Poster abstracts

Transcription

Poster abstracts

Poster abstracts
Poster abstracts
Thursday 7 June
CONNECTING
DIVERSITY
10th Congress of the
European Association for Palliative Care
10th Congress of the European Association for Palliative Care, Budapest, Hungary, 7–9 June 2007
Poster abstracts
218. Sensitivity and specificity of a two-question
screening tool for depression in a specialist
palliative care unit.
Ann Payne 1, Brien Creedon 2, Sandra Barry 3, Carol
Stone 4, Kathleen O’ Sullivan 5, Catherine Sweeney 6,
Tony O’ Brien 6
1
St. Mary’s Orthopoedic Hospital, Block 7, Psychiatry Day
Hospital, Cork, Ireland, Ireland
2
St Vincent’s University Hospital. Elm Park,, Palliative
Medicine, Dublin 4., Ireland
3
Cork University Hospital, Psychiatry, Cork, Ireland
4 St. Lukes Hospital, Palliative Medicine, Dublin 4., Ireland
5
University College Cork, Statistics, Cork, Ireland
6
Marymount Hospice, St. Patrick’s Hospital, Cork, Ireland
Objectives The primary objective in this study is to
determine the sensitivity and specificity of a two-item
screening interview for depression versus the formal
psychiatric interview in the hospice setting, so that we
may identify those individuals suffering from depressive
disorder and therefore optimise their management in
this often-complex population.
Methods A prospective sample of consecutive
admissions (n=167) consented to partake in the study,
and the screening interview was asked separately to the
formal psychiatric interview.
Results The two-item questionnaire, achieved a
sensitivity of 90.7% (95% CI 76.9 - 97.0) and a specificity
of 67.7% (95% CI 58.7 - 75.7). The false positive rate was
32.3% (95% CI 24.3 - 41.3), but the false negative rate
was a low 9.3% (95% CI 3.0 - 23.1).Chi square analysis of
individuals with a past experience of depressive illness,
(n=95), revealed that a significant number screened
positive for depression by the screening test, 55.2%
(16/29) compared to those with no background history
of depression, 33.3% (22/66), (P=0.045).
Conclusion The high sensitivity and low false negative
rate of the two-question screening tool will aid health
professionals in identifying depression in the in-patient
specialist palliative care unit. Individuals, who admit to
a previous experience of depressive illness, are more
likely to respond positively to the two-item
questionnaire than those who report no prior history of
depressive illness, (P=0.045).
219. Illness-related hopelessness in advanced
cancer: influence of anxiety, depression, and
preparatory grief.
Kyriaki Mystakidou 1, Eleni Tsilika 1, Efi Parpa 1, Paraskevi
Athanasouli 2, Maria Pathiaki 1, Antonis Galanos1, Anna
Pagoropoulou 2, Lambros Vlahos 3
Poster abstracts
1 Areteion Hospital, University of athens, School of
Medicine, Pain Relief & Palliative Care Unit, Department of
Radiology, Athens, Greece
2
University of Philosophy, School of Psychology, Athens,
Greece
Medicine, Radiology Department, Athens, Greece
Purpose: The growing interest in the psychological
distress in cancer patients has been the major reason for
the conduction of this study. The aims were to assess the
relationship of hopelessness, anxiety, distress, and
preparatory grief, as well as their predictive power to
hopelessness.
Materials and methods: 94 advanced cancer patients
were surveyed at a palliative care unit in Athens, Greece.
Beck hopelessness Scale (BHS), the Greek version of the
Hospital Anxiety and Depression (HAD) scale and
Preparatory Grief (PGAC) were administered.
Information concerning patients’ treatment received
was acquired from the medical records, while physicians
recorded their clinical condition.
Results: The analysis, showed that hopelessness
correlated significantly with preparatory grief (r=0.630,
p<0.0005), HAD-A (anxiety) (r=0.539, p<0.0005), HAD-D
(r=0.642, p<0.0005), HAD-T (r=0.686, p<0.0005), and
years of education (r=-0.212, p=0.040). Multiple
regression analyses showed that preparatory grief
(p=0.0025), depression (HAD-D) (p<0.0005), gender
(p=0.044), and age (p=0.056), were predictors of
hopelessness, explaining 61.5% of total variance.
Conclusion: In this patient sample, depression,
preparatory grief, as well as patients’ age and gender
were predictors of hopelessness. None of the patients’
clinical characteristics either correlated or predicted
levels of hopelessness.
220. Screening for increased preparatory grief in
advanced cancer patients.
Eleni Tsilika 1, Kyriaki Mystakidou 1, Efi Parpa 1, Maria
Pathiaki 1, Elisavet Patiraki 2, Lambros Vlahos 3
Medicine, Pain Relief & Palliative Care Unit, Department of
Radiology, Athens, Greece
2
University of Athens, School of Nursing, Athens, Greece
Medicine, Radiology Department, Athens, Greece
112
Objectives: The present study aims to determine the
use of “The Preparatory Grief in Advanced Cancer
Patients” (PGAC) Scale for screening increased
preparatory grief according to independent criterion
standards (i.e., the HAD Total scale, the HAD
Depression, and the HAD Anxiety subscales) and to
establish an optimal cut-off point for discriminating
between subjects with and without increased
preparatory grief.
Methods: 100 advanced cancer patients treated in a
Pain Relief and Palliative Care Unit completed the PGAC
and Hospital Anxiety and Depression (HAD) scales,
while researchers recorded data on demographic
characteristics, disease status and treatment regimen.
Results: Optimal balance between sensitivity and
specificity for the PGAC scale as a screening instrument
was achieved at a cut-off score of 40+ for all the criterion
standards (i.e., HAD Total, HAD Anxiety, HAD
Depression), giving a sensitivity range between 84%92%, and specificity between 70%-86%. The area under
the curve (AUC) ranged between 0.867-0.968.
Conclusions: The PGAC scale had a favorable
sensitivity and specificity in identifying cases of
increased preparatory grief. The ROC analyses
demonstrated that the scale is a useful screening
instrument in advanced cancer patients.
221. The Distress Thermometer (DT) a tool to
monitor changes in psychological distress over
time in patients with supportive and palliative
care needs.
Joe Low 1, Sue Gessler 2, Emma Daniells 1, Rachael
Williams 1, Veronica Brough 1, Adrian Tookman3,
Louise Jones 1
1 University College London, Mental Health Sciences,
London, United Kingdom
2
University College Hospital, Gynaecological Oncology,
3 Royal Free Hospital, Palliative Medicine, London, United
Kingdom
Background: The need to screen for psychological
distress in cancer patients has led to the development of
a single item DT. We conducted a study to assess its
psychometric properties in a clinically relevant UK
sample. This presentation reports the behaviour of the
DT and its ability to reflect changes in distress over time.
Method: Out-patients from 6 oncology clinics
completed 4 questionnaires: the DT, Hospital Anxiety &
Depression Scale (HADS), General Health Questionnaire
(GHQ)-12 and Brief Symptom Inventory (BSI)-18 at
baseline, 4 and 8 weeks. Sensitivity to change was
assessed by: 1) comparing the mean change in DT scores
with scores on the criterion measures at the 3 time
points in patients who improved, deteriorated, or did
not change; 2) calculating standardised response means
(SRM) and 95% Confidence Intervals.
Results: 111/171 patients completed questionnaires at
all 3 time-points. Using a DT cut-off score of 4, against
the HADS, GHQ-12 and BSI-18, the mean DT score in
the “improved” group significantly reduced, in the
“constant” group did not significantly change, and in
the “deteriorated” group significantly increased
(p<0.05). The SRM showed the DT was most responsive
to deterioration in GHQ-12.
Conclusions: The DT may be useful as a simple tool to
monitor change in psychological distress over time.
222. Is Macedonia ready for palliative care?
Ann Sturley 1, Blasko Kasapinov 2, Frank Ferris 1
1 San Diego Hospice and Palliative Care, Center for
Palliative Studies, San Diego, California, United States
2
Centre of Public Health, Skopje, Macedonia
Aims: In December 2006 the authors conducted a rapid
appraisal of the needs for palliative care in the Republic
of Macedonia, as part of the Open Society Institute’s
International Palliative Care Initiative. The aims were to
assess existing palliative services, professional education,
policy, national standards and guidelines, and drug
availability for pain management; then to recommend a
plan to meet the identified needs.
Methods: Interviews with key personnel and collection
of relevant statistical data to assess all components of the
WHO Palliative Care Public Health Model.
Results: Although the term “palliative care” is not
familiar to many Macedonians, the incidence of cancer
is increasing in Macedonia, and with it the need for
palliative care. Macedonias low per capita opioid use
indicates that terminally ill patients may not receive
adequate pain relief. A detailed assessment is made of
the educational, policy, and medication needs for a
palliative care program in Macedonia.
Conclusion: We discuss Macedonia’s needs,
preparedness, and next steps in developing a national
palliative care program.
223. THE FIRST EXPERIENCE OF PALLIATIVE
CARE FOR CANCER PATIENTS IN GEORGIA Rema
Ghvamichava, Mikhail Shavdia, Ioseb Abesadze,
Giorgi Metivishvili Cancer Prevention Center
Palliative Care Clinic (Georgia)
Rema Ghvamichava, Mikheil Shavdia, Ioseb Abesadze,
Giorgi Metivishvili
Cancer Prevention Center, Palliative Care, Tbilisi, Georgia
First palliative care clinic for advncerd cancer patients in
Georgia was opened in January 2005. During first year
the clinic served 216 patients, aong them 144 women
(66.7%) and 72 men (33.3%). The patients stayed in the
clinic for approximately 15 days. The average age of the
patients was 56.6. The reason of incurability in 90% was
metastasis, in 10% the locally spreaded tumors. Most
frequent case observed - collorectal cancer (35.6%),
breast cancer (16.2%) and cancer of the genitals (15.3%).
The health condition of the patients with the scale of
the ECOG. Performance status was: I gradation :6.6%,
II:21.7%, III:21.7%, IV:50%. The most frequent
symptoms were: asthenia (91.2%), pain (84.3%),
anorexia (76.4%), the dysfunction of the gastrointestinal tract (70.4%). Among 216 patients, strong pain
was observed in 37.5%, moderate 31.5%, mild 15.3%.
Visual analogy scale was used for pain assessement.
Patients were provided: detoxification 100%, vitamin
therapy 93.1%, pain management therapy 84.3% (by
opioid in 42.9%), energy and appetite stimulation 28.2%, small surgical manipulations (laparocentesis,
pleurocentesis and others) 6.5%, radiotherapy 2.3%,
chemotherapy 44.4%, the correction by
bisphosphonates 5.1%, hormonal therapy 4.2%. In 117
cases 42 patients (29.8%) have been provided care for
second time. Number od lethal cases - 31.5%. Therefore,
the analysis of the palliative care clinic actvities during
first year of its functioing can be cosidered as successfull
medical organization of specific profile.
224. Heart-Rate variability in palliative patients a pilot study
Gernot Ernst
Blefjell hospital, Pain and Palliative Care Unit, Kongsberg,
Norway
Aim of study: Assessing long-term prognosis is still a
challenge in palliative patients. Use of scores (eg. PAP)
has been proposed, but additional assessment methods
are needed. Linear and non-linear measures of heart rate
variability (HRV) have been used in cardiology and
diabetic patients to assess risk factors for sudden cardiac
death. Short-term HRV measurement is a simple bedside
technique causing patients no undue stress. Methods: A
total of 24 cancer patients receiving palliative care will
be included. A short-term HRV measurement was
performed several times on each patient, the number
depending on survival time. Time domain and
frequency domain indices were calculated (SDNN, RMSSD, HF, LF, VLF, and LF/HF). In addition, approximate
entropy (Pincus 1991) was computed as non-linear
measurement. Results: Preliminary results will be
presented on the poster. As expected, heart rate
variability declined in relation to the disease.
Approximate entropy also declined. Some patients
however had a temporary increase in HRV, so the
decline was not linear. Conclusions: As far as we are
aware, this is the first study which has assessed HRV
changes in palliative patients. The preliminary results
are encouraging. HRV is potentially an interesting
bedside tool for the assessment of palliative patients, but
larger
225. The Schedule for Meaning in Life Evaluation
(SMiLE): Validation of a new instrument for
meaning-in-life research
Mechtild Kramer, Gian Borasio, Sibylle L’hoste, Martin
Fegg
Interdisciplinary Center for Palliative Medicine, Munich
University Hospital, Munich, Germany
The Schedule for Meaning in Life Evaluation (SMiLE) is a
newly developed instrument for the assessment of
individual meaning in life (MiL). In the SMiLE,
respondents list 3 to 7 areas which they consider most
important for their MiL, and rate the current level of
subjective importance and satisfaction for each area.
Indices of total weighting (IoW, 20-100), total
satisfaction (IoS, 0-100), and total weighted satisfaction
(IoWS, 0-100) are calculated.?The aim of this study was
to assess the feasibility, acceptability, and psychometric
properties of the SMiLE in its German and English
version.?599 university students took part in the study.
The mean IoWS was 77.7-14.2. Completing the SMiLE
was neither distressing (1.3-1.9 on a scale from 0-10) nor
time-consuming (8.2-3.0 minutes). Test-retest reliability
of the IoWS was good (r=.72; p<.001), 85.6% of all areas
were listed again after a test-retest period of 1 week. For
criterion validity, convergent validity with the Self
Poster abstracts
226. Longitudinal Study of Distress: The
Interactions between Distress Domains and Their
Impact on the Global Distress Experience of
Advanced Cancer Patients from Time of Referral
to Palliative Care Services to Death
KATHARINE THOMPSON 1, SCOTT MURRAY 2,
GORDON MURRAY 3, MARIE FALLON 4
1 STRATHCARRON HOSPICE, Palliative Medicine,
STIRLINGSHIRE, United Kingdom
2 University of Edinburgh, primary health care, Edinburgh,
United Kingdom
3 University of Edinburgh, Public Health Sciences,
Edinburgh, United Kingdom
4
University of Edinburgh, Oncology and Palliative Care,
Background Distress is derived from interactions of
physical, psychological, social and spiritual domains:
The dynamics have not been studied over time.
Aim To explore distress over the terminal phases of
cancer; determining predictors, patterns and the
contribution of each distress domain to global distress.
Method Mixed methods longitudinal study: 100 newly
referred patients were assessed monthly until death or
for 6 months maximum through documentation of
socio-demographics, medical factors and: Memorial
Symptom Assessment Scale (physical), Edinburgh
Depression Scale (psychological), FACIT-Sp-12
(spiritual), Global Distress Thermometer (DT) and indepth interview (qualitative sub-sample of 20 only).
Results Significantly associated with distress: Lack of
information (p=<0.001); social dysfunction (p=0.02).
Trend over first 3 months: Psychological, spiritual and
global distress increase. Over time all domains
correlated significantly with: Global distress;
psychological the most: r=0.737 (p=0.000), and with
each other; psychological and spiritual most: r=-0.616
(p=0.000). Key themes: Family and communication;
physical debility and associated psychological impact;
control; reluctance to disclose distress.
Conclusion The 4 domains are strongly inter-related
but psychological contributes most to global distress.
Distress initially increases from referral except the
physical element: Screening with the DT may encourage
focus on non-physical distress domains, improving
management.
227. Results of a Study to Assess Quality of Life
and Cost of Home-Based Palliative Care Delivery
in New Delhi, India
Harmala Gupta 1, Stephan Tanneberger 2
1
2
CanSupport India, Pain team, New Delhi, India
ANT, Department of Oncology, Bologna, Italy
CanSupport is a home-based palliative care service
looking after people with advanced cancer in New
Delhi, India. We report on a detailed observational study
undertaken jointly by CanSupport and Fondazione ANT
Italia, which runs a hospital/hospice-at-home
programme in Bologna, Italy, from January 2004 to
December 2004, which included 74 patients who were
being assisted by CanSupport under its home care
programme. The objective of this study was to find out
to what extent providing palliative care at home
improves the quality of life of those with advanced
cancer and to calculate what it costs to deliver such care.
The results of our analysis shoiw that assistance from
the CanSupport home care teams changed the situation
significantly for patients. 54% of the patients reported
complete or > 50% reduction of pain using a visual scale
(from 1 to 10). Costs for drugs/nutritional supplements
amounted to < $1 in 27% of the cases, while 69%
calculated that they had spent between $1-$2 and 4%
between $2-$3 while under CanSupport’s care. Based on
our study it can be said that home care delivery by a
qualified team such as CanSupport costs between $4-$5
per patient/ per day. This is a miniscule amount in
comparison to other investments.
Conclusions The study confirmed our hypothesis that
it is possible with very little investment to guarantee
dignity at the end of life to cancer patients in resource
strapped countries.
228. Quality of life in patients with prostate
cancer: (A) comparison between a diseasetargeted questionnaire and an individualised
assessment method
Patrick Stone, Robert Murphy
St George’s, University of London, Division of Mental
Health, London, United Kingdom
Background
Standard quality of life (QoL) instruments do not
address all of the issues that patients consider to be
important. The purpose of this study was to compare the
performance of the Functional Assessment of Cancer
Therapy – Prostate questionnaire (FACT-P) with an
individualised QoL assessment method.
Patients and Methods
Patients (n = 194) completed the FACT-P, the Schedule
for the Evaluation of Individualised QoL - Direct
Weighting (SEIQoL-DW) and a Visual Analogue Scale
(VAS).
Results
Patients scored highest on the “physical” and lowest on
the “prostate specific” domains of FACT-P. The most
frequently identified themes on the SEIQoL-DW were
“Family, friends and relationships”, “Leisure activities”,
“Health”, “Spiritual life” and “Work”. Patients with
metastatic disease rated their QoL significantly (p <
0.0001) lower than other patients on the FACT-P, but not
on the SEIQoL-DW (p = 0.07).
Patients whose global QoL deteriorated between
assessments, showed a significant decrease in QoL on
FACT-P (p = 0.038), but not on SEIQoL-DW or VAS. Of
the patients whose performance status deteriorated
between assessments there was a corresponding change
in the SEIQoL-DW (p = 0.008) and the VAS (p = 0.05) but
not the FACT-P.
Conclusions
There are limitations to both questionnaire-based and
individualised assessments.
229. Quality of life in patients with prostate
cancer: (B) development and application of a
hybrid assessment method
Patrick Stone, Robert Murphy
Background: Investigator-derived quality of life (QoL)
instruments such as the Functional Assessment of
Cancer Therapy Prostate questionnaire (FACT-P) do not
allow participants to weight the relative importance of
QoL domains. We investigated the effect of allowing
patients the ability to weight the relative importance of
the five areas included in the FACT-P (Physical, Social,
Emotional and Functional well-being and Additional
Concerns).
Patients and Methods: Patients (n = 150) completed the
FACT-P and gauged the relative importance of each QoL
domain using a Direct-weighting approach. This was
then used to provide an adjusted Hybrid QoL score.
Patients also completed a Visual Analogue Scale.
Results: Patients considered Social well-being to be the
most important domain and Additional concerns to be
the least important. When patient weightings were
taken into account overall QoL scores increased. The
validity of the Hybrid score was supported by its ability
to distinguish between patients with metastatic and
loco-regional disease and its ability to detect expected
decreases in global QoL over time.
Conclusions: Application of the Direct-weighting
approach to the FACT-P allows assessments to more
accurately reflect individual QoL. Unadjusted QoL scores
may lead researchers to under-estimate the true QoL of
respondents.
230. DEVELOPMENT OF A PALLIATIVE MEDICINE
COMPREHENSIVE COMPUTER BASED SYMPTOM
ASSESSMENT QUESTIONNAIRE
Jordanka Kirkova, Mitchell Russell, Declan Walsh
Cleveland Clinic, Palliative Medicine, Cleveland, United
States
Aims
To report the paper- based framework and development
process of a portable computer symptom assessment
project in palliative medicine.
Methods
Expert opinion, patient face to face interviews and
feedback, and expert focus groups were included in a
paper-based instrument development and testing of the
content and face validity.
Results
A systematic literature review on cancer assessment
instruments compared symptoms and dimensions. A 54
item multi-dimensional (prevalence, severity, distress,
chronicity) instrument was developed. Expert opinion
(4 staff, 4 clinical and 4 research fellows) improved
clarity and comprehensiveness. 30 in- and 32
outpatients were interviewed for face validity. 80%
found the questionnaire appropriate and clear.
Comparing in- to outpatients revealed: median (range)
ECOG 2 (1-4) v 1 (0-4); mean (SD) completion time 43
(14.5) v 27 (10.8) min, p=0.001; compliance 60% v 93 %,
p=0.01. More outpatients (26 v 11, p=0.006) were
comfortable with one level multi-symptom, multidimensional assessment. More inpatients (14 v 3,
p=0.006) were tired after assessment. Eight focus groups
(10-12 physician and nurse experts per group) discussed
symptom definitions and associated symptoms.
Common opinions were systematized for symptoms and
symptom groups.
Conclusions
Patient and expert opinion is important for valid
practical assessments. Paper-based comprehensive multidimensional symptom assessment can be burdensome
for inpatients, and computers may improve flexibility.
231. ‘Fear of the Unknown’ A Retrospective
Analysis of Management of Unknown Primary
Carcinoma in a District General Hospital
Jennifer Doherty 1, Ernie Marshall 2, Clare Littlewood 1,
Muhammad Abbas 3
1 Whiston Hospital, Palliative Care Team, Liverpool, United
Kingdom
2
Clatterbrige Centre for Oncology, oncology, Liverpool,
United Kingdom
3
Whiston Hospital, oncology, Liverpool, United Kingdom
Introduction: Unknown Primary Carcinoma (UKP) is
usually associated with a poor prognosis. Often the
emphasis is on multiple investigations aimed at
uncovering the primary site rather than timely referral
to Oncology and Palliative Care. For patients, their
families and their professional carers, the uncertainty of
the disease process causes great angst. Aim: To
investigate the management of patients with UKP in a
hospital setting. Method: Retrospective case note
analysis of patients with UKP diagnosed in a district
general hospital between 2000 and 2001. Results: 58
case notes analysed. Study group consisted of 31 males
and 27 females. Median age was 67 years. Over half
(55%) of patients had an ECOG performance status of 3
or 4. Median survival was 2.6 months. On average, each
inpatient underwent 5 investigations and 20 blood tests
during admission. Of the 51 inpatients, 12 were not
referred to palliative care including 2 patients who died.
All palliative care referrals were seen within 48 hours of
referral. The first contact with palliative care occurred
on average 18 days after admission, reflecting late
referral. Conclusion: In these patients, protracted
admissions involving multiple investigations should be
avoided. Management should focus on short
admissions, early referral to oncology and palliative care
and symptom control. ECOG performance status is an
important indicator of suitability for chemotherapy. A
multidisciplinary approach is imperative.
232. Detecting symptoms of depression and
anxiety in patients with severe pulmonary
disease: a pilot study
Magnus Lindskog 1, 3, Lars Wahlström 2, Göran Isacsson 2,
Sverre Sörenson 3
1 Karolinska Institutet, Pediatric palliative care/Pediatric
oncology, Stockholm, Sweden
2 Karolinska Universitetssjukhuset, Psychiatry, Stockholm,
Sweden
3 Linköping university hospital, Department of
Pulmonology, Linköping, Sweden
Aim: To evaluate the usefulness of the Hospital Anxiety
and Depression Scale (HADS) for screening of
psychological distress among hospitalized patients with
pulmonary disease.Method: Patients (n=45), requiring
hospitalization at Linköping University Hospital,
department of pulmonology, during July 2005 were
included based on informed consent. Diagnoses
included primary/metastatic lung cancer (51%), COPD
(13%), other pulmonary diagnoses (16%), ongoing
diagnostic work-up (20%). Screening for symptoms of
depression or anxiety was carried out using selfadministered questionnaires containing a Swedish
version of the 14-item HADS. Results: Depression and
anxiety scores were significantly higher in cancer
patients compared to non-cancer patients. Associations
were also observed between depression score and poor
performance status, metastatic disease, and severe pain.
Associations were less apparent for anxiety. Ever use of
anti-depressants/anxiolytics was associated with higher
depression/anxiety scores. Among ‘possible cases’ of
depression/anxiety, affective symptoms had been
documented in either medical or nursing records in
83% (depression) and 61,5% (anxiety).Conclusion: In
this pilot study HADS was found useful as an aid to
identify patients at risk of severe psychological distress.
Although small, the study suggests that certain risk
patients, e.g. with metastatic cancer or ever users of
antidepressants/anxiolytics, may require particular
consideration.
113
Poster abstracts
Transcendence Scale (r=.34, p<.001), the Purpose in Life
Test (r=.48, p<.001), a Numeric Rating Scale on Meaning
(r=.53, p<.001), and divergent validity with the Idler
Index of Religiosity (r=.08, n.s.) were found.?In summary,
the SMiLE shows good psychometric properties in
university students. In comparison to other MiL
instruments, it is a short questionnaire which measures
MiL individually and provides interesting qualitative
information.
Poster abstracts
233. SYMPTOM VARIABILITY IN ADVANCED
CANCER DURING REPEATED MEASUREMENTS
WAEL LASHEEN 1, DECLAN WALSH 1, 2, KATHERINE
HAUSER 1, MATT KARAFA 3
1 Cleveland Clinic, Palliative Medicine, Cleveland, United
States
2
ST CHRISTOPHER HOSPICE, HOSPICE, London, United
Kingdom
3
Cleveland Clinic, Statistics, Cleveland, United States
Aim: In this prospective study we explored symptom
behavior in cancer patients during repeated
measurements.
Methods: Cancer patients admitted to an inpatient
hospice for terminal care completed a daily
questionnaire. The questionnaire was five visual
analogue scales (VAS) for pain, depression, anxiety,
sedation, and nausea; three verbal rating scales for pain,
vomiting, and depression.
Results: 125 hospice inpatients were enrolled; 46 (38%)
completed at least 3 consecutive days of the
questionnaire. Using a “variability index”, symptoms
demonstrated daily variation. Symptoms formed
changing daily correlations. Demographics influenced
both symptom profile at presentation and change over
time. Severity and frequency seemed stable over time. By
dividing patients into those with a symptom versus
those without, we demonstrated significant variation of
the symptom being monitored. New symptom onset
following admission was common. VAS scales revealed
significant inter- and intra-patient inconsistencies.
Discussion / Conclusions: Symptoms exhibit high
variability with repeated measurement. So we concluded
that: (1) Timing of studies is crucial for defining study
outcomes (2) Prevalence studies may be inaccurate for
symptom or treatment follow-up (3) Symptom
incidence following admission is an overlooked measure
of risk assessment (4) VAS scales seem inappropriate for
hospice cancer patients (5) Demographics may
influence symptom variability.
234. IMPACT OF ACUTE COMPLICATIONS ON
QUALITY OF LIFE IN PALLIATIVE LUNG CANCER
PATIENTS.
Verena Gartner 1, Katharina Kierner 1, Michael Weber 2,
Herbert Watzke 1
Poster abstracts
1 Medical University of Vienna, Palliative care unit, Vienna,
Austria
2 Medical University of Vienna, Radiology Department,
Vienna, Austria
Aim of the study: Patients with inoperable lung
cancer have a poor prognosis and frequently suffer from
acute complications of aggressive chemotherapy.
Methods: We conducted a descriptive study in 15 lung
cancer patients (stage IIIB or IV) consecutively referred
to an oncology ward either for scheduled chemotherapy
(SC) (n=9) or for complications of chemotherapy (n=6)
(CC). Quality of life was evaluated by the EORTC QLQC30 questionnaire.
Results: Median age of patients was 66 years (range 4277) All had had chemotherapy in the past. Mean
Karnovsky Index (KI) was similar in CC (KI: 53) and in
SC (KI: 64) patients. CC patients were only slightly worse
in physically related parameters when compared to SC
patients (Physical Functioning: 75.5 vs 80.3; Role
Functioning: 69.4 vs 75.9; Cognitive Functioning: 56.6
vs. 60.4) and symptoms such as pain, dyspnoe, nausea
and fatigue but performed significantly worse in
Emotional Functioning (38.8 vs 60.4) and Social
Functioning (19.4 vs 58.3). Emotional, Cognitive and
Social Functioning as well as fatigue nausea and appetite
were all improved significantly at time of discharge in
CC patients but generally failed to reach the level of SC
patients
Conclusion: Complications of therapy lead to a severe
loss of emotional and social functioning which even
exceeds losses in physical functioning and increase of
physical symptoms. Monitoring physical symptoms of
chemotherapy associated complications only my
underestimate the loss of quality of life in these patients
235. IMPLEMENTATION OF THE MITTZ IN A
PALLIATIVE CARE NETWORK IN THE
NETHERLANDS
Ireen Proot 1, Paula Hoynck van Papendrecht 2, Annemie
Courtens 3
1 Maastricht University, Bioethics and Philosophy,
Maastricht, Netherlands
2
Palliative Care Network South-East Brabant, Eindhoven,
Netherlands
3 Comprehensive Cancer Centre Limburg, Maastricht,
Netherlands
Aim:The Maastricht Instrument on saTisfaction with
Terminal care (MITTZ) measures satisfaction from the
perspectives of terminally ill persons and their
families.This project aimed at implementation of the
114
MITTZ within the Palliative Care Network South-East
Brabant, and at analysis of the care provided by the
health organizations in this network. Method: After
being informed about the MITTZ professionals in the
network invited terminally ill patients and families to
complete the MITTZ.During the project a helpdesk was
available for professionals.Only after consent the
questionnaires have been analyzed further.The results
were presented to the professionals of the network.
Results:The professionals discussed the MITTZ
completed with patient and family, and adapted the care
if needed.All questionnaires (45 patient and 56
caregiver) were available for further
analysis.Opportunities for improvement particularly lay
in the domains continuity/organization of care,
autonomy/control, physical aspects,
information/instruction, emotional support,
existential/spiritual aspects.The network discussed the
results and improved the quality of the care provided.
Conclusions:With the MITTZ information about patient
and caregiver satisfaction with care was identified.This
information is used by the network to improve the
quality of palliative care. Information on comparable
projects in other palliative care networks will be
discussed too.
236. ‘Brief Solution-Focused Practice’. A tailormade psychological approach for palliative care
Dominic Bray, Karen Groves
West Lancs, Southport & Formby Palliative Care Services,
Southport, United Kingdom
The importance of the psychological approach in
palliative care by all professionals cannot be
overemphasised (NICE 2004) 1. For those needing more
formal psychological input the traditional assessment,
formulation and therapeutic work is not only time
consuming, but exhausting and may not be completed
before the end of their short lifespan meaning that the
benefits are never realised or enjoyed. Brief solutionfocused therapy is ideally suited to the palliative care
situation requiring an effective, brief, apparently simple,
positive, approach focused on achievable goals, which
can be learnt and practised by all health professionals.
Furthermore, the goals may in fact be concerned not
only with psychological dimensions eg anxiety, but also
with physical ones eg pain management, choice of
treatment etc.
Solution-focused (SF) approaches start with the
“preferred future” (desired outcome) of the parties
concerned (eg patient, carer, professional, institution),
highlight instances where this is already happening
(strengths), then identify the next steps towards that
preferred future.
This poster describes the approach and its place in
palliative care demonstrating through case studies the
practical application of solution focused practice.
1 National Institute for Clinical Excellence. Improving
Supportive & Palliative Care for Adults with Cancer. 2004
237. Assessment of quality of life in palliative care
Ana Pinto 1, Pedro Ferreira 2
1
Hospital Santa Maria, Lisboa, Portugal
University of Coimbra, School of Economics, Coimbra,
Portugal
2
Palliative care is defined by WHO as the type of care
delivered to patients with an active and progressive
disease and with short life expectancy. Care should be
focused on symptoms relief, on prevention and mainly
on quality of life. One hundred and four patients with
breast and lung cancers with life expectancy less than a
year and aged between 40 and 85 years old were selected
in a specialized oncology hospital. A Portuguese version
of the Palliative Care Outcome Scale (POS) was
administered to them along with other variables
including pathology, treatment and sociodemographics. Construct validity of POS evidenced five
factors: emotional well-being, real fife consequences,
information and support, anxiety and burden of disease.
A moderate to strong correlation was shown when POS
scores were compared to EORTC QLQ-C3o. Test–retest
reliability and internal consistency were very good.
Sensitivity after 1 month was also tested with good
results. Comparing pathologies we observed that the
burden on the patient is sensitive to his/her pathology.
In conclusion, this study evidenced the good
performance of the Portuguese version of the Palliative
Care Outcome Scale.
238. Is continuity of care for the terminally ill
possible when offered by Palliative Support
Teams (PST) in general hospitals (GH)?
