We read with great interest the paper by Rhondali et al.(1) and we
thank them for their contribution to a very worthwhile topic. We are
involved in palliative care research in Mauritania, West Africa, and we
appreciate this piece of research coming from France and we hope it will
stimulate more palliative care research, not just in France but throughout
the francophone world. As the likes of Uganda...
We read with great interest the paper by Rhondali et al.(1) and we
thank them for their contribution to a very worthwhile topic. We are
involved in palliative care research in Mauritania, West Africa, and we
appreciate this piece of research coming from France and we hope it will
stimulate more palliative care research, not just in France but throughout
the francophone world. As the likes of Uganda (2) and Malawi(3) have
benefitted from close ties to Anglophone palliative care researchers based
in Europe and North America, we believe that closer ties between France
and specifically francophone Africa would be greatly beneficial.
In addition to the barriers the paper identified, the authors propose
that difficulty with English could be a further barrier for investigators
in France. Given this suggestion we are a little surprised to note that
the authors chose to publish in an anglophone journal which perhaps could
limit the potential impact of this paper.
In the introduction, the authors state that only 2% of European
Palliative Care research came from France, however this is biased as the
citing source excluded non-English research(4) and the authors acknowledge
that most of the palliative care research from France is published, in
French, in the journal Medecine Palliative. A more encouraging picture is
gained from the 2nd Francophone Palliative Care Congress which was held in
Canada in 2013 where research was presented from Africa, North America,
Europe and Asia. We look forward to the 3rd congress which will be held in
Tunisia, 2015 and at this occasion we hope to see many more francophone
researchers coming from Africa.
This paper highlights multiple barriers which, from our experience,
reflects our context. Here, and in France, we believe creative and
multidimensional solutions are required to overcome these barriers, or
perhaps challenges is a more suitable term implying that they are
surmountable.
Yours sincerely,
David Fearon
PhD Student and Advocate for Palliative Care in Mauritania
Lancaster University
d.fearon@lancaster.ac.uk
Ahmedou Ould Ahmedou
Chief Medical Officer
Centre National d'Oncologie
Nouakchott
Mauritania
1. RHONDALI, W., BERTHILLER, J., HUI, D., et al. 2014. Barriers to
research in palliative care in France. BMJ Support Palliat Care 2014;4:182
-189
2. GRANT, L., BROWN, J., LENG, M., et al. 2011. Palliative care
making a difference in rural Uganda, Kenya and Malawi: three rapid
evaluation field studies. BMC Palliat Care, 10, 8.
3. MURRAY, S. A., GRANT, E., GRANT, A. et al. 2003. Dying from cancer
in developed and developing countries: lessons from two qualitative
interview studies of patients and their carers. BMJ, 326, 368.
4. HUI D, PARSONS HA, DAMANI S, et al. Quantity, design, and scope of
the palliative oncology literature. Oncologist 2011;16:694-703.
I read with interest the letter from McKenna and others describing
the evolution of an algorithm to aid decision making in the withdrawal of
life-sustaining medical devices (LSMDs) (1). The briefly described
scenario involving the development of cancer in a patient with a left
ventricular assist device (LVAD) as a bridge to transplantation is
familiar to us in cardiovascular medicine, as is the resulting need for
decis...
I read with interest the letter from McKenna and others describing
the evolution of an algorithm to aid decision making in the withdrawal of
life-sustaining medical devices (LSMDs) (1). The briefly described
scenario involving the development of cancer in a patient with a left
ventricular assist device (LVAD) as a bridge to transplantation is
familiar to us in cardiovascular medicine, as is the resulting need for
decision making in the moment which often becomes the default position.
While the occurrence of this comorbidity could not have been
anticipated in this transplant candidate, such events will be increasingly
encountered in heart failure patients supported for prolonged periods with
LVADs as destination therapy, and given the exponential rise in implant
rates, this situation will be commonplace in those surviving with
implantable cardioverter defibrillators (ICDs).
While the proposed decision tree provides a useful checklist for LSMD
withdrawal, my impression is that at initiation, the protocol appears
largely reactive. The flow chart seems to imply that any discussion
concerning device withdrawal is broached for the first time at the point
of an unanticipated patient request or when the device recipient is
subject to what may be a rapidly evolving irrecoverable clinical
situation. Any notion of advance care planning is described only in the
setting of assessment of capacity relevant to the Mental Capacity Act.
