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Improving during-life palliative care will improve end-of-life care
- Desmond O'Neill, Paul V. Knight, Jean-Pierre Michel (13 October 2008)
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Case conferencing. An answer to improving generalist end of life care? The Royal Marsden Hospital Experience
- Julia Riley, Clare F Smith (13 October 2008)
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Improving generalist palliative care: an interesting audit.
- Maria McKenna, Kathryn Mannix, Consultant in Palliative Medicine, RVI. (26 November 2008)
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Desmond O'Neill, President-Elect European Union Geriatric Medicine Society, 31 St John's Square, London EC1M 4DN, Paul V. Knight, Jean-Pierre Michel
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This paper offers a useful challenge to defining the terminology of end of life care, as well as attempting to clarify shared competencies between disciplines. As later life is time when such issues most commonly occur, palliative care is a not surprisingly a core competence of geriatric medicine (1). In addition, geriatricians are trained in the difficult art of negotiating the juncture between being gravely ill and dying (2). The European Union Geriatric Medicine Society, representing 15,000 geriatricians in Europe, is currently working with the WHO on guidelines for palliative care for older people, with an expected launch at a symposium in Glasgow in September 2009 (3), and the questions posed in this paper provide useful points for reflection. A key area for clarification is the concept of palliation as a life- long component of health care, starting at a low base, and rising to eventually become the predominant theme (4). This highlights the continuing problem of under-treatment of pain and other symptoms during life, particularly in old age, which mirrors the under-assessment of older peoples' wider needs often encountered in the health system (5). Incorporating modern gerontological and geriatric medicine principles into the care of older people is the key foundation to improving end of life care for older people, and is consistent with the wider goals of United Nations Action Plan on Ageing (6). 1) Geriatric Medicine Section of the European Union of Medical Specialists. Training in geriatric medicine in the European Union. Brussels, Belgium: European Union of Medical Specialists, 1999. www.uemsgeriatricmedicine.org/doc/training_in_geriatric_medicine_in_eu.pdf Accessed 10 Oct 2008. 2) Finucane TE. How gravely ill becomes dying: a key to end-of-life care.JAMA. 1999 Nov 3;282(17):1670. 3) European Union Geriatric Medicine Society. Palliative Care and Medicine and End of Life Issues. www.eugms.org/index.php?pid=199, accessed 13 Oct 2008. 4) Lynn J, Adamson DM. Living well at the end of life: adapting health care to serious chronic illness in old age. Arlington, VA, Rand Health, 2003. 5) AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. Journal of the American Geriatrics Society, 2002, 50:S205–S224. 6) United Nations. Report of the Second World Assembly on Ageing. United Nations, New York, 2002. Competing interests: None declared |
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Julia Riley, Head of the department of palliative medicine Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, Clare F Smith
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Dear Sir Reference: BMJ 2008; 337:a1720 We applaud ‘Improving generalist end of life care (EOLC)’ and present the Royal Marsden Hospital2Home (H2H) pilot program.H2H addresses the issues and overcomes many of the barriers in generalist EOLC identified by Shipman et al(1). The Royal Marsden Hospital is a tertiary referral oncology centre, and therefore ‘progressive disease with no further active oncological treatments’ was our definition of EOLC and the trigger point for referral to the H2H program. The H2H clinical nurse specialist (H2H CNS) assesses each patient’s health, social, financial and spiritual needs and preferences regarding preferred place of care (PPC) and preferred place of death (PPD). Then with the patients consent, a case conference (CC)(2)is organised in their homes. The patient, informal carer, H2H CNS, GP, district nurse, social worker and community palliative care nurse (CPCN) are invited to attend. The patient or GP chairs the CC. Care needs are discussed, and an action plan, including any advanced care planning, is agreed. A responsible professional is allocated for each item of care, and the care plan is documented. Analysis of the first 95 patients entering the H2H program is as follows: Patients were discharged to 35 primary care trusts. The CCs were attended by GPs 78 (82%), district nurses 89 (94%), social workers 23 (24%), CPCN 84 (88%), spiritual advisers (2%), carers 95 (100%). The PPC was home for 95 (100%) patients, of these 67 (71%) have now died. The PPD was not discussed with nine patients. Of those who have died and expressed a PPD, 74% fulfilled this, with 62% home PPD and 84% hospice PPD achieved. Although the total numbers so far are small, comparison with the national statistics shows (3) an impact on actual place of death, with an increase in both home and hospice deaths, and a decrease in hospital deaths (10% in the H2H population) H2H has shown to be a manageable program that can be integrated into a generalist workload. The CC is the time when patients are empowered to make choices about their end of life care. It is a time when social and health care generalists are enabled to take on EOLC in an educational setting where issues pertaining to a particular patients’ care are discussed. We agree with Shipman et al. the way forward is to standardize definitions and to measure outcomes. We will then be able to share information and develop a contemporaneous, electronic, summary care record for palliative care patients that will be accessible to all specialist and generic professionals including the out of hours service providers. Collection of accurate clinical data and measurable outcomes, including health economic data, will ensure the development of improved evidence based models of EOLC. References (1)Shipman C et al Improving generalist end of life care: national consultation with practitioners, commissioners, academics, and service user groups BMJ 2008; 337:848-51 (2)Mitchell G et al Do case conferences between general practitioners and specialist palliative care services improving quality of life? A randomised controlled trail Palliative Medicine 2008; 22:1-9 (3)Department of Health. End of life care strategy: promoting high quality care for all adults at the end of life.. London:DH;2008 Competing interests: None declared |
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Maria McKenna, ST2 CMT Newcastle General Hospital NE4 6BE, Kathryn Mannix, Consultant in Palliative Medicine, RVI.
