Rare cause of dyspnoea: phenazopyridine-induced methemoglobinemia.

Methemoglobinemia, due to the oxidation of iron from ferrous to ferric form in the haemoglobin molecule, results in decreased oxygen delivery to the tissues. Phenazopyridine, a commonly used medication for urinary symptoms, is a rare cause of methemoglobinemia. We report an elderly woman with advanced vaginal cancer, who developed methemoglobinemia following the use of phenazopyridine at a dose of 200 mg three times a day for 14 days. She presented with dyspnoea without cyanosis, oxygen saturation of 70%, methemoglobin concentration of 32.2% in arterial blood gas analysis and haemoglobin of 5 g/dL. This condition was identified and treated with methylene blue and oxygen support, which resulted in complete recovery in two days. Though rare, this highlights the importance of ascertaining reversible causes of symptoms, even in palliative care settings. Medications as an aetiology of symptoms should be considered even if they were used on a long-term basis.

Palliative care outpatients and improved documentation-what matters most? Quality improvement project.

OBJECTIVE: Patients needs should be regularly assessed. We aimed to improve assessment and documentation of needs from baseline 25% in June 2022 to 75% in December 2022. METHODS: The A3, a structured problem-solving continuous-improvement methodology was used. Fish-bone analysis and pareto charts identified root causes; key drivers and interventions were developed. Interventions included (1) documentation templates, (2) a brochure about services, (3) extra team communication skills training, (4) repository in different languages to help patients identify needs, and (5) weekly review meetings. Reliability and sustainability were ensured through ownership and delegation to team members. RESULTS: Documentation of needs increased from baseline 25% to 75% within 3 months. This has been sustained at 83% in August 2023. The total number of patients assessed during the project was 1818. Maximum percentage of documentation was 91%. Mean additional time taken to ask and document needs was 2 min. CONCLUSIONS: Identification and documentation of patient needs and prioritisation are feasible in palliative medicine outpatient clinics. This project has directed the team to provide patient-led palliative care interventions.

Erasmus syndrome: role of specialist palliative care.

Occupational exposure to silica has been seldom implicated to cause systemic sclerosis. Erasmus syndrome is a rare condition where there is development of systemic sclerosis following silicosis. Early diagnosis is essential for appropriate treatment and symptom control. We describe a 42-year-old stone cutter with silicosis who was subsequently diagnosed to have diffuse pattern of systemic sclerosis. A multidisciplinary team including pulmonologists, specialist palliative care physicians, rheumatologists and radiologists were involved in diagnosis and management. Timely diagnosis and a multidisciplinary team management with pharmacological and non-pharmacological measures was essential in holistic care provision. This is the first report of specialist palliative care team facilitating diagnosis of this rare syndrome and promoting integration in the overall care and management.

Palliative care delivery in India during COVID-19 pandemic: role of faith-based hospitals - a qualitative study.

OBJECTIVES: The COVID-19 pandemic challenged palliative care (PC) services globally. We studied the ways healthcare professionals (HCPs) working in faith-based hospitals (FBHs) experienced and adapted care through the pandemic, and how this impacted patients with PC needs. METHODS: In-depth interviews were conducted with HCPs from FBHs serving rural and urban population across India. Thematic analysis was conducted. RESULTS: A total of 10 in-depth interviews were conducted during the COVID-19 pandemic, first wave (4), second wave (4) and between them (2). HCPs described fear and stigma in the community early in the pandemic. Migrant workers struggled, many local health services closed and cancer care was severely affected. Access and availability of healthcare services was better during the second wave. During both waves, FBHs provided care for non-COVID patients, earning community appreciation. For HCPs, the first wave entailed preparation and training; the second wave was frightening with scarcity of hospital beds, oxygen and many deaths. Eight of the 10 FBHs provided COVID-19 care. PC teams adapted services providing teleconsultations, triaging home visits, delivering medications, food at home, doing online teaching for adolescents, raising funds. Strengths of FBHs were dedicated teamwork, staff care, quick response and adaptations to community needs, building on established community relationship. CONCLUSION: FBHs remained open and continued providing consistent, good quality, person-centred care during the pandemic. Challenges were overcome innovatively using novel approaches, often achieving good outcomes despite limited resources. By defining and redefining quality using a PC lens, FBHs strengthened patient care services.

