Stephen Kirkham

Unlicensed uses for medication in a palliative care unit

The aim of this study was to review the extent of drug use for unlicensed purposes in a palliative care unit. We carried out a prospective study of all patients with advanced malignancy admitted to a 10-bed specialist palliative care unit over a 4-month period. Prescriptions were assessed and compared with licensed prescribing indications. Seventy-six patients were included in the study; 689 prescriptions were made using 84 drugs to treat 34 different symptoms. Fifteen per cent of prescribing events were for unlicensed indications. We conclude that drugs are frequently used in the palliative care setting for purposes unsupported by product licences, although usually backed by literature. These drugs are often prescribed for symptoms which are difficult to control.

Bed occupancy, patient throughput and size of independent hospice units in the UK

There are few published figures relating to clinical activity of inpatient hospice units. Aquestionnaire was circulated to 60 independent hospices in the UK asking about number of beds, bed occupancy and number of admissions; 45 units responded. It is concluded that bed occupancy is an unreliable measure which can give significantly different figures depending on how it is calculated, and the number of admissions per bed per year (the throughput) may be the most informative single measure. Formulae for calculating maximum and average throughput for hospices of different size are provided.

Double effect, double bind or double speak?

© Arnold 1999 0267–6591(99)PM284ED Dr Roger Hunt’s Personal View published in this issue (p. 439) is offered as an attempt to generate real discussion relating to several important practical, legal, moral and ethical problems. We would like to start that debate by offering a commentary on his paper and on some of those issues. In defining palliative care, those advising the World Health Organization1 sought to acknowledge and to avoid two fundamental mistakes in caring for people with advanced, progressive, incurable disease. These arose from a failure to recognize dying as a normal process. The first problem was a persistence with futile and burdensome treatments aimed at prolonging life; the second a failure to recognize the value of the final days or weeks of life. This second fault tended to result in paternalistic medical care, which aimed to minimize suffering by hastening dying. Anecdote suggests that the practice of doubling doses of regular opioids until death ensued was not uncommon, and the concept of double effect would appear to have been given legitimacy by the judgement of Mr Justice Devlin (later Lord Devlin) in the trial of Dr John Bodkin Adams in 1957: ‘a doctor ... is entitled to do all that is necessary to relieve pain and suffering, even if the measures he takes may incidentally shorten life’.2 The phrase ‘palliative care ... neither hastens nor postpones death’ was intended to deny this practice, although it clearly does not stand up to a reductionist analysis. It is apparent that much of our practice really does affect the course of an illness, although all experienced practitioners will recognize that the timescale of an illness does not always change in the way one originally anticipates. However, acknowledging that we can and do influence the time of life remaining does not remove our responsibility to avoid the two kinds of mistake described above. To take a single example from the list of treatments that are likely to prolong life, we doubt that anyone has ever proposed that hospice or palliative care workers must never refer a patient for ureteric stenting. On the other hand, we need to acknowledge that stenting of obstructed ureters may simply result in further suffering for the patient and should never be a routine response to a diagnosis of obstructive nephropathy. Hunt suggests that the principle of double effect is tantamount to an admission that a hastened death is an accepted and inevitable effect of a particular treatment. There is, however, an important distinction between a proven effect and a foreseen but uncertain consequence. It is also misleading to suggest that a recognition of double effect results in an exclusive focus on the clinician’s agenda and an undermining of patient autonomy. It is perfectly possible – indeed, desirable – to involve patients in discussions about whether (for instance) they would accept being more drowsy if difficult pain or breathlessness were to be reduced. There is nothing within any principle of double effect that inevitably jeopardizes patient-centred care. We find it both curious and regrettable that double effect is linked specifically with palliative care, and often more particularly as an apologia for the use of strong opioids as analgesics. It is not clear to us why this link with palliative care exists. Does the medical oncologist invoke the principle of double effect when chemotherapy is prescribed in disseminated malignancy? Even though life may be prolonged, toxicity may result in shortening of life, and cure is a rarity. Does the surgeon talk about double effect when recognizing the small but measurable mortality for any surgery, even for a condition that is never life-threatening? The unpredictability of illnesses, coupled with an almost universal wish to rationalize and to seek reasons for what happens makes it inevitable that some treatments will be perceived to have shortly Editorial

Unlicensed uses for medication in a palliative care unit – correction

The aim of this study was to review the extent of drug use for unlicensed purposes in a palliative care unit. We carried out a prospective study of all patients with advanced malignancy admitted to a 10-bed specialist palliative care unit over a 4-month period. Prescriptions were assessed and compared with licensed prescribing indications. Seventy-six patients were included in the study; 689 prescriptions were made using 84 drugs to treat 34 different symptoms. Fifteen per cent of prescribing events were for unlicensed indications. We conclude that drugs are frequently used in the palliative care setting for purposes unsupported by product licences, although usually backed by literature. These drugs are often prescribed for symptoms which are difficult to control.

Book Review: Oxford textbook of palliative medicine

This is the second edition of the most authoritative work encompassing the greater part of palliative care. As such, and as the editors point out in the preface, the title is something of a misnomer: where there is a choice, the emphasis is on palliative care rather than on palliative medicine. There is material here for all disciplines. To start with the statistics: this edition is just over half as long again as its predecessor, containing 1283 pages as compared with 845, although the price has only risen from £95 to £110. (Obsessional neurotics will note a US list price of

Admissions and discharges

139.50 with an exchange rate of

What do we publish

1.65 to the pound; it is unclear how this arithmetic works.) Around 10% of the overall growth seems to be attributable to changes in layout: the rather cramped 1993 volume has been given valuable breathing space. Three completely new sections have been added, on the measurement of symptoms, the principles of drug use and interventional radiology; the section on ethical issues has new authors. The paediatric section has also been substantially enlarged, and there are new chapters on asthenia and on pruritus and sweating. On the other hand, an apparent fourth new section, on communication, appeared as a chapter in the first edition, and many chapters are essentially unchanged. In comparison with the first edition, the overall balance of the book seems to have been improved, and several authors have substantially strengthened their citations of the original evidence. As a single example, the chapter on adjuvant analgesics now has 454 references, compared with 275 in 1993. The new edition thus admirably fulfils its role as a source of evidence-based practice in palliative care; as a manual of what measures might help when specific problems arise it is understandably of less valuable, since the book aims to deal with evidence rather than with anecdote. In short, this edition strengthens the Oxford textbook’s position as the definitive overview of the field and practitioners will want to have it available to them, either in their libraries or on their own bookshelves. The editors are to be congratulated on having drawn together all of this material from over 100 contributors, drawn from many nations and writing for a global audience. Being no stranger to the editor’s problems, I would find this an impossibly daunting task. At some stage though they may have to persuade their contributors to distinguish even more precisely the need to be authoritative from the wish to be comprehensive, lest the book become impossibly unwieldy.