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Most people who are dying want to be cared for at home, but only half of them achieve this. The likelihood of a home death often depends on the availability of able and willing lay carers. When people who are dying are unable to take oral medication, injectable medication is used. When top-up medication is required, a health-care professional travels to the dying person's home, which may delay symptom relief. The administration of subcutaneous medication by lay carers, although not widespread UK practice, has proven to be key in achieving better symptom control for those dying at home in other countries.To determine if carer administration of as-needed subcutaneous medication for common breakthrough symptoms in people dying at home is feasible and acceptable in the UK, and if it would be feasible to test this intervention in a future definitive randomised controlled trial.We conducted a two-arm, parallel-group, individually randomised, open pilot trial of the intervention versus usual care, with a 1 : 1 allocation ratio, using convergent mixed methods.Home-based care without 24/7 paid care provision, in three UK sites.Participants were dyads of adult patients and carers: patients in the last weeks of their life who wished to die at home and lay carers who were willing to be trained to give subcutaneous medication. Strict risk assessment criteria needed to be met before approach, including known history of substance abuse or carer ability to be trained to competency.Intervention-group carers received training by local nurses using a manualised training package.Quantitative data were collected at baseline and 6-8 weeks post bereavement and via carer diaries. Interviews with carers and health-care professionals explored attitudes to, experiences of and preferences for giving subcutaneous medication and experience of trial processes. The main outcomes of interest were feasibility, acceptability, recruitment rates, attrition and selection of the most appropriate outcome measures.In total, 40 out of 101 eligible dyads were recruited (39.6%), which met the feasibility criterion of recruiting 30% of eligible dyads. The expected recruitment target (≈50 dyads) was not reached, as fewer than expected participants were identified. Although the overall retention rate was 55% (22/40), this was substantially unbalanced [30% (6/20) usual care and 80% (16/20) intervention]. The feasibility criterion of 40% retention was, therefore, considered not met. A total of 12 carers (intervention,The success of a future definitive trial is uncertain because of equivocal results in the progression criteria, particularly poor recruitment overall and a low retention rate in the usual-care group. Future work regarding the intervention should include understanding the context of UK areas where this has been adopted, ascertaining wider public views and exploring health-care professional views on burden and risk in the NHS context. There should be consideration of the need for national policy and of the most appropriate quantitative outcome measures to use. This will help to ascertain if there are unanswered questions to be studied in a trial.Current Controlled Trials ISRCTN11211024.This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inMost people in the UK would prefer to die at home, but only half of them achieve this. This usually depends on having able and willing lay carers (family or friends) to help look after them. Once swallowing is not possible, medicine is given continually under the skin (syringe driver). If common problems such as pain, vomiting or agitation break through, health-care professionals attend to give extra doses. The wait for a health-care professional to arrive can be distressing. In the UK, it is legal (but not routine) for lay carers to give needle-free subcutaneous injections themselves. We reworked an Australian carer education package for UK use. The best way to find out if this would work well is to do a randomised controlled trial. This is a test in which, at random, half of the people taking part receive ‘usual care’ and the other half receive the ‘new care’ or intervention. A pilot randomised controlled trial (a ‘test’ trial to see if a larger one is worth doing) was carried out to determine if lay carer injections were possible in the UK. We approached 90 dyads (a dying person and a key carer) and, of these, 40 were willing to take part and 22 completed the follow-up visit, so we could analyse their data. Of these 22 dyads, 16 were in the intervention group (lay carer injects) and six were in the control group (usual care). All carers were asked to keep a diary. Carers and health-care professionals were interviewed (qualitative study) and carer preferences were assessed. This new practice was safe, acceptable and welcomed. Carer confidence increased rapidly, symptom control was quicker and the interviews backed up these findings. Recruitment was low owing to overstretched health-care professionals. Only certain families were picked. Dyads in the usual-care group often wished they were in the intervention group. Carers found it difficult to complete some of the questionnaires that were used to measure the effect of the intervention. Therefore, uncertainty remains as to whether or not a full trial should proceed. Because the practice is already legal, some areas in the UK are already undertaking it. We plan to study what makes this practice possible or less possible to achieve.

