deprescribing at end of life

My pen poised over the drug chart, I hesitate.

Mr Jones* is a 58-year-old patient that my consultation palliative care team is seeing while he’s in hospital with complications of chemotherapy for advanced lung cancer. I am reviewing his discharge medications before he returns home to the care of the community palliative care team.

He is a very optimistic person, not keen to discuss the possibility of his cancer not getting better. An overweight hypertensive smoker, he’s on a full hand of antihypertensives, anti cholesterol medications, vitamin D supplements, a multi-vitamin, and antiplatelet therapy.

His prognosis is likely less than a year in my mind. Does he need all these medications?

A retrospective cohort study by Todd et al examined this question in groups of people with advanced lung cancer in the United States and the UK. The patients had died and been admitted to hospital then discharged at least once in their last 6 months of life.  Continue reading

#ANZSPM18 Conference – New Frontiers

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The Australian and New Zealand Society of Palliative Medicine 2018 Conference #ANZSPM18 is off the a great start, with many excellent plenaries & proffered papers presented on day 1 – following an excellent Trainee Day & pre-Conference workshop on thought leadership.

Day 2 promises to be even more awesome, starting off with keynote speaker Tom Le Blanc sharing his insights on collaboration & integration between palliative care & haematology. The rest of the day will feature a variety of plenaries & concurrent sessions on the new frontiers of palliative medicine – the theme of the conference. I’m also looking forward to the conference dinner tonight!

You can find the sides for my presentation on Palliative Care in Heart & Lung Transplantation here: HLTX PC ANZSPM18 Chi Li

Enjoy!

#ANZSPM Study Day for trainees & new fellows

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Beautiful spaces inside the Victorian Comprehensive Cancer Centre, the new home of the Peter MacCallum Cancer Centre in Melbourne, Australia

[The following article by Dr Sarah Dunlop, advanced trainee in palliative medicine, was first published in the Australian & New Zealand Society of Palliative Medicine (ANZSPM) Newsletter. The next ANZSPM study day will be held on September 6th in Sydney prior the the upcoming ANZSPM 2018 Conference. Follow #ANZSPM18 for updates from this biennial meeting – Chi] 

While there are many benefits of living in Western Australia (the weather, the beaches, and charming, debonair palliative medicine trainees), there are also downsides to living in one of the most isolated cities in the world… specifically the isolation! The decision to travel interstate to a course or conference usually hinges on three questions: can I get the time off, can I afford it, and is it going to improve my practice? So after charming my colleagues into giving a debonair trainee a day off and boarding the red-eye to Melbourne, I can confirm that the Study Day for Trainees and New Fellows met all my requirements.  Continue reading

immunotherapy and the miracle cure

Another insightful article from Dr Ranjana Sriastava, a Melbourne medical oncologist and writer, encapsulates my recent experience as a palliative care doctor on the frontline between hope and dying in a cancer centre.
The anticipated miracles of cancers dissolving before our eyes are common enough for patients and doctors to push on with expensive, sometimes self-funded treatment (at great cost) in preference to the needed preparation by patient and family for dying. For a patient and family perspective, skip down to the comments after the article and read HugiHugo’s description of his wife’s last months while undergoing treatment.

A patient with widely disseminated and aggressive melanoma having immunotherapy grunted at me in frustration last month. “Listen,” he said, “they are all high-fiving over there in the oncology clinic. Why do you want to talk about end of life stuff? It’s really confusing.” Pretty appalled at the idea that we were giving the patient mixed messages, I was fortunate to be able to do a joint consultation with the patient’s medical oncologist to nut out our different perceptions. Unfortunately for the patient, his oncologist confirmed that the treatment was very unlikely to be a miracle and most patients in his situation would live less than a year. To say that the patient was shocked was an understatement. Had he not been referred to my team for symptom management, this conversation would have happened later – or never.

Evidence is emerging that outcomes of immunotherapy in patients with poor performance status are very unimpressive. Patients with poor performance status had been excluded from initial trials.
Where does the deficit in our communication of hope lie? Is it in the delivery by the doctor? The reception by the patient? A bit of both? How can we accurately respond to the portrayal of immunotherapy in the media and social media as a miracle cure, and allow for the possibility of benefit without downplaying the risks?

Sonia

 

 

Raise awareness for World #Delirium Day 15 March 2017

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Delirium is a favourite topic of ours at Palliverse – it is experienced by many people with palliative care needs, including at the end of life, and is often distressing to the person, their loved ones and health professionals providing care. Despite this, it remains poorly recognised, underdiagnosed and poorly treated – not least because the evidence base is still growing.

iDelirium, a federation of the Australasian Delirium Association, European Delirium Association and American Delirium Association, has launched World Delirium Day (#WDD2017) in an attempt to raise awareness of delirium and improve its management.

They have suggested some Actions to Take on #WDD2017. I’ve listed them below & with some thoughts on how to take action.

  • Commit to using the term ‘delirium’

If you hear someone using terms like “agitated”, “restless”, “aggressive” or “pleasantly confused”, think – could this be delirium? I use the term delirium, document it and make sure it’s communicated in the medical record and letters. Recognising and diagnosing delirium allows us to educate patients and their loved ones, as well as providing the best delirium care possible.

