OBJECTIVES:Inaccurate prescribing of as needed medications in haematology/oncology patients poses a significant risk to patient safety and symptom control. This quality improvement initiative aimed to reduce as needed prescribing errors from 30% to below 10% over 12 weeks at Galway University Hospital. METHODS:A multidisciplinary 'Medication Safety Team' was formed, and a baseline audit using point prevalence surveys revealed a 30% as needed error rate, predominantly in dose and frequency domains. Semistructured interviews with non-consultant hospital doctors (NCHDs) identified barriers such as limited knowledge of resources, time pressure and inadequate education. Four Plan-Do-Study-Act cycles were implemented focusing on tools, education, resources and awareness. RESULTS:As needed prescribing errors reduced from 30% to 8%. Stakeholder feedback indicated improved confidence and clarity in prescribing practices. Sustainability is addressed with the introduction of QR-code resources at the point of care and embedding of education at induction for NCHDs. CONCLUSIONS:This initiative demonstrates that structured, stakeholder-driven interventions can meaningfully improve prescribing accuracy. Systematic integration of education and resources supports long-term impact, offering a replicable model for enhancing medication safety in palliative and oncology care settings.

Objectives:Palliative Care provision is a key competency for all physicians. Junior doctors are actively involved in the delivery of end-of-life care in hospitals despite often feeling unprepared to do so. There has been a recent shift toward competency-based education in palliative care. The primary aim of this study was to assess the impact of a novel competency-based workshop on interns' perceived preparedness in providing generalist palliative care at end of life. Methods:A novel competency-based education workshop was designed by a multidisciplinary team including a medicine for the elderly consultant, the director of the intern training program, the hospital end of life coordinator, junior doctors and a palliative care consultant. The workshop consists of five interactive sessions delivered to interns over a three-week period by a member of the multidisciplinary team. The Palliative Care Competence Framework Questionnaire was administered pre and post completion of the workshop to examine the impact of the workshop on attitudes, behaviors, and knowledge. Results:Prior to the intervention, 86% (n = 38) of participants reported feeling inadequately prepared to manage death and dying to the level required in their role. Overall, there was a significantly positive improvement in attitudes (p = 0.0314), behavior (p ≤ 0.0001), and knowledge (p ≤ 0.0001) following the competency-based workshop among participants who completed the pre- and post-intervention questionnaires. Conclusions:The findings from this study suggest a novel competency-based workshop improved interns' perceived preparedness in providing generalist palliative care at end of life. Future initiatives will focus on validating the findings of this study.

to explore a paradigm shift in the definition of opioid-responsive cancer pain in this hypothesis-driven review. Opioid-responsive cancer pain may be misplaced within the definition of chronic pain, chronic pain takes three months to establish, early effective control is worthwhile to achieve. findings, from a bench-to-bed perspective, debates the interpretation of results supporting the hypothesis that opioid-responsive cancer pain could remain ‘constant acute pain’, with explanations, best solutions, for tolerance and/or addiction, in cancer patients compared to those with chronic pain from other conditions. Unraveling the unique apparent properties of opioid-responsive cancer pain empowers knowledge of the process by which acute pain may have the potential to remain acute in nature and not transition into chronic pain. Findings outlined defend the hypothesis of probable sustained acute nature of opioid-responsive cancer pain, importance of early, sustained pain control, opioid reduction and further exploration of this hypothesis in clinical practice.