Ruddy Verbinnen, Fred Louckx
Vrije Universiteit Brussel, Department of Health Sciences,
Brussels, Belgium
Little is known about the views regarding to palliative
care (PC), palliative medicine (PM) and terminal care
(TC) held by PST-professionals in GHs.
Objectives : To provide representative conclusions about
the number of employees and their profession and their
views on PC, PM and TC.
A postal survey was conducted among the
coordinators of all PSTs in GHs in Flanders, with
questions on the number of professionals working both
officially and non-officially and on the work
organization. Answers with the legal obligation of ? FTE
MD, nurse and psychologist per 500 beds were
compared.
57 coordinators (79.2%) provided us with a
representative response. Only 13% of the PSTs have a
sufficient official number of appointed professionals.
About 35 to 60% of the professionals (MDs, RNs,
psychologists, social workers and others) working in a
PST is officially appointed.
Some of the legal obligations are reported to be met
by all PSTs: a.o. to spread the culture of PC and to advise
on PC. 94% report to organize training for professionals,
82% is coordinating admission.
Other reported tasks are not legally prescribed such
as taking care of family (95%), coaching professionals
(92%), providing bedside care (84%), scientific research
(22%).
Continuity of care is possible in a minority of the
GHs. Most PST’s show a considerable amount of
professional voluntary work and fulfill legally prescribed
tasks and take on more than that.
239. Evaluating the effectiveness of hospitalbased palliative care team: the first 3-year audit
using a numeric rating scale in Japan.
Tetsusuke Yoshimoto, Yuki Ishino, Atsuo Hisada,
Atsunaga Kato, Kazuhito Matsubara, Masao Matsuda
Chukyo Hospital, Palliative Care Team, Nagoya, Japan
Background: Over 90% of terminally ill cancer
patients die in acute care hospitals in Japan and since
2002,hospital-based palliative care team (HPCT) services
have been covered by Public Health Insurance for
achieving symptom control.With this date as a turning
point,the number of HPCTs has been increasing.
Despite this increase, there has been limited research
evaluating their effectiveness. In particular,research
using a patient rating scale is very rare.
Aim: This study investigated the effectiveness of HPCT
using a patient rating scale.
Subjects and Method: All cancer cases referred to our
HPCT in the first 3-year period were enrolled in this
study. We prospectively recorded patient symptoms (e.g.
pain and dyspnea) on a structured data-collection sheet
at the first assessment and 1 week later. Numeric rating
scale (NRS; symptom scale of 0-10, 0=no symptom,
10=worst imaginable) was selected as the assessment
tool because both the validity and convenience of NRS
have been established in an acute care setting.
Result: There were 393 cases (528 episodes) referred to
our HPCT. Statistical comparison of the scores between
the first assessment and 1 week after were
performed.The symptom scores after 1 week were
significantly lower than at the first assessment (pain:
2.4±3.0 vs 7.3±2.9, p<0.0001;dyspnea: 2.0±2.0 vs 5.8±3.0,
p<0.001).
Conclusion: HPCT may be sufficiently effective in
achieving symptom control in an acute hospital setting
in Japan.
240. Screening for psychological distress in
palliative care using Touch screen questionnaires
Parvez Thekkumpurath 1, Chitra Venkateswaran 2, Manoj
Kumar 3, Mike Bennett 2
1
2
3
University of Leeds, Leeds, United Kingdom
St-Gemma’s Hospice, Leeds, United Kingdom
Leeds Mental Health Trust, Leeds, United Kingdom
Psychological distress at end of life is less well described,
as the focus has been mainly on problems arising in the
context of diagnosis and treatment of cancer. Screening
for distress is now considered an essential first step in
improving care of these patients.
Aim:The study aims to examine the feasibility and
validity of a set of screening instruments in detecting
psychological distress in a palliative care population
attending two hospices in Leeds, U.K
Method:Patients are recruited by convenient sampling
from St-Gemma’s and Wheatfield’s hospice, Leeds.
Recruited patients, after an initial cognitive screening,
complete a set of three questionnaires (Brief Symptom
Inventory-18, General Health Questionnaire-12 and
Distress Thermometer) on touch screen laptops
developed by Psychosocial Oncology Research Group,
Leeds. After completion of questionnaires a structured
psychiatric interview (SCAN) is carried out by trained
psychiatrists, who are blind to the results of screening.
The two investigators are trained in SCAN and have
established inter-rater reliability.
Initial results: Out of a total number of 62 patients
Poster abstracts
244. Subjective well-being, meaning in life and
personal values in health care professionals
working in palliative care vs. maternity wards
Sibylle L’hoste 1, Gernot Hauke 2, Gian Domenico
Borasio 1, Martin Fegg 1
1
242. The effect of the Liverpool care pathway for
the dying: a multi centre study
Laetitia Veerbeek1, Lia Van Zuylen 2, Siebe Swart 3, Paul
Van der Maas 1, Elsbeth De Vogel-Voogt 1, Carin Van der
Rijt 4, Agnes Van der Heide 1
1 Erasmus MC University Medical Center, Dept. of Public
Health, rotterdam, Netherlands
2
Erasmus MC University Medical Center, Department of
Medical Oncology, rotterdam, Netherlands
3
Nursing Home Antonius IJsselmonde, rotterdam,
Netherlands
4 Erasmus MC - Daniel den Hoed, Department of Medical
Oncology, rotterdam, Netherlands
We studied the effect of the Liverpool care pathway for
the dying (LCP) on documentation of care, symptom
burden, and communication during the last three days
of life. We applied an intervention study. Two hospitals,
two nursing homes, and two home care organisations in
the Netherlands participated. Between November 2003
and February 2005 (baseline period), care was provided
as usual. Between February 2005 and February 2006
(intervention period), the LCP was introduced and used
for all patients for whom the multidisciplinary team
agreed that the dying phase had started. After the death
of a patient, a nurse and a relative filled in a
questionnaire. In the baseline period, 220 patients were
included in the study. Nurses and relatives filled in a
questionnaire for 219 and 130 patients, respectively.
During the intervention period, 255 patients were
included in the study. The LCP was used for 197 of
them. Nurses and relatives filled in a questionnaire for
253 and 139 patients, respectively. Patient characteristics
were comparable in both periods. In the intervention
period, the documentation of care was significantly
more comprehensive as compared to the baseline
period. According to both nurses and relatives, the
average total symptom burden was significantly lower in
the intervention period. Relatives appreciated
communication about the patient’s impending death
equally in both periods. We conclude that LCP use
contributes to the quality of documentation and
symptom control.
243. Prevention of Pathological Fractures: Do
Healthcare Professionals Recognise the Warning
Signs?
Helen Emms, Nicholas Emms, Caroline Usborne,
Andrea Whitfield
St Johns Hospice, Wirral, United Kingdom
Introduction?Patients prognosis with metastatic bone
disease (MBD) has improved. UK guidelines on
investigation and management of MBD exist. Prediction
of pathological fracture before the event is a relevant
clinical problem?Aims?Do healthcare professionals
(HCP’s) recognise features of MBD and impending
pathological fracture. Are they aware of UK
guidelines??Methods?A questionnaire on management
of MBD, awareness of risk factors and guidelines was
given to HCP’s in Specialist Palliative Care (SPC) and
Orthopaedics in our local cancer network?Results?84
responses (67 SPC;17 Orthopaedic). 12/84 knew of
existing UK guidelines. 9/84 were aware of a tool used to
assess risk of pathological fracture.16/84 felt they had
access to a lead orthopaedic surgeon for MBD in their
locality. 41/84 couldn’t name any features of pain that
would make them suspicious of MBD. 10/84 thought
the prognosis of all patients with MBD was less than 12
months. 10/84 were unaware of clinical features and
21/84 could not describe radiological features of
impending pathological fracture. 81/84 felt there was
value including an orthopaedic surgeon in the
management of patients with MBD. 57/84 were aware
surgery should be performed prior to radiotherapy at
the site of impending fracture?Conclusion?Greater
awareness of existing UK guidelines for investigation
and management of patients with MBD is needed. After
this study local guidelines on the Prevention of
Pathological Fractures were implemented
2
Center for Integrative Psychotherapy, Center for Integrative
Psychotherapy, Munich, Germany
According to current theories of social psychology,
subjects who are confronted with mortality exhibit a
distinct way of coping with their fear of death which is
reflected in their personal values and may enhance their
subjective well-being.We have investigated individual
meaning-in-life (MiL), subjective well-being and
personal values in health care professionals (HCP) who
are confronted daily with death (palliative care) or with
new life (maternity ward). A cross-sectional
questionnaire study was performed in four Munich
hospitals.140 HCP took part in the study (response rate,
74%). Self-transcendence values were higher in palliative
care HCP, while self-enhancement values predominated
in the maternity wards. Regression analysis showed that
these differences were not dependent on the working
environment but on religiosity. Palliative care HCP were
older and more religious compared to maternity ward
HCP, and listed significantly more MiL areas which were
related to spirituality or nature experience. No group
differences were found for subjective well-being. A
regression analysis showed that HCP working part-time
scored higher in well-being as compared to full-time
workers.
In summary, there are significant differences in
personal values in both groups, but these seem to
depend on religiosity. The question remains whether
higher religiosity derives from the confrontation with
death or whether more religious individuals are more
likely to work in palliative care.
245. The enigma of documenting nursing care
according to the hospice philosophy
Helena Hallgren 1, Birgit Rasmussen 1, 2
1
2
Axlagarden Hospice, Umea, Sweden
Umea University, Nursing, Umea, Sweden
Background: Although palliative care has improved
markedly in the last decade, there is evidence that
nurses may have insufficient knowledge about the
psychosocial needs of patients. In nursing records,
medical and physical needs are well documented, but
aspects related to a holistic understanding of the
patients’ situation are not. Thus, neither the hospice
philosophy nor the knowledge which is a prerequisite
for individualized patient care is appearing in the
documentation.
Aim: The aim of this developmental project is to
improve nursing care in a hospice by implementing a
new approach to nursing documentation.
Methods: A structure to document nursing care
inspired by Weisman and co-workers
Conclusion: All nurses at the hospice are now required
to document according to the new structure. Evidence
however, show difficulties to leave behind the
traditional biomedical way of thinking and
documenting. Examples and positive and negative
experiences of the implementation process will be
presented and discussed at the conference.
246. EFFECTIVENESS OF SYMPTOM CONTROL IN
ADVANCED CANCER PATIENTS FOR PALLIATIVE
CARE TEAMS IN CATALONIA SPAIN
Rosa Roca 1, Jose Espinosa 2, Albert Tuca 2, Josep PortaSales 2, Xavier Gómez-Batiste 2
1 Hospital Santa Caterine, Palliative care unit, Girona,
Spain
2 Institut Catala d’Oncologia, Palliative Care Service,
Barcelona, Spain
AIM To assess the effectiveness in symptom control,
mainly in pain control, of palliative care teams (PCT) To
promote cooperation between PCT and to identify areas
of improvement METHOD Descriptive, longitudinal
multicentre study.
Subject
Included 159 patients cared for by 111 PCT. (Date: 2428/01/05)VariablesSeverity of 4 symptoms by a verbal
numeric scale (VNS), 0-10. Registered at the 1st visit, and
one week later.
Demographic data.
Statistics Symptom control was analysed using
Wilcoxon sing rang test.
Result
Place of admission was outpatient 19%, Hospital
Support Team 19%, Unit 24%, Home ST 60%.
KPS 50 61,35%
Analysed using Wilcoxon sing rang test
Day 1
Day 7
Table 1
% patients%
patients
VNS
≤3>4
≤3>4
Basal Pain
38.9 61.1
67.5 32.5
Crisis Pain
8.0 92.0
21.1 78.9
Weakness
15.3 84.7
19.2 80.8
Anxiety
25.8 74.2
50.5 49.5
Insomnia
22.6 77.45
4.5 45.5
Number crisis / Day
≤2>3
≤2>3
Nº Crisis
39.8 60.2
73.1 26.9
p
day 1-7
0.0001
0.0001
0.001
0.0001
0.0001
0.0001
CONCLUSION
• The intervention of the PCT through
pharmacological and interprofessional measures
show a significant decrease in the intensity of the
symptoms seven days after the first consultation.
• It will be important to study their repercussion in the
patients and family perception of quality of the endof-life.
247. Measurement of meaning in life: a systematic
review of meaning-in-life scales (1956-2006)
Tobias Skuban, Claudia Bausewein, Gian Domenico
Borasio, Martin Fegg
For patients with terminal illnesses, the question of
meaning in life (MiL) is essential. Loss of MiL is associated
with higher levels of psychological distress and requests
for hastened death. Different scales have been developed
to assess MiL in various samples. However, the extent of
psychometric validation of many scales is unclear.
We conducted a systematic review of published MiL
scales in accordance with the Cochrane Handbook for
Systematic Reviews of Interventions, version 4.2.4. The
scales were evaluated according to the
recommendations of the Scientific Advisory Committee
of the Medical Outcome Trust.
Using EMBASE 1989-2006, OLDMEDLINE 1950-1965,
MEDLINE 1966-2006, PsycINFO 1806-2006 and
PSYNDEXplus 1977-2006, we found 439 papers on MiL
assessment. Nomothetic instruments (e.g. Purpose in
Life Test, Life Regard Index, Sense of Coherence Scale) as
well as idiographic measures (e.g. Meaning in Life
Depth, Schedule of Meaning in Life Evaluation) were
included. The psychometric properties of the scales were
investigated regarding their conceptual and
measurement model, reliability, validity, responsiveness,
interpretability, burden, alternative models of
administration, and cultural and language adaptations
as well as translations. Detailed results will be presented
at the congress.
248. Symptom Control In An Acute Palliative Care
Unit: Preliminary Results
Josep Porta-Sales, Jose Espinosa, Gala Serrano, Silvia Paz,
Cristina Garzón, Albert Tuca, Xavier Gómez-Batiste
Institut Catala d’Oncologia, Palliative Care Service,
Barcelona, Spain
Aim
To study prospectively the efficacy in the control of a
set of core symptoms after 7 days of admission in our
acute palliative care unit.
Material & methods
Patients admitted from 8/06 till 10/06 which fulfil 3
consecutive evaluation for a core set of symptoms (pain,
anorexia, constipation, insomnia, dyspnoea, vomiting,
anxiety and depression) for the days 1, 3 & 7 of stay.
Evaluation was done under the daily clinical practice
without a close protocol. Symptom control was analysed
using Wilcoxon sing rang test, level of significance 0.05.
Results
We admitted 137 patients, being evaluable 41(30%). The
3 main reasons for not being evaluable, multiple causes,
were symptom missing data 78 (57%) cases, admission
less than 7 days 52 (38%) [14 for death], and severe
cognitive failure at admission 13 (10%). Regarding
evaluable patients; 72% were men & mean age 66.2 ys.
Mean stay was 18.5 days & mortality during admission
was 47%. Fifty percent of patients were classified 2 or 3
in the ESS. All symptoms evaluated obtained a sig.
improvement after 7 days, but insomnia and depression.
Conclusions
• Taking into account that 40% of the evaluable
patients were admitted under a crisis situation, at the
end of the first week of admission a significant
symptom improvement is obtained for all core
symptoms but insomnia and depression.
• Results should be taking as a trend, since the small
size of the sample and the possible bias introduced
mainly for the selection of the more fit patients.
115
Poster abstracts
considered eligible so far, 17 opted out, 7 dropped out
and 38 patients completed the assessments. Of the
completed patients approximately 25% has a
diagnosable psychiatric illness, Adjustment disorder
being the most common. Sensitivity, specificity and cutoff’s for the questionnaires ( ROC analysis) will be
presented
Poster abstracts
249. Predictors of patient ratings of depression
on admission to a tertiary-level inpatient
palliative care unit: What is the role of pain and
symptom burden?
Cheryl Nekolaichuk 1, Peter Lawlor 2, 3, Alan Kelly 4,
Robin Fainsinger 1, Eduardo Bruera 5, Sharon Watanabe
1, Hue Quan 6
1
University of Alberta, oncology, Edmonton, Canada
Trinity College Dublin, Faculty of Medicine, Dublin,
Ireland
3
Our Lady’s Hospice, Harold’s Cross, Palliative Medicine,
Dublin, Ireland
4
Trinity College Dublin, Public Health and Primary Care,
Dublin, Ireland
5
UT MD Anderson cancer center, Palliative Care and
Rehabilitation Medicine, Houston, United States
6
Grey Nuns Hospital, Capital Health Regional Palliative
Care Program, Edmonton, Canada
2
Aims: To describe symptom burden and identify
independent predictors of patient-rated depression in
advanced cancer patients on a tertiary palliative care
unit (TPCU). Method: We retrospectively examined
TPCU database records to obtain patient demographics
and Edmonton Symptom Assessment Scale (ESAS)
scores [0-100(worst)]. Consecutive first admission data
for patients surviving more than 3 days were eligible for
analysis. Independent variables (age, gender, cancer,
substance abuse history, 8 ESAS scores) were entered
into multiple regression models to determine
independent associations with the first 36-hour patientrated depression intensity average (dependent variable).
Results: Of the target sample (n=1351), the analyzed
sample consisted of 879 patients (65%) with complete
patient-rated ESAS scores. Median age was 63 and 50%
were men. The four highest median symptom scores
were 60 (appetite), 58 (tiredness), 50 (wellbeing) and 48
(pain, drowsiness). The median for depression was 30.
In simultaneous and stepwise regression models, R 2 was
0.60. In the stepwise model, ESAS scores for anxiety,
wellbeing, nausea and drowsiness were significant
positive predictors for depression (p<0.05). Appetite and
hematological cancers were significant negative
predictors (p<0.05). Conclusions: Depression intensity
in advanced cancer patients is strongly linked with
multidimensional symptoms. Surprisingly, pain and
tiredness were not identified as independent predictors
in this sample.
250. COST EFFECTIVENESS OF ORAL OPIOIDS IN
PAIN MANAGEMENT
Mamuka Tatishvili 1, Rema Ghvamichava 2, Mikheil
Shavdia 3, Ioseb Abesadze 4
1– 4
Poster abstracts
Cancer Prevention Center, Palliaitve Care, Tbilisi,
Georgia
13 kg (92,9%) from total 14 kg of opioids used in
Georgia in 2005 was injectable, whereas oral opioids are
mostly administered for adequate pain relief in world
developed countries. Implementing international
standards, only 46,1% of injectable opioids was used
during two months in our clinic and corresponding
study have been conducted.
Objective: Study of costeffectiveness of oral opioids
for adequate pain management in cancer patients.
Method: While part of the patients was administered
injectable opioids, the other part was prescribed
prolonged oral opioids (12 hours) after defining the
daily dosage. During the period November 4,2005 ;
January1,2006, only 829 ampoules of Sol. Morphini
hydrocloridum 1% - 1 ml have been used in
combination with 323 tablets of Doltard 30 mg. (total
cost 54,91GEL). To achieve the same effect of pain
management during the same period it was estimated
that 1798 ampoules of Sol. Morphini hydrocloridum 1%
- 1 ml (1 amp/4hours ) with total cost of 1348,50 GEL
should be used for 20 patients of the clinic. (Cost of 1
ampoule 0,60 GEL, syringe, alcohol, cotton 0,15 GEL ;
total 0,75GEL). Actually, instead of planned 1348,5 GEL
only 676,6 GEL was spent during two months. So,
economical effect was estimated as 48,8%.
Conclusion: 1. Administration of prolonged oral
opioids appeared to be effective both in respect of
improvement of patients’ quality of life and costeffectiveness 2. Recommendations for Health Care
policy makers have been worked out for improvement
of oral opioid’s availability.
251. CROSS CULTURAL ADAPTATION OF THE
SPANISH VERSION OF THE EDMONTON
SYMPTOM ASSESSMENT (ESAS)
Ana Carvajal 1, Carlos Centeno 2, Julia Urdiroz 3, Marina
Martinez 4, Antonio Noguera 5, Maria Angustias Portela 6
1
University of Navarra, Palliative Medicine, PAMPLONA, Sri
Lanka
2– 6
University of Navarra, Palliative Medicine, PAMPLONA,
Spain
116
It is necessary to be accessible instruments cross cultural
adapted in different languages. The?Edmonton Symptom
Assessment System (ESAS) is an instrument of symptom
assessment widely used in Palliative Care. A process of
adaptation was designed to do a cross cultural adaptation
of the ESAS to Spanish. Five Spanish translations of the
questionnaire were made by Spanish bilingual translators
working in Palliative Care with experience with ESAS.
Four reviewers measured cultural adaptation, clarity and
common language. A committee of three health’s
professional designed the first version. This version was
used in a study with twenty patients with cancer. With
the comments of the participants, the committee choose
a second Spanish version of the questionnaire that was
translated back into English by two bilingual translators
of English origin. Four reviewers evaluated semantic
equivalence, cultural adaptation and psychometric
aspects of each item. With these ratings, the committee
developed a third version of the questionnaire. A second
study was performed with twenty patients. With several
remarks from the evaluators the committee proposed a
final Spanish version of the ESAS. Three items need
clarifications in semantic studies. The final version was
approved by the committee and also the author of the
original English version of the questionnaire. The process
of Spanish adaptation of the questionnaire was
satisfactory. Our group follow working in the validation
of the ESAS in Spanish.
252. Production of a computer-based database
for use in clinical palliative care.
Toshihiko Nakatani, Ruiko Hatto, Nobue Uchida, Takuji
Inagaki, Shihoh Okazaki, Yuji Morita, Yoji Saito
Shimane University Hospital, Palliative Care Centre, Izumo,
Japan
Introduction: It is important to assess and analyze a
patient’s clinical status. Data analysis is indispensable in
providing better care for patients. This requires a good
database of patient information. Often, a database on
paper is not very practical for data analysis. A computerbased database however, appears to be useful for detailed
assessment and analysis. Working in palliative care is
hard in any hospital, and the collection and integration
of patient data into a useful database is equally
problematic.?Aim: We intended to produce a computerbased database for palliative care. We also wanted staff to
be able to input data at bedside.?Method: We prepared
software and hardware as follows. System software:
Microsoft Windows XP Professional Version 2002®,
Microsoft Windows Mobile 5.0®. Application software:
FileMaker Pro 8.0®, FileMaker Mobile 8®. Handheld
computer: Hewlett-Packard iPAQ® The main items in the
database were as follows. Clinical data (ID, diagnosis,
purpose of consult, etc.), physical and psychological
status, medications, projected prognosis, STAS (Support
Team Assessment Schedule), pain score, etc. The
database must be interactively linked between desktop
and handheld computer.?Result: We have produced a
database for which it is possible to input patient data
using a handheld computer at bedside.
253. Evaluation of the palliative care activity
with using palliative care database.
Ruiko Hatto, Toshihiko Nakatani, Keiko Ota, Chie
Itakura, Koji Naora, Yoji Saito
Shimane University Hospital, Palliative Care Centre, Izumo,
Japan
Introduction: The needs for the intervention by
palliative care team (PCT) have been increased in Japan.
The appropriate timing and actions of the PCT is
important to improve the quality of the cancer patients
and their family. Therefore, we utilize a computer-based
palliative care database on the basis of the periodical
assessments to plan a strategy of PCT.
Aim: This study was designed to evaluate the PCT
activity retrospectively with using a palliative care
database to improve the team action.
Methods: We studied characteristics the symptoms
requested to palliative care, the symptoms, which were
needed to be cared by the PCT, and the outcome in the
152 patients, consulted to the PCT from a computerbased database from Apr. 2005 to Mar. 2006.
Results: The main symptoms consulted by the ward
staffs were physical pain (89%) and psychological care
(12%). The patients suffered from physical pain (93%),
anorexia (56%), nausea and vomiting (36%), general
fatigue (35%) at that time. Fifty-two patients died during
the hospital stay. Fifty-six % of them died patients
mainly received the palliative care and 39% received
disease modifying therapy. Their mean hospital stay
were 66 and 79 days, respectively.
Conclusion: The results showed the differences
between the consultation from ward staff and the care
needed for patients, suggesting the importance of timely
repeated assessments and care.
254. Measuring quality indicators in all
Extremaduran palliative care teams
Javier Rocafort 1, Marco Antonio López 2, Laura Blanco 3,
Silvia Librada 4, Beatrice Pop 5
1 Extremaduran Health Service, Regional Palliative Care
Program of Extremadura, Mérida, Spain
2
Extremaduran Health Service, Palliative Care Team
(RPCPEx), Don Benito, Spain
3
Extremaduran Health Service, Regional Palliative Care
4
5
(RPCPEx), Navalmoral de la Mata, Spain
Background: Indicators are widely used as a strategy to
improve quality provision. In palliative care, standard
indicators are not been described and usually programs
or institutions made their own ones. The Spanish
Palliative care Association (SECPAL), made a group of
quality criteria and quality indicators.A group of
professionals from the Extremaduran palliative care
program, revised the SECPAL indicators, adopted 22 of
them and created 6 new ones. The aim of this study is to
identify the percentage of indicators achieved.
Method: 28 indicators were evaluated by two
researchers in the eight Extremaduran palliative care
teams, including data from the year 2005. A minimum
recommended score was defined for every indicator.
Results: All Extremaduran teams participated in the
study. The mean minimum score recommended was
88,39% and the mean achieved was 85,05%. Four
indicators (Weekly meetings; Protocols to wellcome
patients; Other protocols; and Specialized Care
education activities) were more than 20% under the
recommended values.
Discussion: Six indicators (23-28) are self-produced, so
there is no possibility to compare them with other
programs. Other twenty two indicators (1-22) have been
measured in 8 specialized palliative care teams, which
provide care both in hospital and in the community.
Probably the results obtained are not comparable with
other teams working only in hospitals or in the
community. There are not previous studies measuring
these indicators.Some indicators are frequently under
minimum recommended standard and identificate
improvement areas.
255. Attitudes of Nurses a key to outcome
measures in palliative cancer care?
Carina Lundh Hagelin 1, 2, Yvonne Wengström 3, Carl
Johan Fürst 1, 2
1 Karolinska Institutet, Department of Oncology-Pathology,
Stockholm, Sweden
2
Stockholms Sjukhem Foundation, Research and
Development dept, Stockholm, Sweden
3 Karolinska Institutet, Institution of Neurobiology, Caring
Sciences & Society, Section of Nursing, Stockholm, Sweden
Aim: To explore the experience among nurses in
palliative cancer care toward systematic assessments of
quality of life (QoL) by using a questionnaire.
Method: A study-specific semi-structured questionnaire
was constructed. The questionnaire consisted of 6 topic
areas covering experience of routine use of the EORTC
QLQ C-30 in palliative cancer care. The present pilot
study is qualitative and explorative.
Results: Two concepts were constituted in the analysis.
The first was facilitators; including aspects related to
daily work. The feasibility of systematic assessments and
quality assurance was perceived in a positive way. The
nurses also perceived indirect benefits for the patients,
as the patients “being see” by the nurses. Barriers were
the second concept constituted; concerning
questionnaire design issues, readability and intrusive
questions. Time was seen as a barrier, as well as impact
of illness. Other barriers in using this type of assessment
tool was e.g. the nurses judgement of the patients
inability to participate due to subjective and objective
signs of illness or distress.
Conclusion: It is important to use systematic
assessment of QoL to increase patient wellbeing, and it
is also important that this is informed and shaped by
the needs and experiences of individuals and
organizations delivering palliative care. Further research
is also needed to map out the bigger picture of using
quality of life outcome measures in palliative care.
256. Occurrence and nurse documentation of
oral problems in palliative care.
Lilian Fransson 1, Lena-Marie Petersson 2, Carl Johan
Fürst 3
1 Karolinska Instituet, Stockholms Sjukhem, Paliative care
Service, Stockholm, Sweden
2 Karolinska Institutet, Stockholm, Sweden
3
Karolinska Instituet, Stockholms Sjukhem, Palliative Care
Service, Stockholm, Sweden
Poster abstracts
257. Effectiveness of parenteral antibiotics in
terminally ill hospice patients: a retrospective
study
ELINOR BRABIN, LESLIE ALLSOPP
Marie Curie Hospice, Liverpool, United Kingdom
Rationale: The role of parenteral antibiotics in
terminally ill patients is uncertain. There is a need to
establish practice guidelines based on the collective
experience of their effectiveness in hospice care.
Method: Retrospective longitudinal study
Results: Of 209 consecutive admissions to Marie Curie
Hospice Liverpool from June-October 2006, 18 patients
(42-86 years) received 20 courses of parenteral
antibiotics. Consent for treatment was recorded in 13
episodes (65%). In 17 episodes (85%), antibiotic
treatment was based on clinically diagnosed infection,
confirmed on microbiological testing in 5 cases.
Treatment indication in 3 episodes (15%) was acute
deterioration of uncertain cause. The parenteral route
was used for inability to swallow (35%), infection
severity (40%), lack of response to oral antibiotics (20%)
and antibiotic sensitivity precluding oral use (5%). Mean
duration of treatment was 66.3 hours (range 6-144
hours). Antibiotics were discontinued due to nonresponse in 8 episodes (42%), changed to oral antibiotics
following clinical improvement in 9 episodes (47%) and
stopped due to unavailable venous access in 2 episodes
(10.5%). 16 patients died (89%) at a median time
following initial treatment of 15 days (range 40 hours to
9 weeks).
Conclusions: Parenteral antibiotic efficacy in
terminally ill patients could not be readily determined,
although short-term improvements may result.
Justification for use remains arbitrary, in view of high
early mortality.
258. Body composition changes in advanced
cancer associated with Angiotensin-Converting
Enzyme gene polymorphism (ACEGP):
preliminary results.
Antonio Vigano 1, Barbara Trutschnigg 1, Rachel Bond 1,
Seema Brar 1, Nancy Hamel 2, Jean-Francois Theberge 3,
William Foulkes 2, Jose Morais 4
1
McGill University Health Centre, Mcgill Nutrition and
Performance Laboratory, Montreal, Canada
2 McGill University Health Centre, Genetics, Montreal,
Canada
3 Universités de Montréal et McGill, Cancer Research
Laboratory, Montreal, Canada
4 McGill University Health Centre, Geriatric, Montreal,
Canada
Introduction: ACEGP greatly influences functional
status and is currently the gene most involved in human
fitness. Healthy individuals homozygous for the
insertion-insertion polymorphism (II allele) had a
greater anabolic response to intensive exercise than did
those with either insertion-deletion or deletion-deletion
alleles. II allele was associated with lower ACE levels and
insulin resistance, along with higher glycogen stores, fat
stores, and glucose uptake in skeletal muscle of animal
tissues.
Aim: To gather preliminary data on the potential
association between body composition with ACEGP in
human tissue of advanced cancer patients (ACP).
Methods: DNA samples were obtained from 40 patients
18 years or older, newly diagnosed with Stage III
(inoperable)-IV non-small cell lung cancer and
unresectable/metastatic gastrointestinal cancers seen
within the McGill University Health Centre. Muscle
tissue surface area was measured by computerized
tomography. Lean body mass (LBM) and muscularity
(M) of the whole body was calculated by extrapolation
of image analysis used to quantify muscle tissue in
abdominal slices.
Results: II allele was associated with both higher LBM
and M independent of age, gender, diagnosis, and
treatment received.
Conclusion: Our data suggest ACEGP may influence
muscle loss in ACP. The role of ACEGP in the
pathogenesis of cancer cachexia is currently being
investigated in a larger sample of ACP.
259. What does the experience of people with
intellectual disabilities tell us about the concept
of “total pain”?
Linda McEnhill
St. Christopher’s Hospice, Education, London, United
Kingdom
The concept of “total pain” developed by Cicely
Saunders is vital within palliative care.The application of
this concept is a defining aspect of hospice care and
engenders the need for a multi professional team to
meet each of the needs identified within the model (e.g.
spiritual, emotional,existential, psychological pain).
Methods for the assessment of total pain are implicit
within the literature from which it would appear there
may be inherent assumptions about a “baseline” quality
of life; the deviation from which would signify the
presence of aspects of total pain. For the “ordinary”
person this baseline might include notions of
‘relatedness’, “self determination” and “self
actualisation”; but what might a baseline quality of life
look like for the intellectually disabled person and
against what measures might the presence or absence of
‘total pain’ be measured? This presentation will initiate
an exploration into the quality of life literature within
the respective fields of intellectual disability and
palliative care. The “total pain” literature will be
considered alongside personal accounts of death and
dying by people with intellectual disabilities. From this
exploration a tentative hypothesis will be developed as
to what constitutes “total pain” in someone with an
intellectual disability and how this pain should be
assessed and treated.
