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BackgroundRefractory angina can have a significant effect on quality of life. Non-invasive interventions have been suggested but there are few guidelines on management. Our aim was to systematically review all studies that reported non-invasive interventions for refractory angina and report on their effectiveness and safety.MethodsWe performed a literature search of six databases and a grey literature search. Treatments considered first line or second line according to the European Society of Cardiology were excluded, as were interventions that had undergone review within the last 3 years. Design, setting and outcomes were extracted and quality was assessed. A narrative synthesis was undertaken, including an analysis of adverse effects.Results4476 studies were screened, 14 studies were included in our analysis. Interventions were specialist multidisciplinary programmes, transcutaneous electrical nerve stimulation (TENS), perhexiline, medical optimisation, morphine and intranasal alfentanil. The effects of specialist programmes and perhexiline treatment were mixed. Positive effects were reported with TENS, opioids and medical optimisation, with improvements in symptoms, exercise capacity and quality of life. No major adverse effects were noted in any of the treatments.ConclusionThere are non-invasive treatments for refractory angina that are overlooked by current guidelines. While the quality of these studies varies, positive changes have been reported in symptoms, exercise tolerance and quality of life with few adverse effects. There is a need for further research into these treatments which could be useful within the contexts of cardiology and palliative care.

BackgroundEducating medical students to care for patients at the end-of-life is increasingly recognised as an essential component of training. Traditionally, medical student programmes are run by doctors, but patient care is delivered by an interprofessional team. Our programmes in the UK and USA independently developed a teaching experience led by an interprofessional team of palliative care health professionals.ObjectivesThis study explores the palliative care health professionals’ perceptions, regarding their unique role in medical student palliative care education.MethodsThis is the first study to ascertain views of an interprofessional team delivering palliative care education to medical students. Focus groups enable interaction between members of the group as well as the generation of consensus of comments among group members.ResultsTwo major themes were identified: perceived benefits and value of the experience, and the challenges and lessons learnt from the experiences.ConclusionsDespite different structures and settings, this experiential learning in palliative care provided a rewarding interprofessional experience that has historically been difficult to achieve.

Background Medical students and doctors are becoming better prepared to care for patients with palliative care needs and support patients at the end of life. This preparation needs to start at medical school.\ud \ud Objective To assess how medical students learn about death, dying and palliative care during a clinical placement using reflective essays and to provide insights to improve medical education about end-of-life care and/or palliative care.\ud \ud Methods Qualitative study in which all reflective essays written by third-year medical students in 1 year from a UK medical school were searched electronically for those that included ‘death’, ‘dying’ and ‘palliative care’. The anonymised data were managed using QSR NVivo 10 software, and a systematic analysis was conducted in three distinct phases: (1) open coding; (2) axial coding and (3) selective coding. Ethical approval was received.\ud \ud Results 54 essays met the inclusion criteria from 241 essays screened for the terms ‘death’, ‘dying’ or ‘palliative’; 22 students gave consent for participation and their 24 essays were included. Saturation of themes was reached. Three overarching themes were identified: emotions, empathy and experiential and reflective learning. Students emphasised trying to develop a balance between showing empathy and their emotional state. Students learnt a lot from clinical encounters and watching doctors manage difficult situations, as well as from their refection during and after the experience.\ud \ud Conclusions Reflective essays give insights into the way students learn about death, dying and palliative care and how it affects them personally as well as the preparation that is needed to be better equipped to deal with these kinds of experiences. Analysis of the essays enabled the proposal of new strategies to help make them more effective learning tools and to optimise students’ learning from a palliative care attachment.

We read with interest the excellent paper by Maas and colleagues in BMJ supportive and palliative care, December 2013.1 We agree that: palliative care should be available, as needed, alongside disease- modifying treatment; early palliative care can improve outcomes for patients; it's difficult to recognise people with non-malignant diseases who would benefit from comprehensive palliative assessment and interventions before death is imminent. We note that all but one tool found by the authors had a time-frame inherent in their definition of a palliative care patient, and even the RADboud …

Background Patients with advanced heart failure have significant unmet palliative care needs. UK policy recommends identification of those requiring palliative care based on prognosis (last year of life). Aim To explore aspects of a palliative care approach for people with advanced heart failure: recognition of need, transitions in care and impact on patients, family carers and clinicians. Methods Systematic literature review of prognostic variables associated with the last year of life in heart failure. Secondary analysis of contemporaneously collected primary care records from a national database, to compare recognition of the need for palliative care between cancer and heart failure patients. Qualitative semi-structured interviews with patients receiving a palliative approach to care, their carers and clinicians. A mixed method approach with a concurrent triangulation strategy was used; each study was conducted separately and findings were integrated. Findings General practice research database (GPRD) data demonstrated gross inequity between documented recognition of the need for a palliative care approach; heart failure patients were poorly represented on the palliative care register and those that were, were registered close to death. Prognostic markers, identified in both the systematic review and GPRD, had limited clinical usefulness for identifying the last year of life. From interview data, clinicians appeared reluctant to discuss a palliative care approach without clear irreversible deterioration of the patient. However, patients welcomed, and some initiated, conversations regarding the change in focus of care. Following such discussion all involved found this approach beneficial, even with subsequent periods of stability or improvement. Other barriers included lack of recognition of symptoms by clinicians and difficulties in delivering proactive care. Conclusions A palliative care approach before the very end of life is beneficial in this group. A patient centred, problem-based flexible approach to recognising the need for palliative care, rather than prognosis is recommended.

Background Medical students have opportunities to learn about palliative care from talking to patients in a hospice (1). This resource is not fully used, in part due to concerns about patient and student welfare(2). The authors aimed to explore the perceptions and experiences of students talking to patients in a hospice. Method Semistructured ‘indepth’ interviews of 14 medical students, from a medical school in the North East of England, who had spoken with hospice patients as part of their undergraduate education. Findings Overall students found the experience very valuable. Themes arising from the data included: student emotional and personal issues; effect of the hospice environment, staff and patients; learning opportunities and impact of the experience. Despite prior anxieties that the hospice would be depressing and that they would struggle emotionally talking to hospice patients, the visit transformed this view. Other concerns included facing death and dying. After their experience the students felt they would be more able to care for people at the end of life when they qualified. They found that the hospice staff and patients were very supportive and contributed to this change. Opinion varied about the best time to attend hospice during their training but the overall view was that this was less important than the availability of adequate support. The main criticism was that there was insufficient time in the programmed hospice visit and there was a preference for the immersion possible during the longer placement of a student selected component. Illustrative quotes will be used throughout. Conclusion Students are overwhelmingly positive about communicating with patients in a hospice and see it as unique environment in which they can learn vital skills.