Registered nurse verification of expected adult death: new guidance provides direction.

Despite UK national guidance on care after death, it is clear that the bereaved family can experience distress while waiting for the patient's death to be verified. This distress can escalate if there is a delay in verification. Anecdotally, such delays particularly occur out of hours and in community settings. Verification of death is a clinical task and an act of care whereby the identity of the person and death is confirmed. In addition, the subsequent providers of care to the deceased, such as families, mortuary teams, funeral directors and cremation services, have their health and safety protected by the provision of pertinent patient-specific information, for instance, infection risk and implantable devices, within the bounds of confidentiality. During this time, the bereaved family may also receive emotional support and information from the skilled clinician. Registered Nurse Verification of Expected Adult Death (RNVoEAD) guidance and associated competencies have recently been developed to ensure that the registered nurses involved in the patient's care can feel confident about their responsibilities and competent in the process of verifying death. It is hoped that this guidance will help to avoid delays that may cause additional distress to grieving families. This article sets out the rationale for the guidance, as well as discussing outstanding concerns and proposals for future considerations.

Shifting mindsets: work in progress.

The past few months have seen a hive of activity related to the publishing of reports and documents in the UK. July heralded the arrival of the long-awaited final report on the Palliative Care Funding Review (Hughes-Hallett et al, 2011).

Treating cancer-related breakthrough pain: the oral transmucosal route.

Between 40 and 80% of patients with advanced cancer experience breakthrough pain (BTP), a sudden, rapidly escalating flare of pain occurring against a background of otherwise well-controlled persistent pain. Patients often have up to four episodes of BTP each day, with a typical episode reaching its peak intensity in three to five minutes and lasting about 30 minutes in total. It is essential to provide fast and effective relief since BTP reduces the quality of life of patients and their families, and increases health care costs. The usual approach is to treat BTP with a short-acting, 'normal release' oral opioid, but this is absorbed too slowly to treat the typical episode of BTP. As this article explains, oral transmucosal fentanyl citrate (Actiq) is an effective strong opioid that has a rapid onset and short duration of action that closely matches the characteristics of an episode of BTP.

Actiq: an effective oral treatment for cancer-related breakthrough pain.

As a result of improved survival in cancer and the transfer of care from hospital to primary care, community nurses are taking increasing responsibility for the management of patients at all stages of the disease. Persistent or background pain is common, but between 40% and 80% of patients with advanced cancer also experience breakthrough pain (BTP), a sudden, rapidly escalating flare of pain occurring against a background of otherwise well-controlled persistent pain. While background pain can be successfully managed in most patients, BTP presents a particular challenge to community nurses, because short-acting, 'normal release' oral opioid drugs are absorbed too slowly to treat the typical episode. As this article explains, Actiq is an effective strong opioid with a rapid onset and short duration of action that closely matches the characteristics of an episode of BTP.

Lutrol gel: a potential role in wounds?

Excoriated skin from malignant wounds or from their effluent are uncommon but difficult situations. Many preparations are available that may relieve discomfort; however, difficulties arise because such wounds often occur in areas where dressings are difficult to apply and keep in place. Lutrol gel is a thermoreversible gel, first reported as a potentially useful base substance by MacGregor in 1994. We report three cases where lutrol gel appeared to reduce discomfort, improve functional ability, and quality of life for the patient. We also discuss other potentially useful agents for similar situations.

Fungating wounds: informing practice through knowledge/theory.

The assessment and management of fungating wounds is a challenging situation which necessitates nurses using many skills. Literature is limited, especially relating to the psychological issues that arise for the patient and his/her family. As nurses, we must begin to address this by considering how our philosophy, knowledge and theory impact on and inform our practice. This article will critique and explore the different influences that affect our way of being and thinking in the world and how we can guide practice by using our fundamental skills of caring.