The framework for CPST will provide a basis for the development of safe, effective, and ethical use of CPST for patients in palliative care and at the end of life.

The use of sedation and the management of delirium and other difficult symptoms in terminally ill patients in Edmonton has been reported previously. The focus of this study was to assess the prevalence in the Edmonton region of difficult symptoms requiring sedation at the end of life. Data were collected for 50 consecutive patients at each of (a) the tertiary palliative care unit, (b) the consulting palliative care program at the Royal Alexandra Hospital (acute care), and (c) three hospice inpatient units in the city. Patients on the tertiary palliative care unit were significantly younger. Assessments confirmed the more problematic physical and psychosocial issues of patients in the tertiary palliative care unit. These patients had more difficult pain syndromes and required significantly higher doses of daily opioids. Approximately 80% of patients in all three settings developed delirium prior to death. Pharmacological management of this problem was needed by 40% in the acute care setting, and by 80% in the tertiary palliative care unit. The patients sedated varied from 4% in the hospice setting to 10% in the tertiary palliative care unit. Of the 150 patients, nine were sedated for delirium, one for dyspnea. The prevalence of delirium and other symptoms requiring sedation in our area is relatively low compared to others reported in the literature. Demographic variability between the three Edmonton settings highlights the need for caution in comparing results of different palliative care groups. It is possible that some variability in the use of sedation internationally is due to cultural differences. The infrequent deliberate use of sedation in Edmonton suggests that improved management has resulted in fewer distressing symptoms at the end of life. This is of benefit to patients and to family members who are with them during this time.

Patient care frequently focuses on physical aspects of disease management, with variable attention given to spiritual needs. And yet, patients indicate that spiritual suffering adds to distress associated with illness. Spirituality, broadly defined as that which gives meaning and purpose to a person's life and connectedness to the significant or sacred, often becomes a central issue for patients. Growing evidence demonstrates that spirituality is important in patient care. Yet healthcare professionals (HCPs) do not always feel prepared to engage with patients about spiritual issues. In this project, HCPs attended an educational session focused on using the FICA Spiritual History Tool to integrate spirituality into patient care. Later, they incorporated the tool when caring for patients participating in the study. This research (1) explored the value of including spiritual history taking in clinical practice; (2) identified facilitators and barriers to incorporating spirituality into person-centred care; and (3) determined ways in which HCPs can effectively utilize spiritual history taking. Data were collected using focus groups and chart reviews. Findings indicate positive impacts at organizational, clinical/unit, professional/personal and patient levels when HCPs include spirituality in patient care. Recommendations are offered.

The purpose of this study was to examine the frequency and types of antibiotics prescribed in the last week of life in three different palliative care settings, including an acute care hospital, tertiary palliative care unit, and three hospice units. A total of 150 consecutive patients were evaluated, 50 in each of the three settings. Twenty-nine patients (58%) in the acute hospital setting, 26 (52%) in the tertiary palliative care unit, and 11(22%) in the hospice settings were prescribed antibiotics. In the acute care and tertiary palliative care settings, the most frequent route of antibiotic administration was intravenous and, in the hospice setting, oral. We conclude that there is marked variability in the numbers and types of antibiotics prescribed in these different palliative care settings in the last week of life. The high use of intravenous antibiotics and the large number of patients who were still receiving antibiotics at the time of death indicate the need for further prospective studies.