260. Assessing sleep disorders in hospitalized
patients: attention to details
Jorge Eisenchlas, Joanna McEwan, Maximiliano Zuleta,
Cecilia Jacobsen, Marisa Pérez, Lorena Alvarenga,
Gustavo De Simone
Hospital B. Udaondo & Pallium Latinoamerica, Paliative
care Service, Buenos Aires, Argentina
Hospitalized patients frequently suffer sleep
disturbances. Furthermore, perceptions of sleep quality
could differ between patients and professionals.
Objectives:Evaluate the prevalence of sleep
disturbances, its components and the ability of a single
question to assess sleep quality in patients admitted at a
Digestive Disease Hospital in Buenos Aires.
Methods:Every patient admitted to the wards for >6 d.
was assessed using the Pittsburgh Sleep Quality Index
(PSQI) and a screen single item extracted from the Zung
Self-R. Depression Scale:”I have trouble sleeping at
night”.Sleep disorders was defined as a PSQI>4 and/or
VAS>3 (0-10) for the single question. Results:120
consecutive patients were recruited (male 53%). PSQI
was>4 and VAS>3 in 100 and 56 patients respectively
(83.3%and 46.6%). Correlation between the single
question and the PSQI was significant (r0.59;p<0.01).
Sensibility and specificity of the single question were
54% and 90% respectively. Sleep components most
highly rated were latency and duration (m1.68 and
1.56). Subgroup analysis did not show statistical
difference between cancer (n37)and non-cancer patients
(n83) Discussion:This population showed high
prevalence of sleep disorders. A single question did not
show to be useful for screening purposes. The problem
of bad sleep in Hospitals and its assessment, and the
common pattern of sleep disorders in cancer and noncancer patients warrants further investigation.
261. FEASIBILITY STUDY OF THE PALLIATIVE
OUTCOME SCALE (POS) IN HOSPITALIZED
PATIENTS
Jorge Eisenchlas 1, Ernesto Vignaroli 2, Marisa Perez 1,
Mariela Bertolino 2, Lorena Alvarenga 1, Celina
Berenguer 1, Lorena Aranda 2, Silvina Dulitzky 1, Melina
Armada 2, Gustavo De Simone 1
1 Hospital B. Udaondo & Pallium Latinoamerica, Palliative
Care Service, Buenos Aires, Argentina
2 Hospital Tornu-Femeba, Palliative Care Service, Buenos
Aires, Argentina
Patient-reported outcomes are essential to measure the
effectiveness of health-related interventions, although
their use in the palliative care setting remains difficult
AimsEvaluate the possibility of completing the POS by
cancer inpatients assisted by hospital-based palliative
care teams (HPCT) in Buenos Aires
Methods During 4 months, every inpatient submitted to
the HPCT were approached to complete the POS every
3-4 days for 1 week(T1;2;3). Performance status,
educational level, pain, fatigue, MMSE and depression,
were also assessed
ResultsThe POS was offered to 128, 73 and 59 patients at
T1,T2 and T3 respectively (response rate= 65%,63% and
66%). As a whole, the POS was completed 168 times
(rate response 65%;CI95 59-70%). Overt cognitive
impairment accounted for 62% of the failures to fill in
the POS. Of the measured variables, MMSE score was
the only associated with completing the POS.
Furthermore, 75/81 patients with MMSE >19 at T1(93%)
filled the tool. 28/35 patients who did not finished the
primary school (80%;CI95 66-94%) were able to use the
tool atT1. In 24(9%) of the cases patients did not want to
fill the POS
DiscussionCompletion of the POS was possible for the
majority of the inpatients assisted by two HPCT .No
barriers were found to its completion apart from
cognitive impairment. The possibility to complete the
POS by patients with low educational levels makes this
tool useful to explore the effectiveness of palliative care
in developing countries
262. Collecting research data by computers in
palliative care: results from a pilot study
Frode Laugen 1, Line Oldervoll 2, Vanja Stroemsnes 3,
Marianne Jensen Hjermstad 4, Jon Haavard Loge 5, Stein
Kaasa 6
1– 6 Norwegian University of science and Technology,
institute for cancer research and molecular medicine,
Trondheim, Norway
Background: Use of modern computer technology can
give more precise symptom registration. As part of the
PAT-C project, software has been developed for
collecting research data on pain and physical function.
Aim: To explore palliative patients’ reactions towards
the use of computerised assessment of symptoms and
functioning.
Methods: Touch-screen laptops with the PAT-C
software were administered to 20 patients in the in- and
outpatient clinic of The Palliative Medicine Unit (PMU)
at St. Olavs Hospital, Trondheim. To enhance usability,
text was set to 30 pixels and the size of radiobuttons was
twice the standard. Data on the patients’ reactions were
collected by systematic interviews and observations.
Results: Six women and 14 men (mean age 61)
participated. Karnofsky scores ranged from 40 to 100
(median 70). Nine had no previous experience with
computers. Relatives assisted the patients with the
computer assessment in three cases. No one reported
problems with reading the text, but three had
difficulties using the radiobuttons. One person found
the computerized pain body map difficult to
understand. Eleven preferred computer assessment, five
had no preference and three preferred the pen-andpaper format (one missing).
Conclusion: Even if nine of the patients had no prior
experience in using computers, computerised
assessment was preferred.
263. WATCH OUT FOR THE MOUTH -taking care
of the oral cavity in palliative careFederica Bresciani, Isabella Caracristi, Michela Paolazzi,
Claudia Bortolotti, Monica Gabrielli
servizio cure palliative, distretto sanitario, trento, Italy
INTRODUCTION: From Sept.2000 to Sept.2006, the
palliative care services(PCS)of Trento provided care for
1200 oncological patients(Pt) up until the moment of
death.Our experiences revealed a high incidence of
pathologies(Pa) by the oral cavity.The correlated
symptoms are very disturbing to the Pt and contribute
in causing a state of malnutrition.To elaborate an
effective protocol (Pr),that will be able to standardize
preventive intervention and the treatment of Pa that are
caused by the oral cavity in cancer Pt that are under the
care of palliative care services. Bibliographical research
was carried out in Medline and Cochrane.Pr: includes 1)
the preventive phase: identifying the Pt that are at risk,
will allow preventive measures to be taken therefore
minimizing the incidence and morbidity of Pa linked to
oral toxicity; 2) the treatment phase: specific
intervention for each single Pa regarding the oral cavity
is described.
CONCLUSION:Pr is in the phase of being put into
use.Several indicators have been identified to quantify
its results: Number(N)of Pa regarding the oral cavity that
were prevented or diagnosed and treated early on.N Pa
cured,N symptoms correlated to Pa that were diagnosed
and treated N of healthcare professionals that know and
correctly implement the interventions that are described
in the Pr(>75 %). N of Pt that correctly follow the
instructions that they have received as part of the
educational intervention of the Pr(>75 %).
117
Poster abstracts
Background: Oral problems are often underdiagnosed
and undertreated in palliative care patients. The primary
aim of this study was to survey the occurrence of oral
problems in palliative inpatients. A secondary aim was
to audit nurse documentation in patient records
concerning oral problems.
Methods: All patients (n=19) on one hospice ward on
the two days of study in May 2005 was asked to
participate. 18 patients participated. The oral cavity was
assessed with the Revised Oral Assessment Guide
(ROAG).
Results: The majority of the patients had problems
from the oral cavity such as dryness and fured togue.
Hoarse voice and redness of the oral mucous was also
frequent. The documentation in the records was
defective.
Discussion: The result of the study indicates that there
is a need for an assessment tool and for interventions to
improve care associated with problems from the mouth.
An assessment tool is a valuable aid for nurses in their
work with mouth related problems. It is a guide on how
to examine the oral cavity, assess problems found, give
instructions for treatment and provide a structure for
documentation.
Poster abstracts
264. Web based After Death Analysis (ADA) tool
for supporting End of Life care in primary care
Thomas Thomas 1, Helen Meehan 2, Karen Shaw 3,
Collette Clifford 3, Mike Parry 3, Frances Badger 3
1
National Clinical lead, NHS End of Life Care Programme,
Department of Primary Care and General Practice,
Birmingham, United Kingdom
2 Palliative Care Team, Solihull NHS Primary Care Trust,
3 University of Birmingham, School of Health Sciences,
Background The Gold Standards Framework (GSF)
provides primary care teams with a practice-based
model to support end of life care(Thomas 2003).
Monitoring progress with GSF using an After Death
Analysis tool (ADA) can help practices review and
improve end of life care. Anonymised data entered online into the ADA are downloaded to a data-base to
enable intra- and inter-practice review.
Aims 1.To pilot and develop the web based ADA. 2.To
obtain longitudinal data to track progress in delivering
end of life care by adopting the GSF programme, using a
Locally Enhanced Service.
Methods One primary care trust in England introduced
GSF to 37 practices, monitoring progress using the pilot
ADA. 20 questions record care during 5 recent nonaccidental deaths, completed quarterly.
Analysis 1. Quantitative analysis of item responses. 2.
Qualitative interviews with practitioners to identify the
value of the ADA to practice and suggested
developments.
Results Data analysis is in progress and will be complete
by spring 2007. Initial indications are that practices are
finding ADA valuable for auditing care. Suggestions for
improving ADA are made and adopted for national use.
Conclusion Evidence of the value of the ADA is
presented in tracking progress towards improved
patient-centred outcomes in end of life care using GSF.
This tool is of interest for national evaluation of GSF and
end of life care improvements.
265. OUR PLAN FOR THE PATIENT - applying the
N.A.N.D.A. recommendations in TrentoMonica Gabrielli, Federica Bresciani, Monica Claus,
Helmut Menestrina
Poster abstracts
INTRODUCTION: in order to guarantee that the
patient’s (P) problems are adequately cared for and
managed, international literature considers that it is
essential that nursing professionals adopt an
individualized healthcare plan.
OBJECTIVE: to produce an effective instrument that is
able to guarantee that the uniformity of the
interventions, continuity of care and the monitoring of
the P current problems.
METHODS:a workgroup that was made up of Nurses
from the Palliative Care Services of Trento,identified
some of the diagnoses/problems that are the most
frequent to manifest themselves in P during the
terminal phase of their lives,as defined by the
NANDA.The handbook for the healthcare professional
consists of a description of 24 problems with the
diagnoses made by nurses and/or collaborative
problems.Each diagnosis also indicates the expected
results,the interventions that are needed and the
healthcare professionals involved.The operating
synthesis of this instrument is a form which is part of
the healthcare clinical records, it therefore remains at
the home.The form that is used summarizes the
diagnoses and/or collaborative problems that the
patient currently has or that have been cured,which
causes the healthcare professional to re-evaluate them
each time.The instrument has been produced and it is
currently being used.At the present time, after having
evaluated this instrument several times with all the staff
that is involved, it seems to be coherent to the objective
that was proposed and it meets the needs of the P and
the healthcare professionals
266. Heart rate variability for prediction of life
sapn in hospice cancer pateints
Kim 1,
Choi 1,
DoHoon
Youn Seon
hyun Kim 1, Dae Gyeon Kim 1
Jeong A
Kim 2,
Su
1 Korea university Medical Center, family medicine, Seoul,
Korea, South
2
Cheil General Hospital and Women’s Health Care Center,
family medicine, Seoul, Korea, South
The exact prediction on the length of survival is crucial
for hospice patients. Therefore, we studied the
usefulness of heart rate variability (HRV) for predicting
the length of survival. From March 1, 2004 to May 31,
2006, of 71 patients in total, 62 (87%) died. As
performance status scale was lower, as Lymphocyte
percentage was lower, or when combined with dyspnea,
118
the length of survival was much shorter. In the case of
HRV parameters, the group of which the mean heart
rate was more than 100 per minute or the group of
which SDNN is 21.3ms (75% percentile) or less showed a
statistically significantly short length of survival. The
final multivariate analysis reflecting the correction of
the factors such as age, sex, FBS and total cholesterol also
showed that the hazard ratio was 3.217 and 3.08
respectively. Performance status, dyspnea, lymphocyte
percentage were identified as independent prognostic
factors. Among HRV parameters, mean heart rate and
SDNN were meaningful for predicting the length of
survival.
267. Diagnostic Value of Kidney, Ureter, and
Bladder (KUB) Radiographs in Palliative
Management of Gastrointestinal (GI) Symptoms.
Preliminary Findings
Ruth Lagman, Armida Parala, Mellar Davis, Declan
Walsh, Susan LeGrand, Lesley Bicanovsky
Cleveland Clinic, Harry R. Horvitz Center, Cleveland, United
States
Background:
GI symptoms are common and KUB is often used in
assessment. Its utility in guiding decisions and
management is unknown.
Objective:
To assess the value of a KUB in diagnosis and guiding
medical management in an inpatient palliative unit.
Methods:
All patients admitted over 6 months will be included.
Demographics, symptoms, medications, preliminary
diagnosis, radiologic interpretation, management
decisions and outcomes were recorded.
Results:
Initial results involve 32 KUBs .Median age was 62 years
(range 44-89), 14 males, 31 has cancer. Constipation (24)
was the most common complaint, followed by
abdominal pain (17), nausea (15), vomiting (12),
distention (6) and early satiety (5). All patients were on
opioids, 27 on a bowel regimen, and 9 on steroids. The 2
most common reasons for the KUB were constipation
(27) and suspected obstruction (7). Constipation (20)
was the most common interpretation, median
constipation score was 6 (range 0-11). 7 KUBs were
unremarkable and 4 interpreted as obstruction. Official
reading was unremarkable in 25 films, constipation in 4,
ileus in 2, and obstruction in 1. 24 patients had
management aided by the KUB. 22 had enemas/extra
laxatives, 2 opioids, 8 no change in management.
Symptom resolution seen in 26 patients.
Conclusion:
KUB influenced medical management in 69% (22/32).
268. Prospective study of workload in palliative
care unit
Marilene FILBET, Marina PORTIER, Stephane
GOBATTO, Aurelie LAURENT, Mario BARMAKI, Wadih
RHONDALI, Isabelle BRABANT
CENTRE HOSPITALIER LYON SUD, Centre for Palliative
Medicine, Lyon, France, France
Introduction
In France many tools are used for measuring the
workload but they are not adapted for the palliative care
unit’s type of care
Methodology
All caregivers coming in the patient room are requested
to fill a chart recording the time and the task they do in
the room, and if they come by them self or requested by
patient or family.
This record was perform for all the patients admitted in
the unit and during day and night
Results
Global results
The time spend in each patient room by day are:
- 1h 63 for nurses
- 1 h for help nurse
- 0 h 67 Students
- 0h38 physician
- 0h15 for cleaning people
- 0h14 for the chief nurse
- 0h13 re-education and psychomotricity
- 0h10 psychologist
- 0h06 for the social worker
Discussion
The data collection was not so easy and many caregivers
forgot to fill the chart; the results are under-assessed
For each patients the time spend in the room are highly
variable and unpredictable, during day and night; the
adaptation of the workload and the number of
caregivers are very difficult to foreseen.
The time spend in the patient room is only one of the
aspect for the workload in the PCU some time are spend
in communication, preparation, exchanges,
organisation, cleaning…
Conclusions
We need to have and easy and reliable tool to measure
the workload in a palliative care unit
For the staff management
269. Improving the Holistic Assessment of
Palliative Care Patients Needs -A Help the
Hospices Initiative
Dai Roberts 1, Nick Pahl 2
1
2
St Ann’s Hospice, ILD, Stockport, United Kingdom
Help the Hospices, Development, London, United Kingdom
The UK’s NICE guidance on Improving Supportive &
Palliative Care for Adults with Cancer, highlights key
areas for the improvement of patient assessment (NICE 200
4)
. It has also been recognised that a standardised
approach to the assessment of patient’s physical,
psychological social and spiritual needs, together with a
‘specification’, for patient needs assessment tools should
be developed (NAO, 2005, Richardson, Sitzia, Brown et al,
2005).
A Help the Hospices ‘Patient Needs Assessment’
working group was initiated to develop an integrated
care pathway (ICP) for the assessment of palliative care
patients needs on admission to hospice.
Issues to be assessed within the first day/24 hours of
admission included generic/demographic details,
orientation to hospice, functional and physiological
assessments. Days 2-3 focus on assessment of
psychological, social and spiritual domains, ending with
a summary of the patient’s current needs, goals and
proposed actions. All issues within the ICP are recorded,
with unmet items documented through variance
recording. Audit of completion (including assessment of
relevance) was conducted in one hospice setting.
The initiative has resulted in a ‘best practice example’
of holistic assessment for UK hospice. Audit indicates
good levels of completion and relevance of content,
with areas of weakness highlighted. The ICP effectively
addresses the NICE recommendations for the
assessment of specialist palliative care patients.
270. Suffering and Relational Centred Medicine
in Palliative Care
António Barbosa
Faculty of Medicine of Lisbon, Palliative Care/Bioethics
Centre, Lisbon, Portugal
We describe a theoretical model of intervention on
suffering in patients with untreatable and lifethreatening illness as contribute for a more relational
centred health care intervention in palliative care,
allowing caregivers, by means of a meaningful
relationship, to explore all dimensions of suffering and
prioritize and direct their interventions to the patient,
the family and the environment.?We consider that
normal existential anxiety vulnerabilized by threat/loss
of the integrity and/or continuity, as it occurs in
untreatable and life-threatening illness and be
transformed in existential despair with two main
directions related to the meaning attributed to the
vulnerability agents: the loss meaning develop
demoralization syndromes with depressive or detached
modulations, the threat meaning can assume two main
issues: a disbelief/denegation or a anxiety/turbulence
modulation. All this ways of suffering expression are
determined by physical, psychological, mental, sociocultural, family and spiritual components of suffering
that must be recognised in order to help patients, using
a hope construct, to attain a state of existential proud
before dying.We stress the importance of an existential
vigilance in the caregiver/health team in order to be
able to help patients and their families in this important
period of their life.
271. Palliative care needs assesment in rRoma
community.
Daniela Mosoiu 1, Liliana Ilie 2
1
2
Hospice, Education and Training, BRASOV, Romania
Faculty of Medicine, BRASOV, Romania
Aim: to explore the needs and particularities of rRoma
community in Brasov districts (588366 inhabitants out
of them 44600 rRoma) Method: Survey , face to face
administered questionnaire through the rRoma health
care mediators. The questionnaire was piloted on rRoma
health mediators. Results: 1200 questionnaires were
distributed to health mediators, 845 returned and 830
included for final analyzing. rRoma communities in our
study were characterised by: poverty( entertained by lack
of occupation),low education( men doing slightly
better),inappropriate living conditions (space,
sanitary),existing access to health care but no
prophylactic use of it, religion is a private and sensible
topic. There was low awareness in rRoma community
what hospice is and even a lower acknowledgement and
use of services offered by hospice Casa Sperantei. The
main source of information is from person to person
contact (neighbouring, medical staff). When it comes to
Poster abstracts
were integrated at different levels of the system. Reports
were designed and a print out version similar to the
paper version of LCP was made available. A positive test
study of accuracy and user friendliness was performed. It
was possible for the IT specialists at the unit to do all
adaptations of software. ?Conclusion. LCP was
successfully adapted to a computerized patient record
system. Since the number of different IT systems for
patient records is different within hospitals, regions and
countries a “one for all solution” is not possible. The
present study should be seen as an inspirational
example and a sharing of experience.
272. SICP Suggestions of Recommendations on
Palliative Sedation/ Sedation at the end of life
Raffaella Speranza
275. Complementary Therapies at St Joseph’s
Hospice
Bassini Hospital, Milan, Italy
Maura Cochrane
The decision of working process of sedation is still
debated in Italian Palliative Care Units.
The purpose is to consider the practice of sedation
and to help the operators in the difficult decisionmaking process.
In June 2005 a working group was formed under the
auspices of SICP.
The group is multidisciplinary and make up of
nurses, physicians, psychologists, an expert in ethical
problems and a spiritual father, working in different
Italian Palliative Care Units.
The working method consisted of a review of the
international literature before the drafting of
recommendations. After several meetings of discussion
with elaboration of drafts that treated the different
aspects of the sedation processing, was writed a
conclusive paper.
The paper presents several articles: Definition,
Indications, Pharmacological Therapy, Communication
with the patient and the family, Spiritual Aspects,
Ethical Aspects, Management of sedation processing.
The document is directed not only to the attention of
palliative care teams, but also to medical practitioners, to
specialists in hospital wards and to anyone who works in
geriatric clinics to help the interdisciplinary decision
–making process of sedation.
Therefore, we hope to spread in different setting of
care guidelines for valutation and treatment of sedation
and to omogenize the behaviours
St Joseph’s Hospice, Nursing Research, London, United
Kingdom
273. The Borg CR 10 Scale - an alternative to NRS
in symptom assessment?
Marcus Wiklund 1, Carl Johan Fürst 2
Complementary therapies are encompassed within the
concept of supportive care, and are now well established
as part of the multi-disciplinary approach to care at St
Joseph’s Hospice which opened a dedicated
complementary therapy unit (The Wellspring) in
1999.The hospice is located in the richly diverse area of
East London, and one of the main challenges the
developing service has encountered has been
influencing the perception of complementary therapies
among potential service users and adapting the delivery
of the therapies to the cultural mores of the various
groups. For example, many ‘traditional East-Enders’
regard complementary therapy as something for
younger “hippie” new age types, and not for them.
Muslim females, on the other hand, would not undress
for certain therapies, and would only accept a female
therapist. In addition, certain forms of touch therapies
would not be appropriate for a range of cultural and
religious groups.Over the past 7 years the Wellspring
team has worked hard to make the service acceptable to
the many different cultures that are represented in the
hospice. The complementary therapies offered include
aromatherapy, reflexology, acupuncture, massage and
relaxation. Research has been conducted to establish the
benefit of these therapies to our diverse client group.
276. Psychosocial Intervention in C.P.: Art and
Meditation as a road to the Spiritual Dimension
of the Being
Gustavo Rodio 1 2 3, Dorita Gonzalez 1 20 4, Gabriela Boso 1
Ana Laura Ottonello 1 6, Varya Kuis 1 2, Stella
Salgueiro 1 2
20 5,
1
Stockholms Sjukhem Foundation, Stockholm, Sweden
2
Stockholms Sjukhem Foundation and Karolinska Institute,
Stockholm, Sweden
Background. Numeric rating scales (NRS) are
commonly used for symptom assessment in PC, for a
single or several symptoms (eg ESAS). Aim. Do patients
assess symptoms different depending on scale Method.
Ten pts with advanced cancer were included in this pilot
study. Results. Patients mean scores for the three
symptoms at four occasions were generally higher on
the NRS as compared to the Borg CR-10. However, the
differences were not statistically different. All mean and
median scores were <3 on both scales. Generally patients
found it easier to use the Borg CR-10. Patients with
symptom changes during the 15 min interval were
excluded. Discussion. The consistently lower scores on
the Borg CR10 for different symptoms emphasize the
importance of the scale design. The number of patients
was small as was symptom intensity. There is a need for
further development of scales. One clinical aim related
to quality of care is to define a non acceptable degree of
symptom intensity. On the Borg scale the intuitive non
acceptable score is 3 (=moderate), on the NRS a non
acceptable level is not given a priori.
274. Liverpool Care Pathway - integration into
the electronic patient record
Larsson-Daderman 1,
Irene
Marinko 1, Carl Fürst 2
1
Mary-jane
Windus 1,
Uta
Stockholms Sjukhem Foundation, Stockholm, Sweden
2 Stockholms Sjukhem Foundation and Karolinska Institute,
Stockholm, Sweden
Background. Liverpool Care Pathway (LCP) is an
integrated care pathway aiming to improve the care of
the dying patient. LCP was developed at the Marie Curie
Hospice in Liverpool and is increasingly used in the UK
and other countries. Until now a paper based version is
used for LCP. An computerized version of LCP is needed
as part of the development of electronic patient records.
?Aim. To make an integrated electronic version of LCP
for use in the patient record system at a palliative care
unit.?Procedures. The electronic patient record system
is Profdoc Take Care©. The initial and after death
assessments and the continuing follow up parts of LCP
1 Dones Group - Psychosociooncoly, Psychosocial Area,
Buenos Aires, Argentina
2
AAMyCP, Psychosocial, Buenos Aires, Argentina
3 W. Hope - Medical Care, Psychosocial, Buenos Aires,
Argentina
4 Amunay NGO, Psychooncology, Buenos Aires, Argentina
5
Hospital Churruca Visca, Psychooncology, Buenos Aires,
Argentina
6 Hospital Marie Currie, Psychooncology, Buenos Aires,
Argentina
Introduction: We consider spirituality a constituent
dimension of the human existence, present in every
manifestation of its being. Art, in its different
expressions, and meditation are roads that facilitate
access to the spiritual dimension.The psychotherapist
can use these approaches as a tool to allow expression of
the processes of acceptance, communication, coping
and sense of transcendence.Objective: To present
various experiences with patients, who through these
approaches were able to reach acceptance of the process
of disease, the expression of thoughts, feelings,
emotions, and the feeling of integration of the person in
a broader dimension.Methods and Materials: Artistic
work: drawing, mandalas, collage, haiku poetry, short
stories and free writing. Meditation techniques:
conscious breathing, meditation, deep relaxation and
visualization guided by symbols and
images.Conclusion: These expressions, given their
depth and intensity, were facilitated by the above
mentioned techniques. To be able to work with the
expressive capacity within a therapeutic frame,
facilitated verbal and non-verbal communication, and
helped towards the integration of the different aspects of
the being.The experiences conducted allowed us to
observe the richness in the expression of the images,
feelings and emotions, with regard to disease, life and
death; allowing adaptive coping strategies and
enhancing resiliency.
277. A PNIE POINT OF VIEW
(Psychoneuroimmunoendocrinological).COMPLE
MENTARY THERAPEUTICS FOR SYMPTOM
CONTROL.
Gustavo Rodio 1 2 3, Dorita Gonzalez 1 20 4, Gabriela Bosso
1 20 5, Ana Laura Ottonello 10 6, Varya Kuis 1 2, Stella
Salgueiro 1 2
1
Dones Group - Psychosociooncoly, Psychosocial, Buenos
Aires, Argentina
2
AAMyCP, Psychosocial, Buenos Aires, Argentina
3
W. Hope - Medical Care, Psychosocial, Buenos Aires,
Argentina
4
Amunay NGO, Psychooncology, Buenos Aires, Argentina
5
Hospital Churruca Visca, Oncology and Palliative Care,
Buenos Aires, Argentina
6
Hospital Marie Currie, Psychooncology, Buenos Aires,
Argentina
The mind-body dichotomy in health sciences has
divided man, explaining illness with divided models,
applying these criteria on treatment strategies.The
person has been treated as a mind by the psychologist
and a body by the physician, different types of
knowledge and language not integrated at the time of
understanding and treatment. Since the beginnings of
the XX century the transdisciplinary constructions have
allowed us to go beyond psyche soma reductionism,
understanding man as a unity within a multiplicity, a
complex system Bio-Psycho-Social-Spiritual, who as such
is not possible to assist with models that sustain such
dichotomy.The PNIE model applied to P.C. could sustain
the efficacy of non-pharmacological interventions of
the psychosocial area of symptom control in chronic,
progressive and disabling diseases. Such interventions
are non-invasive; they promote a better quality of life,
reducing distress, anxiety, depression, pain, nausea, etc,
preserving the autonomy of the person and respecting
their individuality. These complementary techniques
are: relaxation, meditation, visualization, biofeedback,
hypnosis, etc.The PNIE intervention model reveals the
complex psychological and physiological processes
which interact dynamically in the onset and control of
symptoms. They show the mind-gene interconnections
involved (Rossi 1977), which maximize drug action,
producing larger effects with smaller doses, which
would result in less side effects.
279. EVIDENCE OF ART-THERAPY EFFICACY IN
PATIENTS WITH TERMINAL CANCER.
Nadia Collette, Antonio Pascual
Hospital Santa Creu i Sant Pau, Unitat de Cures Pal.liatives,
Barcelona, Spain
Emotional and spiritual issues require innovative
interventions of the interdisciplinar palliative team. Arttherapy can be there a strong allied health profession.
The aim of this study was to determine the benefits of
individual art-therapy process for adult terminal cancer
inpatients, using a quasi-experimental pre-post data
design (n=51). Method: Prior to and after a minimum
of three 30-60 min creative sessions, we used openended questions to inpatients, families and team to
evaluate their percepcions of the experience. The
Palliative Care Outcome Scale (POS) and the Mac Gill
Quality-of-life Questionnaire (MQOL) were used to
assess the quality of life. Intensity of symtoms was
measured by Edmonton Symptom Assessment System
(ESAS) and Support Team Assesment Schedule (STAS).
Results: Patients, families and team expressed a high
level of satisfaction with the process and 78.4% of
patients comunicated the feeling to get better. The
greatest benefits observed were distraction, emotional
relief, well-being, relaxation and renewal experiences
such as memories, creativity or higher acceptance of the
reality. Statistically significant increase was proved in all
the quality of life parameters, as well as a significant
reduction of the majority of symptoms. Conclusion:
This study provides some evidence of the benefits of arttherapy within the palliative approach. We plan a
randomized controlled study to confirm the specific
contribution of this creative treatment.
280. The role of a physiotherapist at the
Hungarian Hospice Foundation
Nóra Ferdinandy
Hospice Foundation, Palliative Care Team, Budapest,
Hungary
The presentation will introduce the work that I have
been doing at the Hungarian Hospice Foundation in the
past five years.
The Foundation was established fifteen years ago and
works in two main sectors; home care and in-patient
care at the Budapest Hospice House.
The Foundation works also as a method center where
Hungarian as well as foreign applicants – including
college students studying physiotherapy – can take
advantage of further education in specific fields several
times a year.As a physiotherapist I am a member of a
multidisciplinary team. 95% of the patients suffer from
metastatic cancer. Their final two months are
dominated with pain, fatigue and in most cases
lymphatic edema. Making a concerted effort to better
the quality of life and to ease the pain of our patients is
our primary concern.I will give an overview of my job,
tasks and responsibilities and introduce the methods
and tools, as well as, the aims and results which have
119
Poster abstracts
palliative care needs and ways to fulfil them: drugs for
pain, food, nursing support are rated as most important
and specialized centres to admit patients in need for
palliative care and trained persons from the rRoma
community to make home visits are seen as the
solutions. Main cause of dependence and death
reported were non-malignant diseases rather than
cancer. Conclusion: the low use of palliative care
services by rRoma members are both the results of low
awareness and inappropriate design of the services
Poster abstracts
given us so much strength to carry out this noble task.
281. Alternative Therapy in Cancer In seeking of
the Miracle Cure or the Power and the Ethics of
the advertisement
Nikolay Yordanov 1, Rumen Stefanov 2
1 Interregional Cancer Hospital - Vratsa, Palliative Care,
Vratsa, Bulgaria
2 Interregional Cancer Hospital - Vratsa, Vratsa, Bulgaria
No matter how successful is the treatment of cancer
there is long standing tradition in Bulgaria – The cancer
patients and their relatives use, are willing to use or even
insist to use other kinds of treatments concomitant or
instead of the well established anticancer treatment
modalities as surgical treatment, radiotherapy and
chemotherapy. These treatment options are often called
alternative medicine or non traditional or unofficial
methods of treatment. Often there are little or even no
evidences for their effectiveness. Usually these kinds of
treatment in Bulgaria are not prescribed by the
physician responsible for the anticancer treatment.
Many of these alternative treatment modalities are
usually performed by the patient and his/her relatives
without asking for opinion or informing the responsible
for patient’s treatment oncologist. In this investigation
the authors asked patients and their relatives about their
use of alternative treatment modalities, how they
learned about these treatment possibilities, did the
patients informed about these kinds of treatment the
responsible for their treatment oncologist. The patients
were asked about the efficacy of the applied alternative
treatment, its effectiveness and their satisfaction of the
preformed treatment.