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This paper highlights the importance of generalists in provision of end of life care and reminds us of their role in palliation of a range of symptoms. Nausea and vomiting are common and unpleasant symptoms which have a significant impact on quality of life. In people with a terminal illness, the prevalence of nausea is about 60% and of vomiting about 30% (1). Despite advances in anti-emetic drug therapy and publications of guidelines in palliative care, there has been little change in the incidence or severity of these symptoms over the past 20 years (2). Nausea and vomiting are symptoms frequently encountered by physicians and surgeons in a hospital environment, and these clinicians (rather than specialists in palliative care) would be responsible for first-line management. We, therefore, conducted an audit of staff anti-emetic prescribing preferences, using a recently published national guideline as our standard. Methods Using the guideline “Clinical Knowledge Summary: Palliative cancer care - nausea and vomiting” (2007 updated version), we devised 7 brief clinical vignettes and asked participants to choose 1 of 5 anti-emetics in that situation. The choice of anti-emetics was the same for each vignette (choices were cyclizine, haloperidol, levomepromazine, metoclopromide and ondansetron). The questionnaire was circulated amongst medical and surgical doctors and nurses in a large NHS hospitals trust via ward meetings, postgraduate education meetings and direct contact. All replies were anonymised, but participants indicated their profession and grade. Results A total of 105 responses were received; the majority were completed by doctors (83%), 9 participants were nurses and 9 were final year medical students. There was a wide spread of medical grades (24 F1, 5 F2, 19 SHO, 23 SpR, 16 Consultants) and a mixture of specialities. Overall, 69 doctors were physicians, 18 were surgeons, the remainder did not specify. Maximum possible score on the questionnaire was 7 marks for 7 correct choices: there were two possible correct choices for one of the scenarios, but respondents were only asked to select one drug and were given a mark if either of the appropriate anti-emetics was chosen. The mean score on the questionnaire was 1.81 (median 2, range 0-7). Medical students scored lowest with a mean of 0.88 and SHOs the highest with a mean of 2.21. Only 8 participants (7.6%) correctly identified haloperidol as the appropriate first line anti emetic for chemically mediated nausea and vomiting (vignette: nausea during titration of opioids), but 66 (63%) correctly selected cyclizine or levomepromazine for use in end-of-life nausea and vomiting. All the nurses in the sample correctly identified appropriate end-of-life anti-emetics. Ondansetron was not the correct first line anti-emetic in any of the vignettes, despite this, it was chosen 160 times. Discussion These results suggest that prescribers are not aware of which anti- emetics to select for particular indications, despite the provision of national guidelines. Although we did not measure clinical outcomes, it could be supported that poor prescribing does not relieve symptoms. The most consistently accurate choice was for an end-of-life vignette, where all nurses and most doctors identified an appropriate anti-emetic. This may reflect the widespread use of the Liverpool End of Life Care Pathway (LCP) with associated symptom-management prescribing guidance, which is supported by staff education and feedback. The cost of ineffective prescribing is in unmet symptoms, unnecessary side effects and unwarranted expenditure. The cost of ondansetron for 5 days is £107.90, compared with £3.90 for metoclopromide, £1.50 for haloperidol, £20.10 for levomepromazine or £7.35 for cyclizine at the Clinical Knowledge Summary recommended doses (3). Direct education of staff, rooted in their regular clinical practice, has significantly improved end-of-life anti-emetic knowledge. A similar approach to prescribing anti-emetics for other palliative care indications is planned, with a repeat audit after education and embedding of local guidelines. References 1) Kinley J. Controlling nausea and vomiting in palliative care patients. Nurse Prescribing 2005; 3(4): 141-150. 2) Doyle D, Hanks GWC, MacDonald N eds. Oxford Textbook of Palliative Medicine, third edition. Oxford: Oxford University Press, 2004. 3) British National Formulary 56, September 2008 Edition. Competing interests: None declared |
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