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Background Palliative sedation is a commonly accepted medical practice. This study aims to clarify how palliative sedation is regulated in various countries and whether this may impact its practice. Methods An online survey requesting regulations on palliative sedation was conducted in Belgium, Germany, Hungary, Italy, The Netherlands, Spain, Romania and the UK. Purposive sampling strategy was used to identify clinicians from different medical fields and legal experts for each country. Regulations were analyzed using the principles of the European Association for Palliative Care Framework on palliative sedation. Country reports describing how palliative sedation is regulated were elaborated. Results One hundred and thirty-nine out of 223 (62%) participants identified 31 laws and other regulations affecting palliative sedation. In Spain, 12 regional laws recognize palliative sedation as a right of the patient at the end of life when there are refractory symptoms. In Italy, the law of informed consent and advance directives specifically recognizes the doctor can use deep sedation when there are refractory symptoms. There are also general medical laws that, while not explicitly referring to palliative sedation, regulate sedation-related principles: the obligation of doctors to honour advance directives, informed consent, the decision-making process and the obligation to document the whole process. In Germany, the Netherlands and the UK, palliative sedation is also regulated through professional guidelines that are binding as good practice with legal significance. Conclusions Palliative sedation is considered in the general law of medical practice, in laws regarding the patient's autonomy, and through professional guidelines. [ABSTRACT FROM AUTHOR]

Objectives: Treatment escalation plans (TEPs) are vital in communicating a ceiling of care. However, many patients still deteriorate and die without a pre-established ceiling of care for attending clinicians to rely on. We aimed to increase the proportion of suitable patients that have TEPs in place in a rural district general hospital.Methods: We undertook three 'Plan-Do-Study-Act' (PDSA) cycles between 1 December 2016 and 9 June 2017. These cycles aimed to assess the problem, implement a solution and monitor its sustainability. We sampled all acute medical admissions at different time points, focusing on the acute medical unit. We identified patients requiring TEP forms using SupportiveandPalliative Care Indicators Tool. Stakeholders were surveyed during the project, and a process communication map was developed to understand the human interfaces that occur when producing a TEP.Results: We sampled a total of 323 patients (PDSA 1, n=128; PDSA 2, n=95; PDSA 3, n=100). Following implementation of a 'talking to your doctor about treatment' leaflet, the proportion of patients who did not have a TEP but required one fell from 43% (n=38, PDSA 1) to 27% (n=20, PDSA 3) then to 23% (n=77, PDSA 3) (CI 0.6631 to 39.917, p=0.028).Conclusions: This study highlights the challenges of TEP form completion. The impact of our intervention appeared to raise awareness of advanced care planning. The information contained in our leaflet could be distributed in more innovative ways to ensure patients unable to access textual information are able to receive this message. [ABSTRACT FROM AUTHOR]

Background: older people aged 80 and over are increasingly providing end-of-life care to spouses at home and often do so for long periods of time, while also trying to manage their own illnesses and disabilities. Little of the research on older spousal carers has focussed on the oldest carers; hence, the needs of this particular population are not fully known. Objective: to explore the experiences of the 'oldest carers' in caring for a dying spouse at home. Methods: secondary analysis was undertaken on a subset of data from a larger qualitative interview study; this dataset comprised 17 interviews from participants aged 80 or over. Framework analysis methods were used, with items derived from the thematic analysis of the main study. Results: the oldest carers in this subset demonstrated high levels of resilience and the ability to adapt to their caring role. Caring until death was accepted as an integral part of the commitment made to their partner as part of the 'wedding contract'. Carers felt they benefitted from the support provided by family, friends and care services; however, their own care needs were not always recognised by health and social care services. Conclusions: these findings underscore the complexity of the oldest carers' experiences and challenges in times of illness and end of life. Healthcare professionals should be alerted to the myriad ways caregiving is enacted in serious illness and seek opportunities for developing supportive interventions specifically for older carers. [ABSTRACT FROM AUTHOR]

Objective: Literature reviews suggest limited evidence of efficacy of antidepressant medication in patients with advanced cancer. This study was carried out to observe the longitudinal effect of antidepressant medication in a cohort of advanced cancer patients.Method: Patients were recruited from hospice day care settings and followed up longitudinally by series of measures for depression for 6 months or until death.Results: Six hundred and twenty nine patients recruited. One hundred and fifty six patients in total (25%) were receiving antidepressant medication for a median of 9.5 weeks (range 0–36 weeks) and a mean of 12.2 weeks. There was no significant difference in scores on depression measures over time for patients receiving antidepressant medication.Conclusions: Antidepressant medication for advanced cancer patients appeared to have little impact on depression scores. We postulate the holistic approaches within hospice day care may in themselves be interventions for depression thereby masking effect of pharmacological treatment. Further research should explore multi-intervention models for management of depression in advanced cancer. [ABSTRACT FROM AUTHOR]

Background: despite a mortality rate of approximately 30% in acute stroke, little is known about the palliative care needs of this group of patients. Design: prospective study of 191 acute stroke patients admitted to hospital in England. Biographical, medical and strokerelated data were collected. Participants completed the Sheffield Profile for Assessment and Referral to Care (SPARC), a screening tool for referral to specialist palliative care. Findings: over 50% reported moderate to significant fatigue-related problems. Approximately 50% reported symptom-related problems (e.g. pain) or psychological distress (e.g. anxiety). Approximately 25% had concerns about death or dying, and 66% had concerns about dependence and disability. Over 50% were worried about the impact of stroke on family members. There were significant main effects of dependence (Barthel Index) (F1,123 = 12.640 P = 0.001) and age (F4,123 = 3.022 P = 0.020), and a significant three-factor interaction between dependence, age and co-morbidities (F9,123 = 2.199 P = 0.026) in predicting total SPARC scores. Conclusions: acute stroke patients have a high prevalence of palliative care needs. Acute stroke services should use the SPARC for needs assessment. Priority for assessment should be given to patients with a score of <15/20 on the Barthel Index, a tool already used in most stroke services. [ABSTRACT FROM AUTHOR]