Background We describe two complex cases in the setting of COVID-19 at the End of Life, to enhance learning for all patients. Case Presentation Maintenance of sustained comfort in two cases required multiple drugs, specifically selected for symptoms that necessitated three separate pumps delivering continuous 24-hour subcutaneous infusion. Case Management Management of sustained comfort included opioid, midazolam, anti-secretory, diclofenac for intractable temperature, phenobarbital for extreme agitation, in one, where seizure activity was present, while insomnia, was a prominent feature of another. Management of Akatasia was also required. Case Outcome Attention to each individual patient’s rapidly evolving symptoms, during the dying phase, with a thorough differential diagnosis, wa s vitally important in the context of a ‘Good Death’. This was achieved in both cases, reflected by evidence at the bedside of comfort and a minimum need for ‘as required’ drugs in the last days of life. Conclusions COVID-19 being a new illness, we need to prospectively study the symptom burden/clustering at End of Life and learn from management of this new disease for other illnesses also. Further research is required to develop protocols on; when does Midazolam dose reach tolerance and when should an alternative drug such as phenobarbital for sustained Gamma-Aminobutyric Acid effects be initiated; examine the optimal approach to sustained temperature control; be cognisant of extrapyramidal side effects of drugs used at End of Life and consider looking at a lack of need for ‘as required’ drugs in the last days of life as an outcome measure of sustained comfort. Keywords covid-19 , end-of-life , symptom burden/clustering , symptom control , quality of life , sustained comfort

Aims Akathisia is a disturbing, reversible but under-diagnosed extrapyramidal side effect of medications used in palliative medicine. We assessed patients’ subjective experience of akathisia and response to procyclidine, an anticholinergic used to treat extrapyramidal effects. We also aimed to discuss future areas of research and alternatives to akathisia-causing medications. Methods Suitable patients were retrospectively identified by palliative medicine physicians in a tertiary hospital and a chart review was undertaken. Information gathered included the account of their experience of akathisia, use of inciting medications, treatment, and outcome. Results 20 patients were identified, 12 females, 8 males. Mean number of days on the inciting drug(s) to onset of akathisia symptoms was 18.1. Mean number of days from commencing inciting drug(s) to diagnosis was 20.9. Patients’ descriptions revealed similarities including feeling “locked in” and a need to constantly move. One patient described a “glass coffin” enclosing her. 16 patients had full response to treatment with procyclidine, 3 had partial response requiring up-titration of dosing, response was not documented in 1. Conclusions Akathisia is an elusive symptom that can have dramatic reversibility when treated. Lack of recognition causes unnecessary patient suffering. Procyclidine appears to aid diagnosis and be an effective treatment. Protocols to reduce incidence and guide diagnosis and management are proposed. Further studies are required, in which subjective outcome measures are used and medications to treat akathisia are studied. Recognition remains challenging, causing significant distress for palliative patients, for whom quality of life is paramount.

BACKGROUND:We describe two complex cases in the setting of COVID-19 at the End of Life, to enhance learning for all patients.CASE PRESENTATION:Maintenance of sustained comfort in two cases required multiple drugs, specifically selected for symptoms that necessitated three separate pumps delivering continuous 24-hour subcutaneous infusion.CASE MANAGEMENT:Management of sustained comfort included opioid, midazolam, anti-secretory, diclofenac for intractable temperature, phenobarbital for extreme agitation, in one, where seizure activity was present, while insomnia, was a prominent feature of another. Management of Akatasia was also required.CASE OUTCOME:Attention to each individual patient's rapidly evolving symptoms, during the dying phase, with a thorough differential diagnosis, wa s vitally important in the context of a 'Good Death'. This was achieved in both cases, reflected by evidence at the bedside of comfort and a minimum need for 'as required' drugs in the last days of life.CONCLUSIONS:COVID-19 being a new illness, we need to prospectively study the symptom burden/clustering at End of Life and learn from management of this new disease for other illnesses also. Further research is required to develop protocols on; when does Midazolam dose reach tolerance and when should an alternative drug such as phenobarbital for sustained Gamma-Aminobutyric Acid effects be initiated; examine the optimal approach to sustained temperature control; be cognisant of extrapyramidal side effects of drugs used at End of Life and consider looking at a lack of need for 'as required' drugs in the last days of life as an outcome measure of sustained comfort.

