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Objectives: In India, Palliative care remains inaccessible, especially in remote areas. This study aimed at exploring the experience of caregivers related to arranging palliative care at home, for personnel and family members of an armed force. Materials and Methods: Qualitative study based on thematic analysis of semi-structured interviews with adult caregivers - either serving personnel or their dependent family members. Results: Lack of palliative care in rural areas makes arranging home care challenging for Indian caregivers, especially in armed forces. The families stay alone and personnel cannot be there to look after loved ones. Constraints of leave, financial and legal problems, frequent movement and social isolation disrupt care as well as family and community support systems, leading to psycho-social problems and stress for the serving personnel as well as families. Educating staff, integrating palliative care into existing medical services, coordinating with other agencies to increase awareness and provide care at home, access to opioids, timely leave, reimbursement of expenses, increased family accommodation, guidance about benefits, and considerate implementation of transfer policy can help mitigate some of their problems. Conclusion: These caregivers face physical exhaustion, psycho-social, financial, legal, and spiritual issues- some common to all rural Indians and others unique to the armed forces. Understanding their experiences will help the providers find solutions, especially in relation to the unique needs of the men in uniform.

While education of specialists in paediatric palliative care (PC) and palliative medicine remains an important priority, it is also imperative to upscale education efforts for other healthcare professionals, policy makers, and governments in order to integrate PC into the care of an estimated 21 million children globally. PC education should be available to all child-focused healthcare professionals and beyond in order to correct misconceptions that threaten to impede delivery of adequate PC to children. That can be done through advocacy and through mass media, as well as through targeted educational initiatives based on an understanding of adult education theory. Novel online and other teaching strategies offer the opportunity to reach unprecedented numbers of people.

Background/Introduction There is an urgent need to continue palliative care professional development (CPD) for all those delivering health care, especially in view of health needs of the population currently affected by the Covid-19 pandemic. Face to face teaching, whilst preferable to date, has not been possible. The face to face interaction at the start of a Masters course in Palliative medicine was transitioned to virtual learning. We explored the impact of using technology on the learning experience of participants both in terms of comfort with the virtual environment and its impact on their learning Methods Prospective evaluation of a redesigned face to face teaching programme. Participants were asked if the virtual learning environment or technology had impacted on their learning using a 5 point scale for each of the sessions. A further delayed evaluation is underway, to explore the continued impact of the sessions. Results 13 sessions forming a 3 day programme were evaluated. 252 responses were received (45% response rate) 223/252 responded that all was well, 18/252 mentioned some technical difficulties but with no negative impact on learning, 8 mentioned technical issues which did impact on learning, 2 mentioned being uncomfortable with the virtual learning environment with no impact on learning and 1 person described being uncomfortable with negative impact.Results to date of the delayed evaluation have been received from 16 participants (response rate of 32%). Conclusions Enabling virtual CPD to continue to skill and enable the health care workforce to deliver palliative care to patients is paramount, especially while Covid-19 restrictions to face to face gatherings continue. With attention to teaching techniques (delivery style, focused content and use of interaction), neither the technology or a virtual learning environment, negatively impact learning for the majority of students. Further exploration of prospective data is underway.

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/Introduction The Covid-19 pandemic created immense unexpected pressure on postgraduate health care professional students undertaking academic study. The role of a community of practice within an international cohort of postgraduate students became apparent as the pandemic progressed. Needing a supported space away from social media in which to discuss developing issues, and a forum in which useful resources could be shared swiftly became apparent. A closed ‘Discussion board’ facility was used within the virtual learning platform in which themes and collections of support, ideas and materials were developed. Methods Qualitative thematic analysis of anonymised contributions to the Discussion board 25th March 2020 - 31st July 2020. Permission was sought retrospectively from all participants on the Discussion Board; any information from those not willing for their content to be included was deleted from the transcripts before review. The transcripts were reviewed by 2 independent researchers for content and context. Results 13 themes developed. Sharing resources (March); ethical issues, communication skills (including virtual communication), symptom control, team support and leadership, the challenge of covid 19 in remote communities, the collateral damage of the pandemic for children, involving the family remotely and maintaining one’s own wellbeing in a pandemic ( April); Developing services, moving forward and quality improvement ( May); moral courage and managing the symptom of breathlessness (June). Conclusions The generation of themes reflected the unprecedented challenges of the phase of the pandemic being experienced. Symptom control, communication skills and ethics leading to their application in different settings and the need after the first few weeks for team support, mental resilience and leadership. Valuable reflections and resources have been developed to help support future surges.

