Goal setting as a measure of outcome in palliative care.

Setting goals and assessing outcomes are essential elements in palliative care. This paper describes a multiprofessional project, conducted under the auspices of clinical audit, which attempted to evaluate important outcomes of care. Over a six-month period there were 123 consecutive admissions to the hospice. These patients and their carers, as well as the staff, were encouraged to set explicit goals for, and evaluate outcomes of, their care. As anticipated, we encountered many difficulties in this, but there were benefits. We were able to record goals of admission from the patient in 97 cases (79%), their main carer in 74 cases (63%) and from hospice staff in 120 cases (98%). Patient and carer goals were often more functional and specific whereas the staff goals tended to be more problem or symptom focused. The achievement of these goals was evaluated by patients, carers and staff at discharge or death (where possible) with the majority being fully or partially met. Only 15 patients and 9 carers thought that some or all of their goals had not been achieved with just 4 recording that their goals had changed. Overall, it was a worthwhile (although time-consuming) exercise and, as a result of the 'audit', clear goals and outcomes from patient, carer and staff perspectives are now routinely recorded for all admissions to the hospice and are used to focus multiprofessional patient review. Having analysed the process as well as the results of the 'audit', we would encourage others not to be daunted from undertaking similar projects.

Radiotherapy for bone pain.

Painful bone metastases are a common problem for cancer patients. Although current evidence supports the use of a single fraction of radiotherapy as the treatment of choice, many radiotherapists, for a variety of reasons, continue to use fractionated regimens. Over one six month period 105 patients received external beam irradiation for painful bone metastases at the Royal London Hospital (RLH). Thirty-one per cent of the patients were aged 70 or over. The treatment of 97 of these patients was assessed. They had a total of 280 sites treated over the course of their disease. Fifty-nine per cent of sites treated received a fractionated course of radiotherapy. Site significantly influenced fractionation. Overall response rates of 82% were achieved. Fractionation did not appear to influence this. Ten patients received large field irradiation. Fifteen patients had five or more sites irradiated, of whom only one received hemibody irradiation.

Retreatment with radiotherapy for painful bone metastases.

PURPOSE: To evaluate the response to reirradiation of painful bone metastases following initial treatment with radiotherapy. METHODS AND MATERIALS: A retrospective analysis of 105 consecutive patients treated with palliative radiotherapy for painful bone metastases. A total of 280 individual treatment sites were identified, of which 57 were retreated once and 8 were retreated twice. RESULTS: The overall response rate to initial treatment was 84% for pain relief, and at first retreatment this was 87%. Seven of eight patients retreated a second time also achieved pain relief. No relation to radiation dose, primary tumor type, or site was seen. CONCLUSIONS: In patients relapsing after radiotherapy to painful bone metastases who have responded initially, reirradiation can be recommended with a similar probability of response.

Radiotherapy for painful bone metastases.

Bone metastases are a frequent cause of morbidity in patients with malignant disease. Pain is the commonest symptom; it can be treated successfully in the majority of patients by local external beam irradiation. Controversy exists over which regimen should be used, with a single dose necessitating only one treatment visit to the radiotherapy department, or a fractionated course requiring several visits. Many radiotherapists continue to use fractionated regimens despite the current evidence that single fractions are as effective. Many reasons exist for this, including departmental policy and training, fears of recurrence, problems with retreatment of previously treated areas, fears of increased early and late morbidity, and attempts at promoting recalcification. The majority of these reasons are theoretical and have yet to be substantiated. In many patients, symptomatic bone metastases are widespread, and hemibody irradiation, although more toxic, should be considered in order to avoid the need for repeated courses of local treatment.

Indolent mucoid carcinoma of stomach.

In a review of 574 cases of gastric carcinoma, 50 (8.7%) proved to be mucoid using defined microscopic criteria. Three histological types were recognized: pure signet-ring cell carcinoma (three cases); tumour of mixed pattern (41 cases); and an easily recognized, well differentiated type (six cases). This last group pursued an indolent course and had a mean survival time of nine years compared with mean survival times in the other two groups of five and 18 months respectively.

Acute toxic dilatation of the colon in Crohn's colitis.

Twelve new cases of acute toxic dilatation of the colon in Crohn's colitis treated by total colectomy and ileorectal anastomosis are reported, and criteria for making the diagnosis are given.The complication has occurred in 6% of patients diagnosed as having Crohn's disease of the colon treated at the Gordon Hospital since 1948. The patients have been predominantly young adult females, with a short preoperative history of disease. The sigmoidoscopic appearance of the rectum preoperatively has been no indication of the likelihood of recurrent disease at the anastomosis. Only four patients still have successfully functioning ileorectal anastomoses and four patients have died from the effects of the disease.