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Palliative Extended and Care at Home (PEACH) is a rapid response nurse-led package of care mobilized for palliative care patients who have an expressed preference to die at home. This study aimed to identify the demographic and clinical predictors of home death for patients receiving the package. Deidentified data were used from administrative and clinical information systems. Univariate and multivariate analyses were conducted to assess association of sociodemographic factors with mode of separation. Furthermore, 1754 clients received the PEACH package during the study period. Mode of separation was home death (75.7%), hospital/palliative care unit admission (13.5%), and alive/discharged from the PEACH Program (10.8%). Of participants with clear preference to die at home, 79% met their wish. Multivariate analysis demonstrated cancer diagnosis, patients who wished to be admitted when death was imminent, and patients with undecided preference for location of death were associated with an increased likelihood of being admitted to the hospital. Compared with those with spousal caregivers, those cared for by their child/grandchild and other nonspouse caregivers were significantly associated with a decreased likelihood of being admitted to the hospital/palliative care unit. Our results show that opportunities to tailor home care based on referral characteristics to meet patient preference to die at home, at individual, system, and policy levels, exist.

Advanced dementia is a life-limiting illness that requires a palliative approach to care. Decline in eating/drinking represents a milestone in progression that warrants decision-making and planning of care. In long-term care (LTC), this is best conducted via family case conferences.

ObjectivesSymptoms of raised intracranial pressure (ICP) in recurrent high-grade glioma (HGG) generally require corticosteroid treatment, often causing toxicity with variable effects on ICP symptoms. Acetazolamide reduces ICP when used in other clinical non-cancer settings. The aim of the study was to explore whether the addition of oral acetazolamide enables safe dexamethasone dose reduction in management of raised ICP in recurrent HGG.MethodsParticipants had recurrent HGG with any of dexamethasone recommencement, dose increase or dependency; prior/current bevacizumab was an exclusion. Eligible participants were randomised 1:1 to acetazolamide or placebo for 8 weeks. Standardised protocols were used for dexamethasone dosing, with planned dose decrease from day 5 once ICP symptoms were stable. The primary endpoint was a composite of dexamethasone dose reduction and stable Karnofsky Performance Status Secondary endpoints included toxicity and feasibility.ResultsThirty participants (15 per group) were enrolled (mean age 58 years) from seven Australian sites. The mean baseline dexamethasone dose was 6.2 mg. Mean duration on study treatment was 38 days (placebo group) and 31 days (acetazolamide group) with nine participants (30%) completing all study treatments (six placebo, three acetazolamide). Study withdrawal was due to adverse events (n=6; one placebo, five acetazolamide) and disease progression (n=6 (three per arm)). Four participants (13%) (two per arm) were stable responders. Ten participants experienced a total of 13 serious adverse events (acetazolamide arm: five participants (33%), six events, two related).ConclusionsThe study closed early due to poor accrual and increasing availability of bevacizumab. The addition of acetazolamide did not facilitate dexamethasone reduction.Trial registration numberACTRN12615001072505.

Objective:To ascertain palliative physicians’ and consultation-liaison psychiatrists’ perceptions of depression care processes in patients with very poor prognoses, exploring key challenges and postulating solutions. Methods:A qualitative focus group study involving three 1-h online focus groups (2 palliative medicine and 1 psychiatry) were conducted between November-December 2020. Fellows and trainees were recruited from Australian and New Zealand Society of Palliative Medicine (n  =  11) and Royal Australian and New Zealand College of Psychiatrists (n  =  4). Data underwent conventional qualitative content analysis. Results:Participants perceived depression care to be complex and challenging. Perceived barriers included: inadequate palliative care psychiatry skills with variation in clinical approaches; lack of supportive health infrastructure (poor access to required interventions and suboptimal linkage between palliative care and psychiatry); lack of research support; and societal stigma. Suggested solutions included integrating care processes between palliative care and psychiatry to improve clinician training, establish supportive health systems and promote innovative research designs. Conclusions:Developing clinician training, supportive health systems and innovative research strategies centering on integrating palliative care and psychiatry care processes may be integral to optimising depression care when providing care to people with very poor prognoses.

•This article reviews the status quo of the available evidence and guidance for geriatric oncology clinical practice, training and education for radiation therapists worldwide.•We explore the unique clinical role that radiation therapists play in the management of older adults undergoing radiation therapy.•We define multiple clinical care points in which the radiation therapists role could potentially expand or specialise into geriatric screening, assessment and intervention to optimise the care of older adults.•Current GO educational offerings and future directions to improve RTT knowledge and skills around caring for older adults are outlined.