282. The Combined use of Complementary
Therapies and Bio-medically Oriented Health
Care in Palliative Stages of Cancer: A Narrative
Analysis
Johanna Hök 1, Caroline Wachtler 2, Torkel Falkenberg 1,
Carol Tishelman 1, 3
Poster abstracts
1 Karolinska Institutet, Department of neurobiology, care
sciences and society, Stockholm, Sweden
2 Lund University, Department of Clinical Sciences,
Stockholm, Sweden
3 Stockholms Sjukhem Foundation, Stockholm, Sweden
People with advanced cancer commonly use
complementary and alternative therapies (CATs). Rather
than using CATs and biomedically-oriented health care
(BHC) in isolation, these different therapies are often
used in a complementary fashion. Little research to date
has given attention to individuals’ experiences of the
combined use of BHC and CATs. This paper therefore
examines one individual’s negotiation between
complementary self-care methods and BHC. Using
narrative analysis, we explore how a personal narrative is
told, in addition to what is told, in order to see how
meaning of the negotiation between different therapies
is created. Our analysis suggests that the BHC may
maintain a vital role as a frame of reference even for the
use of certain CATs. It also became apparent how one
CAT can be used for different purposes simultaneously
by one individual. A positive example is shown of how a
spouse’s experience of positive communication about
CATs with a BHC provider was interpreted by the spouse
as indicative of a shift from a hierarchical to a more
collaborative relationship. Such increased collaboration
between stakeholders is an important aspect of models
of ‘integrative medicine’. Our findings highlight the
need for an open and respectful dialogue about CATs
between patients, their significant others and BHC
providers.
283. The use of Phallus Impudicus as a
complementary remedy in palliative care in
cancer
Sergejs Kuznecovs, Klara Jegina, Ivans Kuznecovs
Preventive medicine Society, Cancer Research Laboratory,
Riga, Latvia
Background: Phallus Impudicus extract (PhI) is regarded
as a complementary cancer therapy and the most
commonly used palliative care remedy in Latvia. This
study aimes to determine whether the use of PhI
prolongs survival time of patients with advanced cancer.
Methods: During the period from 1991 to 2006, 25415
cancer patients with bronchogenic carcinoma, breast,
ovarian colon, rectum, stomach carcinoma and
melanoma were involved in a prospective long-term
epidemiological cohort study, including 11548 patients
used PhI and 13867 control patients, who had used or
had not used other complementary therapies. Main
outcome measures were survival time and
psychosomatic self-regulation.
Results: In the nonrandomized matched-pair study,
survival time of patients used PhI was longer for all types
120
of cancer studied. In the pool of 2008 matched pairs,
mean survival time in the PhI groups (6.52 years) was
roughly 52% longer than in the control groups (2.95
years; P < .001). Synergies between PhI use and selfregulation manifested in a longer survival advantage for
PhI patients with good self-regulation (68% relative to
control group; P = .05) than for patients with poor selfregulation. The best results was observed in groups of
patients with breast and ovarian cancer.
Conclusions: The use of PhI as a complementary
remedy in palliative care can achieve a clinically relevant
prolongation of survival time of cancer patients and
appears to stimulate self-regulation.
284. Attitudes to Acupuncture among Patients
and Physiotherapists in Oncology care
undertaken.
Results:
Health Related Quality of Life (HRQOL) has improved in
17 patients (68%), among them, 9 (53%), felt less
fatigue, better vitality claimed 7 patients (41%), better
appetite - 4 subjects (~ 24%),psychological
improvement in 9 patients (53%). Difference between
patient’s evaluation of their own health improvement
(68%) and doctor’s evaluation of the same patient’s
quality of life improvement (64%) was not significant.
Conclusions:
Blood transfusion improves HRQOL in most cases
(68%). Treatment of anemia improves quality of life in
patients with cancer. Apparently the first administration
of blood is more effective than sequent ones.
Key words: transfusion,anemia,cancer,health - related
quality of life (HRQOL)
Anna Enblom 1, 3, Johanna Selmonsson 2, Malin Asterud
2
, Sussanne Borjesson 1
287. Cancer as an Anticipated Form of Loss
1
Institution of Medicine and Care, Division of Nursing
Science, Linköping, Sweden
2 Health University, Physiotherapy programme, Linköping,
Sweden
3
the Vardal Institute, the Swedish Institute for Health
Sciences, Sweden, Sweden
The purpose of our two cross-sectional studies was to
study how satisfied radiotherapy (RT) patients were with
their antiemetics and if they had an interest in
acupuncture (study A) and to explore oncology
physiotherapists experience and attitude to acupuncture
(study B). Method Study A comprised 368 RT patients.
Study B included 117 oncology physiotherapists. All
participants answered a questionnaire. Result 145
(40%) of the patients in general and 63% of those
treated over pelvis/abdominal fields felt nausea. Of
the145 nauseous patients, 25% reported good or
moderate effect of antiemetics given. One third asked
for additional antiemetics, while 40% rejected
antiemetics. Of all patients, 145 (40 %) were interested
in acupuncture for nausea and 136 (38%) asked for
more information about the method. In study B, one
third of the 117 physiotherapists believed acupuncture
would be appropriate in 50% of oncology patients but
only 8% answered that 50% of the patients actually
received acupuncture. Sixty six (56%) gave acupuncture.
The most common conditions were pain (42 % of the
therapists), chemotherapy induced nausea (38%),
vasomotor problems (28%), xerostomia (17%), RT(16%) or morphine- (16%) induced nausea.
Conclusion Three quarters of the nauseous patients
either asked for more treatment against nausea or
rejected antiemetics. Both patients and physiotherapists
seem to consider acupuncture as an appropriate
method, but it seems to be underused in oncology.
Katalin Muszbek, Eszter Biró, Tamás Halmai
Hungarian Hospice Foundation, Budapest, Hungary
Objective: According to our research spanning all the
five cancer centres of Hungary and a total of 924
patients, 45% of Hungarian cancer patients suffer from
clinical depression while 44% suffer from symptoms of
extreme anxiety. Our psycho-oncology service seeks to
improve patients’ coping mechanisms and quality of
life. Better psychological condition, in turn, helps accept
the difficulties of treatment, alleviate side-effects and
increase the expectance of recovery.
Method: Our psycho-oncology service offers
psycological assistance to cancer patients from the
moment of diagnosis on. The therapy is adjusted to the
special needs and condition of the patient due to a
psychological diagnosis. Beside the exploration of
psychological problems it is inevitable to assess the
patients’ various resources that can serve as basis for the
development of individual coping strategies.
Results: Due to our experience, the psychological state
of many patients might be identified as anticipated
bereavement. According to our therapeutical experience,
about 95% of the patients report to have an improving
quality of life. Sleeping disorders and depressive
symptoms are relieved or even lifted, the relationship
with their family members improve, their everyday life
remains balanced even during the period of treatment.
Conclusions: The bad psychological condition of
cancer patients and their reaction to a shocking loss can
be improved through the means of psychotherapy. This
is why we have to make psychological assistance
available to all oncology patients.
288. Sexual Dysfunction and Cancer: a Behavioral
Intervention Study
285. An exploration of massage and
communication, including recommendations for
teaching strategies to enable colleagues to use
touch in safe and therapeutic ways.
Karin Stinesen
Sahlgrenska University hospital, Cancer, Gothenburg,
Sweden
Lisa Smith
Sir Michael Sobell House, Nursing Services, Oxford, United
Kingdom
This paper/poster presentation offers an exploration of
how touch and massage may be used in palliative care to
enhance communication and develop therapeutic
relationships. Critical analysis of an incident from
practice will identify and analyse how touch may be
used therapeutically to create an environment in which
trust may be initiated and developed. The roles of trust,
touch and massage in the mindful development of
therapeutic relationships will be explored. An attempt
will be made to distil the elements of what might be
taught to colleagues in the palliative care setting to
enable them to appreciate and use touch in therapeutic
and safe ways for the benefit of people nearing the end
of their lives.
286. Use of blood transfusion in palliative care
patients. Health-Related Quality Of Life.
Feliks Blaszczyk, Anna Oronska
Lower Silesian Oncology Center, Palliative Care Team,
Wroclaw, Poland
Bacground:
Anemia is defined as an abnormally low haematocrit or
hemoglobin concentration in peripheral blood; it also is
defined as multi - symptom syndrome with fatigue
being the primary symptom characterized by low
hemoglobin level. Anemia occurs frequently in patients
with cancer and is associated with impaired health related quality of life. Treatment of anemia results in
significant improvement in energy and day - time
activity.
Material and method:
25 patients in palliative care were asked a few questions
in a questinnaire. Questions considered patients
condition and well being after blood transfusion being
Sexuality and cancer at any stage is today a fairly well
mapped field. We know quite a lot about the sexuality
issues associated with cancer. However, our knowledge
of how to actually help these patients is so far very
limited. Therefore, this study focuses on behavioral
interventions, using both educational as well as
psychotherapeutic methods in order to target cancer
related sexual dysfunction. Purpose: The purpose of this
study is to, based on the women’s own words, approach
a way to ameliorate their suffering with interventions
that are today much needed, but rarely offered.
Methods: We start by interviewing the patients about
their needs in the area of sexuality. It is very important
to base the interventions that follow on the patients’
own words. Thereafter, we intervene with educational
group sessions and also with psychotherapeutic
sessions. If indicated, either intervention could include
the partner of the patient. Result: This study has just
started and the results are not yet available to us.
However, the types of questions that come up at our
clinic indicate that this is a much needed area to study.
Reserach implications: With the number of longterm
cancer survivors increasing, quality of life issues become
increasingly important to acknowledge. This study puts
an important quality of life issue on the agenda in our
multidisciplinary cancer team and will likely inspire
further research.
289. HOW ART THERAPY IN PALLIATIVE CARE
UNIT CAN HELP PATIENT AND FAMILY?
WADIH RHONDALI, AURELIE LAURENT, MARIO
BARMAKI, ISABELLE BRABANT, MARILENE FILBET
CENTRE HOSPITALIER LYON SUD, Department for
Palliative Medicine, Lyon, France, France
Art therapy is under developed in palliative care units
(PCU) in France as are the complementary therapies in
general. The palliative care team are often reluctant to
Poster abstracts
introduce new treatement or activities in this
environnement.
Aims: the aims of this study was to explore the benefit
of the art therapy in releiving suffering for patients and
family in palliative care.
Method: Six cases studies will be described and will
illustrate the use of the art therapy in a PCU. They are
-1-communication with patients unable to express their
pain and suffering
-2-the patient is rebuilding self -confidence and selfesteem
-3-the patient start to take an active role in the relation
ship
-4-the patient re-establishes their social position
-5-the patient is able to forget their disease during the
therapy
-6-the patient is able to create a gift for the relatives and
care givers
Conclusion:The experience of the art therapy in our
PCU has been valuated by patients, relatives and
staff.We plan a formal prospective study to evaluate the
impact of the art therapy on quality of life and
satisfaction of patients, family and staff.
(Chinese herbs, Vilca cora) were placed. Energy
therapies, acupuncture and homeopathy were used
uncommonly. 10% of CAM-users reported that used
more than one CAM therapy together.The analysis of
responders group showed that the profile of the CAM
user in our centre was that of elder people (mean of age:
57 vs 51) , female (68%) and city occupier (68%). It was
interesting that only 76% of CAM-users discussed with
their doctor about CAM therapy.CONCLUSION: In our
centre more than half (58%) pts who received palliative
chemotherapy, used CAM during conventional
treatment. Health-care staff need to be aware of such use
of CAM and to be able to educate pts appropriately.
References
Connel,C (1998) Something Understood:Art Therapy in
cancer care.Leatherhead:Wrexham Publications
Guex, P(1994) An introduction to psycho
Kelly D Int J Palliat Nurse 2002 Mar;8(3):108 What role for
teh arts in palliative care
Background: More than 70 % of severely ill patients
with cancer suffer from xerostomia (mouth dryness),
most commonly due to multiple drug treatment.
Dryness of mouth has a profound negative effect on
well-being and can apart from general discomfort lead
to difficulties swallowing, chewing and speaking.
Withdrawal from social life activities due to eating and
communication problems is reported. Traditional
treatments including candies, moisturizing products
and saliva substitutes has shown short time effects.
Research indicates that acupuncture might constitute a
treatment option for xerostomia.Aim: To investigate if
treatment with acupuncture is a viable option for
hospice patients with xerostomiaMethods: During a
one year period 14 hospice patients with cancer
reporting dryness of mouth and associated problems
were offered acupuncture treatment. Ten acupuncture
treatments were given in a five weeks period. To
measure the effect of acupuncture, a Visual Analogue
Scale (VAS), the Xerostomia Inventory and a
measurement of saliva were implemented before, during
and after treatment.Result: Since the data analysis is
currently in progress the final result and the discussion
will be presented at the conference. Preliminary result
shows that the patients experienced some alleviation of
mouth dryness, but that a five weeks treatment period
may be too long for such a sick group of patients since
six of the patients passed away before the series of
treatment could be completed.
Yuuko Moriyama, Mikiko Kawaguchi, Youko
Hashimoto, Aki Urakawa, Harumi Fujii, Kyoichi Adachi
Shimane University Hospital, Department of nutrition,
Izumo, Japan
Aim
To clarify the efficacy of health food supplement served
by the hospital nutritionists for the patients treated by
palliative care team.
Subjects and Methods
Study subjects were 50 admitted patients with
malignant diseases who were cared by palliative team
and individually supported by the nutritionists between
January 2005 and October 2006. All patients were
interviewed whether they used supplements before
admission and what they expected the supplements.
The several kinds of supplements were served to adjust
the condition of each patient.
Results
Forty percentage of patients used health food
supplements before admission. The patients expected
the supplements to improve their stamina, the
immunological response and tasty sensation. The
number of patients who were administrated by the
nutritive liquids, dietary fibers, powder refreshing drinks
which containing with glutamine, fiber and
oligosaccharide, and nutritive drinks with trace
elements were 80, 10, 30 and 55%, respectively. The
mean percentage of served supplements intake and the
mean period of supplement dosage were 73.3±31.8%
and 28.5±33.0 days, respectively. The modifications of
supplements dosage method by freezing, making jelly,
etc. were effective, and the supplements improved
stomatitis and taste disturbance.
Conclusion
The adequate administration of supplements had
favorable effect for patients cared by palliative team.
291. Use of complementary and alternative
medicine in cancer patients: results of survey in
the single cancer centre in Poland (Olsztyn)
Anna Lowczak 1, Agnieszka Jagiello-Gruszfeld 2,
Marzenna Ziomek 2, Irena Bil 2
1 ZOZ MSWiA z Warminsko-Mazurskim Centrum
Onkologii, Palliaitve Care, Olsztyn, Poland
Onkologii, Palliaitve Care, Olsztyn, Poland
Onkologii, Department of Medical Oncology, Olsztyn,
Poland
Onkologii, Department of Medical Oncology, Olsztyn,
Poland
BACKGROUND: The aim of this study was to explore the
use of complementary and alternative medicine (CAM)
in cancer patients (pts) in the our cancer centre.
PATIENTS AND METHODS: In the October 2006
descriptive questionnaires was collected from 56 pts in
the out-patient clinic. All pts received chemotherapy as
metastatic setting. The mean of age of pts was 54 years
(range: 22 – 80), the male : female ratio is 1 :3. 42% of
responders live in the rural area. RESULTS: Data suggest
that CAM is popular among cancer patients. Current
CAM use was reported by 58 % of responders. Most
often shark cartilage and fish oil were used (46%). In the
subsequent position mind-body intervention and herbs
Liv Meidell 1, 2, Birgit Rasmussen 1, 2
1
2
Axlagarden Hospice, Palliaitve Care, Umea, Sweden
293. THE PRESENTATION OF A SYSTEM TO
NAVIGATE IN COMPLEMENTARY CARE (CC) AND
TO SUPPORT THE CAREGIVER TO FIND A SUPPLY
ON MEASUREMENT OF THE NEED OF THE
PALLIATIVE PATIENT.
295. Which place has complementary care for a
palliative expert in a pluralistic network of
palliative homecare?
LUK NAVEAU, MYRIAM ARREN, TINE DE VLIEGER, LUT
VAN DEN BOSCH
Palliative Care Network Antwerp (PHA), Palliative Homecare
services, antwerp, Belgium
IntroductionComplementary care(CC) is improving the
sense of well beingCC is seen as an adjunctive to
conventional medical treatment.The nurses offer advice
and support to all the patients and care givers who want
to introduce CCBecause not all CC are founded on
scientific research, it is often difficult to give CC a place
within the mission of a networkAims Palliative experts
are skilled partners whenever implementation of CC is
requiredThese experts can place CC on the map of the
palliative landscapeThey aren’t experts in practicallyoriented ways but advisorsThey can, by means of their
knowlegde of indications, counter-indications and
general points of attention in the field of CC, give
support to create a safe environment to and increase the
wellbeing of the patientMethodOrganisation of internal
educationObtaining a clear view into the types of CC,
their scientific relevance and effectivenessDesign a
mutual point of view and a clear image to cope with CC
within the organisation by creating a policy
noteResultsThe capability to cope with questions and to
give advise concerning CC will get a forum within the
given task of a palliative networkConclusionTaking in
consideration the tasks of a network it is important to
give CC a neutral place in the path of a healthcare route
as the patient is free to choose any CC in addition to the
existing healthcare servicesThis must always be
supported by adequate knowledge
296. REHABILITATION IN TERMINAL ILLNESS
LUK NAVEAU, TINE DE VLIEGER, MYRIAM ARREN, LUT
VAN DEN BOSCH
Oscar Escolante, José Maria Mateos, Emilia Bermejo,
Pedro Rus, Antonio Ramos, Vicente De Luis
Fundación Instituto San José, madrid, Spain
Introduction: CC and complementary therapy (CT)
want the increase of quality of life and to achieve the
most possible optimalisation of symptom management.
The purpose is to increase comfort, the feeling of well
being and the quality of life. The nurses of the
multidisciplinary homecare team of “Palliatieve
Hulpverlening Antwerpen” give advice and support to
the patient, the family and all involved actors in the care
when they have needs concerning CC and CT with the
development of a particular system that helps to
navigate in this particular support. This system is a guide
that geared all activities in the palliative care pathway to
one another. Aims: Create an uniform step-by-step plan
that support all caregivers and improve access to the
patient perception concerning extension of comfort.
Method: A 5 step by step plan. Results: Increase
engagement, discussion about needs in CC, CT and
palliative care; it check if CC CT is meaningful for the
patient. The information is focused on improvement of
well being, evaluation and report on the effect of the
recommendations on well being. The nurse is the
intermediary through all involved actors in care.
Conclusion: This system make an uniform approach
possible to geared CC, CT and palliative care and
stimulate the caregivers to have attention for patient
needs about CC and CT.
294. DOCUMENTS TO EVALUATE THE
IMPLEMENTATION OF COMPLEMENTARY CARE
(CC) IN PALLIATIVE CARE (PC).
LUK NAVEAU, TINE DE VLIEGER, MYRIAM ARREN, LUT
VAN DEN BOSCH
Introduction: CC and complementary therapy (CT)
Introduction: Palliative rehabilitation improves the
quality of survival. It is a matter of discussion the value
of performance status as prediction of survival.
Objectives: 1.To assess the convenience of suggesting
rehabilitation treatment in terminally ill patients. 2.To
establish objective diagnostic criteria in order to include
these patients in treatment programs.
Method:1.Descriptive qualitative study of medical
consultations received from the PCU by the
Rehabilitation Team. 2.Period of study: 01/01/05 to
31/12/06. 3.Statistical analysis of the results with the
SPSS 11.5 program. Preliminary results (2005): A
total of 79 medical consultations were received, 14 of
them for patients in Palliative Care situation (18%) 6 out
of the 14 (43%) were discharged home after improving
their performance status. 8 of 14 (57%) died; 5 (36%)
showed an improvement of their functional status;
2 (14%) presented complications that led to decease;
1 (7%) died before the beginning of rehabilitation.
Conclusions: It is necessary to include rehabilitation in
Palliative Care Units and to define protocols of
treatment in Palliative Rehabilitation in order to identify
the patients who would benefit the most.
297. The Clinical Effects of Music Therapy in
Palliative Medicine and Hospice Patients
Lisa Gallagher, Ruth Lagman, Ellen Shetler, Mellar
Davis, Declan Walsh, Susan LeGrand
Cleveland Clinic, Harry R. Horvitz Center, Cleveland, United
States
Background: There are few quantitative studies
involving music therapy individuals with advanced
illness. The differences in clinical effects in palliative
medicine and hospice patients are unknown.
Aim: To assess the clinical effects of music therapy in
palliative medicine and hospice patients.
121
Poster abstracts
290. Efficacy of health food supplement for the
patients treated by palliative care team
292. Is acupuncture a treatment option for
hospice patients with xerostomia?
wants the increase of quality of life and to achieve the
most possible optimalisation of symptom management.
The purpose is to increase comfort, the feeling of well
being and the quality of life. The nurses of the
multidisciplinary homecare team of “Palliatieve
Hulpverlening Antwerpen” evaluate systematically the
needs in CC and CT. Aims: The evaluation of physical
symptoms and the psychosocial impact; CC can be a
surplus in palliative care; evaluation improve
communication between the patient and caregiver.
Method: An evaluation tool based on the Edmonton
Symptom Assessment Scale (ESAS). Results: Increasing
possibilities in palliative care and creating possibilities to
evaluate CC on physical and psychosocial effects.
Conclusion: A systematic evaluation tool improve the
well being of the patient through quality of care and the
communication about the impact of CC in palliative
care.
Poster abstracts
Methods: 100 age and gender matched palliative
medicine and hospice patients were prospectively
evaluated. Visual analog scales, the Happy/Sad Faces
Assessment Tool, and a behavior scale recorded pre- and
post-music therapy scores. Symptoms included pain,
anxiety, depression, shortness of breath, and mood.
Behaviors were facial expression, body movement, and
verbalizations/vocalizations.
Results: A paired t-test (P<0.05) demonstrated that with
both programs combined all symptoms and behaviors
improved and were statistically significant. Between
programs, however, only mood, facial, movement and
verbal were statistically significant (P<0.05, t-test).
Comparing the goals between programs using the Chisquare test (P<0.05), decreased pain, anxiety, depression,
shortness of breath, stress, increased mood, selfexpression, decision-making, renewed interest in music,
and positive family interaction were statistically
significant.
Conclusion: There are differences in the clinical effects
of palliative medicine and hospice patients.
298. Music Therapy and Quality of Life of Cancer
Patients in Palliative Care
Malgorzata Stanczyk
University of Medical Sciences, Palliative Care Centre,
Poznan, Poland
This project concerns the effect of music therapy
sessions on the quality of life people suffering from
cancer. Music therapy can improve the QOL by
addressing the emotional, spiritual and physical
needs.The sessions incorporated receptive music
listening, imagery, singing, music improvisation,
relaxation offered individually or in a group. In this
study three groups of Hospice Palium patients
participated, total of 75 patients diagnosed with
cancer.QOL was measured by McGill QOL
Questionnaire. T-test was used and the results differed
significantly (p<0.05) before and after music therapy
interventions. Music therapy influenced emotional
symptoms that includes anxiety, depression, low selfesteem, feelings of isolation and also reduce stress,
relieve discomfort, relieve muscle tension and reduce
patient’s experience of pain. The results suggest that
music therapy is an essential component to improve the
QOL of patients with cancer.
299. The VILA-project
Nina Kvant 1, Lena Olsson 1, Ulf Nilsson 1, Eva Albinsson
1, Ulf Jakobsson 2, Eva Persson 1, Ann-Louise Christensen
1
, Anette Fäldt 1
1
Poster abstracts
Kävlinge municipality, Kävlinge, Sweden
2
Lund University, Department of Health Sciences, Lund,
Sweden
A specialist end of life care team was included in the
municipal care provided by Kävlinge municipality,
Sweden. The aim of the project was to improve end of
life care e.g. in terms of patient as well as next-of-kin
participation and symptom control. The team consisted
of five enrolled nurses, who had received special
training before the start of the project. Registered nurses,
a physician, dentist, occupational therapist, physical
therapist and a priest were also connected to the team as
an external resource. The project was ongoing for one
year (2004-2005) and included 29 care recipients (age:
49-97 years; 13 women and 16 men) and their next-ofkin. All care recipients had an expected survival time of
three months. The intervention group was compared
with controls who received regular care. At the end of
2005, the project was evaluated by means of
questionnaires sent to the next-of-kin of patients who
had died as well as to all staff concerned. The result of
the evaluation was for the most part positive and
improvement was particularly noticeable in three
specific areas: information provided by the health care
professionals, symptom control (i.e. pain relief,
handling anxiety and nausea) and follow-up/contact
with the next-of-kin after death. The next-of-kin also
stated that they felt more involved in care decisions. The
general opinion among the health care professionals in
the municipality was that the project had been a success
and had led to higher quality care of the terminally ill
patients. Thus, the introduction of the specialist end of
life care team significantly improved nursing care in the
municipality.
300. The role of the Cancer Experiences
Collaborative in the development of research
capacity in supportive and palliative care: Older
adults
Katherine Froggatt 1, Jane Seymour 2, Chris Bailey 3
1 University of Lancaster, International Observatory on End
of Life Care, Lancaster, United Kingdom
2 University of Nottingham, School of Nursing and
Midwifery, Nottingham, United Kingdom
122
3
University of Southampton, School of Nursing and
Midwifery, Southampton, United Kingdom
Background
In 2006, the Cancer Experiences Collaborative (CECo), a
partnership between five UK universities, was funded for
five years to develop research capacity in supportive and
palliative care. One of the themes is “Care for the older
adult towards the end of life”. In the UK, over 80% of
deaths and 75% of cancer deaths occur in people aged
over 65. Care in the last year of life for older people is a
key priority for palliative care and public health.
Aims
1. To identify older adults priorities in end of life care; 2.
To examine end of life care decision making; 3. To
understand preferences for place of care; 4. To explore
and evaluate older adult’s involvement in the design of
palliative care interventions; 5. To develop common
approaches to research methods.
Methods
A series of protocol generation events bring together
collaborators (researchers, clinicians, service users) to
develop research proposals for which funding will be
sought. Capacity building occurs through “State of the
Science” meetings focusing on different aspects of older
adults experiences, to which novice and experienced
collaborators are invited.
Outcomes
An interdisciplinary research programme reflecting the
views of older people, using a range of innovative
methods which enhances the quality of research in this
field. To date, we have obtained funding for a seminar
series on the “Psychological and Social Aspects of Dying
in Old Age”.
301. The need for teachnig palliative care dogmas and reality . Will Hungary’s accession to
the EU be implemented in the field of palliation?
Szántó János 1, Hegedüs Katalin 2
1
University of Debrecen Medical and Health Science Center,
Department of Oncology, Debrecen, Hungary
2
Semmelweis University, Institute of Behavioral Sciences,
Budapest, Hungary
Medicine in the educational system of the former
socialist countries is still taught on an organic basis,
which excludes the study of the human psyche. This
paternalistic, materialistic and treatment-oriented
approach to medical training has resulted in
underdeveloped palliative medicine. Altough advocates
of palliative care (PC) have been trying to introduce PC to
cancer centres in general, specific problems remain to be
solved by each individual country. The authrs introduce
a teaching model, which they have established in
Hungary. The chapters are as follows. 1. Core courses (40
classes), including death and dying, hospice, pain
management and symptom control, care of dying, and
psychosocial family support. 2. Vocational courses (40
classes), including practical nursing skills, mental health
of personnel, case studies, and physician’s experience in
palliative care. 3. Courses for skilled hospice nurses and
co-ordinators (710 classes). The authors underline the
importance of teaching PC for they believe that it is an
extremely important issue in medical education.
302. Factors that Influence the Completion of
Advance Directive Among A Racially Diverse
Population of Older Adults in the United States
Karen Bullock 1, 2, Karen Blank 2, 3
1
University of Connecticut, School of Social Work, West
Hartford, United States
2
Hartford Hospital, School of Social Work, Hartford, United
States
3
University of Connecticut, Department of Medicine,
Farmington, United States
Background: End-of-life decision-making is often a
difficult process and one that many elderly patients and
their families are not prepared to undergo. While
proactive planning for end-of-life care might be ideal,
this process does not typically begin until late in the
patient’s illness trajectory. Several studies examining
end-of-life issues have shown racial differences in across
ethnic groups and there is evidence that black
Americans are less likely to discuss their end-of-life care
and complete advance directives such as living wills,
durable power of attorney for health care (DPAHC), and
Do Not Resuscitate Orders (DNR) than white Americans.
However, these studies have not looked specifically at
older adults. Although the lack of participation in APC
among black Americans has been documented, factors
that influence APC among older black Americans is
poorly understood. This study describes the association
between race and the completion of advance directives
among black and white older adults in the U.S. It also
addresses how beliefs and attitudes influence advance
care planning practices across the racial groups.
Methodology: Black (n=102) and white (n=100) older
community dwelling adults participated in an
educational program about advance care planning and
end-of-life care preferences. After being exposed to the
educational module, elderly persons aged (55+) who
spoke and understood English completed questionnaires
about their end-of-life care beliefs, attitudes, and
preferences. Measures: Dependent variable completion of advance directiveAntecedent variables age, gender, religion, marital status Independent
variable – raceIntervening variables – attitudes and
beliefs about the medical system and end-of-life care
Results: Unadjusted bivariate results found Black
patients less likely to complete advance directives than
White patients (odds ratio = 0.60; P < .001). Attitudes
toward the medical system seem to have a negative
influence on the completion of advance directives. The
negative relationship between black older adults intent
to complete an advance directive was unaffected when
controlled for gender, marital status and religion.
303. Flick the Trip : Falls Prevention in Palliative
Care
Bronwen Hewitt, Alex Sydney-Jones, Stephen Turk, Kate
Weyman, Stephen Brooker, Lesley Sinclair
Sacred Heart, St Vincent’s Hospital, Palliative Care Centre,
Sydney, Australia
The Sacred Heart Falls Project aimed to develop
innovative and imaginative strategies to help minimise
the falls risk for palliative care patients, either in the
community or inpatient settings. PC patients are
considered to be more at risk of falls due to increased
frailty, the potential for decreased mobility and impaired
cognition, polypharmacology and complex social
situations. A multi-disciplinary working group was
formed to examine current research, gather baseline
data and pilot strategies to try to minimise the falls risk
in this vulnerable population. The project has been
active throughout 2006 and has carried out literature
searches, liaised with other organisations and services
dealing with falls prevention in elderly populations and
gathered baseline data collection. It has also successfully
piloted strategies to minimise risk such as a Colour
Coding System for patient gait aids, the purchase of a
high/low bed and promoted the involvement of staff by
conducting a survey to generate innovative ideas which
have included the use of fluorescent toilet seats and
underfloor lighting (both to help prevent falls at night).
304. Expert views on palliative care for older
people. Results from two expert meetings of the
Comprehensive Cancer Centre South (CCCS) in
the Netherlands.
Thirza Olden
Comprehensive Cancer Centre South, Palliative Care,
Eindhoven, Netherlands
In two expert meetings, twenty-five professionals
working in geriatrics and palliative care were invited to
discuss the WHO-publication “ Better Palliative Care for
Older People”. Purpose was to identify important issues
in palliative care for the elderly in the CCCS-region. Five
major issues in palliative care for older people emerged
as most critical:
- Because of variability in the elderly, it is difficult to
make general comments or develop guidelines.
- It is difficult to define the beginning of the palliative
phase of older patients, thus palliative care is under
assessed.
- Older palliative patients suffer from ageism; prejudice,
stereotyping and a general lack of interest in their
situation.
- There is lack of coordination of care and adjustment of
various medical treatments older patients receive.
- Many older people are frail.
The experts reported overall recognition of the WHOpublication and concluded that more knowledge and
better access to palliative care facilities have to be
developed to meet needs of older palliative patients.
Based on these findings, the CCCS is developing several
projects and studies to improve palliative care in the
elderly.
305. THE ROLE OF KINETIC THERAPY FOR
PATIENTS WITH RHEUMATOID ARTHRITIS (RA) LAST STAGE
Luminita Georgescu 1, Elena Nicolau 2, Cristina Necsoi 3,
Andrei Dumitru 4
1– 4
University of Pitesti, Kinesitherapy, Pitesti, Romania
Aim of study
The present paper is trying to asses the best kinetic
therapy program for last stage RA patients (as part of the
palliative care plan) in order to assure their
independence in caring out the activities of daily living
(ADL).
Methods
The study was realized at the Center for Social Assistance
and Long Term Care Pitesti, on a lot of 4 patients with
Poster abstracts
306. A model of palliative care for nursing homes
Paul Paes 1, 2, Leonie Armstrong 2, Lilian Errington 1,
Marianna Fischer 2, Sylvia O’Hanlon 3, Kath McMurray0
, Wendy Prentice 5, Dorothy Reeves 1, Teresa Sanchez 4,
Karen Torley 2
308. Let no such ending come to me, O God!*
Being hospitalized and demented
Zsuzsanna Endrody
Catholic Services of Charity, Budapest, Hungary
Aim of project/study: Health- and social care systems
in Hungary now are suffering from rapid changes. This
presentation reports on Catholic Services of Charity’s 15
years experience working with long term patients with
dementia and their families. The presentation will
involve review of characteristic examples, to attract the
problems, the families, the patients, the nursing homes
staff and the healthcare professionals facing with during
a crisis situation, when the demented person should be
hospitalized. The study shows the deep need for a
dementia-friendly environment and well-trained in
dementia-care healthcare professionals in hospitals.
