Clinical trials of medicinal cannabis for appetite-related symptoms from advanced cancer: a survey of preferences, attitudes and beliefs among patients willing to consider participation.

BACKGROUND: Australian clinical trials are planned to evaluate medicinal cannabis in a range of clinical contexts. AIMS: To explore the preferences, attitudes and beliefs of patients eligible and willing to consider participation in a clinical trial of medicinal cannabis for poor appetite and appetite-related symptoms from advanced cancer. METHODS: A cross-sectional anonymous survey was administered from July to December 2015 online and in eight adult outpatient palliative care and/or cancer services. Respondents were eligible if they were ≥18 years, had advanced cancer and poor appetite/taste problems/weight loss and might consider participating in a medicinal cannabis trial. Survey items focused on medicinal rather than recreational cannabis use and did not specify botanical or pharmaceutical products. Items asked about previous medicinal cannabis use and preferences for delivery route and invited comments and concerns. RESULTS: There were 204 survey respondents, of whom 26 (13%) reported prior medicinal cannabis use. Tablets/capsules were the preferred delivery mode (n = 144, 71%), followed by mouth spray (n = 84, 42%) and vaporiser (n = 83, 41%). Explanations for preferences (n = 134) most commonly cited convenience (n = 66; 49%). A total of 82% (n = 168) of respondents indicated that they had no trial-related concerns, but a small number volunteered concerns about adverse effects (n = 14) or wanted more information/advice (n = 8). Six respondents volunteered a belief that cannabis might cure cancer, while two wanted assurance of efficacy before participating in a trial. CONCLUSION: Justification of modes other than tablets/capsules and variable understanding about cannabis and trials will need addressing in trial-related information to optimise recruitment and ensure that consent is properly informed.

The impact of opioids, anticholinergic medications and disease progression on the prescription of laxatives in hospitalized palliative care patients: a retrospective analysis.

Definitive risk factors for constipation in palliative care remain poorly defined. A retrospective analysis of 211 admissions to a palliative care unit was undertaken, with the main aim being to identify some factors, which influence laxative prescription. On univariate analysis, significant unadjusted associations were found between two or more prescribed laxatives and a diagnosis of malignancy, morphine equivalent dose, type of illness phase and the subsequent phase type, length of phase, anticholinergic load imposed by medications, symptom severity and functional status. Multiple ordinal logistic regressions revealed the prescription of one laxative to be significantly associated with oral morphine-equivalent dose, total anticholinergic load (odds ratio [OR] 1.4, 95% CI = 1.0-2.0), disease progression to terminal phase and death (OR 0.1, 95% CI = 0.0-0.3), and length of phase (OR 1.1, 95% CI = 1.0-1.2). Similar results were obtained for the prescription of two or more laxatives. Two additional measures of function, toileting (OR 3.6, 95% CI = 1.6-8.2) and transfer (OR 0.4 95% CI = 0.2-0.9), also became significant. Total anticholinergic load was significantly associated with the prescription of a single laxative (OR 1.4, 95% CI = 1.0-2.0) and two or more laxatives (OR 1.8, 95% CI = 1.3-2.5) for each unit increase in anticholinergic load. Opioids and in particular opioids prescribed at higher doses, the total anticholinergic load associated with prescribed medications, the degree of impaired physical function of a person, their length of stay in a palliative care unit and their proximity to death were all strongly related to the prescription of laxatives.

Differing management of people with advanced cancer and delirium by four sub-specialties.