Older people living with frailty and/or cognitive impairment who have coronavirus disease 2019 (COVID‐19) experience higher rates of critical illness. There are also people who become critically ill with COVID‐19 for whom a decision is made to take a palliative approach to their care. The need for clinical guidance in these two populations resulted in the formation of the Care of Older People and Palliative Care Panel of the National COVID‐19 Clinical Evidence Taskforce in June 2020. This specialist panel consists of nursing, medical, pharmacy and allied health experts in geriatrics and palliative care from across Australia. The panel was tasked with developing two clinical flow charts for the management of people with COVID‐19 who are i) older and living with frailty and/or cognitive impairment, and ii) receiving palliative care for COVID‐19 or other underlying illnesses. The flow charts focus on goals of care, communication, medication management, escalation of care, active disease‐directed care, and managing symptoms such as delirium, anxiety, agitation, breathlessness or cough. The Taskforce also developed living guideline recommendations for the care of adults with COVID‐19, including a commentary to discuss special considerations when caring for older people and those requiring palliative care. The practice points in the flow charts emphasise quality clinical care, with a focus on addressing the most important challenges when caring for older individuals and people with COVID‐19 requiring palliative care. The adult recommendations contain additional considerations for the care of older people and those requiring palliative care.

BackgroundIn December 2013, a partnership between five local health districts and a non-governmental organisation implemented the Palliative Care Home Support Packages (PEACH) Program. The PEACH Program aims to support palliative care clients in their last days of life at their own home. This study sought to evaluate the quality of care delivered by the service from the perspective of clients’ primary carers.MethodsA letter was sent to carers of clients 6–10 weeks after the client’s death, inviting them to participate in an anonymous survey. The survey measured the level of satisfaction on various aspects of the service using FAMCARE and Likert scales, and invited for comments about the care received and suggestions for improvement.ResultsOut of 17 aspects of care provided by the PEACH Program, 13 were scored with ‘exceptional’ or ‘acceptable performance’. The highest satisfaction was observed in meeting clients’ physical needs and providing pain relief. The most dissatisfaction was observed in addressing spiritual matters, family conferences and information about treatment side effects. Ninety-five per cent of responses were either ‘satisfied’ or ‘very satisfied’ with the overall care provided at home during the last week of the client’s life.ConclusionThe results of this research provide further evidence to the field of what constitutes a good home death and the support mechanisms required to enable this. The results also have strong implications on how local services provided by the PEACH Program are delivered in the future.

ObjectivesDelirium is common in palliative care settings. Management includes detection, treatment of cause(s), non-pharmacological interventions and family support; strategies which are supported with varying levels of evidence. Emerging evidence suggests that antipsychotic use should be minimised in managing mild to moderate severity delirium, but the integration of this evidence into clinical practice is unknown.MethodsA 21-question online anonymous survey was emailed to Association for Palliative Medicine members in current clinical practice (n=859), asking about delirium assessment, management and research priorities.ResultsResponse rate was 39%: 70% of respondents were palliative medicine consultants. Delirium guidelines were used by some: 42% used local guidelines but 38% used none. On inpatient admission, 59% never use a delirium screening tool. Respondents would use non-pharmacological interventions to manage delirium, either alone (39%) or with an antipsychotic (58%). Most respondents (91%) would prescribe an antipsychotic and 6% a benzodiazepine, for distressing hallucinations unresponsive to non-pharmacological measures. Inpatient (57%) and community teams (60%) do not formally support family carers. Research priorities were delirium prevention, management and prediction of reversibility.ConclusionThis survey of UK and Irish Palliative Medicine specialists shows that delirium screening at inpatient admission is suboptimal. Most specialists continue to use antipsychotics in combination with non-pharmacological interventions to manage delirium. More support for family carers should be routinely provided by clinical teams. Further rigorously designed clinical trials are urgently needed in view of management variability, emerging evidence and perceived priorities for research.

IMPORTANCE: Older adults with cancer are at risk of overtreatment or undertreatment when decision-making is based solely on chronological age. Although a geriatric assessment is recommended to inform care, the time and expertise required limit its feasibility for all patients. Screening tools offer the potential to identify those who will benefit most from a geriatric assessment. Consensus about the optimal tool to use is lacking. OBJECTIVE: To appraise the evidence on screening tools used for older adults with cancer and identify an optimal screening tool for older adults with cancer who may benefit from geriatric assessment. EVIDENCE REVIEW: Systematic review of 4 databases (MEDLINE, Embase, CINAHL [Cumulative Index to Nursing and Allied Health Literature], and PubMed) with narrative synthesis from January 1, 2000, to March 14, 2019. Studies reporting on the diagnostic accuracy and use of validated screening tools to identify older adults with cancer who need a geriatric assessment were eligible for inclusion. Data were analyzed from March 14, 2019, to March 23, 2020. FINDINGS: Seventeen unique studies were included, reporting on the use of 12 screening tools. Most studies were prospective cohort studies (n = 11) with only 1 randomized clinical trial. Not all studies reported time taken to administer the screening tools. The Geriatric-8 (G8) (n = 12) and the Vulnerable Elders Survey-13 (VES-13) (n = 9) were the most frequently evaluated screening tools. The G8 scored better in sensitivity and the VES-13 in specificity. Other screening tools evaluated include the Groningen Frailty Index, abbreviated comprehensive geriatric assessment, and Physical Performance Test in 2 studies each. All other screening tools were evaluated in 1 study each. CONCLUSIONS AND RELEVANCE: To date, the G8 and VES-13 have the most evidence to recommend their use to inform the need for geriatric assessment. When choosing a screening tool, clinicians will need to weigh the tradeoffs between sensitivity and specificity. Future research needs to further validate or improve current screening tools and explore other factors that can influence their use, such as ease of use and resourcing.