Since 2015 a whole-of-community program to promote advance care planning (ACP) within one Queensland Hospital and Health Service (HHS) catchment has spread statewide, financed by Queensland Health (QH) agencies and led by the Statewide Office of Advance Care Planning (SOACP). The program aims to identify ACP-eligible patients, invite and finalise ACP discussions, and ensure documented care preferences are easily retrievable by clinicians to guide future care if a person loses capacity. The SOACP established a digital infrastructure whereby quality-audited ACP documents are uploaded to a software platform accessible to all QH clinicians, private medical specialists, ambulance paramedics, general practitioners (GPs), and registered nurses, including those in residential aged care facilities (RACFs). The SOACP also hosts a website providing resources for clinicians and patients, delivers educational events and mentorship to GPs and hospital and RACF staff, and employs ACP facilitators working across all QH HHSs. The program has seen yearly increases in the numbers of ACP documents uploaded from around the state, with up to 79% of eligible patients in some hospitals receiving ACP, significant ACP uptake in RACFs, and acceptance by GPs to engage in ACP. Audits reveal high concordance between stated preferences and hospital care received, and ACP patients, compared to matched non-ACP controls, more frequently die out of hospital, have fewer inpatient days during their last 6 months of life, and receive less invasive care, with similar results seen among same-patient cohorts post-ACP. Barriers and enablers to ACP have been identified which will inform program evolution.

BACKGROUND: While most people say they would prefer to be cared for and to die at home, this outcome is often not achieved. This represents a service gap that general practitioners (GPs) are optimally positioned to fill. OBJECTIVES: The aim of this paper is to synthesise existing evidence-based frameworks of palliative care together with other resources, to present a cohesive model of care that GPs can easily systematise to guide high-quality home-based palliative care. DISCUSSION: Key clinical processes include advance care planning and development of medical goals of patient care plans and terminal care plans. Three essential elements for high-quality palliative care incorporated into the model include a compassionate GP, the care team and various practical resources. Palliative care sits well within the GP specialist scope of practice. GPs have at their disposal many resources that effectively and efficiently support them in their palliative care practice.

Background: Whilst the majority of seriously ill people wish to die at home, only half achieve this. The likelihood of someone dying at home often depends on the availability of able and willing lay carers to support them. Dying people are usually unable to take oral medication. When top-up symptom relief medication is required, a clinician travels to the home to administer injectable medication, with attendant delays. The administration of subcutaneous injections by lay carers, though not widespread practice in the UK, has proven key in achieving home deaths in other countries. Our aim is to determine if carer-administration of as-needed subcutaneous medication for four frequent breakthrough symptoms (pain, nausea, restlessness and noisy breathing) in home-based dying patients is feasible and acceptable in the UK. Methods: The paper describes a randomised pilot trial across three UK sites, with an embedded qualitative study. Dyads of adult patients/carers are eligible, where patients are in the last weeks of life, wish to die at home, and lay carers who are willing to be trained to give subcutaneous medication. Dyads who do not meet strict risk assessment criteria (including known history of substance abuse or carer ability to be trained to competency) will not be approached. Carers in the intervention arm will receive a manualised training package delivered by their local nursing team. Dyads in the control arm will receive usual care. The main outcomes of interest are feasibility, acceptability, recruitment rates, attrition and selection of the most appropriate outcome measures. Interviews with carers and healthcare professionals will explore attitudes to, experiences of and preferences for giving subcutaneous medication and experience of trial processes. The study has obtained full ethical approval. Discussion: This study will rehearse the procedures and logistics which will be undertaken in a future definitive randomised controlled trial, and will inform the design of such a study. Findings will illuminate methodological and ethical issues pertaining to researching last days of life care. The study is funded by the National Institute for Health Research (Health Technology Assessment [HTA] project 15/10/37). Trial registration: ISRCTN, ISRCTN 11211024. Assigned 27 September 2016, http://www.isrctn.com/ISRCTN11211024. Keywords: End-of-life care, Care of the dying, Palliative care, Symptom control, Carer administration, Randomised pilot trial

