- Correspondence to Dr Bill Noble, Academic Unit of Supportive Care, University of Sheffield, Sykes House, Little Common Lane, Sheffield, S11 9NE, UK; email@example.com
Treating depressive symptoms in patients with a short prognosis is one of the perennial problems encountered by palliative care teams. In spite of current practice, and the fact that some guidelines include the use of psychostimulants, there is a lack of evidence for their use and a study comparing the psychostimulant, Methylphenidate with placebo in palliative care services is long overdue. My choice of Carlos Centano, Alvaro Sans and colleagues’ paper on their multicentre, double-blind, randomised placebo-controlled clinical trial is an important contribution to the sparse data relating to the question. Lauren Rayner and Matthew Hotopf's editorial sets out the context and some implications for practice and research that may be reasonably drawn from the work.
In an ambitious paper with a public health perspective, Jeroen Hasselhaar and colleagues attempt to estimate the size of the European population in need of palliative care and find considerable variation between the countries of the European Union. The study calculated the number of persons dying of cancer and chronic diseases in Europe, taking into account regional differences. It comes up with the figure of between 2.14 and 4.97 million people a year.
Looking forward to finding ways of coordinating care for large numbers of palliative care cases, Clair Smith and colleagues’ feature on ‘Coordinate My Care’ describes a care pathway for patients with palliative care needs supported by an electronic record. It appears to offer a technical solution to the problem of how to integrate the care of patients in a complex ecology of healthcare providers. The system, designed by Julia Riley's Group, displays the patient's diagnosis, prognosis, current and anticipated problems, advanced care plan, resuscitation status and patients wishes. It is accessible by family doctors, community nurses and emergency services and is due to roll out to cover London healthcare services in the coming year.
Taking a national view, Albert Tuca's paper reports survey of all 60 Spanish palliative care hospital support teams and collected data on their structure and organisational outcomes. The project included a cohort study of 364 advanced cancer patients that described clinical outcomes relating to symptom control.
Susanne Claessen and colleagues contribute to the search for quality indicators to apply to palliative care services. The Consumer Quality Index Palliative Care is a structured questionnaire for measuring the quality of palliative care from the perspective of care users. It is designed to inform quality improvement by linking responses about experience of care to responses about the importance of those aspects of care. The paper reports preliminary work and points out that whether the instrument can discriminate differences in quality of care between organisations remains an important question.
We have a diverse collection of articles on specific clinical topics in this issue. Christine Rowland's systematic review examines differences as well as changes in Health Related Quality of Life between lung cancer patients who smoke compared to those who quit or never smoked. The authors suggest that their findings support the argument for programmes to address the specific needs of this group during their final months. Edith Ubogagu and colleagues’ feature on managing terminal haemorrhage in patients with advanced cancer discharged home for end-of-life care presents a guideline in the form of an algorithm, informed by a literature search. Jessica Hwang's qualitative study of survivors of allogeneic stem cell transplantation uses data from cognitive interviews and focus groups. Participants discussed late effects of therapy, most commonly graft-versus-host disease, and how they experienced continuing and lasting health effects. Stephen Kier and Julia Sterling's uncontrolled pilot study aims to make a preliminary assessment of the efficacy of massage therapy on patient-reported psychological outcomes and Quality of Life in patients with brain tumours. It points to a picture of improving quality of life within a treatment programme and emphasises the need for a controlled clinical trial to define the benefit of this example of complementary therapy.
Meanwhile, back in the lab, Torill Fladvad and colleagues’ study examined data from 2201 cancer pain patients in the European Pharmacogenetic Opioid Study. Here, they explore the relationship between genetic variation, in the form of 112 single nucleotide polymorphisms (SNPs) in 25 candidate genes relevant for opioid efficacy, to six parameters of phenotype; average pain intensity, pain right now, worst pain intensity, pain at its least, pain relief and pain interference. None of the phenotypes were associated with variation in the selected SNPs. This finding echoes the previous study's conclusion that opioid dose was similarly unrelated to these 112 SNPs. The search for useful pharmacogenetic technology to aid the prescription of analgesics goes on.
We have an editorial on the state of the art of e-learning in our field by Bee Wee who has lead an important UK initiative on end of life care education on the web.In the education section, Jennifer Hayes’ small questionnaire study of hospice inpatients highlights, once again, their wish to be involved in medical student teaching, but also highlights their concerns about physical examination. The obligation that some feel to participate has implications for medical educators and the way we obtain consent for teaching activity on our patients.
To complete the eclectic mix, we have two contributions on the nature of spiritual care. Shane Sinclair's paper on how to do spiritual care reports an ethnographic study that explores the provision of spiritual care for patients at the end of life by healthcare professionals. He presents a framework that aims to provide clinicians with a way to incorporate spiritual care into clinical practice. Mark Cobb offers a different insight with a synoptic model to find an explanation of how spirituality operates in the totality of patients’ lives. It is set out to include aspects of spirituality that remain neglected by researchers and practitioners.
Finally, John Birtwhistle offers an exploration of the struggle of a bereaved father when experience challenges belief in his commentary concerning Ben Jonson's poem, ‘On My First Son’. The boy died of the plague in 1603 and Jonson's work eloquently reflects the pain of loss through the language of the intellectual and spiritual worlds he inhabited. If these 400-year-old thoughts seem familiar, it might be that Jonson's contemporary, Shakespeare has already laid out the landscape in the mind of the modern day reader.
- Accepted 8 October 2012.
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