Large non-age-specific radiotherapy utilisation rate (RTU) studies have demonstrated that actual RTU is below the optimal recommended utilisation rate for both curative and palliative intent radiotherapy indications. The optimal utilisation rate for the geriatric oncology cohort of patients has not yet been determined. The purpose of this research was to examine the actual RTU for patients treated in New South Wales (NSW), Australia as a function of increasing age, and the relationship between RTU and tumour site, travelling distance and socio-economic status.

Oral health problems among people receiving palliative care are common and can significantly affect quality of life. Nurses are at the frontline of palliative care in Australia. However, how optimal oral health care is addressed in clinical practice by palliative nurses is not known.

A pandemic coronavirus, SARS‐CoV‐2, causes COVID‐19, a potentially life‐threatening respiratory disease. Patients with cancer may have compromised immunity due to their malignancy and/or treatment, and may be at elevated risk of severe COVID‐19. Community transmission of COVID‐19 could overwhelm health care services, compromising delivery of cancer care. This interim consensus guidance provides advice for clinicians managing patients with cancer during the pandemic. During the COVID‐19 pandemic: In patients with cancer with fever and/or respiratory symptoms, consider causes in addition to COVID‐19, including other infections and therapy‐related pneumonitis.For suspected or confirmed COVID‐19, discuss temporary cessation of cancer therapy with a relevant specialist.Provide information on COVID‐19 for patients and carers.Adopt measures within cancer centres to reduce risk of nosocomial SARS‐CoV‐2 acquisition; support population‐wide social distancing; reduce demand on acute services; ensure adequate staffing; and provide culturally safe care. Measures should be equitable, transparent and proportionate to the COVID‐19 threat.Consider the risks and benefits of modifying cancer therapies due to COVID‐19. Communicate treatment modifications, and review once health service capacity allows.Consider potential impacts of COVID‐19 on the blood supply and availability of stem cell donors.Discuss and document goals of care, and involve palliative care services in contingency planning. This interim consensus guidance provides a framework for clinicians managing patients with cancer during the COVID‐19 pandemic. In view of the rapidly changing situation, clinicians must also monitor national, state, local and institutional policies, which will take precedence. Australasian Leukaemia and Lymphoma Group; Australasian Lung Cancer Trials Group; Australian and New Zealand Children's Haematology/Oncology Group; Australia and New Zealand Society of Palliative Medicine; Australasian Society for Infectious Diseases; Bone Marrow Transplantation Society of Australia and New Zealand; Cancer Council Australia; Cancer Nurses Society of Australia; Cancer Society of New Zealand; Clinical Oncology Society of Australia; Haematology Society of Australia and New Zealand; National Centre for Infections in Cancer; New Zealand Cancer Control Agency; New Zealand Society for Oncology; and Palliative Care Australia.

Delirium is a prevalent acute neurocognitive condition in patients with progressive life-limiting illness. Delirium remains underdetected; a systematic approach to screening is essential. Delirium at the end of life requires a comprehensive assessment. Consider the potential for reversibility, illness trajectory, patient preference, and goals of care before proceeding with investigations and interventions. Management should be interdisciplinary, and nonpharmacologic therapy is fundamental. For patients with refractory and severe agitation or perceptual disturbance, judicious use of medication may also be required. Carers and family should be seen as partners in care and be involved in shared decision making about care.

IntroductionMorphine may decrease the intensity of chronic breathlessness but data from a large randomised controlled trial (RCT) are lacking. This first, large, parallel-group trial aimed to test the efficacy and safety of regular, low-dose, sustained-release (SR) morphine compared with placebo for chronic breathlessness.MethodsMultisite (14 inpatient and outpatient cardiorespiratory and palliative care services in Australia), parallel-arm, double-blind RCT. Adults with chronic breathlessness (modified Medical Research Council≥2) were randomised to 20 mg daily oral SR morphine and laxative (intervention) or placebo and placebo laxative (control) for 7 days. Both groups could take ≤6 doses of 2.5 mg, ‘as needed’, immediate-release morphine (≤15 mg/24 hours) as required by the ethics review board. The primary endpoint was change from baseline in intensity of breathlessness now(0–100 mm visual analogue scale; two times per day diary) between groups. Secondary endpoints included: worst, bestand average breathlessness; unpleasantness of breathlessness now, fatigue; quality of life; function; and harms.ResultsAnalysed by intention-to-treat, 284 participants were randomised to morphine (n=145) or placebo (n=139). There was no difference between arms for the primary endpoint (mean difference −0.15 mm (95% CI −4.59 to 4.29; p=0.95)), nor secondary endpoints. The placebo group used more doses of oral morphine solution during the treatment period (mean 8.7 vs 5.8 doses; p=0.001). The morphine group had more constipation and nausea/vomiting. There were no cases of respiratory depression nor obtundation.ConclusionNo differences were observed between arms for breathlessness, but the intervention arm used less rescue immediate-release morphine.Trial registration numberACTRN12609000806268.

