Speaking up at conference question and answer sessions-disruptive behaviour typography and assessment scale.

Conferences can be a space to present new research, network, and provide an opportunity for learning. Delegates can meet field leaders, peers, top doctors, and international colleagues in various areas of expertise. Challenging behaviours, in particular in the question and answer session, but also during lectures themselves, may reduce overall enjoyment and learning. The authors of this article have written an observational reflection on some observed behaviours and have come up with a 10-point assessment scale. The article aims to stimulate discussion on what constitutes disruptive conduct, but also serves as a guide for conference session chair-people and delegates to spot patterns of contribution that may be unwelcome.

COVID-19 and Hospital Palliative Care - A service evaluation exploring the symptoms and outcomes of 186 patients and the impact of the pandemic on specialist Hospital Palliative Care.

BACKGROUND: Patients hospitalised with COVID-19 have increased morbidity and mortality, which requires extensive involvement of specialist Hospital Palliative Care Teams. Evaluating the response to the surge in demand for effective symptom management can enhance provision of Palliative Care in this patient population. AIM: To characterise the symptom profile, symptom management requirements and outcomes of hospitalised COVID-19 positive patients referred for Palliative Care, and to contextualise Palliative Care demands from COVID-19 against a 'typical' caseload from 2019. DESIGN: Service evaluation based on a retrospective cohort review of patient records. SETTING/PARTICIPANTS: One large health board in Scotland. Demographic data, patient symptoms, drugs/doses for symptom control, and patient outcomes were captured for all COVID-19 positive patients referred to Hospital Palliative Care Teams between 30th March and 26th April 2020. RESULTS: Our COVID-19 cohort included 186 patients (46% of all referrals). Dyspnoea and agitation were the most prevalent symptoms (median 2 symptoms per patient). 75% of patients were prescribed continuous subcutaneous infusion for symptom control, which was effective in 78.6% of patients. Compared to a 'typical' caseload, the COVID-19 cohort were on caseload for less time (median 2 vs 5 days; p < 0.001) and had a higher death rate (80.6% vs 30.3%; p < 0.001). The COVID-19 cohort replaced 'typical' caseload; overall numbers of referrals were not increased. CONCLUSIONS: Hospitalised COVID-19 positive patients referred for Palliative Care may have a short prognosis, differ from 'typical' caseload, and predominantly suffer from dyspnoea and agitation. Such symptoms can be effectively controlled with standard doses of opioids and benzodiazepines.

What makes for a 'Top Doc'? An analysis of UK press portrayals of so-called top doctors.

OBJECTIVE: To determine the characteristics of medical practitioners designated 'top doctor' or 'Top Doc' in the UK press. DESIGN: Observational study of news stories related to the term top doctor (or Top Doc) with analysis using data from publicly available databases. SETTING: News reports in the UK press accessed via a database from national newspapers from 1 January 2019 to 31 December 2019, prior to the COVID-19 pandemic. Stories relating to disciplinary/criminal matters were analysed separately. MAIN OUTCOME MEASURES: Results were cross-referenced with the General Medical Council register of medical practitioners for gender, year of qualification, whether on the general practitioner (GP) or the specialist register, and if on the specialist register, which specialty. RESULTS: There was a gender divide, with 80% of so-called top doctors being male. National top doctors had been qualified for a median time of 31 years. Top doctors are widely spread among specialties; 21% of top doctors were on the GP register. Officers of the British Medical Association and the various Royal Colleges are also well represented. 'Top doctors' facing disciplinary proceedings are more overwhelmingly male, working in hospital specialties and less obviously eminent in their field. CONCLUSION: There is no clear definition of a 'top doctor', nor are there objective leadership criteria for journalists to use when applying this label. Establishing a definition of 'top doctor', for instance, via the UK Faculty for Medical Leadership and Management, which offers postnominals and accreditation for high-achieving medical professionals, may reduce subjectivity.

Hospital Specialist Palliative Care Team Influence on End-of-Life Care in Coronavirus Disease 2019? A Retrospective Observational Cohort Study.