Emerging evidence suggests that methadone has a specific role in the management of treatment resistant cancer-related pain.ObjectivesTo investigate the utilisation pattern, safety and efficacy of methadone prescribed as an analgesic for the management of complex cancer-related pain in an acute hospital inpatient setting.MethodsA retrospective longitudinal observational study of patients prescribed methadone as an analgesic between April 2020 and July 2021 was performed.Changes in coprescribed baseline opioid, use of breakthrough opioid analgesic, patient rated pain scores and adverse side effects were analysed.Results16 patients with complex cancer-related treatment resistant pain who were prescribed methadone were included in the study. Of the 16 patients, 14 patients had metastatic disease. Pain was classified in 14 patients as mixed nociceptive-neuropathic and in 2 patients as neuropathic. 13 patients were coprescribed methadone with a pre-established opioid. Methadone was associated with a statistically significant decrease in both opioid breakthrough analgesic by 61%±28% (p<0.001), and coprescribed opioid by 17%±12% (p=0.015). Patient rated pain scores were also significantly decreased (p<0.001).ConclusionMethadone appears to have a specific role in the management of complex cancer pain, neuropathic pain, opioid-tolerance and opioid-induced hyperalgesia, which may be attributable to N-methyl-D-aspartate receptor antagonism.

Abstract BACKGROUND AND AIMS Point prevalence studies are observational studies, without intervention, and involve collecting data, in patients in multiple care units, at a specific time. It provides no information on outcomes but provides information on how common a problem is, and current management. This type of study can be an ongoing program consisting of multiple research collection days, each performing multiple, independent studies simultaneously. The point prevalence studies are purely observational, and no intervention is required by the study protocol. The aim of the study is to understand prescribing patterns of analgesia to dialysis patients and incidence of pain among them. METHOD This project is a prospective, observational, multicentre, 2-day, point prevalence study of three chronic dialysis units on the prevalence of pain in all patients in receipt of dialysis. Data were gathered regarding analgesia prescribed to patients and whether patients reported pain to the haemodialysis (HD) staff. RESULTS A total of 164 patients were audited, with an average age of 67.8 years. Approximately 19.5% of dialysis patients presenting reported pain. The average age of these patients was 70 years. The most common cause was MSK (34%) then cramps (31%), vascular access pain (16%), ‘other’ (13%) and vascular wounds (6%). Approximately 12.5% of those patients with pain were reviewed by a doctor. Approximately 50% of the patients are prescribed analgesia. This varied amongst dialysis units with 52% and 26% of patients in the two public units prescribed analgesia and 70% of patients in the private unit. Types of analgesia prescribed to HD patients were paracetamol (75.46%), neuropathic agent (20.12%), codeine (6), tramadol (4), tapentadol (3), pure opioid (4), buphenorphine patch (3) and lidocaine patches (2). CONCLUSION This shows a significant impact of pain amongst dialysis patient presenting daily to dialysis units. A prospective research study is planned using a novel Pain App specifically developed for HD patients. This may be structured as a Cluster Clinical trial to compare and contrast outcomes in different centres.

Traditionally changes in quality of life (QoL) are assessed using self report questionnaires. They rely on the assumption that the patient’s point of reference does not change over time. However in reality patients with chronic and life threatening illness appear to undergo an adaptation to their disease or “Response Shift” (RS). In this study of a population of patients with advanced lung cancer receiving palliative chemotherapy we examine for a RS in subjective QoL. Methods: 33 patients completed the Schedule for the Evaluation of Individual Quality of Life (SEIQoL), SEIQOL–DW and the EORTC-QLQ C-30 at diagnosis. At 1, 3 and 6 months patients completed SEIQoL/ SEIQOL–DW and retrospectively re-assessed their baseline QoL (the “then” test) using SEIQoL-DW. Results: The initial mean SEIQoL-DW score was 67.48 changing to 66.71 at one month. Retrospectively, patients reassessed their initial mean SEIQoL-DW score as 59.61, suggesting a RS of 7.87 (p ≤0.0001) and an actual improvement in QoL of 7.1 points. At three months the mean SEIQoL-DW score was 65.13; retrospectively patients rated their QoL at one month much lower, mean SEIQoL-DW then – test’ score was 59.92, suggesting a RS of 6.79 (p = 0.0013). At six months patients’ mean SEIQoL-DW score was 61.86. Again, when retrospectively rating their QoL at three months they rated it lower, mean SEIQoL-DW score of 58.84, indicating a ‘positive’ RS of 6.28 (p = 0.0007). Conclusion: Traditional pre/post SEIQOL–DW scores show little change in subjective QOL however by incorporating the ‘then-test’ we can see that patients have undergone a RS and a significant positive change in subjective QOL. By explicitly measuring RS it may be possible to assess changes in QoL with greater validity and sensitivity.