Due to the changing demographics of ageing and death in Australia, general practitioners (GPs) are caring for greater numbers of people with advanced chronic conditions that will soon lead to death. GPs play a pivotal role in proactively preparing these people for end of life.This article introduces GPs to a framework of care, based on a palliative care approach, which supports proactive management of end-of-life care for older Australians living in the community.Embedding the above framework into routine practice can help GPs deliver care, aligned with patients' preferences, at the right time and in the right place. Experience has shown that implementing proactive management of end-of-life care can increase satisfaction with GP care and help GPs meet the clinical, legal and ethical challenges associated with caring for older patients with advanced progressive conditions.

Context The adjunctive use of paracetamol (acetaminophen) with strong opioids has become entrenched practice in palliative care pain management, despite little evidence to support its use. Objective The study aim was to investigate potential analgesic benefits of 4g of paracetamol daily for palliative cancer patients requiring high-dose opioids. Methods Thirty-one patients, using at least 200mg of oral morphine equivalent daily, were recruited to a prospective, double-blinded, randomized, crossover trial. Patients received usual medications plus 4g of paracetamol or placebo for five days each in random order. Primary outcome, effect on pain, was assessed using daily diaries, including a numerical rating scale (NRS) from zero (no pain) to 10 (unbearable) and recording numbers of breakthrough analgesics. Secondary outcomes—nausea, vomiting, cognitive impairment, constipation, and overall well-being—were assessed using the NRS. Data from the last four days of each treatment were analyzed. Patients also indicated in which part of the study their pain was better controlled. Results Twenty-two patients, requiring a median dose of 255mg of oral morphine equivalent daily, completed the trial. There were no significant order or treatment-by-order interaction effects for any variable; paired t -tests were conducted to investigate change in mean levels on outcome variables with placebo vs. paracetamol. For none of the variables was there a statistically significant difference when assessed with placebo compared with paracetamol. No change approached clinically significant levels, with a mean difference in rated pain of 0.16, and mean difference of 0.42 for a number of breakthrough medications. Fifteen patients were undecided whether paracetamol improved pain. Conclusions These data do not support the common practice of adding regular paracetamol daily as an adjunct to high-dose opioids for pain control in cancer patients receiving palliative care.

Acute episodic breathlessness in patients receiving palliative care is a distressing symptom with little evidence-base to inform management. This pilot, double-blind, controlled, crossover study compared the effects of nebulized hydromorphone, systemic hydromorphone and nebulized saline for the relief of episodic breathlessness in advanced cancer patients. On three occasions of acute breathlessness, patients randomly received either nebulized hydromorphone, a systemic breakthrough dose of hydromorphone or nebulized saline together with a blinding agent. Breathlessness was scored before and 10, 20, 30, and 60 minutes post-treatment completion using a 100 mm visual analog scale. Twenty patients completed the trial. Ratings did not differ significantly across pretest treatments. Change in ratings from pretest to 10 minutes after completion of nebulization (about 20 minutes after administration of systemic hydromorphone) indicated that each of the treatments resulted in statistically significant improvements in breathlessness, with no significant differences between treatments. Over time, breathlessness decreased significantly for all treatments, with no significant differences between treatments. Only nebulized hydromorphone produced a rapid improvement in breathlessness that reached a magnitude considered to be clinically important. Interpretation of these results is considered in relation to our definition of clinical significance, the dose of hydromorphone used and the possibility of a placebo effect. This study can serve to inform the design of future trials to investigate the management of incident breathlessness.