Objectives: The coronavirus 19 disease (COVID-19) pandemic has led to a renewed focus on end-of-life care. The majority of COVID-19 deaths occur in hospital, with patients cared for by generalists and hospital specialist palliative care teams (HSPCTs). This project aims at exploring the potential influences of HSPCTs on end-of-life care in COVID-19. Methods: A retrospective observational study was carried out by exploring four end-of-life care themes in a Scottish hospital population who died from COVID-19. Comparison was made between cohorts seen by HSPCTs versus generalist clinicians. Results: Analysis of 119 patients across NHS Greater Glasgow and Clyde (NHSGGC) health board demonstrated that COVID-19 patients seen by HSPCTs were more likely to be younger (median 77 vs. 81 years; p = 0.02), have a cancer diagnosis (21.7% vs. 5.4%; p = 0.01), die sooner after admission (median four vs. six days; p < 0.01), and be commenced on a syringe driver (89.1% vs. 42.5%; p < 0.01). Differences detected across four end-of-life care themes comparing HSPCTs with generalist teams were minimal with documentation and prescribing in keeping with available guidance. Conclusion: Consistencies in end-of-life care observed across NHSGGC cohorts draw attention to the potential wider impact of HSPCT roles, including education, guideline development, and mentoring. Understanding such diverse effects is important to support funding and development of HSPCTs. Further research is required to better quantify the impact and heterogenous influences of HSPCTs in general.

Symptom burden and clinical profile of COVID-19 deaths: a rapid systematic review and evidence summary.

The spread of pandemic COVID-19 has created unprecedented need for information. The pandemic is the cause of significant mortality and with this the need for rapidly disseminated information for palliative care professionals regarding the prevalence of symptoms, their intensity, their resistance or susceptibility to symptom control and the mode of death for patients. METHODS: We undertook a systematic review of published evidence for symptoms in patients with COVID-19 (with a specific emphasis on symptoms at end of life) and on modes of death. Inclusion: prospective or retrospective studies detailing symptom presence and/or cause or mode of death from COVID-19. RESULTS: 12 papers met the inclusion criteria and gave details of symptom burden: four of these specifically in the dying and two detailed the cause or mode of death. Cough, breathlessness, fatigue and myalgia are significant symptoms in people hospitalised with COVID-19. Dyspnoea is the most significant symptom in the dying. The mode of death was described in two papers and is predominantly through respiratory or heart failure. CONCLUSIONS: There remains a dearth of information regarding symptom burden and mode of death to inform decisions regarding end-of-life care in patients dying with COVID-19. Rapid data gathering on the mode of death and the profile of symptoms in the dying and their prevalence and severity in areas where COVID-19 is prevalent will provide important intelligence for clinicians. This should be done urgently, within ethical norms and the practicalities of a public health, clinical and logistical emergency.

Unsuitable for the intensive care unit: what happens next?

CONTEXT: In recent years numbers of referrals to intensive care units (ICU) throughout the United Kingdom has been increasing. A number of referrals to the ICU are considered to be inappropriate for a variety of reasons, including those patients who are felt to be either too well for admission, or have comorbidities making survival unlikely and aggressive interventions unsuitable. OBJECTIVES: This study aims to examine the outcomes and symptoms in those patients who are unsuitable for admission to ICU. By looking at this population we hope to ascertain if this is an at-risk group in terms of symptomatic or care needs at the end of life. METHODS: This was as an observational prospective study with the sample population identified via the ICU referrals process. All patients referred to the ICU for admission but deemed unsuitable were recorded and followed up by researchers on the wards. RESULTS: Fifty patients were identified between January and April 2009. Outcomes at one week were split between "death" (34%), "discharge" (24%), and ongoing illness/rehabilitation (40%). Levels of comorbidity were high, with a corresponding prevalence of severe breathlessness in all outcome groups. CONCLUSION: The results suggest there are small numbers of patients with uncontrolled symptoms who could benefit from specialist input from the palliative care team. The identification of the imminently dying should facilitate appropriate communication of this by clinical staff and allow the relevant social, psychological, and spiritual preparations for death that are the hallmark of good care of the dying.

Propofol for terminal sedation in palliative care: a systematic review.

INTRODUCTION: We undertook a systematic review of published evidence of the effectiveness of propofol for terminal sedation. INCLUSIONS: Prospective or retrospective trials (controlled or uncontrolled) or case series of propofol for sedation in advanced incurable disease in either generalist setting or specialist palliative care units. EXCLUSIONS: Use in anesthetic or intensivist settings (e.g., intensive care units); pediatric use. Identification of relevant studies: Using the search terms: [Hospice Care/OR Terminal Care/OR Palliative Care/OR palliative.mp] AND [Propofol/]. Studies were identified using a detailed search strategy from a number of electronic databases: Embase (1988-2005); MEDLINE (1966-2005) Cinahl (1982-2005), Cancerlit (1962-2005) The Cochrane Database of Systematic Reviews 2005 Issue 4. Hand searches of a number of palliative care journals were also undertaken (Palliative Medicine, Journal of Pain and Symptom Management, Progress in Palliative Care, Journal of Palliative Care, Journal of Palliative Medicine). No restriction was placed on the language of the original article. RESULTS: Four articles--all case series or case reports--reporting generally favorable reports of the use of propofol as sedation for intractable symptoms in the last days of life especially when one or more other drugs have failed. Since these four articles are essentially hypothesis-generating, the article also discusses the possibility of the design of a clinical trial to compare propofol with other drugs used in this situation.

