Background: Approximately one-third of rapid response team consultations involve issues of end-of-life care. We postulate a greater occurrence in patients with a life-limiting illness, in whom the opportunity for advance care planning and palliative care involvement should be offered. Aims: We aim to review the characteristics and compare outcomes of rapid response team consultations on patients with and without a life-limiting illness. Design/Setting: A 3-month retrospective cohort study of all rapid response team consultations was conducted. The sample population included all adult inpatients in a major teaching hospital network. Results: We identified 351 patients – including 139 with a life-limiting illness – receiving a total of 456 rapid response team consultations. The median time from admission to the first rapid response team consultation was 3 days. Patients with a life-limiting illness had a significantly higher mortality rate (41.7% vs 13.2%), were older (72.6 vs 63.5 years), more likely to come from a residential aged-care facility (29.5% vs 4.1%) and had a shorter hospital stay (10 vs 13 days). Rapid response team consultations resulted in a change to more palliative goals of care in 28.5% of patients, of whom two-thirds had a life-limiting illness. Conclusion: Patients with a life-limiting illness had worse outcomes post–rapid response team consultation. Our findings suggest that a routine clarification of goals of care for this cohort, within 3 days of hospital admission, may be advantageous. These discussions may provide clarity of purpose to treating teams, reduce the burden of unnecessary interventions and promote patient-centred care agreed upon in advance of any deterioration.

CYP2B6*6 allele and age substantially reduce steady-state ketamine clearance in chronic pain patients: impact on adverse effects

AIMS Ketamine analgesia is limited by low intrinsic efficacy compounded by large interindividual variability in drug responses, possibly due to the heterogeneity in drug concentration. The CYP2B6*6 allele is associated with substantially reduced ketamine metabolism in vitro and, therefore, may affect ketamine clearance. Our aims were to examine the impact of the CYP2B6*6 allele on ketamine plasma clearance and on adverse effects in chronic pain patients. METHODS CYP2B6 genotypes were identified in 49 chronic pain patients who received 24 h continuous subcutaneous infusions of ketamine. Steady-state plasma concentrations of ketamine (Css,k ) and norketamine (Css,nk ) were determined using HPLC. RESULTS The median plasma clearance of ketamine after 100 mg 24 h(-1) dose was significantly lower in patients with the CYP2B6*6/*6 (21.6 l h(-1) ) and CYP2B6*1/*6 (40.6 l h(-1) ) genotypes compared with patients with the CYP2B6*1/*1 genotype (68.1 l h(-1) , P < 0.001). The ketamine : norketamine plasma metabolic ratio was significantly higher in patients with the CYP2B6*6/*6 genotype than in those with the CYP2B6*1/*6 and the CYP2B6*1/*1 genotypes (P < 0.001). Patients who experienced adverse effects had lower plasma clearance (45.6 l h(-1) ) than those who did not (52.6 l h(-1) , P = 0.04). The CYP2B6*6 genotype and age, and their combined impact explained 40%, 30% and 60% of the variation in Css,k , respectively. Similar results were observed after higher doses. CONCLUSIONS The CYP2B6*6 allele is associated with a substantial decrease in steady-state ketamine plasma clearance in chronic pain patients. The decreased clearance and resultant higher plasma concentrations may be associated with a higher incidence of ketamine adverse effects.

Ketamine and Cancer Pain: The Reports of My Death Have Been Greatly Exaggerated

Theauthorsaretobecongratulated on successfully completing a placebo-controlled, ran-domized controlled trial in 185 patients receiving palliative care—nomean feat.However,wequestionwhethertheauthors’sweepingconclusionthat “Ketamine does not have net clinical benefit when used as anadjunct to opioids and standard coanalgesics in cancer pain”

Dexamethasone for Cancer-Related Fatigue

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Percutaneous sacroplasty for painful bone metastases: A case report

The occurrence of bone metastases is common in patients with advanced cancer. The literature supports percutaneous vertebroplasty and kyphoplasty as minimally invasive procedures to relieve pain and improve quality of life for selected patients with disabling pain from pathological vertebral fractures secondary to bone metastases.

Successful large volume ‘lymphocentesis’ for refractory lymphoedema in lower and upper limbs: Letters to the Editor