ObjectivesWe aimed to identify and evaluate: (1) treatment-emergent adverse events (TEAE (worse or new since baseline)) and the subgroup of severe TEAEs in a placebo-controlled 7-day randomised trial of regular, low-dose, sustained-release oral morphine for chronic breathlessness and (2) clinical characteristics associated with TEAE.MethodsSafety analysis of trial data. Adults with chronic breathlessness (modified Medical Research Council breathlessness score ≥2) due to heart or lung disease, or cancer, not on regular opioids were eligible. Symptoms associated with opioids (TEAE of special interest) were systematically sought using Common Terminology Criteria for Adverse Events (CTCAE) grading. Other harms could be reported at any time. The relationship between characteristics and presence of ≥1 TEAE of special interest was explored using univariable logistic regression analyses.Results1449/5624 (26%) Adverse Events from 279 participants were TEAE of which 150/1449 (10%) were severe (CTCAE grades 3–5). 1086/5624 (75%) were events of special interest of which 41/1086 (4%) were severe. Compared with placebo, morphine was not associated with more TEAE or severe TEAE of special interest (TEAE: OR 0.53, 95% CI 0.21 to 1.38, p=0.20; severe TEAE: OR 0.96, 95% CI 0.27 to 3.41, p=0.95) nor with CTCAE severity grade (χ2=4.39, p=0.50). Among the 26/150 (17%) with severe TEAEs, study withdrawal was more common in the morphine arm (18/26 (69%) morphine arm; 8/26 (30%) placebo arm). None of the severe TEAEs was a respiratory harm.ConclusionsSevere morphine-associated toxicity was uncommon and not associated with study arm. Clinical consequences were minor and self-limiting.Trial registration numberACTRN126000806268.

Systematic reviews and guidelines are available to guide management of cough in lung cancer, but evidence for intervention efficacy is limited, and little research has yet described current practice.

The literature describing the incidence of sleep difficulty in CNS cancers is very limited, with exploration of a sleep difficulty symptom trajectory particularly sparse in people with advanced disease. We aimed to establish the prevalence and longitudinal trajectory of sleep difficulty in populations with CNS cancers receiving palliative care nationally, and to identify clinically modifiable predictors of sleep difficulty.

IMPORTANCE: Antipsychotics are widely used for distressing symptoms of delirium, but efficacy has not been established in placebo-controlled trials in palliative care. OBJECTIVE: To determine efficacy of risperidone or haloperidol relative to placebo in relieving target symptoms of delirium associated with distress among patients receiving palliative care. DESIGN, SETTING, AND PARTICIPANTS: A double-blind, parallel-arm, dose-titrated randomized clinical trial was conducted at 11 Australian inpatient hospice or hospital palliative care services between August 13, 2008, and April 2, 2014, among participants with life-limiting illness, delirium, and a delirium symptoms score (sum of Nursing Delirium Screening Scale behavioral, communication, and perceptual items) of 1 or more. INTERVENTIONS: Age-adjusted titrated doses of oral risperidone, haloperidol, or placebo solution were administered every 12 hours for 72 hours, based on symptoms of delirium. Patients also received supportive care, individualized treatment of delirium precipitants, and subcutaneous midazolam hydrochloride as required for severe distress or safety. MAIN OUTCOME AND MEASURES: Improvement in mean group difference of delirium symptom score (severity range, 0-6) between baseline and day 3. Five a priori secondary outcomes: delirium severity, midazolam use, extrapyramidal effects, sedation, and survival. RESULTS: Two hundred forty-seven participants (mean [SD] age, 74.9 [9.8] years; 85 women [34.4%]; 218 with cancer [88.3%]) were included in intention-to-treat analysis (82 receiving risperidone, 81 receiving haloperidol, and 84 receiving placebo). In the primary intention-to-treat analysis, participants in the risperidone arm had delirium symptom scores that were significantly higher than those among participants in the placebo arm (on average 0.48 Units higher; 95% CI, 0.09-0.86; P = .02) at study end. Similarly, for those in the haloperidol arm, delirium symptom scores were on average 0.24 Units higher (95% CI, 0.06-0.42; P = .009) than in the placebo arm. Compared with placebo, patients in both active arms had more extrapyramidal effects (risperidone, 0.73; 95% CI, 0.09-1.37; P = .03; and haloperidol, 0.79; 95% CI, 0.17-1.41; P = .01). Participants in the placebo group had better overall survival than those receiving haloperidol (hazard ratio, 1.73; 95% CI, 1.20-2.50; P = .003), but this was not significant for placebo vs risperidone (hazard ratio, 1.29; 95% CI, 0.91-1.84; P = .14). CONCLUSIONS AND RELEVANCE: In patients receiving palliative care, individualized management of delirium precipitants and supportive strategies result in lower scores and shorter duration of target distressing delirium symptoms than when risperidone or haloperidol are added. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12607000562471.

