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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.

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.