Method: Evaluation results of workshops. The
participants of the workshops are caregivers (family
members), long term care staff-members, family
doctors, hospital nurses and doctors. During the
workshop the participants according their experiences
identify risk factors for people with dementia in
hospitals. Conclusion: Much to do increase awareness
to importance of proper care setting in hospitals and
healthcare-institutions, importance of palliative care at
the end-of life care for people with dementia. *These
rows are from poem Alexander Petofi, the famous
Hungarian poet.
4
1
North Tyneside Palliative Care Team, North Tyneside,
United Kingdom
2
Marie Curie Hospice, Newcastle upon Tyne, United
Kingdom
3
North Tyneside General Hospital, North Tyneside, United
Kingdom
4
Princes Court Nursing Home, North Tyneside, United
Kingdom
5 King’s College London, London, United Kingdom
Aim of study?To develop, implement and evaluate a
model of palliative care for patients in nursing homes
Background A significant number of patients with
progressive, incurable diseases reside in nursing homes.
This paper describes one model of care designed to meet
their palliative care needs. Method In North Tyneside,
most patients with continuing care needs are admitted
to Princes Court nursing home. After a strategic review,
the following changes took place and were evaluated:
• Weekly palliative care multidisciplinary meeting
• Regular input from a clinical nurse specialist, social
worker and physiotherapist
• Educational programme
• Complimentary therapies programme
• Partnership with Marie Curie Cancer Care to enable a
senior nurse to work alongside staff
Results The weekly meeting and input from specialist
palliative care have enabled discussion of symptoms,
psychological and social issues for each patient.
Advanced care planning has happened and some
patients have been discharged home. The Marie Curie
inpatient nurse had a major impact in assessing and
meeting the training needs of staff, and acting as a
senior mentor. The model has successfully improved
staff skills, governance, and morale when dealing with a
large number of dying patients.
Conclusion
The provision of palliative care for nursing homes is an
important priority. This paper describes a successful
model of collaboration between the NHS, private and
voluntary sector.
307. Observation about cancer in old patients
Constantin Bogdan, Gabriela Rahnea-Nita
Romanian Society for Palliatology and Thanatology,
Oncology and Palliative Care, Bucharest, Romania
Palliative oncogeriatrics is a distinct teritory between
oncology - palliative care - geriatrics. The arguments for
palliative oncogeriatrics are: population ageing and
increasing of life expectorancy, increasing of cancer at
old patients, difficulties in active therapy (surgery,
chemotherapy, radiotherapy), poor response at some
treatments, comorbidity, changes due to ageing process,
specifity of palliation intervention. In the year 2005, in
St.Luke Hospital, Chronic Oncology-Palliative Care
Ward were admited 1673 patients; 1177 were old
patients. The incidence of main localisation of cancer in
old patients was : women ( > 55 years old): breast cancer,
lung cancer, bowel-rectal cancer, head and neck cancer.
The particularities of therapy in palliative oncogeriatrics
are presented. In conclusion, palliative care of old
patients has an important role, making posible a good
quality of life.
310. Living and Dying in Alternative Housing for
People with Dementia - The Contribution of
Palliative Care
Elisabeth Reitinger, Sabine Pleschberger
University of Klagenfurt, IFF-Palliative Care and
Organizational Ethics, Vienna, Austria
Background Alternative Housing for people with
dementia is gaining importance in current debates on
caring for elderly people. Surprisingly innovative forms
of housing for people with dementia do not seem to
refer to issues of hospice and palliative care. People
living there do have palliative care needs if death and
dying should take place there. On the other hand
palliative care for elderly people is yet in its beginnings
and has rather focussed on nursing homes. Aims In
light of this the ongoing study (10/06-07/07) explores
how palliative care can contribute to care in alternative
housing forms and vice versa, i.e. how expertise in
caring for people with dementia can aid developments
in palliative care. Methods Qualitative interviews with
experts in the field of alternative housing for people
with dementia as well as in palliative care from
Germany and Austria are conducted (n=10-15). This
perspective is completed by focus groups with
professionals of alternative housing models and an
interdisciplinary workshop that connects people from
both fields. Conclusion Central issues are the way
people are supported in their last phase, how ethical
questions are dealt with and how “dying in place”
through a better involvement of palliative care can be
offered. First results will describe different forms of
cooperation and integration respectively and outline
perspectives on common strategies of these two
innovations in care for elderly people with dementia.
311. “Palliative Care in the Community- joint
training initiatives for community and hospice
nurses and doctors in St Petersburg, Russia”
Irina Yubrina 1, Mikhail Dotsenko 1, Greta Ross 2, Eduard
Moskalev 3
1 St. Petersburg Medical Academy I.I. Mechnikov, Family
Medicine Department, Saint Petersburg, Russian Federation
2 Louth County Hospital, Family Medicine Department,
Louth, United Kingdom
3 Kalininsky District, Hospice No. 4., Saint Petersburg,
Russian Federation
The role of the GP team in the management of patients
with terminal illnesses is undergoing change.
Palliative care is an extremely important field for
management of patients in the terminal stage of their
illness, when all possibilities for curative treatment are
exhausted, and a patient is preparing for the end-of-life
stage. Traditionally palliative care has been associated
with end-stage cancer care, although now it is accepted
that many patients in the terminal phase of severe
chronic illness have the same needs as cancer patients, eg
for effective analgesia, for relief of distressing symptoms,
psychological support, etc.
Currently, the majority of persons in Russia with
palliative care needs are managed by doctors or nurses
who have not had any special training in the care of
such patients. Neither is there a unified policy or
protocols for collaboration between different
organisational structures, concerning shared decisionmaking between General Practice personnel, patients
and relatives, hospices and hospital specialists caring for
these patients, hence many patients come to the end of
their life without adequate therapeutic, psychological,
social, and spiritual support. There is a need to reform
the rules and regulations surrounding the medical and
non-medical care of persons admitted into hospice care
and to develop ‘hospice-at-home’ type of services under
the care of trained community nurses and doctors.
312. Can the Liverpool Care Pathway ( LCP)
sucessfully be used within acute elderly care at
the end of life?
Elizabeth Rees, Fiona Hicks, Amanda Henderson,
Norman Barclay
Leeds Teaching Hospitals Trust, Palliative Care Team, Leeds,
United Kingdom
Background: The Liverpool Care Pathway (LCP) was
primarily developed for use with dying cancer patients.
Leeds Teaching Hospitals forms one of the largest Trusts
in the UK with approximately 2000 beds within 6
hospitals and cares for just over 3000 deaths per year.
Aims: To explore how transferable the LCP is to elderly
care within an acute hospital.
Methods: The pathway was implemented in all areas
using identical paperwork and educational material. We
undertook a prospective audit of patient deaths (n = 40)
post implementation of the LCP within medical and
clinical inpatient oncology wards (n =3) and compared
it with an identical audit of patient deaths (n = 50)
within medicine for the elderly wards (n = 5).
Results: The LCP has been met with enthusiasm within
all clinical settings. The numbers of variances reported
and achievement of goals between the two groups was
almost identical with regard to symptom management,
despite the noticeable differences in both diagnosis, age
and length of time on pathway (see below). Also of note
40 % of the elderly medicine patients died from stroke.
Wards
Age
Length
of time
on LCP
Diagnosis
Oncology
61.5 yrs
(23 – 81)
31.5 hrs
(1-240)
Cancer
n = 40
Medicine for
the Elderly
85 yrs
(70 – 100)
76 hrs
(2 -360)
Cancer n = 9
Non cancer
n = 41
Conclusion: The LCP can successfully be transferred for
use within medicine for the elderly to guide end of life
care delivery without adaptations.
313. Espoused choices, marginalised voices: The
paradox of prefered place of care for older
terminally ill people
Susan Duke 1, Joanne Wilson 2
1 Southampton University, School of Nursing and Midwifery,
Southampton, United Kingdom
2 Royal Berkshire Hospital Foundation Trust, Hospital
Palliative Care Team, Reading, United Kingdom
Aim To identify factors influencing achievement of
older people’s preferred place of care (PPC) and
implications for hospital palliative care teams.
Method Quantitative and narrative analysis of case
notes of older people referred to a hospital palliative care
service in 2005
Sample n=164 ≥70yrs diagnosis: cancer 77% non-cancer
23%
Results Irrespective of diagnosis our sample had
complex health & social needs. PPC was achieved for
67% of whom 53% went home, 25% to nursing home,
9% to hospice, 3% to community hospital and 6% chose
to stay in hospital. 8 people were too ill to identify PPC.
The narratives demonstrate that older people’s PPC is
influenced by complexity of funding provision; bias
towards malignant illness in this process; separation of
social and health care providers; and a family member
willing to be carer/care manager. Timely care planning is
influenced by the ability to anticipate deterioration in
older people.
Discussion Adopting the policy of PPC has
strengthened older peoples’ voices but revealed how
these are paradoxically compromised by funding
processes designed to support choice. To fairly represent
older people’s choices the palliative care team needed to
embrace discharge planning and carer preparation and
develop skills in recognising approaching death in older
people.
Conclusion Achieving older people’s PPC is a complex
inter-relation between policy, health, social and
professional issues.
123
Poster abstracts
RA stage IV, aged 70 to 78 years old (case studies model).
For evaluation purpose we used the RAOS scale
(Rheumatoid and Arthritis Outcome Score), the
autonomy Katz scale for ADL and the Doloplus pain
scale.Based on those evaluations and the functional
assessment we established a personalized kinetic
treatment program (massage, passive and active
mobilization techniques, hydrotherapy, occupational
therapy) associated with pharmacological therapy. The
therapy sessions were held 2 h/day, 5 times /week, 6
months.
Results
The final testing showed an improvement of the
patients’ quality of life, who progressed from being
totally dependent towards a partial dependence (a
medium Katz scale improvement of 25%, amelioration
of RAOS functional state) and from a continuous
painful state towards just bearable painful episodes
(initial medium score 28 and final 20).
Conclusions
A personalized kinetic program, as part of the palliative
care plan, can markedly improve the patients’ quality of
life. The combined kinetic program and medical
treatment lead towards an amelioration of dependence
and a reduction of the pain level.
Poster abstracts
314. Specialist palliative care as a preferred place
of care for older people: prejudiced by caution?
Joanne Wilson 1, Susan Duke 2
1
Royal Berkshire Hospital Foundation Trust, Hospital
Palliative Care Team, Reading, United Kingdom
2
Southampton University, School of Nursing and Midwifery,
Southampton, United Kingdom
Background Older people are less likely to be admitted
to specialist palliative care (SPC) compared to younger
people yet perceive this as a positive option 1.
Aim To identify factors influencing achievement of
older people preferred place of care (PPC) where this is
SPC and their needs meet the referral criteria.
Method Quantitative and narrative analysis of case
notes of all patients meeting SPU referral criteria referred
to hospital palliative care team in 2005.
Sample n=33, ≥70yrs, diagnosis: cancer 85%, noncancer 15%
Results Irrespective of diagnosis, our sample had high
symptom burden and carer fatigue. SPC was perceived as
a positive option and contributed to reducing
patient/family distress by resolving tension associated
with other choices (eg high care needs at home). 18
patients were transferred to SPC. Reasons for those not
transferred include: continuing active management of
disease or acquired infections; concern about ongoing
care following SPC admission; SPC priorities for
admission and waiting times.
Discussion Adopting the policy of PPC has confirmed
that older people view SPC favourably and have needs
that SPC can meet but that this choice is prejudiced by
caution around ongoing care and how patients are
prioritised on SPC waiting lists. Further, there is a need
for a medical plan that is congruent with the plan for
SPC to prevent delay in transfer. The high symptom
burden raises questions around timing of referral and
the recognition of approaching death.
315. Moroccan Muslim Views on End-of-Life
Decision Making in Antwerp, Belgium.
Stef Van den branden, Bert Broeckaert
Katholieke Universiteit Leuven, Interdisciplinary Centre for
the Study of Religion and World Views, leuven, Belgium
Poster abstracts
Until now, Muslim views on end-of-life decision making
form a hardly developed research area in Belgium and
most European countries. This exploratory qualitative
research (Grounded Theory Methodology) is based on
in-depth interview techniques (n=30) with male
Moroccan elderly (<60) Muslims living in Antwerp, with
local imams, Moroccan GP’s in Antwerp and with a
Moroccan nurse working in an Antwerp palliative care
ward in a hospital setting. We found an extremely
dismissive attitude (haram) towards every form of active
termination of life: Allah is the only one to decide upon
the life of a patient. The majority of our respondents
would permit withdrawing or refusal of life sustaining
treatment only if every treatment alternative has been
tried without cure as a result. To them every Muslim has
the duty to look for treatment when sick, with treatment
being the most important way through which Allah can
cure the patient. From this research we conclude that all
type of respondents share the view that ‘patience’ and
‘consciousness’ present the bottom line to every ethical
decision at the end of life: the wellbeing of the patient is
central, with an integration of both the physical – being
without pain – and the spiritual – as shown in the
importance of a good relationship with Allah – level.
316. Palliative care in stroke - a critical review of
the literature
Tony Stevens 3, Sheila Payne 3, Christopher Burton 5,
Julia Addington-Hall 4, Amanda Jones 2
1 University of Sheffield, School of Nursing and Midwifery,
Sheffield, United Kingdom
2 Sheffield Teaching Hospitals Trust, Stroke Services,
3 University of Lancaster, International Observatory on End
4 University of Southampton, School of Nursing and
Midwifery, Southampton, United Kingdom
5 University of Central Lancashire, Dept of Nursing, Preston,
United Kingdom
Stroke results in high levels of mortality and morbidity,
and can cause a wide range of distressing symptoms and
problems. Very little is known however about the nature
and extent of palliative care services that are available to
this patient group, the ways in which such services
could be delivered and by whom. The aim of this
literature review was to identify studies that have
investigated the palliative care needs of stroke patients.
Employing the principles of a systematic search, a review
of six electronic databases (British Nursing Index,
CINAHL, Cochrane Library, Medline, PsycINFO and
Scopus), covering the last ten years was conducted. From
124
a total of 6440 hits, seven papers were retrieved that
explored the palliative care needs of patients diagnosed
with stroke, only one of which was an intervention
study. The major themes of those papers deemed as not
relevant included epidemiological studies, biomedical
investigations, studies of psychological morbidity after
stroke, discharge strategies and comparisons of
rehabilitation initiatives. The review highlighted three
significant themes. First, the high levels of unmet
palliative need experienced by both patients and
caregivers. Second, the review showed there was a
paucity of data in regard to the differentiation between
provision of palliative care services for patients who die
in the acute phase of stroke and for those patients who
die later. Third, as a result of this limited research base,
the preferences of stroke patients and their families in
relation to palliative care services are largely unknown.
317. Specialist palliative care and non cancer
illness. Availability and access to specialist
palliative care in hospices in Northern England
for patients with non cancer life threatening
illness
Julie MacDonald
University of Hull, hEALTH AND sOCIAL CARE, hULL,
United Kingdom
Objective. Research looked at available specialist
Palliative care in the north of england and access to these
services by patients with non cancer illness. Methods.
Triangulation with qualitative and quantitative methods.
Purposive sample. Questionnaires and face to face
interviewing. Multiple data sources utilised e.g admission
policies, mission statements. Ethical approval granted
Findings. Average percentage spread had a ratio of
85%cancer and 15% non cancer most referrals were for
cancer. Staff felt poorly qualified to deal with non cancer
patients, admission policies reflected that non cancer
patients could be cared for Conclusions. Hospices
actively marketing their services to non cancer patients
despite haveing funding difficulties. Hospices were aware
of national guidelines and were developing services to
meet these. Staff still found that the majority of referrals
were for cancer patients which may be because health
care professionals are not referring these types of patients
or that patients themselves do not wish to avail
themselves of the services
318. Palliative care and intellectual disability exploring the knowledge of specialist palliative
care providers in Kent
Rachel Forrester-Jones 1, David Oliver 2
1 University of Kent, Tizard Centre, Canterbury, United
Kingdom
2 Wisdom Hospice, Rochester, United Kingdom
Aim
As people with intellectual disability (ID)live longer
their health and social care needs increase, particularly
with progressive illnesses, such as cancer or dementia.
The involvement of specialist palliative care
(SPC)services with this group of patients appears to be
small and this study aims to investigate the knowledge
of health care professionals working in SPC in the care
of people with ID.
Methods
Focus groups will be held in 7 hospices and SPC
providers in Kent. Topics for discussion will include
levels of professional experience in the care of people
with ID, as well as areas of concern and barriers to care
provision.
Results
Initial focus groups discussions with senior doctors in
palliative medicine within Kent have suggested that the
involvement of SPC services with people with ID is
small, even though the population of this patient group
is large. Specialists stated that their knowledge, training
and experience in the care of people with ID was low. It
is expected that the focus groups will show similar
results, indicating reasons for gaps in knowledge and
training needs.
Conclusions
It is anticipated that SPC providers have little contact
with or training on the care of patients with ID. Whilst
there is no obvious discrimination there is a need for
greater awareness of ID amongst staff so that the needs
of people with ID can be addressed adequately and
appropriately.
319. End of life care for patient with motor
neurone disease / amyotrophic lateral sclerosis
David Oliver 1, Colin Campbell 2, Richard Sloan 3, Nigel
Sykes 4, Carole Tallon 5, Sandi Webb 6
1
Wisdom Hospice, Rochester, United Kingdom
St Catherine’s Hospice, Scarborough, United Kingdom
Joseph Weld Hospice, Dorchester, United Kingdom
4
St. Christopher’s Hospice, London, United Kingdom
2
3
5
6
Cynthia Spencer Hospice, Northampton, United Kingdom
St Wilfrid’s Hospice, Chichester, United Kingdom
Aims
The aim of this study was to look at the experience of
specialist palliative care (SPC) services in the UK in the
end of life care for people with MND/ALS.
Methods
A retrospective audit of 47 patient notes was undertaken
in 6 different hospices. The data were then analysed
together.
Results
47 patients’ notes were analysed – 24 male and 23
female.
7 (15%) received non-invasive ventilation and 1 (2%)
had received tracheostomy ventilation. 17 (36%) had a
gastrostomy.
Most patients, 42 (89%) died from respiratory failure.
16 (34%) deteriorated within 24 hours and the
majority, 34 (72%), deteriorated within 3 days.
The majority of professionals (83%) and families (81%)
had anticipated that death was imminent, but only
70% of patients were felt to be aware.
62% received a subcutaneous infusion of medication in
the last few days (mean 2.9 days) – commonly
morphine (mean dose 44mg/24 hours), midazolam
(mean dose 54mg/24 hours) and glycopyrronium
(mean dose 1.0mg/24 hours).
Discussion
The end of life of patients with MND/ALS had often
involved SPC and the services were often involved in
decision making throughout the disease progression.
Death was usually following a short period of
deterioration, and this was usually anticipated by
families, but not always by patients. The use of
medication is important in the management of
symptoms and minimising distress at this time, and is
commonly given by subcutaneous infusion.
321. An evaluation of use of symptom control
guidelines for end stage heart failure in cardiac
network
Clare Littlewood 1, Helen Rainford 2, Christine Gardener
2
1
st Helens& Knowslet Hospitals, Palliative Care Team,
Liverpool, United Kingdom
2
Cheshire & Merseyside cardiac network, Cardiac network,
Background
In response to local need a joint initiative between
palliative care and cardiac networks in Merseyside &
Cheshire in 2005 developed referral criteria and
symptom control guidelines for professionals caring for
patients with end stage heart failure.Cheshire &
Merseyside Cardiac Network (CMCN) distributed the
guidelines via heart failure nurses in community and
acute trusts.Guidelines were also downloadable from
both network websites.
Methods
Questionnaire designed and distributed to heat failure
nurses within CMCN to evaluate use and effectiveness
of guidelines
Results
Guidelines are being used within both acute and
community settings but were of greater use to heart
failure nurses in community who had less contact with
other professionals of their own discipline and from
other teams.
However despite network acceptance of collaboration,
there was evidence that some heart failure nurses had
not yet used them
Conclusion
Guidelines were valued by cardiac teams and despite
some areas reporting low usage there was evidence of a
willingness for collaborative working. However lack of
awareness of guidelines amongst wider health
community, particuarly General Practioners and district
nurses was apparent. Further work needs to be carried
out on sucessful dissemination methods of network
guidelines
322. Exploring the palliative care needs of service
users with neurological conditions
Eleanor Wilson 1, Jane Seymour 1, Aimee Aubeeluck 1,
Christina Mason 2
1 University of Nottingham, School of Nursing,
Nottingham, United Kingdom
2
St Joseph’s Hospice, Research, London, United Kingdom
Aim:
To explore the palliative and end of life care needs of
adults with progressive long-term neurological
conditions.
Background:
Progressive long-term neurological conditions require
palliation from diagnosis. This study focuses on the
most common conditions: Motor Neurone Disease
(MND), Multiple Sclerosis (MS), Parkinson’s disease
(PD), with a special focus on Huntington’s Disease (HD)
Poster abstracts
Proposed Outcomes: The study will enable better
understanding of:
• The views and educational needs of staff;
• The experiences and expectations of patients and
families;
• The experience and quality of life of informal carers;
• The range of patterns and circumstances of death
and dying of people with long-term neurological
conditions;
• Issues encountered in delivery of end of life care to
people with long-term neurological conditions.
323. The prevalence and management of diabetes
in a specialist palliative care unit
Humaira Jamal, Sue Gale, Ivan Trotman
mount vernon hospital, Palliative Medicine, middlesex,
greater london, United Kingdom
Aim: To determine the prevalence and management of
diabetes in a specialist palliative care unit(SPCU)
Method: Consecutive patients admitted to a SPCU
during a 7 month period were examined for diabetes.
Those identified were asked to complete a
questionnaire which assessed 8 domains including a 10
point quality of life (QOL) visual analogue scale (VAS).
A score of 4 or more was considered to have a moderate
to severe effect on QOL. Their subsequent course was
monitored until death or discharge.
Result: Of the 177 new patients ,15(8.55) were diagnosed
as diabetic. Nine patients developed diabetes whilst on
steroids, 6 had type 2 diabetes. 11 were female and 4
male, mean age 73 ( range 58-88). 14 patients had a
diagnosis of cancer and 1 had COPD. The following
symptoms were reported: thirst (4), polyuria (2), weight
loss(1), lethargy (7) and neurological disturbance(3).
Dexamethasone doses ranged from 4-40 mg/day. 6
patients did not receive anti-diabetic treatment, 4 were
on oral hypoglycaemics and 5 on insulin. Four patients
had a VAS of 4 or more indicating a moderate to severe
impairment in QOL and 8 were too ill to complete this
part of the evaluation. Nine patients were discharged.
Of the 6 patients who died during the audit, one
became hypoglycaemic in the terminal phase requiring
IV glucose and the remaining five had blood sugars
ranging from 5-15 not requiring treatment.
Conclusion: This audit suggests that the prevalence of
diabetes in an inpatient population is approximately 3
times that of the general population. The majority of
the patients would appear to have developed
symptomatic diabetes as a result of corticosteroid
therapy highlighting the need for a consensus on the
management of diabetes in these patients.
324. Developing a neurological palliative care
service in Turin - a literature review and needs
assessment
Simone Veronese 1, David Oliver 2
1 F.A.R.O. foundation, Turin, Italy
2 University of Kent, Canterbury, United Kingdom
INTRODUCTION: There is increasing involvement of
palliative care within neurology but there is a little
evidence for the efficacy of Specialist Palliative Care
Services (SPCS) in improving outcomes.
AIMS: Three groups of patients with advanced
neurological disease will undergo assessment of their
needs: ALS (amyotrophic lateral sclerosis), MS (multiple
sclerosis), and PD (Parkinson’s disease and related
disorders).A new SPCS which aims to meet the needs of
neurological patients is being developed and a formal
evaluation will be undertaken.
METHODS: A literature analysis has been performed
showing concerns about unsatisfactory pain
management and symptom relief, psychological and
spiritual unmet needs, barriers to the palliative
approach, high rates of request for assisted dying, gaps in
knowledge of neurologists on clinical, ethical and legal
aspects of the care of dying patients, and a lack of a clear
model of SPCS for these conditions. Further needs
assessment has been undertaken with discussion with
European SPCS and neurologists involved in ALS, MS,
and PD care in Turin. A qualitative assessment of a
sample of patients and relatives will start in 2007.
RESULTS: The preliminary data from the needs analysis
and the assessment of the patient group will be
presented.
CONCLUSIONS: Neurological patients are able to
benefit from palliative care involvement, in
collaboration with other neurological services.
325. How can we best provide palliative care in
advanced dementia? Assessment of need and
development of an intervention.
Ingela Thuné-Boyle 1, Martin Blanchard 1, Elizabeth
Sampson 1, Louise Jones 1, Adrian Tookman 2, Michael
King 1
1 University College London, Mental Health Sciences,
2
Royal Free Hospital, Palliative Medicine, London, United
Kingdom
The end of life care received by patients with advanced
dementia is often inconsistent with principles of
palliative care. Patients are hospitalised repeatedly,
receive inadequate pain control and the use of artificial
feeding is commonplace despite contrary evidence of its
efficacy. This study aims to define the palliative care
needs of these patients.A qualitative methodology was
applied using semi-structured interviews. Twenty carers
of patients with advanced dementia, and 20 health care
professionals involved in their care, were interviewed.
The main themes identified included attitudes towards
end of life care, communication and decision making.
Relatives had conflicting views, recognising patients’
poor quality of life but would encourage artificial
feeding as ‘starving to death’ was unacceptable. Most
had very little information regarding illness progression.
Nurses and professional carers recognised the terminal
nature of dementia but encouraged active treatments
such artificial feeding as “All patients deserve a chance”.
Doctors were against artificial feeding but were often
guided by relative’s wishes in their decision making.
Advance care planning discussions may be beneficial,
keeping relatives better informed and supported in their
care decisions. Better education for health care
professionals around end of life care may also be useful
as this could lead to more appropriate care and a
reduction in hospital admissions.
families and professionals from other countries and
cultures via the internet.
327. What are the key issues identified by Heart
Failure Nurses in the UK working with patients at
the end of life?
Anita Sargeant 1, Sheila Payne 1,, Jane Seymour 2,,
Christine Ingleton 3,, Sue Ward 4
1 University of Lancaster, Institute for Health Research,
Lancaster, United Kingdom
3
University of Nottingham, School of Nursing, Nottingham,
United Kingdom
4 Sheffield Hallam University, School of Health and
Wellbeing, Sheffield, United Kingdom
5
University of Sheffield, School of Health and Related
Research, Sheffield, United Kingdom
Aim: To identify key issues raised by specialist nurses
providing care to heart failure patients at the end of life
as part of the baseline evaluation of the Marie Curie
‘Delivering Choice Programme’ in the UK.
Method: Specialist heart failure nurses working in the
community and hospital settings within three UK sites
were invited to participate. Three focus groups (n=15)
took place between October 2005 and November 2006.
A semi-structured aide memoire was designed to seek
information about the nurses’ roles, referral processes
and working relationship with local palliative care
services. The data were thematically analysed.
Results:The provision of good end of life care and the
capacity for patients to plan and discuss end of life
choices is dependent upon the skills, knowledge and
experience of heart failure nurses. The uncertain
trajectory of heart failure and the possibility of sudden
death are challenges to the traditional model of
palliative care. Experienced nurses can identify the
terminal phase and discuss end of life choices with
patients. They report that regular contact with patients
for symptom management prevents unwanted hospital
admissions and provides carer support. Lack of out of
hours support leads to crisis admissions and changes in
end of life care plans. Good palliative care for heart
failure patients can be achieved through the
development of collaborative working relationships and
education initiatives between heart failure and palliative
care services.
326. An international survey of end of life care of
people with MND/ALS
David Oliver 1, Nigel Sykes 2, Richard Sloan 3, Colin
Campbell 4, Carole Tallon 5, Takishi Nakajima 6
1
Wisdom Hospice, Medical, Rochester, United Kingdom
St. Christopher’s Hospice, Medical, London, United
Kingdom
3 Joseph Weld Hospice, Medicine, Dorchester, United
Kingdom
4 St Catherine’s Hospice, Medicine, Scarborough, United
Kingdom
5 Cynthia Spencer Hospice, Medicine, Northampton, United
Kingdom
6 Niigata National Hospital, Neurology, Akasaka
Kashiwazaki city, Japan
2
Aim To examine the similarities and differences across
countries in the care of people with ALS / MND, in
relation to:
Attitudes to end of life discussions
• Ventilatory support
• Gastrostomy feeding
Method Questionnaire, sent to six hospices in the UK,
a palliative care team in the US and a special interest
neurology group in Japan, completed for at least the last
10 MND patients who had died.
The questionnaire covered:
Evidence of cognitive impairment?Use of non-invasive
and invasive ventilation?Use of gastrostomy
feeding?End of life discussions?Mode of death?Duration
of the final phase of the illness?Medication used in the
final stages of life
Results: 112 questionnaires were returned (47 UK, 10
USA, 55 Japan). Most patients died from respiratory
failure or pneumonia. The length of disease progression
was greatest in Japan, associated with a higher use of
invasive ventilation. Discussion about end of life issues
varied: ??More discussions on gastrostomy in UK
• More discussion on advance directives in the USA.
• Opioids were widely used, although the use varied
between centres
Conclusion
• There are differences from country to country and
from unit to unit within a country in the assessment
and management of ALS / MND. There are
widespread discussions about the management of
disease progression, although this varies between
countries.
• These discussions should occur early in the disease
progression, as cognitive loss may subsequently alter
the ability of the patient to be fully involved.
• These differences will impact on patient care, as
patients increasingly have contact with patients,
328. How do the levels of physician contact differ
between cancer and heart failure patients in
Scotland during the last four weeks of life?
Anita Sargeant 1, Sheila Payne 1,, Jane Seymour 2,,
Christine Ingleton 3,, Sue Ward 4
3 University of Nottingham, School of Nursing, Nottingham,
United Kingdom
4 Sheffield Hallam University, School of Health and
5 University of Sheffield, School of Health and Related
Research, Sheffield, United Kingdom
Aim: To assess the level of physician contact with
cancer and heart failure patients during the last four
weeks of life as part of the baseline evaluation of the
Marie Curie ‘Delivering Choice Programme’ in the UK.
Method: We took a random sample of patients who
died in hospital or at home from cancer or heart failure
between January and June 2005 in Tayside, Scotland.
For patients who died at home (n = 70), we studied their
GP records for up to four weeks before death. For
patients who died in hospital (n= 100), we studied their
hospital notes for up to four weeks before death. We did
not have the resources to cross reference notes where
patients moved care settings. Using a structured pro
forma we recorded the number of doctor-patient
contacts, investigations and the prescribing of strong
opioids.
Conclusion: 50 cancer patients died in hospital, and 50
at home. 50 HF patients died in hospital, and 20 at
home. Heart failure patients who died in hospital
received more physician contacts and investigations in
the four weeks prior to death than cancer patients who
died in hospital. Among all patients who died at home,
cancer patients received more General Practitioner
contacts and out of hours support than heart failure
patients. In the final week of life all patients received
increased clinical contacts. The results show that the
focus of care for heart failure patients in hospital at the
end of life remains primarily life prolonging rather than
supportive.
125
Poster abstracts
Methods:
The research is in progress. It uses a multi-method
design in three sites in the UK; 1) six neurological care
centres run by a Charity; 2) an independent hospice in
an urban, multi-ethnic city; 3) an NHS specialist outpatient clinic. Methods of data collection include:
• Observation of staff and service users (n=2 care
centres)
• Case studies of service users and their informal carers
(n=5)
• Focus groups with health and social care
professionals (n=50)
• Interviews with bereaved informal carers (n=15)
• Huntington’s Disease Quality of Life Battery for
Carers (HDQoL-C) (n =200)
• Audit of deceased patients’ notes (n=100)
Poster abstracts
329. Adapting the Liverpool Care of the Dying
Pathway for patients dying of End Stage Renal
Disease: A National Pilot
Douglas 1
1
1, 2
Claire
, John Ellershaw , Fliss Murtagh ,
Joanna Chambers 1, Martine Meyer 1, Matthew Howse 1,
Alistair Chesser 1, STEPHANIE GOMM 1, Polly Edmonds
1, Deborah Murphy 1
1
Marie Curie Palliative Care Insitute Liverpool, PALLIATIVE
CARE SERVICES, Liverpool, United Kingdom
2 King’s College London, PALLIATIVE CARE SERVICES,
Introduction In February 2005 the UK National
Service Framework for Renal Services (Part 2) was
produced. A significant proportion was dedicated to End
of Life Care and recommendations were made that tools
such as the Liverpool Care of the Dying Pathway (LCP)
should be used to enhance care for the patient dying
with End Stage Renal Disease (ESRD). Thus a National
Steering Group was established, consisting of health
professionals from Renal and Palliative Medicine. The
aim was to adapt the generic LCP to accomodate
patients dying of ESRD.
