Mainstreaming palliative care for cancer patients in the acute hospital setting.

Palliative care is now emerging as an integrated part of mainstream health care delivery. The importance of patient choice regarding place of dying means that a substantial proportion of palliative care provision occurs in community settings. In part, this is due to the inappropriateness of the acute hospital setting for the care of dying patients. However, most patients with cancer and other terminal illnesses are diagnosed and treated in acute hospitals. Acute hospitals are also the most common setting where people actually die. Therefore, there remains a need for skilled and compassionate provision for the care of dying patients in the acute hospital setting. This paper presents a case for the provision of palliative care services in teaching hospitals. It further argues that a high level of integration between cancer treatment services and palliative care services is needed to optimize the care of cancer patients.

Provider perspectives on palliative care needs at a major teaching hospital.

Jericho Metropolitan Hospital (JMH) is a major Australian teaching hospital which lacked a designated palliative care service at the time this study was conducted. A questionnaire addressing palliative care service needs, and educational and support needs of staff, was sent to 267 multi-disciplinary oncology staff at JMH. A response rate of 83% was achieved. Staff identified a number of palliative care needs that were being particularly poorly addressed by existing services. These included: spiritual support, cultural needs, grief and bereavement support, pleasant surroundings, adequate privacy and facilities for families. The majority of respondents identified the following issues as critical problems in palliative care provision: lack of a designated palliative care service, lack of palliative care education of staff, unmanageable caseloads and inadequate physical facilities for the provision of care. Only 24% of respondents reported having had any palliative care education, and 92% of respondents expressed a need for further education. The majority of respondents (79%) expressed a need for improved staff support. There was a significant association between perceived need for improved support and professional discipline (chi2 = 31.33, P < 0.002), with medical staff being significantly less likely than other staff groups to report a need for improved support. Overall, the health providers surveyed identified major deficiencies in the provision of palliative care to cancer patients at JMH and in the palliative care education and support for staff caring for terminally ill cancer patients. The findings support the need for a designated palliative care service at JMH to improve the standard of care of dying cancer patients, and the need for improved palliative care education and support for staff.

Pituitary adenomas: long-term results for radiotherapy alone and post-operative radiotherapy.

PURPOSE: Analysis of prognostic factors and long-term results of treatment of pituitary adenomas. METHODS AND MATERIALS: The study involved a retrospective review of outcome in a series of 268 patients with pituitary adenomas, treated at the Queensland Radium Institute from January 1962 to December 1986. The study population included 108 patients treated with radiotherapy alone and 160 patients treated by surgery and post-operative radiotherapy. In each group, univariate and multivariate analyses were conducted of possible prognostic factors including age, sex, performance status, tumor type, tumor extent, visual disturbance, radiotherapy dose, and field size. RESULTS: For radiotherapy alone, the 10-year progression-free survival rate was 60%, and overall tumor control was obtained in 77%. Univariate analysis suggested that tumor type and radiotherapy field size were of prognostic significance. Multivariate analysis confirmed that Prolactinoma subtype and increasing radiotherapy field size were independently predictive of reduced progression-free survival. Long-term visual complications occurred in 1% of patients treated by radiotherapy alone. In patients treated by surgery and post-operative radiotherapy, the 10-year progression-free survival rate was 77%, and overall tumor control was achieved in 83%. Univariate analysis suggested that tumor type, completeness of surgical excision, and radiotherapy dose were predictive of outcome. However, on multivariate analysis, only the extent of surgical excision predicted prognosis independently. Long-term visual sequelae were noted in 3% of patients treated by surgery and post-operative radiotherapy. CONCLUSION: Both radiotherapy alone and post-operative radiotherapy are effective in long-term control of pituitary adenomas, and produce acceptably low complication rates.

Cholecystectomy and adenomatous polyps of the large bowel.

Seventy two patients (39 women) with colonic adenomas were compared with 72 adenoma free controls (39 women) to investigate the possible association between previous cholecystectomy and the subsequent development of adenomas. Data were gathered retrospectively from medical records. Overall there was no significant association between colonic adenomas and previous cholecystectomy. When women are considered separately, however, eight cases and no controls had undergone cholecystectomy (odds ratio infinity lower 95% confidence limits 1.7, p greater than 0.01). No association between previous cholecystectomy and large bowel adenomas was found in men. Four of nine (44.4%) women with right sided colonic adenomas had undergone previous cholecystectomy compared with only three of 23 (13%) women with left sided adenomas.