BMJ Supportive & Palliative Care最新文献

Background: Over time, kidney supportive care (KSC) - the application of the principles of palliative care to patients with chronic kidney disease - has been recognised as essential to kidney care.

Purpose: To describe the series of recent steps made by the International Society of Nephrology (ISN): endorsing KSC as a core component of integrated kidney care; developing consensus definitions of KSC and conservative kidney management (CKM) and creating an international curriculum on KSC and CKM.

Conclusion: Synthesising best evidence and practice, the curriculum provides an invaluable resource for all clinicians, including those working in palliative care. This article charts that journey and summarises the scope and content of the KSC/CKM curriculum.

Background: Intraoperative deaths, though statistically rare, may evoke varied emotions among operating room (OR) staff that remain underrecognized and inadequately addressed.

Aim: To synthesise the qualitative evidence regarding experiences of OR staff following patient death in the OR. A secondary aim is to unpack strategies to support OR staff following an intraoperative death experience.

Design: Narrative review of qualitative studies.

Data sources: Peer-reviewed databases (PubMed, EMBASE, CINAHL, Web of Science, Scopus and Cochrane Review Library) and grey literature sources (such as thesis databases) were extensively searched for peer-reviewed primary studies and non-peer-reviewed literature respectively reporting on intraoperative deaths or deaths occurring in the OR.

Results: Six studies were retained. The synthesis revealed that unexpected OR deaths or those deaths perceived as sudden or preventable evoked more severe and enduring psychological repercussions, marked by guilt, hypervigilance, emotional and moral distress.In contrast, anticipated fatalities, particularly in patients with advanced illness, evoked less intense emotions but did not eliminate emotional tolls. The findings revealed divergent coping mechanisms among OR professionals: surgeons often engaged in meaning-making or employed emotion-focused and problem-focused strategies to process loss. In contrast, anaesthetists described emotional desensitisation over time. Nurses, meanwhile, navigated a pervasive culture of silence.

Conclusion: The emotional toll captured underscores urgent needs for interventions, such as team-based debriefing support, alongside systemic reforms to normalise vulnerability and integrate emotional stewardship into institutional policies.Addressing this is not only ethically imperative but critical to sustaining a resilient workforceand ensuring patient safety in an era of escalating surgical demand.

Objectives: This study aimed to evaluate the prognostic significance of the corneal reflex in predicting death within 24 hours among terminally ill patients with cancer.

Methods: This prospective observational study was conducted with patients with advanced cancer admitted to the hospice centre of Gyeongsang National University Hospital who were in the phase of impending death. Corneal reflex and other end-of-life signs were assessed three times daily by trained nurses using standardised criteria. Mixed-effects logistic regression was used to identify predictors of death within 24 hours, and diagnostic performance was examined for 24-96 hours.

Results: A total of 665 observations was analysed. Absence of corneal reflex was strongly associated with death within 24 hours (OR 5.48, p<0.001), with a 24-hour mortality rate of 70.7%. It showed high specificity (85.0%) and positive predictive value (70.7%). Even among patients with a Richmond Agitation-Sedation Scale score of -4 or -5, absence of the corneal reflex remained a significant predictor of 24-hour mortality (71.2% vs 37.1%, p<0.001). Other significant predictors included peripheral cyanosis, oxygen desaturation and low blood pressure.

Conclusions: Absence of corneal reflex is a specific and clinically useful sign of imminent death within 24 hours in terminally ill patients with cancer, supporting its application in end-of-life prognostication and decision-making.

Objectives: Men with castrate-resistant prostate cancer (CRPC) suffer from symptoms related to both their disease and its treatment with marked variation between individuals with respect to symptom expression. This study aimed to determine whether genetic variation in cytokine expression is associated with symptom severity.

Methods: An exploratory prospective, longitudinal consecutive patient cohort study was undertaken across two Queensland sites. Patient characteristics including tumour burden and current treatment were collected at baseline. Symptom severity was assessed 3-4 weekly for up to 6 assessments, with blood taken for genetic analysis once only during the study. Cytokine gene variants of each participant were assessed using a panel of single nucleotide polymorphisms (SNPs) most described in the literature.

Results: Of the 66 participants, 27/66 (41%) had a low, and 39/66 (59%) a high tumour burden. Symptom severity was not related to tumour burden or patient characteristics. Of the 142 SNPs analysed from 62 participants, 15 SNPs from 7 genes were significantly associated with symptom severity. After Benjamini-Hochberg adjustment, SNPs rs2069772 from Interleukin-2 (IL2) and rs230494 from Nuclear Factor kappa-light-chain-enhancer of activated B cells (NFKb) remained significant.

Conclusion: Although multiple factors can influence symptom severity, genetic variation may play a part. The early identification of men likely to develop severe symptoms during the course of their prostate cancer could theoretically enable symptoms to be managed more aggressively from an early stage. These preliminary findings need to be replicated in a larger cohort of men with CRPC.

