Friday, 11 July 2008

BMC Health Services Research 2008 Vol 8

A method to determine spatial access to specialized palliative care services using GIS
Jonathan Cinnamon ; Nadine Schuurman and Valorie A Crooks
2008 ; VOL 8 (2008-01-07)
From BioMed Central [PDF] [Abstract]
Page: 140

Canadian Family Physician 2008 ; Vol 54 ; Apr

Management of bone metastases
Andre Bonneau
From UK PubMed Central [PDF] (/1967 - 05/2008)
Page: 524-528

Computer-based information tool for palliative severe pain management.

An interdisciplinary computer-based information tool for palliative severe pain management.
Journal of the American Medical Informatics Association : May-Jun 2008 vol. 15, no. 3, p. 374-82
Kuziemsky-Craig-E, Weber-Jahnke-Jens-H, Lau-Francis, Downing-G- Michael.
OBJECTIVES: As patient care becomes more collaborative in nature, there is a need for information technology that supports interdisciplinary practices of care. This study developed and performed usability testing of a standalone computer-based information tool to support the interdisciplinary practice of palliative severe pain management (SPM). DESIGN: A grounded theory- participatory design (GT-PD) approach was used with three distinct palliative data sources to obtain and understand user requirements for SPM practice and how a computer-based information tool could be designed to support those requirements. RESULTS: The GT-PD concepts and categories provided a rich perspective of palliative SPM and the process and information support required for different SPM tasks. A conceptual framework consisting of an ontology and a set of three problem-solving methods was developed to reconcile the requirements of different interdisciplinary team members. The conceptual framework was then implemented as a prototype computer-based information tool that has different modes of use to support both day-to-day case management and education of palliative SPM. Usability testing of the computer tool was performed, and the tool tested favorably in a laboratory setting. CONCLUSION: An interdisciplinary computer-based information tool can be developed to support the different work practices and information needs of interdisciplinary team members, but explicit requirements must be sought from all prospective users of such a tool. Qualitative methods such as the hybrid GT-PD approach used in this research are particularly helpful for articulating computer tool design requirements.

The American journal of hospice & palliative care, Apr-May 2008, vol. 25, no. 2,

Palliative care in overdrive: patients in danger.
The American journal of hospice & palliative care, Apr-May 2008, vol. 25, no. 2,
p. 155-60

Prediction of patient survival by healthcare professionals in a specialist palliative care inpatient unit: a prospective study.
p. 139-45
Twomey-Feargal, O-Leary-Norma, O-Brien-Tony.
Accurate prognostication is an enormous challenge for professionals caring for patients with advanced disease. Few studies have compared the prognostic accuracy of different professional groups within a hospice setting. The aim of this study was to compare the ability of 5 professional groups to estimate the survival of patients admitted to a specialist palliative care unit. No group accurately predicted the length of patient survival more than 50% of the time. Nursing and junior medical staff were most accurate while care assistants were least accurate. When in error, senior clinical staff tended to under- estimate survival. Independent mobility on admission was the only variable predictive of length of survival. Thus, professional groups differ in their prognostic accuracy. An awareness of a group's propensity to over- or under-estimate prognosis should be incorporated into future work on prognostication models.

Some common problems faced by hospice palliative care volunteers.
p. 121-6
Claxton-Oldfield-Stephen, Claxton-Oldfield-Jane.
This paper examines 4 common problems that many hospice palliative care volunteers in Canada (and the United States) encounter, namely, being underutilized, being placed with a patient too late in the patient's illness, feeling undervalued by some members of the medical staff, and not being able to do more to help patients and their families. The implications of each of these problems are discussed along with suggestions for overcoming them. Finally, some ideas for future research are proposed.

