Perceived Palliative Care Education Needs of GP Trainees: A National Study.

CONTEXT: GP's provide palliative care in the community. Managing complex palliative needs can be challenging for GPs and even more so for GP trainees. During the postgraduate training period GP trainees are working in the community but have more time for education. This time in their career could present a good opportunity for palliative care education. For any education to be effective their educational needs must first be clarified. OBJECTIVES: To explore the perceived palliative care education needs and preferred education methods of GP trainees. METHODS: A national, multisite qualitative study involving a series of semistructured focus group interviews with third and fourth year GP trainees. Data were coded and analyzed using Reflexive Thematic Analysis. RESULTS: Perceived Educational Needs: five themes were conceptualized: 1) Empowerment vs. Disempowerment; 2) Community Practice; 3) Intra- and Interpersonal Skills; 4) Formative Experiences; 5) Contextual Challenges. PREFERRED EDUCATIONAL METHODS: Three themes were conceptualized: 1) Oriented Learning-experiential vs. didactic; 2) Practicalities; 3) Communication Skills. CONCLUSION: This is the first multisite national qualitative study exploring the perceived palliative care educational needs and preferred educational methods of GP trainees. Trainees expressed a unanimous need for experiential palliative care education. Trainees also identified means to address their educational requirements. This study suggests that a collaborative approach between specialist palliative care and general practice is necessary to create educational opportunities.

Palliation in a pandemic: the human cost of achieving the greater good.

The onset of the COVID-19 pandemic in early 2020 created major challenges for specialist palliative care services. Significant ethical challenges have arisen in practising a holistic approach to patient and family care, while observing local and national health care policy in the face of a global pandemic. This report highlights the challenges that arose for a patient, family members and staff consequent on COVID-related visiting restrictions. An integrated specialist palliative care inpatient unit and elderly care facility in Ireland. A 50-year-old married mother of three teenagers and one 12-year-old child with advanced amyotrophic lateral sclerosis is described. The patient could not speak or move her limbs. She communicated using an eye gaze device. She had previously declined enteral feeding, and noninvasive ventilatory support was not tolerated. Her husband was particularly attentive and remarkably intuitive in identifying her unspoken needs. At the start of the pandemic, visiting was severely curtailed in line with national policies. The change in visiting policies caused enormous distress to the patient, her family and to the staff members. IT devices were of limited benefit. The current pandemic has had a significant impact on families and health care professionals in which balancing individual need and traditional freedoms against the wider societal need are necessary in limiting the spread of COVID-19.

Informed Consent for the Orthopaedic Surgeon.

¼: In the United States, orthopaedic surgeons have a legal obligation to obtain informed consent from patients before performing surgery; it is a process that includes a signed written document. ¼: There are specific legal requirements that vary somewhat by state but generally include disclosure and documentation of the diagnosis, an explanation of the recommended procedure, a conversation about the risks and benefits of the procedure, and a discussion about alternative treatments. ¼: Inadequate disclosure of risks and alternatives is associated with increased indemnity risk. ¼: Studies have shown that many consent processes and forms are suboptimal.

Cross-sectional examination of extrapyramidal side effects in a specialist palliative care inpatient unit.

OBJECTIVES: Extrapyramidal side effects (EPSEs) are serious potentially reversible side effects of antipsychotic and other medications that can cause distress for patients. A core principle of palliative care involves optimising quality of life. If side effects of medications are burdensome, it is imperative that we address this issue. The aim of the study was to determine and describe the burden of EPSEs in a specialist inpatient unit. METHODS: Consenting patients who met inclusion criteria were assessed for EPSE with two validated screening tests, the Modified Simpson-Angus Scale (MSAS) and Barnes Akathisia Rating Scale (BARS). Additional demographic data were collected including medications associated with EPSE, previous history of EPSE and known risk factors that may predispose a patient to EPSE. RESULTS: 43% inpatients met inclusion criteria. At least 66% of patients were taking regular medications associated with EPSE. Of those, 25% were taking ≥2 medications associated with EPSE. The MSAS revealed 50% scored <3, 44% scored 3-5% and 6% scored 6-11. Seven patients had at least one 'not rateable score'. In the BARS (sitting±standing), 94% scored 0/5 and 6% scored 1/5. 12.5% of participants were able to stand for 2 min to complete the BARS. CONCLUSIONS: 50% screened positive for EPSE. The complete BARS was unsuitable for most participants. The MSAS, while allowing a not rateable score, may underestimate EPSE. The frailty of an inpatient unit population impacts on applicability of screening tools and may therefore underestimate the burden of the problem in this population. Development of a population-specific screening tool warrants further investigation.

