Paracentesis for cancer-related ascites in palliative care: An international, prospective cohort study.

BACKGROUND: Paracentesis is commonly undertaken in patients with cancer-related ascites. AIM: To systematically investigate the symptomatic benefits and harms experienced by patients with cancer undergoing paracentesis using real-world data in the palliative care setting. DESIGN: Prospective, multisite, observational, consecutive cohort study. Benefits and harms of paracentesis were assessed between 01/07/2018 and 31/02/2021 as part of routine clinical assessments by treating clinicians at four timepoints: (T0) before paracentesis; (T1) once drainage ceased; (T2) 24 h after T1 and (T3) 28 days after T1 or next paracentesis, if sooner. SETTING/PARTICIPANTS: Data were collected from 11 participating sites across five countries (Australia, England, Hong Kong, Malaysia and New Zealand) on 111 patients undergoing paracentesis via a temporary (73%) or indwelling (21%) catheter: 51% male, median age 69 years, Australia-modified Karnofsky Performance Score 50. RESULTS: At T1 (n = 100), symptoms had improved for most patients (81%), specifically abdominal distension (61%), abdominal pain (49%) and nausea (27%), with two-thirds experiencing improvement in ⩾2 symptoms. In the remaining patients, symptoms were unchanged (7%) or worse (12%). At least one harm occurred in 32% of patients, the most common being an ascitic leak (n = 14). By T3, 89% of patients had experienced some benefit and 36% some harm, including four patients who experienced serious harm, one of which was a fatal bowel perforation. CONCLUSION: Most patients obtained rapid benefits from paracentesis. Harms were less frequent and generally mild, but occasionally serious and fatal. Our findings help inform clinician-patient discussions about the potential outcomes of paracentesis in this frail population.

Pharmacovigilance in hospice/palliative care: Net effect of amitriptyline or nortriptyline on neuropathic pain: UTS/IMPACCT Rapid programme international consecutive cohort.

BACKGROUND: Real-world effectiveness of interventions in palliative care need to be systematically quantified to inform patient/clinical decisions. Neuropathic pain is prevalent and difficult to palliate. Tricyclic antidepressants have an established role for some neuropathic pain aetiologies, but this is less clear in palliative care. AIM: To describe the real-world use and outcomes from amitriptyline or nortriptyline for neuropathic pain in palliative care. DESIGN: An international, prospective, consecutive cohort post-marketing/phase IV/pharmacovigilance/quality improvement study of palliative care patients with neuropathic pain where the treating clinician had already made the decision to use a tricyclic antidepressant. Data were entered at set times: baseline, and days 7 and 14. Likert scales graded benefits and harms. SETTING/PARTICIPANTS: Twenty-one sites (inpatient, outpatient, community) participated in six countries between June 2016 and March 2019. Patients had clinician-diagnosed neuropathic pain. RESULTS: One hundred and fifty patients were prescribed amitriptyline (110) or nortriptyline (40) of whom: 85% had cancer; mean age 73.2 years (SD 12.3); mean 0-4 scores for neuropathic pain at baseline were 1.8 (SD 1.0). By day 14, doses of amitriptyline were 57 mg (SD 21) and nortriptyline (48 mg (SD 21). Fifty-two (34.7%) patients had pain improvement by day 14 (amitriptyline (45/110 (43.3%); nortriptyline (7/40 (18.9%)). Thirty-nine (27.7%) had new harms; (amitriptyline 29/104 (27.9%); nortriptyline 10/37 (27.0%); dizziness (n = 23), dry mouth (n = 20), constipation (n = 14), urinary retention (n = 10)). Benefits without harms occurred (amitriptyline (26/104 (25.0%); nortriptyline (4/37 (10.8%)). CONCLUSIONS: Benefits favoured amitriptyline while harms were similar for both medications.

Reviewing the use and quality of machine learning in developing clinical prediction models for cardiovascular disease.

Cardiovascular disease (CVD) is one of the leading causes of death across the world. CVD can lead to angina, heart attacks, heart failure, strokes, and eventually, death; among many other serious conditions. The early intervention with those at a higher risk of developing CVD, typically with statin treatment, leads to better health outcomes. For this reason, clinical prediction models (CPMs) have been developed to identify those at a high risk of developing CVD so that treatment can begin at an earlier stage. Currently, CPMs are built around statistical analysis of factors linked to developing CVD, such as body mass index and family history. The emerging field of machine learning (ML) in healthcare, using computer algorithms that learn from a dataset without explicit programming, has the potential to outperform the CPMs available today. ML has already shown exciting progress in the detection of skin malignancies, bone fractures and many other medical conditions. In this review, we will analyse and explain the CPMs currently in use with comparisons to their developing ML counterparts. We have found that although the newest non-ML CPMs are effective, ML-based approaches consistently outperform them. However, improvements to the literature need to be made before ML should be implemented over current CPMs.

