Clinical features of audible upper airway secretions ("death rattle") in patients with cancer in the last days of life.

PURPOSE: Audible upper airway secretions ("death rattle") is a common problem in cancer patients at the end-of-life. However, there is little information about its clinical features. METHODS: This is a secondary analysis of a cluster randomised trial of clinically-assisted hydration in cancer patients in the last days of life. Patients were assessed 4 hourly for end-of-life problems (including audible secretions), which were recorded as present or absent, excepting restlessness/agitation, which was scored using the modified Richmond Agitation and Sedation Scale. Patients were followed up until death. RESULTS: 200 patients were recruited, and 186 patients died during the study period. Overall, 54.5% patients developed audible secretions at some point during the study, but only 34.5% patients had audible secretions at the time of death. The prevalence of audible secretions increased the closer to death, with a marked increase in the last 12-16 h of life (i.e. the prevalence of audible secretions was highest at the time of death). Of those with audible secretions at the time of death, 24 had had a previous episode that had resolved. Development of audible secretions was not associated with use of clinically-assisted hydration, but there was an association between audible secretions and restlessness/agitation, and audible secretions and pain. However, most patients with audible secretions were not restless/agitated, or in pain, when assessed. CONCLUSION: Audible secretions ("death rattle") are common in cancer patients at the end-of-life, but their natural history is extremely variable, with some patients experiencing multiple episodes during the terminal phase (although not necessarily experiencing an episode at the time of death).

Do physical symptoms predict psychological issues in patients with cancer?: the Memorial Symptom Assessment Scale-Short Form.

OBJECTIVES: This study aimed to determine if individual physical symptoms were predictive of psychological disorders. METHODS: This study was a secondary analysis of data from two studies which used the Memorial Symptom Assessment Scale-Short Form (MSAS-SF) to assess both physical and psychological symptoms. Correlation between individual symptoms and the validated psychological subscale (MSAS-PSYCH) were performed using Spearman's coefficient. Linear regression analysis was performed to assess whether correlated symptoms predicted the presence of psychological disorders. RESULTS: 1507 patients' data were analysed. The physical symptoms of pain, lack of energy, drowsiness, dizziness, constipation, 'feeling bloated' and 'I don't look like myself' were correlated with MSAS-PSYCH. Other physical symptoms existed independently to psychological symptoms. None of these physical symptoms were independently predictive of a mood disorder. CONCLUSIONS: This study presents a large data set evaluating psychological symptom correlations. There are certain physical symptoms which correlate with mood disorders, but these are not independently predictive. It is not known whether the correlative data are cause or effect. Comprehensive assessment remains essential to assess all problems. TRIAL REGISTRATION NUMBER: The trial registered was at National Institute for Health Research Clinical Research Network Portfolio (Central Portfolio Management System (CPMS) ID 30723) Integrated Research Application System Identification (IRAS) ID 198753.

Symptom prevalence and severity in palliative cancer medicine.

OBJECTIVES: To establish symptom prevalence and associated distress in a large cohort of UK patients with cancer referred to a palliative care team. METHODS: This is a secondary analysis of two large data sets of patients with advanced cancer. Each patient had completed the Memorial Symptom Assessment Scale-Short Form to assess 32 symptoms and related distress. Data frequencies were conducted in Excel. RESULTS: 1507 patients were recruited. The most common symptoms were lack of energy (89%), pain (83%), feeling drowsy (77%) and dry mouth (70%). 67% of patients had psychological symptoms, with 31% of all patients having significant psychological distress. CONCLUSIONS: Symptom burden is significant in palliative patients with cancer. Structured symptom assessment with access to relevant supportive services is recommended.

Clinically assisted hydration in patients in the last days of life ('CHELsea II' trial): a cluster randomised trial.