Given the prognostic ambiguity intrinsic to the heart failure disease
trajectory, advance care planning might offer significant advantage to
these patients and their families encumbered with such uncertainty. While
the use of advance directives by those with heart failure is increasing,
specific device related decision making remains the exception (2,3).
However, preparedness planning for end of life care incorporating
palliative care consultations has been shown to be of benefit in those
being considered for LVAD therapy (4), and prospective pre-implantation
discussion about this issue is mandated in the in the position statement
on ICD deactivation from the Heart Rhythm Society in the United states and
supported by the European Heart Rhythm Association (5). Such a dialogue
would also be necessary as part of the description of the benefits and
burdens of device therapy required of an ethically framed valid informed
consent process and central to the premise of shared decision making in
advanced heart failure (6).
Having been opened prior to device implantation, it would seem
appropriate to revisit these end of life care discussions at intervals
during follow up, perhaps reducing the complexity of the management of the
inevitable crises, and avoiding some of the dilemmas linked to clinical
situations such as that described (7). The authors may wish to consider
incorporating an element referring to device related advance care planning
early in their proposed algorithm.
References
1) McKenna M, Wrightson N, Regnard C, Clark S. Life-sustaining medical
devices at the end of life. BMJ Support Palliat Care
doi:10.11.1136/bmjspcare-2012-000364.
2) Habal MV, Micevski V, Greenwood S. et al. How aware of advanced care
directives are heart failure patients, and are they using them? Canad J
Cardiol 2011, 27:376-81.
3) Tajouri TH, Ottenberg AL, Hayes DL, Mueller PS. The use of advance
directives among patients with implantable cardioverter defibrillators.
Pacing Clin Electrophysiol. 2012 , 35:567-73.
4) Swetz KM, Freeman M, AbouEzzeddine OF. et al. Palliative medicine
consultation for preparedness planning in patients receiving left
ventricular assist devices as destination therapy. Mayo Clin Proc 2011,
86:493-500.
5) Lampert R, Hayes DL, Annas GJ. et al. HRS Expert Consensus Statement
on the Management of Cardiovascular Implantable Electronic Devices (CIEDs)
inpatients nearing end of life or requesting withdrawal of therapy. Heart
Rhythm. 2010, 7:1008-26.
6) Allen LA, Stevenson LW, Grady KL. et al. Decision making in advanced
heart failure: a scientific statement from the American Heart Association.
Circulation 2012, 125:1928-52.
Kirkpatrick JN, Fedson SE, Verdino R. Ethical dilemmas in device
treatment for advanced heart failure. Curr Opin Support Palliat Care.
2007, 1:267-73.
I am perplexed why this paper by Jandhyala and Fullarton has
concluded that "FBT (fentanyl buccal tablet) may have some efficacy
advantages over ODT (sublingual oral transmucosal fentanyl) and OTFC
(compressed lozenge oral transmucosal fentanyl)..." in the management of
breakthrough cancer pain when a paper published at the same time in
another journal (Smith H, A comprehensive review of rapid-onset opioids
for breakthr...
I am perplexed why this paper by Jandhyala and Fullarton has
concluded that "FBT (fentanyl buccal tablet) may have some efficacy
advantages over ODT (sublingual oral transmucosal fentanyl) and OTFC
(compressed lozenge oral transmucosal fentanyl)..." in the management of
breakthrough cancer pain when a paper published at the same time in
another journal (Smith H, A comprehensive review of rapid-onset opioids
for breakthrough pain, CNS Drugs 2012;26(6)509-535)concludes that "The
findings of this review suggest that the efficacy and safety of the
approved rapid-onset opioids are comparable".
Some concerns arise. Jandhyala and Fullarton in their introduction quote
the Portnoy definition of cancer breakthrough pain as "typically rapid in
onset (within a few minutes) and short in duration (around 30 min", go on
to show)that FBT produces similar levels of pain relief as ODT within that
period but then base their conclusions on pain relief up to 60 minutes
after pain initiation.
Further, the differences in pain intensity when FBT and ODT are considered
after 60 minutes, for example, are 0.75. Under the "Contributors"
section, Dr Jandhyala is listed as undertaking the clinical interpretation
of the data. In his clinical experience is such a change in pain score
clinically meaningful?
