Constipation is a highly prevalent and distressing symptom in patients with advanced, progressive illnesses. Although opioids are one of the most common causes of constipation in patients with advanced, progressive illness, it is important to note that there are many other potential etiologies and combinations of causes that should be taken into consideration when making treatment decisions. Management approaches involve a combination of good assessment techniques, preventive regimens, appropriate pharmacological treatment of established constipation, and frequent monitoring. In this vulnerable patient population, maintenance of comfort and respect for individual preferences and sensitivities should be overriding considerations when making clinical decisions. This consensus document was developed by a multidisciplinary group of leading Canadian palliative care specialists in an effort to define best practices in palliative constipation management that will be relevant and useful to health care professionals. Although a wide range of options exists to help treat constipation and prevent its development or recurrence, there is a limited body of evidence evaluating pharmacological interventions. These recommendations are, therefore, based on the best of the available evidence, combined with expert opinion derived from experience in clinical practice. This underscores the need for further clinical evaluation of the available agents to create a robust, evidence-based foundation for treatment decisions in the management of constipation in patients with advanced, progressive illness.
Prior to 1 year ago, undergraduate medical palliative medicine education at the University of Alberta in Edmonton, Alberta, was limited to a 1-hour didactic session and one-half day patient visit. A new integrative curriculum has allowed for increased educational exposure to palliative care for medical students. Topic content has expanded and different teaching modalities are used to aid learning. A highlight of the program is Bus Rounds where small groups of students visit terminally ill patients in either a hospice or home setting. After their training, the students performed well on two examination questions dealing with palliative care issues.
Division of Palliative Medicine, Department of Oncology, University of Alberta, Edmonton Palliative Medicine Program, Grey Nuns Hospital, 1100 Youville Drive W, Edmonton, Alberta, Canada. email@example.com
Little is known about complementary therapy services (CTs) available in Canadian palliative care settings.
An online survey was e-mailed to multiple Canadian palliative care settings to determine the types and frequency of CTs provided and allowed, who are the CT providers, funding of CT services, and barriers to the provision of CTs.
The response rate was 54% (74/136). Eleven percent of surveyed palliative care settings provided CTs, and 45% allowed CTs to be brought in or to be used by patients. The three most commonly used CTs were music (57%), massage therapy (57%), and therapeutic touch (48%). Less than 25% of patients received CTs in the settings that provided and/or allowed these therapies. CTs were mostly provided by volunteers, and at most settings, limited or no funding was available. Barriers to the delivery of CTs included lack of funding (67%), insufficient knowledge of CTs by staff (49%), and limited knowledge on how to successfully operate a CT service (44%). For settings that did not provide or allow CTs, 44% felt it was important or very important for their patients to have access to CTs. The most common reasons not to provide or allow CTs were insufficient staff knowledge of CTs (67%) and lack of CT personnel (44%).
Overall, these findings were similar to those reported in a US-based hospice survey after which this survey was patterned. Possible reasons for these shared findings and important directions regarding the future of CT service provision in Canadian palliative care setting are discussed.
Acupuncture involves the insertion of needles into designated acupuncture points to aid in the treatment of symptoms and to improve health.
A survey was conducted in a tertiary palliative care unit where 50 patients with advanced cancer were surveyed to determine their understanding of, use of, and interest in acupuncture.
Twenty-seven (54%) patients provided an accurate understanding of acupuncture. Although only 30% of patients had previously used acupuncture to treat noncancer medical conditions and only 10% had used it for cancer related symptoms, 80% of patients were interested in seeing an acupuncture practitioner on the care unit if one was made available.
Although few advanced cancer patients on a tertiary palliative care unit had previously received acupuncture, many had a general understanding of this complementary therapy, and expressed an interest in seeing an acupuncture practitioner.
Graduating medical students from the class of 1999 from McGill University and the University of Alberta completed a self-administered, anonymous, pilot survey to determine students' perspectives on how their educational experience in common palliative care topics contrasted with their educational experience in the diagnosis and management of hypertension, non palliative aspects of breast cancer, and patients dying of acquired immune deficiency syndrome (AIDS).
