Comment: Thursday’s child has far to go
Jonathan Koffman
pp 223-223
We emerge deserving of little credit; we who are capable of ignoring the conditions that make muted people suffer. The dissatisfied dead cannot noise abroad the negligence they have experienced. Nearly 40 years ago, John Hinton drew attention to the deficiencies that were evident in the care offered to many patients with advanced disease and their families. While we have witnessed a dramatic growth in palliative care provision and a greater understanding of the needs of patients, actual access to services has been wholly inequitable.
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Practical management of diabetes mellitus
Mary-Ann McCann, Clare White, Simon Au and Max Watson
pp 226-229
Diabetes mellitus is a syndrome characterised by chronic hyperglycaemia that is due to relative insulin deficiency, resistance or both. Worldwide, the estimated prevalence of diabetes in 2000 was 2.8%, affecting 171 million people; by 2030, the prevalence is predicted to reach 4.4%, affecting 377 million people. In palliative care, the prevalence of diabetes is often higher. It may be pre-existing, or may develop after the cancer diagnosis due to the disease process – for example, pancreatic failure – or secondary to medication, such as steroids. During the last two decades, advances in the management of diabetes have centred around improving glycaemic control. The number of available oral hypoglycaemic agents has increased significantly, which translates into more therapeutic options and complex decision-making for prescribers. In the palliative care setting, the management of diabetes mellitus can prove difficult, as a patient’s needs are often changing.
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An overview of opioids in palliative care: part 1
Julia Riley, Joy Ross, Sophy Gretton and Anna-Marie Stevens
pp 230-233
Opioids are the oldest and most effective agents for the short- and long-term control of moderate-to-severe pain. Morphine is the strong opioid of choice for the treatment of moderate-to-severe cancer pain, according to guidelines from the WHO, and is the gold standard to which other new analgesics are compared. The WHO analgesic ladder recommends a therapeutic strategy whereby, with rising severity of pain, increasing doses of analgesic drugs are prescribed moving from one step on the ladder to the next. Since its publication, new opioids have become available. Opioids that are now available differ in a number of ways, including: route(s) of administration, dose sizes available, onset of action, mechanism of action, route of metabolism and presence of active metabolites.
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Case study masterclass 29: Psychological care in palliative day care
Isabel Dosser and Jacqueline S Nicol
pp 234-235
Mark is a 49-year-old man with oesophageal cancer and liver metastases; his disease has not responded to chemotherapy. He is married to Margaret who is 38 and has multiple sclerosis (MS). Mark has two sons from a previous marriage and is in contact with them but does not visit them often because they live in Canada. Mark and Margaret have one daughter, Maria who is seven.
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Case study masterclass 28 answers: Another challenging patient with a primary brain tumour
Lucy Boyland
pp 235-235
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Latin American survey on the treatment of cancer pain
Jairo Moyano, Franklin Ruiz, Stefan Esser, Eduardo Bruera and Annelli Vainio
pp 236-240
Opioid drugs are indispensable in the treatment of cancer-related pain and monitoring their consumption provides a broad indicator of the quality of care that cancer pain patients are receiving. There is evidence of low opioid consumption in Latin America. According to the International Narcotics Control Board (INCB) data (1997), the consumption of morphine (mg/capita) – excluding recreational use – in some countries was: Colombia 1.19; Peru 0.10; Venezuela 0.046; Chile 1.52; Mexico 0.04; Ecuador 0.007. This is clearly lower in comparison with well-developed Western countries, such as Denmark 77.08 and Canada 38.04.
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Transferring patients from hospices to nursing homes
Margaret Reith and Caroline Lucas
pp 241-243
The aim of palliative care is to achieve good quality of life and a dignified death, preferably in the patient’s preferred place of care (PPC). For many people who do not wish, or for whom it is not practical, to die at home, a hospice that specialises in end of life care offers the next best option and is indeed often the PPC. If, however, a UK hospice patient’s clinical condition unpredictably stabilises, a dilemma arises since the average length of stay in a hospice bed must remain at 10–12 days to use beds equitably and efficiently. The alternative option is to transfer those suffering from life-limiting illnesses from hospices which provide free specialist palliative care to ‘care homes with nursing’, which can be an emotive and difficult issue for patients, families and staff. It may be contrary to people’s wishes and best interests.
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Living alone and dying at home: a realistic alternative?
Marit S Jordhøy and Gunn Grande
pp 244-247
During recent decades, home care has been a main focus within palliative care and is based on the philosophy and belief that dying at home is the preferred ideal for patients and their families. Accordingly, there has been considerable expansion of palliative care services to enable care and death at home. These initiatives have been accompanied by increased emphasis on home care within healthcare policy in several countries. It is debatable whether the latter is the result of a growing acknowledgement of the benefits of palliative care or related to increased strains on existing healthcare resources – hospital beds in particular. Regardless, the result is that the palliative care community and healthcare politicians have been working towards the same goal. Despite this, the proportion of patients who die at home is still a minority, raising the question of whether dying at home is truly a preferable and realistic alternative for larger subgroups of patients.
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User involvement in cancer care research
Nic Hughes
pp 248-250
For many academics, professional researchers and clinicians engaged in healthcare research, traditional approaches to identifying research problems and questions have tended to overlook consultation with people who use health services. This situation is changing, along with the increasing democratisation of society and the growth in consumerism. Researchers are more frequently expected to consult with and to involve service users and members of the public at each stage of the research process. For some research commissioners this is now mandatory. Models for how this can be achieved have appeared in the literature and, in the UK, an organisational infrastructure has been constructed to stimulate and support user involvement in research. But, for many researchers, this remains a new, untried and untested approach to research activity.
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A palliative care unit for AIDS and cancer sufferers in Cambodia
Brigide Maigret, Jessy Bonnet, Paulette Ferlender and Philippe Poulain
pp 253-256
Situated on the Indochinese Peninsula, Cambodia is a country of roughly 181,000 square kilometres and about 13.5 million inhabitants, with an annual population growth of 2%. The country is divided into 24 provinces, with a great disparity in terms of population density (from 12 to 350 inhabitants/km2 – apart from the capital, which has a density of 4,000 inhabitants/km2).
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Providing palliative care for prisoners
Miriam Colleran and Liam O’Síoráin
pp 257-260
Rold proposed that the treatment of sick and imminently dying inmates is a reflection of our principles as a society. Interest in the provision of palliative care for inmates in American prisons developed in response to the number of AIDS-related deaths of inmates. The cases of Billy Bell and Michael Joseph LeBlanc heightened public and prison officials’ awareness of prisoners with terminal illness and especially of their medical, psychological and spiritual needs.
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