BackgroundAlthough palliative care is an important public healthcare issue worldwide, the current situation in the Asia-Pacific region has not been systematically evaluated.ObjectivesThis survey aimed to clarify the current status of palliative care in the Asia-Pacific region.MethodsQuestionnaires were sent to a representative physician of each member country/region of the Asia Pacific Hospice Palliative Care Network (APHN). The questionnaire examined palliative care service provision, information regarding physician certification in palliative care, the availability of essential drugs for palliative care listed by the International Association for Hospice and Palliative Care (IAHPC) and the regulation of opioid-prescribing practice.ResultsOf the 14 member countries/regions of the APHN, 12 (86%) responded. Some form of specialist palliative care services had developed in all the responding countries/regions. Eight member countries/regions had physician certifications for palliative care. Most essential drugs for palliative care listed by the IAHPC were available, whereas hydromorphone, oxycodone and transmucosal fentanyl were unavailable in most countries/regions. Six member countries/regions required permission to prescribe and receive opioids.ConclusionsThe development of palliative care is in different stages across the surveyed countries/regions in the Asia-Pacific region. Data from this survey can be used as baseline data for monitoring the development of palliative care in this region.

ObjectivesLoss of appetite is prevalent in palliative care and distressing for patients and families. Therapies include corticosteroids or progestogens. This study explores the net effect of dexamethasone on anorexia.MethodsProspective data were collected when dexamethasone was started for anorexia as part of routine care. The National Cancer Institute's Common Toxicity Criteria for Adverse Events (NCICTCAE) Likert scales assessed severity of anorexia and immediate and short-term harms at 2 time points: baseline and 7 days.ResultsThis study (41 sites, 8 countries) collected data (July 2013 to July 2014) from 114 patients (mean age 71 (SD 11), 96% with cancer). Median Australian-modified Karnofsky Performance Scale was 50% (range 20–70). Mean baseline NCICTCAE anorexia score was 2.7 (SD 0.6; median 3). 6 patients died by day 7. Of 108 evaluable patients, 74 (68.5%; 95% CI 59.0% to 76.7%) reported ≥1 reduction anorexia scores by day 7, of whom 30 were 0. Mean dexamethasone dose on day 7 was 4.1 mg/day (SD 3.4; median 4; range 0–46 mg). 24 patients reported ≥1 harms (32.4% CI 22.6% to 44.1%; insomnia n=10, depression n=7, euphoria n=7 and hyperglycaemia n=7). Of 24 patients with no benefit, 10 reported ≥1 harms.ConclusionsThis study shows positive and negative effects of 7 days of dexamethasone as an appetite stimulant in patients with advanced life-limiting illnesses. Identifying clinicodemographic characteristics of people most at risk of harms with no benefit is a crucial next step. Longer term follow-up will help to understand longer term and cumulative harms.

IntroductionReal-world effectiveness of many medications has been poorly researched, including in hospice/palliative care. Directly extrapolating findings from other clinical settings may not yield robust clinical advice. Pharmacovigilance studies provide an opportunity to understand better the net impact of medications. The study aimed to examine immediate and short-term benefits and harms of pregabalin in routine practice for neuropathic pain in hospice/palliative care.MethodsA consecutive cohort of 155 patients from 62 centres in 5 countries was started on pregabalin and studied prospectively. Data were collected at three time points: baseline; day 7 (immediate, short-term harms); ad hoc reports of any harms ≤21 days; and day 21 (short-term benefits).ResultsMedian dose for 155 patients at day 21 was 150 mg/24 h. Benefits were reported by 61 patients (39%), of whom 11 (7%) experienced complete pain resolution. Harms were reported by 51 (35%) patients at or before 7 days, the most frequent of which were somnolence, fatigue, cognitive disturbance and dizziness. 10 patients (6%) ceased pregabalin due to harms, but 82 patients (53%) were being treated at 21 days. In regression modelling, people with worse baseline pain derived more benefit (OR=8.5 (95% CI 2.5 to 28.68).ConclusionsPregabalin delivered benefit to many patients, with 4 of 10 experiencing pain reductions by 21 days. Harms, occurring in 1 in 3 patients, may be difficult to detect in clinical practice, as they mostly involve worsening of symptoms prevalent at baseline.

