Methadone as an adjuvant analgesic.

Methadone as an 'adjuvant' has proven to be effective and safe to be used in conjunction with opioids. Generally, only a low dose is required to improve pain control.

Myotonic dystrophy type 1: palliative care guidelines.

Palliative care for adults with neuromuscular conditions is an emerging field. Previous guidelines regarding myotonic dystrophy and palliative care have only mentioned end-of-life care and little else. The following guidelines have been written using national experts as a description of best practice as part of the Dystrophia Myotonica National Care Guidelines Consortium.

Will the unusual become usual? A new legal change that aims to increase discussions around organ and tissue donation in England.

UK guidelines recommend that discussions about organ and tissue donation are conducted as part of end-of-life care. However, there are several barriers to discussing organ donation, and this is reflected in a critical shortage of donors. This article explores who should start the conversation about donation and how all healthcare practitioners can maximise their communication skills to have success in this area. It is particularly pertinent to be upskilled in this area in light of the recent legal change in England, where the system moved from an opt-in to a 'soft' opt-out one. Based on a similar legal change that took place in Wales and global data, it is unlikely that the legal change alone will prompt an increase in donation rates in England. This article proposes suggestions to increase awareness and conversations among healthcare professionals and patients with education, public health campaigns and interventions rooted in psychological theory.

Potential impact of eradicating malaria on gender inequality within agricultural households in sub-Saharan Africa.

The international development community has shown an increased interest in the links between malaria and gender inequality over the past two decades. Working towards the ambitious goal of eradicating malaria by 2040, suppressing the malaria burden could accelerate progress in reducing gender inequality within agricultural households in sub-Saharan Africa. Although numerous studies have examined narrow aspects of the relationship between malaria and gender inequality, little progress has been made in understanding how eliminating malaria could affect gender inequality within agricultural households. This Open Letter focuses on the amount of time women farmers dedicate to caregiving for malaria cases among children in agricultural households, and how reducing time spent on this activity could reduce gender inequalities and impact agricultural productivity. We argue that a research agenda is needed to inform a multi-disciplinary approach to gain this understanding. We conclude by discussing the means through which a reduction in gender inequalities in agricultural households could impact the effectiveness of vector control interventions.

Clozapine toxicity: a cautionary palliative care tale.

OBJECTIVE: This case report presents an unusual case of clozapine toxicity secondary to reduced smoking habit mimicking a patient approaching end of life. METHODS: It is a cautionary tale for palliative care specialists, perhaps unaware of the effect of cigarette smoke on metabolism of this antipsychotic, to be aware of. RESULTS: Following specialist advice and change of antipsychotic medication, this patient's condition improved to the point that he was discharged from the hospice. CONCLUSION: Palliative care specialists should be aware that reducing cigarette consumption can alter metabolism of clozapine, potentially causing drug accumulation and toxicity with features which mimic deterioration towards end of life. Specialist advice should be sought in such a situation.

Palliative opioid use, palliative sedation and euthanasia: reaffirming the distinction.

We read with interest the extended essay published from Riisfeldt and are encouraged by an empirical ethics article which attempts to ground theory and its claims in the real world. However, such attempts also have real-world consequences. We are concerned to read the paper's conclusion that clinical evidence weakens the distinction between euthanasia and normal palliative care prescribing. This is important. Globally, the most significant barrier to adequate symptom control in people with life-limiting illness is poor access to opioid analgesia. Opiophobia makes clinicians reluctant to prescribe and their patients reluctant to take opioids that might provide significant improvements in quality of life. We argue that the evidence base for the safety of opioid prescribing is broader than that presented, restricting the search to palliative care literature produces significant bias as safety experience and literature for opioids and sedatives exists in many fields. This is not acknowledged in the synthesis presented. By considering additional evidence, we reject the need for agnosticism and reaffirm that palliative opioid prescribing is safe. Second, palliative sedation in a clinical context is a poorly defined concept covering multiple interventions and treatment intentions. We detail these and show that continuous deep palliative sedation (CDPS) is a specific practice that remains controversial globally and is not considered routine practice. Rejecting agnosticism towards opioids and excluding CDPS from the definition of routine care allows the rejection of Riisfeldt's headline conclusion. On these grounds, we reaffirm the important distinction between palliative care prescribing and euthanasia in practice.

Response to: the adult multidisciplinary respiratory neuromuscular clinic.

A new "traffic light" system is recommended to identify adult NMD patients who would benefit from advance care planning and possible referral to palliative care services https://bit.ly/3mVDY0P.

Death rattle: reassuring harbinger of imminent death or a perfect example of inadequacies in evidence-based practice.

PURPOSE OF REVIEW: Death is the inevitable consequence of life. Although clinicians are unlikely to accurately pinpoint when death is likely to occur in the people they care for, the death in a person with a diagnosis of malignant and nonmalignant tends to involve a period of predictable progressive clinical and functional deterioration. During this time, it is common for death rattle to occur. Due to its presentation, death rattle can cause stress and distress to caregivers. This often prompts clinicians to consider medical interventions that are not only ineffective in treating the problem but may also do harm. RECENT FINDINGS: There is a dearth of research related to the management of death rattle. SUMMARY: The article discusses the existing evidence in the management of death rattle, considerations for clinicians in the absence of reliable evidence and suggests areas for future research.