Inequities in childhood immunisation coverage associated with socioeconomic, geographic, maternal, child, and place of birth characteristics in Kenya.

BACKGROUND: The global Immunisation Agenda 2030 highlights coverage and equity as a strategic priority goal to reach high equitable immunisation coverage at national levels and in all districts. We estimated inequities in full immunisation coverage associated with socioeconomic, geographic, maternal, child, and place of birth characteristics among children aged 12-23 months in Kenya. METHODS: We analysed full immunisation coverage (1-dose BCG, 3-dose DTP-HepB-Hib (diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type B), 3-dose polio, 1-dose measles, and 3-dose pneumococcal vaccines) of 3943 children aged 12-23 months from the 2014 Kenya Demographic and Health Survey. We disaggregated mean coverage by socioeconomic (household wealth, religion, ethnicity), geographic (place of residence, province), maternal (maternal age at birth, maternal education, maternal marital status, maternal household head status), child (sex of child, birth order), and place of birth characteristics, and estimated inequities in full immunisation coverage using bivariate and multivariate logistic regression. RESULTS: Immunisation coverage ranged from 82% [81-84] for the third dose of polio to 97.4% [96.7-98.2] for the first dose of DTP-HepB-Hib, while full immunisation coverage was 68% [66-71] in 2014. After controlling for other background characteristics through multivariate logistic regression, children of mothers with primary school education or higher have at least 54% higher odds of being fully immunised compared to children of mothers with no education. Children born in clinical settings had 41% higher odds of being fully immunised compared to children born in home settings. Children in the Coast, Western, Central, and Eastern regions had at least 74% higher odds of being fully immunised compared to children in the North Eastern region, while children in urban areas had 26% lower odds of full immunisation compared to children in rural areas. Children in the middle and richer wealth quintile households were 43-57% more likely to have full immunisation coverage compared to children in the poorest wealth quintile households. Children who were sixth born or higher had 37% lower odds of full immunisation compared to first-born children. CONCLUSIONS: Children of mothers with no education, born in home settings, in regions with limited health infrastructure, living in poorer households, and of higher birth order are associated with lower rates of full immunisation. Targeted programmes to reach under-immunised children in these subpopulations will lower the inequities in childhood immunisation coverage in Kenya.

Intranasal Fentanyl Versus Placebo for Treatment of Episodic Breathlessness in Hospice Patients With Advanced Nonmalignant Diseases.

CONTEXT: Episodic breathlessness is a distressing and difficult to treat symptom because of its short duration. Fast actioned intranasal fentanyl (INF) is potentially more suitable than oral opioids. OBJECTIVES: To examine the feasibility, preliminary efficacy, and safety of INF for the treatment of episodic breathlessness from advanced nonmalignant conditions in hospice patients. METHODS: Phase IIB, double-blind, randomized controlled, multisite, INF citrate solution vs. placebo crossover feasibility study. Opioid-tolerant patients were to treat six episodes of breathlessness using INF spray. The primary outcome was change in the Visual Analogue Scale for dyspnea (VAS-D) score from baseline to 15 minutes after study drug's administration (VAS-D15). Other outcomes were to collect demographic data and determine the use of rescue medications, safety, and feasibility of the study design. RESULTS: Twenty-one of 49 eligible patients were enrolled, and 19 (90%) patients completed the study. The mean difference in VAS-D15 between fentanyl and placebo was -3.37 mm (95% CI = -10.35 to 3.61 mm; P = 0.337). There was no statistically significant or clinically meaningful difference between INF and placebo in relieving the sensation of discomfort in episodic breathlessness. No significant drug-related adverse event or detrimental effect on vital signs was observed. CONCLUSION: We found no difference between INF and placebo in relieving episodic breathlessness in nonmalignant conditions. INF was well tolerated, and the study design proved to be feasible in hospice patients with advanced diseases. Future study using higher concentration of fentanyl solution may be warranted.

Development of an international Core Outcome Set (COS) for best care for the dying person: study protocol.

