Palliative Medicine

The classification and natural history of human immunodeficiency virus (HIV) infection is outlined briefly, followed by a detailed consideration of the prognostic factors that form the basis for effective medical communication and decisionmaking in palliative care. The broad clinical spectrum of AIDS and selected management problems are discussed, including palliation by control of oppportunistic infections, neuropsychiatric disorders (including AIDS-related dementia) and safety in the use of corticosteroids. The article ends with consideration of when to stop specific AIDS-related treatments in advanced disease.

The first 100 consecutive admissions to a new palliative care (hospice) unit for people with AIDS were analysed retrospectively. The results illustrate the differences from, as well as the common ground with, traditional cancer palliative care.

Forty relatives of cancer patients who had been admitted to the Roxburghe House Continuing Care Unit, Aberdeen, Scotland, were studied in order to find out their needs — emotional, practical and the need for information or instruction — and how these needs were associated with their adjustment to the imminent loss of a loved one. A questionnaire on the services typically offered by terminal care staff was developed in order to assess the frequency and nature of support by hospice staff and the extent to which these services were meeting the needs of family members. Of the care services studied, those meeting the emotional needs of the relatives were the most sought after and the most utilized at the unit. In addition, the results indicated that although the unit staff seemed to be responding to those relatives who were distressed, staff support did not appear to alleviate the distress of family members. Nevertheless, those relatives who did not receive support but had desired it seemed highly anxious and distressed. The necessity of a routinely administered checklist on the needs of relatives of patients in a terminal care centre is indicated from this study.

Although there is increasing awareness of the importance of palliative care, services for terminally ill patients in hospital are often less well developed than those in the community. This study evaluated the problems of patients who were terminally ill, with the diagnosis of cancer, in a large teaching hospital during a six-week period. The data collected were then used as a basis for establishing a hospital palliative care team. This paper outlines the possible roles of research in the development of palliative care services.

The importance of good communication between patient and professional in palliative care is emphasized, its role in care defined and its place in obtaining the patient's valid consent described. The limitations placed on it by the need for confidentiality are discussed and the type of communication required for disclosure of the diagnosis and prognosis to the patient is considered. This article is written in terms of the doctor—patient relationship, but in the full recognition that palliative care is a team activity and that all members of the team share in communication with the patient. However, the doctor is normally the leader of the team and the principles of the ethics of communication which apply to him (or her) also apply to the other members of the team who share in the care of the patient.

The quality of life of terminally ill patients and their manner of dying are as much influenced by psychological and emotional factors as by their physical status. Such factors may be responsible for the development or the aggravation of physical symptoms.

The role of venting percutaneous gastrostomy (PG) is decribed in the management of five patients with nausea and vomiting or visceral pain due to terminal advanced obstructive intra-abdominal carcinomatosis. Percutaneous endoscopic gastrostomy (PEG) was used in three cases, the other two were inserted under radiological control and at laparotomy respectively. Impressive symptom relief was obtained in all cases with minimal morbidity. Two of the patients survived for prolonged periods of time (two and five months respectively) at home, and fluid and electrolyte imbalance did not appear to be a clinical problem in either case. The other three patients had brief but comfortable terminal illnesses in the hospice. The wider study of this procedure is advocated for obstructive or motility complications of advanced intra-abdominal malignancy, and also for nonmechanical causes of intractable nausea and vomiting in terminal illness where pharmacological measures fail. For this small but distressed subgroup of patients, PG may be a more effective and acceptable alternative to the prolonged use of nasogastric tubes. Further evaluation of effectiveness, impact on biochemistry, hydration and quality of life is required, particularly for longer-term use.

Spirituality as it is manifested within the hospice setting is reviewed. Essentially, spirituality is inherent in all. It is deeply centred and assumes varying levels of importance in each individual's life. There appears to be a need within all of us to have a purpose in life and to make sense of life's events, never more so than when challenged by a life-threatening illness. This may be the first time that the reality of death comes into focus. The way we cope with life's personal traumas and tragedies is, for many, based upon a sound philosophy of belief or a belief in God or a supreme being. Essential to coping is the loving support of family, friends and caregivers. Caring is essentially spiritual in nature. An attempt will be made to assess how people faced with a terminal illness cope with and without a framework of religious beliefs.

In-hospice music therapy is defined as the planned, systematic application of music and the relationship between the therapist, patient and family to promote the comfort of the entire person — body, mind, and spirit. It is suggested that the music therapist serves an important role in the hospice team. The author explores multiple dimensions of her role as a hospice music therapist including the development of the music therapy resource centre, programme design and implementation, the education and training of team members, and meeting patients' and families' total needs at home and in the hospice inpatient unit. Music therapy referral criteria, objectives and interventions are discussed and the music therapist's role in facilitating volunteer, staff, and bereavement support groups is explained.

Reduced hydration and feeding is here defined as a reduction in the intake and quality of drink or food sufficient to produce weight loss, nutritional deficiency, or both. Advanced disease includes any progressive disease process in which the prognosis is limited. This flow diagram outlines the management of reversible and irreversible causes of reduced intake.

In 1990, palliative care services in Japan entered a new era when the national government authorized medical insurance cover for hospice care. Within the last decade, gradual yet remarkable progress has taken place in the perception of the need for palliative care services in Japan. The first Japanese hospice opened in 1981, followed by three other hospices over a nine-year period. These have been well received both by the public and medical professionals, although many difficulties have been encountered in establishing them. It is hoped that further development will include an increase in the number of hospices, a growing awareness within general hospitals of a hospice-style approach to care and an expansion in home care services.

Previous repression in eastern Europe has not prevented the development of palliative care. Progress has continued despite difficulties, and suggestions are made to ensure that this progress continues.