Care of older people and people requiring palliative care with COVID-19: guidance from the Australian National COVID-19 Clinical Evidence Taskforce.

INTRODUCTION: Older people living with frailty and/or cognitive impairment who have coronavirus disease 2019 (COVID-19) experience higher rates of critical illness. There are also people who become critically ill with COVID-19 for whom a decision is made to take a palliative approach to their care. The need for clinical guidance in these two populations resulted in the formation of the Care of Older People and Palliative Care Panel of the National COVID-19 Clinical Evidence Taskforce in June 2020. This specialist panel consists of nursing, medical, pharmacy and allied health experts in geriatrics and palliative care from across Australia. MAIN RECOMMENDATIONS: The panel was tasked with developing two clinical flow charts for the management of people with COVID-19 who are i) older and living with frailty and/or cognitive impairment, and ii) receiving palliative care for COVID-19 or other underlying illnesses. The flow charts focus on goals of care, communication, medication management, escalation of care, active disease-directed care, and managing symptoms such as delirium, anxiety, agitation, breathlessness or cough. The Taskforce also developed living guideline recommendations for the care of adults with COVID-19, including a commentary to discuss special considerations when caring for older people and those requiring palliative care. CHANGES IN MANAGEMENT AS RESULT OF THE GUIDELINE: The practice points in the flow charts emphasise quality clinical care, with a focus on addressing the most important challenges when caring for older individuals and people with COVID-19 requiring palliative care. The adult recommendations contain additional considerations for the care of older people and those requiring palliative care.

Using aggregated single patient (N-of-1) trials to determine the effectiveness of psychostimulants to reduce fatigue in advanced cancer patients: a rationale and protocol.

BACKGROUND: It is estimated that 29% of deaths in Australia are caused by malignant disease each year and can be expected to increase with population ageing. In advanced cancer, the prevalence of fatigue is high at 70-90%, and can be related to the disease and/or the treatment. The negative impact of fatigue on function (physical, mental, social and spiritual) and quality of life is substantial for many palliative patients as well as their families/carers. METHOD/DESIGN: This paper describes the design of single patient trials (n-of-1 s or SPTs) of a psychostimulant, methylphenidate hydrochloride (MPH) (5 mg bd), compared to placebo as a treatment for fatigue, with a population estimate of the benefit by the aggregation of multiple SPTs. Forty patients who have advanced cancer will be enrolled through specialist palliative care services in Australia. Patients will complete up to 3 cycles of treatment. Each cycle is 6 days long and has 3 days treatment and 3 days placebo. The order of treatment and placebo is randomly allocated for each cycle. The primary outcome is a reduction in fatigue severity as measured by the Functional Assessment of Cancer Therapy-fatigue subscale (FACIT-F). Secondary outcomes include adverse events, quality of life, additional fatigue assessments, depression and Australian Karnovsky Performance Scale. DISCUSSION: This study will provide high-level evidence using a novel methodological approach about the effectiveness of psychostimulants for cancer-related fatigue. If effective, the findings will guide clinical practice in reducing this prevalent condition to improve function and quality of life. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12609000794202.

An Open-Label Pilot Study Testing the Feasibility of Assessing Total Symptom Burden in Trials of Cannabinoid Medications in Palliative Care.

Background: There is considerable interest in the use of cannabinoids for symptom control in palliative care, but there is little high-quality evidence to guide clinical practice. Objectives: Assess the feasibility of using global symptom burden measures to assess response to medicinal cannabis, to determine median tolerated doses of cannabidiol (CBD) and tetrahydrocannabinol (THC), and to document adverse events (AEs). Design: Prospective two-arm open-label pilot trial of escalating doses of CBD and THC oil. Setting/Subjects: Participants had advanced cancer and cancer-related symptoms in a palliative and supportive care service in an Australian cancer center. Measurements: The main outcome measures were the number of participants screened and randomized over the time frame, the number of participants completing days 14 and 28 and providing total symptom distress scores (TSDSs) (measured using the Edmonton Symptom Assessment Scale), and the change from baseline of the TSDS at day 14. Results: Of the 21 participants enrolled (CBD, n = 16; THC, n = 5), 18 (86%) completed the primary outcome measure at day 14 and 8 completed at day 28. The median maximum tolerated doses were CBD, 300 mg/day (range 100-600 mg); THC, 10 mg/day (range 5-30 mg). Nine of 21 patients (43%) met the definition of response (≥6 point reduction in TSDS). Drowsiness was the most common AE. Conclusions: Trials of medicinal cannabis in advanced cancer patients undergoing palliative care are feasible. The doses of THC and CBD used in this study were generally well tolerated and the outcome measure of total symptom distress is promising as a measure of overall symptom benefit. Trial registration: ACTRN12618001205224.