Tracey judgement and hospice DNACPR orders: steady as she goes or seismic change?

OBJECTIVES: The 2014 Court of Appeals decision with respect to Tracey vs Cambridge University Hospital ('the Tracey judgement') changed the requirements for discussing Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions with patients. This study is a retrospective case note review aiming to identify any changes in practice around discussing DNACPR decisions in hospices following the judgement. METHODS: 150 case notes from 2013 (before the Tracey judgement) were compared with 150 case notes from 2015 (following the Tracey judgement). These notes came from five hospices in the West Midlands. The notes were analysed to determine if the judgement resulted in changes to how frequently DNACPR decisions were discussed with patients and their families, as well as whether there were any changes in the documentation of reasons for not discussing such decisions. RESULTS: Discussions with patients around DNACPR decisions increased from 31% to 60% and with relatives from 29% to 59% following the Tracey judgement. Prior to the judgement the most frequently documented reason for not discussing was to avoid distress (23%), whereas after judgement it was patients lacking capacity to engage in such a discussion (40%). There was a lack of consistency and clarity in defining the concept of 'physical or psychological harm'. CONCLUSIONS: Although DNACPR decisions are being discussed more frequently with patients and families following the Tracey judgement, clarity on what constitutes 'physical or psychological harm' caused by these discussions is still required. Future research must examine whether the judgement is delaying or preventing DNACPR decisions being made.

Conscientious objection and physician-assisted suicide: a viable option in the UK?

Conscience objection is a proposed way of ensuring that medical practitioners who object to physician-assisted suicide may avoid having to be involved in such a procedure if this is legalised. This right on the part of healthcare professionals already exists in certain circumstances. This paper examines the ethical and legal grounds for conscientious objection for medical professionals and shows how it is heavily criticised in circumstances where it is already used. The paper comes to the conclusion that as the grounds and application of conscience objection are no longer as widely accepted, its future application in any legislation can be called into question.

Community palliative medicine out-of-hours needs and the 7-day week: a service evaluation.

BACKGROUND: Evidence regarding out-of-hours (OOH) community palliative care provision is required to inform the need for a 7-day work. AIM: This paper seeks to provide evidence for this discussion by defining general practitioners' (GPs) OOH workload and patients' demographics, symptomology and interventions. By quantifying the challenges faced, we can understand current practice and focus on what provision is required. DESIGN: Using Shropshire Doctors Co-operative's recorded data, the authors have collated a representative picture of the OOH GP palliative care practice over a year from 161 OOH GP-patient interactions. SETTING: Primary care. RESULTS: Palliative care makes up 11.4% of the total OOH GP home visits (HV). Overall 56% of OOH GP HVs are for patients who are expected to die within 48 hours, with 80% of the symptoms being agitation, secretions and pain. Overall 5.7% of OOH GP palliative HVs resulted in hospital admission; however, this decreased to 0.6% adjusting for the last 48-hour prognosis. CONCLUSION: OOH Shropshire GPs deal with a wide variety of scenarios in a heterogeneous population. The greatest demand is from 17:00 to 00:00 (65% of the total shift) on weekdays, and from 09:00 to 00:00 on weekends (82% of the shift). These data begin to quantify the role being performed by OOH GPs, have implications for service provision and support 7-day work.

Eliminating malaria by 2040 among agricultural households in Africa: potential impact on health, labor productivity, education and gender equality.

Background: Ambitious goals have been set to eradicate malaria by the year 2040. Given the high poverty levels and the intense levels of malaria transmission in sub-Saharan Africa, suppressing malaria in rural agricultural communities in these regions will be one of the greatest challenges to achieving malaria eradication. This study has two objectives. The first is to estimate how eradicating malaria by 2040 would affect agricultural households in sub-Saharan Africa. The second is to identify where additional research is needed to develop better estimates of how eradicating malaria by 2040 would affect those households. Methods: Using agricultural census data and malaria morbidity data, we developed estimates of the number of malaria cases in 2018 among agricultural households with fewer than 10 hectares of land for 35 countries in sub-Saharan Africa. By combining these estimates with additional evidence from the literature, we analyzed how achieving malaria eradication by 2040 would affect indicators related to four Sustainable Development Goals: health, poverty, education and gender equality. Results: Our analysis found that achieving malaria eradication by 2040 would prevent approximately 841 million cases of malaria and thereby decrease the number of lost workdays among agricultural households by approximately 3.2 billion days. Eradicating malaria by 2040 would also increase the number of school days attended by children by 1.5 billion days while also reducing the number of caregiving days provided by women for malaria cases by approximately 1.1 billion days. Conclusions: This article analyzes the impact of eradicating malaria among agricultural households in sub-Saharan Africa using indicators related to four of the Sustainable Development Goals. Enhanced data collection efforts related to these four indicators would facilitate more rigorous estimates of how eradicating malaria would affect these indicators over the next two decades.