BACKGROUND: In contrast to typical measures employed to assess outcomes in healthcare such as mortality or recovery rates, it is difficult to define which specific outcomes of care are the most important in caring for dying individuals. Despite a variety of tools employed to assess different dimensions of palliative care, there is no consensus on a set of core outcomes to be measured in the last days of life. In order to optimise decision making in clinical practice and comparability of interventional studies, we aim to identify and propose a set of core outcomes for the care of the dying person. METHODS: Following the COMET initiative approach, the proposed study will proceed through four stages to develop a set of core outcomes: In stage 1, a systematic review of the literature will identify outcomes measured in existing peer reviewed literature, as well as outcomes derived through qualitative studies. Grey literature, will also be included. Stage 2 will allow for the identification and determination of patient and proxy defined outcomes of care at the end of life via quantitative and qualitative methods at an international level. In stage 3, from a list of salient outcomes identified through stages 1 and 2, international experts, family members, patients, and patient advocates will be asked to score the importance of the preselected outcomes through a Delphi process. Stage 4 consists of a face-to-face consensus meeting of international experts and patient/family representatives in order to define, endorse, and propose the final Core Outcomes Set. DISCUSSION: Core Outcome Sets aim at promoting uniform assessment of care outcomes in clinical practice as well as research. If consistently employed, a robust set of core outcomes for the end of life, and specifically for the dying phase, defined by relevant stakeholders, can ultimately be translated into best care for the dying person. Patient care will be improved by allowing clinicians to choose effective and meaningful treatments, and research impact will be improved by employing internationally agreed clinically relevant endpoints and enabling accurate comparison between studies in systematic reviews and/or in meta-analyses.

Declining oral intake towards the end of life: how to talk about it? A qualitative study.

BACKGROUND: Decreasing oral intake is common towards the end of life and a potential source of distress and concern for patients, relatives, whanau and clinicians. This paper provides insight to inform practice regarding clinicians' perceptions, practices, responses and communication with patients and their companions regarding declining oral intake towards the end of life. METHODS: In this qualitative study ten specialist palliative care staff participated in semi-structured interviews. Qualitative thematic analysis was used to analyse the data. FINDINGS: Three themes were identified: declining oral intake was a natural part of the dying process; responding empathetically; and clinicians described specific aims and ways regarding communication. CONCLUSION: Insight into clinicians' endeavours to manage declining oral intake and support the wellbeing of patients, families, and whanau can inform practice. However the perspectives of family, whanau and health professionals continue to show significant variation regarding the communication given and received around declining oral intake towards the end of life.

Funding models in palliative care: Lessons from international experience.

BACKGROUND: Funding models influence provision and development of palliative care services. As palliative care integrates into mainstream health care provision, opportunities to develop funding mechanisms arise. However, little has been reported on what funding models exist or how we can learn from them. AIM: To assess national models and methods for financing and reimbursing palliative care. DESIGN: Initial literature scoping yielded limited evidence on the subject as national policy documents are difficult to identify, access and interpret. We undertook expert consultations to appraise national models of palliative care financing in England, Germany, Hungary, Republic of Ireland, New Zealand, The Netherlands, Norway, Poland, Spain, Sweden, Switzerland, the United States and Wales. These represent different levels of service development and a variety of funding mechanisms. RESULTS: Funding mechanisms reflect country-specific context and local variations in care provision. Patterns emerging include the following: Provider payment is rarely linked to population need and often perpetuates existing inequitable patterns in service provision. Funding is frequently characterised as a mixed system of charitable, public and private payers. The basis on which providers are paid for services rarely reflects individual care input or patient needs. CONCLUSION: Funding mechanisms need to be well understood and used with caution to ensure best practice and minimise perverse incentives. Before we can conduct cross-national comparisons of costs and impact of palliative care, we need to understand the funding and policy context for palliative care in each country of interest.

Pharmacovigilance in hospice/palliative care: the net immediate and short-term effects of dexamethasone for anorexia.

OBJECTIVES: Loss 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. METHODS: Prospective 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. RESULTS: This 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. CONCLUSIONS: This 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.

The Role of Magnetic Resonance Imaging in the Investigation and Management of Invasive Lobular Carcinoma-A 3-Year Retrospective Study in Two District General Hospitals.

