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Background Covid-19 had a dramatic effect on the delivery of health care across all settings: institutions reduced footfall and strict social distancing measures were introduced. Face to face consultations were reduced; referrals to a community palliative care team (CPCT) increased. Referral data was explored for trends in referral patterns that might inform optimal use of resources. Methods A retrospective notes review was undertaken for referrals received in the first 4 weeks of the pandemic after ‘lockdown’ in UK. Numbers were compared to 2019. Information was sought on reason for referral and resulting actions. Results 92 referrals were received, an increase of 26% from 2019. 11 patients died before first assessment, 2 declined a visit because of self isolation and 1, no longer needed CPCT input. 40% referrals were from primary care, 33% from specialty nurses, 13% from palliative care hospital teams, 7% from oncology and 5 others from secondary care. 78% had cancer, 14% - frailty, 5% - dementia and the remainder end stage liver and heart disease. Referral information for the 79 patients reviewed cited pain in 24%, ‘support’ (not specified) -18%, advance care planning (ACP) mentioned specifically in 14%. Covid 19 affecting usual treatment or follow up plans leading to referral was mentioned in 27%. On first review, 65% needed some aspect of ACP, 43% had pain, 82% had other symptom needs, 15% -ADL needs, 20% - mood problems, 18% care or financial needs, 11% were in the last days of life. Conclusions Although alternative health care delivery was imperative at the time to ensure hospital capacity, the impact on care delivered by CPCT cannot be underestimated. Referrals increased, 27% appearing to be as a direct result of altered services elsewhere. There is a need to work collaboratively across all settings as future surges of the pandemic progress.

Background Malignant bowel obstruction (MBO) is a common presentation in palliative care and can cause challenging symptoms. It has been suggested that the H2-receptor antagonist ranitidine may have a role in the management of MBO as an antisecretory medication to reduce volume of gastrointestinal secretions. Methods A questionnaire was sent via email to all UK adult hospices with inpatient units to investigate how ranitidine is currently being used for patients with MBO. Results 60% (99 of 165) of eligible hospices completed the questionnaire. 76% reported using hyoscine butylbromide most commonly as a first line antisecretory medication for patients with MBO. 84% of hospices reported using ranitidine for selected patients although only 8% reported using it as a first line antisecretory agent. Hospices that use ranitidine are most commonly administering it via continuous subcutaneous infusion for patients with acid related symptoms (88%), combined with other antisecretory medications (80%), as a second or third line antisecretory medication (68%) and for gastrointestinal protection (66%). Reasons cited for not using ranitidine included a lack of perceived need, lack of evidence, non-inclusion in clinical guidelines and issues of practicality. Responders highlighted the need for an individualised approach to prescribing in MBO with failure of other medications, nature of symptoms and nature of obstruction among factors influencing use of ranitidine. Multiple hospices reported recently starting to use ranitidine or using it more frequently than they had done previously. An Australian randomised controlled trial that used ranitidine as part of a ‘standard’ treatment regime in MBO was a commonly cited instigator for change. Conclusions Ranitidine is being used by the majority of UK hospices for selected adults with MBO despite a limited evidence base. Further research should be encouraged to evaluate the effectiveness of ranitidine and to clarify its role for patients with MBO.

Background With the introduction of phase 1 of the new Internal Medicine curriculum in August 2019, there is a need to consider how best to implement the Palliative Medicine aspect of the curriculum. Method Our aim was to explore the extent of Palliative Medicine experience gained during Core Medical Training (CMT) from current specialty trainees in Wales to help guide implementation of the new curriculum. An online survey was sent to Welsh Palliative Medicine trainees, South Wales Palliative Medicine Specialty Doctors, and registrars on the General Medicine on call rotas in Abertawe Bro Morgannwg UHB in February 2019. Results 17 trainees responded, 76% felt they had received sufficient exposure to Palliative Medicine during CMT. Overall, responders felt confident in managing different aspects of palliative care, particularly recognising limited reversibility, the dying patient (88%) and communication around end of life care issues (94%). The best way to teach these palliative care skills is unresolved. Suggested effective methods included palliative care placement (94% of responders agreed), small group teaching and communication skill workshops (59%). Discussion Our survey shows that the majority of responders were positive about their CMT experiences in Palliative Care. Some commented that most of these skills were learnt after starting specialty training, or from a CMT rotation in a hospice. Almost two-thirds of responders were Palliative Medicine middle grades suggesting more proactive approaches in seeking out these learning opportunities. Continued attention to placement opportunities, small group teaching and communication skills workshops would seem at present to be the most relevant response.

The Association for Palliative Medicine (APM) of Great Britain and Ireland has developed a core curriculum for palliative medicine. To establish the appropriateness of this core curriculum as a standard against which training can be measured, we have examined how doctors from different medical, social and cultural backgrounds view its various elements. In 1998, we succeededin tracing 304 of 390 doctors, past students of the University of Wales College of Medicine's Diploma in Palliative Medicine. Each was sent a postal questionnaire that asked them to rate the importance to their own clinical practice of each element of the APM core curriculum. Two-hundred sixty-three questionnaires were returned a response rate of 87%. The ages rangedfrom 30 to 71 (mean 44) years; 56% (147) were female. Forty per cent (105) were general practitioners, and 37% (97) hospice and 23% (61) hospital-based. Eighty-three per cent (220) were fromthe UK, 5% (14) from the rest of Europe, 8% (21) from the Far East and 3% (8) from other countries. The majority of respondents agreed that all elements of the APM core curriculum were of ‘very great' or ‘great' importance to their current clinical practice. Respondents' medical, social or cultural setting had only very minor effects on their attitude to individual elements. The elements of the curriculum perceived as being of greatest importance were: communication with patients and their families, assessment, diagnosis and treatment of pain, multiprofessional team working and psychological responses to illness and bereavement. Clinicians from a wide variety of backgrounds confirm the relevance of the APM core curriculum. This justifies its adoption as the audit standard against which the quality of training and educational programmes in Palliative Medicine should be judged.