Context: The aim of this study was to profile a cardiac rehabilitation population in the West of Ireland and establish Subjective Quality of Life (SQoL), using The Schedule for Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW), a validated subjective QoL measure. Bothersome symptoms (SB) and Symptom Interference in SQoL (SBIQoL) were also assessed using a using a modified SEIQoL-DW. Objectives: QoL is a difficult concept to define, therefore the medical profession often premise QoL on health and illness. The focus of this study was to explore the QoL needs of a cardiac population, with a view to informing the development of a newly formed cardiac rehabilitation support group. The SEIQoL-DW was developed to overcome the limitations of quantitative questionnaires, as it is based on the individual’s personal view of life and its quality. Methods: SQoL, symptoms and SBIQoL, of 22 individuals, who had suffered a cardiac event were explored. SEIQoL-DW is a semi-structured interview, enabling the individual to convert their perspectives into scientific values. QoL areas of importance to patients are called ‘cues’. A modified SEIQoL-DW was used to assess SB and SBIQoL. Data were analysed using both quantitative analysis and qualitative descriptive analysis. Findings: Participants highlighted a range of QoL cues; findings from this study showed that 45% of participants did not rate ‘health’ in the first five QoL cues. A significant number of participants experienced symptoms; a medium negative correlation was found between symptom interference and QoL, rho = -0.353, with high levels of symptom interference associated with low levels of QoL. Conclusions: The range of QoL cues and bothersome symptoms identified in this study had implications for the development of the group, with participants eager to participate and talk candidly about their needs. SEIQoL-DW proved to be an acceptable, reliable and valid technique for measuring both individual QoL, SB and SBIQoL, taking greater consideration of individual perspectives compared with traditional measurement approaches. The significance of nominated symptoms and SBIQoL warrants further attention, especially if these symptoms are reversible.

BACKGROUND:The Irish Medical Council has identified gaps in knowledge and communications skills of new-entrant doctors in legal, ethical and practical aspects of end of life care.AIMS:To determine the frequency with which junior doctors deal with end of life care and patient death and to evaluate the impact this has on their psychological wellbeing.DESIGN:A questionnaire was distributed to junior doctors to determine the frequency with which the participants had managed a patient at end of life. An abbreviated Posttraumatic Stress Disorder Checklist-Civilian version was used to evaluate psychological distress. Critical incident technique interviews explored the challenges of caring for patients at end of life.SETTING/PARTICIPANTS:A total of 110 junior doctors in two teaching hospitals in Ireland completed the questionnaire: 39 (35.5%) interns and 71 (64.5%) senior house officers. In addition, 31 interviews were carried out with interns, senior house officers and registrars.RESULTS:The majority (81.8%) had pronounced a death with 39.4% of senior house officers doing so more than 10 times. Three quarters (75.5%) had discussed end of life with a patient's family. Of the 110 respondents that completed the posttraumatic stress disorder checklist, 11.8% screened positively for posttraumatic stress disorder. Challenges identified at interview included lack of knowledge and preparedness, difficulty communicating with family members, a lack of support and a feeling of failure.CONCLUSIONS:Junior doctors are regularly carrying out tasks related to end of life care, resulting in high levels of psychological distress. Further training and a change in culture are required.

