Palliative Medicine

In an era of ever increasing emphasis on cost-effectiveness of health care, and with the introduction of the internal market, there is now an urgent need for information on the costs and quality of palliative care. This paper highlights the complexities involved in acquiring and measuring such information and discusses methods which were tried out in an exploratory study. The study took the form of in-depth case studies in two hospices, one in the voluntary sector and one in the NHS.

We compared two measures that have been used by professionals to assess the quality of life and care of patients wtih advanced cancer. The Support Team Assessment Schedule (STAS) is an instrument for palliative cancer support teams to record and evaluate their care; the Hebrew Rehabilitation Centre for the Aged Quality of Life (HRCA-QL) index was used in the National Hospice Study (USA) to assess patients with advanced cancer. STAS has 17 items, each scaled 0 (best) to 4 (worst), and HRCA-QL has five items scaled 0 (worst) to 2 (best). The STAS and the HRCA-QL were assessed contemporaneously by the members of one support team on 128 consecutive patients referred over 17 months. Seventy-four patients spent more than four weeks in care. Ratings for four out of five HRCA-QL items deteriorated significantly in the four to six weeks before death. HRCA-QL index items correlated with similar STAS items. Correlations were highest at referral, especially in patients seen more than four weeks before death (e.g. symptom control (STAS) with health (HRCA-QL) Spearman's p = -0.64) and the HRCA-QL total was correlated with STAS subtotal of six items (p = -0.45). There were few correlations at death. The findings support the validity of both measures for the aspects compared, but indicated that STAS was more sensitive to changes in patients in the last six weeks of life.

This paper describes a postal survey of palliative care services and teams which were identified in the 1992 Directory of Hospice Services in the UK and Ireland. Its aims were to investigate how units assess the need for bereavement follow-up, and to determine the nature and extent of services provided for bereaved adults. We sent out 397 questionnaires, of which 187 were returned, a response rate of 47%. Results indicate that 156 respondents (84%) provided follow-up and a further 13 (7%) were planning bereavement services. Only 48 (25%) units undertook formal standardized risk assessment procedures to allocate appropriate services; in 41 units (85%) this was done by a nurse. Of the remaining 125 units, 58 (46%) reported basing their decisions on clinical impressions. Content analysis of the formal assessment instruments revealed 39 subcategories, which were broadly grouped into three areas: circumstantial factors at or near to the time of death, personal factors and social factors. Recommendations are made for further study.

Much has been written about the ethics of experimental research upon human subjects, particularly where such subjects can be said to be in a vulnerable position in relation to the researcher. This paper attempts to address such questions with reference to people who are dying. A case is made to defend the view that no research is morally justifiable with this client group. Less extreme views are also explored. One justification for such research activity comes from a rights-based perspective and another from the weighing of benefits and harms. In the process of exploring these issues, the author attempts to demonstrate that no research methodology can be said to be benign.

Breathlessness secondary to both cancer and non-malignant disease is a distressing, exhausting symptom which, to date, has been difficult to control. This paper reports a chart review undertaken on patients referred to the Ottawa Civic Hospital's Palliative Care Service over the 18-month period from 1 January 1992 to 30 June 1993. The intent of the review was to assess the recorded efficacy and safety of nebulized opioid use on patients with complaints of dyspnoea. Fifty-four patients were treated and subjective data have been compiled. The treatment was found to be effective, safe and convenient for the majority of the patients studied. In addition, nebulized opioids have been demonstrated as a treatment modality which is feasible for self-administration by the patient at home.

The relationship between corticosteroids and peptic ulceration, together with the major complications of gastrointestinal haemorrhage and perforation, remains an area of clinical concern. This paper reviews the literature regarding peptic ulceration and corticosteroids. Risk factors related to an increased incidence of peptic ulceration in patients prescribed corticosteroids are discussed. These include: total dose of corticosteroid, previous history of peptic ulceration, advanced malignant disease and concurrent prescribing of nonsteroidal anti-inflammatory drugs (NSAI Ds). It is suggested that prophylaxis should be considered for those patients with two or more risk factors. Choice and efficacy of prophylaxis is also considered.

This study looks at the clinical and thiamine status of 50 terminally ill patients who were admitted to a palliative care unit. Thiamine levels were found to be abnormally low in 28% of the patients and borderline in a further 36%. Cognitive impairment, as measured by the mini-metal state examination (MMSE) of Folstein, Folstein and McHugh, was present in 68% of those tested and a significant correlation was found between the MMSE status and thiamine levels.

Spinal analgesia can provide excellent pain relief for a small group of patients in whom conventional modalities have failed. The role of spinal analgesia in the palliative care setting is discussed and illustrated by the experience at St Gemma's Hospice over a two-year period. Special emphasis is placed on the difficulties that may need to be overcome when using this form of analgesia. The management of spinal infusions can produce some unique problems to the hospice or home care team, but the benefits often far outweigh the difficulties.

In 63 evaluable palliative care patients requiring intermittent bolus subcutaneous administration of medication, who were randomly assigned either a standard metal subcutaneous needle or a PTFE (Vialon®) catheter, there was a significantly greater incidence of local reactions at the insertion site with the metal needles (9/30) compared with the PTFE catheters (2/33). Despite this, there was no significant difference between the two in functional survival. Volume of medication injected per day was the best predictor of total time that the subcutaneous lines remained in situ.