Objective: To assess the effect of adding 1 mg dexamethasone to syringe drivers on the viability time of subcutaneous cannulation sites in palliative care patients. Design: Prospective, double-blind, randomised, controlled trial in which patients received half their daily infused medications plus 1 mg dexamethasone in 1 mL saline through one subcutaneous site (test site) and the other half of their medications plus 1 mL saline through another symmetrically placed site (control site). Participants and setting: Palliative care patients from the inpatient units at two hospices, recruited between 1999 and 2002. Main outcome measure: Difference in time that the test and control sites remained viable. Results: 38 patients consented and were randomised. Twenty did not complete the trial because their participation in the study finished before either site broke down. Eighteen patients either partially completed (at least one site broke down) or fully completed (both sites broke down) the trial. In these 18 patients, test sites lasted 3.6 days longer than control sites (95% CI, 1.5–5.8 days; P = 0.002). Twelve patients fully completed the trial. In this group, test sites lasted 3.9 days longer than control sites (95% CI, 0.6–7.2 days; P = 0.025). Conclusions: The addition of 1 mg dexamethasone to syringe drivers significantly

Objective To explore the practices of members of the Australian and New Zealand Society of Palliative Medicine (ANZSPM) in assessing and treating depression in palliative care patients. Methods Semistructured questionnaires were forwarded to ANZSPM members in consecutive mail-outs to survey diagnostic and treatment practices for depression. Results The response rate was 62.3%. The median prevalence of depression, as perceived by respondents, in the present respondent patient populations was 20% (range 0%–90%); 57.1% of respondents always assessed for depression, whereas 42.9% assessed for depression sometimes. The majority (98.9%) of respondents relied on clinical interviews to assess depression; non-somatic symptoms of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria were more useful than somatic symptoms. The depression screening tools most frequently used were one- and two-item questions. Pharmacological and non-pharmacological methods were used to treat depression, with selective serotonin reuptake inhibitors the most frequently prescribed medications. Psycho-educational and supportive counselling were the most frequently used non-pharmacological interventions. Nominated measures to augment depression management included improving access to psychiatry, psychology and other allied health services, the development of a screening tool specific to palliative care patients and associated guidelines for depression management. Conclusions This is the first Australasian study to explore the practice of medical practitioners regarding depression in palliative patients. Incorporation of screening tool questions into palliative care assessment interviews may warrant future research. What is known about the topic? Depression in palliative care patients has a negative impact on quality of life; however, little is known about how Australasian palliative care medical practitioners manage depression in this patient population. What does this paper add? To the researchers’ knowledge, this is the first Australasian study that explores the practices of local palliative care specialists in the management of depression in palliative patients. What are the implications for practitioners? Overall management of depression in palliative care populations by Australasian practitioners is similar to that of their European colleagues. Consensus is that for assessment of depression in palliative patients, non-somatic symptoms of DSM-IV criteria are more useful than somatic symptoms. Practitioners report the need for improved access to psychiatric, psychological and other support services, for a palliative care-specific depression screening tool and for depression management guidelines applicable to palliative care patients.

Background: Palliative care services strive to support people to live and die well in their chosen environment, with optimal symptom control and a pattern of care supportive of laycarers. The likelihood of patients remaining at home often depends upon laycarers, who may be required to manage subcutaneous medications. Aim and Design: This study reports the development, trial and evaluation of a package that teaches laycarers to manage subcutaneous medications used for symptom control in home-based patients. The package was developed by palliative care stakeholders and comprises an educational session, delivered by nurses, and a range of demonstrative, audiovisual and written resources. Settings/Participants: The package was trialled across 24 sites and was evaluated by 76 laycarers (pre- and post-use) and 53 nurses (at study completion). Results: Outcomes of primary interest were perceived global usefulness of the package and rated relevance of components. Laycarers and nurses rated the usefulness and relevance of the package highly – all means were above 5 on a 7-point scale. Also, laycarers were invited to comment on the package, and three focus groups for 26 nurses explored post hoc issues following package implementation. Conclusions: In terms of the palliative patient’s illness trajectory, consensus was that the time for package introduction depended upon each particular clinical situation and laycarer. Nursing opinion was divided concerning whether it is safe and appropriate for laycarers to manage subcutaneous injections. Nevertheless, this study demonstrates that the package supports laycarers to manage subcutaneous medications. This has important implications for families, services and health-care systems.

