Many patients at the end of life receive care that is inappropriate or futile and, if given the opportunity to discuss their care preferences well ahead of death, may well have chosen to forgo such care. Advance care planning (ACP) is a process of making decisions about future health care for patients in consultation with clinicians, family members and important others, and to safeguard such decisions if patients were to lose decisional capacity. Although ACP has existed as an idea for decades, acceptance and operationalisation of ACP within routine practice has been slow, despite evidence of its benefits. The chief barriers have been social and personal taboos about discussing the dying process, avoidance by medical professionals of responsibility for initiating, coordinating and documenting discussions about ACP, absence of robust and standardised procedures for recording and retrieving ACP documents across multiple care settings, and legal and ethical concerns about the validity of such documents. For ACP to become part of mainstream patient-centred care, accountable clinicians working in primary care, hospitals and nursing homes must effectively educate colleagues and patients about the purpose and mechanics of ACP, mandate ACP for all eligible patients, document ACP in accessible formats that enable patient wishes to accurately guide clinical management, devise methods for reviewing ACP decisions when clinically appropriate, and evaluate congruence between expressed patient wishes and actual care received. Public awareness campaigns coupled with implementation of ACP programs sponsored by collaborations between hospital and health services, Medicare locals and residential care facilities will be needed in making system-wide ACP a reality.

Objective: To describe the natural history, treatment and cost of Ross River virus‐induced epidemic polyarthritis (RRV disease). Design: Questionnaire‐based longitudinal prospective study. Participants and setting: Patients in the greater Brisbane area, Queensland, diagnosed with RRV disease by their general practitioners based on clinical symptoms and paired serological tests between November 1997 and April 1999. Main outcome measures: Scores on two validated quality‐of‐life questionnaires (Clinical Health Assessment Questionnaire and Medical Outcomes Study Short Form 36) were obtained soon after diagnosis and one, two, three, six and 12 months thereafter. Scores were compared between patients diagnosed with RRV disease alone and those with RRV disease plus other conditions. Results: 67 patients were enrolled. Most patients with RRV disease alone had severe acute symptoms, but followed a consistent path to recovery within three to six months. Other conditions, often chronic rheumatic diseases or depression, were identified in half the cohort; their quality‐of‐life scores suggested stable chronic illness between six and 12 months after diagnosis. Non‐steroidal anti‐inflammatory drugs (NSAIDs) were taken by 58% of patients (average use, 7.6 weeks; range, 2–22 weeks). Time off work averaged 1.9 days, and direct cost to the community was estimated as $A1018 per patient. Conclusions: Symptom duration and frequency of long‐term symptoms may have been overestimated by previous studies of RRV disease. Disease persisting six to 12 months after RRV diagnosis was largely attributable to other conditions, highlighting the need to seek other diagnoses in RRV patients with persistent symptoms.

Objective The aim of the present study was to develop, implement and explore the effects of a program in advance care planning (ACP) within a tertiary hospital general medicine service. Methods Before-after exploratory mixed-methods analysis was conducted of an ACP program comprising seven components designed to overcome well-documented barriers to ACP in clinical practice. The results of pre-ACP program audits performed in June 2014 were compared with those of post-ACP audits performed over 5 months from July to November 2014. The main outcome measure was the number of advance care plans completed in patients considered eligible for ACP based on a life expectancy of 12 months or less as assessed by two prognostication instruments. Questionnaire surveys ascertained staff perceptions of ACP and the usefulness of training and resources in ACP. Results Pre-ACP program analysis of 166 consecutive patients deemed eligible for ACP revealed that only 1% had a documented advance care plan. Following ACP implementation, 115 of 215 (53%) potentially eligible patients were considered able to participate in ACP discussions and were approached to do so before discharge, of whom 89 (77.4%) completed an advance care plan, whereas 26 (23.6%) declined. This equated to an overall completion rate for all potentially eligible patients of 41% compared to 1% pre-ACP (P<0.001). Major barriers to ACP perceived by at least 30% of questionnaire respondents included the reluctance of patients and family to discuss ACP, insufficient time to initiate or complete ACP, patient and/or family factors that rendered ACP impractical, inadequate communication skills around end-of-life issues, confusion about who was primarily responsible for conducting ACP and difficulty using ACP documentation forms. Enabling factors included dedicated ACP workshops, facilitator and resource packages for staff, and ACP brochures for patients and family. Conclusion A multifaceted ACP program in a general medicine service led to completion of an advance care plan in more than three of four patients considered eligible for, and who participated in, ACP. However, although program components were tailored to overcome known barriers to ACP, staff indicated ongoing difficulties, with less than half of ACP-eligible patients completing advance care plans. What is known about this topic? Advance care planning is increasingly recognised as an important part of hospital care for older patients with advanced chronic disease. However, research indicates that ACP discussions are rare in hospital settings because of various barriers that are not adequately addressed in the design of ACP programs. What does this paper add? The present exploratory study of the development, implementation and evaluation of an ACP program in a tertiary hospital general medicine service shows that program components designed to overcome specific barriers to ACP discussions was associated with a >75% completion rate of advance care plans among ACP-eligible patients who participated in ACP discussions. D...