  • Screen your patients for delirium

People at risk of delirium, who should be screened, include those with serious illness, those aged over 65 years and those with underlying cognitive impairment. This includes many of the people cared for by palliative care services! The diagnosis of delirium may be missed, delayed or misdiagnosed without screening, as signs may be subtle (especially in hypoactive delirium).  There are multiple simple bedside screening tests for delirium, and although not all these have been validated in the specialist palliative care setting, they are still useful. The 4AT is a freely available screening tool that can be administered by any health professional and does not require training.

  • Listen to patient and family stories about the experience of delirium

What may seem “pleasantly confused” to staff members can be very distressing for the delirious person and their families. Being agitated, aggressive or “just not themselves” can be distressing for patients and families to witness – it is important to acknowledge these emotions and provide education about delirium. (See “Michael’s Story: the fear on his face was palpable” for a wife’s experience of her husband’s undiagnosed delirium.)

  • Engage your leadership in a discussion of delirium

If the above isn’t enough to convince your leadership to take note, delirium also increases the risk of health care complications like falls, pressure injuries, prolonged length of stay, and mortality. For those in Australia, World Delirium Day is a great time to introduce your leadership to the recently released Delirium Clinical Care Standard (which we’ve covered here before).

  • Educate health professionals about delirium

Delirium does not “belong” to just one group of health professionals or one specialty. It’s common, especially in palliative care, and important for us all to know about it.  Some of my favourite educational resources are freely available at the Scottish Delirium Association, plus this 5-minute video from UK-based  Delirium Champion Dr MS Krishnan. (I’ve shared this before but it’s worth sharing again!)

As a final bid to raise awareness, you can participate in a #WDD2017 Thunderclap via your Facebook, Twitter or Tumblr account, to alert your friends and followers to the importance of delirium.

free Australian webinars on advance care planning and palliative care

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Decision Assist is running a series of free webinars on advance care planning and palliative care.

For those of you new to webinars, you can watch the presentation live on the internet and interact with the presenters, or just watch the presentation later. Some health services and aged care facilities are watching them together as part of their continuing professional development or education programs.

Here is a link to register. The next one is presented by Ilsa Hampton, CEO, Meaningful Ageing Australia

Decision Assist Aged Care Webinar Series – Grief, trauma and loss
Tuesday 6 December 2016 | 1.30 pm – 2.15 pm AEDT

http://www.webcasts.com.au/decisionassist061216/

Regards, Sonia (who also works for Decision Assist!)

 

#ANZSPM16 tweet chat: Medicinal cannabis and palliative care

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In recent years scientific research into the effects of cannabinoids has been on the increase. Some would say that not-so-scientific research on the effects of cannabis has been underway for many hundreds of years, in many different countries and cultures.

Until recently I didn’t know that our own bodies produce endogenous cannabinoids, the various effects of which are still being studied. 

Two years ago, colleagues had informed me that at the Montreal Conference 2015 it was a ‘smokingly hot’ topic. The most widely studied cannabis-derived cannabinoids are Cannabidiol (CBD) and Tetrahydrocannabinol (THC.) You may have heard of some of the medications that have ‘come to market’ since then:  Continue reading

Highlights from day 1 #ANZSPM16

We had a terrific day one at the #ANZSPM16 conference in Perth. The conference, mainly catering to palliative doctors in Australia and New Zealand, takes place in the luxurious Duxton hotel close to the Swan River in Perth.

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Highlights from #ANZSPM16 pre-conference workshops

The Australian and New Zealand Society of Palliative Medicine (ANZSPM) 2016 Conference opens today. A number of excellent pre-conference workshops were held yesterday, including:

  • A comprehensive trainee day, including a great workshop from Katrina Anderson on self-care and reflection about love, strength, vulnerability and respect; the use of methadone (Pippa Hawley); the challenges of providing palliative care in residential aged care facilities (Douglas McGregor), patients and families with vulnerable personalities (David Kissane), and the neuroanatomy of distress (Lisa Miller)
  • A great presentation on the role of media in palliative care, followed by a hands-on workshop in the afternoon, under the encouraging guidance of Marie Mills; and
  • Supervisor workshop, lead by Michelle Gold and Brian Le

Team Palliverse will be broadcasting from the #ANZSPM16 Conference for the next three days. If you are at the conference, please come and say g’day – and recharge your devices – at the social media hub!

#ANZSPM16 – How does literature enrich our understanding of illness and dying?

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If, like me, you appreciate the arts and enjoy becoming engrossed in the literature (not indexed on PubMed)—then this workshop is for you!

On the morning of Sunday, 11th September #ANZSPM16 delegates will be treated to the workshop:

From Tolstoy to Garner: How literature enriches our understanding of illness & dying.

The workshop will be facilitated by: Gabrielle Brand, Felicity Hawkins, Carol Douglas, Mary McNulty, Valerie Henry, and Anna Petterson.

For more background on the use of arts and literature in palliative care, continue reading!

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