What do palliative medicine consultants do?

A workload study of consultants in palliative medicine was carried out, in which a task inventory questionnaire was sent to the consultant members of the Association for Palliative Medicine of Great Britain and Ireland. The median number of hours per week worked by a palliative medicine consultant was 49.5 (mean 51.3), excluding time on-call and breaks. The median consultant first on-call roat is 1:3. Palliative medicine consultants work a median of 22.5 direct clinical and 4.5 indirect clinical hours per week. This is very similar to the hours worked by consultants in other specialties who work an average 51.3 h per week, but with a median on-call rota of 1:6. Further studies are planned to monitor the patterns of consultant activity and workload in this specialty.

Palliative day care: what do services do? Palliative Day Care Project Group.

Palliative day care has expanded rapidly in the recent years, but the types of care available vary. To understand more about the different models of day care we conducted a questionnaire survey of the 43-day care centres in North and South Thames Regions in England (total population 13.75 million). The questionnaire covered: management, staffing and organizational policies; the numbers, types and reasons for referral; and the services and care provided. Forty (93%) centres responded. Centres had operated for between 1 and 16 years, mean 8 years. A total of 2268 day care places (mean per centre, 57) were available per week--with an estimated 1.77 places per 10,000 population. Twenty centres had never had a waiting list or had to prioritize patients; 30 had a discharge policy. The mean time the longest patient had been attending was 4.5 years, range 1-12 years. There were a total of 3627 new referrals per year or 3.06 per 10,000 population. Of the 2054 patients recorded by day care centres during a week of detailed monitoring, 1850 (90%) had cancer and 204 had other diseases--most commonly HIV or AIDS, motor neurone disease or stroke. Thirty-four centres were managed by nurses, two by social work or social service professionals, and the remainder by people with other backgrounds. Most units had doctors, nurses, chaplains, managers, aromatherapists and hairdressers, but occupational therapists, social workers, chiropodists, dietitians and music and art therapists were much more varied, as was whether these posts were paid. The most common activities were: review of patients' symptoms or needs, monitoring symptoms, bathing, wound care, physiotherapy, hairdressing and aromatherapy. Centres describing themselves as more or mostly social were less likely to undertake daily assessment of new symptoms and wound care (chi-squared 13.0, 10.1, respectively, df 4, P < 0.05). However, we found no significant differences between centres describing themselves as more medical or more social in reported levels of staffing, who was in charge, funding or most activities. The findings suggest that there are core activities offered in palliative day care, but also variations in medical assessments, nurse-led clinics, trips, art and music therapy, and artistic activities.

The level of need for palliative care: a systematic review of the literature.

Palliative care services have developed rapidly over the past 30 years, with little evaluation as to how needs have been met by these new services. As part of a systematic review of palliative care, evidence of the needs of patients and carers has been evaluated from the current literature. Of the total of 673 articles related to the 10 areas within the main review, 64 provided evidence on the need for palliative care services over the period from 1978 to 1997. A further nine articles were added in November 1998 after the end of the study of update the review with more recent research. Need can be assessed in one of two ways: either by adopting an epidemiological approach or by examining health service usage. In the former, evidence is provided on disease-specific mortality, and related to the duration of symptoms prior to the patient's death. As an example of this, it is suggested that services may need to provide pain control for 2800 patients per million (p/M) population dying from cancer each year and 3400 p/M with noncancer terminal illness. Using health service usage as an indicator of need, 700-1800 p/M with cancer and 350-1400 p/M with noncancer terminal illness would require a support team or specialist palliative home care nurse, with 400-700 cancer p/M and 200-700 noncancer p/M requiring inpatient terminal care. Studies indicate that at present usage, palliative care is being provided by 40-50 hospice beds/M. Despite this provision, there remains evidence that in certain areas of care such as pain control, there still remains a high degree of unmet need.

Patient and carer preference for, and satisfaction with, specialist models of palliative care: a systematic literature review.

This systematic literature review examined the impact of specialist models of palliative care on consumer satisfaction, opinion and preference over the past 20 years. From the literature search, 83 relevant papers were identified. Research findings from North America did not reveal any reliable or consistent trends, and this was due primarily to methodological flaws in the research. In the UK, consumers are more satisfied with all types of palliative care, whether provided by inpatient units or in the community, than with palliative care provided by general hospitals. Even though research findings consistently indicate that consumers appreciate the psychosocial climate in hospices, this research was based on small-scale local studies which were mainly focused on a single hospice. The dearth of high quality, comprehensive research was notable on the impact on consumer preference, opinion or satisfaction of hospice home care services, and other forms of palliative care in the community. It was concluded that further research is needed into consumer priorities for patients dying of noncancer diseases, and into the possible impact of patient characteristics on consumer satisfaction, opinion and preference for specialist models of palliative care.