Background: Most palliative care patients prefer to be cared for at home. While promoting quality of life for patients, this preference impacts on their caregivers. Lay caregivers in Australia can be required to deliver and adjust complex medication regimens. This study aimed to investigate caregivers’ perceptions concerning the injection of subcutaneous medications. Methods: Fourteen caregivers were interviewed on two occasions, once during the caregiving phase and two months after bereavement. Results: In the first interview, caregivers expressed anxieties associated with their ability to undertake the task of administering injections, including fears of overdosing their family member. In the bereavement interview caregivers reflected they were pleased they had contributed to the symptom relief of a family member and that although they would not necessarily volunteer to inject family members again, they were generally empowered by the experience. It is important for health professionals to support lay caregivers to successfully achieve their extended caregiving role.

Objective: To pilot and evaluate an intervention aimed at increasing the palliative care capacity of primary health care providers in rural and remote communities. Design: Pre- and post-workshop, and three months follow-up questionnaires. Setting: Four locations in Far North Queensland. Subjects: One hundred and forty-nine primary health care providers ranging from personal care workers to general practitioners (GPs). Interventions: Fourteen workshops were conducted. These were tailored to local palliative case loads facilitated by a specialist palliative care team from the Mt Olivet Hospice Service. Workshop content consisted of introductory didactic teaching based on participant-nominated topics, small group case management discussions and a session devoted to psychosocial and counselling inputs. Main outcome measures: Cost, GP reach, evaluation of educational and clinical objectives. Results: Average cost per participant – excluding wages – was $271. Thirty-two per cent of local GPs attended the workshops and 93.2% of participants reported that the workshops had satisfied their educational learning objectives. Evaluation of GP clinical performance revealed significant improvements in confidence regarding palliative care knowledge and skill levels as well as the management of common palliative symptoms. Evaluation of other primary health care providers’ clinical performance showed significant improvements in skills, management and rated knowledge. Conclusions: This intervention is relatively inexpensive, has reasonable reach and is effective as measured by educational and clinical outcomes.

Background Implantable cardioverter defibrillators (ICDs) reduce mortality in patients with certain cardiac conditions and are widely used in contemporary cardiac care. Increasingly, patients with ICDs are referred to palliative care services for management either of cardiac conditions, related co-morbidities or unrelated diseases. An ICD can have the defibrillator component deactivated thus avoiding futile and painful electrical shocks to the dying patient. Developing a strategy to sensitively manage deactivation of ICDs is an essential component of contemporary end of life/advance care planning. Aim To develop a strategy to ensure timely defibrillator deactivation in palliative patients across all environments of care. Methods Following a literature search concerning deactivation of ICDs, issues were explored in clinical meetings and workshop sessions. Stakeholders including cardiologists/electro-physiologists, specialist palliative care clinicians, general practitioners, lawyers, ethicists and patient liaison representatives drafted the strategy. Results The strategy was endorsed by Queensland Health, documented as a Clinical Practice Guideline and disseminated. It includes components relating to patient/relative wishes and history taking, communication between stakeholders, clinical alert notifications, procedures for emergency deactivation of devices, consent and documentation processes. Magnets for emergency use are located in palliative care units and doctors9 medical bags. Discussion This inclusive strategy has decreased the risk of futile shocks in palliative patients in part by emphasising a particular component of advance care planning. It has been used successfully in acute, community and residential aged care settings. Conclusion Palliative care services need to adapt to contemporary clinical advances and incorporate such advances into the patients9 advance care plans.