Methods Nine pilot sites within England were
nominated and a retrospective case-note audit on 20
patients who had died in each renal unit was performed.
This looked at documentation of care around death. As
patients with renal failure are susceptible to drug
toxicity, a subgroup was formed to propose new LCP
symptom control prescribing guidelines, according to
current evidence and best practice.
Results The goals of the generic LCP were found to be
transferable for patients dying with ESRD. The most
challenging area was producing safe and practical
guidelines for the management of pain, as the evidence
for the use of opioids in renal failure is poor. However, a
consensus was reached and symptom control
prescribing guidleines for the patient dying with ESRD
have been produced and piloted. These guidelines will
be discussed.
330. An audit of referral practice of patients with
end stage renal disease to the Royal Liverpool
University Hospital Palliative Care Team
Poster abstracts
Alistair McKeown, Ruth Agar, Heino Hugel, John
Ellershaw
PMarie Curie Palliative Care Institute, Liverpool, Palliative
Care, Liverpool, United Kingdom
Aims
This retrospective survey assessed the referral practice for
patients with end stage renal failure (ESRF) from the
nephrology wards to the palliative care team in a large
teaching hospital in the North-West of England. In
addition symptoms in this group were assessed.
Methods
49 referrals with “renal” as a primary diagnosis over a
two-year retrospective period were identified from
computerised referral data. General and palliative care
notes were reviewed by the researchers and a data
collection tool designed and completed. Data was
analysed with SPSS.
Results
Most common reasons for referral were for “placement”
(38.6%) and “dying/distressed” patients (22.7%),
although psychological support was also prevalent
(15.9%). Renal teams discussed stopping dialysis in the
majority of cases (89%), but documented preferred place
of care less frequently (48.3%) and rarely achieved
discharge to these locations (21.4%). There was a broad
symptom complex, with fatigue and anorexia the most
frequent dominating problems.
Conclusion
While renal teams are thorough when discussing
dialysis and prognosis, there seem to be issues regarding
discharge to preferred place of care. Increased usage of
the LCP and regular usage of the place of care
documentation from the end of life initiative may
improve this situation.
carer met monthly using action learning to share
experiences,took action and learnt from that action to
meet the following objectives:?Enable renal and
palliative care teams to work together to influence access
to palliative care;?Enhance care for patients managed
conservatively or withdrawing from dialysis;?Extend use
end-of-life care tools.
Results: Sharing of information:- documentation of
multi-disciplinary team decisions in a supportive care
register/database; use of out-of-hours hand-over
forms;community patient- held records and supportive
care directories.Increase profile of conservative
management via local kidney patient associations.
Identifying gaps in care:- use of Care of Dying
Pathway in all care settings; improve communication
between services by the Gold Standards Framework, and
access to palliative care services.
Education:- communication skills training for renal
teams and renal failure management for palliative care
teams.
Service development:- renal conservative management
clinics.
Conclusion: Action learning has initiated new and
enhanced existing resources for patients/carers by
improving skills across the interface of renal and
palliative care services.
332. Delivering effective end-of-life care for
people with advanced heart failure
Kirsty Boyd 1, Allison Worth 1, Scott Murray 1, Marilyn
Kendall 1, Rebekah Pratt 1, Jo Hockley 1, Martin Denvir 2,
Dawn Arundel 3
1 University of Edinburgh, General Practice, Edinburgh,
United Kingdom
2
Lothian Universities NHS Trust, Edinburgh, United
Kingdom
3
Lothian Primary Care NHS Trust, Edinburgh, United
Kingdom
Aims of the study
1.To explore the experiences of patients with advanced
heart failure and their informal carers, and assess the
extent to which services meet their needs from diagnosis
to death.
2.To integrate the perspectives of key professionals and
formulate needs-led models of care for patients with
end-stage heart failure
Methods
• Serial, longitudinal interviews were conducted with
30 patients with advanced heart failure (NYHA grade
III/IV), their informal carers (n = 25) and professional
carers (n = 39)
• Four focus groups were held with professionals and
patients/carers to develop recommendations about
service models
Results
Models of care explored included heart failure nurse
specialists, palliative care, primary care and geriatricianled care. Key features of effective models include: good
quality relationships; continuity of care, with integrated
assessment and case management; regular monitoring;
supported self-management; flexible role boundaries;
anticipatory care planning; carer support; and a range of
psychosocial support services.
Conclusion
End-of-life care for people with heart failure is currently
inequitable; effective care can be provided by any
service. Training in chronic disease management,
supported self-management and the palliative care
approach is essential if generalist health professionals
are to coordinate heart failure palliative care in the
community.
333. ‘Equity of Access’. Provision of a Palliative
Care Nurse Specialist Service for Non Malignant
Disease
Barbara Morgans, Karen Groves
331. Interface of Palliative Care and Renal
Services : Impact of an Action Learning Set?
Stephanie Gomm 1, Hilary Robinson 2, Catherine
Byrne 3, David New 4, Susan Heatley 5, Gill Hurst 6
1 hope hospital, Palliative Care Team, salford, United
Kingdom
2
hope hospital, renal medicine, salford, United Kingdom
3
hope hospital, Palliative Care Team, salford, United
Kingdom
4
hope hospital, renal medicine, salford, United Kingdom
5
central manchester and childrens teaching hospital, renal
medicine, Manchester, United Kingdom
6 central manchester and childrens teaching hospital, renal
medicine, Manchester, United Kingdom
Aim: To assess the effect of a multi-professional action
learning set on access to palliative care for renal
patients/carers across Gr Manchester,UK.
Method: 9 renal and palliative care practitioners and a
126
Specialist Palliative Care Services are often concerned
that if they open their doors to those with non
malignant disease they will be inundated with referrals
and overwhelmed with work. They also fear that their
knowledge and skills will not be sufficient to meet the
needs of these patient groups.
This poster describes the experience and
achievements of a New Opportunities Fund funded
Palliative Care Nurse Specialist, working across hospital
and community within an Integrated Specialist
Palliative Care Service, to respond to referrals for
patients with non malignant disease and to build a
service suitable to their needs.
The three year project figures demonstrate the
appropriateness and timeliness of the referrals made, the
development of a manageable non malignant service
within the already existing integrated service and the
working relationships developed across boundaries with
respiratory, cardiology and neurology specialist services
and others, providing continuity of care.
334. Complementing the Community developing a commmunity complementary
therapy service for patients living with end-stage
non-malignant disease
Nigel Hartley, Elaine Syrett, Sally Hood
ST CHRISTOPHER HOSPICE, Allied Health, London, United
Kingdom
Complementary therapy has proved to offer significant
benefits to people affected by terminal cancer.
Recognising these benefits, and it’s suitability to those
affected by non-malignant end of life diseases, St
Christopher’s carried out a three month review of
Complementary Therapy Resources available for people
living with end-stage non-malignant disease within the
St Christophers catchment area. As a result of the initial
findings of this review, we developed and provided a
Complementary Therapy service for those living with,
or affected by, non-malignant disease, as part of the St
Christopher’s community outreach programme. A
group of specialist palloiative care nurses provided
aromatherapy, hypnotherapy, relaxation and stress
management, through individual and group sessions to
patients, family members and carers, who were referred
into the St Christopher’s Hospice Home Care nursing
team, or who were accessible via direct referral through
their GP or related organisation. The service was
provided within the patients home and also within GP
surgeries.
This presentation will outline the project, highlight
the benefits of such therapies being delivered by dual
qualified nurses, and also present findings from a
research study carried out by Kingston University
alongside the programme.
335. Changing Perspectives: From Care of
incurably ill to chronically ill - Experience form
Northern Kerala, India.
Anil Paleri
Institute of Palliative Medicine, Palliaitve Care, Calicut,
India, India
Palliative care teams may not be able to stay away from
caring for chronically ill along with incurably ill when
there is community participation, as its priorities will
reflect in the program and issues are similar. 2 examples
are discussed.
1: Participation by a Local Self Government Institution
(LSGI) in palliative care programme. In Kerala the
responsibility of health is with LSGIs so they could take
decisions locally. In Kizhuparamba Panchayath (a LSGI),
with a population of 15000, 23 have cancer, 16 are
bedridden, 8 have psychiatric illnesses, 8 on
antituberculosis therapy & 30 have chronic diseases. The
LSGI has evolved a long term care and palliative care
program for them.
2: Community Psychiatry Program: Stigma, poor social
support and compliance etc. make care of psychiatric
patients difficult. Palliative care initiatives in
Malappuram District responded to this by having a
community psychiatry program. Volunteers are trained
to follow up and support these patients. Now there are
regular psychiatry OPDs in 9 places, home care and
rehabilitation programs. 180 patients are cared for of
which 7 are rehabilitated.
The examples show that with active community
participation the scope of palliative care may be
widened to include other chronically ill. Governments
can be made to participate in the process when the
community has the power to decide for them selves.
336. Improving end of life care for patients
considered unsuitable for admission to the ICU: is
there a role for the Integrated Care Pathway for
the Dying Patient?
Alison Roberts 1, Valerie O’Donnell 1, Mark Pugh 2,
Richard Swindell 3
1 Lancashire Teaching Hospitals NHS Trust, Palliative Care,
Preston, United Kingdom
2 Lancashire Teaching Hospitals NHS Trust, Anaesthesiology
& Critical care, Preston, United Kingdom
3 Christie Hospital, Statistics, Manchester, United Kingdom
Aims
To evaluate whether quality of end of life care, in this
patient group, can be improved by the use of the
Integrated Care Pathway for the Dying Patient (ICP).
Methods
A prospective controlled trial comparing care of patients
placed on the ICP with those who were not. All patients
at the Royal Preston Hospital considered unsuitable for
ICU admission, as they were unlikely to survive, were
potentially eligible. Using the ICP as a gold-standard,
notes were reviewed and family satisfaction with end of
life care was rated using a questionnaire which was sent
to the patient’s next-of-kin 4 to 6 weeks after death.
Poster abstracts
337. Improving end of life care for chronic heart
failure patients: let’s hope it’ll get better, when I
know in my heart of hearts it won’t?
Richard Harding 1, Lucy Selman 1, Teresa Beynon 2, Fiona
Hodson 2, Elaine Coady 2, Caroline Hazeledene 2, Irene
Higginson 1
1 King’s College London, Department of Palliative care,
Policy and Rehabilitation, London, United Kingdom
2 Guy’s and St. Thomas’ NHS Foundation Trust, London,
United Kingdom
AIM Chronic heart failure (CHF) has high mortality and
symptom burden, but scant evidence to guide clinical
practice. This study aimed to determine the
problems/preferences of CHF patients/families to
improve end-of-life CHF care. METHOD Semistructured qualitative interviews with 20 patients (NYHA
functional classification III-IV); 11 family carers; 6
palliative clinicians & 6 cardiology clinicians.
Transcripts imported into NVIVO & coded line-by-line,
coding frame reviewed by research team. RESULTS
Patients’ left ventricular ejection fraction range 22.5-50
(mean 34%, SD=8.3). Patients & families reported a wide
range of end-of-life preferences, primarily determined
by age and functional/cognitive status. None had
discussed these with clinicians, and none aware of
future care modality choices. Patients & carers reported
fear and anxiety, and were uninformed of the
implications of diagnosis. Only 2 carers had discussed
end-of-life preferences with the patient. Cardiac staff
confirmed they rarely raise such issues with patients.
Disease-specific barriers (e.g. uncertainty and public
perception of the benign nature of CHF) and specialismspecific barriers (Cardiology focus on curative
approaches and need for communication training) to
improving end-of-life care were identified.
CONCLUSION The integrated data provides 3
recommendations to improve care in line with policy
directives: sensitive provision of information &
discussion of end-of-life; mutual education of
cardiology/palliative staff; mutually agreed palliative
care referral criteria.
338. MANAGING ADVANCED MOTORNEURONE
DISEASE (MND) AT HOME
NURIA ARRARAS 1, MARTA LLOBERA 1, EVA BARALLAT
1, RAMONA GONZALEZ 1, CONCEPCIO TAMARIT 1,
JUDIT PUIG 1, ANGELS RAMOS 1, JAUME CANAL 2
1
Hospital Santa Maria, PADES, Lleida, Spain
Hospital Jaume d’Urgell, Unitat de Cures Pal.liatives,
Balaguer, Spain
2
Introduction
Terminal MND patients can be looked after at home if
there is a good relationship between primary health
care, home care teams and relatives.We describe the
interdisciplinary daily working with MND patients by
two home care teams.
Methods
Retrospective and descriptive study. Data were obtained
from medical records over a period of one year.
We study the following items:1. Social and
demographical:Age,gender,diagnosis,distance from
home to the health centre. 2. Time from diagnosis. 3.
length of follow up. 4. Most prevalent symptoms. 5.
Number of visits carried out by each team member. 6.
Reason of discharge. 7. Scales: Barthel, Pfeiffer,
Karnoffsky. 8. Emotional impact on caregivers evaluated
with a categorical scale.
Results
27 patients were included . 10 m/17 f.Age from 46 to 78
years.14 patients were diagnosed less than 12 months
before first visit. Main symptoms:dysphagia (20),
neuropathic pain (15), shortness of breath (15),
weakness (24), depression (18). discharge: Death (9),
acute hospital (4), nursing home (1), long term unit (4),
symptom controlled (4), other (3). Main caregiver:
wife/husband (12), brother/brother-in-law (10), others
(5). Mean of emotional impact among caregivers
7,67/10.
Discussion
Admission on the home care programme was not
related to the time from diagnosis but of the functional
impairment, symptoms and caregivers burnout.
Symptom control in terminal MND patients did no
differ from oncological terminal patients. MND patients
with longer survival receive more specific attention,
mainly from physioteraphist
339. A Network Approach to the Formulation of
Guidelines for the Management of End-Stage
Respiratory Disease
Jennifer Smith 1, Clare Littlewood 2
1 Countess of Chester Hospital, Palliative Care Team,
Chester, United Kingdom
2
St Helens and Knowsley Hospitals, Palliative Care Team,
Prescot, United Kingdom
Aim Patients with end-stage respiratory disease
frequently have uncontrolled symptoms and unmet
needs.The holistic approach has much to offer.Within
Merseyside and Cheshire respiratory medicine,specialist
palliative care and primary care have worked
collaboratively to improve palliative care (PC) provision.
Methodology A “think-tank” event was held,attended by
medical and nursing staff from primary and secondary
care,patient and carer representatives and managers,to
identify PC services of possible benefit to patients with
end-stage respiratory disease and effective models of
service delivery.This highlighted the need to develop
symptom control and referral guidance for appropriate
patients and to formulate a regional directory of PC
services available for them.Difficulties introducing the
concepts of palliative and terminal care to patients and
carers and determining prognosis were
acknowledged.The need for a joint educational event
was identified.A working party with representation from
both specialities and primary care was set up to realise
the work identified.
Results Symptom control and referral guidelines and a
regional service directory have been developed.A joint
education event was held and was very well received.
Conclusion A further educational event and
development of information leaflets for patients and
carers introducing the concept of PC are planned.
340. The attitudes of critical care staff towards
end-of-life care guidance: A survey questionnaire
Laura Chapman, Maureen Gambles, Kate Richardson,
Tamsin McGlinchey, Deborah Murphy
Marie Curie Palliative Care Institute Liverpool, Palliative
Staff working in Intensive Care units (ITU) are
frequently exposed to dying patients, but this is not
reflected in the protocols and guidance available to
them. For this reason the Liverpool Care Pathway for the
Dying Patient (LCP) was amended through a process of
action research for use on ITU, and implemented
following an education programme.
Aim To assess the attitudes of ITU staff towards the ITU
LCP.
Method A validated survey questionnaire was distributed
to 100 ITU staff of all disciplines and grades. The
questionnaire had been developed for use on health care
professionals using any integrated care pathways.
Responses to statements were recorded on a Likert scale,
where 1 = strongly disagree and 5 = strongly agree. The
dimensions examined included whether the LCP had a
positive effect on clinical practise, its role as a risk
management tool and the appropriateness of the
format.
Results The view of the LCP was positive in all
dimensions, with similar scores to those given by
hospice nurses completing the same questionnaire.
Conclusion The LCP is transferable to an ITU
environment, and is seen as positive tool by ITU staff.
The questionnaire has also highlighted areas of
educational need which can be addressed.
341. Comparisons of the nature and outcomes of
referrals to a hospital specialist palliative care
team between patients with cancer and noncancer diagnoses.
Ruth Flockton, Kate Richardson, Maureen Gambles,
John Ellershaw
episode of care. Comparisons have been made between
the two patient groups.
Results There were 2672 referrals over five years. 16% of
referrals had a non-malignant disease. 26.5% of patients
with a cancer diagnosis were referred at the time of
diagnosis of their illness compared to 16.4% of those
with a non-cancer diagnosis. Patients with malignant
diseases were most commonly referred for pain control
(28.7%). Patients with non-malignant disease were most
commonly referred for management of the dying phase
(46.8% compared to 12.7% of those with cancer).
Patients with a non-cancer diagnosis were more likely to
die in hospital (61.3%) than those with a cancer
diagnosis (32.7%) and less likely to be transferred to the
hospice (3.2% compared to 17.5%).
Conclusion
This review shows there is a difference in the type of
referrals to the palliative care team for patients with
cancer and non-cancer diagnoses. There is a role for
education of general healthcare providers about the role
of specialist palliative care in the management of
patients with a non-cancer diagnosis.
342. A study of British Heart FoundationHeart
Failure nurse and their current Palliative Care
skills and knowledge
Deborah O’Hanlon
Trinity Hospice, Palliative Care, London, United Kingdom
In 2003 NICE guidance recognised the complexity of
the needs of heart failure patients and recommended
that patients and their carers have access to professionals
with palliative care skills within their own heart failure
teams. The WHO in 2004 further supported this and
suggested that it would be unrealistic to expect the
current palliative care workforce to further expand and
meet the needs of this increasing patient’s population.
Aim.The aim of this study was to explore the palliative
care and symptom control knowledge currently held by
British Heart Foundation Heart Failure Clinical Nurse
Specialist’s in the UK. Identifying gaps in knowledge
and educational needs for both the field of palliative
care and heart failure were key outcomes.Method.The
identified sample was contacted via email informing
them of the study. The BHF also informed their nurses
of the research and the need for their participation.All
were then posted (via first class postage) a survey with a
SAE for returning completed to researcher, with the
deadline date specified as two weeks.They were then recontacted via email two weeks after the survey was
posted, reminding them to return ASAP and were then
re-sent the survey.Response rate was
65%.Conclusion.BHF heart failure nurses felt it is their
role to provide palliative care to their patients but lack
the communication skills, symptom control knowledge,
confidence and support to be able to do this effectively.
343. Letter on future care
Helen Herz
Calvary Health Care Sydney, Palliative Care, Sydney,
Australia
Motor Neurone Disease (MND) is a relentlessly
progressive neuromuscular disease for which there
remains no cure. It presents in varying ways, robbing
people of the ability to speak or swallow, or of the ability
to walk or to breathe independently. cognitive changes
may develop. MND progresses and death is usually due
to respiratory failure or aspiration pneumonia. It
presents a predictable although patient-specific course
for which planning is possible.
A disease-specific individualised advance directive or
‘letter on future care’ has been in use by the
multidisciplnary MND service at Calvary since 2001. It
value is as a tool to facilitate discussions on planning
future care. The process for discussion was adapted from
Oliver et al PalliativeCare in Amyotrophic Lateral
Sclerosis however, the end product, the ‘letter on future
care’ is not known to be in use elsewhere.
The study aims to determine whether the ‘letter’
helps in planning and preparing for death and whether
it assists the carer during the bereavement phase.
Semi-structured interviews will be held in
February/March with two groups of 17 former carers
where the person with MND has died. All carers
participated in discussions on future care. In one group
a ‘letter’ was produced. The interviews will be
audiotaped, transcribed and coded using standard
qualitative research methods. Themes will be elicited.
Characteristic quotes will be identified.
Marie Curie Palliative Care Institute, Liverpool, Liverpool,
United Kingdom
Aim This project reviews the nature of referrals to a
specialist palliative care team in a teaching hospital. We
have compared the referrals between patients with a
malignant disease and those with a non-malignant
disease from 2001 to 2006.
Method Data is collected regarding diagnosis, reason
for referral, symptoms reported and the outcome of the
127
Poster abstracts
Results
Nineteen patients were eligible, all within the control
group. Seven (39%) questionnaires were returned. The
median survival following ICU review was 13 (1-126)
hours. Patients often had several co-morbidities. High
levels of intervention continued in the majority of
patients with poor anticipatory prescribing of PRN
subcutaneous medications. High levels of satisfaction
were reported by respondents for all aspects of care.
Discussion regarding the terminal nature of their family
member’s illness was less satisfactory.
Conclusion
This study has been thought provoking, despite not
entirely fulfilling the original aim. Although
respondents reported high levels of satisfaction with
care, the median survival and high levels of intervention
suggest the potential for further improvement in care
through the introduction of the ICP.
Poster abstracts
344. CAL and Palliative Care - Responding to
Diversity
Patricia Mckinnon 1, Stephen Brooker 2
1 Sacred Heart, St Vincent’s Hospital, Social Work
Department, Sydney, Australia
2 Sacred Heart, St Vincent’s Hospital, Nursing, Sydney,
Australia
THIS POSTER depicts a project undertaken by the
palliative care multidisciplinary team in a specialist
palliative care unit, working with the acute respiratory
team, to determine the palliative care needs of CAL
patients and their carers.
AIM : firstly, to establish whether there is a diversity of
needs distinct from patients with malignancies.
Secondly, to identify whether peculiar knowledge and
skills development or particular resources and
provisions are indicated, to provide best palliative care
needs of this non cancer group.
CONTENT covers data collected on reasons for referral,
interventions by health professionals, utilisation of the
service, family/carer involvement, patterns of need physical and psychosocial. An audit tool to assess these
aspects was developed -results are tabulated.
Collaborative co-investigations by the acute respiratory
service are reported, from a survey of CAL patients
perceptions of their palliative care needs, towards an
interdisciplinary approach at the interface with
palliative care.
FINDINGS indicate CAL patients with palliative care
needs have more episodic events of illness, are more
socially marginalised, less resourced, more prone to
access acute settings, less likely to have End of Life Care
discussions.
THE OUTCOME is a projected model for linking
palliative care for CAL patients through stages and
diverse places of care and service delivery options.
345. Manageability of referrals to hospice projects
for non-cancer patients
Jane Frankland, Angie Rogers, Julia Addington-Hall
Poster abstracts
Midwifery, Southampton UK, United Kingdom
Aim
One documented concern about the expansion of
palliative care to non-cancer patients is that existing
services will be overwhelmed. Using data from a
formative evaluation of innovative hospice projects in the
United Kingdom for non-cancer patients, funded by Help
the Hospices, this paper will consider what can be learnt
about the manageability of referral rates to such services.
Method
The evaluation comprised 4 case studies, where
qualitative data were collected from a range of
personnel, both within and without the hospice, plus
data from 16 further projects, collected from one or two
key informants. Semi-structured interviews were tape
recorded, fully transcribed and analysed using a
framework approach.
Results
Early concerns were common among hospice staff and
management regarding the possibility of large numbers
of referrals of non-cancer patients and the impact on
other patients. Referral rates have proved to be varied.
When projects experienced high early demand they
were able to find ways to adjust to and manage the
demand. Initial analysis suggests that issues important
to referrals include the project’s aim, background work,
development of relationships with potential referrers,
referral criteria and other health professionals’
knowledge of the service.
Conclusion
These data indicate that hospice projects for non-cancer
patients are not necessarily overwhelmed with patients,
and that high levels of demand can be managed.
346. Issues in education provision for new
hospice services for non-cancer patients.
education to their staff in a variety of ways, both formal
and informal. Initial analysis suggests that on-going and
informal education and support in practice are vital to
knowledge and skills provision and confidence building.
ConclusionHospices who are working to extend
palliative care to non-cancer patients need to set up
mechanisms for continued education and support for
staff in practice, to reinforce and extend formal
education. Specialists from other relevant disciplines
have an important role to play in this provision.
347. Cardiac Medicine Prescribing In A Specialist
Palliative Care Unit - A Prospective Audit
Graham Whyte
Beatson Oncology Centre, Clinical Oncology, Glasgow,
United Kingdom
Intoduction: Deciding when a cardiac medication is no
longer essential in a palliative care setting is a difficult
decision.Many drugs felt to be appropriate and well
tolerated earlier in the course of a patients illness may
no longer be beneficial. The decision on stopping these
drugs is made easier in the last few days of life but the
area that is unclear is those patients that still have a few
weeks or months to live.
Aims: To obtain a baseline of the number of cardiac
medications patients wre still prescribed on admission
to a local hospice and to ascertain their views on
discontinuing these if proposed.?Methods: A
Prospective audit was carried out of all admissions to a
local hospice over a 3 month period. Interviews were
carried out to assess drug history and cardiac risk before
proposing to discontinue certain drugs. Patients views
on discontinuing these medicines were also recorded.
Results: 76 patients were recruited. 39% of patients were
prescribed at lest one cardiac drug.Of this group only
10% had any ongoing symptoms.16 out of 76 patients
were taking anti-hypertensives however 36% of these
patients had a systolic blood pressure of under
100mmHg. 95% agreed with discontinuation of their
medicines if proposed.
Conclusion:This evalution shows that a number of
patients are still taking perhaps unecessary cardaic
medications towards the end of life.Greater awareness
and education is required in the community and
hospital setting to address this issue.
348. Right to dye is not right to kill : the French
approach on end of life policy
Bernard Devalois, Arnaud Leys, Laurence Geneston
USP, 92, Puteaux, France
The new French law (2005) concerning end of life
policy is strongly in opposition with the Dutch or
Belgian approach. It recognizes the right for everyone to
refuse medical futilities. But it denies everyone,
including MDs, the right to kill another person, even if
this one asks for it. It details strict procedures for
decisions concerning limitation of treatments at the
end-of-life.
* If the patient is able to decide for himself, he is
the only one who can appreciate if the treatment can
be considered as a medical futility or not. It’s true for
an end-of-life patient or for a patient receiving an
active life-sustaining treatment (including artificial
nutrition or hydratation). Medical staff must stop the
active treatment if it is the patient’s decision, even if
the consequence is the patient’s death.
* If the patient is unable to decide for himself, it’s
the medical staff who has to decide about a
therapeutic withholding or withdrawal. At least two
MDs have to decide what they think to be the
patient’s best interest in their own opinion. They
have to consider many factors: advanced directives,
surrogate (if he exists) and relatives’ opinions.
In all cases, palliative care is necessary until the death,
including treatment for pain, suffering, anxiety and any
uncomfortable symptoms. Relatives must be cared for.
In any case, medical staff cannot act to speed up the
dying process (ie euthanasia).
Julia Addington-Hall, Jane Frankland, Angie Rogers
Midwifery, Southampton UK, United Kingdom
349. Palliative Care in Public Health Research
Nils Schneider, Anke Bramesfeld, Larissa Burruano
AimA potential barrier to the extension of specialist
palliative care to non-cancer patients is the skill base of
current palliative care specialists, which is commonly
oncology related. Data from an evaluation of innovative
hospice projects for non-cancer patients in the United
Kingdom, funded by Help the Hospices, are used to
consider the education and training needs of and
provision for project staff. Method Qualitative
interviews were conducted with a range of personnel
within 4 case study projects, plus with key informants
from a further 16 projects. Interviews were tape
recorded, transcribed and analysed using a framework
approach. ResultsData show early concerns about noncancer skills and knowledge to be common among staff
taking on this new role. The hospice projects provided
128
Hannover Medical School, Epidemiology, Social Medicine
and Health System Research, Hannover, Germany
Aim: To examine to what degree palliative care is
represented in the pertinent academic journals of public
health, and what the major subjects are. Method: We
analysed the European journals in the Journal Citation
Report (categories Health Care Science & Services, Public
Environmental & Occupational Health, Health Policy &
Services; years 1996-2005; search terms palliative care,
palliative medicine, terminal care, hospice care). Using
qualitative (inductive category development) and
quantitative procedures, the material was thematically
encoded. Results: 82 journals with 57,737 articles were
found. 166 articles were on palliative care (0.3%), with
the majority (55%) concentrating on a small circle of
journals (4%). The absolute quantity of palliative
publications and their percentage among all
publications have continuously increased from 0.1% in
1996/97 to 0.4% in 2004/05. The largest group of papers
(42%) appeared in journals with impact factors less than
1, and the largest group of all papers in journals with
impact factors of 1 to 1.999 (51%). 17 subject-related
categories were generated; the largest category consisted
in patients’ and relatives’ perspective (12% of the
publications), followed by the health care
professionals’education (10%) and perspective (9%).
Conclusions: There is need for more Public Health
research in palliative care in terms of reach and top-level
impact and a broader topical spectrum.
350. The Effects of Hospice Share-care Program in
Taiwan
Tsui-hsia Hsu, Shu-chun Hsiao, Shin-lan Koong
Bureau of Health Promotion Department of Health, Cancer
Control and Prevention Division, Taipei, Taiwan
Background:There are only about 12% patients who
die in cancer accept the hospice care in Taiwan, in order
to expand the hospice care, the Bureau of Health
Promotion Department of Health constructed a hospice
share-care program, to push a hospice-palliative care
team and a non hospice-palliative care team care the
survival expects less than 6 months cancer patients
together outside the hospice ward. Methods:The search
instruments included (1)Hospice share-care record:
Collect the data that the patient looks after each
time.(2)Patient and family members’ satisfaction
investigates form.(3)Original diagnosis and treatment
team investigates form.Analysis:The description
covariance and Chi-Square design were used in this
study. The purpose is a study whether the implement of
the hospice share-care program can promote hospice
utilization, the patient’s caring need and physically
caring situation, patients and family members accept
caring satisfied situation, and whether the hospicepalliative care team can help original diagnosis and
treatment team to care a terminal cancer
patient.Results:The major findings were: (1) there were
7205 cancer patients to accept hospice share-care, so in
2005 at least 19% terminal cancer patients accept the
hospice care in Taiwan.(2) the satisfaction of the
patients and family members is 4.87(The full marks is
5)(3) 90% medical members think the hospice sharecare can promote the quality of the condition of illness
control. Conclusion:The hospice share-care program is
successful of promote the hospice and palliative care to
outside the hospice ward. In the future, it will need to
develop the indicator for quality of care.
351. FIT FOR PURPOSE:MODERNISING THE
MINIMUM DATA SETCOLLECTION IN THE UNITED
KINGDOM
CLARE LITTLEWOOD 1, BARBARA JACK 1, JOHN
ELLERSHAW 1, DEBBIE MURPHY 1, ANNE EVE 2
1 Marie Curie Palliative Care Insitute Liverpool, Palliative
2 National Council Palliative care, Palliative Care, London,
United Kingdom
BACKGROUND
The Minimum Data Set for Specialist Palliative Care
services was developed in 1995 to provide annual data
on services in the U.K. The development of payment by
results and health resource groups,together with
identified limitations of the current MDS including
missing data, the potential for double counting and a
68% return rate, resulted in a current collaborative
project to revise and update the MDS.
METHOD
Action research was utilised for the study as a group
activity that focuses on partnership between researchers
and participants involved in the change process.
Purposive sampling was used to invite key stakeholders
including multidisciplinary specialist palliative care
services involved in completing the MDS from across
England and Wales.38 respondents attended 3
workshops, where each section of the MDS were
discussed and revised. Revised sections were returned to
participants for review.
RESULTS
A consensus existed that the MDS did not completely
reflect current patient workload, extent of services
provided or development of integrated
services.Additionally, with the development of regional
Cancer Network Groups, some data was more
appropriately collected regionally.