Emergency anaphylaxis protocols: A cross-sectional analysis of general practice surgeries and pharmacies in both the urban and rural setting in Ireland.

BACKGROUND: The incidence of anaphylaxis appears to be increasing worldwide with cases in the community outnumbering those in the hospital setting. General practice (GP) surgeries and pharmacies, based in the community, are often the first point of contact for many patients suffering from anaphylaxis. OBJECTIVES: To determine if studied GP surgeries and pharmacies have an anaphylaxis protocol on site and have access to an anaphylaxis kit; to explore GP's and pharmacists' personal experiences with management of anaphylaxis. METHODS: A cross-sectional, questionnaire-based study was performed examining anaphylaxis protocols in a sample of general practices and pharmacies from some counties in Ireland. This consisted of a sample from rural and urban settings. The study commenced in October 2014. RESULTS: Nineteen of 24 GPs (79%) and 9 (29%) pharmacies had an anaphylaxis protocol (P < 0.001). Twenty-four (100%) GP practices and 12 pharmacies (39%) surveyed had an anaphylaxis kit on site. Twelve GPs (50%) had treated a patient with anaphylaxis in the surgery while 8 (33%) had treated a patient in the community. One pharmacist (3%) had witnessed anaphylaxis in practice. Two pharmacies and one GP had been contacted by local businesses to alert them to a case of anaphylaxis. CONCLUSION: In contrast to national and international guidelines only 79% of GPs and 29% of pharmacies in this study from Ireland had an anaphylaxis protocol onsite.

Doctor-Related Medication Safety Incidents on a Specialist Palliative Medicine Inpatient Unit: A Retrospective Analysis of Three Years of Voluntary Reporting.

Patients receiving palliative care and those at the end of life are known to be susceptible to medical errors. Errors related to medications are the most avoidable cause of patient harm. This retrospective study examined reported anonymized medication safety incidents, related to physician errors, assessed by the risk committee in a specialist palliative care unit over a 3-year time period. The aim of the study was to describe medication errors, with specific attention paid to what type of errors occurred and when these errors happened. Of the 218 reported medication safety incidents 28% (n = 62) were related to doctor prescribing. The data showed that there was a wide variation per year in the numbers of reported medication safety incidents. Medication prescribing errors were the most common error, followed by medication omissions. Medication safety incidents are at least in part dependent on staff reporting. Fostering a culture of openness that is blame free is crucial to medication error reporting. Formal reporting may help to increase patient safety and forms an essential element in the clinical governance and risk management of an institution.

Perinatal vs genetic programming of serotonin states associated with anxiety.

Large numbers of women undergo antidepressant treatment during pregnancy; however, long-term consequences for their offspring remain largely unknown. Rodents exposed to serotonin transporter (SERT)-inhibiting antidepressants during development show changes in adult emotion-like behavior. These changes have been equated with behavioral alterations arising from genetic reductions in SERT. Both models are highly relevant to humans yet they vary in their time frames of SERT disruption. We find that anxiety-related behavior and, importantly, underlying serotonin neurotransmission diverge between the two models. In mice, constitutive loss of SERT causes life-long increases in anxiety-related behavior and hyperserotonemia. Conversely, early exposure to the antidepressant escitalopram (ESC; Lexapro) results in decreased anxiety-related behavior beginning in adolescence, which is associated with adult serotonin system hypofunction in the ventral hippocampus. Adult behavioral changes resulting from early fluoxetine (Prozac) exposure were different from those of ESC and, although somewhat similar to SERT deficiency, were not associated with changes in hippocampal serotonin transmission in late adulthood. These findings reveal dissimilarities in adult behavior and neurotransmission arising from developmental exposure to different widely prescribed antidepressants that are not recapitulated by genetic SERT insufficiency. Moreover, they support a pivotal role for serotonergic modulation of anxiety-related behavior.