Pro re nata prescribing in a population receiving palliative care: a prospective consecutive case note review.

OBJECTIVES: To document pro re nata (PRN) prescribing practices and to identify patterns with respect to clinical characteristics and the medications prescribed. DESIGN: Prospective consecutive case note review. SETTING: Two interrelated consultative hospice and palliative care services in regional Victoria, Australia. PARTICIPANTS: Terminally ill inpatients and community-based individuals (N = 203) at the time of referral to a hospice or palliative care service. MEASUREMENTS: Number of medications that the referring physician prescribed on a PRN basis and on a regular basis for symptom control; comorbid disease, performance status, comorbidity burden, disease phase, and survival. RESULTS: Mean number of PRN medications prescribed was 3.0, with significantly higher rates in the last week of life (rate ratio (RR) = 1.30, 95% confidence interval (CI) = 1.07-1.59) and during the terminal phase of disease (RR = 1.36, 95% CI = 1.09-1.68). One-quarter of prescriptions were for medications that met the Beers consensus criteria for potentially inappropriate medication use in elderly persons. CONCLUSION: These descriptive baseline data are new. A mean of three different medications allows responsiveness to a variety of fluctuating symptoms, but there was a large range within the sample, indicating that some individuals and their caregivers have a high burden of administration-related decision-making.

Deciding what information is necessary: do patients with advanced cancer want to know all the details?

Communicating effectively with patients who have advanced cancer is one of the greatest challenges facing physicians today. Whilst guiding the patient through complex diagnostic and staging techniques, treatment regimens and trials, the physician must translate often imprecise or conflicting data into meaningful personalized information that empowers the patient to make decisions about their life and body. This requires understanding, compassion, patience, and skill. This narrative literature review explores current communication practices, information preferences of oncology patients and their families, and communication strategies that may assist in these delicate interactions. Overwhelmingly, the literature suggests that whilst the majority of patients with advanced cancer do want to know their diagnosis and receive detailed prognostic information, this varies not only between individuals but also for a given individual over time. Barriers to the delivery and understanding of information exist on both sides of the physician-patient relationship, and family dynamics are also influential. Despite identifiable trends, the information preferences of a particular patient cannot be reliably predicted by demographic, cultural, or cancer-specific factors. Therefore, our primary recommendation is that the physician regularly asks the patient what information they would like to know, who else should be given the information and be involved in decision making, and how that information should be presented.