The objective of this study was to develop, implement and evaluate an end-of-life (terminal) care pathway and associated infrastructure suitable for Australian residential aged care facilities that improves resident and health system outcomes. The residential aged care end-of-life care pathway was developed by a multidisciplinary collaboration of government and non-government professionals and incorporated best clinical management for dying residents to guide care and increase palliative care capacity of generalist staff. Implementation included identifying and up-skilling Link Nurses to champion the pathway, networking facilities with specialist palliative care services, delivering education to generalists and commencing a Palliative Care Medication Imprest System in each facility. The primary outcome measure for evaluation was transfer to hospital; secondary measures included staff perceived changes in quality of palliative care provided and family satisfaction with care. Results indicated that the pathway, delivered within a care framework that guides provision of palliative care, resulted in improved resident outcomes and decreased inappropriate transfers to acute care settings. What is known about the topic? Residential aged care facilities (RACFs) are the hospices of today. Many RACF staff are not confident in the delivery of high quality palliative care, resulting in inappropriate transfers of dying residents to acute care facilities. Needs-based palliative care pathways are being used increasingly to direct care in a variety of healthcare environments. What does this paper add? Provides the first evidence in Australia that a residential aged care end-of-life care pathway (RAC EoLCP) improves outcomes of care for dying residents and results in fewer residents being inappropriately transferred to acute care facilities. What are the implications for practitioners? Use of the RAC EoLCP will improve resident and health system outcomes by guiding the delivery of high quality palliative care and improving the palliative care capacity of generalist health providers.

The binocular visual field of the pigeon, measured ophthalmoscopically, is ovoid in shape. It is 114 degrees in vertical extent and centered and widest (37 degrees) about the eye-beak axis (i.e. the line passing through the straight edge of the beak and the midpoint of a line connecting the centres of the pupils). The area dorsalis projects 10 degrees-15 degrees below the eye-beak axis where the field is 35 degrees wide. The stereotyped peck response of the pigeon entails birds pausing twice. At the first fixation, the image of a grain is on the area dorsalis and at the final fixation the grain is centered within the widest part of the binocular field.

The results of behavioural experiments determining contrast sensitivity functions (CSFs) for the eagle Aquila audax and man at two low luminances are compared. At 20 cd/m2 the shapes of the CSFs are similar: both species show a peak in sensitivity with attenuation of higher and lower spatial frequencies. The human is more sensitive at all frequencies and up to one hundred times more sensitive at low frequencies. The relatively poor performance of the eagle under these conditions may result from its adaptation to achieve high resolution in conditions of high luminance and contrast. At 2 cd/m2 the eagle no longer shows attenuation of low frequencies. This result is discussed with reference to lateral inhibition.

Simultaneous spatial-discrimination thresholds of 6 human subjects were measured at luminances between 0.2 and 2000 cd/m2. Subjects were tested on a forced-choice discrimination task which required them to distinguish between test and control stimuli of high contrast square-wave gratings with similar space-average luminances. The form of the function depicting the relationship between acuity and luminance is similar to that obtained by other researchers. The estimated maximum acuity of 72 cycles/degree (c/deg) is higher than the commonly cited value of 60 c/deg and this is probably due to the combination of the high stimulus luminance and the psychophysical technique employed in this study.

In the brown falcon the relationship between acuity, as measured using a task designed to test minimum-separable acuity, and luminance was investigated as well as the possible determinants of that relationship. The maximum acuity was 73 c/deg and was found to be resistant to decreases in luminance. Maximum behavioural acuity corresponds closely with the maximum anatomical resolving power of the eye, though it is postulated that, in the first instance, acuity is optically constrained. The flat acuity-luminance function of the falcon results from adaptations which increase the optical sensitivity of the eye compared with the globose eye of strongly diurnal falconiformes.

Behavioural acuity of the wedge-tailed eagle was determined across a range of luminance. Maximum acuity is between 132 and 143 c/deg and with decreasing luminance acuity declines sharply. The maximum anatomical resolving power of the eagle's deep fovea was calculated as 140 c/deg. This calculation was based upon ophthalmoscopic measurement of posterior nodal distance and estimates of photoreceptor spacings made from fixed foveal tissue and corrected for shrinkage. Maximum behavioural acuity and anatomical resolving power correspond closely and approach the highest frequency (157 c/deg) transmitted by the minimum pupil diameter of the eye. These findings are discussed with reference to current theories of visual functioning.