Background:Internationally, delirium prevalence in palliative care is reported to range between 26–88%, yet little is known about the occurrence of delirium in Australian palliative care inpatient populations.Aims:To: 1) ascertain 24-hour delirium point-prevalence in an Australian palliative care inpatient population; 2) test the feasibility and acceptability of the delirium measurement methodology.Methods:This was a prospective cross-sectional study. Delirium was measured in patients of two palliative care units using the Nursing Delirium Screening Scale, Memorial Delirium Assessment Scale and DSM-5 diagnostic criteria. Descriptive statistics were used to report patient demographics, palliative care phase, function, delirium measure completion, and proportion of patients with a positive screen and diagnosis.Results:Patients (n=47) had a mean age of 74 years (SD+10) and mostly malignant diagnoses (96%). All patients were screened for delirium, but few were capable of completing the Memorial Delirium Assessment Scale (n=2). One-third of patients (34%) screened positive for delirium and 19% were diagnosed as delirious according to the DSM-5.Conclusion:The Nursing Delirium Screening Scale and physician application of DSM-5 proved feasible and acceptable, while the Memorial Delirium Assessment Scale did not. Patients' advanced age and proportions screening positive for delirium and diagnosed as delirious attest to the need to rapidly recognise, assess and respond to patients experiencing this distressing disorder while being cared for in palliative care inpatient settings.

Models of palliative care need to address the unmet needs of children, young people and families.

Introduction There is limited research into the role of occupational therapy in discharge planning in palliative care. This study aimed to explore patients’ and caregivers’ perceptions of occupational therapy in the context of discharge home from an inpatient palliative care setting.Method Semi-structured interviews were conducted with patients and caregivers following discharge home from inpatient palliative care. Participants were selected using purposive sampling and data was thematically analysed.Results Five caregivers and three patients were interviewed. Three main themes emerged: (1) shared roles in discharge planning; (2) perceived benefits of occupational therapy; and (3) adapting to discharge home. Patients and caregivers viewed occupational therapy as the practical help needed to achieve discharge. They had difficulty differentiating between professional roles and perceived the discharge process as a shared responsibility between themselves and the clinicians. Adapting to discharge home involved coping with the uncertain and unexpected, where limited understanding of professional roles meant participants did not know who to seek assistance from.Conclusion Occupational therapy was viewed as the practical help needed for discharge home from a palliative care setting. Clinicians need to take primary responsibility for understanding each other’s roles and providing information on who can assist after discharge.

Cancer pain remains a major public health concern. Despite effective treatments being available to manage the majority of cancer pain, this debilitating symptom is frequently under treated. As cancer has becomes a chronic disease a range of health professionals, including community nurses in Australia are increasingly caring for people living with cancer related pain. Yet, little is known about community nurses capacity to assess and manage cancer pain in accordance with best available evidence.

ObjectiveHospice/palliative care patients may differ from better studied populations, and data from other populations cannot necessarily be extrapolated into hospice/palliative care clinical practice. Pharmacovigilance studies provide opportunities to understand the harms and benefits of medications in routine practice. Gabapentin, a γ-amino butyric acid analogue antiepileptic drug, is commonly prescribed for neuropathic pain in hospice/palliative care. Most of the evidence however relates to non-malignant, chronic pain syndromes (diabetic neuropathy, postherpetic neuralgia, central pain syndromes, fibromyalgia). The aim of this study was to quantify the immediate and short-term clinical benefits and harms of gabapentin in routine hospice/palliative care practice.DesignMultisite, prospective, consecutive cohort.Population127 patients, 114 of whom had cancer, who started gabapentin for neuropathic pain as part of routine clinical care.Settings42 centres from seven countries. Data were collected at three time points—at baseline, at day 7 (and at any time; immediate and short-term harms) and at day 21 (clinical benefits).ResultsAt day 21, the average dose of gabapentin for those still using it (n=68) was 653 mg/24 h (range 0–1800 mg) and 54 (42%) reported benefits, of whom 7 (6%) experienced complete pain resolution. Harms were reported in 39/127 (30%) patients at day 7, the most frequent of which were cognitive disturbance, somnolence, nausea and dizziness. Ten patients had their medication ceased due to harms. The presence of significant comorbidities, higher dose and increasing age increased the likelihood of harm.ConclusionsOverall, 42% of people experienced benefit at a level that resulted in continued use at 21 days.

ObjectiveThe aim of this study was to evaluate the cost-effectiveness of a home-based palliative care model relative to usual care in expediting discharge or enabling patients to remain at home.DesignEconomic evaluation of a pilot randomised controlled trial with 28 days follow-up.MethodsMean costs and effectiveness were calculated for the Palliative Care Extended Packages at Home (PEACH) and usual care arms including: days at home; place of death; PEACH intervention costs; specialist palliative care service use; acute hospital and palliative care unit inpatient stays; and outpatient visits.ResultsPEACH mean intervention costs per patient ($3489) were largely offset by lower mean inpatient care costs ($2450) and in this arm, participants were at home for one additional day on average. Consequently, PEACH is cost-effective relative to usual care when the threshold value for one extra day at home exceeds $1068, or $2547 if only within-study days of hospital admission are costed. All estimates are high uncertainty.ConclusionsThe results of this small pilot study point to the potential of PEACH as a cost-effective end-of-life care model relative to usual care. Findings support the feasibility of conducting a definitive, fully powered study with longer follow-up and comprehensive economic evaluation.