Invasive lobular carcinoma (ILC) accounts for 5-15% of breast cancers. In comparison to other types of breast cancer, ILC is more likely to be associated with multifocal and contralateral breast involvement as well as a tendency to a diffuse infiltrative growth pattern which can represent a diagnostic challenge. The National Institute of Clinical Excellence guidelines in 2009 recommended the use of magnetic resonance imaging (MRI) in the preoperative assessment of ILC. This study aims to assess compliance with the guidelines in two District General Hospitals and the utility of MRI in the investigation of ILC. All cases of ILC between 2011 and 2013 were retrospectively identified from the pathology database and their breast imaging findings, pathology report, and operative intervention were reviewed. A total of 126 patients were identified with ILC, of these 46 had MRI preoperatively (36.5%). MRI upgraded mammography/ultrasound diagnoses in 10 patients (21.7%). MRI showed multicentric unilateral disease in 17 patients (37.0%) occult on ultrasound/mammogram, with these patients undergoing mastectomy and 16/17 (94.1%) confirmed multifocality on pathology. MRI showed a contralateral lesion in 9 patients (19.6%), four (8.7%) of which were malignant and had bilateral surgery, and five (10.9%) were benign on further imaging/biopsy. MRI also downgraded three patients (6.5%) to unifocal disease with reported multifocal appearances on mammography/ultrasound, and these patients underwent breast-conserving surgery. MRI adds significant additional information to mammograms/ultrasound in ILC and should be undertaken in all such cases preoperatively assuming no contraindication.

A randomised, double-blind controlled trial of intranasal midazolam for the palliation of dyspnoea in patients with life-limiting disease.

PURPOSE: Anxiety is a major component of breathlessness and is often palliated with benzodiazepines. Midazolam is a short-acting water-soluble benzodiazepine with a rapid onset of action and short half-life. Intranasal midazolam had been shown to be of marked clinical benefit in an uncontrolled pilot study for the control of dyspnoea. A blinded randomised controlled study was therefore undertaken across four Australasian palliative care services. METHODS: All participants received six numbered study nasal spray (SNS) bottles, three of which contained midazolam and three placebo. They were instructed to use one SNS bottle on each day they were breathless, for 6 days within 2 weeks. Dyspnoea scores were recorded before and at set time intervals following the first use of each SNS bottle. RESULTS: Across all SNS bottles, the maximum change of 2.1 on an 11-point numerical rating scale was seen at 60 min. There was no difference in dyspnoea score between the two arms. Approximately 50 % of participants in each arm had a positive response (i.e. ≥2 point change in dyspnoea score from baseline). Anxiety scores at baseline were low. The most common adverse event was local nasal reactions. CONCLUSION: Intranasal midazolam had no clinical benefit over intranasal placebo for the control of dyspnoea. The low level of anxiety at baseline and dose of active drug delivered may have been important factors. Many participants found the SNS bottles to be a challenging mode of drug delivery. This study confirms the importance of placebo-controlled trials for defining best clinical practise.

The challenge of providing palliative care to a rural population with cardiovascular disease.

PURPOSE OF REVIEW: There is a growing burden of end-stage cardiovascular disease in the aging Western world and a need to improve access to best evidence-based care, including patients located in rural areas. RECENT FINDINGS: Disparities are evident within rural settings for patients with cardiovascular disease. Useful guidelines exist to guide clinical services integration. Palliative care and cardiac services need to integrate their services defining the primary care lead with heart failure nurses coordinating. Earlier communication around disease implications, symptom burden and objectives of care feed into the integrated model for best and agreed outcomes to be achieved. Telehealth can assist a rural population when it is part of that integrated care model but more research on telemonitoring is required before conclusions can be drawn on the role of this expensive technology. Individual care plans can assist all involved. Subcutaneous furosemide may play a part in keeping a patient at home and with good palliative care the place of death can be the patient's home, if that is desired. SUMMARY: Rural patients with end-stage heart failure can be well supported at home as long as the model of care is united to support them. This includes heart failure nurse coordination based in the cardiac team, palliative care and general practice support.

Bereaved relatives' perspectives of the patient's oral intake towards the end of life: a qualitative study.

