Absorption of rectally administered phenytoin: a pilot study.

OBJECTIVE: To test the hypothesis that rectally administered phenytoin is absorbed in healthy volunteers. DESIGN: This single-center, open-label crossover pilot study compared rectal absorption with intravenous administration of phenytoin injectable solution (7 mg/kg) in healthy volunteers. Twelve serial blood samples were taken from each volunteer beginning at time zero until 36 hours following administration. These were analyzed for presence of phenytoin by immunoassay. SETTING: The study took place at St. Paul's Hospital, a tertiary care center. PARTICIPANTS: Funding permitted for a sample size of five healthy participants, two men and three women, aged 21-45 years. Selection was by volunteer sample. Inclusion criteria were as follows: no known medical conditions, not receiving medication, no history of adverse drug reactions or allergies, not known to be pregnant, and normal liver function as determined per study protocol. MAIN OUTCOME MEASURES: Signs of absorption as indicated by presence of phenytoin in blood samples, maximum concentrations (Cmax), time to Cmax (tmax), AUC, and apparent bioavailability. RESULTS: Maximum mean concentrations of 2.4+/-1.1 mg/L (mean +/- SD) following rectal administration and 11.2+/-1.6 mg/L following intravenous administration were achieved during the first one to two hours (tmax in both treatment arms). Mean apparent bioavailability of the rectally administered phenytoin was 24.4+/-13.4% (15.8-44.1%). CONCLUSIONS: Results from this pilot study demonstrate that rectal absorption of phenytoin begins within 30 minutes following single-dose administration and was reported by four out of five volunteers to be the preferred route. Further studies are required before extrapolation can be made to the patient population.

Decision making at the end of life: a model using an ethical grid and principles of group process.

Those who provide care for the dying seek to address issues of pain and suffering in the context of the psychological, spiritual, mental, and physical complexities of the individual experiencing a terminal illness. People who are dying are still living. They have the right to be in control of their lives. The staff (caregivers) also have an integrity which must be preserved. They too must be connected to the decision-making process. The reality of palliative care brings up unresolved psychological issues, often turbulent personal issues, for all involved in the process. This can cause extra unnecessary pain and suffering for all concerned. It is essential that a real (unflinching) and an ethical relationship between the patient and the staff be maintained and valued as these issues are confronted and resolved. This relationship will be subject to group process influences, which must be recognized and embraced. Avoidance of these issues can lead to unfairness, misunderstanding, shame, and lasting resentment among the caregivers, as well as to tragic consequences for the patient and the family. The purpose of this article is to describe a decision-making process in palliative care that includes the use of ethical principles as well as features of group process. The ethical grid was adapted and developed from the work of Jonsen, Siegler, and Winslade. The features of group process are based on theories of group work as defined by Trotzer; Johnson and Johnson; Gladding; Bion; Yalom; and Amundson, Borgen, Westwood and Pallard.

Well-being at the end of life: Part 1. A research agenda for psychosocial and spiritual aspects of care from the patient's perspective.

This article reviews the scientific literature concerning psychosocial and spiritual aspects of palliative care for the patient with cancer. It discusses 4 separate areas: the continuum of care, communication, spiritual and psychological issues, and psychotherapeutic and behavioural management of physical symptoms. Most of the research could be classified as fundamental according to the Cancer Control Framework of the National Cancer Institute of Canada. In some areas, even fundamental research was lacking. There is a need for clearer and more relevant definitions of the desired outcomes of interventions and also for the development of appropriate quantitative and qualitative methods. We must determine which interventions can be initiated earlier in the disease trajectory and can provide benefit at the palliative phase. Given the burden of suffering that palliative care aims to address, relatively little research in this area has been conducted.