One last concern. This paper concludes that FBT may have some advantages
over the other fentanyl preparations (in contrast to the conclusions of
Smith quoted above). As this paper was funded by Cephalon, the
manufacturer of FBT and the lead author is the Interim Medical Manager of
that company only very definite data should have allowed an endorsement of
their product to avoid potential claims of a conflict of interest.
Re: Opinions of the patients with cancer on the relative importance
of place of death in the context of 'good death'.
By: Melaine Waghorn, Holly Young and Andrew Davies: BMJ Support Palliative
Care 2011:1 310-314
I am grateful for the opportunity to respond to Waghorn et al, 2011
study on opinion of patient with cancer on the relative importance of
place of death.
Having looked at the four highlighted domains ass...
Re: Opinions of the patients with cancer on the relative importance
of place of death in the context of 'good death'.
By: Melaine Waghorn, Holly Young and Andrew Davies: BMJ Support Palliative
Care 2011:1 310-314
I am grateful for the opportunity to respond to Waghorn et al, 2011
study on opinion of patient with cancer on the relative importance of
place of death.
Having looked at the four highlighted domains associated with a 'good
death' stated as:
? Being treated as an individual, with dignity and respect
? Being without pain and other symptoms
? Being in familiar environment
? Being in the company of close family and/or friends
If the patient fit into the above domains, I think the place of death is
not very important as per the result of this study. I would also add to
the above domains that, no matter the place a patient may prefer to die
what is important is that every individual want to have a peaceful death,
settling/making restitution, forgiving and being forgiven for any wrongs
with family members/friends, and making right standing with God. Fukui,
Kawagoe & Masako (2003) stated that most patients prefer home death or
hospice, despite these facts, most cancer patients in the United Kingdom
die in hospital bed. Most people currently die in hospital despite the
vast majority saying they would prefer to die at home in familiar
surroundings, close to family and friends (Lansley, 2010). From the above
citations,it means that their wishes are not very important.
Taking one site (setting) for the study does not give a result that could
be generalized. This is because most patients in some part of the world
diagnosed with advanced cancer do not see any need of going to the
hospital for treatment. They/family members feel that death is eminent as
such spending money in hospital bed is a waste. Evidence shows that
patients make fewer visits to their Doctors after psychological
interventions (Chiles et al, 2006). The setting should have included
homes, nursing homes and palliative/hospice centers.
The study may not be well applied to most part of the world due to
either non-availability of nursing homes or poverty to really have options
to where they would prefer to die. To the patient what is important is
getting quality care in the last days of life.
Reference
Chile J. A. et al 2006. The impact of psychological interventions on
medical cost offset: a meta-analytic review clinical psychology: Science
and Practice, 6:2,204-220
Fukui S, Kawagoe H, and Masako S. 2003. Determinants of the place of death
among terminally ill cancer patients under home hospice care in Japan.
Palliative Med. 17: 445-53
Lansley, A. 2010. Patients to have choice of where to die. Health Service
Journal. From: http://www.hsjjobs.com/?wTmc_id=HSJ
Akon E. Ndiok: Department of Nursing Science, University of Calabar,
Calabar. Nigeria.
This study generated discussion in our hospice about the importance
of breaking bad news well and also the importance of these discussions in
non cancer related disease. It was interesting the study showed 'people
with heart failure had engaged in much less discussion about their
condition, and most did not recall a specific conversation with their
doctor about their prognosis'. I recently reviewed the literature on
chr...
This study generated discussion in our hospice about the importance
of breaking bad news well and also the importance of these discussions in
non cancer related disease. It was interesting the study showed 'people
with heart failure had engaged in much less discussion about their
condition, and most did not recall a specific conversation with their
doctor about their prognosis'. I recently reviewed the literature on
chronic heart failure and a recurrent theme is that patients with chronic
heart failure have frequent thoughts about death both during acute
exacerbations and also in more chronic stable phases of their illness. As
clinician's we need to be aware of the predictors of end stage heart
failure and preferably embark on end of life conversations with our
patient's before this time. One study (Setoguchi S et al. Hospitalizations
in patients with heart failure. J Am Coll Cardiol. 2009;54(18):1703) found
approximately one third of patients die within a year of an admission for
heart failure and mortality figures are similar to that of bowel and
ovarian cancer so it is crucial to discuss advance care planning and
prognosis which can help alleviate patient fears, address concerns and
overall aim for better palliative care in the patients preferred setting.