BACKGROUND: Patients approaching death often have a decreasing oral intake, which can be distressing for relatives. Little is known about the relatives' experiences with and perceptions of oral intake at the end of life. AIM: This study aims to contribute to a more thorough understanding of relatives' concerns regarding decreased oral intake of the patient at the end of life. DESIGN: Qualitative interview study: semi-structured interviews were transcribed verbatim and analysed using qualitative content analysis. SETTING/PARTICIPANTS: Twenty-three bereaved relatives of patients who had been referred to a New Zealand palliative care service were interviewed. RESULTS: All relatives experienced significant changes in patients' oral intake at the end of life. Oral intake towards the end of life was considered important and is perceived as meaningful by relatives in different ways, such as nutritional value, enjoyment, social time, daily routine and a way of caring. Relatives responded differently to decreasing oral intake; some accepted it as inherent to the dying process, others continued efforts to support the patient's oral intake. Some relatives perceived decreasing oral intake as the patient's choice, and some viewed maintaining oral intake as part of the battle against the disease. Relatives recalled limited communication with health-care professionals concerning oral intake at the end of life. CONCLUSIONS: This study revealed the complexity of meaning relatives' experiences with dying patients' decreasing oral intake. Their perceptions and concerns were related to their awareness of the imminent death. These findings can guide staff involved in care delivery to better support relatives.

Staff perceptions of the impact of the Liverpool Care Pathway in aged residential care in New Zealand.

AIM: To determine staff perceptions of the impact of the Liverpool Care Pathway for the dying patient (LCP) in three aged residential care facilities in New Zealand. METHODS: A mixed methodology approach was adopted, including the use of a survey, focus groups, and individual interviews. FINDINGS: Fifteen of 194 staff participated in the focus groups (five nurses and nine health-care assistants). The interviewees included three GPs, one registered nurse, and one manager. The post-implementation survey response rate of 13% was poorer than the 32% response rate to a pre-implementation survey reported elsewhere. Nevertheless, there was congruence across the data sources. The participating staff perceived multiple benefits to residents, family, whãnau, and staff following implementation of the LCP. CONCLUSION: As a tool the LCP was effective in supporting, guiding, and prompting care delivery. However, challenges remained, particularly regarding environmental factors.

Staff perceptions of end-of-life care following implementation of the liverpool care pathway for the dying patient in the acute care setting: a New Zealand perspective.

BACKGROUND AND METHODS: Ensuring appropriate palliative and end-of-life (EOL) care in the acute environment is complex and challenging. The Liverpool Care Pathway (LCP) aims to support staff to provide holistic EOL care utilizing a structured framework to prompt and guide care. We report on the post-implementation findings of a mixed methodology (survey and focus group [FG] forums) study into staff perceptions of EOL care following the pilot implementation of the LCP into two acute wards. RESULTS AND CONCLUSIONS: Study results suggest that within acute settings staff perceive that the LCP improves EOL care overall, assists interdisciplinary communication around death and dying, and that is a useful tool to positively influence decision making and care delivery. Further research into aspects of staff communication, diagnosing dying, changing direction of care, and the physical environment is warranted.

Evaluating the role and value of a national office to coordinate Liverpool Care Pathway implementation in New Zealand.

BACKGROUND: New Zealand is one of 20 countries implementing the Liverpool Care Pathway for the Dying Patient (LCP) to improve quality care of the dying. The LCP is an integrated care pathway that guides healthcare professionals to deliver evidence-based, best practice care to dying patients and their families in the last days and hours of life, irrespective of diagnosis or care setting. Currently the LCP Central Team coordinates LCP implementation and dissemination for all international collaborating countries except New Zealand, from its base in Liverpool in the UK. With the support of the LCP Central Team, New Zealand is the first country to establish a National Office to assume the responsibility for promoting the sustainable implementation of the LCP within its own borders and context of end-of-life care. AIMS: To evaluate the role and value of a New Zealand National LCP Office (NZ LCP Office) from the perspective of key stakeholders. METHODS: A mixed methods approach was applied, which intentionally combined two different survey methods in sequence. In Phase 1, key stakeholders (n = 28) were interviewed to explore their perspectives for the role and value of the NZ LCP Office. Findings from Phase 1 informed an online questionnaire distributed to a larger group of key stakeholders (n = 36, 62% response rate) in Phase 2. RESULTS: When considering the role of the NZ LCP Office, key stakeholders identified two core services as highly important, namely the promotion of the sustainable implementation of LCP and the provision of a national LCP information network. Other key initiatives identified by key stakeholders as important included the NZ LCP Office continuing to work in consultation and collaboration with the LCP Central Team and to be a voice for end-of-life care issues in New Zealand. The value or benefit of the NZ LCP Office was endorsed, in that service performance was rated as good or very good by at least 90% of the respondents, plus 40% of participants perceived the NZ LCP Office had contributed to positive changes in LCP document compliance, program integrity and improvement in care of the dying to a moderate extent. CONCLUSION: Having a National LCP Office in New Zealand to coordinate sustainable LCP implementation and maintain the integrity of the LCP program within the context of the country's own healthcare system was seen as crucial by key stakeholders.

