Background Palliative radiotherapy (PRT) is commonly used to treat symptoms of advanced cancer. PRT has been associated with elevated 30-day mortality (30DM). A Rapid Access Palliative Clinic (RAPC) can streamline the treatment process for patients receiving treatment. Aims We reviewed the PRT practices in a radiation oncology network in Ireland, and the implementation of a RAPC. Patient outcomes were assessed to inform future treatment decisions. Methods A retrospective review of all patients who received PRT over 6 months in 2018 in St. Luke’s Radiation Oncology Network (SLRON) was undertaken. We assessed 30DM rates, demographics and referral to specialist palliative care (SPC) services. Subsequently, a retrospective analysis was conducted of a RAPC which ran for 6 months from 2019 to 2020. We assessed treatment data and mortality. Results Over 6 months, 645 patients commenced PRT in the SLRON. The 30DM for this cohort was 15.8% ( n = 102), with most patients having lung primaries. Of the 30DM cohort, only 55% ( n = 56) were referred to SPC services and only 26.4% ( n = 27) had performance status recorded. Over 6 months, 40 patients attended 28 RAPCs. Of these, 88% ( n = 35) received PRT. Single fraction therapy was utilised in 60% and 48% of patients underwent CT simulation and treatment on the same day. Ultimately, 75% of patients received SPC referral. Conclusions Referral rates to SPC services and documentation of performance status were low in our 30DM retrospective review cohort. The RAPC facilitated quick treatment turnaround, fewer hospital visits and referral to SPC services.

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.

### Learning Point for Clinicians Hypercalcaemic hyperparathyroid crisis is a rare but dangerous life-threatening manifestation of parathyroid disease. Initial management includes aggressive rehydration and intravenous bisphosphonate therapy. Definitive management involves parathyroidectomy. Accurate identification and prompt management is required to avert potentially life-threatening complications of this condition. A 63-year-old woman presented to the medical assessment unit with a three week history of vomiting, polydipsia, polyuria and constipation. She had no history of renal stones, osteoporosis or low mood. The patient had a longstanding history of hypertension for which she was receiving propranolol and type 2 diabetes mellitus, treated with metformin. She was mildly confused being orientated to person and place but not to time. She had an otherwise normal physical examination. Her pulse was 84, regular in rhythm and normal in character. Her …