INTRODUCTION: Delirium in advanced cancer is prevalent, with limited prospective data to guide management. The aim was to survey current practice of specialists using two contrasting cases of delirium in cancer. METHODS: A questionnaire was designed to identify investigations and treatment used, in relation to two cases. RESULTS: Overall response rate (n = 270) was 30%. Place of care: Only 35% of medical oncologists would consider care at home for a patient with reversible delirium compared with 66% of other specialists. INVESTIGATIONS: 85% specialists would order basic bloods, however, medical oncologists were more likely to use oxygen saturation and head computed tomography, psychogeriatricians more likely to order thyroid function and palliative medicine specialists less likely to order chest X-ray and urine culture. Greater than 40% of specialists would do no investigations for terminal delirium. TREATMENT: Medical oncologists use more pre-emptive therapies and more likely to use a benzodiazepine as agent of choice, and Palliative medicine specialists used significantly more neuroleptics to treat hypoactive symptoms of delirium. DISCUSSION: The survey emphasise significant areas of variability in the management of delirium in advanced cancer. Furthermore, evidence to guide management in ways that draw on the strengths and knowledge of each specialty is urgently needed.

Asking questions can help: development and preliminary evaluation of a question prompt list for palliative care patients.

Question prompt lists (QPLs) have been shown to be an inexpensive and effective communication tool for patients in oncology consultations. We aimed to develop and pilot a QPL for palliative care (PC) patients. In order to identify suitable questions for inclusion in the QPL, we conducted focus groups and individual interviews with 19 patients, 24 carers and 22 PC health professionals. A further 21 health professionals reviewed the draft document. The draft QPL was piloted in 23 patients. In total, 112 questions were identified and grouped into eight categories. All participants felt that the QPL, in booklet form, could be a useful tool. Out of 23 patients in the pilot study, 22 agreed that the QPL was helpful, contained useful questions, was easy to understand and would be useful in the future. State anxiety (STAI) decreased after receiving the booklet and seeing the doctor in 16 out of 19 patients (overall anxiety decreased by a median of 8, IQR 1-13). Participants in the pilot study endorsed the inclusion of end-of-life issues in the QPL, despite some reservations expressed about this by health professionals in the individual interviews. We have identified a specific QPL that might facilitate useful dialogue between PC patients and their doctor. The QPL has strong support from patients, their carers and relevant health professionals.

Treatment of recurrent aspiration pneumonia in end-stage dementia: preferences and choices of a group of elderly nursing home residents.

BACKGROUND: Clinicians are often faced with the dilemma of how best to manage patients with advanced dementia who present to the hospital with repeated episodes of aspiration pneumonia. Rarely, if at all, are the opinions of the group that is most likely to be directly affected, that is the older nursing home resident, sought. This study seeks to fill that gap. AIMS: To study the choices and preferences of a group of elderly nursing home residents in the treatment of recurrent aspiration pneumonia on a background of severe disability from end-stage dementia. METHODS: A descriptive cross-sectional interview study using a hypothetical scenario carried out in six nursing homes within eastern Sydney, from June to August 2000. Views and attitudes towards hospitalization, antibiotic use, tube feeding and other treatment measures, given a situation of recurrent aspiration pneumonia and end-stage dementia, were obtained. RESULTS: Fifty-two elderly nursing home residents who were cognitively intact and not depressed were interviewed. Most of the subjects would prefer further hospital admissions (61.5%, P<0.1) and would choose to have antibiotic treatment (73.1%, P<0.001). Slightly more than half would not agree to artificial ventilation. Sixty-nine percent of the respondents would not agree to feeding via a nasogastric tube (P<0.05) and 71% would not agree to a feeding gastrostomy (P<0.001). Most would agree to a modified diet (75%, P<0.0001) and to continue oral feeding despite the attendant risk of re-aspiration (59.6%, P<0.01). CONCLUSIONS: The participants generally preferred to be treated in a hospital setting given the scenario. Most disagreed with the use of artificial feeding.

A palliative care approach to end-stage neurodegenerative conditions.

INTRODUCTION: Neurodegenerative conditions, such as Alzheimer's disease, Parkinson's disease and motor neurone disease, are progressive and incurable conditions that ultimately lead to a state of total functional incapacitation and death. These conditions are "terminal" and, therefore, should be managed with a palliative care approach. This article highlights some of the issues in caring for patients with end-stage neurodegenerative conditions from a palliative perspective. METHODS: This review is based on evidence from pre-existing medical literature on the above subject and the authors' personal experiences and observations. CONCLUSION: Patients with end-stage neurodegenerative conditions have needs similar to that of advanced cancer patients. Therefore, the principles and practice of palliative care should be applied to such patients. This may also mean that palliative care training should be undertaken in nursing homes, where a large number of such patients are located.

