Grading clinical guidelines for the use of transmucosal immediate-release fentanyl products in breakthrough pain.

Pain is a complex symptom that is commonly feared in palliative care owing to its significant effects on patients' quality of life (QoL), and is directly associated with morbidity. More specifically, the management of breakthrough pain (BTP) is particularly important. Opioids play a major part in the management of BTP, and the various transmucosal immediate-release fentanyl (TIRF) products are a common treatment choice. This paper considers the strength of the evidence underlying recommendations regarding the use of TIRF. Failure to consider the quality of evidence in practice can lead to misguided recommendations. Guidelines should therefore be used to inform clinicians of the quality of the underlying evidence and whether recommendations are strong or weak. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach is increasingly being adopted worldwide as it provides a system for rating quality of evidence and strength of recommendations that is clear, comprehensive, transparent, and practical. This paper adopts the GRADE approach to assess the strength of recommendations made in a 2011 review by Zeppetella in order to develop guidelines for the use of TIRF. The recommendations include that TIRF products can be considered for first-line treatment and that they should be individualised to patients who are on a background opioid.

Identifying and treating depression at the end of life and among the bereaved.

Depression is a common psychological condition among patients at the end of life, and it can also affect a patient's family both before and after their loved one's death. It is estimated that around 25% of palliative care patients are diagnosed with depression during their illness, and that a majority experience depressive symptoms. If left unrecognized and untreated this may lead to more severe illness symptoms, poor communication with family members and, ultimately, reduced quality of life and a poor prognosis. Early assessment and management using appropriate tools as a guide are essential for enabling early treatment so that patients can be comfortable and meet unfulfilled goals during their end-of-life care. Palliative care staff play an essential part in recognizing and treating depression in patients, and by focusing on those at risk they can help to reduce the number who will go on to develop the condition. This article provides an overview of the nature of the problem in palliative care patients and bereaved families, looking at how targeted monitoring and intervention can help to alleviate the burden in the former and how support can benefit the latter.

Anger: a common form of psychological distress among patients at the end of life.

Psychological distress is common in palliative care patients and their families, and anger is a complex component of distress experienced by many patients at the end of life. Anger can be a form of tension release, as well as a coping mechanism for the patient and a way to disguise fear and anxiety. The interdisciplinary team are responsible for recognising psychological distress in patients, assessing their needs, and providing adequate psychological support. Although a certain level of psychological distress such as anger is expected in terminally ill patients owing to their situation, such responses may also be dysfunctional. This paper aims to highlight the challenges and complexities of adequately assessing and supporting palliative care patients who are presenting with psychological distress in the form of anger, in order to relieve their suffering and assist them in resolving their issues and improving their quality of life. Anger can be difficult to treat, and for some patients can be more distressing than some physical symptoms. Hence this paper also aims to offer anger management guidance to palliative care practitioners.