Objectives: To evaluate whether the Isle of Wight (IoW) Just-in-Case (JIC) scheme to supply and administer anticipatory medication to end-of-life patients was performing to an appropriate level of performance.

Methods: A retrospective chart review was conducted on patients who were considered end of life and who died at home on the IoW during 2022.

Results: JIC medication was prescribed to 88% (n=70/80) of patients. Of these patients, half were administered at least four of the five medicines listed on the IoW JIC scheme. Almost three-quarters (71%, n=50/70) of patients had the standard dosage regimens amended to provide individualised treatment, and 96% (n=67/70) of patients saw some alterations to their ongoing management after initialisation of treatment. The time between prescribing and administration of JIC medication was short.

Conclusions: The JIC scheme on the IoW allowed patients to receive timely and individualised care. One or more JIC drugs were administered to a higher proportion of patients than in previous studies; further work is required to establish why (eg, the use of a 24/7 home visiting palliative care nursing team in this locality) and whether this led to improved family confidence that symptoms were effectively controlled.

Objectives: To explore patterns, variation and barriers in the provision of specialist psychological care in non-hospice palliative care settings across England.

Methods: A convergent mixed-methods e-survey of specialist psychological professionals (SPPs) and clinical leads in non-hospice palliative care settings across England. The 45-item survey included open and closed questions on service configuration, workforce, access, training, confidence levels and barriers and service improvement. Quantitative data were analysed descriptively and qualitative responses using content analysis.

Results: 19 services responded, predominantly urban based. All but one reported access to an SPP, but capacity was limited (mean whole time equivalent 0.53), with only 29% of services having full-time provision. Access to psychology was frequently restricted by diagnosis, prognosis, service eligibility or discharge status. Training provision and supervision were inconsistent, with generally high staff confidence where present. Key barriers included system fragmentation, poorly integrated Information Technology, constrained clinical space, workforce shortages and delays in accessing psychological input.

Conclusions: Specialist psychological provision in non-hospice palliative care remains uneven and capacity constrained. Investment in dedicated SPP roles, strengthened training and supervision infrastructure and improved cross-system integration are needed to support equitable access to psychological care.

Objectives: Higher specialty trainees are expected to achieve clinical and non-clinical skills during training in preparation for a consultant role. However, evidence from many specialties from different countries suggests that new consultants are less prepared in non-clinical skills. The transition from trainee to a consultant phase can be challenging. The study aims to identify if new UK Palliative Medicine consultants, within 5 years of their appointment, feel prepared in clinical and non-clinical skills after completing specialty training and understand the support available for them.

Method: An online survey, designed using previous literature, was distributed via the Association for Palliative Medicine email and social media. Five-point Likert scales and drop-down options to record preparedness were used. Ethics approval was obtained.

Results: Forty-four participants from different UK regions completed the survey; 80% were female. The majority felt very/extremely prepared in audit (84%), clinical skills (71%), interaction with colleagues (70%). Majority moderate preparation was human resources (50%), organisation structure (68%) and leadership (52%). Most were not at all or slightly prepared in financial management (70%) and in complaint management (43%). The majority (75%) reported that departmental colleagues gave the most support in stressful situations but almost 49% did not have formal support.

Conclusion: New palliative medicine consultants require support with some non-clinical roles such as management of complaints and finances. This is consistent with findings from other specialties. New consultants would benefit from formal support. Future research could focus on how trainees could be supported to gain more experience in non-clinical domains.

Pain is one of the most distressing symptoms that patients experience as they approach the end of life. Opioids remain the gold standard of care, but the need for alternative options continues to grow, especially in the face of opioid unresponsive pain or opioid side effects. Clonidine, a drug initially known as a nasal decongestant and anti-hypertensive, has shown promise through its depression of the sympathetic nervous system by inhibiting norepinephrine release. It has since shown potential as an analgesic post-operatively, helping to reduce overall opioid use while providing adequate pain relief. This systematic review aimed to collate and analyse the available literature on the use of clonidine as an analgesic for palliative care patients. A comprehensive literature search was performed on CENTRAL, SCOPUS, MEDLINE, EMBASE and ClinicalTrials.gov for studies assessing the use of clonidine as analgesia for patients under palliative care. Twelve studies involving 194 patients were included. All studies were either case reports or case series. Clonidine was used as both monotherapy and as an adjunct through a variety of delivery methods, including intrathecal, perineural, subcutaneous and transdermal. Clonidine has shown initial potential to provide adequate analgesia while reducing overall opioid usage. However, further research is required to form a stronger evidence base and gain further insight into its future role in this field. Further insight is also required into more easily accessible delivery, such as oral, subcutaneous and transdermal routes.