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There is little in the literature describing hospital specialist palliative care units (PCUs) within the NHS. This paper describes how specialist PCUs can be set up within and be entirely funded by the NHS, and outlines some of the challenges and successes of the units. Having PCUs within hospitals has offered patients increased choice over their place of care and death; perhaps not surprisingly leading to a reduced death rate in the acute hospital. However, since the opening of the PCUs there has also been an increased home death rate. The PCUs are well received by patients, families and other staff within the hospital. We believe they offer a model for excellence in cost-effective inpatient specialist palliative care within the NHS.

Background: Non-pharmacological breathlessness management programmes have been shown to be beneficial in the management of lung cancer–related dyspnoea for more than 10 years. What is not so clear is how they work. Aim: To evaluate how patients with intrathoracic malignancy (lung cancer or pleural mesothelioma) undergoing the non-pharmacological breathlessness management programmes benefited from the programme, using a qualitative methodology. Design and Setting: Consecutive patients completing the programme were invited to be interviewed (semi-structured and audio-recorded) about their experiences of the programme, what had helped them and how. Interviews were transcribed and analysed using interpretative phenomenological analysis. Results: Nine patients were interviewed. Seven major themes emerged, they are summarised as follows: (1) Mixed prior expectations of the programme, (2) flexibility of delivery and additional support needs, (3) physiotherapist attributes and skills in developing an effective helping relationship, (4) adoption of new techniques, (5) the effects and impact of the programme and new techniques, (6) difficulties and barriers to achieving change and (7) facing an uncertain future beyond the programme Conclusion: The non-pharmacological breathlessness management programme appears to offer a wide range of benefits to patients, including improving functional capacity, coping strategies and self-control. Such benefits are most likely to be due to a combination of breathing control, activity management and the therapist qualities.

The conference was divided into a morning of anorexia/cachexia and an afternoon of fatigue, interspersed by the Bertram Louis Abrahams lecture, delivered by Professor Declan Walsh from Cleveland, Ohio, entitled ‘Mechanisms of fatigue in advanced disease’. In the morning the prevalence of

Breathlessness is common in advanced disease and can have a devastating impact on patients and carers. Research on the management of breathlessness is challenging. There are relatively few studies, and many studies are limited by inadequate power or design. This paper represents a consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup. The aims of this paper are to facilitate the design of adequately powered multi-centre interventional studies in breathlessness, to suggest a standardised, rational approach to breathlessness research and to aid future ‘between study’ comparisons. Discussion of the physiology of breathlessness is included.

The outcomes of the first 4 years of a physiotherapy led non-pharmacological breathlessness management programme for patients with intrathoracic malignancy are described. Of the 169 patients enrolling, only 14 completed the full 4-week programme. All reported improvements in some parameters measured though these did not reach statistical significance. These patients tended to be fitter, had longer median survival and the mechanism of their breathlessness was not progressive cancer. The 155 patients who did not complete the programme had a short median survival (95 days), and tended to have cancer related breathlessness. Of these, 131 were seen, 85 receiving part of the programme, 15 needing other services and 31 started but died during the programme. Objective post intervention scores could not be made in this group, but anecdotal quotes suggested benefit. In a group whose natural history is a relentless deterioration over a period of months, pre- and post-intervention symptom scoring is difficult to achieve. It is suggested that a qualitative approach might be more sensitive at identifying which aspects of the service are most appropriate. Palliative Medicine 2007; 21: 285—287

Background Estimation of prognosis is a common request. Many methods have been considered but are often complex or unreliable. Some palliative medicine physicians feel the best guide may be the recent rate of change in physical condition. For example, if a patient perceives their condition has been changing weekly they may have a prognosis of weeks; if day by day the prognosis is likely to be days. No research has been done to show whether this is an accurate guide, despite it being widely used. Methods Adults with cancer admitted to an NHS inpatient specialist palliative care unit were recruited (exclusion criteria: 1. lacking capacity; 2. if it was thought the study may cause unnecessary distress). Patients were asked “how has your condition changed recently?" (plus a further probe of "do you think things have been changing daily/weekly/monthly?" if required) but were not asked directly about prognosis. Ethics approval was obtained. Data was collected on patient9s perception of rate of change, consultant9s estimate of prognosis and actual survival time. Aim To determine whether the proposed research question was a reliable indicator of survival time. Results Eight patients were recruited. There was similarity between patient perceived rate of change, doctor prognosis estimate and actual survival time in most cases. Numbers were smaller than anticipated due to concerns about causing distress in patients, although this did not occur in participating patients.

Background The End of Life Strategy makes clear the importance of patient choice. The subsequent drive towards community end of life care masks the reality that even in the best performing areas, over 40% of people will continue to die in hospital. Patient9s preferences change as death approaches, with the popularity of hospices significantly increasing. This paper describes one approach by a NHS trust seeking to improve the delivery of palliative and end of life care. The trust made a strategic decision, alongside community initiatives, to invest in a 19 bedded hospital palliative care unit. Aim To examine the effectiveness of a hospital palliative care unit. Methods The effectiveness of the unit was measured in terms of patient statistics, complexity and quality of care. Results The average length of stay was 13 days, proportion of patients who died 62% and occupancy running over 80%. Patient experience data demonstrates high levels of satisfaction, especially in the domains of pain control, respect and dignity, doctors and nurses. Patients were found to have a poorer performance status and require non-oral drugs than a nearby hospice. Staff satisfaction was high. Overall trust performance in Liverpool Care Pathway measures also improved over this time. Conclusion The unit successfully improved the general dissatisfaction with hospital palliative and end of life care. Positive patient/family feedback and high usage demonstrated that this model could achieve 3 goals: -a better level of palliative care for patients than can be delivered in non-palliative care environments -a cost-effective model: the costs were the same as other medical wards -patient choice. The number of patients who died in a palliative care setting raised the proportion of patients dying in a specialist palliative care environment to the highest in the country. A second unit will open shortly.