The aim of this review is to summarize the current state of the science in physical symptoms and other end-of-life care domains andor illness-specific outcomes in palliative care. The review includes progress in outcome measure development and interpretation, with specific reference to the clinical trial context.

Palliative care clients often have a reduced quality of life (QOL). The purpose of this study was to explore the QOL trajectory of clients and carers newly referred to a community palliative care service. A total of 49 clients and 43 carers respectively completed the McGill QOL scale (MQOL) and the caregiver QOL cancer scale (CQOLC) questionnaires. Baseline data relating to demographics, health status, and QOL are presented for the 49 participants and their 43 carers, and these are compared with follow-up data from 22 clients and 13 carers (matched pairs). On average, there were no significant differences between baseline and follow-up QOL scores in any respects for either clients or carers, including measures of burden, disruptiveness, positive adaptation, and financial concerns. Whether this indicates that the care administered succeeded in cancelling out the worsening of the clients' conditions or whether it indicates a shortcoming of the care was not assessed.

Objective:The prevalence of chronic pain in Australia has only been previously estimated for the state of New South Wales. The aim of this study was to focus estimates on pain severe enough to interfere markedly with daily function irrespective of contact with health services in another region, South Australia. Methods:A whole of population random face‐to‐face survey method (n=2,973) was used, directly standardised against the whole population for age, gender, country of birth and rurality. Respondents were asked about chronic pain and the degree to which it interfered with daily activities. Results:The prevalence of chronic pain was 17.9%, and pain that interfered extremely with activity 5.0%. Chronic pain was associated with older age, living alone, lower income, not being in full‐time work and lower educational levels in bivariate analyses, however in multifactor analyses the only significant associations were not currently working (p<0.001) and lower levels of educational achievement (p=0.042). Pain that interfered extremely with activity in multifactor analysis was associated with work status where the odds ratio for work‐related injury compared to those in full time work was 19.3 (95% CI 7.30‐51.3; p<0.001). Conclusions:This study highlights the high levels of pain with extreme effects on day‐to‐day life (one in 20 people), the complex inter‐relationships of the factors (educational achievement, work status) associated with chronic pain and the impacts that these factors have on the people experiencing such disabling pain in the long‐term.

A wide range of services are provided to palliative care clients to alleviate pain and improve their quality of life. The purpose of this study was to explore the perceptions of clients and their carers regarding palliative care services in New South Wales, Austalia. Ten patients and their carers (n=7) were randomly selected from a sample of palliative care clients and were informed of the study and interviewed. Interview data were coded independently by three researchers and thematic analysis was undertaken. The themes identified were similar for both clients and carers and included: access to services; service provision; impact on way of life; usefulness of services; and staffing. An additional theme identified by clients was the burden of caregiving on carers. Knowledge of perceptions and concerns of client and carers is important to consider when planning palliative care services.

Delirium is a neuropsychiatric syndrome that occurs frequently in cancer patients, especially in those with advanced disease. Recognition and effective management of delirium is particularly important in supportive and palliative care, especially in view of the projected increase in the elderly population and the consequent potential for the number of patients both diagnosed and living longer with cancer to increase substantively.

With increasing use of medicinal cannabis for symptom management, clinical trials nurses need to consider the various legal, social, ethical, and interdisciplinary care issues of implementing these clinical trials, especially in a palliative care population.

ObjectiveUse of palliative care in hospitals for people at end of life varies. We examined rate and time of in-hospital palliative care use and associated interhospital variations.MethodsWe used admissions from all hospitals in New South Wales, Australia, within a 12-month period, for a cohort of adults who died in 73 public acute care hospitals between July 2010 and June 2014. Receiving palliative care and its timing were based on recorded use.ResultsAmong 90 696 adults who died, 27% received palliative care, and the care was initiated 7.6 days (mean; SD: 3.3 days) before death. Over the 5-year period, the palliative care rate rose by 58%, varying extent across chronic conditions. The duration of palliative care before death declined by 7%. Patient (demographics, morbidities and service use) and hospital factors (size, location and availability of palliative care unit) explained half of the interhospital variation in outcomes: adjusted IQR in rate and duration of palliative care among hospitals were 23%–39% and 5.2–8.7 days, respectively. Hospitals with higher rates often initiated palliative care earlier (correlation: 0.39; p<0.01).ConclusionDespite an increase over time in the palliative care rate, its initiation was late and of brief duration. Palliative care use was associated with patient and hospital characteristics; however, half of the between hospital variation remained unexplained. The observed suboptimal practices and variability indicate the need for expanded and standardised use of palliative care supported by assessment tools, service enhancement and protocols.