I welcome this small but useful study highlighting the fear and
reluctance of patients and practitioners in using morphine in the setting
of chronic heart failure. Over 50% of chronic heart failure patients
suffer from pain and caution is needed with nearly all analgesics- NSAIDS
and COX2 are contraindicated, neuropathics agents can trigger arrhythmias,
steroids exacerbate salt and water retention, soluble drugs such as c...
I welcome this small but useful study highlighting the fear and
reluctance of patients and practitioners in using morphine in the setting
of chronic heart failure. Over 50% of chronic heart failure patients
suffer from pain and caution is needed with nearly all analgesics- NSAIDS
and COX2 are contraindicated, neuropathics agents can trigger arrhythmias,
steroids exacerbate salt and water retention, soluble drugs such as co-
codamol can contain a high salt content,and transdermal analgesics may be
limited with significant oedema , so not only is morphine useful for
managing dyspnoea in chronic heart failure but it may be a useful
medication to provide analgesia when options are limited. Clinicians need
not fear morphine use as it can have excellent results for symptom control
when used appropriately in this group of patients.
Many patients are ill because of wrong choices they made in their
life (eg smoking, excessive drinking, poor diet etc). How are we going to
ensure that they make the 'right choices' with their individual budgets
particularly if direct cash payments are made? How do we prevent the
exploitation of these individuals? This is not a 'paternalistic 'concern.
The checks and balances needed would be no more different from havin...
Many patients are ill because of wrong choices they made in their
life (eg smoking, excessive drinking, poor diet etc). How are we going to
ensure that they make the 'right choices' with their individual budgets
particularly if direct cash payments are made? How do we prevent the
exploitation of these individuals? This is not a 'paternalistic 'concern.
The checks and balances needed would be no more different from having a
legally binding 'lower speed limit' around schools rather than relying on
individual's common sense.
What about postcode lottery?. Individual service costs in London are
generally higher than in north but ill health is more prevalent in north.
[1] Would the patients from different regions have a different budget for
the same service? What criteria would be adopted for funding each region?
If age is used, people in north would certainly lose out. [2]
Individual budgets are, in principle, a very good idea but the
practicalities of implementation can make it into a white elephant . [3]
Lessons need to be leant from the Dutch experience.[4]
References
1 Hacking JM, Muller S, Buchan IE. Trends in mortality from 1965 to 2008
across the English north-south divide: comparative observational study.
BMJ 2011;342:d508-d508.
2 Bambra CL. Clear winners and losers are created by age only NHS
resource allocation. BMJ 2012;344:e3593-e3593.
3 Duffy SJ. Why Clinicians Should Embrace Individual Budgets. BMJ
Support Palliat Care Published Online First: 31 March 2012.
doi:10.1136/bmjspcare-2011-000118
4 Ginneken E v., Groenewegen PP, McKee M. Personal healthcare
budgets: what can England learn from the Netherlands? BMJ 2012;344:e1383-
e1383.
I am delighted to read Abel et al's conceptual paper regarding a
social model of care, utilising a compassionate communities framework. As
the paper has outlined, Milford Care Centre, Limerick, Ireland commenced a
Compassionate Communities pilot project in 2011. This project aims to
empower communities and reduce fear and stigma associated with death,
dying, loss and care. The project is being led...
I am delighted to read Abel et al's conceptual paper regarding a
social model of care, utilising a compassionate communities framework. As
the paper has outlined, Milford Care Centre, Limerick, Ireland commenced a
Compassionate Communities pilot project in 2011. This project aims to
empower communities and reduce fear and stigma associated with death,
dying, loss and care. The project is being led by a specialist palliative
care provider and does not aim to displace service provision. An element
of the Limerick project being explored for development in 2012-3 is a
community mentor project.
I would like to point out that the mentor project has not yet
commenced, and was not in operation at the time this paper was published.
Furthermore, it is our intention that access to the model, when
established, will most likely be patient and family initiated and not
service led as suggested in this paper by Abel.
I would be most grateful if this clarification could be published to
ensure our project is communicated clearly to readers.