Pediatric palliative care: an assessment of physicians' confidence in skills, desire for training, and willingness to refer for end-of-life care.
p. 100-5
Sheetz-M-Joan, Bowman-Mary-Ann-Sontag.
This study determines the confidence levels of physicians in providing components of pediatric palliative care and identifies their willingness to obtain training and to make palliative care referrals. Surveys were mailed to all physicians at Primary Children's Medical Center. The survey instrument includes 3 demographic items, 9 items designed to assess physician confidence in core palliative care skills, and 4 items designed to assess what steps physicians would be likely to take to assure that patients receive palliative care. Physicians were asked to rate their confidence levels to provide palliative care components on a 4-point scale for each of the items. Five hundred ninety-seven surveys were mailed, with 323 usable surveys returned. The proportion of physicians who rate their ability to provide palliative care as confident or very confident ranges from 74% for giving difficult news to families to 23% for managing end-of-life symptoms. Thirty-six percent of the physicians say they would be likely or very likely to attend training to improve their ability to provide palliative care to children. Eighty-six percent would be likely or very likely to refer for a palliative care consult and 91% to a home health agency or hospice. There is wide variation in the confidence levels of physicians to provide the core components of palliative care. Few are interested in obtaining additional training, but most are willing to obtain consultation or to refer to a palliative care service. These results argue in favor of hospital-based palliative care teams and for specialty training and certification in pediatric palliative care.

End-of-life care in Hancock County, Maine: a community snapshot.
p. 132-8
Ostertag-Susan-G, Forman-Walter-B.
This study presents a model for identifying end-of-life concerns in 1 rural community: Hancock County, Maine. Focus groups and structured interviews were held with primary care physicians, hospice staffs, clergy, hospice board members, long-term care facility staffs, and families of patients who had died either with or without hospice services. A list of suggestions for action within the community was generated from the interviews. Specific ideas targeted for implementation as a result of this project were educational sessions for long-term care facility staff, hospital grand rounds for primary care physicians, collaboration to bring information to the general public, stronger liaisons between long-term care facility and hospice staffs, and investigation of the development of a dedicated hospice facility. This is a simple, easily accomplished model to evaluate hospice needs in a small community.

Use of thromboprophylaxis in palliative care patients: a survey among experts in palliative care, oncology, intensive care, and anticoagulation.
p. 127-31
Kierner-Katharina-A, Gartner-Verena, Schwarz-Maria, Watzke-Herbert-H.
Study-based guidelines on thromboprophylaxis are not available for palliative care patients. The authors asked a panel of academic medical experts in palliative care, oncology, blood coagulation, and intensive care to select a prophylactic regimen out of 5 predefined options for a virtual patient with advanced bronchial cancer in different clinical settings. Primary prophylaxis for venous thromboembolism was withdrawn by all physicians when the patient had a Karnovsky's index of 10 and was described as dying. It was given by 25% of physicians when the patient had a Karnovsky's index of 20 and by 85% when Karnovsky's index 40 was still 40. Similar results were obtained in the situation of secondary prophylaxis of venous thromboembolism and when the patient was described as having a history of chronic atrial fibrillation. This data clearly show that thromboprophylaxis is delivered according to a compound estimate of risks and benefits of such prophylaxis in a specific palliative care situation.

To die, to sleep: US physicians' religious and other objections to physician-assisted suicide, terminal sedation, and withdrawal of life support.
p. 112-20
Curlin-Farr-A, Nwodim-Chinyere, Vance-Jennifer-L, Chin-Marshall-H, Lantos-John-D.
This study analyzes data from a national survey to estimate the proportion of physicians who currently object to physician-assisted suicide (PAS), terminal sedation (TS), and withdrawal of artificial life support (WLS), and to examine associations between such objections and physician ethnicity, religious characteristics, and experience caring for dying patients. Overall, 69% of the US physicians object to PAS, 18% to TS, and 5% to WLS. Highly religious physicians are more likely than those with low religiosity to object to both PAS (84% vs 55%, P < .001) and TS (25% vs 12%, P < .001). Objection to PAS or TS is also associated with being of Asian ethnicity, of Hindu religious affiliation, and having more experience caring for dying patients. These findings suggest that, with respect to morally contested interventions at the end of life, the medical care patients receive will vary based on their physicians' religious characteristics, ethnicity, and experience caring for dying patients.