Staff perceptions of end-of-life care in the acute care setting: a New Zealand perspective.

BACKGROUND: Understanding current end of life (EOL) care delivery in acute care is an important prerequisite to positively influencing practice, and published New Zealand (NZ) and international data are limited. Therefore, staff perceptions of EOL care in the hospital setting were investigated via survey. This article presents key findings. METHOD AND RESULTS: A total of 610 staff members in a 194-bed regional hospital were surveyed regarding their perceptions of EOL care, which yielded a response rate of 29% with 179 surveys returned. Respondents were from medical, nursing, and allied health staff working in medical, surgical, elder health, and a regional cancer treatment service. Responses to Likert scale statements regarding the Care of the dying, Communication, Teamwork, Documentation, Attitudes to death and dying in the workplace, and Barriers to the care of patients, their whanau (a NZ Maori word that refers to extended family or family group), and families frequently contrasted with additional and explanatory comments. The thematic analysis of written text identified five themes: The reality of care, The team dynamic, The direction of care, Knowledge and education, and Environmental and organizational factors. CONCLUSION: The quality and timeliness of EOL care was significantly influenced by the elements informing the themes and the pervasive nature and importance of communication. Meeting the needs of dying patients in acute care was complex but a significant priority for staff.

Staff perceptions of end-of-life care in aged residential care: a New Zealand perspective.

BACKGROUND: Increasingly, aged residential care (ARC) facilities are places where the lives of older people with complex care needs end. Hence, end-of-life (EOL) care is a significant component of work for ARC staff. In the absence of New Zealand research, staff perceptions of EOL care were sought at three aged-care facilities in a New Zealand District Health Board region. The research provided valuable data regarding care delivery and can be used to inform the introduction of an integrated care pathway (ICP). EOL care pathways are not commonly used in New Zealand ARC facilities and the influence of ICPs, such as the Liverpool Care Pathway (LCP) for the dying patient has not been investigated. Additionally, most international studies report on the introduction of the LCP without baseline preimplementation data. DESIGN: In the present study, staff (n = 195) involved in caring for residents, their families, and whanau at EOL were surveyed to obtain demographic data and staff perceptions of EOL care via Likert scale and open ended questions. RESULTS: A response rate of 32% was obtained. Respondents indicated a relatively high level of confidence regarding their care of the dying, including aspects of communication, teamwork and use of documentation. However, this was often contradicted by their written responses. Written comments were analyzed thematically and six themes identified: the naturalness of dying; the character of care; care relationships; emotional response; knowledge; and the organizational environment. Data analysis provided a rich and informative description of staff perceptions of EOL and issues influencing care.

Erlotinib in advanced non-small cell lung cancer: efficacy and safety findings of the global phase IV Tarceva Lung Cancer Survival Treatment study.

INTRODUCTION: Erlotinib is a small molecule inhibitor of epidermal growth factor receptor tyrosine-kinase activity that has been shown to significantly increase survival for patients with previously treated advanced non-small cell lung cancer. Here, we report safety and efficacy data from a large, global, open-label, phase IV trial of erlotinib (Tarceva Lung Cancer Survival Treatment). METHODS: Patients who had previously failed on chemotherapy or radiotherapy and were unsuitable for these treatments were treated with oral erlotinib (150 mg/d) until disease progression or unacceptable toxicity. RESULTS: The disease control rate was 69% in 5394 patients for whom best response data were available. Survival data were available for 6580 patients. Median progression-free and overall survival times were 3.25 months and 7.9 months, respectively. The 1-year survival rate was 37.7%. Among the 6580 patients included in the safety analysis, 799 (12%) experienced one or more erlotinib-related adverse events (AEs, other than prespecified AEs defined in the protocol), and only 4% experienced an erlotinib-related serious AE. Of the 6580 patients for whom data were available, dose reductions were reported in 1096 (17%), the majority (95%) due to an erlotinib-related AE (most commonly rash 65% or diarrhea 10%). Treatment was discontinued for 337 patients (5%) because of erlotinib-related AEs. Incidence of erlotinib-related rash was investigated as a separate end point. Seventy-one percent of patients for whom data were available experienced erlotinib-related rash; of these, the majority of cases were grade 1/2 (59%). CONCLUSIONS: These data confirm the favorable efficacy and safety profile of erlotinib in a large heterogeneous non-small cell lung cancer population.