We read with interest Heng and Hardy’s letter ‘Large volume subcutaneous lymphoedema drainage’. This case is exceptional with respect to the volume of fluid drained. We would like to add to their letter with a case of similarly large volume lymphoedema drainage (‘lymphocentesis’) of 11 L in a 45-year-old patient over a 4-day period. This patient had castrate-resistant prostate cancer with bone metastasis, extensive pelvic nodal disease and gross lymphoedema primarily due to retroperitoneal fibrosis. He had lower limb pitting oedema to his waist, with associated skin tightness and an area of fluid leakage directly from his left calf. Subsequent to the procedure, his mid-calf circumferences decreased by 2 cm on the left and 1 cm on the right. Mid-thigh circumferences decreased by 10 and 4 cm on the left and right respectively. The patient reported a dramatic improvement in mobility and pain, with a marked reduction in the latter from 8 of 10 to 1 of 10 on an 11-point visual analogue scale (VAS); his analgesics were unchanged. Prior drainages had also removed significant (although smaller) volumes: 1.9 L (from only one foot), 1.5 L (drainage lines blocked by clot) and 4.2 L. Drainages consistently reduced pain scores, by an average of three points on the pain VAS. The largest improvement was proportional to the volume drained. From the time of the first drainage, the patient lived for 168 days and had no significant procedural complications. Transient fluid leakage after removal of needles did occur, but required only observation and no active intervention. Mild renal impairment was seen; however, the patient was also dehydrated from poor fluid intake and this recovered to normal within 1 week. We have found subcutaneous drainage to be effective in cancer patients with refractory tense lymphoedema not responding to conventional treatment. In our practice, we have found efficacy across multiple types of metastatic cancer, regardless of cause (e.g. hypoalbuminaemia, lymphadenopathy, radiotherapy fibrosis). However, we have excluded cases with tissue lichenification and only considered the procedure in cases of gross pitting oedema. We have also modified Clein and Pugachev’s original procedure by reducing the number of drainage sites from six needles per leg to two; to reduce the risk of entanglement of tubing and falls. Needles are re-sited if drainage is poor. We also consider drainage in upper limbs if the oedema is refractory to all other treatment, following success in a patient with metastatic breast cancer with refractory gross lymphoedema in her right upper limb. In this case, mid-forearm and wrist circumferences reduced by 2 and 2.6 cm, respectively, and a total of 1 L was drained. Finally, we recommend prophylactic oral antibiotics for 1 week; we believe this low morbidity addition is warranted, although evidence is lacking. Of interest, we have seen improvement in patientreported pain and well-being, with even small volumes of fluid drained (50–100 mL). Thus, the place of the placebo effect should be considered in any future research. In summary, our experience supports Heng’s suggestion that drainage may be a useful intervention in patients with refractory lymphoedema.

Communicating end-of-life care goals and decision-making among a multidisciplinary geriatric inpatient rehabilitation team: A qualitative descriptive study:

Background: In geriatric inpatient rehabilitation settings, where the goal is to optimise function, providing end-of-life care can be challenging. Aim: The aim of this study is to explore how end-of-life care goals and decision-making are communicated in a geriatric inpatient rehabilitation setting. Design: The design is a qualitative descriptive design using semi-structured individual and group interviews. Setting/participants: This study was conducted in a 154-bed facility in metropolitan Melbourne, Australia, providing geriatric inpatient rehabilitation for older patients; medical, nursing and allied health clinicians, who had cared for an inpatient who died, were recruited. Data collection: Participants were interviewed using a conversational approach, guided by an ‘aide memoire’. Results: A total of 19 clinicians participated in this study, with 12 interviewed individually and the remaining 7 clinicians participating in group interviews. The typical patient was described as older, frail and with complex needs. Clinicians described the challenge of identifying patients who were deteriorating towards death, with some relying on others to inform them. How patient deterioration and decision-making was communicated among the team varied. Communication with the patient/family about dying was expected but did not always occur, nor was it always documented. Some clinicians relied on documentation, such as commencement of a dying care pathway to indicate when a patient was dying. Conclusion: Clinicians reported difficulties recognising patient deterioration towards death. Uncertainty and inconsistent communication among clinicians about patient deterioration negatively impacted team understanding, decision-making, and patient and family communication. Further education for all members of the multidisciplinary team focusing on how to recognise and communicate impending death will aid multidisciplinary teams to provide quality end-of-life care when required.

Acute Cancer Pain Syndromes in Palliative Care Emergencies

Acute pain syndromes in palliative care are predominantly malignant in origin. These are often emergencies due to the severity of the pain, its meaning to the patient, the disruption of ongoing curative treatment, and the resultant erosion of quality of life. A prompt accurate pain assessment is a vital component of clinical management, followed by analgesic intervention and attention to the physical, psychological, social, and spiritual aspects of pain. Clinicians should develop excellent communication skills to support patients, their families, and also other healthcare professionals in the delivery of optimal care. Pain S. Lam (*) Department of Medicine, Cairns and Hinterland Hospital and Health Service, Cairns, QLD, Australia e-mail: sophia.lam@health.qld.gov.au L. William Palliative Medicine, Monash Health, Eastern Health, Monash University, Melbourne, VIC, Australia e-mail: leeroy.william@monash.edu P. Poon Supportive and Palliative Medicine, Monash Health, Eastern Palliative Care, Monash University, Clayton, VIC, Australia e-mail: peter.poon@monash.edu # Springer International Publishing AG, part of Springer Nature 2018 R. D. MacLeod, L. Block (eds.), Textbook of Palliative Care, https://doi.org/10.1007/978-3-319-31738-0_79-1 1 will not always be managed according to the expectations of others, and so how we deliver care and explain the limitations of treatment is important. Acute cancer pain that is not managed well can become chronic in nature. The development of chronic pain can greatly reduce the functional ability and mood of patients over time. As with all symptoms, managing the acute presentation should lead to an investigation of causative factors, mechanism of pain, and potential therapeutic interventions. Acute pain syndromes can be approached via two causative mechanisms: treatment-related pain and pain directly related to the cancer process. A multimodal and multidisciplinary approach to treatment is often required to not only help the patient, but also to support the family during an uncertain and unsettling period of care.

Perspectives of cancer treatment providers regarding voluntary assisted dying in Victoria: Voluntary assisted dying and cancer

A survey of cancer treatment providers at our institution exploring their perspectives regarding voluntary assisted dying in Victoria and the imminent legislation showed that while almost all were aware of the Bill (92%), reported knowledge and understanding of it was much less (38%). As many clinicians supported the Bill as opposed it (28%); 44% were uncertain of their stance. Most were unwilling to directly provide voluntary assisted dying; if they did, would refer to palliative care services for ongoing support.

Bilateral cordotomy post-failure of intrathecal analgesia in a palliative care setting.

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