As the prevalence of end-stage renal disease (ESRD) has risen significantly during the last 10 years, renal replacement therapy (RRT) remains a limited resource. In addition, 25% of new dialysis patients in the United Kingdom are older than 75 years and have the greatest increase in uptake of RRT.1 For most patients with ESRD, RRT prolongs life and alleviates symptom burden. However, in those aged 75 years and older, when first commencing RRT, the survival advantage may be substantially reduced by comorbidity, in particular, by ischemic heart disease,2 with probability of survival of 71% at one year and 54% at two years in Europe,3 59% and 43%, respectively, in the U.S.

91 Background: Use of quality of life information as a tool to aide decision making in routine clinical practice is uncommon. The Schedule of Evaluation for Individual Quality of Life Direct Weighting (SEIQoL DW) is a measurement tool that captures the multidimensionality and uniqueness of the individual allowing him/her to define areas of importance to their quality of life and to demonstrate its measure of importance. It was hypothesised that routine quality of life measurement of patients followed by graphical presentation of this information to the clinician, may bridge views of clinicians and patients to improve quality of life outcome. Methods: A randomised controlled trial of 65 patients receiving chemotherapy for advanced cancer was conducted to measure differences in perception of quality of life over 4 time-points of patients in the intervention group whose quality of life was reported to the clinical team compared to patients in the control group whose quality of life information was not reported to the clinical team .The primary objective was to compare quality of life outcome and examine differences between groups. Results: Findings demonstrated improvement in quality of life of all patients from baseline to time point 4. (P = > 0.05). The top four cues nominated by patients as important to their quality of life were health (92%), social activity (64%), keeping active (58%) and family support (43%).Closer analysis of these individual cues showed interesting differences between the intervention and control group. Participants in the intervention group demonstrated a 51% improvement in perception of health functioning compared to 19% improvement in perception of health functioning in the control group (p = 0.014).Paradoxically there was a decline in patient perception of functioning in other cues (social activity, keeping active and family support) with no significant difference between groups. Conclusions: Review of Individual QoL assessments by the clinican had a clinically significant impact on the patients reported measurement of ‘health’ thus suggesting that utilisation of QoL measurements by the clinician positively impacts the patient.

Purpose: To assess the effects of iliofemoral vein stent placement on symptomatic lower extremity swelling (LES), presumed to be lymphedema, in patients with cancer.Materials and Methods: During the period 2005-2013, 62 patients (38 female; age, 60.4 y +/- 15.4) with histology-proven metastatic disease and LES resistant to standard therapies were evaluated and found to have venous outflow obstruction. Steins were placed in the iliofemoral veins or inferior vena cava, or both, and evaluated by color Doppler ultrasound or contrast-enhanced computed tomography during the follow-up period. Patient symptoms were assessed using the Venous Disability Score (VDS) and the Galway Limb Swelling score, a patient-directed, 5-question symptom scoring system.Results: Stents were successfully placed in all patients. During the follow-up period, in-stent thrombosis occurred in 13 patients, and additional stents were placed in 3 patients to treat luminal narrowing. The mean VDS improved significantly (P < .05): from 3.0 +/- 0 on the day of the procedure to 2.95 +/- 0.22 on day 3, 2.0 +/- 0.33 on day 7, and 1.87 +/- 0.34 on day 30. The mean Galway Limb Swelling score also improved significantly (P < 0.001): from 3.6 +/- 0.74 on the day of the procedure to 1.96 +/- 0.91 on day 3, 1.06 +/- 0.78 on day 7, and 0.6 +/- 0.66 on day 30. During the follow-up period, 60 patients died as a result of their underlying malignancy (mean, 230 d; range, 5-1,080 d).Conclusions: Iliofemoral or iliocaval venous stent placement may have a valuable role in patients with metastatic disease and symptomatic LES associated with venous obstruction.