CONCLUSION
An action research approach enabled a national
consultation process to be completed
effectively.Involving a wide sample of stakeholders
ensured revisions were made based upon a national
consensus of opinion and met the changing provision
of Specialist services. Further information regarding the
Poster abstracts
352. Use of Continuous Subcutaneous Infusions
(CSCI) via a Syringe Driver within St Helens and
Knowsley Specialist Palliative Care Service
Jan Leatherbarrow 1, Carolyn Jennings 1, Maggie Cooke 2,
Margaret McConaghy 3, Andrew Dickman 1
1
Whiston Hospital, Palliative Care Team, Liverpool, United
Kingdom
2
St Helens PCT, Palliative Care Team, Liverpool, United
Kingdom
3
for specialized palliative care, the network offers five
places per 100.000 inhabitants, which is in accordance
with the guideline of the national health insurance
companies. In 2005 in total 332 patients were admitted
for intramural terminal or respite care. This is about
20% of all patients who died from cancer in Amsterdam.
The average stay was 35 days. Before admission to
specialized intramural palliative care, 64% of the
patients were in a hospital and 29% were at home. Main
objectives of the network are (1)to improve the
quality/continuity of care, (2) development of written
and electronic information to patients, relatives and
caregivers and (3) implementation of a local education
program. This program focuses on the professionals
within the network and all other professional caregivers
in Amsterdam and Diemen.
358. Developing guidance for advance care
planning: a consultation exercise
Willowbrook Hospice, Liverpool, United Kingdom
Introduction Specialist Palliative Care Services within
the locality aim to provide an integrated service with
regard to CSCI via syringe drivers.
Objectives To undertake an audit of the current
practice of CSCI via syringe drivers.
Method This prospective study reviewed relevant
health records and medication charts. The investigators
completed a proforma for each patient; a target of at
least 20 patients for each location was set.
Results Proformas were completed for 23 (community),
20 (hospital) and 20 (hospice) patients respectively. For
all locations, the commonest reason for introducing a
syringe driver was for the control of symptoms at the
end of life (42 out of 63 patients, 67%). The patient had
been referred to the specialist palliative care team in
65% of the cases in both the community and hospital.
Syringe drivers were used for less than 7 days in 70% of
the cases and 78% of the patients died whilst the syringe
driver was in situ. There was clear variation in the way
that CSCI via syringe drivers were monitored in each of
the three sites.
Conclusions This study identified that syringe driver
use is poorly monitored within the hospital and
community, exposing patients to risk of over -infusion,
under-infusion, unrecognised site reaction and solution
problems. There was inadequate prescribing practice in
these two sites, increasing the risk of drug errors.
353. Out Of Hours (OOH) Prescribing in Palliative
Care Units: A Survey of Current Practice in the
U.K.
AMANDA GREGORY 1, 2, JENNIFER TODD 2, STEVEN
WANKLYN 1, 2
1 Guy’s and St. Thomas’ NHS Foundation Trust, Palliative
Medicine, London, United Kingdom
2 Trinity Hospice, London, United Kingdom
A review of the Out of Hours (OOH) prescribing policy
at an independent hospice in the U.K. led to the
development of a postal questionnaire to establish the
current accepted practice in palliative care units
throughout the U.K. One hundred and forty four units
were sent the questionnaire;94 units responded (65.3%).
All responding units had non-resident on-call medical
cover. The mean recommended travel time from the
unit for on-call cover was 34 minutes (median 30
minutes, range 15–60 minutes). Although verbal orders
appear to be the most popular communication method
for OOH prescribing (84.1%), other systems were in use
including email, fax and BlackBerry®. Anticipatory
prescribing, use of patient group directions and further
development of nurse prescribing, should minimise the
need for remote prescribing. However, there still needs
to be a system in place to manage an unexpected change
in a patient’s condition, requiring prescription of a
medicine, when there is no medical cover on site. In a
culture where there is increasing emphasis on clinical
governance, clear policies for managing risk should be
in place. Guidelines currently available from
professional bodies are open to interpretation. This was
demonstrated in the survey by the wide variation in
accepted prescribing practice. There is a lack of clarity
relating to the use of remote prescribing. Legislation has
not kept up with changes in working patterns and
technology - this will need to change.
354. Network Palliative Care Amsterdam/Diemen.
A result of the Dutch policy on pallitive care.
first hospice (in Tbilisi) has been accomplished under
financial support of different NGOs and foundations
(OSI, SOCO, OSGF and etc.). Since 2005 PC programs
are financed by Governmental and Municipal budgets
(one hospice, 3 mobile teams in Tbilisi) supporting PC
of 120 patients simultaneously. As pain management
still remains the most unresolved problem legislative
basis regulating opioid prescription and drug availability
is under preparation.Conclusion: Integration of PC in
National Health plan overall the country necessitates:
incorporation of PC in medical and social educational
programs, increasing of Governmental financing as well
as financing from regional budgets, optimization of
relevant legislation.
355. Specialist Palliative Care Out-of-hours Advice
in Lancashire and South Cumbria
Sarah Yardley 1, Valerie O’Donnell 2, Nicholas Sayer 3,
Clive Shelley 4
1 St Johns Hospice, Palliative Care, Lancaster, United
Kingdom
2
Royal Preston Hospital, Palliative Care, Preston, United
Kingdom
3 Morecambe Bay Hospitals NHS Trust, Palliative Care,
Barrow, United Kingdom
4 St Johns Hospice, Palliative Care, Lancaster, United
Kingdom
Aims To establish the practice of specialist palliative
units providing telephone advice out of hours and
compare with national standards. To establish a policy
for provision of a quality service across the region.
Method There are 7 units in the area staffed on a 24hour basis. All policies and / or protocols were assessed
in addition to 25 samples of documented telephone
calls from each unit. Each unit was compared to its own
standards and to best practice as outlined in the
National Institute for Clinical Excellence (NICE)
Guidelines for Supportive and Palliative Care 1.
Results The level of service provided varies
considerably. Only 2 units have a formal advice line. All
advice lines are nurse led. There is variable medical
support available. A wide range of professionals and
non-professionals use the services. There is no standard
funding.
Conclusion None of the units currently meet the
national standards, including the NICE
recommendation of specialist advice being available 24hours a day. A good practice model has been developed.
The model contains recommendations for staffing
levels, training requirements, protocols, documentation,
audit and funding.
Reference: 1. NICE (2004) Supportive and Palliative Care:
The Manual
Jane Seymour 1, Claire Henry 2
1 University of Nottingham, School of Nursing, Nottingham,
United Kingdom
2 NHS, NHS End of Life Care Programme, Leicester, United
Kingdom
In the UK, advance decisions to refuse medical
treatment have been legalised under the Mental
Capacity Act of 2005. They are one aspect of the wider
process of advance care planning. We report on a
process of consultation which led to guidance for
Advance Care Planning (ACP) being developed for
health and social care professionals working in England.
Aim: to develop clear guidance for health and social care
professionals in England about ACP and associated
terms, including advance decisions.
Method: a consensus building activity involving
consultation and collaboration with experts in the field
and front line staff.
Outcomes: a paper which will be distributed to health
and social care professionals providing the following
information: 1) Definitions of: advance care planning;
statement of wishes and preferences, advance decisions
and lasting power of attorney; 2) Key principles and
professional responsibilities in Advance Care Planning;
4) Principles of record making; 4) Core competencies; 5)
Recommendations for future work.
Conclusion: The consultation exercise revealed a
number of areas of confusion which can impede the
development of practice in ACP. These are mirrored in
the research literature. The paper produced provides
practical guidance on core competences, education and
training of different professional groups and related
ethical and legal implications.
359. Possibilities of Fundraising in A Country
Without the Tradition of Donation
Katalin Muszbek, Cecília Keresztes, Rita Ádám
356. Should adult specialist palliative care inpatient units have automated external
defibrillators (AEDs)? A survey of policy and
practice in the United Kingdom.
Emma Hall
St Christopher’s Hospice, Medicine, London, United
Kingdom
Introduction/aims
AEDs (automated external defibrillators) are widely
available in public places but there is no consensus on
their use in specialist palliative care (SPC) units. Many
SPC units now accept patients with non-malignancy
and less advanced disease. The aim of this survey was to
establish how many units possess and have used AEDs,
to examine access to training and experience with ICDs
(internal cardiac defibrillators).
Methods
Questionnaires,developed with feedback from members
of the Association of Palliative Medicine science
committee, were posted to medical directors of adult
SPC in-patient units across the United Kingdom.
357. Incorporation of Palliative Care in National
Health Plan (From private to Governmental
financing)
Objective: The Hungarian Hospice Foundation has
been working for fifteen years. Each year, it has to cover
50 percent of its budget from donations. Since Eastern
Europe has got no tradition of donations, the
Foundation has drawn up its own strategy of
fundraising.
Method: Three factors form the basis of this strategy of
fundraising:1.Tenders: Projects proclaimed by the
government or various national and international
organizations.2.Donations: Individuals as well as
companies offer not only financial assistance but also
through different regularly managed services. A new
form of financial assistance is the online donation page
on the website of the Foundation.3.Personal income tax:
In Hungary, individuals can offer 1 percent of their
personal income tax to NGOs. This is in fact the main
source of income for most organizations, including our
Foundation which lays special emphasis on memorable
campaigns that successfully address its target groups.
Results: One percent of the personal income tax and
the tenders invited became the main means of
fundraising. Out of the campaigns of some 23,000
organizations (2004), the one of our Foundation ranks
among the 30 most successful.
Conclusions: PR and communication became an
integral part of the functioning of the Hungarian
Hospice Foundation. Nowadays, these are inevitable
elements in the functioning of any NGO in Hungary.
Dimitri Kordzya, Irina Tsirkvadze, Tamari Rukhadze
Wim Jansen
Association Humanist’s Union, Tbilisi, Georgia
Network Palliative Care Amsterdam, Amsterdam,
Netherlands
Formation of local networks palliative care is one of the
main objectives of the national policy on palliative care.
The country is now fully covered by 73 local networks.
The government finances network coordination.
Development of the network palliative care
Amsterdam/Diemen started in 1999, as one of the ten
pilot-projects in the Netherlands. In 2005 twelve
organizations participate in this main-city-network.
With a population of 765.000 inhabitants and 39 places
Aim: To analyze the experience of the first steps of
Palliative Care (PC) development in Georgia for
elaborating of strategy for its further integration overall
the country. Methods: Comparative analysis of PC
development in Georgia with the analogues of Eastern
European countries was used.Results: In 2001-2004 PC
development in Georgia passes the similar way as the
most Former Soviet countries did: trained staff
preparation, creation of special literature in native
language, promotion of ethical environment;
implementation of home-based PC mobile teams and
360. “The 6 S” - key words as a palliative care
strategy
Ing-Britt Cannerfelt
ASIH Långbro Park, Palliative Care, Stockholm, Sweden
Aim: To describe the use of “The 6 S”- key words at a
palliative care unit with both a palliative ward and home
care services. Background:Six questions, developed by
Weisman (1974), have been transformed and redefined
into six criteria to evaluate a good death. Rinell
Hermansson (1990) selected six key words beginning
129
Poster abstracts
action research process,the changes made to the MDS
and the second stage of the action research cycle
piloting the revised MDS will be presented.
Poster abstracts
with the letter S, to represent each of the six items. The
six keywords were Self-image, Self-determination, Social
relations, Symptom control, Synthesis and Surrender.
These six key words were suggested to be suitable to use
for care planning, nursing documentation and
evaluation of the care (Ternestedt 1998).These “6 S” key
words may be used as a guideline to secure the intention
of the palliative care. This method regards the patient as
an individual human being. Method and result:We
started in 1999 to use “the 6 S” as a structure for
conversation when meeting relatives after a patient’s
death. Since 2002, the use of the keywords is routine
even in care planning and documentation.To evaluate
the usefulness of the 6 S as a palliative strategy a
questionnaire was used. The keywords were easy to use
in care planning situations but more difficult in nursing
documentation.
361. Influencing Nursing Policy in Hungary
Zoltán Balogh 1, Márta Kökény 2
1 Council of the Hungarian Paramedical Professionals,
Budapest, Hungary
2
Council of the Hungarian Paramedical Professionals,
Community and Hospice Nursing, Budapest, Hungary
The Council of the Hungarian Paramedical Professionals
established in 2004. This new regulatory body will play
a key role in the professional development of
paramedical workers and in the consruction of the
national health and nursing policy. The Council was
being formed to represent almost all paramedical health
care workers, such a community and hospice nurses in
Hungary and to help professional workers in their more
independent work both professional and ethical way.
The Council supposed to represent health care workers
individually and to contribute to health policy through
maintaining health care workers’ social, economical
interest in order to improve health care for the
Hungarian population. ?The responsibilities of the
Council include individual management of professional
matters through directly elected bodies and officials,
within the framework defined by legislation, definition
and representation of professional ethical, economic
and social interests, and contribution of the formulation
of health policy, and improvement of the provision of
health and nursing care of the population in accordance
with their importance in society. ?The Section of the
Community and Hospice Care Nursing of the Council is
taking part in the work of some steering and ad hoc
committees. For instance, we work in the committee
examining professional competence and nursing
education. We also make technical proposals for the
portfolio in regards of the legislative decisions.
362. THE PROCESS OF EVALUATION THE
CATALONIAN WHO DEMOSTRATION PROJECT AT
15 YEARS.
Xavier Gomez-batiste 1, 3, Josep Porta-sales 1, Antonio
Pascual 2, Maria Nabal 6, Jose Espinosa 1, Silvia Paz 1,
Cristina Minguell 3, Dulce Rodriguez 4, Joaquim
Esperalba 5, Marina Geli 3
Poster abstracts
1 Institut Catala d’Oncologia, Palliative Care Service,
Barcelona, Spain
2 Hospital Santa Creu i Sant Pau, Palliative Care Service,
Barcelona, Spain
3 Government of Catalonia, Dept. of Health, Barcelona,
Spain
4 Catalan-Balear Society for Palliative Care, President,
Barcelona, Spain
5
Institut Catala d’Oncologia, Medical Director, Barcelona,
Spain
6 Palliative Care Unit, Lleida, Spain
Department of Health. Government of Catalonia The
Catalonia WHO demonstration project started to
implement in 1990, due to cooperation between the
Catalan Department of Health and the Cancer Unit at
the WHO (Geneva), as a formal WHO Demonstration
Project.
Method
Formal evaluation process was carried out, which
included a quantitative and a qualitative part, which
consisted in a semi-structured survey with a DelphiEFQM methodology.
Results
In 2005, 21,400 patients (59% cancer and 41% noncancer) were cared. Estimated coverage for cancer was
79.4%, and for non-cancer of 25.0 to 56.5%. The
geographical coverage was >95%. Specialist resources
include 63 Palliative Care Units , with 552 beds (79
/million inhabitants), 34 Hospital Support Teams, 70
Home Care Support Teams , 16 Specialist reference
Outpatient’s clinics and specific teams for pediatrics and
aids. There are 140 full time doctors working in
palliative care. The cost of the specialist palliative care
network is over 40 millions ¤. Estimated global savings
is 48 millions ¤. Strong opioid consumption has
increased from 3.5 kg/million inhabitants by 1989 to 21.
After qualitative analysis 10 specific projects to be
implemented in the next 10 years were chosen.
130
Conclusions
After 15 yrs. we consider that Catalonian Palliative Care
system has been properly developed but still exist room
for improvement.
363. A Hospices experience of introducing an
organisation wide Incident and Near Miss
Reporting system.
Jan Codling
“tackling patient safety collectively and in a systematic
way can have a positive impact on the quality of care…”
( National Patient Safety Agency 2004). ‘An Organisation
with a Memory’ (DoH 2000) noted that “Many
incidents could be avoided if only the lessons of
experience were properly learned.” An incident
reporting system was introduced into a UK Hospice.
Training on the benefits of incident reporting and the
promotion of a ‘learning’ rather than a ‘blame’ culture,
was followed by the development of an incident
reporting form and supporting guidance. Subsequently,
quarterly and annual reports summarise trends, agreed
actions and subsequent changes in practice. In 12
months, 384 incidents were reported, comprising 214
accidents (180 involving patients and 34 non patients),
61 other health and safety incidents (18 related to
security risks) , 50 communication incidents (32 related
to written or verbal communication), 47 drug errors (22
related to drug administration) and 12 incidents relating
to general clinical care. 9 ‘near misses’ were also
reported. Introduction of an incident reporting system
has facilitated an open and learning culture. Examples
of resulting actions to improve care will be discussed
and include revision of the drug prescribing sheet and
mandatory drug management training for all nurses and
the introduction of a falls risk assessment. Future
development plans include auditing resulting changes
in practice.
364. Removing regulatory barriers to opioid
availability in Serbia: A step forward
Snezana Bosnjak 1, Ivana Popovic 1, Karen Ryan 2, John
Ely 3, David Joranson 2, Aaron Gilson 2
1 Institute for Oncology and Radiology of Serbia, Oncology
Intensive Care Unit, Belgrade, Serbia
2 University of Wisconsin Comprehensive Cancer Center,
Pain & Policy Studies Group, Madison, United States
3 Midwest Palliative and Hospice CareCenter, Glenview,
United States
Overly restrictive national drug control policies are a
barrier to opioid availability. In 2004, consumption of
morphine in Serbia was 2.08 mg per person, among the
lowest in Europe (11.79 mg per person). Oral morphine
is currently not available. One health professional from
Serbia was awarded an International Pain Policy
Fellowship (IPPF) Grant to learn how to evaluate
national policy and work with government to remove
regulatory barriers. As a part of IPPF,a preliminary
evaluation of national drug control laws and regulations
was undertaken using WHO Guidelines for Achieving
Balance in National Opioids Control Policy. The
following regulatory barriers were identified: 1)
outdated terminology that defines opioid analgesics
only in relation to addiction and health impairment, 2)
restrictions to opioid dose or duration of therapy,
depending on the diagnosis (cancer vs. other diseases)
and 3) prescription (Rx) related barriers (restricted
amount and number of opioids per Rx, unduly short
validity of Rx, use of a duplicate Rx form). In addition,
there is no recognition in law that it is the government’s
obligation under internatinal narcotic conventions to
ensure adequate availability of opioids while preventing
abuse and diversion, or that opioids are indispensable
for the relief of pain and suffering. An Action Plan was
developed to facilitate acknowledgement of the medical
value and necessity of opioid analgesics, and to remove
regulatory barriers to their availability.
365. Palliative Care in the National Cancer
Control Programme in Hungary
Katalin Muszbek 1, Katalin Hegedus 2, Ágnes Ruzsa 1
1
Hungarian Hospice-Palliative Association, Budapest,
Hungary
number of organisations involved in palliative care has
doubled, with a current figure of 54. As a result of our
lobbying activity, palliative care became part of the
National Cancer Control Programme in 2006, which, in
turn, is part of the National Development Plan. The plan
aims at the development of the palliative network
throughout the regions of the country as well as the
integration of palliative training into gradual education
in the period between 2006 and 2011. The reform
process of medical care also includes a change in the
structure of hospital beds with more beds for palliative
care. The Hungarian Hospice-Palliative Association
became a member of the National Medical Board.
Conclusion: The commitment of the state to palliative
care means the potential of growth and development in
the following years.
366. Integration of palliative care into the health
care system - the role of participation and
organizational development
Klaus Wegleitner, Katharina Heimerl, Andreas Heller
University Klagenfurt, IFF-Palliative Care and
Organizational Ethics, Vienna, Austria
The integration of palliative care into the national
health care systems is a priority of health care policy in
the European Union. Nevertheless it can be observed,
that top down strategies and straight-line political
planning concepts are facing limitations. ?Over the past
years an alternative type of research projects, to develop
palliative care concepts and structures, has been
established and implemented in different regions of
middle Europe; e.g. Styria, Vorarlberg, Upper Austria,
Burgenland (A), South Tyrol (It), Grisons (CH) and
Luxembourg. The meta-analysis gives a review of
different ways of participation and the role of
organizational development in these project
processes.?The approach based on the understanding,
that implementation of palliative care in health care
systems can only succeed through developing
organizations, their subsystems and their local structural
environments. Of particular importance is the
mindfulness for local and cultural distinctions and a
broad participation of the local actors: the health care
professionals and those who are concerned, the patients
and their relatives. ?The project processes result in
regional specific concepts of palliative care, where the
multiple perspectives of the local actors are integrated,
and which refer to the existing health care strutures. The
implementation processes enable cooperation and
sustainable regional development of palliative care.
367. Fund raising for a home-care palliative
service in a little area in Hungary
Agnes Ruzsa 1, Edit Németh 2, Nóra Tóth 3
1 Zala County Hospital, Oncological Dept., Zalaegerszeg,
Hungary
2
Hospice Foundation, Oncological Dept., Szombathely,
Hungary
3 Hospice Foundation, Oncological Dept., Szombathely,
Hungary
Introduction: The home-care-palliative service is the
basic need of the terminally ill cancer patients.To create
and manage a foundation was the goal of the authors.
The process of changing in financial support is reported
by experience of the last 15 years.
Methods: The authors used the method of a retrospective
statistical analysis of cancer mortality in their area as the
indicator of the need of palliative care.
Dicussion: In the beganning by the support of Soros
Foundation they provided palliative care for 4-20
patients in a year, but the need was 10x more. After a
very systematic campaign in the local newspaper, radio
and TV, authors were lobbying in the local government
for support. The people had a chance to make an offer of
1 % of their tax for the foundation. At least they asked
for competitions from other foundations, organizations
and collected donations in concerts of local orchestra.
The team is providing care for >100 cancer patients per
year. The NHS provides the 60%, the local government
10 %; the 1 % of the tax of the people of the area is also
10 % of the budget in a year. The absent support is
coming from different competitions and donations.
Conclusions: The home-care palliative service is wellknown and acceptable for the people of the area. The
service is free of charge for the patients.
2
Objective: Expanding and improving palliative care
through the National Cancer Control Programme.
Method: The main topic of the conference meeting
organized in 2005 by the OSI and the WHO was the
integration of palliative care in the National Cancer
Control Programme. Afterwards, we did a lot of
lobbying for this purpose.
Results: Due to the appropriate legal regulation, the
appearance of minimal professional conditions and the
frameworks of financing established in 2004, the
368. Policy decision-making strategies in
palliative care planning
Urska Lunder 2, Lisa Quinn 2
1
Palliative Care Development Institute, Ljubljana, Slovenia
Open Society Institute, International Healthcare
Management, Budapest, Hungary
2
Background: In Slovenia emerging new initiatives for
palliative care in different settings of health care and
Poster abstracts
369. Palliative Care: The public Health Strategy
Jan Stjernsward
Oxford International Centre for Palliative Care, Oxford,
United Kingdom
Why a Public Health Stategy:
A public health strategy offers the best opportunity for
implementing knowledge through cost effective
intervention that can reach everyoneThis strategy will
be most effective when it involves the society through
collective and social action. The problem addressed
must be of significance for large populations and there
must be available scientifically valid interventions that
are acceptable and maintanable at community level.
There are four key components that must be established
for a WHO public health approach in palliative care.
They are: 1) appropriate policies, 2) adequate drug
availability, 3) education of healthcare workers and the
public and 4) implementation of palliative care services
at all levels throughout the society and empowerment
of the community. The four components must be
addressed in a coordinated way to be effective.
The results from the first 16 countries, both high
income-, middle- and low income countries, that have
established or are establishing National or State
Palliative care Programs have been analyzed and
Outcomes, divided into immediate, intermediate and
long term will be presented in detail. This covers also
institutionalisation of palliative care into the Health care
systems and patient coverage achieved through the
Goverment and the Community approaches.
Reasons for successes as well as failures and lessons
learnt will be presented and conclusions for strategies
and were to go next will be discussed.
370. Coordination of the World Hospice and
Palliative Care Day in Hungary in 2006
371. The CEE & FSU Palliative Care Monthly Email
Newsletter
374. How and where will we die by 2030: An
analysis of future needs in an ageing population
Katalin Hegedus, Agnes Zana, Elena Vvedenskaya
Barbara Gomes, Irene Higginson
Hungary
King’s College London, Palliative Care, Policy &
Rehabilitation, London, United Kingdom
Aim: To present the Newsletter as an online palliative
information and communication form for Central and
Eastern Europe and Former Soviet Union, and also to
inform the world about the regional palliative efforts.
Results: The Newsletter is published in English and
Russian, distributed to 760 e-mail addresses. From
February 2005 to November 2006, 20 issues of the
Newsletter released so far introduced detailed country
reports of 14 countries. We have found EasternEuropean key-personalities in every country who help
us to publish news in the Newsletter and we involved
Western-European and US consultants. We regularly
publish reports on model-programs of a region or city,
report on important international and national
congresses, professional and informal events; and
publish declarations of those congresses.
Conclusions: The Newsletter - supported by the OSI
and EAPC - became one of the taskforces of the
European Association for Palliative Care, continuing the
work of the EAPC East.
Aim: Ageing societies have growing needs for end of life
care but these have rarely been projected in detail. We
have analysed future dying trends by place of death for
England & Wales.
Method: Mortality trends and forecasts were obtained
from official statistics on the numbers of annual deaths
by age and place of death. Different scenarios were
modelled using past trends to estimate numbers of
deaths by place of death to 2030.
Results: The number of annual deaths fell by 8% from
1974 to 2003 but will rise by 17% from 2012 to 2030.
People will die increasingly in advanced age, with the
deaths of the 85’s and over rising from 31.9% in 2003 to
43.5% in 2030. The national proportion of home deaths
stands currently at 18% (2003) and has been falling
since 1974. Long-term projections show that if this past
trend continues, the number of home deaths can reduce
further by 46-75%. This will mean that less than one in
ten will die at home. Alternatively, if recent trends of
inpatient deaths continue, numbers of home deaths will
nearly double from 100,000 to 200,000 people dying at
home by 2030.
Conclusion: The projections underline the urgent need
for planning of structures and resources to
accommodate a large increase of deaths. Either inpatient
facilities increase substantially or twice as many people
will need community end of life care by 2030. Our
model for projecting future trends can be used for
analysis in other countries.
372. Focusing on essential pain medication
accessibility for palliative care: APCA’s response
to policy implications
Faith Mwangi Powell
Palliative Care Association Humanists Union (AHU),
International Development, Kampala, Uganda
To promote the availability of essential pain medication
in the continent, the African Palliative Care Association
held an innovative regional drug accessibility workshop
in June 2006 in Entebbe, Uganda to: (i) improve
participants knowledge of the policy changes necessary
to make opioids available and (ii) support their
development of tangible action plans to facilitate policy
change.
Method
The workshop focused on six African countries, each
sending a six-person technical team. Participants
completed a pre-workshop self-assessment checklist and
the Barriers to Opioid Availability Test, and received
workshop presentations on pain control, drug
conventions, and access to analgesics.
Results
Common and unique barriers to opioid and other
essential medications accessibility were identified. These
informed the interactive development of countryspecific action plans by participants and expert
workshop facilitators that aimed to address recognized
policy impediments. Subsequently, significant
movement on appropriate drug availability for pain
management has been noted by the participating
countries. Consequently, the APCA Entebbe workshop
has been acknowledged as a best practice in Africa by
OGAC and the USG Palliative Care Technical Workgroup.
Conclusion
This innovative workshop format has proven a critical
lever to changing palliative care drug policy agendas; its
success has resulted in the exploration of similar
workshops in southern and western Africa in 2007.
375. Using the Korea declaration to advance
international palliative care
373. Bisphosphonates for bone prophylaxis in a
palliative day care setting. The value of audit and
re-audit in service development.
Katherine Clark, Paul Glare
Eva Varga, Agnes Zana, Katalin Hegedus, Katalin Munk
Hungary
Aim: To present the PR and policy activity of the World
Hospice and Palliative Care Day: the way how became
from 3-4 planned to 17 realized events in Hungary
within 2 weeks
Method: Online and phone communication with
member associations to prompt, inspire, give ideas to
them, continuous promotion of the events on our and
international homepages, preparation an online
newsletter on the passed off events and information
permanently the policy-makers and the press. An
additional goal was to connect the separately working
hospice units with each other and with the umbrella
organization (Hungarian Hospice Palliative Association)
and inspire them used the internet for a rapid change of
information.
Results: Our small team had been working with 52
member associations to help them to realize that
communication with civil society is the base of a close
co-operation, charity and volunteer work in the future.
Remarkable events were organized throughout the
country: concerts, theatre performances, masses,
painting auction, exhibition of children drawings,
charity ball, radio programme etc.
Conclusion: PR activity and publicity can do a lot in
familiarizing hospice and palliative care and supporting
the social role in the future.
Sharon Baxter, Nick Pahl
Help the Hospices, Palliative Care, London, United Kingdom
At the 2nd Global Summit of National Palliative Care
and and Hospice Associations held in Seoul, Korea, 2005
the Korea Declaration was prepared by Sharon Baxter
from the Canadian Hospice and Palliative Care
Association for the Worldwide Palliative Care Alliance
The Declaration is a useful document for palliative
health services who have little insight into palliative care
and the benefits that can be achieved through good
palliation. It has been used in global advocacy by
providing a basis for organizations (particularly national
associations) to make their case to policy makers and
Governments.
The declaration will be evaluated in early 2007 as to
its effect and the areas in which it has been used
although it has already demonstrated to be an
important step forward in placing palliative care firmly
on the agenda of all health services across the world.
This poster will describe the declaration, how it has
been used and the results of the evaluation of the
benefits of its use.
376. Retrospective Audit of the Approach to all Inpatient Deaths in an Australian Teaching
Hospital
Sydney Cancer Centre, Royal Prince Alfred Hospital,
Palliative Care, Sydney, Australia
Pola Grzybowska
Princess of Wales Hospital, Y Bwthyn, Bridgend, United
Kingdom
Aims To evaluate a clinical pathway developed for the
monitoring of infusional bisphosphonates. Setting A
specialist palliative day care hospital adjacent to a district
general hospital. Method A clinical pathway was
developed and put into use in 2006, following audits in
2004 and 2005. These allowed standards to be set and
demonstrate areas of concern clinically. All audits were
retrospective case note audits. The standards set related
to documentation of renal function, blood calcium and
calcium supplementation. Results 15 patients were
assessed in the first audit. In the 2005 audit there were
29 patients and in 2006, 20 patients, with 94, 105 and
92 treatment cycles respectively to analyse. Unrecorded
renal function was 70%, 40%, and 0% in consecutive
years and unrecorded corrected calcium 59%, 8%, 0%.
Deferred treatments, because of abnormal biochemistry
2005 (21%), 2006(1.1%). Conclusions The
implementation of standards allowed the process of
pathway development. Documentation improved as did
the quality of results and the consistency of actions of
the multi-professional team. More patients are had their
treatments as planned. The team, the patients and the
GP were aware of the treatment, its complications and
its monitoring.
Background
The majority of deaths in our society occur in hospitals.
Previous authors suggest that despite the high numbers
of deaths, the care of dying hospitalised patients is not
always optimal. (1). From this, it is reasonable to
extrapolate that all nurses and doctors who work in
hospitals do not possess the core skills necessary to
provide basic comfort at the end of life.
The needs of dying patients have been considered by
Ellershaw et al (2,3, 4) and these have worked these into
the excellent Liverpool Care Pathway for the Dying
guidelines to steer care at the end of life (5). The
guidelines indicate that basic to the care of dying
patients and their carers is the need to ensure that:?*
The correct diagnosis of dying has been made and
communicated to the carers (formal and informal)
involved in the care of this patient,
* Measures to address physical and spiritual comfort are
clearly charted and readily available,
* Clear documentation of all these issues is available.
Aims
This chart review will report the quality of care provided
patient deaths at RPAH over a period of two months
from all units in the hospital from 1st July to 31st August
2006 inclusively, excluding deaths that occurred in the
A&E, ICU and operating theatres. This will be based on a
retrospective review of all the charts of patients who
died over this period by the two palliative care
131
Poster abstracts
hospice are not enough to foster development on the
national level effectively. Beyond conventional actionoriented, grant-giving and capacity-building activities,
more rigorous policy-design is urgently needed.
Professional networks are needed to implement
comparative and applied policy research for
development of national palliative care.
Methods: The policy context of palliative care in
Slovenia was analysed and possible policy strategies were
examined. As a result of this process, the authors offer a
methodology and knowledge of a policy decisionmaking process through the work conducted on the
issue of palliative care in the cases analysed.
Results: Different approaches for specific cultural and
political conditions are needed to predict the outcomes
of implementation of different palliative care strategies.
Strategies must meet fundamental criteria: equity,
effectiveness, efficiency, continuity, cost, technical
capability and political feasibility. Political conditions
may skew the prioritisation of some of those criteria,
resulting in tradeoffs in the selection of feasible policy
solutions between the core principles and values of
palliative care versus the economic and political
feasibility.