A Likert scale ranging from "excellent," scored 1, "very poor," scored 5, was used. Students also estimated the number of hours they spent, during their training, in operating rooms, on home visits to terminally ill patients, and in interprofessional teaching.
Sixty of 114 (53%) students from McGill University, and 53 of 110 (48%) students from the University of Alberta responded to the survey. The mean ratings of education experience in the various topics for both universities combined were as follows: hypertension, 2.03; breast cancer, 2.33; cancer pain, 3.42; communicating with dying patients, 3.32; and caring for patients with AIDS, 4.15. The average number of hours spent in the operating room, on home visits to terminally patients, and in interprofessional teaching for both universities combined were 155 hours, 4.2 hours, and 16 hours, respectively. Of the responding students from both universities 83% favored increased palliative care teaching.
Despite the disproportionate number of hours spent in operating rooms compared to palliative care community exposure, only two students, one from each university, favored shortening surgical rotations to allow for increased time for palliative care education. Recommendations, including increasing palliative care education during clinical clerkships, are provided to improve medical students' perceptions of their educational experiences in palliative care education.
Canada does not have a standardized ethical and practice framework for continuous palliative sedation therapy (CPST). Although a number of institutional and regional guidelines exist, Canadian practice varies. Given the lack of international and national consensus on CPST, the Canadian Society for Palliative Care Physicians (CSPCP) formed a special task force to develop a consensus-based framework for CPST.
Through a preliminary review of sedation practices nationally and internationally, it was determined that although considerable consensus was emerging on this topic, there remained both areas of contention and a lack of credible scientific evidence to support a definitive clinical practice guideline. This led to the creation of a framework to help guide policy, practice, and research.
This framework was developed through the following steps: 1) literature review; 2) identification of issues; 3) preparation of a draft framework; 4) expert consultation and revision; 5) presentation at conferences and further revision; and 6) further revision and national consensus building.
A thorough literature review, including gray literature, of sedation therapy at the end of life was conducted from which an initial framework was drafted. This document was reviewed by 30 multidisciplinary experts in Canada and internationally, revised several times, and then submitted to CSPCP members for review. Consensus was high on most parts of the framework.
The framework for CPST will provide a basis for the development of safe, effective, and ethical use of CPST for patients in palliative care and at the end of life.
A survey was conducted in fall 2001/spring 2002 to provide an update on the status of undergraduate palliative medicine education in Canada. The survey identified that the majority of palliative care teaching occurs in the pre-clinical years of medical school, with supervised patient encounters occurring primarily during electives. The coverage of palliative care topics is inconsistent across curricula. Student evaluation methods also vary, with only one school using simulated patients. More than half the schools have an academic division or department of palliative care medicine, although faculty with protected academic time are few in number. A number of barriers to palliative medicine education were identified, including competition for time within the undergraduate curriculum, and lack of resources for curriculum development and teaching. Respondents recommended increased clinical exposure, curriculum development, student assessment and evaluation, faculty development, and improved infrastructure. Following these recommendations, the Undergraduate Palliative Medicine Committee has dedicated itself to developing and fostering a strategic implementation plan to improve palliative medicine education in Canadian medical schools.
The purpose of this study was to examine the frequency and types of antibiotics prescribed in the last week of life in three different palliative care settings, including an acute care hospital, tertiary palliative care unit, and three hospice units. A total of 150 consecutive patients were evaluated, 50 in each of the three settings. Twenty-nine patients (58%) in the acute hospital setting, 26 (52%) in the tertiary palliative care unit, and 11(22%) in the hospice settings were prescribed antibiotics. In the acute care and tertiary palliative care settings, the most frequent route of antibiotic administration was intravenous and, in the hospice setting, oral. We conclude that there is marked variability in the numbers and types of antibiotics prescribed in these different palliative care settings in the last week of life. The high use of intravenous antibiotics and the large number of patients who were still receiving antibiotics at the time of death indicate the need for further prospective studies.