Delirium at the end of life.

INTRODUCTION: Delirium is common in the last weeks of life, occurring in 26% to 44% of people with advanced cancer in hospital, and in up to 88% of people with terminal illness in the last days of life. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of interventions at the end of life in people with delirium caused by underlying terminal illness? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found three systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: artificial hydration; barbiturates; benzodiazepines; haloperidol; opioid switching; phenothiazines; and propofol.

Nausea and vomiting in people with cancer and other chronic diseases.

INTRODUCTION: Nausea and vomiting occur in 40-70% of people with cancer, and are also common in other chronic conditions such as hepatitis C and inflammatory bowel disease. Nausea and vomiting become more common as disease progresses. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for nausea and vomiting occurring either as a result of the disease or its treatment, in adults with cancer? What are the effects of treatments for nausea and vomiting occurring either as a result of the disease or its treatment, in adults with chronic diseases other than cancer? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found nine systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: 5HT(3) antagonists, antihistamines, antimuscarinics, atypical antipsychotics, benzodiazepines, butyrophenones, cannabinoids, corticosteroids, haloperidol, metoclopramide, NK1 antagonists, phenothiazines, prokinetics, 5HT(3) antagonists plus corticosteroids, and venting gastrostomy.

Delirium at the end of life.

INTRODUCTION: Delirium is common in the last weeks of life, occurring in 26-44% of people with advanced cancer in hospital, and in up to 88% of people with terminal illness in the last days of life. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of interventions at the end of life in people with delirium caused by underlying terminal illness? We searched: Medline, Embase, The Cochrane Library and other important databases up to February 2006 (BMJ Clinical evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found three systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: artificial hydration, barbiturates, benzodiazepines, haloperidol, opioid switching, phenothiazines, and propofol.

The evidence base of palliative medicine: is inpatient palliative medicine evidence-based?

BACKGROUND: In 2001, Good and Stafford published a study attempting to show that inpatient palliative medicine is evidence-based. AIM: To critically examine the papers cited in support of the claim that palliative medicine is evidence-based. METHOD: All the papers cited were re-examined by at least two reviewers. The papers were graded using a tool used in the production of 22 evidence-based national clinical guidelines over the past three years. Differences of opinion about quality were resolved by discussion or independent arbitration. RESULTS: The 41 papers cited by Good and Stafford included 25 randomized controlled trials (RCT), six other controlled studies and 10 uncontrolled studies. Sample size. Mean sample size was 160 (range 9-1404). The median sample size was 56; 19/41(46%) had <50 subjects; 30/41 (73%) had <100. Power calculations. 16/25 (64%) of RCTs, had no power calculations, making it difficult to draw conclusions about true differences between groups. Quality rating and grade of evidence: Of the RCTs 15/25 (60%) had a high risk of bias; of the other controlled studies 5/6 (83%) had a high risk of bias. Applicability. The studies were generally applicable to a population with advanced disease: 30/41 (73%) related with populations with advanced disease. CONCLUSIONS: This study demonstrates that studies cited in support of palliative medicine as an evidence-based specialty are of variable, and at times poor quality. This study seems to show that the claim that inpatient palliative medicine is evidence-based is at best tenuous and at worst misleading. Palliative Medicine 2007; 21 : 623-627.

Clinical guidelines.

Clinical guidelines are likely to be an important part of medical practice for the foreseeable future. Guidelines at their best are tools for consistency and effectiveness in patient care. Guideline methodology has evolved such that there are internationally agreed standards with which to develop and assess guidelines. Guideline development groups should ideally be multidisciplinary in composition and if possible have patient representation. Key to the process is the rigour of the systematic review in order to assess the best evidence on which to base recommendations. Guideline recommendations should be explicitly linked to the evidence. In order to safeguard trust, guideline development groups must have editorial independence of government, industry and special interest groups, while at the same time having regard to the implications of their recommendations. Implementation of guidelines by passive dissemination is largely ineffective; effective dissemination requires an imaginative approach tailored to the intended audience.