BackgroundMedications used to manage symptoms in patients with cancer have associated, but poorly understood, harms. The aim of this study was to explore the temporal relationship between oral morphine equivalent daily dose (MEDD), oral diazepam equivalent daily dose (DEDD) and the daily anti-cholinergic load (ACL) with cognitive and gastrointestinal symptoms, performance status, quality of life and survival in patients receiving palliative care.MethodsSecondary longitudinal analysis of cancer decedents (n=235) from a palliative care trial with multiple outcome measures. At each time-point MEDD, DEDD and ACL were calculated. Multilevel modelling was used to investigate ?independent associations between MEDD, DEDD and ACL, and cognitive and gastrointestinal symptoms, quality of life, performance status and survival.ResultsCognitive and gastrointestinal symptoms, performance status, and quality of life worsened over time. In the adjusted multilevel analysis significance remained for worsening performance status (MEDD, p=0.001; DEDD, p<0.001; ACL p=0.035) and shorter time to death (MEDD, p<0.001; ACL, p<0.01).ConclusionCommonly used palliative medications were associated with deteriorating performance status and shorter time to death. This analysis highlights the importance of adjusting for other variables, including other medication when exploring medication-related harms. An understanding of the risk-benefit balance of medications is needed to maximise net benefit for patients. Future work to delineate interactions between classes of drugs and drug-related harms and to evaluate early assessment and management of side-effects is needed in order to maximise net benefit.

ObjectiveNon-invasive ventilation (NIV) is widely used in the management of acute and acute-on-chronic respiratory failure. Understanding the experiences of patients treated with NIV is critical to person-centred care. We describe the subjective experiences of individuals treated with NIV for acute hypercapnic respiratory failure.DesignQualitative face-to-face interviews analysed using thematic analysis.SettingAustralian tertiary teaching hospital.ParticipantsIndividuals with acute hypercapnic respiratory failure treated with NIV outside the intensive care unit. Individuals who did not speak English or were unable or unwilling to consent were excluded.Results13 participants were interviewed. Thematic saturation was achieved. Participants described NIV providing substantial relief from symptoms and causing discomfort. They described enduring NIV to facilitate another chance at life. Although participants sometimes appeared passive, others expressed a strong conviction that they knew which behaviours and treatments relieved their distress. Most participants described gaps in their recollection of acute hospitalisation and placed a great amount of trust in healthcare providers. All participants indicated that they would accept NIV in the future, if clinically indicated, and often expressed a sense of compulsion to accept NIV. Participants' description of their experience of NIV was intertwined with their experience of chronic disease.ConclusionsParticipants described balancing the benefits and burdens of NIV, with the goal of achieving another chance at life. Gaps in recall of their treatment with NIV were frequent, potentially suggesting underlying delirium. The findings of this study inform patient-centred care, have implications for the care of patients requiring NIV and for advance care planning discussions.

BackgroundDelirium is common in patients receiving palliative care. Management includes assessment, reversal of underlying causes, non-pharmacological interventions and family support. Given recent evidence, antipsychotics should be avoided in mild-moderate delirium.MethodsA 20-question online anonymous survey was emailed to all Association for Palliative Medicine (APM) members. UK and Irish palliative medicine specialists in current clinical practice (n=859) were asked about delirium assessment, management and research priorities.ResultsResponse rate was 39% (335/859). Of these, 70% (234/335) were consultants, 15% (51/335) were specialist trainee registrars in palliative medicine and 15% (50/335) were associate specialists. Overall, 85% (285/335) had over 5 years of specialist palliative medicine experience. They worked in a variety, and often multiple settings, across hospital, hospice and community. Delirium guidelines were inconsistently used, with 42% (115/276) using local guidelines and 38% (104/276) using no guidelines. Most, 184/314 (59%) never use a tool to screen for delirium at inpatient admission. Most would use non-pharmacological interventions to manage delirium, either alone (106/275; 39%) or more commonly with an antipsychotic (160/275; 58%). The majority, 248/273 (91%) would prescribe an antipsychotic to a delirious patient with distressing hallucinations, with 190/273 (70%) using typical antipsychotics and 43/273 (16%) using atypical antipsychotics first line. Most inpatient (153/270; 57%) and community teams (97/161; 60%) do not formally support family carers. Informal verbal support was offered by 24% (64/270) in the inpatient setting and 22% (35/161) in community settings. Research priorities were prevention, prediction of reversibility and management (non-pharmacological and pharmacological).ConclusionMost responding APM members do not formally screen for delirium at inpatient admission. Many use an antipsychotic along with non-pharmacological interventions to manage delirium, and nearly all prescribe an antipsychotic to treat distressing hallucinations. Further rigorously designed clinical trials are urgently needed in view of management variability, emerging evidence and perceived priorities for research.

The article focuses on the practice and support of residential care providers for advanced dementia. It says that people living with advanced dementia calls for a palliative approach that is directed to the needs of their illness trajectory, symptoms, and needs of the family. It states that the National Framework for Action on Dementia 2006-2010 and the NSW Dementia Service Framework 2010-2015 have distinguished the need to resource and train aged care staff to deliver high quality care.