47 e-Letters

  • Extended palliative care experiences in the undergraduate medical curriculum - a solution for doctor burnout?

    I read with interest “Does a one day hospice placement for medical students do more harm than good?” [1]. As a 4th year medical student at The University of Liverpool, and having recently undertaken a 4 week palliative care placement, I would like to weigh in on the themes discussed.
    As Ward et al. pointed out, Foundation year 1 doctors (interns) regularly care for patients at the end of life, but undergraduate training is often deficient. Issues around dying and death is one of the most commonly reported sources of junior doctors stress [1][2].
    Personal distress from the care of the dying is a factor to burnout; a well-documented condition with detrimental outcomes for healthcare professionals and patients. Given the central reality of death in medicine, it seems paradoxical these issues are not better addressed in undergraduate medical training [2] [3] [4].
    The GMC’s publication ‘Tomorrow’s Doctors’, states “Graduates must know and understand the principles of treatment including...palliative care”. Despite this, a systematic review found inconsistent palliative care teaching within undergraduate curriculums. As a result, junior doctors are often unprepared and distressed when caring for palliative care patients [5] [6].
    During the 4th year of the MBChB curriculum at The University of Liverpool, students undertake a 4 week palliative care and oncology placement. This consists of three weeks in a local hospice, one week at a specialist cancer hospi...

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  • Author response to 'Blood Transfusions: time for a change in practice?'

    We read and agreed with several points in the editorial [1] that accompanied our main research paper about UK clinicians' views on blood transfusion practice [2]. We have additional responses to the editorial.

    We recognise the lack of evidence about red cell transfusion within palliative care, which is why we undertook the largest audit of transfusion practice to date [3]. We analysed 465 transfusion episodes over 3 months from 121 UK hospices. Patients were not usually investigated for the anaemia. Of those that were, a significant proportion would have benefited from B12, folate or iron supplements, although rarely used. Despite being at higher risk of transfusion-associated circulatory overload (TACO), risk-mitigation practices like weighing patients or restricting transfusion to one unit (before review), were only undertaken in 15% of patients. In terms of patient benefit only 83 (18%) had improvement maintained at 30 days; 142 (31%) <14 days, and 50 (11%) had none. 150 patients (32%) were dead at 30 days, over double the predicted number.

    While documented death rates and major morbidity from red cell transfusion are low in the general population, there is growing evidence of under recognition and under reporting. A study across 157 UK hospitals showed that 4.3% of inpatients >60 years had increasing respiratory distress post-transfusion, but only one-third diagnosed with TACO by the hospital were reported to the SHOT Haemovigilance Group [...

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  • DNACPR- a medical decision?

    This was a very interesting article. As a professional with frequent intensive care duties early discussions about patient’s wishes are best. Ideally, these should take place away from the acute setting. This is what we always hope to have for our unconscious patients being admitted to the unit.

    Unfortunately, these discussions are a bonus rather than routine practice even in end stage disease. Perhaps this partly explains the difference in expectation between the medical team and the family. This leads to management disagreements. It is not uncommon to hear a family “wanting everything doing” for their loved ones in a DNACPR conversation.

    In our training we have always been taught that DNACPR is a medical decision. It is good practice nevertheless to communicate any such major management decisions to the family. Nevertheless, there appears to be a move towards completely patient/family centred care. There are multiple occasions a DNACPR is not put in place as the family will not agree, despite a consensus among multiple consultants.

    In this climate, with the family often seen as the representative of the patient without capacity, is a DNACPR decision still a medical decision?


    Hiccups, also known as singultus, is an involuntary spastic contraction of the diaphragm and intercostal muscles that leads to inspiration of air, followed by abrupt glottic closure.1 They can be classified based on duration: bouts (up to 48 hours); persistent (48 hours to 1 month); intractable (more than 1 month) and recurrent.2 Through its constant interruptive nature hiccups can have serious consequences, including dehydration, fatigue, insomnia, lower quality of life, malnutrition, psychological stress, and weight loss.1
    The cause can be peripheral or central. Peripheral causes are from irritation to the phrenic or vagus nerve. Central causes can be divided into neurological, like cerebrovascular accident, brain trauma, intracranial tumor, non-neurological conditions (e.g., infections), multiple sclerosis, and Parkinson’s syndrome.3 In our case the exact reason for hiccups was unknown but most likely brain metastasis.
    A 47-year-old gentleman with stage IV non-small cell carcinoma of lung, with progressive lung and bone metastasis, was admitted with worsening hiccups, pain, and vomiting. He was initially started on metoclopramide 40mg IV over 24 hours; dose was increased to 60mg with no benefit and later oral baclofen added (10mg three times a day).4 The hiccups responded to baclofen but his sensorium deteriorated likely due to disease progression. He was unable to take oral medications or tolerate nasogastric tube insertion. Since baclofen is available only...

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  • Not just in palliative care

    Elizabeth Davies uses palliative care "to explore the potential use of poetry in healthcare". And indeed its use can be much wider. As she points out, "For those who enjoy reading poetry, discussing or writing it can become a means of expressing emotion, making sense of events and putting a biographical story togerther."
    That was my experience following the deaths, in a motor vehicle accident, of my eldest son Marcus and his partner Rachael. Verse written, wept over, and repeatedly revised during the year after their deaths was, I'm sure, helpful in my coming to accept, at a 'gut level' as well as intellectually, what had happened.
    And it wasn't helpful just to me. When a selection of the verse (1) was published to raise money for a trust in memory of Marcus and Rachael, it also proved useful to some who had suffered similar bereavement, perhaps because the writer had experienced the same hell as them:
    "but our souls too
    are pierced by a sword." (2)
    (1) 'As Well as Joy - Elegies for Marcus and Rachael'; Rachael Gloag and Marcus Fitchett Memorial Medical Education Trust, Dunedin, 1998
    (2) Ib.; p. 40. 'The Feast of the Presentation of Jesus in the Temple'.