Background/Introduction Interaction and a community of practice are integral to postgraduate education. Previously, face to face (F2F) teaching allowed an opportunity for these factors to evolve naturally. Due to Covid -19 restrictions, this interaction needed to transition to virtual learning for a Palliative Medicine MSc. We explored the use of breakout room and use of a ‘chat’ function on a virtual learning platform to stimulate interaction and create a community of practice. These features were used within sessions for case based discussions, team building activities and immediate whole group responses to particular palliative care issues and challenges, enabling the cohort of students to build on each other’s comments. Methods Participants were invited to send immediate free-text evaluation of the sessions. These results were screened for comment on breakout rooms, and thematic analysis used to explore feelings towards this teaching strategy. Results 252 responses were received across all sessions (45% response rate). Results were screened for reference to breakout rooms and use of the chat function. Thematic analysis revealed that these were positively received (‘More breakout rooms’, ‘really good’), and gave rise to an opportunity for people to interact within a virtual learning environment. Additional unsolicited feedback to the course team indicated satisfaction with the delivery style ‘ ‘I felt like there was still a really nice feeling of camaraderie, and that I got to know a lot of the others with the breakout rooms. I also felt much less inhibited using the chat function than I would putting my hand up in a lecture’ Conclusions Breakout rooms, and the use of the ‘chat’ function, were found to be an excellent medium with which to facilitate interaction and develop a community of practice. Using all aspects of technology to successfully support delivery of palliative care education can enhance palliative care knowledge during this time when F2F education is not possible.

Background/Introduction Social distancing and work load as a result of Covid-19 has resulted in the loss of face to face (F2F) education in health care settings. The need for greater use of telephone and video consultations, in addition to mastering optional communication whilst wearing personal protective equipment (PPE) during the pandemic has created additional challenges and learning needs at a time when palliative care skills are in great need. The Cardiff MSc includes practical communication skills as part of the annual F2F teaching. Content and delivery style needed to change in 2020 to reflect the current situation. Methods Stakeholder analysis of curriculum content to inform the revised programme and delivery and evaluation of the sessions. Results Discussion led to the development of a combination of webinars, interactive demonstration using specifically filmed scenarios prompting discussion in small groups, group discussions of challenges and strategies for current communication and role play in small groups of virtual consultations with formative feedback for participants. There was a 45% response rate for immediate evaluation and 32% response rate for the delayed evaluation 4 weeks following the day. Immediate evaluation showed the majority of participants (96%) rated the sessions of the day ‘good’ or ‘very good’. On delayed evaluation, 90% of respondents reported a solid or comprehensive understanding of the concepts, 66% reported already using what they had learnt in practice. Conclusions The previously F2F communication skills teaching successfully translated to the online environment, including using ‘breakout groups’ to hold interactive demonstrations as prompts for discussion and to role play virtual and telephone consultations to help participants reflect on and develop optimal communication skills for these situations.

Context: One of the principle obstacles identified in suboptimal management of pain in worldwide cancer patients is inadequate assessment of pain which in turn leads to poor management. In Sri Lanka, this is heralded by the lack of medical or nursing professionals qualified in Palliative Medicine/Care to date in Sri Lanka. Aim: The aims of this clinical audit were to raise awareness and optimize the assessment of pain among resident patients of a tertiary care cancer hospital by oncology doctors. Methods: A simple “pain and associated symptom chart” was designed for the doctors of the tertiary care cancer institution to document pain experienced by resident cancer patients in terms of intensity, both upon admission and on daily clerking. The expected standards were 100% documentation for each, regardless of the presence of pain on a visual analog scale (0–10). Documentation of the site and character of pain were expected to be 80% each. Results: Despite conducting three audit cycles with staff training and clarifications in between, the pain assessment practices did not be improve significantly (P > 0.05). In the third/ultimate audit cycle, it was noted that 23.5% of the charts were marked as “0” pain intensity upon admission and have been neglected thereafter. Conclusions: Pain assessment practices of the tertiary care oncology unit concerned was suboptimal. Therefore, it is of utmost importance to explore obstacles and incorporate pain assessment as a mandatory routine practice in clinical oncology units.