Specialist community palliative care services--a survey of general practitioners' experience in Eastern Sydney.

The role of the general practitioner (GP) in providing palliative care in the community is of increasing importance. Concomitantly, there is more interaction between the palliative care support services and the GP. Even when there is input from the palliative care support services, there can be barriers that impede effective delivery of palliative care by the GP. These include poor communication between the GP and the supporting team, inaccessibility of the service and inadequate after-hours coverage. We carried out a postal survey to assess what experiences and perceptions GPs working within the Eastern Sydney Area had of our palliative care support service. The response was generally favourable, with most GPs finding the level of communication, accessibility, usefulness of advice given and degree of follow-up visits by the service to be adequate. However, an important number felt that we tended to over-hospitalise our patients.

A pitfall to avoid when starting a patient on transdermal fentanyl.

BACKGROUND: A woman with advanced carcinoma of the ovary developed fentanyl toxicity while being changed from oral morphine to transdermal fentanyl. OBJECTIVE: To explain the reason for the toxicity and ways to avoid it. DISCUSSION: The transdermal fentanyl patch is proving to be a safe, well tolerated and effective treatment modality in the control of cancer pain, but care has to be exercised when using this drug, especially at the time of initiation, as the consequences may be disastrous for the patient.

Dignity in dying: a preliminary study of patients in the last three days of life.

The final three days of life of 50 consecutive patients on a busy integrated palliative care service is described, with regard to final cause of death, symptom control, drug prescription, retention of personal function, and other measures possibly relevant to dignity in dying. Good symptom relief was maintained without rapid or high escalation of doses of morphine or sedatives. Personal function was maintained in at least a moderate degree in the majority of patients. This study also illustrates some of the difficulties in describing and evaluating the concept of "dying with dignity".

The use of corticosteroids in the management of bilateral malignant ureteric obstruction.

Ureteric obstruction is not an uncommon complication of malignant disease or its treatment. We describe the effectiveness of a corticosteroid in a patient with bilateral ureteric obstruction from metastatic colon cancer causing acute renal failure. We presume that the effectiveness was because of its activity in reducing edema related to the tumor. Other modalities of treatment are discussed but each case requires individualization of treatment with due ethical consideration.

Palliative care in bilateral malignant ureteric obstruction.

Bilateral ureteric obstruction is an uncommon complication arising from malignancy and its treatment. There are several effective methods of overcoming the obstruction but the choice of option requires careful consideration of various factors pertaining to each individual. These factors include the patient's age, premorbid health and lifestyle, and the extent and rate of disease. Patient and family expectations, goals and priorities need careful consideration in the context of the patient's prognosis. If measures to relieve the obstruction are not to be undertaken, symptom control then becomes paramount. This paper explores the various options and decision making by focusing on representative patients encountered in the practice of the Central Sydney Area Health Palliative Care Service.

Central Sydney Palliative Care Service: potential and limitations of an integrated palliative care service based in a metropolitan teaching hospital.

Palliative care needs to be available wherever needed, in hospital and home, and should be part of mainstream health care. Palliative care should be concurrent with anti-disease therapy, and includes but goes beyond "terminal care". The World Health Organization (WHO) encourages such development. Palliative care in Australia takes on many forms. Central Sydney Palliative Care Service based in Royal Prince Alfred Hospital (RPAH), Camperdown, is an example of mainstream palliative care integrating home and hospital care. Almost all units of RPAH refer patients to the palliative care service. Approximately 1000 new patients are referred annually by doctors (specialists or general practitioners) for medical consultation. Registrar (fellow) training in palliative medicine is a feature of the service. Palliative care in a hospital or community-based service is an issue of justice and equity, and gives structure to compassion.