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Background15%–20% of critical care patients die during their hospital admission. This service evaluation assesses quality of palliative care in intensive care units (ICUs) compared with national standards.MethodsRetrospective review of records for all patients who died in four ICUs (irrespective of treatment limitation) between 1 June and 31 July 2019. Descriptive statistics reported for patient characteristics, length of stay, admission route, identification triggers and palliative care delivery.ResultsForty-five patients died, two records were untraced, thus N=43. The dying process was recognised in 88% (n=38). Among those where dying was recognised (N=35), 97% (34) had documented family discussion before death, 9% (3) were offered religious/spiritual support, 11% (4) had review of hydration/nutrition and 6% (2) had documented preferred place of death. Prescription of symptom control medications was complete in 71% (25) opioids, 34% (12) haloperidol, 54% (19) midazolam and 43% (15) hyoscine. Combining five triggers—length of stay >10 days prior to ICU admission 7% (3), multiorgan failure ≥3 systems 33% (14), stage IV malignancy 5% (2), post-cardiac arrest 23% (10) and intracerebral haemorrhage requiring mechanical ventilation 12% (5)—identified 60% (26) of patients. Referral to the palliative care team was seen in 14% (5), and 8% (3) had specialist palliative care team review.ConclusionsRecognition of dying was high but occurred close to death. Family discussions were frequent, but religious/spiritual needs, hydration/nutrition and anticipatory medications were less often considered. The ICUs delivered their own palliative care in conjunction with specialist palliative care input. Combining five triggers could increase identification of palliative care needs, but a larger study is needed.

ObjectivesTo describe the current, real-world use of non-steroidal anti-inflammatory drugs for pain and the associated benefits and harms.MethodsA prospective, multicentre, consecutive cohort pharmacovigilance study conducted at 14 sites across Australia, Aotearoa/New Zealand and the UK including hospital, hospice inpatient and outpatient services. Pain scores and harms were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events at baseline, 2 days and 14 days. Ad-hoc safety reporting continued until day 28.ResultsData were collected from 92 patients between March 2018 and October 2021. Most patients had cancer (91%) and were coprescribed opioids (90%). At 14 days, 83% of patients had benefit from non-steroidal anti-inflammatory drugs and 22% had harm. The most common harms were nausea (8%), vomiting (3%), acute kidney injury (3%) and non-gastrointestinal bleeding (3%); only 2% were severe and no patients ceased their non-steroidal anti-inflammatory drugs due to toxicity. Overall, 65% had benefit without harm and 3% had harm without benefit.ConclusionsMost patients benefited from non-steroidal anti-inflammatory drugs with only one in five patients experiencing tolerable harm. This suggests that short-term use of non-steroidal anti-inflammatory drugs in patients receiving palliative care is safer than previously thought and may be underused.

Upper respiratory tract secretion accumulation with noisy breathing (‘death rattle’) is caused by salivary secretions pooling within the hypopharynx. It occurs in people who cannot swallow, usually in the last days of life.1–3 It is reported in 12%–92% of dying patients3–6; the weighted mean prevalence is 35%.5 The noise and secretions can be distressing for some family members and staff.5–8 They are reportedly not associated with subjective respiratory distress,4 5 although those with the problem often have impaired consciousness so patient impact is unclear.5 Antimuscarinic drugs (eg, glycopyrronium and hyoscine butylbromide) reduce new secretion formation.2–4 Systematic reviews have found no benefit of antimuscarinics over placebo. They advise against their routine use once noisy upper respiratory tract secretions are present.3 5 9 Although they reduce production, they do not remove existing secretions. The idea of preventative prophylactic …

BackgroundEducating medical students to care for patients at the end-of-life is increasingly recognised as an essential component of training. Traditionally, medical student programmes are run by doctors, but patient care is delivered by an interprofessional team. Our programmes in the UK and USA independently developed a teaching experience led by an interprofessional team of palliative care health professionals.ObjectivesThis study explores the palliative care health professionals’ perceptions, regarding their unique role in medical student palliative care education.MethodsThis is the first study to ascertain views of an interprofessional team delivering palliative care education to medical students. Focus groups enable interaction between members of the group as well as the generation of consensus of comments among group members.ResultsTwo major themes were identified: perceived benefits and value of the experience, and the challenges and lessons learnt from the experiences.ConclusionsDespite different structures and settings, this experiential learning in palliative care provided a rewarding interprofessional experience that has historically been difficult to achieve.