p. 88-92,
What bothers you the most? Initial responses from patients receiving palliative care consultation
Shah-Mindy, Quill-Timothy, Norton-Sally, Sada-Yvonne, Buckley-Marcia, Fridd-Charlotte. Abstract
The purpose of this investigation is to describe how hospitalized palliative care patients respond to the question What bothers you the most? at the time of initial consultation. A retrospective descriptive content analysis of first person responses routinely recorded during initial interview (n = 286) was carried out. Responses were grouped in 7 major categories: physical distress (44%) ; emotional, spiritual, existential, or nonspecific distress (16%); relationships (15%); concerns about the dying process and death (15%) ; loss of function and normalcy (12%); distress about location (11%); and distress with medical providers or treatment (9%). Fifteen percent of responses were unable to be reliably categorized. Although many of our patients were not able to answer open-ended questions because of illness, those who did shared a wide range of concerns that provided a starting point for clinical prioritization. Further research into the use of such simple questions at time of initial consultation is warranted.

p. 93-9
Lullament: lullaby and lament therapeutic qualities actualized through music therapy
Lullabies and laments promote new awareness, enculturation, adaptation, and grief expression. These concepts' relevance to palliative care, however, has not been examined. In this study, a music therapist used a grounded theory-informed design to reflexively analyze lullaby and lament qualities, evident in more than 20 years of personal palliative care practice. Thus, the construct lullament emerged, which signified helpful moments when patients' and families' personal and sociohistorical relationship with lullabies and laments were actualized. Specific music could be both a lullaby and a lament. A music therapist can enable the lullament through providing opportunities for music-contextualized restorative resounding, expressed psychobiologically, verbally, musically, and metaphorically.

p. 106-11
Needs of elderly patients in palliative care
Wijk-Helle, Grimby-Agneta.
A pilot study on elderly patients' end-of-life needs was performed at a Swedish geriatric palliative ward. Thirty patients (15 men and 15 women; mean age, 79 years) with a primary diagnosis of cancer and admitted for palliative care were interviewed by a nurse using semistructured interviews. The study included demographic data, physical and psychologic status, and naming and ranking of individual needs. Elimination of physical pain was ranked as the primary need of half of the patients. Only when pain was eliminated or absent did other important needs (psychological, social, spiritual) appear frequently.

Transdermal and orally administered opioids

Clinical experience with transdermal and orally administered opioids in palliative care patients--a retrospective study.
Full text available at ProQuest
Japanese journal of clinical oncology, Apr 2007 (epub: 22 May 2007), vol. 37, no. 4, p. 302-9
Clemens-Katri-Elina, Klaschik-Eberhard.
BACKGROUND: Transdermal fentanyl is a widely used opioid for the treatment of cancer pain. Simplicity of use and high patient compliance are the main advantages of this opioid. However, based on our clinical experience, transdermal fentanyl is often not efficacious in terminally ill palliative care patients. We thus retrospectively examined the pain management and need for opioid switching in cancer patients admitted to our palliative care unit. METHODS: Of 354 patients admitted to our palliative care unit from 2004 through 2005, 81 patients were pre-treated with transdermal fentanyl. Demographic and cancer-related data (diagnosis, symptoms, pain score on a numeric rating scale (NRS)), analgesic dose at admission and discharge were compared. Statistics: mean +/- SD, ANOVA, Wilcoxon's test was used for inter-group comparisons, significance P < 0.05, adjusted for multiple testing. Pain scores are given in median (range). RESULTS: Mean transdermal fentanyl dose at admission was 81.0 +/- 55.8 microg/h. In 79 patients transdermal fentanyl treatment was discontinued. In two patients, analgesic treatment according to WHO I provided sufficient pain relief. The other 77 patients were switched to other opioids: 33 patients to oral morphine and 44 to oral hydromorphone. In patients switched to morphine the dose at discharge (104.7 +/- 89.0 mg) was lower than at admission (165.5 mg morphine equivalence). In patients switched to hydromorphone the dose of 277.8 +/- 255.0 mg morphine equivalent was higher at discharge than at admission (218.2 +/- 131.4 mg morphine equivalence--considering an equianalgesic conversion ratio morphine: hydromorphone = 7.5: 1). Pain scores decreased significantly after opioid rotation (NRS at rest/on exertion: 4 (0-10)/7 (2-10) versus 1 (0-3)/2 (0-5); P < 0.001). CONCLUSIONS: In the patient group switched to morphine, sufficient pain relief was achieved by lower equianalgesic morphine doses, compared with the doses at admission. In the patient group switched to hydromorphone, higher equianalgesic morphine doses were needed at discharge, considering an equianalgesic conversion ratio of morphine: hydromorphone = 7.5: 1. Patients with far advanced cancer often suffer from sweating and cachexia, which may have negative effects on the absorption of transdermal fentanyl. Opioid switching to oral morphine or hydromorphone was well tolerated and proved to be an efficacious option for cancer pain treatment.