We would like to thank Drs Satchithananda, Hookey and Sister Ingram
for their interest in our editorial. We welcome this opportunity to
respond. We framed our discussion in the setting of left ventricular
systolic dysfunction as this is where the robust evidence base for heart
failure therapy has evolved. The evidence base for effective therapy for
the clinical syndrome of heart failure with preserved systolic functio...
We would like to thank Drs Satchithananda, Hookey and Sister Ingram
for their interest in our editorial. We welcome this opportunity to
respond. We framed our discussion in the setting of left ventricular
systolic dysfunction as this is where the robust evidence base for heart
failure therapy has evolved. The evidence base for effective therapy for
the clinical syndrome of heart failure with preserved systolic function
(HFpSF) is much weaker, with very few randomised controlled clinical
trials (RCTs). However, we accept that the symptomatic burden and
mortality risk for those with HFpSF is comparable, and loop diuretic
therapy for the associated dyspnoea and congestion is no less applicable
to that clinical cohort. Indeed, differentiating between such sub-
populations may be largely irrelevant as many heart failure patients
exhibit demonstrable abnormalities of both systolic and diastolic
function.
While there are differences in the assignment of weighting in terms
of the class of recommendation and hierarchy of evidence on the
conventional use of loop diuretics over the range of acute and chronic
heart failure treatment guidelines, and RCTs may be hard to justify
ethically, we have an experiential
repository of about 40 years of clinical practice
with the use of oral and intravenous furosemide across the clinical
spectrum of heart failure. Accumulation of this experience underpins
clinical judgement and is consistent with the development of so called
'tacit knowledge' which has been proposed as fundamental to evidence base
development 1.
Certainly, individualising patients' dosing regimens with appropriate
clinical monitoring is mandated for this therapy to be effective and safe,
irrespective of the route of furosemide administration as demonstrated in
Diuretic Optimization Strategies Evaluation (DOSE) trial 2. The
successful use of this approach specifically for the prescription of
subcutaneous (SC) furosemide was apparent in the Scarborough study cited
in our editorial in which a wide dosing range was employed 3. This study
also demonstrated the effectiveness of multidisciplinary team working,
widely accepted as beneficial across the entire heart failure disease
trajectory, and no less relevant at the end of life 4. Indeed, the
recently published NICE heart failure quality standards require such an
approach, integrating the complementary clinical skills of both heart
failure and palliative care professionals to support those with moderate
to severe heart failure 5.
The main driver behind our editorial was concern about the largely
empirical adoption of SC furosemide by the palliative care community for
the treatment of patients dying with heart failure as the primary terminal
illness or as a comorbidity without addressing the need for systematic
assessment of effectiveness or clinical risk. This use of SC furosemide
for some of the sickest heart failure patients challenges the accepted
treatment paradigm, but also provides opportunity for formal clinical
evaluation, and we welcome the authors' potential contribution to
development of the evidence base for this form of therapy.
James M Beattie
Department of Cardiology, Heart of England NHS Foundation Trust,
Birmingham, UK; National Clinical Advisor, NHS Improvement.
Miriam J Johnson
Hull York Medical School, University of Hull; St Catherine's Hospice,
Scarborough, UK.
References
1. Thornton T. Tacit knowledge as the unifying factor in evidence
based medicine and clinical judgement. Philos Ethics Humanit Med. 2006
1:2
2. Felker GM, Lee KL, Bull DA. et al, Diuretic strategies in
patients with acute decompensated heart failure. N Engl J Med 2011;
364:797-805
3. Zacharias H, Raw J, Nunn A. et al. Is there a role for
subcutaneous furosemide in the community and hospice management of end-
stage heart failure? Palliat Med 2011,25: 658-63.
4. Ryder M, Beattie JM, O'Hanlon R. et al. Multidisciplinary heart
failure management and end of life care. Curr Opin Support Pall Care
2011, 5: 317-21.
5. NHS National Institute for Health and Clinical Excellence. Heart
failure quality standard, June 2011. Available from
http://www.nice.org.uk/guidance/qualitystandards/chronicheartfailure/home.jsp
We read the editorial concerning the use of subcutaneous furosemide
in heart failure with interest. We feel that there is a substantial
opportunity for misinterpretation of the editorial by readers not as
familiar with the issues raised as the eminent authors themselves.