  • Circles of care

    Many thanks for this interesting article which overviews the historical and social developments in the Western world. With respect to definition of communities in the context of compassionate communities, we defined quite specifically what this is in our article Circles of care: should community development redefine the practice of palliative care?Abel J, et al. BMJ Supportive & Palliative Care 2013;3:383–388. doi:10.1136/bmjspcare-2012-000359. Communities exist in the context of inner and outer networks, supported by the surrounding community. These networks are no longer defined by geographical boundaries as there are forms of support involving digital technology. Support is given in many ways and it is the resilience of these community networks that makes an enormous difference at end of life, as explained by Horsfall et al in their research End of life at home: Co-creating an ecology of care
    D Horsfall, A Yardley, R Leonard, K Noonan… - 2015 - researchdirect.westernsydney.edu …

  • How do you define voluntarily stopping eating and drinking?

    Dear Editor
    In this issue, Shinjo et al reported that, among Japanese home hospice physicians and palliative care specialists, 32% replied that they had experience in caring for patients who had voluntarily stopped eating and drinking (VSED). 1 Their mean years of clinical experience overall, and in the field of palliative medicine, were 26 years and 13 years, respectively. According to the authors, Japanese patients were also trying to implement VSED to hasten their deaths themselves.

    We congratulate the authors on publishing this very important epidemiologic data in Japan. As the authors point out, the study is limited by both recall and social desirability biases, which could explain some inaccuracy in their survey results. Moreover, we wonder whether the way in which VSED was defined in this study also contributed to the relatively high prevalence of physicians who had experience with this practice.

    In their questionnaire, VSED was defined as “terminal ill patients electing to stop taking water and nutrition despite the fact that they do not suffer from a difficulty in oral intake such as gastrointestinal obstruction or cachexia”. VSED is an under-recognized practice and there are few data available. Especially in Japan, as they reported, only half of the palliative care physicians were aware of VSED. While their definition was not inaccurate, it is possible that this definition failed to convey the gravity of VSED and, as a result, physicians...

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  • A comment to Shinjo T et al.: collusion in VSED

    Letter to the Editor
    Shinjo et al. recently surveyed Japanese home hospice and palliative care physicians’ with regard to their experiences of caring for patients who voluntarily stop eating and drinking (VSED) in order to hasten death and questioned their opinion towards continuous deep sedation (CDS) as a mean to relieve patients’ refractory symptoms during VSED (1). According to the authors, attitudes of non-acceptance of CDS in VSED (36%) may have been related to the opinion that the use of sedatives during VSED was commensurate with euthanasia. Compared to Dutch family physicians - of whom an overwhelming majority endorsed CDS in VSDE -, acceptance was rather low among Japanese physicians (15%), and the authors evoke that physicians may face a « moral conflict in respecting the patient’s self-determination and allowing patient suicide ».
    While we value the authors’ contribution to this clinically relevant topic, we would like to complete their point of view with regard to the possible underlying reasons of the physicians’ attitudes. Indeed, ethical elements may play a role, but psychological dynamics may also have influenced their stance. We have previously raised attention to the existence of collusions in end-of-life care (2). Collusion, an unconscious dynamic between patients and caregivers, occurs in situations which reflect an unresolved psychological issue shared by the involved persons; it may provoke strong emotions and unreflected behaviour (3). F...

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  • Preferred Place of Death: Time for a Rebirth

    In McCaughan’s qualitative study,(1) I was drawn by two themes identified from interviews with clinicians and relatives of patients with haematological cancers: ‘mismatch between the expectations and reality of home death’ and ‘a preference for hospital death.’ This challenges the established dogma that most people would wish to die at home, if they had the choice.(2)

    The paper goes on to posit reasons, namely that patients with haematological cancers can have complicated clinical trajectories, with difficult-to-manage symptoms towards the end of life. Whilst this is true, it can also be more broadly applied to many terminal disease trajectories, in which single organ failure can progress to multi-organ involvement, brittle health and the risk of sudden deterioration. This can be frightening for both the patient and their close ones, hence an emergency call and blue light to A&E. Inpatient symptom control and support may then ineluctably become inpatient terminal care.

    In fact, desire for a home death is likely an overstated assertion, particularly as people approach the terminal phase of illness,(3) and particularly in conditions other than cancer.(4) The ideal of a home death may be very different to the reality of managing complex symptoms without the 24-hour access to medical professionals or support available in a hospital or hospice.

    The National End of Life Care Intelligence Network identifies death in the ‘usual place of residence’ (home...

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  • EPaCCS and the need for research
    Matthew J Allsop

    We agree with Sleeman and Higginson [1] who emphasised the need to gather evidence of effectiveness of EPaCCS before widespread and uncritical adoption by the NHS. An EPaCCS evaluation framework was recently developed by our team on behalf of end of life commissioners in Leeds [2]. There was, and remains, a scarcity of guidance on approaches to gathering evidence for EPaCCS but we identified factors that highlight the c...

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