This audit aimed to measure: the prevalence of indwelling urinary catheters in patients at the end of life; the use of nursing documentation relating to catheter insertion and care; and prevalence of continence screening on admission. The audit involved a retrospective examination of case notes of patients who died on two oncology wards and a hospice at a large teaching hospital in the south of England. The audit showed that 63% of patients had an indwelling catheter during their admission. Documentation relating to urinary catheter insertion and care was present in 75% of cases, and 75% of patients received continence screening on admission. The findings confirm that indwelling urinary catheters are frequently used as a tool to manage urinary difficulties at the end of life, but that the indications for insertion and continued use can be unclear. Research is needed to establish appropriate use.
BackgroundSeizures are common in the palliative care population. For patients who are unable to take oral medication, seizure management can become problematic but there is little consensus on best practice, particularly for patients with longer prognoses.AimTo examine prescribing of non-oral and 'as required' anticonvulsant medication across multiple palliative settings (community/hospice/acute hospital).MethodA regional multi-centre audit of prescribing practice was conducted from October to December 2017. Inclusion criteria: adult patients requiring anticonvulsant medication but unable to take oral preparations. Practice was assessed against regional Palliative Care guidelines. Data was collected retrospectively via a SmartSurvey proforma.ResultsTwenty-six patients across six centres were included. When unable to take oral medications, 25 patients (96%) commenced a continuous subcutaneous infusion (CSCI). Fourteen patients were prescribed levetiracetam (250 mg-3 g/24 hours), seven were prescribed midazolam (15–30 mg/24 hours), two were prescribed sodium valproate (600 mg/24 hours) and two were prescribed combination levetiracetam (3 g) and midazolam (30–40 mg). One patient had no regular anticonvulsant as they were imminently dying. Where prognosis was estimated, 80% of patients commencing a midazolam CSCI were felt likely to survive less than a week Seizures were controlled in 69% of patients with initial doses prescribed. 'As required' anticonvulsant medication was prescribed for 23 patients (88%); all were prescribed subcutaneous midazolam (2.5 mg-10 mg). Phenobarbital (8 patients), buccal midazolam (one patient) and rectal diazepam (one patient) were also prescribed. The majority of patients (92%) died and almost half (46%) died within a week of parenteral anticonvulsant prescription.ConclusionLevetiracetam via CSCI was the most commonly used parenteral anticonvulsant. Midazolam via CSCI tended to be used for patients with a poorer prognosis (under one week). Regional guidelines need to be reviewed to reflect clinical practice. Given the widespread use of levetiracetam, further research is warranted to guide use in the palliative care setting.
BackgroundAbdominal paracentesis is widely used as a symptom control measure for malignant ascites. In the UK, ultrasound guided insertion has become standard practice in some specialist palliative care units. This has resulted in variation in practice between units, inconsistent training opportunities and perceived difficulties for trainees to achieve procedural competencies.AimThe aim of this study was to establish the views of Palliative Medicine trainees on their experience, competency and the role of ultrasound in paracentesis.MethodsAn online questionnaire was sent out to all trainees registered with The Association of Palliative Medicine. 81/230 trainees responded (35%). 72 % were in their final year of training.ResultsIn the preceding 12 months 75% of trainees had performed paracentesis on less than three occasions, 39% had not put in a single drain. 49% of trainees anticipated difficulties in achieving the required procedural competence by the end of training due to fewer opportunities, often having to arrange specific clinical attachments to meet the training objectives. In 33% of units all cases were ultrasound guided yet only 5/81 trainees were trained to use ultrasound. 78% trainees felt competent to insert a drain without ultrasound although 39% believed all drains should be placed under ultrasound guidance.ConclusionsParacentesis is a mandatory skill required to complete training in Palliative Medicine. This study has shown that many units only perform ultrasound guided procedures and yet only 6% of trainees are trained in this technique. Therefore there are fewer opportunities for training as evidenced by 39% of trainees not performing paracentesis within 12 months. Most still feel competent to perform paracentesis but this study raises questions regarding maintaining procedural competency and who will train the trainees in the future. If the trend towards ultrasound guidance continues it should become a skill all trainees must learn.
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