Palliative care for patients with head and neck cancer

Experience of palliative care for patients with head and neck cancer through the eyes of next of kin.
Head & neck, Apr 2008, vol. 30, no. 4, p. 479-84
Ledeboer-Quirine-C-P, Offerman-Marinella-P-J et al
BACKGROUND: Little is known about how palliative care is experienced by patients with head and neck cancer and their relatives. The aim of this retrospective study was to analyze this care from the point of view of surviving relatives. METHODS: Fifty-five surviving relatives of patients with head and neck cancer treated at our department were enrolled in this study. Forty-five returned a completed questionnaire. RESULTS: Medical treatment during the palliative stage was judged as sufficient in most cases, but was often felt to be intrusive. The majority of patients had more need for psychosocial and physical support. Contact between head and neck surgeon and patient was sufficient. Many relatives found information about the terminal stage unsatisfactory. CONCLUSION: Not all aspects of palliative care for head and neck patients are sufficient, and improvements are, in our setting, necessary, specifically within the psychosocial field. This supports the initiation of our Expert Center to improve quality of life in the palliative stage.

Wednesday, 9 July 2008

Journal of pain and symptom management Apr 2008 vol. 35, no. 4

Bereaved family members' evaluation of hospice care: what factors influence overall satisfaction with services?
p. 365-71
Rhodes-Ramona-L, Mitchell-Susan-L, Miller-Susan-C, Connor-Stephen-R, Teno-Joan-M.
As patients near the end of life, bereaved family members provide an important source of evaluation of the care they receive. A study was conducted to identify which processes of care were associated with greater satisfaction with hospice services from the perception of bereaved family members. A total of 116,974 surveys from 819 hospices in the United States were obtained via the 2005 Family Evaluation of Hospice Care, an online repository of surveys of bereaved family members' perceptions of the quality of hospice care maintained by the National Hospice and Palliative Care Organization. Overall satisfaction was dichotomized as excellent vs. other (very good, good, fair, and poor). Using multivariate logistic regression, the association between overall satisfaction and the individual item problem scores that compose the Family Evaluation of Hospice Care were examined. Bereaved family members were more likely to rate overall satisfaction with hospice services as excellent if they were regularly informed about their loved one's condition (adjusted odds ratio (AOR)=3.76, 95% confidence interval (CI)=3.61-3.91), they felt the hospice team provided the right amount of emotional support to them (AOR=2.21, 95% CI=2.07-2.38), they felt that the hospice team provided them with accurate information about the patient's medical treatment (AOR=2.16, 95% CI=2.06-2.27), and they could identify one nurse as being in charge of their loved one's care (AOR=2.02, CI=1.92-2.13). These four key processes of care appear to significantly influence an excellent rating of overall satisfaction with hospice care.

The potential role of zuclopenthixol acetate in the management of refractory hyperactive delirium at the end of life.
p. 336-9
Tarumi-Yoko, Watanabe-Sharon.
Case-Reports, Letter.

Clinical and economic impact of palliative care consultation.
p. 340-6
Hanson-Laura-C, Usher-Barbara, Spragens-Lynn, Bernard-Stephen.
Palliative care consultation is the most common model of hospital- based services in the United States, but few studies examine the impact of this model. In a prospective study, we describe the impact of palliative care consultation on symptoms, treatment, and hospital costs. Patients receiving interdisciplinary palliative care consultations from 2002 to 2004 were approached for enrollment; 304 of 395 (77%) patients participated. Measures included diagnosis, treatment decisions, and symptom scores. To test impact on costs, a one-year subset of cases with lengths of stay >4 days (n=104) was compared to all available controls (n=1,813) matched on the 3Mtrade mark All Patients Refined Diagnosis Related Group, Version 20, and mortality risk scores. Half of the patients were younger than 65 years, 28% were African American, and 61% had cancer. Median Palliative Performance score was 20 (range, 10-100). Recommendations were implemented in 88% of cases; new do not resuscitate/do not intubate orders were written for 34% of patients, new comfort care orders for 44%, and 27% were referred for hospice care. Symptom scores improved from Day 1 to Day 3, with greatest improvement in pain (2.6-1.4, P<0.001). p="0.03).">50% hospital days with palliative care consultation. Palliative care consultation is followed by decisions to forego costly treatment and improved symptom scores, and earlier palliative care intervention results in greater cost-savings.