Opioids are commonly used for cancer-related pain in advanced disease and about 75% of people have a good response. However, undertreatment is common, and opioids are often started only weeks before death. Undertreated pain might decrease survival in some, although prospective studies to delineate how pain and opioids affect cancer progression and survival in various malignancies are absent.1 One systematic review found that most (11 of 17) studies in advanced prostate cancer showed pain to be an independent prognostic factor for shorter survival.1 However, five studies defined pain by analgesic use, making it difficult to determine if pain or opioid use was more important. In breast, colorectal or lung cancer evidence was insufficient to definitively determine if pain independently influences survival.1 In a secondary data analysis, recurrent ovarian cancer pain was an independent marker for shorter overall survival.2 In this study, survival was shorter in those with pain and without pain medication compared with those on sufficient pain medication.2 Clinicians and patients are understandably concerned, respectively, about prescribing and taking opioids. These concerns include side effects, addiction and the perception that opioid use indicates the end of …

▸ Button E, Chan RJ, Chambers S, et al. BMC Cancer 2017;17:213. This systematic review looked at identifying prognostic factors in the last 3 months of life that are associated with increased risk of mortality for haematological malignancy; most patients were predominantly treated with aggressive curative or life-prolonging intent. This included 28 studies; mostly were in the intensive care unit settings and retrospective. The prognostic factors were categorised into five groups, mainly: demographics; interventions (eg, vasopressor support or mechanical ventilation), physiological complications (eg, bone marrow or multiorgan failure); disease characteristics and laboratory blood values. Using the QUIPS tool, most …

Studies have demonstrated that whereas some opioids have little effect on immunity (eg, buprenorphine), others can be immunosuppressive (eg, morphine) or immunostimulatory (eg, tramadol). However, a variety of approaches have been used, especially in vitro and animal models, and the findings are variable. We hypothesised that opioids have differential effects on immunity via direct actions on neutrophils, monocytes, natural killer (NK) and T cells, and this is the first study to systematically evaluate the influence of eight opioids on neutrophil and monocyte phagocytosis and oxidative burst responses, NK cell cytotoxicity and T cell responsiveness in vitro.Peripheral blood was obtained from healthy volunteers, and the effects of clinically relevant concentrations of morphine, tramadol, fentanyl, buprenorphine, methadone, oxycodone, diamorphine and codeine on phagocytosis and oxidative burst responses were determined using whole blood flow cytometry. The influence of opioids on the capacity of resting and IL-2 stimulated isolated peripheral blood mononuclear cells (PBMCs) to kill NK cell-sensitive K562 cells, and the responsiveness of PBMC subpopulations to IL-2 and polyclonal stimulation were also evaluated.Methadone, oxycodone and diamorphine inhibited the production of IL-6 by IL-2 stimulated PBMCs. None of the opioids consistently influenced the other measured immune parameters, although there was a trend for morphine, tramadol, fentanyl and buprenorphine to inhibit phagocytosis and oxidative burst responses to Escherichia coli.Preliminary studies using standardised in vitro methodologies have demonstrated that some therapeutic opioids suppress IL-6 production. Although this might potentially suppress bacterial defence mechanisms, it would have little direct effect on anticancer immunity. These findings should be confirmed in larger in vitro and clinical studies.

Background The legal blood morphine concentration for driving in England and Wales has been set at 80 µg/L, based on consensus. There is little information regarding the doses likely to cause levels above this limit. Knowledge of the dose-concentration relationship would aid doctors’ prescribing ?decisions and individualised advice. The aim of this study was to investigate the in silico relationship of oral morphine dose and plasma concentration in the context of a morphine plasma concentration of 80 µg/L in different patient groups. Methods A dose-concentration in silico model for different genders, ages and morphine formulations was generated using Simcyp, a population-based pharmacokinetic simulator. This software simulates absorption and metabolism in a physiology based modelling platform, calculating a range of steady state dose-plasma concentrations across a diverse population. The morphine model created was validated against clinical pharmacokinetic data for oral immediate-release and modified-release preparations. This model calculates only morphine ?concentrations not its active metabolites; in line with the ?driving law. Results Older age, female gender, modified-release formulation and renal dysfunction were associated with higher plasma concentrations at steady state. Except in females over 80 years old or in people with impaired renal function, morphine doses below 120 mg/d were unlikely to result in a morphine plasma concentration above 80 µg/L. In males less than 40 years old with normal renal function, doses up to 250 mg/d were unlikely to result in a morphine plasma concentration above 80 µg/L. An immediate-release morphine dose taken alongside modified-release morphine leads to a higher plasma concentration. Conclusion These derived morphine dose-concentrations could provide a reference frame for the prescribing clinician. However, the decision and communication to the patient must ?primarily take into account clinical judgment, the individual patient‘s level of impairment and insight for any given dose and plasma concentration.