INTRODUCTION: Provision of clinically assisted hydration (CAH) at the end of life is one of the most contentious issues in medicine. The aim of the 'CHELsea II' trial is to evaluate CAH in patients in the last days of life. The objectives are to assess the effect of CAH on delirium, audible upper airway secretions, pain and other symptoms, and overall survival, as well as the tolerability of CAH, and the health economic impact. METHODS AND ANALYSIS: The study is a cluster randomised trial, involving 80 sites/clusters (mainly hospices) and 1600 patients. Sites will be randomised to an intervention, and this will become the standard of care during the trial. Intervention 'A' involves continuance of drinking (if appropriate), mouth care and usual end-of-life care. Intervention 'B' involves continuance of drinking, mouth care, usual end-of-life care and CAH, that is, parenteral fluids. The fluid may be given intravenously or subcutaneously, the type will be dextrose saline (4% dextrose, 0.18% sodium chloride) and the volume will be dependent on weight.Participants will be assessed every 4 hours by the clinical team. The primary endpoint is the proportion of participants who develop delirium determined using the Nursing Delirium Screening Scale (using a cut-off score of ≥2). A mixed-effects logistic regression will be used to assess the difference in the odds of developing delirium between the interventions. ETHICS AND DISSEMINATION: Ethical committee approval has been granted by the Brighton and Sussex Research Ethics Committee (REC) (main REC for the UK: reference-IRAS 313640), and by the Scotland A REC (REC for adults with incapacity in Scotland: reference-22/SS/0053-IRAS-317637). The consent process follows the Mental Capacity Act: if the patient has capacity, then consent will be sought in the normal way; if the patient does not have capacity, then a personal/nominated consultee will be approached for advice about the patient entering the study. The consent process is slightly different in Scotland.The results of the trial will be published in general medical/palliative care journals, and presented at general medical/palliative care conferences. TRIAL REGISTRATION NUMBER: ISRCTN65858561.

Exploring the experience of returning to work after personal bereavement.

BACKGROUND: The ability of nurses with experience of personal bereavement to work with patients can have immediate and/or long-term repercussions on their personal and professional life. AIMS: To explore the experience of a personal bereavement, through the death of a significant relative or friend, for nurses working in palliative care. METHODS: A multicentre qualitative study interviewed nurses working in palliative care who experienced a significant bereavement within the last 24 months. FINDINGS: Key themes: circumstances surrounding bereavement; conflict between the personal and professional; returning to work; grief as a continuum. Advice to bereaved nurses was for them to be open and honest and that work can be grounding; that they should take time off; that grief does not stop on returning to work; and that they should do what feels right for them. CONCLUSIONS: Bereaved palliative care nurses strive to maintain their roles in the face of bereavement. Hospices have a significant part to play in offering ongoing support and flexibility.

Good concordance between patients and their non-professional carers about factors associated with a 'good death' and other important end-of-life decisions.

OBJECTIVES: The aim of this study was to investigate concordance between patients and non-professional carers about factors associated with a 'good death' and other end-of-life decisions. METHODS: Patients completed a questionnaire about end-of-life care issues, and were asked to rank the importance of factors linked to a 'good death'. Carers also completed a questionnaire about end-of-life care issues relating to the patient, and whether or not they agreed with those choices (ie, medical treatments, PPD). Carers were also asked to rank the importance of factors linked to a 'good death' to the patient, and to them personally at that point in time. RESULTS: Only 69% of patients stated they had discussed their preferences for end-of-life care with their respective carer. The rankings were similar for the patient and the carer's views of what was important for the patient, although the patients ranked 'to be involved in decisions about my care' as less important than the carers, while the carers ranked 'to have sorted out my personal affairs' as less important than the patients. CONCLUSIONS: When discussions around end-of-life choices do occur, carers generally appear to agree with the patients' preferences around end-of-life treatment, and preferred place of death.

A cluster randomised feasibility trial of clinically assisted hydration in cancer patients in the last days of life.

BACKGROUND: The provision of clinically assisted hydration at the end-of-life is one of the most contentious issues in medicine. AIM: The aim of this feasibility study was to answer the question 'can a definitive (adequately powered) study be done?' DESIGN: The study was a cluster randomised trial, with sites randomised on a one-to-one basis to intervention 'A' (regular mouth care and usual other care) or intervention 'B' (clinically assisted hydration, mouth care and usual other care). Participants were assessed every 4 h, and data collected on clinical problems, therapeutic interventions and overall survival. SETTING/PARTICIPANTS: The study was conducted at 12 sites/'clusters' with specialist palliative care teams (4 cancer centres and 8 hospices), and participants were cancer patients in the last week of life who were unable to maintain sufficient oral fluid intake. RESULTS: The study achieved its pre-determined criteria for success. Two hundred patients were recruited to the study, and 199 participants completed the study, over a 1-year period. A total of 38.5% participants discontinued clinically assisted hydration due to adverse effects: none of these adverse events were rated as 'severe' or worse in intensity. The primary reasons for discontinuation were site problems ( n = 2), localised oedema ( n = 13), generalised oedema ( n = 5), respiratory secretions ( n = 6) and nausea and vomiting ( n = 1). CONCLUSION: The results of this feasibility study suggest that a definitive study can be done, but that minor changes are needed to the protocol to standardise the administration of clinically assisted hydration (which may reduce the incidence of certain adverse effects).

The Influence of Low Salivary Flow Rates on the Absorption of a Sublingual Fentanyl Citrate Formulation for Breakthrough Cancer Pain.