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Increased communication between staff and family, in the form of a Palliative Care Case Conference, may reduce stress, anxiety and unwanted hospitalisations during the palliative phase.

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Renal impairment is common in patients with advanced illness and can complicate management when attempting to control pain. The ideal opioid to use in renal failure is one that is completely metabolized to inactive components that are not dependent on the kidneys for elimination. The drugs thought to meet these criteria to the greatest extent are the lipophilic opioids (fentanyl, alfentanil, and sufentanil) and methadone.Delivering opioids to patients on dialysis and achieving pain control poses an even greater challenge. The opioid must be suitable for patients with grossly abnormal renal function. It is also preferable if it is not removed completely during dialysis.The factors that determine whether or not a drug is filtered during dialysis are the molecular weight (MW) of the compound and its degree of protein binding, volume of distribution (VD), and solubility (WS). 1 Molecules less likely to be removed by dialysis have low MW and WS, are highly protein bound, and have a high VD. Using these criteria, one would anticipate that morphine, a drug of relatively low protein binding and moderate WS, would be removed by dialysis, whereas methadone with its high protein binding, high VD, and low MW would not be removed. Fentanyl and sufentanil are highly protein bound, with low WS and a high VD. Therefore, these drugs should not be removed during dialysis. Reports that support this premise have been published. 2 We present a case of a young man rendered anephric following surgery for bilateral ureteric transitional cell carcinoma (TCC), with

IN REPLY: Period analysis resulted in estimates of 40-year absolute and relative (absolute/population) survival curves. The Methods section of the article by Brenner and Hakulinen 1 states that the estimates are intended to reflect cumulative survival experience for newly diagnosed patients. It is not clear how this differs from "current estimates of long-term survival expectations."Patients diagnosed 40 years ago did remain at increased risk of death through the 1990s, as demonstrated by relative conditional probabilities by decade. This point does not depend on period analysis, which uses conditional probabilities from the past for projections into the future. To the extent that the past conditional probability estimates will no longer apply, we cannot rely on the accuracy of the projections in the coming decades, empirical observations from previous decades notwithstanding.The implausible assumption of a cure for death would indeed have provided a striking but irrelevant example. I sincerely hope the breast cancer cure scenario is neither implausible nor irrelevant. Stephanie GreenPfizer Inc, New London, CT Author's Disclosures of Potential Conflicts of InterestThe author indicated no potential conflicts of interest. Acetaminophen in Cancer Pain TO THE EDITOR:A nonopioid (such as paracetamol or a nonsteroidal anti-inflammatory drug) was added as an essential component of step 2 of the revised version of the WHO analgesic ladder 1 to reflect the relatively low analgesic potential of the "weak" opioids (codeine and dextropropoxyphene). This supports the use of combined preparations (eg, paracetamol/codeine and paracetamol/dextropropoxyphene). The use of paracetamol as an adjunct to "strong" opioids such as morphine is optional at step 3 of the WHO ladder but has become entrenched in palliative care "folklore," despite little evidence of its benefit.The article by Stockler et al 2 is well designed and takes into account many of the problems inherent in palliativecare research (eg, the need for short study times, easy assessments, and telephone follow-up). The conclusion, however, that paracetamol improves pain in cancer patients already taking opioids is not well supported by the data presented. The only significant result in favor of adding paracetamol to the analgesic regimen was an average difference on two assessment days of 0.4 on an 11-point verbal numeric scale of pain (P ϭ .03). One must question the clinical benefit of this. No other pain end point (Visual Analog Scale for pain, patient preference, and need for breakthrough medications) was statistically different. In addition, there was no difference in the balance between analgesia and adverse effects as measured by nausea and vomiting, drowsiness, and constipation scores. Although the average increase in overall well-being was just significant at the P ϭ .05 level, this is arguably the softest outcome measure, as the determinants of wellbeing are multifactorial.The requirement of palliative patients to swallow an additional 10 large tablets a day fo...