Challenges to delivering evidence-based palliative medicine.

Established as a medical specialty in 1987, palliative medicine approaches middle age facing existential questions of identity, purpose and vision. Time has weakened strong foundations laid by Dame Cicely Saunders in research, education and clinical excellence. Clinical knowledge gaps are wide, and widening. Palliative medicine research is underfunded and underrepresented in discourse. Despite huge advances in modern medicine, there is still clinical uncertainty about simple interventions, such as whether artificial hydration at the end of life is helpful or harmful. Where good quality data do exist, the pace of change is slow, if change is happening at all. Trial design often fails to assess the holistic impact of interventions, using primary endpoints that are inconsistent with outcomes most valued to the patient. Recent years have seen a rapid expansion in innovation and investment in digital technologies, embraced by many in palliative medicine. Experience shows that caution must be applied where the evidence base is sparse. While as a specialty we must remain forward looking and progressive in our mindset, it cannot be assumed that these new interventions alone will provide the solutions to the old problems that exist in palliative medicine.This review summarises the key points presented in the Palliative Medicine section of the RCP Clinical Medicine Conference, 2022.

Cancer-associated venous thromboembolism and the non-vitamin K antagonist oral anticoagulants: a review of clinical outcomes and patient perspectives.

INTRODUCTION: Cancer-associated venous thromboembolism remains an important but challenging aspect in the treatment of patients with cancer. Recently, alternatives to injection of low-molecular-weight heparin (LMWH) have been introduced, the non-vitamin K antagonist oral anticoagulants (NOACs), which could potentially alleviate patients from burdensome daily injections. AREAS COVERED: This review discusses the available evidence exploring the role of NOACs in the treatment and secondary prevention of cancer-associated venous thromboembolism, from randomized trials, observational data, contemporary guideline recommendations, and patient perspectives. EXPERT OPINION: Edoxaban, rivaroxaban, and apixaban have proven attractive alternatives to LMWH for the treatment of cancer-associated venous thromboembolism. Contemporary guidelines have promptly endorsed the use of NOACs in patients with most cancer types. Nonetheless, issues remain regarding bleeding risk, interactions with medical cancer treatment, and the effectiveness and safety for extended treatment periods. There are head-to-head comparisons of the NOACs, and therefore no data favoring the use of one NOAC over the others. Patient's preferences are highly diverse and should be part of routine considerations when weighing risks and benefits associated with various available anticoagulant drugs.

Development and Psychometric Assessment of a Spirituality Questionnaire for Indian Palliative Care Patients.

INTRODUCTION: There are only a few studies on spirituality among palliative care patients in India. This gap in research may be caused by the absence of relevant questionnaires and scales specifically designed for Indian palliative care populations. In this study, we describe the development of such a questionnaire and explain its psychometric characteristics. METHODS: We designed a questionnaire on the basis of a systematic review of the literature. After a review of the questionnaire by specialists and a subsequent pilot study, the questionnaire was amended. The final questionnaire consisted of a list of 36 spirituality items. It was administered to a sample of 300 cancer patients attending the pain clinic of a tertiary hospital in New Delhi. RESULTS: A factor analysis led to four factors explaining 54.6% of variance: Shifting moral and religious values (Factor 1), support from religious relationship (Factor 2), existential blame (Factor 3), and spiritual trust (Factor 4). The skewness and kurtosis for Factors 1, 3, and 4 were within a tolerable range for assuming a normal distribution, but Factor 2 was skewed. The alphas showed that the four factors have an acceptable internal consistency. Statistically significant associations were observed for age and Factor 3 (P = 0.004), gender and Factor 4 (P = 0.014), marital status and Factors 3 (P = 0.002) and 4 (P = 0.001), educational level and Factors 3 (P < 0.001) and 4 (P < 0.001), and pain scores and Factors 1 (P < 0.001), 2 (P < 0.001), and 3 (P = 0.001). CONCLUSION: The questionnaire offers promising prospects for the study of spirituality among palliative care patients in India.