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.

Background International evidence suggests there are barriers to homeless patients accessing healthcare, including palliative services, despite poor health outcomes and the average age of mortality in the UK homeless being 30 years younger than the mainstream population. The literature calls for in-reach palliative services to hostels, shelters and the streets to meet the palliative need. These conclusions arise from research with homeless staff, but the perceptions of palliative healthcare professionals had not been explored to see if this is achievable in practice. Method A novel peer-reviewed online survey allowing quantitative and qualitative responses was distributed to 227 adult hospices listed with Hospice UK. Any palliative health professional working within these services was eligible to participate. Results 129 palliative healthcare professionals responded. Participants included consultants, speciality doctors, nurses, clinical nurse specialists, social workers, physiotherapists, occupational therapists and counsellors. All 12 regions of the UK were represented. There was a wealth of palliative experience (two thirds had over 10 years‘ experience) but minimal training in palliative care specifically for people experiencing homelessness. Notable challenges to supporting this group included difficulty engaging community services (e.g. GP registration, safe provision of controlled medications), difficulties over discharge destinations from hospices if not an end-of-life admission, and challenging client behaviour. Respondents felt palliative care should extend support to this population through supporting homeless services as well as engaging the multi-disciplinary team. This may require flexibility to established referral pathways and ways of accessing palliative care. Conclusion Flexibility and collaboration with homeless organisations and multi-disciplinary health care teams is imperative to ensure equitable palliative delivery to homeless populations. More training and education is needed for palliative care workers to understand caring for this population and for homeless staff to understand palliative care services. Further research is needed to understand how to achieve this care delivery in practice.

Background There is a growing focus on research in Palliative Medicine but the challenges in undertaking research in this area are significant. One of these challenges is often perceived to be the process of obtaining ethical approval from a Research Ethics Committee (REC). The aim of this project was to review the published literature relating to the research ethics process within palliative medicine and relate that to qualitative and quantitative data on this process from students undertaking a Palliative Medicine MSc at Cardiff University. Methods A literature search was conducted through an OVID database search and hand-searching relevant journal articles. This identified seven articles which were reviewed in order to provide a qualitative assessment of the literature. A semi-structured online questionnaire was designed and distributed via email to all previous palliative medicine MSc candidates at Cardiff University from 2010–2015. Qualitative data was reviewed by hand to explore common themes within the replies. Results A common theme identified from the published literature was a perception that many RECs take a cautious approach to the palliative patient population. Of the 129 alumni, 114 were contacted and 34 replied. The student’s feedback highlighted that some RECs are unfamiliar with qualitative research and the process is time-consuming. However, 85% of the students surveyed stated that they obtained approval without significant change to the project. Conclusion This study highlights some of the barriers to research in palliative medicine and shows that students are still faced with variable insight into the nature of this research from RECs. Further study in this area is important to ensure that necessary research within palliative medicine is not avoided due to barriers in the ethical approval process. A strong palliative medicine presence within RECs may be beneficial to the appropriate assessment of research within this field.