Osimertinib-induced radiation recall pneumonitis.

Radiation recall pneumonitis (RRP) is a type of radiation induced lung injury that develops in a previously irradiated lung field and is triggered by administration of chemotherapeutic or immunomodulating agents. To our knowledge there is only one report of Osimertinib induced RRP. The predominant symptoms include dyspnea and cough which usually resolve after stopping the inciting agent and with glucocorticoids. We describe a 52-year-old lady with lung cancer who developed Osimertinib induced RRP. She had significant dyspnoea and cough despite stopping Osimertinib and treatment with corticosteroids. She was referred to specialist palliative care team for alleviation of symptoms. Her symptoms responded well with non-pharmacological measures and pharmacological agents including opioids and mirtazapine. This is the first report on the effect of supportive care interventions on symptom relief in Osimertinib induced RRP.

Paramedics and serious illness: communication training.

OBJECTIVES: The need to empower Ambulance Service staff at the point of delivery of end of life care (EoLC) is crucial. We describe the delivery, outcomes and potential impact of the Serious Illness Conversation project delivered to Welsh Ambulance Service Trust (WAST) staff. Over an 18-month period, 368 WAST staff attended face-to-face teaching, which included serious illness conversation communication skills, symptom control and 'shared decision making'. METHOD: Data collected from WAST staff were used to gain insight on perception of their role and challenges within the context of EoLC, understand the impact of teaching on self-confidence and identify impact on the wider service. A mixed methods approach was used for data analysis. RESULTS: WAST staff view themselves in several important roles, acting as 'facilitators' to patient-centred, seamless care, providing support, liaison between services and practical help in patient care at the end of life. The difficult questions and situations pertaining to EoLC were related to discussions on death and dying and managing expectation. The predominant barriers identified related to communication. Quantitative outcomes on the six communication domains indicate statistically significant improvement in self-assessed confidence. The overall impact to the wider ambulance service suggests a trend towards better use of resources. CONCLUSION: The perceived roles and challenges identified by paramedics can help in customising training objectives. The initial outcomes from the ongoing project with WAST demonstrate increased confidence in handling communication issues. Initial successive surveys suggest teaching is making a real life impact on patient care at end of life.

'COVID-19 and palliative medicine: faith-based hospitals in India'.

OBJECTIVES: Faith-based organisations (FBOs) in India provide health services particularly to marginalised communities. We studied their preparedness and delivery of palliative care during COVID-19 as part of a mixed-method study. We present the results of an online questionnaire. METHODS: All FBOs providing palliative care in India were invited to complete an online questionnaire. Descriptive analysis was undertaken. RESULTS: Response rate was 46/64 (72%); 44 provided palliative care; 30/44 (68%) were in rural or semiurban areas with 10-2700 beds. Fifty-two per cent (23/44) had dedicated palliative care teams and 30/44 (68%) provided it as part of general services; 17/44 (39%) provided both. 29/44 (66%) provided palliative care for cancer patients; 17/44 (34%) reported that this was more than half their workload.The pandemic led to reduced clinical work: hospital 36/44 (82%) and community 40/44 (91%); with reduction in hospital income for 41/44 (93%). 18/44 (44%) were designated government COVID-19 centres; 11/40 (32%) had admitted between 1 and 2230 COVID-19 patients.COVID-19 brought challenges: 14/44 (32%) lacked personal protective equipment; 21/44 (48%) had reduced hospital supplies and 19/44 (43%) lacked key medications including morphine. 29/44 (66%) reported reduction in palliative care work; 7/44 (16%) had stopped altogether. Twenty-three per cent (10/44) reported redeployment of palliative care teams to other work. For those providing, palliative care 32/37 (86%) was principally for non-COVID patients; 13/37 (35%) cared for COVID-19 patients. Service adaptations included: teleconsultation, triaged home visits, medication delivery at home and food supply. CONCLUSIONS: FBOs in India providing palliative care had continued to do so despite multiple challenges. Services were adapted to enable ongoing patient care. Further research is exploring the effects of COVID-19 in greater depth.