When other treatments fail to relieve suffering in the imminently dying patient, PST is a valid palliative care option.

This article reviews the literature pertaining to the metabolism of several of the commonly used opioids, and the known activity of their metabolites. The effect of renal failure on the pharmacokinetics of these drugs and metabolites is then reviewed. Finally, the effect of renal dialysis on opioid drugs and metabolites is reviewed. Based on the review, it is recommended that morphine and codeine are avoided in renal failure/dialysis patients; hydromorphone or oxycodone are used with caution and close monitoring; and that methadone and fentanyl/sufentanil appear to be safe to use. Note is made that the "safe" drugs in renal failure are also the least dialyzable.

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 conflict of wishing to "parent" a dying adult child while recognizing the child's autonomy creates uncertainty for parents at an already stressful time. Facilitating parent-child communication during the illness is important. After the death of the adult child parents may continue to face difficulty with their perceived role in society (parent and/or bereaved person), and sometimes within their family. Health care professionals should make greater efforts to include the parents of the dying adult in the circle of care. The bereavement experience of these parents is intense and long-lasting. Further research is needed regarding the ways in which health care providers can best assist parents to successfully integrate this profound loss.

BackgroundIn Tanzania, a country of 42 million, access to oral morphine is rare.AimTo demonstrate the effectiveness of palliative care teams in reducing patients’ pain and in increasing other positive life qualities in the absence of morphine; and to document the psychological burden experienced by their clinical providers, trained in morphine delivery, as they observed their patients suffering and in extreme pain.SettingOne hundred and forty-five cancer patients were included from 13 rural hospitals spread across Tanzania.MethodA mixed method study beginning with a retrospective quantitative analysis of cancer patients who were administered the APCA African POS tool four times. Bivariate analyses of the scores at time one and four were compared across the domains. The qualitative arm included an analysis of interviews with six nurses, each with more than five years’ palliative care experience and no access to strong opioids.ResultsPatients and their family caregivers identified statistically significant (p < 0.001) improvements in all of the domains. Thematic analysis of nurse interviews described the patient and family benefits from palliative care but also their great distress when ‘bad cases’ arose who would likely benefit only from oral morphine.ConclusionPeople living with chronic cancer-related pain who receive palliative care experience profound physical, spiritual and emotional benefits even without oral morphine. These results demonstrate the need for continued advocacy to increase the availability of oral morphine in these settings in addition to palliative care services.