Background Since its inception in 1987, undertaking the ‘Cardiff Diploma/MSc’ has helped develop many Palliative Medicine specialists, teachers, service leaders and researchers both within the UK and Internationally. With annual financial support, first awarded in 2006, from the Commonwealth Scholarship Commission, doctors from India have been supported to undertake the Cardiff University MSc in Palliative Medicine. Objectives This survey looks to quantify the impact of undertaking the Cardiff University Palliative Medicine Diploma or MSc on Indian doctors’ practice. Method All Indian alumni were invited to complete a short, 10-question, anonymous on line survey. Response rate was 61% (n=37). Respondents were asked to score (0–100) the impact the MSc had on their clinical, teaching, management/service lead, and research roles. As a measure of impact respondents were also invited to give details of any publications and special interests subsequently developed. Results On a scale of 0–100 (zero to high impact) average collated self-scored impact of undertaking the MSc in Palliative Medicine were; clinical role 82% (50–100); teaching role 82% (30–100); management/service lead role 68% (20–100) and research role 74% (35–100). Over 50 journal publications, 20 International poster presentations and several conference workshops were listed as a result of MSc work. 70% of respondents had developed a special interest as a result of undertaking the Diploma/MSc. Conclusion 10 years on it would seem that the Cardiff University MSc has had significant impact. Future plans include collaboration with the India alumni, to roll out further teaching and training material and to develop international research between the Cardiff team and India.

A synthetic route amenable to large-scale synthesis of the glycine antagonist (2R,4E)-7-chloro-4-(2-oxo-1-phenyl-pyyrrolidin-3-ylidene)-1,2,3,4-tetrahydroquinoline-2-carboxylic acid, (2R,3R,4R,5S)-6-(methylamino)hexane-1,2,3,4,5-penta-ol 12 is presented. The route consists of four stages of chemistry. Stage 1 starts from 5-chloro-2-iodoaniline hydrochloride and is a three-step telescoped stage consisting of an imine formation with ethyl glyoxalate, Mannich reaction using vinyloxytrimethylsilane, and subsequent Wittig reaction with (2-oxo-1-phenyl-3-pyrrolidinyl)triphenylphosphonium bromide. The stage 1 product (4E)-2[(5-chloro-2-iodophenyl)amino]-4-(2-oxo-1-phenyl-pyrrolidin-3-ylidene)butanoic acid ethyl ester 17 is subjected to an enzyme-catalysed kinetic resolution to prepare the single (2R)-enantiomer 19 as the ethyl ester. Stage 3 is the intramolecular Heck reaction to yield (2R,4E)-7-chloro-4-(2-oxo-1-phenyl-pyrrolidin-3-ylidene)-1,2,3,4-tetrahydroquinoline-2-carboxylic acid ethyl ester 31. The final...

The need for palliative care education remains vital to contribute to the quality of life of patients, both adults and children, with cancer in Africa. The number of patients with cancer continues to rise, and with them the burden of palliative care needs. Palliative care has been present in Africa for nearly four decades, and a number of services are developing in response to the HIV/AIDS epidemic. However, the needs of cancer patients remain a challenge. Education and training initiatives have developed throughout this time, using a combination of educational methods, including, more recently, e-learning initiatives. The role of international and national organisations in supporting education has been pivotal in developing models of education and training that are robust, sustainable, and affordable. Developing a material for education and professional development needs to continue in close collaboration with that already in production in order to optimise available resources. Seeking ways to evaluate programmes in terms of their impact on patient care remains an important part of programme delivery. This article reviews the current situation.

The article describes the development of the postgraduate palliative medicine programs at the University of Cape Town (UCT) through collaboration with the Palliative Medicine Division from the University of Wales College of Medicine in Cardiff, United Kingdom. The course is presented as a distance-learning program supported by web-based learning with three face-to-face teaching sessions during the course. UCT recognized the urgent need to assist African doctors in developing the medical skills required to care for an ever-increasing population of patients and their families who are faced with terminal illness and the physical, emotional, psychosocial, and spiritual distress associated with end-of-life issues. Since 2001, 139 postgraduate students have registered for the course, 10% of whom are from African countries other than South Africa. Using the experience from UCT in distance-learning programs, the Hospice Palliative Care Association developed an interdisciplinary course, "Introduction to Palliative Care." This course recognizes that, although improvement in patient care and palliative care will come as undergraduate training in palliative care is established, it is essential that previously qualified health care professionals are able to enhance their palliative care knowledge, skills, and attitudes. Trainers provide support to participants over a six-month period and assist in the transference of knowledge and skills into the workplace.

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.