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.
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.
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 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 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...
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...
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