Gastrointestinal problems in patients with advanced gynaecological malignancy.

Gastrointestinal problems are among the most common problems encountered in the management of women with far advanced gynaecological malignancy. They frequently have a multifactorial aetiology and may require a number of different strategies for effective management. Recognition of the central role of alimentary function in human life is essential to effective treatment. Elucidation of the probable cause of each problem is essential. A thorough knowledge of the natural history of the disease and the patient's current status and future prospects is needed to ensure the highest standard of care for the individual suffering from the problem.

Care of the patient close to death.

The recognition that the patient is close to death is essential and usually possible. Assessment must be meticulous, goals clearly articulated, and strategies for symptom relief and comprehensive care defined and monitored. Death should not be obstructed by futile measures. The wish of a patient to be allowed to die needs to be respected, as well as a patient's anguish in the face of imminent and unwanted death. The final phase of life (hours or days) should not be seen as a time of treatment failure, but as a time for completion of tasks in peace and dignity, even in the mist of weakness and profound surrender.

Approaching cancer pain relief.

Pain is defined as an unpleasant experience-it is subjective and achieving pain relief is achieving a change in the patient's experience. There needs to be an adequate concept of a human person (an ecological model will be discussed) and a logical process for approaching pain relief in an individual patient (e.g. the plan used in the Sydney Institute of Palliative Medicine). Communication with the patient is critical to get a grasp of him or her as a person, their environment, personal experience and cultural background. Then encourage him or her to tell the story of the cancer saga as they perceive it, listening carefully for the matters which may have given rise to acute distress (for example, delay in diagnosis) and how they adjusted to this. The individual is conveying a great deal about him or herself as they tell their story. Next the story of the treatment and their experience of it, and then the response of their tumour to it--then the story of their pain: when it began, its characteristics, how it evolved, what factors worsen the pain, what relieves it, etc. This is followed by careful clinical examination to clarify what could be the most likely mechanism(s) responsible for the noxious stimulus. Some investigation (e.g. X-ray) may be justified to assist clarification--but not before making a clinical diagnosis (best guess) and commencing treatment with drugs or other logical measures with some local action--depending on the most probable mechanism. Paracetamol/non-steroidal anti-inflammatory drugs (NSAIDs) etc may be logical. Threshold factors should be attended to--comfort, concern always, or anxiolytic or antidepressant drugs if the patient is pathologically anxious or depressed. The opioid drugs--with morphine still as the gold standard--should be appropriately used. This involves careful calibration of dose (below sedative level) normally with an immediate-release, preparation--and, in the case of morphine, specific counselling concerning 'myths' to ventilate fears of dying, fears of addiction, fear of tolerance, etc. It is irresponsible to use an opioid without assessing the prior state of the bowel (? loaded) or without prescribing a laxative. When neuropathic pain does not respond to a correctly calibrated opioid, it may be necessary to add certain antidepressants, anticonvulsants, gabapentin, steroid, etc. A system must be set in place for evaluation of pain relief: relief is usually possible.

Postgraduate training in palliative medicine: the experience of the Sydney Institute of Palliative Medicine.

The experience of the Sydney Institute of Palliative Medicine (Australia) in providing training positions in palliative medicine for around 70 doctors is outlined. The history, development and the key characteristics of the training programme, as well as the nature and range of trainees and their outcome are discussed. Strengths and weaknesses of such a programme are appraised and strategic directions for the future enunciated.

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".

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.

The palliative effects of octreotide in malignant disease.

Octreotide is a synthetic analogue of somatostatin with a longer half-life than the native peptide. It has been used extensively in a variety of clinical settings for some years. More recently, its uses in malignant disease processes have been studied and it is proving to be an excellent addition to the palliative care pharmacy. We look at the current uses of octreotide for the palliation of malignant disease with particular emphasis on inoperable malignant bowel obstruction. Octreotide may palliate nausea and vomiting in this distressing condition when other therapies fail. Octreotide may also control severe diarrhoea and help in the closure of fistulae from benign and malignant conditions. It has unique analgesic properties. Radio-labelled isotopes of octreotide may be used to image some tumours. Recently, it has also shown potential in anti-cancer treatment.

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.

Unrecognized constipation in patients with advanced cancer: a recipe for therapeutic disaster.

Morphine-induced constipation can lead to therapeutic disasters by several mechanisms. It can be readily prevented by administration of appropriate laxatives, but the importance of this simple intervention is often overlooked. Problems resulting from uncontrolled constipation include not only fecal impaction and spurious diarrhea, but also pseudoobstruction of bowel causing abdominal pain, nausea and vomiting, and serious interference with drug administration and absorption. Cancer pain may also be exacerbated. All of these contribute unnecessarily to morbidity and costs of health care. A case that exemplifies many of these problems is presented and discussed.

Palliative care and melanoma: the care of the patient with progressive disease.

The World Health Organization has taken the lead in recent years in encouraging an appropriate focus on palliative care which includes but goes beyond terminal care. Comprehensive care of patients with advanced progressive disease requires increased emphasis, with adequate resources. Management of major symptoms is a crucial component of such a care program and requires the application of recent advances in palliative therapeutics (notably but not only good quality pain management), whether or not direct antitumor strategies are being continued. The choice of treatment approaches must be related to the patient's personal priorities.

Myeloproliferative and lymphoproliferative disorders in Tasmania, 1972-80: occupational and familial aspects.

All cases in a population-based series of myeloproliferative and lymphoproliferative (LP) disorders diagnosed in usual residents of Tasmania between 1972 and 1980 were asked for occupational histories and the occurrence of similar diseases in their close relatives. Occupational risks were observed for males who had farmed, mined, or worked in foundries and for women who had farmed or had been hairdressers. For individual diagnoses, the risk to farmers was seen to vary with age at diagnosis, sex, and region. With regard to familial risks, the LP and MP groups seemed to breed true, relatives being affected with a disorder from the other group not more often than would be expected by chance. The risks were of two kinds: Those to siblings and that between parent and child, particularly between mother and son. Occupational risks for the familial cases were limited to farming particularly in males diagnosed at 65 years of age or older. Females possessed elevated risks for the LP group only, and their highest relative risk was for those diagnosed before age 65. This evidence suggests that familial clustering of these disorders partly may be due to common environmental exposures in males from rural kindreds.

Myeloproliferative and lymphoproliferative disorders in Tasmania, 1972-80: patterns in space and time.

During the period 1972-80, 866 patients with myeloproliferative (MP) and lymphoproliferative (LP) disorders were diagnosed in Tasmania. The residential histories of these cases were compared with those of population-based controls. No space-time clustering was demonstrated by individuals of any single diagnosis or group of diagnoses, nor were any regional differences in incidence detected. However, urban-rural differences were observed. Rural exposures were important especially in early childhood and at specific intervals before onset for certain diagnoses. Farm residence in early life yielded heightened relative risks, especially for sufferers from chronic lymphocytic leukemia and acute nonlymphoblastic leukemia. Regional analysis demonstrated elevated risks of residence in orcharding and dairying regions and in an urban-industrial municipality. High risks were associated with latent periods before diagnosis. The findings suggest environmental agents, acting prenatally or in early life, as well as in adult life, as important risk factors in the later development of MP and LP disorders.