What are the essential medications in pallative care? - a survey of Australian palliative care doctors.

BACKGROUND: There is a disparity of availability and cost of drugs in the community for palliative care patients through the Pharmaceutical Benefits Scheme (PBS) compared to those available to inpatients in public hospitals. METHODS: The Joint Therapeutics Committee of the Australian and New Zealand Society of Palliative Medicine, Palliative Care Australia and the Clinical Oncological Society of Australia surveyed palliative care practitioners in Australia to compile a list of drugs they considered essential. RESULTS: Drugs nominated generally had good levels of evidence for use in palliative care, although many practitioners still used some without evidence of benefit. DISCUSSION: We are now working with the Commonwealth Department of Health and Ageing to agree on a list of drugs for specific palliative care indications. As a result, the first ever section in the PBS for a specific patient population has been created. There is a need for high quality studies in palliative care to determine the best drugs to add to the list.

Survival after enrollment in an Australian palliative care program.

Palliative care services aim to achieve the best quality of life for patients by controlling pain and other physical symptoms and attending to their psychospiritual needs. There have been many studies across different countries looking at timing of referral to palliative care services. Almost universally, timing of referral to palliative care is 'late' in the course of the patients' illness. This study looked at survival of patients after enrollment in an Australian integrated palliative care service that consists of inpatient beds (hospice), community care and consultation services. We analyzed the survival of 1138 patients enrolled over a 30-month period. The mean age was 70.1 years and 55% of the patients were male. The most common cancers were lung (19.1%), colorectal (13.4%) and prostate (5.8%), with nonmalignant disease accounting for 5.6% of all patients. The median length of survival was 54 days, with 9.3% of the patients dying within 7 days and 16.96% of patients living longer than six months. Perhaps more importantly than median survival is the time spent on a palliative care program in the overall context of diagnosis till death. The median percentage of time since diagnosis spent on the program was 17%. Timing of referral should be dependent on the need for intervention for physical or psychological symptoms. This can be meaningful whether the number of days till death is small or large.

The compatibility and stability of midazolam and dexamethasone in infusion solutions.

The delivery of subcutaneous medication by continuous infusion is common in palliative medicine. Many centers combine multiple medications, but the analytical confirmation of the compatibility and stability of these combinations has rarely been performed. This study examined the compatibility and stability of midazolam and dexamethasone using high performance liquid chromatography. Nine different solutions were prepared in polypropylene syringes by combining these two drugs with 0.9% sodium chloride. When these two drugs were combined in a syringe, there was significant loss of midazolam over 48 hours, with only 60-80% of the initial concentration remaining in syringes stored at 35-39 degrees C. This study demonstrates that cloudiness of a solution is not the only predictor of drug loss and that drug loss may occur even in solutions that remain clear at time of preparation. The clinical implications of these results are that dexamethasone and midazolam should not be combined in syringe driver solutions.

Survey of bereavement support provided by Australian palliative care services.

OBJECTIVE: To determine the prevalence, staffing, methods, timing and allocation of bereavement programs in Australian palliative care services. DESIGN: Questionnaire-based postal survey. SETTING AND PARTICIPANTS: The questionnaire was mailed in January 2007 to all 324 palliative care centres identified from the Australian Palliative care national directory 2004. RESULTS: 236 of the 324 centres responded (73%), and 95% of these undertook bereavement follow-up, with similar prevalence in metropolitan and regional areas. Staff from a range of disciplines were involved in coordinating and delivering these services, with nurses taking on these roles in most regional centres. Common types of bereavement follow-up included individual sessions and visits, telephone contact, letters, anniversary cards and memorial services. Most centres (74%) approached the bereaved within 2 weeks of the death, and 83% of centres offered bereavement support to families or "significant others" of all patients who died under their care. Some form of risk assessment for complicated grief was performed by 69% of participating centres. CONCLUSION: Bereavement care is an integral part of Australian palliative care services. Given the multidisciplinary staffing demonstrated, it is important that those coordinating and delivering these programs are adequately trained and supported. There is a need for further research to guide the development of bereavement support practice.

Advances in palliative care relevant to the wider delivery of healthcare.

The availability of a variety of opioids, together with the discovery of new uses for old drugs (such as ketamine), assists individualised pain management in palliative care. Experience in palliative care provides reassurance that the effective use of opioids and sedatives does not accelerate the approach of death. In taking patient histories, recognising the spiritual component of life experience enlarges the focus of care. Interdisciplinary care brings many different insights to care situations in a prospective and cooperative way. Models of bereavement care established in palliative care units deserve wider implementation in medicine. An "experiential" model of medical student education encourages a focus on the whole experience of patients and their journey with their carers.