This particularly relates to:
1 The heart failure syndrome
It is important to emphasize that the editorial relates to the treatment
of congestive symptom...
We read the editorial concerning the use of subcutaneous furosemide
in heart failure with interest. We feel that there is a substantial
opportunity for misinterpretation of the editorial by readers not as
familiar with the issues raised as the eminent authors themselves.
This particularly relates to:
1 The heart failure syndrome
It is important to emphasize that the editorial relates to the treatment
of congestive symptoms in patients suffering with the heart failure
syndrome irrespective of its causal mechanism i.e. left ventricular
systolic dysfunction is only one of many mechanisms inducing this syndrome
i.e.50% of patients hospitalised with heart failure do not have left
ventricular systolic dysfunction[1,2].
2 The use of furosemide in heart failure symptom relief.
It is important to recognise that the lack of evidence suggested for
subcutaneous furosemide is equally applicable to any route of delivery for
furosemide i.e. there are no placebo controlled randomised trials
demonstrating the longer term benefits of furosemide (irrespective of its
administration route) in terms of morbidity and mortality in heart
failure. Indeed there is a discrepancy in the analysis of the evidence for
the Grade 1 recommendation for furosemide (i.e. evidence and or general
agreement that a treatment or procedure is beneficial, useful and
effective) suggested both by American and European guidelines in heart
failure. The European Society of Cardiology guideline [3]suggests the
level of evidence is 'B' (i.e. limited populations evaluated. Data derived
from a single randomised trial or from non-randomised studies) wheras the
American Heart Association [1] evaluates the same evidence as 'C' (i.e.
very limited populations evaluated. Only consensus opinions of experts,
case studies or standards of care).
3 The efficacy and dosing of subcutaneous furosemide
The argument in favour of this practice is clearly documented by the
authors . Difficulties in dosing subcutaneous diuretics should be taken
within the similar uncertainties existing for the administration of any
diuretic irrespective of its route. The most recent (and only randomised
large scale trial of diuretics in decompensated heart failure) suggest no
substantial clinical difference between dose size or frequency of
administration of intravenous diuretics for decompensated heart
failure[4]. There is no reason to suspect that this lack of clear efficacy
of any single intravenous diuretic regime should not equally apply to
subcutaneously administered furosemide.
It is additionally not unusual within the evidence based practice of heart
failure to extrapolate evidence into populations not represented within
that evidence e.g. the majority of ACEI and B blocker trials have
populations entirely unrepresentative of clinically encountered
populations[5].
5 Clinical expertise and patient values
Heart failure is not a diuretic deficiency disease. Therefore the use of
increasing doses of diuretics, their need for titration, measures of
their success and the need for other cardiac and non-cardiac interventions
to reduce symptoms should all occur within the framework of a multi-
disciplinary heart failure programme (irrespective of the route of
administration of the augmented diuretic)[1,3]. Our own practice
specifically with regard to subcutaneous diuretics is to use professionals
skilled in the management of congestive symptoms to regularly titrate the
dose of subcutaneous diuretics until a pre-specified goal or end point is
reached. Weight reduction is only one feature of this assessment. It
should be noted that in a registry of over 100,000 patients hospitalised
with heart failure one third of patients lost < 2.3 Kg and 16% gained
weight over their entire hospitalisation [2].
While we agree with the authors that there is a need for further
evaluation of the use of subcutaneous fursoemide in the management of
advanced heart failure (indeed we are seeking to add to the evidence base
in this area), we feel that it may be unhelpful to isolate only this area
of heart failure management for comment. We hope that contextualising the
editorial's concerns (within the available knowledge of current heart
failure practice) will ensure the continued use of this route of
administration to afford patients' choice and control in the management of
their progressive chronic illness.
References
1 Hunt SA, Abraham WT, Chin MH, Feldman AM, et al. 2009 Focused update
incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and
Management of Heart Failure in Adults A Report of the American College of
Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines Developed in Collaboration With the International Society for
Heart and Lung Transplantation.. Circulation. 2009;119:1977-2016,
2 Gheorghiade M, Filippatos G. Reassessing treatment of acute heart
failure syndromes: the ADHERE Registry. European Heart Journal Supplements
(2005) 7 (Supplement B), B13-B19
3 Dickstein K, Cohen-Solal A, Filippatos G et al. ESC guidelines for the
diagnosis and treatment of acute and chronic heart failure 2008: the Task
Force for the diagnosis and treatment of acute and chronic heart failure
2008 of the European Society of Cardiology. Developed in collaboration
with the Heart Failure Association of the ESC (HFA) and endorsed by the
European Society of Intensive Care Medicine (ESICM). Eur J Heart Fail.