▸ Nanni MG, Biancosino B, Grassi L. J Affect Disord 2014 May;160:87–91. This study investigated the relationship between pre-loss criteria for complicated grief and post- bereavement diagnosis of complicated grief. This was carried out in a hospice in North East Italy, in which 60 family members of patients who were admitted and who had a 30 day survival of less than 30% as predicted by the Palliative Prognostic Score completed the Pre-Death Inventory of Complicated Grief. This is a 13-item questionnaire which uses a Likert sale to investigating care givers mood and feelings. Six months after the death, family members were interviewed at their home for Complicated Grief using the Inventory of Complicated Grief-Structured Clinical Interview (with 17 criteria required for a diagnosis of complicated grief). 18% of caregivers had complicated grief at 6 months. The scores obtained before the bereavement from the Pre-Death Inventory of Complicated Grief tool were higher among those who developed complicated grief. Pre-loss criteria related to traumatic distress, separation distress and emotional symptoms in general were significantly related to a post-loss diagnosis of complicated grief, while no effect was shown on duration of pre-loss distress. The authors encourage the use of short screening tools, like the Inventory of Complicated Grief, to help identify people at risk of developing complicated grief, although acknowledge their findings need confirmation in larger, multisite studies. ▸ Kavalieratos D, Mitchell EM, Carey TS, et al. J Am Heart Assoc 2014; 3: e000544.[OpenUrl][1][Abstract/FREE Full Text][2] doi: … [1]: {openurl}?query=rft.jtitle%253DJ%2BAm%2BHeart%2BAssoc%26rft_id%253Dinfo%253Adoi%252F10.1161%252FJAHA.113.000544%26rft_id%253Dinfo%253Apmid%252F24385453%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=ahaoa&resid=3/1/e000544&atom=%2Fbmjspcare%2F4%2F2%2F128.atom

▸ Fallon M, Hoskin PJ, Colvin LA, et al. J Clin Oncol 2015. Published Online First. In a multicenter, double-blind randomised trial in adults with moderate to severely painful radiologically-proven bone metastases due to receive radiotherapy, pregabalin (titrated over 4 weeks) was compared to placebo. From nearly 2000 patients screened, 233 were randomly assigned (the target was 260): 117 to placebo and 116 to pregabalin; all were included in the analysis. Patients had a variety of cancers, with prostate, breast and lung being the most common. In the pregabalin arm, 45 patients (39%) had a reduction of ≥2 points in worst pain by week 4 (the primary end point), compared with 47 (40%) in the placebo arm. The secondary end points of average pain, pain interference, or quality of life were also the same between arms. There were significant improvements in mood and a decrease in breakthrough pain episodes with pregabalin. There were no differences …

Background Leeds Teaching Hospitals is a flagship trust for the EoLC strategy. We aim to improve the identification of these patients, and critically the communication with the patient, family and primary care. Method We conducted a retrospective review of clinic and discharge letters from patients who died as an in-patient or within 28 days of discharge. All were under the care of a respiratory physician during two 6 month periods in 2011 and 2012. Data is currently being collected for 6 months in 2013 and will be presented. Results Notes from a total of 186 and 181 patients, with a median age of 74.4 and 75.0 years, were reviewed in 2011 and 2012 respectively. Between 2011 and 2012 there was an increase in the proportion of deaths post-discharge from 22% to 29%. Documentation of a palliative intent to therapy was noted and communicated to primary care in 21% of in-patient deaths during both years. Documentation of palliative intent on the discharge summary for patients dying within 28 days of discharge fell from 78% to 40%. Conclusions The commonest causes of death for in-patients were pneumonia, lung malignancy and COPD. Those who died within 28 days of discharge had lung malignancy, other malignancy, ILD and COPD. The majority of patients with a documented communication about palliative intent had a diagnosis of thoracic malignancy. This reflects a more predictable disease trajectory and MDT decisions of “best supportive care”. Lack of confidence around predicting terminal disease in other respiratory diagnoses may account for the differences in rates of communication. In EoLC communication between professionals is a critical step in improving patient care and is particularly challenging in those with non-malignant disease.