Web site: Carer administration of as-needed subcutaneous medication

Seriously ill people often want to spend their last few days of life at home being cared for by family and friends.  This web site details how carers, who are looking after a very ill person at home can be taught to give extra (top-up) doses of medication when experiencing "breakthrough" symptoms not controlled by their regular medication.  This information and web site should only be used by carers who have been identified and assessed as suitable by healthcare teams.

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Article: Opioids for breathlessness

Chronic breathlessness is a disabling and distressing condition for which there is a growing evidence base for a range of interventions. Non-pharmacological interventions are the mainstay of management and should be optimized prior to use of opioid medication. Opioids are being implemented variably in practice for chronic breathlessness.  This narrative review summarises the evidence defining current opioids for breathlessness best practice and identifies remaining research gaps.

Johnson, M.J. & Currow D. C. 2020.  Opioids for breathlessness: a narrative review.  BMJ Supportive & Palliative Care.  10 (3) p 287 - 295.

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Article: Pain, physical symptoms and functional assessment in progressive neurological disease in palliative care

The aim of the research was to identify the most frequent symptoms of patients with progressive neurological disease (PND) in relation to their functional state.  It then aimed to see if an intervention in the form of consultations with a multidisciplinary palliative care team decreased the symptom burden, disease progression and functional state.  Patients were allocated to either the intervention group or control group.  Pain and fatigue were identified as the symptoms that troubled the patients most.  After the intervention, there was a statistically significant improvement in the evaluation of 9 out of 11 symptoms (except excretion and urination) among the patients from the intervention group compared with the control group

Buzgova, R. et al. 2020.  Pain, physical symptoms and functional assessment in progressive neurological disease in palliative care.  BMJ Supportive and Palliative Care.

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Article: Neuropathic pain in advanced cancer: causes and management

Managing neuropathic pain in patients with advanced cancer can be challenging: it often requires an adjuvant analgesic and what works for one person may not work for another. Pain that is unresponsive to pharmacological approaches may require interventional procedures that are not usual in pain management and requires a multidisciplinary approach. Nurses play a key role in assessing the severity of the pain along with managing treatments.

Perdue, C. 2019. Neuropathic pain in advanced cancer: causes and management. Nursing Times, 115(11) p52-56.

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Article: Patients' needs regarding anxiety management in palliative care

This Dutch study aimed to get insight into the support needs of anxious hospice patients with advanced cancer.  14 patients were included in the study and 13 interviewed within 6 months of their death.  Information,  open communication, a sense of control, safety, adequate symptom management and respect for patients' coping strategy were the 6 main expressed needs.  The authors conclude healthcare professionals can make a significant contribution in supporting anxious patients before death with further research focusing on the development of a systematic approach to this.

Zweers, D. 2019.  Patients' needs regarding anxiety management in palliative cancer care: a qualitative study in a hospice setting.  American Journal of Hospice and Palliative Medicine.  36 (11) p 947-954.

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Article: Hydration and symptoms in the last days of life

At end of life, oral fluid intake is often reduced.  Consensus about the most appropriate management of this situation is lacking.  The objective of this Dutch study is to investigate to what extent the amount of fluid intake, preceding and during the dying phase is related to the occurrence of death rattle and restlessness.   371 patients were included in the study.  Death rattle was reported at least once in 149 (40%) of patients but not associated with the amount of fluid intake during the days before dying.  Terminal restlessness was reported in 96 (26%) of patients. It wasn't associated with a lower amount of fluid intake in the days before dying, however terminal restlessness during the last 24 hours of life was associated with a higher amount of fluid during 48 - 25 hours before death.  The authors conclude that a higher amount of fluid (>250mL/day) during 48 - 25 hours before death may be associated with the occurrence of terminal restlessness.

Lokkers, M. et al. 2019.  Hydration and symptoms in the last days of life.  BMJ Supportive & Palliative Care, epub ahead of print. August 2019/.