Background: current understanding of quality of life in heart failure is largely derived from clinical trials. Older people, women and those with co-morbidities are underrepresented in these. Little is known about factors predictive of quality of life amongst older people with heart failure recruited from community settings. Objective: to identify factors predictive of quality of life amongst older people recruited from community settings. Design: prospective questionnaire survey. Setting: general practice surgeries located in four areas of the UK: Bradford, Barnsley, East Devon and West Hampshire. Subjects: a total of 542 people aged >60 years with heart failure. Methods: participants completed a postal questionnaire, which included a disease-specific measure (Kansas City Cardiomyopathy Questionnaire), a generic quality-of-life measure (SF-36) and sociodemographic information. Results: a multiple linear regression analysis identified the following factors as predictive of decreased quality of life: being female, being in New York Heart Association (NYHA) functional class III or IV, showing evidence of depression, being in socioeconomic groups III-V and experiencing two or more co-morbidities. Older age was associated with decreased quality of life, as measured by a generic health-related quality-of-life tool (the SF-36 mental and physical health functioning scales) but not by a disease-specific tool (the Kansas City Cardiomyopathy Questionnaire). Conclusion: findings from the study suggest that quality of life for older people with heart failure can be described as challenging and difficult, particularly for women, those in a high NYHA class, patients showing evidence of depression, patients in socioeconomic groups III-V, those experiencing two or more co-morbidities and the 'oldest old'. Such information can help clinicians working with older people identify those at risk of reduced quality of life and target interventions appropriately. [ABSTRACT FROM AUTHOR]

Aim: to provide an evidence base for strategies, and effectiveness of the transfer of patient information between hospital and community for older people with physical illness. [ABSTRACT FROM PUBLISHER]

The high specificity of phenolic glycolipid I (PG-I) in the identifying individuals with leprosy appears to be attributable to the species-specific trisaccharide region of the molecule. Synthetic glycoconjugates were produced by coupling the corresponding terminal mono- or disaccharide to bovine serum albumin by reductive amination. Conjugates which contained only the terminal sugar maintained in its pyranose form, the terminal disaccharide with only the terminal sugar in its pyranose form and the terminal disaccharide with both the 3,6,di-o-Me-glucose and 2,3,di-o-Me-rhamnose sugars in their pyranose forms, were all highly active in the enzyme-linked immunosorbent assay (ELISA) and showed good concordance with native PG-i in analysis of sera from leprosy patients. The antibody levels to the glycoconjugates in tuberculosis patients and patients with other mycobacterial infections were not significantly different from the levels in normal healthy control subjects. A few of the leprosy sera showed much stronger binding to conjugates which contained the disaccharide with both sugars in the pyranose form than to conjugates with only the terminal sugar in its pyranose form. Therefore a synthetic conjugate which contains the intact disaccharide region of PG-I may provide the most sensitive antigen for the large scale serodiagnosis of leprosy. [ABSTRACT FROM AUTHOR]

Antibodies to the major phenolic glycolipid purified from Mycobacterium leprae have been demonstrated previously in sera of leprosy but not tuberculosis patients using an ELISA. The major antigenic determinants on this molecule were investigated using antisera raised in rabbits to the purified glycolipid and with a pool of sera from human lepromatous leprosy patients. A small, but significant cross-reaction was observed with the glycolipids from M. bovis and M. kansasii, which contain the phenolphthiocerol dimycocerosate part of the molecule but have different sugars, and also with a semi-synthetic 'attenuation indicator lipid' which shares the phenolphthiocerol but has no sugars. There was however no cross-reaction with phthiocerol dimycocerosate. The disaccharide, corresponding to the two terminal sugars of the M. leprae glycolipid has been chemically synthesized and shown to inhibit the reaction between glycolipid and antibody in the ELISA. The cross-reactivity observed with the M. bovis and M. kansasii glycolipids was not inhibited by the synthetic disaccharide. These findings suggest that the cross-reactivity is associated with the phenol ring and implies the disaccharide may be a unique antigenic determinant of M. leprae. [ABSTRACT FROM AUTHOR]

Serological activity against a purified phenolic glycolipid from Mycobacterium leprae, which may be obtained in large amounts from M. leprae infected armadillo liver, was investigated using immunodiffusion and an enzyme linked immunosorbent assay (ELISA). Generally a good correlation was obtained between these techniques, but the ELISA was more sensitive and convenient. Relatively high IgG and IgM anti-glycolipid antibody levels were found in lepromatous leprosy patients. The antibody titres to the glycolipid were, however, low when compared with antibody titres to crude sonicates. Since the glycolipid is present in large quantities, this suggests that it is not very immunogenic. Antibody against the glycolipid especially of the IgM class, was demonstrable in some tuberculoid leprosy patients, although at much lower titres than in the lepromatous leprosy sera. In lepromatous leprosy patients that were skin smear negative after more than 5 years of treatment the IgG anti-M. leprae derived glycolipid activity had decreased markedly. The anti-IgG and IgM glycolipid antibody levels in tuberculosis patients did not differ significantly from the levels in appropriate normal healthy subjects. The glycolipid antibody levels in patients infected with M. kansasii, M. avium or M. intracellulare also fell within the range of normal healthy individuals. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "The Effect of Age on Referral to and Use of Specialist Palliative Care Services in Adult Cancer Patients: A Systematic Review," by Jenni Burt and Rosalind Raine, published in the 2006 issue.