Screening for discomfort as the fifth vital sign using an electronic medical recording system: a feasibility study.
p. 430-6
Morita-Tatsuya, Fujimoto-Koji, Namba-Miki, Kiyohara-Emi et al
Late referral to a specialized palliative care service hinders quality symptomatic management. The aim of this article is to describe the feasibility and clinical usefulness of screening for patient discomfort as the fifth vital sign using an electronic medical recording system to identify patients with undertreated physical symptoms. For the electronic medical recording system, all admitted patients received routine nurse assessment of discomfort (defined as any physical symptom) at every vital signs check using Item 2 of the Support Team Assessment Schedule Japanese version (STAS). All medically treated cancer patients admitted to seven oncology units were automatically screened at one-week intervals. Positive screening was defined as a STAS score of 2 or more at least two times during the previous week. For each patient identified by screening, a palliative care team reviewed the medical record and provided written recommendations when other treatments might improve the patient's physical symptoms. Of 629 patients screened, 87 (14%) initially met the positive screening criteria. Fifteen (17%) were false positive due to psychiatric symptoms without physical symptoms or due to misrecording. Of 72 cases with actual discomfort, 33 had already been referred to the palliative care team, 14 had received adequate palliative care as determined by the palliative care team, 14 had self-limiting transient discomfort, and one patient died before the screening day. In the remaining 10 cases (11% of symptomatic patients, 1.7% of all screened patients), the palliative care team recommended potentially useful interventions for symptom control; seven patients were referred to the palliative care team within one week. The time required for all screening processes was about 30 minutes per week. This experience demonstrates that screening for patient discomfort as the fifth vital sign using an electronic medical recording system can be successfully implemented and may be useful in facilitating early referral of distressing patients to the specialized palliative care service.

I will do it if it will help others: motivations among patients taking part in qualitative studies in palliative care.
p. 347-55
Gysels-Marjolein, Shipman-Cathy, Higginson-Irene-J.
The aim of this study was to explore patients' and carers' preferences and expectations regarding their contribution to research in palliative care through the use of qualitative interviews. Data were collected in the context of two studies exploring the experiences of care of palliative care patients and carers. Both studies recorded the recruitment process, numbers of patients or carers accepting and declining, and the circumstances of interviews. Participants were asked about their motivation to participate in research. The data were analyzed by labeling patients' reflections on their motivations for participating in these studies and identifying themes. Analysis of the recruitment process revealed differential patterns in decline and acceptance of interviews by patients with different conditions and across settings. Among cancer patients, 21 /51 declined; the proportion with other conditions that declined was small, and was 0/10 for patients with motor neuron disease. Motivation to participate in the studies was related to (1) altruism, (2) gratitude and concerns about care, (3) the need to have somebody to talk to, and (4) the need for information or access to services. Palliative care patients and carers were capable of deciding whether to participate in interviews and negotiating how they wanted this to happen. This strengthens the argument for patients' autonomy in deciding whether to participate in research. Patients and carers have different motivations for participation, reflecting the heterogeneity of the palliative care population. This suggests a need for ethics committees to reconsider their views and widen their perspectives on the involvement of palliative care patients and carers in research.