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Article: Delirium: non pharmacological and pharmacological management

Delirium is particularly common in palliative care, with up to 88% of patients developing delirium in the last weeks to hours of life.   This editorial provides overview of delirium including the diagnosis, identifying and reversing underlying causes if appropriate and management of the condition.

Boland, J. 2019. Delirium: non pharmacological and pharmacological management.  BMJ Supportive and Palliative Care.

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Article: Sleep assessment and interventions for patients living with cancer from the patients' and nurses' perspective

Although sleep disorders are common, it is an overlooked problem in cancer care. 129 patients with cancer and 113 registered nurses working with cancer patients were recruited to this study.  The majority of patients (69.8%) reported having poor sleep quality and the majority of nurses (86.7%) reported they had never screened patients with cancer for any sleep problems.  Only 8% of patients who reported having problems sleeping to a nurse received interventions to promote better sleeping.  The authors concluded assessment of sleep disturbances in patients with cancer should be unified using a comprehensive valid tool, as well as providing evidence-based interventions according to patients needs.

Khater, W. et al. 2019.  Sleep assessment and interventions for patients living with cancer from the patients' and nurses' perspective.  International Journal of Palliative Nursing, 25 (7) p 316 - 324.

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Article: Use of pain scales and observational pain assessment tools in hospital settings

The complex and dynamic nature of pain makes its assessment and management challenging for healthcare professionals. This article discusses the various pain scales and observational pain assessment tools that are available, and the evidence to support their use.

Gregory, J. 2019. Use of pain scales and observational pain assessment tools in hospital settings.  Nursing Standard, 34 (9) p 70 - 74.

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Article: Assessment and management of chronic pain

Chronic pain can have significant physical, psychological and social effects on a person's life, as well as their family and friends. This article outlines the biomedical and psychosocial factors that can influence an individual's pain experience that should be considered as part of the assessment and management of chronic pain.  It also discusses the management options, including neural blockade and analgesics as well as non -pharmacological approaches.

Howarth, A. & Poole, D. 2019.  Assessment and management of chronic pain.  Nursing Standard, 34 (9) p75 - 81.

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Article: Opioid use in palliative care: new developments and guidelines

This UK article describes the analgesic options available in palliative care.  It reviews recent evidence and guidelines and explores patients' and prescribers common concerns about opioid use.

Bemand-Querishi, L. et al. 2019. Opioid use in palliative care: new developments and guidelines.  Prescriber, April 2019. P 25 - 31.

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Article: Anticipatory syringe drivers: a step too far

An editorial piece discussing the findings of the recent Gosport War Memorial Hospital inquiry and the practice of anticipatory prescribing of syringe drivers in palliative care.

Bowers, B. et al. Anticipatory syringe drivers: a step too far.  BMJ Supportive & Palliative Care. 2019 online.

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Article: Noisy upper respiratory tract secretions: pharmacological management

A short overview of the practical management of noisy upper respiratory tract secretions.

Boland, J. & Boland, E. 2019.  Noisy upper respiratory tract secretions: pharmacological management.  BMJ Supportive & Palliative Care, online.

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Article: Use of low dose sedative medication at end of life

This study investigated current practices when using sedative medication at the end of life in London palliative care organisations. It consisted of focus groups of clinicians and examining documented sedative use in patient records.  Participants all reported the use of sedative medication for managing agitation or distress, selecting drugs and dosages as appropriate.  None used structured observational tools to assess effect, strongly preferring clinical observation and judgement.  The authors concluded practice in these London settings broadly aligns with the EAPC framework for using sedation at end of life but lacks any objective monitoring of depth of sedation.  A follow up study explores the use and feasibility of monitoring sedation in practice.

Vivat, B. 2019.  Palliative care specialists in hospice and hospital/community teams predominantly use low doses of sedative medication at the end of life for patients comfort rather than sedation: Findings from focus groups and patient records for I-CAN-CARE.  Palliative Medicine, online.