CONTEXT: Salivary gland hypofunction may affect the absorption of drugs through the oral mucosa, which in turn may affect their clinical efficacy (e.g., onset of action). OBJECTIVES: The aim of this study was to assess the pharmacokinetics of a sublingual fentanyl orally disintegrating tablet (Abstral, Prostrakan Inc.) in a group of cancer patients with salivary gland hypofunction. METHODS: Nine cancer patients with salivary gland hypofunction underwent a series of three pharmacokinetic studies with the sublingual fentanyl orally disintegrating tablet. In the first phase, the patients received no pretreatment; in the second phase, the patients were allowed to moisten the oral cavity before dosing; in the third phase, the patients were given pilocarpine hydrochloride (saliva stimulant) before dosing. Fentanyl concentrations were measured using a method of high-performance liquid chromatography with validated tandem mass spectrometric detection. RESULTS: The Tmax was longer, the Cmax was lower, the AUC0-30 lower, and the AUClast lower in the phase involving no pretreatment; the Tmax/Cmax/AUC0-30/AUClast were similar in the phase involving moistening of the oral cavity and the phase involving giving pilocarpine hydrochloride. CONCLUSION: The pharmacokinetics of the sublingual fentanyl orally disintegrating tablet appear to be negatively affected by the presence of salivary gland hypofunction, although the moistening of the oral cavity before dosing results in a pharmacokinetic profile similar to that seen with the giving of pilocarpine hydrochloride.

Alternative forms of hydration in patients with cancer in the last days of life: study protocol for a randomised controlled trial.

BACKGROUND: The provision of clinically assisted hydration at the end of life is one of the most contentious issues in medicine, and indeed within the general population. The reasons for contention include: a) the lack of evidence for or against; b) the disparate opinions of healthcare professionals; and c) the generally positive opinions of patients and their carers about clinically assisted hydration. METHODS/DESIGN: The study is a cluster randomised trial to assess the feasibility of conducting an adequately powered, randomised controlled trial of clinically assisted hydration in patients with cancer in the last days of life. Twelve sites, four National Health Service (NHS) hospitals and eight NHS/voluntary sector hospices in the United Kingdom, will be randomised to give either standard intervention A: continuance of oral intake and regular mouth care, or standard intervention B: continuance of oral intake, regular mouth care and clinically assisted hydration. Patients will be included if they: i) have a diagnosis of cancer; ii) are aged ≥ 18 yr; iii) have an estimated prognosis of ≤ 1 week and iv) are unable to maintain sufficient oral intake (1 L per day, measured/estimated); and v) are able to give informed consent. Patients will be excluded if they have contra-indications to receiving clinically assisted hydration. The primary endpoint of interest is the frequency of hyperactive delirium ('terminal agitation'), and this will be assessed using the Modified Richmond Agitation and Sedation Scale (administered every four hours). Other data to be collected include the frequency of pain, respiratory secretions ('death rattle'), dyspnoea, nausea and vomiting, adverse effects to clinically assisted hydration and overall survival. In addition, data will be collected on the use of anti-psychotic drugs, sedative drugs, analgesics, anti-secretory drugs and other end-of-life medication. The study has obtained full ethical approval. DISCUSSION: A randomised controlled trial of clinically assisted hydration in end-of-life care is urgently required. This feasibility study will allow methodological and ethical issues to be understood and addressed to ensure that a robust, adequately powered, randomised controlled trial is designed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02344927 (registered 4 June 2014).

Opinions of patients with cancer on the relative importance of place of death in the context of a 'good death'.

OBJECTIVE: The primary objective of the study was to determine the relative importance of place of death to patients with advanced cancer being treated at a cancer centre in England. METHODS: Demographic data were collected from the electronic patient record system, with additional information obtained from the patients themselves. Patients were questioned about a variety of end of life issues, including preferred place of death (PPD), and 'acceptable' places of death. They were also asked to rank the importance of factors previously linked to a 'good death'. RESULTS: 120 patients participated in the study. 51 (42.5%) patients stated that 'home' was their PPD, while 80 (67%) patients stated that home was an acceptable place of death. Patients from areas with worse deprivation scores were less likely to want to die at home than patients from areas with better deprivation scores (p=0.03). The most important factors associated with a good death were 'to have my pain/symptoms well controlled', 'to not be a burden to my family' and 'to have sorted out my personal affairs' respectively. Place of death was ranked as the seventh most important factor. DISCUSSION: Place of death is undoubtedly an important factor in achieving a good death for some patients and carers. However, for others a home death is either unimportant or to be avoided. The results of this study, and the results of similar studies, suggest that place of death may not be a good marker of the quality of end of life care.