PURPOSE:This study was conducted to evaluate the extent to which quality of life (QoL) assessment has been incorporated into clinical trials of patients with advanced non-small cell lung cancer (NSCLC) receiving palliative chemotherapy.PATIENTS AND METHODS:Phase III trials for patients with NSCLC treated with palliative chemotherapy were identified by a literature search of PubMed. All abstracts and relevant articles from August 1986 to October 2011 were reviewed. The primary focus was on (a) whether these articles had incorporated QoL as an endpoint, (c) what instruments were used to measure QoL and (c) impact of chemotherapy on QoL.RESULTS:There were 3,780 items indexed under 'quality of life and lung cancer'. One hundred three studies were identified which measured QoL using validated QoL instruments. Fifty-five of these trials assessed the effects of palliative chemotherapy on QoL in patients with advanced NSCLC. The European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire was the most widely used questionnaire; other commonly used measurement scales used were the Functional Assessment of Cancer Therapy-Lung and the Lung Cancer Symptom Scale. The majority of studies showed that chemotherapy had a positive impact on QoL and disease-specific symptoms.CONCLUSION:It is now widely accepted that QoL should be considered as a primary endpoint of treatment in patients with advanced lung cancer both in clinical practice and clinical trials to further define meaningful response. As the traditional outcome measures of survival and tumour response are poor in this population, QoL assessment may offer a more comprehensive approach to evaluating the relative risks and benefits associated with treatments.

Journal of Palliative MedicineVol. 15, No. 9 Letters to the EditorEnd-of-Life Enhancement: A Novel Introduction of Medical Students to Palliative MedicineCamilla Murtagh, Eileen Mannion, Gerald Flaherty, and Dypnma WeldronCamilla MurtaghDepartment of Palliative Medicine, Galway University Hospitals, Galway, Ireland.Department of Medicine, National University of Ireland, Galway, Ireland.Search for more papers by this author, Eileen MannionDepartment of Palliative Medicine, Galway University Hospitals, Galway, Ireland.Department of Medicine, National University of Ireland, Galway, Ireland.Search for more papers by this author, Gerald FlahertyDepartment of Medicine, National University of Ireland, Galway, Ireland.Search for more papers by this author, and Dypnma WeldronDepartment of Palliative Medicine, Galway University Hospitals, Galway, Ireland.Department of Medicine, National University of Ireland, Galway, Ireland.Search for more papers by this authorPublished Online:4 Sep 2012https://doi.org/10.1089/jpm.2012.0191AboutSectionsView articleView Full TextPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"End-of-Life Enhancement: A Novel Introduction of Medical Students to Palliative Medicine." , 15(9), pp. 965–966FiguresReferencesRelatedDetailsCited ByPalliative Care in Undergraduate Medical Education—How Far Have We Come?28 July 2016 | American Journal of Hospice and Palliative Medicine®, Vol. 34, No. 8Curricular Innovations for Medical Students in Palliative and End-of-Life Care: A Systematic Review and Assessment of Study Quality20 March 2015 | Journal of Palliative Medicine, Vol. 18, No. 4 Volume 15Issue 9Sep 2012 InformationCopyright 2012, Mary Ann Liebert, Inc.To cite this article:Camilla Murtagh, Eileen Mannion, Gerald Flaherty, and Dypnma Weldron.End-of-Life Enhancement: A Novel Introduction of Medical Students to Palliative Medicine.Journal of Palliative Medicine.Sep 2012.965-966.http://doi.org/10.1089/jpm.2012.0191Published in Volume: 15 Issue 9: September 4, 2012PDF download

rates for QOL difficulties. The proportion of centers that do provide long-term follow-up care, however, is encouraging. This trend may prove important for investigators by providing increasing opportunities to examine long-term QOL outcomes (at least through early adulthood). Our group is currently conducting a multicenter study to evaluate long-term outcomes among adult survivors of pediatric bone marrow and stem cell transplantation.

valid in Korea. However, Korean patients felt that relationships with friends and neighbors were different from those with family, indicating that the social/family well-being domain needed cultural adaptation. One item about coping with illness was cross-culturally specific and did not load significantly on the emotional well-being domain. Cronbach a reliability coefficients for the 4 domains ranged from 0.83 to 0.88. CONCLUSION: This finding indicated that there were crossculturally common and culture-specific QOL items. Validation of the scale is recommended for Korean patients with various types of cancer.