The Schedule for Meaning in Life Evaluation (SMiLE): validation of a new instrument for meaning-in-life research.
p. 356-64
Fegg-Martin-J, Kramer-Mechtild, L-hoste-Sibylle, Borasio-Gian- Domenico.
The Schedule for Meaning in Life Evaluation (SMiLE) is a respondent- generated instrument for the assessment of individual meaning in life (MiL). In the SMiLE, the respondents list three to seven areas that provide meaning to their lives before rating the current level of importance and satisfaction of each area. Indices of total weighting (IoW; range, 20-100), total satisfaction (IoS; range, 0-100), and total weighted satisfaction (IoWS; range, 0-100) are calculated. The objective of this study was to assess the feasibility, acceptability, and psychometric properties of this newly developed instrument in its German and English versions. A total of 599 students of the Ludwig- Maximilians University, Munich and the Royal College of Surgeons, Dublin, took part in the study (response rate, 95.4%). The mean IoW was 85.7+/-9.4, the mean IoS was 76.7+/-14.3, and the mean IoWS was 77.7+/-14.2. The instrument was neither distressing (1.3+/-1.9) nor time-consuming (1.9+/-1.9), as assessed by numeric rating scales (range, 0-10). Test-retest reliability of the IoWS was r=0.72 (P<0.001); 85.6% of all areas were listed again after a test-retest period of seven days. Convergent validity was demonstrated with the Purpose in Life test (r=0.48, P<0.001), the Self-Transcendence Scale (r=0.34, P<0.001), and a general numeric rating scale on MiL (r=0.53, P<0.001). There was no correlation of the SMiLE with the Idler Index of Religiosity. Preliminary data indicate good feasibility and acceptability of the SMiLE in palliative care patients. The psychometrics of the SMiLE are reported according to the recommendations of the Scientific Advisory Committee of the Medical Outcomes Trust. Descriptors MODELS-PSYCHOLOGICAL/*; PALLIATIVE-CARE/*PX (psychology); PSYCHOMETRICS/*MT (methods), *ST (standards); VALUE-OF-LIFE/*. ATTITUDE; HUMANS; PERSONAL-SATISFACTION; REPRODUCIBILITY-OF-RESULTS. Language English. Publication type Journal-Article, Research-Support-Non-US-Govt, Validation-Studies. Journal subset IM. Country of publisher United-States. Journal code 0008605836. Information provider NLM. Notes Publication model: Print-Electronic; Cited medium: Print; ISSN: Print. Publication year 2008. Publication date 20080400. Entry date Date created: 20080324 Date completed: 20080618. (COPYRIGHT BY National Library of Medicine, Bethesda MD, USA)

Skin cancer

Skin cancer: follow-up, rehabilitation, palliative and supportive care.
Journal of the German Society of Dermatology, Jun 2008, vol. 6, no. 6, p. 492-8; quiz 499
Ugurel-Selma, Enk-Alexander.
Follow-up, rehabilitation and palliative/supportive care are essential parts of the care and treatment of skin cancer patients. This review provides an overview on the state of knowledge and recent developments in these three disciplines, hereby providing standard operating procedures for the dermatologist in the care of skin cancer patients. Especially in follow-up and supportive care, the results of recent clinical trials have led to significant changes in the standard of care. These new insights and their consequences are the special focus of this article.
Journal-Article, Review.

Palliative care and circumstances of dying in German ALS patients

Palliative care and circumstances of dying in German ALS patients using non-invasive ventilation.
Amyotrophic lateral sclerosis : official publication of the World Federation of Neurology Research Group on Motor Neuron Diseases,
Apr 2008, vol. 9, no. 2, p. 91-8
Kuehnlein-Peter, Kuebler-Andrea, Raubold-Sabine, Worrell-Marcia, Kurt-Anja et al
Non-invasive ventilation (NIV) is known to improve quality of life and to prolong survival in amyotrophic lateral sclerosis (ALS) patients. However, little is known about the circumstances of dying in ventilated ALS patients. In the light of the debate on legalizing euthanasia it is important to provide empirical data about the process of dying in these patients. In a structured interview, 29 family caregivers of deceased ALS patients were asked about their own and the patient's attitude toward physician-assisted suicide (PAS) and euthanasia, circumstances of dying, and the use of palliative medication. Quantitative and qualitative content analysis was performed on the data. Non-recurring suicidal thoughts were reported by five patients. Three patients and seven relatives had thought about PAS. Seventeen caregivers described the patients' death as peaceful, while choking was reported in six bulbar patients. In final stages of dying, the general practitioner (GP) was involved in the treatment of 10 patients, with palliative medication including sedatives and opiates being administered in eight cases. In conclusion, in contrast to the Netherlands, where 20% of terminal ALS patients die from PAS or euthanasia, only a small minority of our patients seems to have thought about PAS. The legal situation in Germany (where euthanasia is illegal), a bias due to the selection of NIV patients as well as a high percentage of religious patients and those with good levels of social support from family and friends, might account for this. Most of our patients died peacefully at home from carbon dioxide narcosis, but choking was described in some bulbar patients. Thus, palliative care, especially the use of opiates, anxiolytics and sedatives should be optimized, and the involvement of GP should be strongly encouraged, especially in bulbar patients.