2008 Oct;10(10):933-89.
4 Fonarow GC Comparative Effectiveness of Diuretic Regimens. N Engl J Med
2011; 364:877-878
5 Mattie J. Lenzen1,*, Eric Boersma1, Wilma J.M. Scholte op Reimer et
al. Under-utilization of evidence-based drug treatment in patients with
heart failure is only partially explained by dissimilarity to patients
enrolled in landmark trials: a report from the Euro Heart Survey on Heart
Failure. European Heart Journal (2005) 26, 2706-2713
Dear Editor,
We read with great interest the paper by Rhondali et al.(1) and we thank them for their contribution to a very worthwhile topic. We are involved in palliative care research in Mauritania, West Africa, and we appreciate this piece of research coming from France and we hope it will stimulate more palliative care research, not just in France but throughout the francophone world. As the likes of Uganda...
I read with interest the letter from McKenna and others describing the evolution of an algorithm to aid decision making in the withdrawal of life-sustaining medical devices (LSMDs) (1). The briefly described scenario involving the development of cancer in a patient with a left ventricular assist device (LVAD) as a bridge to transplantation is familiar to us in cardiovascular medicine, as is the resulting need for decis...
I am perplexed why this paper by Jandhyala and Fullarton has concluded that "FBT (fentanyl buccal tablet) may have some efficacy advantages over ODT (sublingual oral transmucosal fentanyl) and OTFC (compressed lozenge oral transmucosal fentanyl)..." in the management of breakthrough cancer pain when a paper published at the same time in another journal (Smith H, A comprehensive review of rapid-onset opioids for breakthr...
Re: Opinions of the patients with cancer on the relative importance of place of death in the context of 'good death'. By: Melaine Waghorn, Holly Young and Andrew Davies: BMJ Support Palliative Care 2011:1 310-314
I am grateful for the opportunity to respond to Waghorn et al, 2011 study on opinion of patient with cancer on the relative importance of place of death. Having looked at the four highlighted domains ass...
This study generated discussion in our hospice about the importance of breaking bad news well and also the importance of these discussions in non cancer related disease. It was interesting the study showed 'people with heart failure had engaged in much less discussion about their condition, and most did not recall a specific conversation with their doctor about their prognosis'. I recently reviewed the literature on chr...
I welcome this small but useful study highlighting the fear and reluctance of patients and practitioners in using morphine in the setting of chronic heart failure. Over 50% of chronic heart failure patients suffer from pain and caution is needed with nearly all analgesics- NSAIDS and COX2 are contraindicated, neuropathics agents can trigger arrhythmias, steroids exacerbate salt and water retention, soluble drugs such as c...
Many patients are ill because of wrong choices they made in their life (eg smoking, excessive drinking, poor diet etc). How are we going to ensure that they make the 'right choices' with their individual budgets particularly if direct cash payments are made? How do we prevent the exploitation of these individuals? This is not a 'paternalistic 'concern. The checks and balances needed would be no more different from havin...
Dear Editor,
I am delighted to read Abel et al's conceptual paper regarding a social model of care, utilising a compassionate communities framework. As the paper has outlined, Milford Care Centre, Limerick, Ireland commenced a Compassionate Communities pilot project in 2011. This project aims to empower communities and reduce fear and stigma associated with death, dying, loss and care. The project is being led...
We would like to thank Drs Satchithananda, Hookey and Sister Ingram for their interest in our editorial. We welcome this opportunity to respond. We framed our discussion in the setting of left ventricular systolic dysfunction as this is where the robust evidence base for heart failure therapy has evolved. The evidence base for effective therapy for the clinical syndrome of heart failure with preserved systolic functio...
We read the editorial concerning the use of subcutaneous furosemide in heart failure with interest. We feel that there is a substantial opportunity for misinterpretation of the editorial by readers not as familiar with the issues raised as the eminent authors themselves. This particularly relates to: 1 The heart failure syndrome It is important to emphasize that the editorial relates to the treatment of congestive symptom...
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