ObjectivesThe majority of people would prefer to die at home and the stated intentions of both statutory and voluntary healthcare providers aim to support this. This service evaluation compared the preferred and actual place of death of patients known to a specialist community palliative care service.DesignAll deaths of patients (n=2176) known to the specialist palliative care service over a 5-year period were examined through service evaluation to compare the actual place of death with the preferred place of death previously identified by the patient. Triggers for admission were established when the patients did not achieve this preference.ResultsBetween 2009 and 2013, 73% of patients who expressed a choice about their preferred place of death and 69.3% who wanted to die at home were able to achieve their preferences. During the course of their illness, 9.5% of patients changed their preference for place of death. 30% of patients either refused to discuss or no preference was elicited for place of death.ConclusionsDirect enquiry and identification of preferences for end-of-life care is associated with patients achieving their preference for place of death. Patients whose preferred place of death was unknown were more likely to be admitted to hospital for end-of-life care.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It provides recommendations on the assessments and interventions for this group of patients receiving palliative and supportive care.Recommendations• Palliative and supportive care must be multidisciplinary. (G)• All core team members should have training in advanced communication skills. (G)• Palliative surgery should be considered in selected cases. (R)• Hypofractionated or short course radiotherapy should be considered for local pain control and for painful bony metastases. (R)• All palliative patients should have a functional endoscopic evaluation of swallowing (FEES) assessment of swallow to assess for risk of aspiration. (G)• Pain relief should be based on the World Health Organization pain ladder. (R)• Specialist pain management service involvement should be considered early for those with refractory pain. (G)• Constipation should be avoided by the judicious use of prophylactic laxatives and the correction of systemic causes such as dehydration, hypercalcaemia and hypothyroidism. (G)• Organic causes of confusion should be identified and corrected where appropriate, failing this, treatment with benzodiazepines or antipsychotics should be considered. (G)• Patients with symptoms suggestive of spinal metastases or metastatic cord compression must be managed in accordance with the National Institute for Health and Care Excellence guidance. (R)• Cardiopulmonary resuscitation is inappropriate in the palliative dying patient. (R)• ‘Do not attempt cardiopulmonary resuscitation’ orders should be completed and discussed with the patient and/or the family unless good reasons exist not to do so where appropriate. This is absolutely necessary when a patient's care is to be managed at home. (G)
Although the more recently introduced antipsychotic drugs are increasing in popularity, the pattern of symptomatology when taken in overdose is not well defined. We monitored all enquiries to the National Poisons Information Service, London (NPIS, London) concerning antipsychotic drugs over a 9-month period in 1997 and report our findings concerning four drugs (olanzapine, clozapine, risperidone and sulpiride). All overdoses involving a single agent were followed up by a letter to the enquirer requesting details and outcome of the case. Although a total of 574 enquiries involving the selected antipsychotic drugs were received, only 45 of these cases involved overdose with a single agent. There were no fatalities or cases of convulsions in the series. Cardiac arrhythmias were only noted with sulpiride. Symptoms were most marked with clozapine, with a majority of patients experiencing agitation, dystonia, central nervous system (CNS) depression and tachycardia. Olanzapine and sulpiride produced a range of different symptoms, while most patients who had taken risperidone were asymptomatic. Monitoring poisons centre enquiries is a useful way of comparing overdose toxicities. We conclude that at least two of the novel antipsychotic agents, olanzapine and risperidone, appear to have a favourable overdose profile, which suggests that they are safer in overdose than the phenothiazines and butyrophenones.
The perceived lack of social support for patients dying at home is a significant trigger for admission to a hospice. The provision of sitters to support patients dying at home may ensure people achieve their preference. Commissioners consider preferred place of care to be a marker of quality, but clinical events that precipitate admission are often outside the influence of the palliative care team.
The patient was diagnosed in 2004, at the age of 24 years, with gestational trophoblastic disease. This was three years after her last pregnancy. Initial treatment did not induce remission, and she developed lung and skin metastases in 2005. Treatment continued with chemotherapy (cisplatin, etoposide, and methotrexate) and an autologous bone marrow transplant. She also underwent a hysterectomy. After this treatment, there was some improvement, with regression of the lung nodules. However, her human chorionic gonadotropin (hCG) did not fall significantly at any point. She underwent a course of capecitabine chemotherapy, but at this point, symptom issues were becoming difficult to manage.The main problem came from painful skin metastases. These were raised hemangioma-type lesions widespread over the body, including thorax, scalp, and vulva, and were confirmed to be histologically similar to the primary malignancy. Toward the later stages of her disease, she developed lesions in her right nostril and her left lower eyelid. They were painful to touch and would bleed if traumatized. She was unable to brush her hair, and clothing/underwear caused discomfort.Several approaches were adopted to manage this pain. She was commenced on opioids, which were effective in the initial stages. Topical lidocaine and diamorphine were used for the vulval lesions, but with little effect. Radiotherapy to the lesions on the thorax was not helpful. Good pain relief was gained with gabapentin, but systemic disease was advanced by this point. Treatments, such as ketamine, were not used as the patient had a somewhat chaotic lifestyle and had difficulties managing medication.The patient deteriorated from the point of view of her lung disease. She became increasingly breathless, with an intractable cough and hemoptysis. She died earlier this year. CommentGestational trophoblastic disease with skin metastases is exceedingly rare. 3 It has been difficult to monitor trends of this disease due to the lack of a clear classification system and the absence of histological diagnosis in some cases. 1
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