The impact of different models of specialist palliative care on patients' quality of life: a systematic literature review.

This study set out to systematically review the research evidence about the impact of alternative models of specialist palliative care on the quality of life of patients. Eighty-six relevant papers were identified and reviewed, including 22 descriptive and 27 comparative studies. We found few comparative trials of reasonable quality. There was some evidence that in-patient palliative care provided better pain control than home care of conventional hospital care, but this research was dated and open to criticism. Research on palliative home care teams and co-ordinating nurses has demonstrated limited impact on quality of life over conventional care for patients dying at home. These negative findings may be due to the limitations of the assessment tools used. There is a need for larger studies to provide clear evidence as to whether specialist palliative care services provide improvements in patients' quality of life. This review does not exclude the possibility that models of care might be justifiable on other grounds such as patient preference or cost-effectiveness.

An audit of long-stay patients in an inner city palliative care centre.

An audit was carried out of patients with long admissions to a palliative care centre in central London. The records of patients remaining in the centre for more than 28 days were examined to see whether there were particular features characteristic of long-stay patients which could be identified to improve future admission planning.

Epidural complications and a case of malignant meningitis.

We report a case in which the signs of a malignant meningitis could have been confused with complications of an in-dwelling epidural catheter which was being used for analgesia. This confusion could have had disastrous implications for the patient's pain relief. We also discuss some of the issues and problems surrounding the use of in-dwelling epidurals in terminal care patients.

Hospice at home--a new service for patients with advanced HIV/AIDS: a pilot evaluation of referrals and outcomes.

Between 50 and 70% of patients with a terminal illness indicate a preference to remain at home for as long as possible until their death. Nevertheless, a much smaller percentage actually die at home in England and Wales. A new hospice-at-home service in North London for patients with HIV/AIDS is described in this report. Terminal care for HIV/AIDS patients can be provided at home by a multidisciplinary team which offers 24-hour care.

Epidural diamorphine and bupivacaine stability study.

Diamorphine and bupivacaine are commonly used together for spinal analgesia, although stability data relating to the mixture of the two drugs have not actually been established. We therefore performed a stability study using high performance liquid chromatography for both drugs and the British Pharmacopoeia 2,6-dimethylaniline limit test for bupivacaine, over a period of eight days and at room temperature. Diamorphine and bupivacaine were combined in various concentrations in 100 ml bags for use with the Bard patient controlled analgesia pump. We found no significant change in concentration of either drug, and the 2,6-dimethylaniline limit test was well within set limits. We therefore conclude that it is safe to combine these two drugs in this way.

A multicentre phase II trial of vindesine in malignant melanoma.

Fifty-three evaluable patients with advanced malignant melanoma have been treated with vindesine 3 mg/m2 i.v. weekly for a minimum of 6 weeks. An objective response rate of 26% was attained with 17% complete remissions, 78% of which were in stage II disease. The treatment was well tolerated, with alopecia the only clinically significant side-effect (43% of patients). Vindesine is superior to DTIC and should be considered as the best currently available drug for malignant melanoma.

Gastric pseudolymphoma.

Six histologically proved cases of gastric pseudolymphoma are described. This uncommon benign condition often simulates ulcerated gastric carcinoma radiologically, and pathologically it may cause considerable confusion with malignant lymphoma. Recognition of this condition is important to prevent unnecessary and often hazardous treatment whether by surgery or radiotherapy and to prevent inclusion in series of malignant gastric lymphoma, so that falsely high survival rates are not recorded.

Hazards of hepatic artery infusion of streptozocin.

Three patients with metastatic malignancy received streptozocin by hepatic artery infusion through a percutaneous transfemoral catheter. Two patients developed major arterial thrombosis, from which one died. The other suffered renal damage following displacement of the catheter tip. Possible avoidable risk factors are identified.

Hodgkin's disease and pemphigus.

The second case of pemphigus associated with Hodgkin's disease is reported. Circulating pemphigus auto-antibodies were detected in this patient and cell-mediated (T cell) immunity was markedly depressed. It is postulated that this T-cell immunodepression predisposed the patient to the development of pemphigus.

Pituitary function in patients receiving intermittent cytotoxic and corticosteroid therapy for malignant lymphoma.

Diurnal variation in plasma-cortisol was studied immediately before and after intermittent steroid therapy in seven patients receiving monthly courses of quadruple chemotherapy for Hodgkin's or non-Hodgkins lymphoma over a period of 6 months. The serum-thyroid-stimulating-hormone (T.S.H.) response to intravenous T.S.H.-releasing factor was also measured before and during the first course and before the second and fourth courses. The morning plasma-cortisol concentration fell significantly over 6 months when measured immediately before the start of each course. The mean evening cortisol concentration also fell over this period. In most patients the T.S.H. response showed a downward trend during treatment, although in two patients the response returned to normal whilst they were still undergoing therapy.