Inadequate physician knowledge, particularly in areas of pain assessment and use of analgesics, has been identified as a major factor contributing to poor pain management in cancer patients. In most medical schools, teaching in Palliative Care at both the undergraduate and postgraduate levels is limited or nonexistent. Baseline knowledge and changes in knowledge in areas relevant to Palliative Care were assessed by the use of 2 16-question examinations (Exams A and B) in 78 second-year Family Medicine Residents from the University of Alberta Family Medicine Residency Program. The residents participated in a two-week rotation on the Acute Palliative Care Unit at the Edmonton General Hospital or Grey Nuns Community Health Centre between September 1991 and February 1996. The residents were randomly assigned on their first day (Time 1) to complete either Exam A or B and were subsequently crossed over on their final day of the rotation to complete the alternate Exam (Time 2). Six domains were represented in the Exams as follows: pain assessment, opioid use, adjuvant medications, delirium, urinary catheterization, and hydration. Improvements were noted in the mean percentage results in Time 2 compared with Time 1 for Exams A, B, and A and B combined. Mean global percentage results were 53 +/- 15 versus 73 +/- 13 (p < 0.001) at Times 1 and 2, respectively. There were significant improvements for domains in Time 2 compared to Time 1 (p < or = 0.05) for combined A and B Exam except for urinary catheterization. Despite these documented improvements in scores, serious deficiencies were identified particularly in the areas of pain assessment and opioid use, namely opioid sude effects and issues involving dependence, addiction, and tolerance. Examinations, such as the two used in this study, can be a useful aid in assessing physician knowledge in addition to structuring teaching in Palliative Care. Examination content will require updating as knowledge in Palliative Care evolves.

Complementary medications appear to be gaining popularity among cancer patients. When we surveyed 143 advanced cancer patients attending an outpatient pain and symptom clinic at a regional cancer centre as to their use of complementary medications and nutritional supplements, we found 37% (53/143) to be making use of complementary medications. Users tended to be younger (mean age 53.3 years) and have a preference for purchase from health stores, with 61% of complementary medications being bought there. Health store staff were the primary recommenders for both men and women and especially for those over 60 years of age. Of the 197 complementary medications purchased, 78 (39.6%) were herbs, 67 (32.5%) were vitamins, 13 (6.6%) were minerals, 21 (10.7%) were other medications including shark cartilage, and 21 (10.7%) could not be identified. Both anticancer effect and the promotion of well-being were prominent among the stated reasons for using these medications.

Constipation is a highly prevalent and distressing symptom in patients with advanced, progressive illnesses. Although opioids are one of the most common causes of constipation in patients with advanced, progressive illness, it is important to note that there are many other potential etiologies and combinations of causes that should be taken into consideration when making treatment decisions. Management approaches involve a combination of good assessment techniques, preventive regimens, appropriate pharmacological treatment of established constipation, and frequent monitoring. In this vulnerable patient population, maintenance of comfort and respect for individual preferences and sensitivities should be overriding considerations when making clinical decisions. This consensus document was developed by a multidisciplinary group of leading Canadian palliative care specialists in an effort to define best practices in palliative constipation management that will be relevant and useful to health care professionals. Although a wide range of options exists to help treat constipation and prevent its development or recurrence, there is a limited body of evidence evaluating pharmacological interventions. These recommendations are, therefore, based on the best of the available evidence, combined with expert opinion derived from experience in clinical practice. This underscores the need for further clinical evaluation of the available agents to create a robust, evidence-based foundation for treatment decisions in the management of constipation in patients with advanced, progressive illness.

Major Depressive Disorder (MDD) is prevalent in patients with advanced cancer, and can have a negative impact on patients' quality of life. Available antidepressants, often have delayed benefits of several weeks, and therefore are of limited utility in the palliative care setting. Psychostimulants provide more rapid onset of action, but frequently require dose escalation because of problems with tolerance. There is a growing body of evidence that N-methyl-D-aspartate (NMDA) receptor antagonists, such as ketamine, signficantly and rapidly improve depressive symptoms in treatment resistant depression. However, studies conducted to date have not included advanced cancer patients. We report on a case where intravenous ketamine 'bursts' (0.5 mg/kg infused over 60 minutes) were used to treat an intractable MDD in a patient with metastatic prostate cancer. Initial positive response was not sustained, and response to a repeat treatment was even more transient. Adverse effects were mild and self-limiting. We conclude that a well-designed, randomized study of IV ketamine "bursts" in cancer patients suffering from depression is needed to further establish the role and appropriate dosing of ketamine in this patient population. Given that ketamine can be used as an adjuvant for difficult pain syndromes in cancer patients, it would be of interest to assess its impact on the mood in patients receiving this treatment for pain.