Pain practice vol. 8, no. 3 May-Jun 2008

A decision analysis model to justify and approve off-label drug use in pain and palliative care.
p. 153-4
Comment, Editorial.
Comment on: Pain Pract. 2008 May-Jun; 8(3):157-63.

Off-label use of drugs in pain medicine and palliative care: an algorithm for the assessment of its safe and legal prescription.
p. 157-63
Verhagen-Constans-C, Niezink-Anne-G-H, Engels-Yvonne-Y et al
Off-label medication use is common practice, particularly in difficult to treat patients who have already tried commonly accepted medication unsuccessfully. Health authorities try to regulate this practice to protect the patient's safety and to prevent over consumption of new and more expensive drugs. Justified off-label drug use requires a thorough assessment. Physicians, in cooperation with formulary committees, need tools to structure this assessment. The evaluation algorithm for off-label prescription we present here, to be used after identification of a planned off-label application, consists of four steps. Step 1 indicates the extent of the problem and the need for further investigation. Step 2 is the decisional process evaluating the necessity of off-label use in identified prescriptions and confirmation as to what extent it needs further investigation. In step 3, the scientific knowledge to support the proposed off-label use is gathered in a short or extensive evaluation trajectory. The short trajectory consists of assembling the information approved in other countries or in accepted guidelines and textbooks, whereas the extensive trajectory is necessary when the indication, route, or formulation is not approved nationally or internationally. Assessment needs to be based on a literature research on the clinical and pharmacological information of the product. Step 4 is the acceptance or rejection of the off-label use of the drug for the indication at hand. Those four steps need to be carefully documented. Treatment outcome will then be closely monitored, documented, and made available to professionals, thus allowing for regular update of recommendations. This algorithm can help formulary committees to develop a strategy for evaluating off- label prescriptions in well-defined conditions, and help healthcare providers to develop protocols and guidelines.
Comment in: Pain Pract. 2008 May-Jun; 8(3):153-4.

Progress in Palliative Care 2008 ; VOL 16 ; PART 2

A retrospective analysis of dexamethasone use on a Canadian palliative care unit
Pilkey , J . ; Daeninck , P . J .
Page: 63-68
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Total parenteral nutrition for patients with advanced life - limiting cancer : decision - making in the face of conflicting evidence
Clay , A . S . ; Abernethy , A . P .
Page: 69-78
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Reflections on the introduction of an art group into the day unit of a specialist palliative care unit
Lawton , S
Page: 79-80
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International Journal of Palliative Nursing 2008 ; VOL 14 ; PART 5

Children's palliative care : `thinking outside the box'
Downing , J
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 212-213
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Student nurses' attitudes towards death and dying in south - east Iran
Iranmanesh , S . ; Savenstedt , S . ; Abbaszadeh , A .
2008 ; VOL 14 ; PART 5
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 214-219
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Living with a terminal illness : patient and family experiences of hospital end - of - life care
Spichiger , E
2008 ; VOL 14 ; PART 5
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 220-229
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Supporting children and families facing the death of a parent : part two
Kennedy , C . ; McIntyre , R . ; Worth , A . ; Hogg , R .
2008 ; VOL 14 ; PART 5
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 230-237
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Pain in elderly hospitalized cancer patients with bone metastases in Norway
Torvik , K . ; Holen , J . ; Kaasa , S . ; Kirkevold , O . ; Holtan , A . et al
2008 ; VOL 14 ; PART 5
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 238-247
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Transition to a Canadian paediatric hospice . Part one : planning a pilot study
Steele , R . ; Derman , S . ; Cadell , S . ; Davies , B . ; Siden , H . ; Straatman , L
2008 ; VOL 14 ; PART 5
From EBSCO ( CINAHL with Full Text ) - via Athens
Page: 248-256
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