Available to download

Article: Delirium management by palliative medicine specialists

Delirium is common in palliative care.  A 21 question online anonymous survey was emailed to APPM members in current clinical practice (n=859) asking about delirium assessment, management and research priorities.  The response rate was 39%.  Delirium guidelines were used by some: 42% used local guidelines but 38% used none.  The survey showed delirium screening on admission is suboptimal, with most specialists using antipsychotics in combination with non-pharmacological interventions.  More support is required for family members along with clinical trials in view of the variation in management.

Boland, J. W. 2019. Delirium management by palliative medicine specialists: a survey from the association for palliative medicine of Great Britain and Ireland.  BMJ Supportive & Palliative Care,  March 2019 - online p 1-8.

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Article: Malignant hypercalcaemia: definition, symptoms and treatment

Hypercalcaemia - an abnormally high level of calcium in the blood - is common in advanced cancer. It can often be successfully treated, whether with bisphosphonates or the monoclonal antibody denosumab, and the side-effects of treatment can often be managed. However, many patients face the challenges posed by other burdensome symptoms of malignant disease and a poor prognosis. This article provides an extensive overview of malignant hypercalcaemia, including its causes, symptoms, treatment and implications for nursing practice.

Beland, P. 2018. Malignant hypercalcaemia: definition, symptoms and treatment. Nursing Times, 114 (11) p 40-44.

Article: Anticipatory prescribing of injectable medications for adults at the end of life in the community

The anticipatory prescribing of injectable medications to provide end of life symptom relief is an established community practice in a number of countries. However, the evidence base to support this practice is unclear. An extensive literature search was carried out.   The results showed healthcare professionals believe anticipatory prescribing provides reassurance, effective symptom control and helps to prevent crisis hospital admissions. The attitudes of patients towards this remains unknown.  It was found to be a low cost intervention but there was inadequate evidence to draw conclusions about its impact on symptom control, comfort or crisis hospital admissions.  The authors conclude the views and experiences of patients and their family carers towards anticipatory prescribing need urgent investigation along with further research to investigate the impact on patients' symptoms, comfort, safety and hospital admissions.

Bowers, B. et al. 2018. Anticipatory prescribing of injectable medications for adults at the end of life in the community: a systematic literature review and narrative synthesis. Palliative Medicine, published online December 2018

Medicinal cannabinoids in palliative care

This Australian article discusses the use of medicinal cannabis for refractory symptoms in palliative care.  It provides an overview of the guiding principles of palliative symptom management, the symptom areas where cannabinoids have been evaluated and other practical considerations to be aware of.

Agar, M. 2018.  Medicinal cannabinoids in palliative care.  British Journal of Clinical Pharmacology, June 2018.

Available to download or request a copy from the library

Clinical Practice Guidelines: Diagnosis, assessment and management of constipation in advanced cancer

Constipation is a commonly experienced problem and a significant source of  discomfort and distress.  The 2018 European Society of Medical Oncology (ESMO) updates guidelines for the diagnosis, assessment and management of constipation in advanced cancer.  A recommendation for the use of peripherally acting mu-opioid receptor antagonists (PAMORAS) is made.

Larkin, N. I. et al. 2018.  ESMO Clinical Practice Guidelines: Diagnosis, assessment and management of constipation in advanced cancer.  Annals of Oncology 29 (4) 111-125.

Available to download or request a copy from the library

Article: Achieving successful subcutaneous access in palliative care

Subcutaneous administration of medications is a well-recognised route for delivering prescribed therapies, in particular analgesia for patients requiring palliative care. This article discusses how technological developments are resulting in subcutaneous access devices that are easy to insert and can meet the needs of a growing population, as well as complying with the latest guidelines on sharps safety. 

Gabriel, J. 2018. Achieving successful subcutaneous access in palliative care.  International Journal of Palliative Nursing, 24 (6) p 282 - 287.

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