Conclusions: Through this type of rational decisionmaking methodology, strategic solutions can be
developed, which are feasible and applicable for health
care systems.
Poster abstracts
physicians based in the hospital.
Specially, the aims are:
* To consider whether inpatients regardless of diagnosis
died receiving good basic end of life care as suggested
by the Liverpool Care Pathway for the Dying (5), * To
consider the complexity of the deaths and of the
patients who required complex end of life care, to
consider the number actually referred to palliative
care,
* To use the collected data to identify the hospital’s
standard of end of life care and consider further
changes based on the results of the audit.
Methods
Data will be retrieved from the hospital files by either of
the two palliative physicians of RPAH, using a proforma
designed for the purpose of this audit.
Conclusions
The results of this audit will be used to define the
quality of care provided to patients at the time of death
in a teaching hospital. This audit will provide the first
audit of all groups of patients, which to our knowledge
has not yet been reported in an Australian hospital. It is
hoped this audit will support the Palliative Care team
when considering the need to improve hospital-wide
quality of care offered at the time of death.
377. PALLIATIVE CARE WORK, BETWEEN DEATH
AND DISCHARGE
Margaret O’Connor
Monash University, School of nursing, Midwifery and Social
Care, Melbourne, Australia
This paper discusses a small quality improvement study
that was undertaken in a palliative care unit (PCU), to
demonstrate reasons for the lengthy patient turnover
time after the death of a patient. There is a dearth of
literature describing the role of the nurse in providing
care of the family and others after the patient has died.
The aim of the study was to undertake a post-death
survey from the nursing perspective, of activities and
the time required to complete tasks associated with
follow-up care to the deceased patient and his/her
family unit. Details of the post-death episode for all
patients who died in the PCU over two time periods
were collected using a newly designed tool.
Study findings demonstrate that most deaths in this
Unit occur out of business hours. In addition, the study
has highlighted the protracted nature of post-death care,
because of a variety of factors. Nursing work after death
is complicated by a lack of multi-disciplinary and
ancillary support, particularly out of business hours.
These factors prolong the time between patient death
and removal of the deceased, thus delaying admission of
new patients. This project has provided important
information both from a quantitative viewpoint as well
as giving some insight into the role of the nurse after
death occurs.
378. LINKING THE PARTS:- ARTICULATING THE
ROLE OF CONSULTANT PALLIATIVE CARE NURSES
IN ACUTE HOSPITALS.
Margaret O’Connor
Poster abstracts
Monash University, School of Nursing & Midwifery,
Melbourne, Australia
Palliative care nurse consultants (PCNC) in acute
hospitals have become integral to service delivery.
Despite little literature that describes the role, anecdotal
reports indicate that it is pivotal – in connecting
services, in liaison and advocacy, both within the
hospital and to other services. ?A three phase study
explored the roles to ascertain strengths and limitations,
to provide direction for further development. The
study’s primary aim was to describe and evaluate the
role of PCNC in acute hospitals. ?The design
incorporated:
- interviews with the PCNC, to explore aspects of the
role;
- 2 weeks of data collection to measure the activities
undertaken;
- open-ended interviews with managers to ascertain
their perspectives of the role.
The study articulated the role of the PCNC for the
incumbents and will be a resource for newly developing
roles. The PCNC were well regarded by their managers.
PCNC’s perform a vital role, especially providing
individualised care within acute care settings and in
many instances, being the first point of introduction of
palliative care to patients and families. The integration
of palliative care and acute approaches is important so
that palliative care is not a last minute consideration.
379. Obstacles to alleviating the suffering of
palliative care patients: healthcare providers’
point of view
Serge Daneault 1, Véronique Lussier 2, Suzanne Mongeau
2, Dominique Dion 3, Pierre Paillé 5, Évelyne Hudon 3,
Louise Yelle 4, Claude Sicotte 6
132
1
Notre-Dame Hospital, Palliative Care Service, Montreal,
Canada
2
Université du Québec in Montreal, Montreal, Canada
3
University of Montreal, Department of Family Medicine,
Montreal, Canada
4
Notre-Dame Hospital, Department of Oncology, Montreal,
Canada
5
Sherbrooke University, Faculty of Education, Sherbrooke,
Canada
6
University of Montreal, Department of Health
Administration, Montreal, Canada
Backround
Suffering related to serious illness is considerable and
sometimes intensified through the provision of
healthcare services. Since obstacles to the alleviation of
suffering remain as yet insufficiently researched, the
present study aims to document them from the
healthcare providers’ perspective.
Sampling frame
Setting : general and teaching hospitals
Subjects: Healthcare providers (93): 43 physicians, 34
nurses, 12 non professional workers, 4 social workers, all
involved in full or part-time care with terminally ill
patients.
Methodology
Qualitative study using in-depth interviews transcribed
for content and conceptual analysis, and focus groups
for validation of emerging theory. Coding, comparative
analysis and interpretation of data were conducted by
several coinvestigators.
Results
Healthcare providers point to many obstacles, which
can be subdivided into four main categories: 1.
Obstacles stemming from shortages (of funds,
personnel, and time); 2. Those related to the system’s
organization (erosion of accountability, insufficient
teamwork or support for caregivers); 3. Those
pertaining to the dominant philosophy of healthcare
(favouring interventions focused on survival at the
expense of care); 4. Lastly, obstacles stemming from our
healthcare system’s sociocultural environment.
Conclusions
Obstacles to the alleviation of suffering represent a
major challenge for the palliative care movement,
requiring its input so that the healthcare system as a
whole can be mobilized around this fundamental aim.
380. Nurses’ experiences of caring for dying
patients outside special palliative care settings
Birgitta Wallerstedt 1, Birgitta Andershed 2
1
Health Care Centre, Palliative Care Team, Vimmerby,
Sweden
2
Örebro University, Dept of Caring Sciences, Örebro, Sweden
Background: It has been increasingly common that
patients are dying in different care cultures and
settings.This places great and partly new demands on
organizations, staff and relatives.Nurses have also
different possibilities to prepare end of life care.
Aim: To describe nurses’ experiences of caring for dying
patients outside special palliative care settings.
Methods: Tape-recorded qualitative interviews were
conducted with a total of nine nurses in home care,
community care and hospitals. The interviews were
analysed according to phenomenological methodology.
Results: Three structures were found:ambition and
dedication, everyday encounters and satisfaction/
dissatisfaction. The results describe the
nurses’ambitions to give dying patients and their
relatives high-quality care.In the ‘everyday encounters’
the following key constituents emerged: responsibility,
cooperation, experience and knowledge, feelings, time
and resources. Despite the nurses’ high ambitions they
experienced greater or lesser degrees of dissatisfaction in
caring because of insufficient cooperation, support,
time and resources.But the contact with patients and
relatives, functioning collegial cooperation as well as
increasing knowledge, experience and personal growth,
gave the nurses satisfaction in their work.
Conclusion:The results elucidate the need for
discussion about the conditions for giving palliative care
outside hospices and other special palliative care
settings.
381. Prospective pricing of palliative care for
patients with non small cell lung cancer in
Germany
Christoph Ostgathe 1, Ronald Walshe 2, Jürgen Wolf 2,
Michael Hallek 2, Raymond Voltz 1
1 University Hospital of Cologne, Department of Palliative
Medicine, Cologne, Germany
2 University Hospital of Cologne, Department of Oncology,
Cologne, Germany
Background: Five year survival of patients with non
small cell lung cancer (NSCLC) is below 15%. Therefore
an early integration of palliative care according to the
2002 WHO definition is indispensable. Methodical and
financial aspects of prospective pricing of palliative care
within a program of integrated care for patients with
NSCLC are demonstrated. Methods: Four areas of
service were defined: Hospital support, home care, day
care and in-patient care. Resource use was estimated,
using real cost data from the University Hospital
Department of Finance. Resource use for patients with
NSCLC was forecasted on the basis of operating
experience, data of the core documentation in Germany
and recommendation from the European Commission.
Results: Expected average hospital support team services
were priced at 483 euros and budgeted for 10% (stage 1)
to 90% (stage 4) of patients. Home care (60 visits, 4573
euros) and day care (5 visits) services were budgeted for
between 5% (stage 1) and 30% (stage 4). The resulting
prospective reimbursements range from 393 euros (stage
1) to 2503 euros (stage 4). In-patient care was excluded
from the prospective payments and is reimbursed
separately. Conclusions: For the first time, global
reimbursements covering palliative hospital support,
home care and day care for patients with NSCLC were
prospectively calculated and negotiated. The contractual
specification of palliative care services may contribute to
transparency and quality in cancer care.
382. Implantable cardioverter defibrillators
(ICDs) at the end of life
Paul Paes, Pamela Ransom
North Tyneside Palliative Care Team, North Tyneside,
United Kingdom
Aim
The development of guidelines for managing
implantable cardioverter defibrillators (ICDs) at the end
of life.
Background
An increasing number of ICDs have been inserted into
patients at risk of developing ventricular arrhythmias.
These patients often have progressive cardiac or other
co-morbid conditions. As patients near the end of life,
the use of ICDs may no longer be appropriate. The latest
version of the Liverpool Care pathway now includes a
section on ICDs.
Method
A literature review was conducted to explore the issues
of ICDs at the end of life. In addition, a series of
consultations took place with cardiologists, ICD
technicians, primary care, secondary care, palliative care
and the Northern Cardiac Network to develop clear
guidelines.
Results
Dying patients are at risk of receiving inappropriate and
unpleasant electric shocks if they develop an arrhythmia
in the terminal phase of illness. Indications for
deactivation of ICDs are identified, the appropriate time
to discuss this with patients and the procedure for
deactivation.
Conclusions
With an increasing number of patients with ICDs
anticipated, the need to address issues at the end of life
is important. This paper describes the formation of
guidelines to cover some of these issues.
383. Revision of the document “Changing Gear:
Managing the Last Days of Life in Adults”
Ruth Flockton 1, Lucy Sutton 2, Deborah Murphy 1, John
Ellershaw 1
1 Marie Curie Palliative Care Institute, Liverpool, Liverpool,
United Kingdom
2 National Council Palliative care, London, United Kingdom
Aim
The project reviewed the document, Changing Gear:
Managing the Last Days of Life in Adults which was
published originally in 1997 by the National Council for
Palliative Care.
Method
A multi-professional steering group was formed to lead
the review of the document. The literature was reviewed
and a new document drafted.
Results
Changing Gear reviews the national documents that
have been published in recent years. The End of Life
Care Programme is introduced and its aims outlined.
The value of the end of life care tools (Preferred Place of
Care, Gold Standards Framework and Liverpool Care
Pathway) is highlighted. In particular the importance of
advanced care planning and communication between
healthcare professionals, the patient and their family is
described.
Healthcare professionals who are caring for patients
in all care settings can use the guidelines. Advice is given
on the assessment of the symptom control needs of
patients and on managing physical, social,
psychological and spiritual symptoms. The document
provides advice on the use of drugs in the last days of
life to achieve symptom control.
Conclusions
Guidance is provided on care so distinct from the
palliative care given earlier in the patient’s disease that it
Poster abstracts
384. The first year activity of a pharmacists group
in Japan : symptom control studies on patients
with cancer
Motohiko Sano 1, 2, Akiko Harada 2, Hisamitsu Takase 2,
Toshimasa Itoh 2, Hideya Kokubun 2, Mitsuru Shiokawa
2, Hiroko Takahashi 2, Emi Ryu 2, Tsutomu Suzuki 2,
Hajime Kagaya 2
1
Saitama Medical Center Saitama Medical University,
Department of Pharmacy Services, Saitama, Japan
2
Symptoms Control Research Group(SCORE-G), Tokyo,
Japan
Cancer is the number one cause of death in Japan. Over
300,000 people die from cancer annually, and over
ninety percent of them die at general hospitals. Though
Japan is one of the major industrial powers, it consumes
an extremely small amount of narcotics for medical use.
The majority of cancer patients who receive treatment at
facilities other than those specializing in the treatment
of cancer succumb to the illness without receiving the
proper palliative care. One of the causes of this is the
lack of useful information on palliative care for general
hospitals. The Symptoms Control Research Group
(SCORE-G) was established in July 2003 to provide
useful and comprehensible information for the medical
staff and patients at general hospitals. Presided over by
Motohiro Matoba MD, SCORE-G consists of doctors,
nurses and pharmacists in Japan. Subsequently, SCOREG Pharmacists (SCORE-G Ph.) was established as the
pharmaceutical research section of SCORE-G in January
2005. Comprised of 21 professors of pharmacology and
pharmacists employed at various sized hospitals, it takes
a pharmacological approach to relieving cancer pain
and symptoms and provides significant information to
hospitals nationwide. SCORE-G Ph. continues to work
toward its goal of making proper palliative care available
to all cancer patients in Japan, and hopes to share its
many new findings in Japan and the rest of the world.
Activities of SCORE-G Ph. to date shall be presented at
the academic conference.
385. The Northern Territory Indigenous Palliative
Care Model - its evolution, implementation and
integration with existing services.
Mark Boughey
Territory Palliative Care, Royal Darwin Hospital, Darwin,
Australia
Providing culturally appropriate and best practice
palliative care to Australian Aboriginal and Torres Strait
Islander people has been a particular challenge to
palliative care services in the Northern Territory of
Australia. With its overall population of 200,000 people
dispersed over one-sixth of the Australian land mass,
Aboriginal Australians comprise 29% of this population
and make up 45% of Territory Palliative Care’s caseload
with 81% living in remote, non-urban areas.
The past three years has seen the evolution and
development of the Northern Territory Indigenous
Palliative Care Model which has been developed in
conjunction with & the implementation of a
population needs- based public health approach
palliative care service provision in the Northern
Territory.
I will be presenting the main elements and structure
of the Northern Territory’s Indigenous Palliative Care
Model, how this has been implemented to engage
indigenous communities, give case studies to
demonstrate how it is operating and show how it is
placed and works within the existing palliative care
services of the Northern Territory of Australia. The
integration of both models and development of
resource material has allowed for considerable crosscultural education, learning and understanding.
386. HIV/AIDS Palliative Care Program in the
Nizhny Novgorod Region
Elena Vvedenskaya 1, 2, Oxana Shilova 2, Grigory
Moshkovich 2, Ludmila Varlova 2, Larisa Bykova 2
1 Nizhny Novgorod State Medical Academy, Nizhny
Novgorod, Russian Federation
2
Centre of Public Health, Palliative care unit, Nizhny
Novgorod, Russian Federation
Issues: HAART has not been available for most patients
until recently and HIV/AIDS in Russia for many people
remains a fatal illness and the global burden of this
disease continues to grow exponentially. Marginalized
communities bear an increased burden with regard to
limited access to comprehensive, quality care addressing
this wider range of needs and end-of-life care. Skilled
palliative and end-of-life care is important to the total
care of patients with HIV/AIDS. Description: A pilot
regional HIV/AIDS palliative care project started in
Nizhny Novgorod region in June 2005 and was
supported by the Global Fund. A multidisciplinary
palliative care team was set up. Palliative care is provided
in the outpatient and day care departments at the AIDS
Center, in the inpatient infectious diseases department
for HIV-patients, in a city tuberculosis hospital, and in
the community. The mobile team consists of a doctor, a
nurse, a social worker, a psychologist, and a driver.
Lessons learned: Our experience has showed an
unmet need for palliative care of HIV/AIDS patients. The
projects success can be attributed to the services
engagement of HIV/AIDS and tuberculosis primary care
providers. Different patients need both comprehensive
inpatient and home care. Recommendations: A
multidisciplinary model, which incorporates HIV,
tuberculosis and end-of-life care expertise, both
inpatient and home care, is a replicable example of
comprehensive palliative/hospice care delivery for
people living with HIV/AIDS. The projects experience is
very important for further palliative care development
in different regions across the country.
387. Palliative home care of cancer patients in
Estonia and Finland: differences and similarities
on the example of 6 months.
Kadri Suija 1, Kaiu Suija 2, Kari Ojala 3
1
Association of Cancer in south-western Finland, Palliative
Care at Home, Turku, Finland
2
Association of Cancer in south of Estonia, Palliative Care
at Home, Tartu, Estonia
3 Association of Cancer in south-western Finland, Palliative
Care at Home, Turku, Finland
Aim of study: observe and compare the differences
and similarities of palliative home care in Turku,
Association of Cancer in south-western Finland and in
Tartu, Association of Cancer in south of Estonia.
Methods: the investigation used the medical
documents of patients treated within the programme of
palliative home care between 01.01.2006– 31.07.2006 in
the area of Turku and Tartu. We compared the
patients’age structure, diagnosis, applied pain care and
facts connected to their death.
Results: During the before mentioned period there
were 59 patients in Tartu and 97 patients in Turku.
Comparing the patients’ age structure we can say that
most patients (61% in Tartu and 65% in Turku) were
born in the years of 1920-1939.
The most common type of cancer among the treated
patients in Tartu was intestinal cancer and in Turku
prostate cancer.?29% of the cancer patients in Turku
and 15% in Tartu did not get regular pain care. Strong
opioids were used similarly. 17% of the patients were
taking weak opioids in Tartu and 8% in Turku.
94% of the patients in Tartu and 13 % in Turku died at
home.
Conclusion: On the basis of this retrospective analysis
there were no considerable differences between the
patients of palliative home care in Turku and in Tartu.
The interesting differences came evident in the
percentage of deaths at home and pain care with nonopioids, possibly reflecting differences in cultural
background and local traditions in managing palliative
care.
388. The impact of a partnership between a
specialist palliative care unit and a nursing home
Paul Paes 1, 2, Leonie Armstrong 2, Marianna Fischer 2,
Kath McMurray 3, Teresa Sanchez 3, Karen Torley 2
1 North Tyneside Palliative Care Team, North Tyneside,
United Kingdom
2
Marie Curie Hospice, Newcastle upon Tyne, United
Kingdom
3 Princes Court Nursing Home, North Tyneside, United
Kingdom
Aim
To describe the impact of a partnership between a
specialist palliative care inpatient unit and nursing
home to improve the quality of palliative care.
Background
In North Tyneside, most patients with continuing care
needs are admitted to Princes Court nursing home.
There are a number of challenges in end of life care
here: high staff turnover, shift length/patterns, skills mix
and the stress of caring for dying people.
Method
A partnership with the Marie Curie Hospice enabled a
senior inpatient nurse to work in Princes Court,
identifying the needs of the unit and implementing
changes to improve care.
Results
The hospice in-patient nurse worked across all shifts to
work with every member of staff. A training plan was
developed and implemented. This included use of
pathways; team-working; syringe drivers and other
equipment; communication skills and care of the dying.
Princes Court was linked in with the out-of-hours
palliative care advice line. Staff at the nursing home
valued having the hospice nurse, both personally and
professionally. Confidence and job satisfaction
increased. Patients and families perceived an
improvement in holistic care.
Conclusion
This paper describes a successful partnership between a
nursing home and a specialist inpatient unit to improve
the skills of staff, and meet the palliative care needs of
patients. Ongoing funding is being secured to make this
partnership permanent.
389. EXPLORING THE PREFERENCES OF CANCER
PATIENTS REGARDING PLACE OF DEATH:
PRELIMINARY RESULTS FROM A PROSPECTIVE
STUDY
Sinead Kelly 1, Eoin Tiernan 1, Team Homecare 1, Gerard
Bury 2, Barbara Dooley 3, Ciaran O’Boyle 4
1
Blackrock Hospice, Dublin, Ireland
University College Dublin, Department of General Practice,
Dublin, Ireland
3 University College Dublin, Department of Psychology,
Dublin, Ireland
4
Royal College of Surgeons in Ireland, Department of
Psychology, Dublin, Ireland
2
Objective: Determining and meeting preferences for
place of death has been proposed as an important
outcome for services. We wished to determine the
preferred place of death of patients referred to a
specialist palliative care homecare team and to examine
whether preferences changed over time.
Method: Over a one year period, patients referred to the
homecare service, were asked their preferences regarding
place of death. Patients were followed longitudinally
and preferences checked until death approached.
Preferences were only sought if it was felt to be
appropriate to do so.
Results: Of 120 patients who have died to date, 69
(57.5%) were asked their preference regarding place of
death. 37 patients were asked more than once: 12 (32%)
did not change their preference; 7 (19%) changed their
preference over time; 4 (11%) were asked initially, then
became too unwell to ask again; 14 (38%) were not asked
initially but were asked over time.
64% of patients who were asked succeeded in dying in
the place of their choice.
Documentation of reasons why patients were not asked
was very helpful in understanding more about this
issue.
Conclusion: Exploring preferences for place of death is
important in facilitating patient choice and in
examining how effective a service is in meeting that
choice. Healthcare professionals must explore
preferences for place of death longitudinally, as
preferences can change over time and opportunities for
asking can change with changes in the patients
condition.
390. Workplace stress and social support among
nurses working in palliative care and nurses
caring for elderly patients
Nóra Szabó 1, Gábor Szabó 2, Katalin Hegedus 3
1 Semmelweis Medical University, Institute of Behavioural
Sciences, Budapest, Hungary
Aim and hypothesis: The aim of the survey is the
comparative investigation of palliative care nurses and
nurses caring for elderly patients in terms of vital
exhaustion, social support and the degree of workplace
stress. Hypothesis: due to interdisciplinary approach of
the service and regular supervisions nurses working in
palliative care are in a more favorable situation than
nurses caring for elderly patients.
Methods: A cross-sectional study was performed among
nurses working in palliative care (N=25) and nurses
caring for elderly patients (N=50) using a self-assessment
questionnaire. The inventory comprised test battery
satisfaction (Rahe, Tolles, 2002), vital exhaustion (Appels,
Mulder, 1988), social support (Caldwell, 1987), and
workplace stress (Siegrist, 1996) questionnaires.
Results: In terms of social support palliative care nurses
are in a more favorable position (P=0.048). Vital
exhaustion tended to be higher among nurses caring for
elderly patients (P=0.068), and the values of workplace
stress are significantly higher for them than for nurses
working in palliative care (P=0.034 on outer effort scale,
P=0.035 on inner effort scale).
Conclusions: Interdisciplinary approach of palliative
care, regular trainings and supervisions may promote
nurses’ acceptance and appreciation, and greater social
support may reduce nurses’ vital exhaustion and the
degree of workplace stress. This model might be
applicable for other groups of nurses as well.
133
Poster abstracts
resembles “a gear change”. The guidelines empower the
general healthcare provider caring for patients in the last
days of life.
Poster abstracts
391. Morphine prescribing by nurses. An
evaluation of the impact of a morphine
prescribing programme in Sub Saharan Africa
394. Hospital Consultant views on Palliative Care
in the acute sector
397. Factors Influencing Referral to an Integrated
Specialist Palliative Care Service
Maire O’Riordan, James Adam
Jennifer Balls, Rachel Quibell, Anne Pelham, Andrew
Hughes
Barbara Jack 1, Anne Merriman 2
1 Edge Hill University, Faculty of Health, Liverpool, United
Kingdom
2
Hospice Africa Uganda, Clinical, Kampala, Uganda
Background: Nurse prescribing is undergoing major
reforms in the western world expanding the prescribing
powers of nurses, although still met with some
resistance. In sub Saharan Africa nurses have been
prescribing morphine since 2003. A lack of access to
doctors coupled with large numbers of patients with
cancer and HIV resulted in a programme to allow nurses
to prescribe morphine. Following policy changes in
2003 nurses completing a 9 month Community
Palliative Care Course at Hospice Africa Uganda can
prescribe morphine. The study aim was to evaluate the
impact of this prescribing.
Methods: A qualitative methodology using focus group
interviews was adopted. A purposive sample of members
from clinical, educational teams and current students
from Hospice Africa Uganda were recruited to the study.
24 volunteers participated in 3 audio taped focus groups.
Data was analysed for emerging themes using thematic
analysis.
Results and Discussion: There was a general consensus
nurses? being allowed to prescribe morphine was
beneficial for patients, families and the clinical team.
Benefits including pain relief and enhancing patients
quality of life were noted. Economic impactof reduced
travelling costs to obtain the morphine were stressed.
Course students referred to initial concerns surrounding
prescribing morphine and the importance of the course
in preparing them for the role. This paper discusses
these findings and potential explanations given.
Marie Curie Hospice, Palliative Care Medicine, Glasgow,
United Kingdom
Hospital Palliative Care Teams(HPCT) provide a liaison
service and therefore much of their activity depends on
how palliative care is perceived and used by hospital
colleagues.?Aim: The aim of this project was to ascertain
the views of hospital clinical consultants on palliative
care in the acute sector.?Method: A postal questionnaire
exploring consultants views on their own palliative care
skills, on specialist palliative care provision and on the
future direction of palliative care services was sent to 197
consultants in 2 Scottish teaching hospitals with 109
replies received (55%)?Results: 53% of consultants were
caring for patients requiring palliative care. They were
less confident in managing dyspnoea, psychological and
spiritual distress. The main reasons for referring to the
HPCT were symptom control (53%) and terminal care
(47%). 91% believe that the HPCT has a role in the
management of many non-malignant diseases. 73%
believe that the HPCT should be involved with all dying
patients.?Conclusions: Hospital consultants caring for a
significant number of patients requiring palliative care
are less confident managing psychological and spiritual
distress but use the HPCT more for management of
physical symptoms. They would like HPCT involvement
with non malignant disease and for all dying patients.
More evaluation and debate is needed on the state of
general palliative care in the acute sector and on the
future of hospital specialist palliative care
395. Use of a Template to improve Documentation
of Assessment
Niaz Memon, Karen Groves
392. ‘24 hours a day’. Perceived need for ‘out of
hours’ specialist palliative care advice
Queenscourt Hospice, Southport, United Kingdom
Gateshead Hospitals and Primary Care Trust, Integrated
Palliative Care Team, Gateshead, United Kingdom
Aims
To explore barriers to referral in order to improve equity
of access to an integrated specialist palliative care
service.
Method
393 questionnaires were sent to four groups of referrers general practitioners, district nurses, hospital doctors
and hospital nurses. The questionnaire sought both
quantitative and qualitative information to explore
understanding of specialist palliative care, practical
barriers to referral and understanding of the integrated
team structure. The study was approved by the Local
Ethics Committee.
Results
The response rate was 51% of which 63% of respondents
had previously made referrals.
Interim analysis of understanding of palliative care
revealed that 26% of respondents did not know which
patients to refer and 62% were unaware of the team’s
referral criteria. 22% believed that the palliative care
team would only see cancer patients, and 27% were
unaware that palliative care could be involved before the
last 6 months of life
Practical barriers included a poor awareness of the
referral form system and that telephone referrals would
be preferred.
Analysis of understanding of the integrated team
showed widespread misunderstanding of team
composition, however the majority of respondents
understood the concept of an integrated service.
Conclusion
This study has identified several areas which could be
addressed in order to improve equitable access to
specialist palliative care.
Karen Groves
Merseyside & Cheshire Cancer network, Palliative Care
Clinical Network Group, Integrated Services Subgroup,
One of the key recommendations (15) of the National
Institute for Clinical Excellence (NICE) Palliative and
Supportive Care Guidance (Mar 2004) suggests that
Specialist Palliative Care Advice should be available on a
24 hour, 7 days a week basis. Cancer Networks (of which
there are 34 in England) are charged with the
responsibility of drawing up specifications for this
service for their own network area.
The Integrated Services Subgroup of Merseyside &
Cheshire Cancer Network, Palliative Care Clinical
Network Group, included in its workstream
consideration of how this guidance might be met. As a
preliminary to writing a specification, the group sent
out a survey of all hospital and community services to
ask about their experience of needing specialist
palliative care advice out of hours and surveyed
community and hospital specialist palliative care
services to ask what “out of hours” services should look
like and how they should be provided.
This poster presents the results of the survey and
perceived need for “out of hours” specialist palliative
care advice from both sides.
Poster abstracts
393. ‘Home or not home?’ Documentation of
Preferred Place of Care in Specialist Palliative
Care
Catherine Wilcox, Alison Meehan, Karen Groves
Specialist Palliative Care Services in West Lancs,
Southport & Formby area use shared multiprofessional
electronic clinical records. As a service we had recently
agreed a standard place and way of recording the
preferred place of care.
A three month retrospective audit was undertaken
early on to establish whether team members were
routinely recording the preferred place of care as had
been agreed. Of 206 referrals to hospital, community
and hospice during this period overall only 23% had the
PPC correctly recorded.
This poster outlines the audit results and the actions
which resulted from it to improve PPC recording.
134
Standardised assessment is a requirement of the NICE
(National Institute for Clinical Excellence 2004) and
Cancer Peer Review measures in the U.K.
West Lancs, Southport & Formby Palliative Care
Services share multiprofessional electronic clinical
records. A method of standardised recording using a
template was agreed by all members of the clinical team
to help to meet the requirements and to aid the easy
retrieval of information quickly by any clinician.
Assessments should be recorded in a standard format
of time : place : people present : physical : psychological
: spiritual : social : insight/information : carers needs :
plan : follow up (who, when, where).
A retrospective audit of the assessment records of 131
referrals were identified for a 2 month period May – Jun
2006.
60% had documentation as the agreed template. 26%
had documentation under the majority of the headings
suggested.
The poster displays the finding s of the audit and the
actions taken to improve the recording using the
assessment template.
396. A nine month survey of home care vs.
hospice care at the St. Lazarus Hospice in Krakow,
Poland.
Tomasz Gradalski 1, Barbara Burczyk Fitowska 2, Ewa
Nalezna-Chmielek 3
1– 3
St Lazarus Hospice, Krakow, Poland
The St. Lazarus Hospice was founded in 1993. Since
1998, when the 30 bed hospice was opened, patients,
who had been previously cared for at home only, have
had the possibility of being admitted and spending their
last days in the hospice. The aim of the study was to
compare a group of 201 home care patients (HP) with
315 in-patients (IP) who died between Jan 1st and Sept
30th in 2006. Retrospective evaluation of their files
revealed that both groups were comparable within the
gender (56,7% females in HP vs. 52,4% in IP), age (mean
68,4 (32-96), median 71,0 vs. 69,4 (29-97), 71,0 years)
and the longer length of care in the HP group (mean 45
(1-323), median 22 in HP vs. 29 (1-712), 13 days in IP).
In the HP group there were more colon/rectum primary
cancers (14,4 vs.7,0%) but less CNS (4,5 vs. 9,5%), head
and neck (2,0 vs. 6,7%) and also non cancer patients
(0,5 vs. 8,9%). The most common physical complains
noticed were: pain (73,6% HP vs. 67% IP), weakness
(73,6 vs. 93,7%), anorexia (35,3 vs. 70,2%), general
discomfort (19,9 vs. 62,5%), dyspnea (28,4 vs. 35,6%)
and depression (14,4 vs. 48,3%). There were marked
differences between the most common drugs used:
Morphine (55,7 vs. 49,5%), Tramadol (22,9 vs. 27,3%),
Fentanyl (14,9 vs. 28,3%), steroids (29,4 vs. 56,5%),
anxiolytics (37,8 vs. 49,8%), antibiotics (17,9 vs. 49,2%)
and Haloperidol (14,4 vs. 25,1%). The small differences
between HP and IP do not explain the marked
disparities in physical complaints and the drugs used.
398. Developing a breathlessness intervention
service using the MRC framework for the
development and evaluation of complex
interventions.
Morag Farquhar 1, Sara Booth 2, Petrea Fagan 2, Irene
Higginson 1
1 King’s College London, Department of Palliative care,
2 Addenbrooke’s Hospital, Palliative Care Team, Cambridge,
United Kingdom
Aim of study:
To describe the role of the MRC framework in
developing and remodelling the Breathlessness
Intervention Service (BIS).
Method:
Phase I data (qualitative interviews with users of the
pilot BIS: patients, carers, and referrers) were presented
to the BIS to facilitate remodelling of the service.
Following a period of remodelling, individual service
providers submitted written evidence of service changes.
These were mapped against Phase I data and a consensus
statement on resulting changes to the BIS was
developed.
Result:
Phase I found the pilot BIS to be a highly valued service
by users (patients, carers and referrers). It identified
aspects of the service that users regarded as positive, but
also some that required further development. The
resulting remodelling of the service addressed:
redrafting of the patients’ introductory letter to BIS; the
location of care; the format of individual patient plans;
the development of quality assured and accessible
patient information leaflets; carer support; guidance
regarding seeking medical assessment for changes in
breathlessness; and enhanced inter-professional liaison.
The remodelled service is being evaluated by a Phase II
randomised controlled trial.
Conclusion:
The process of remodelling and identifying changes to
the BIS provides a trail of evidence for the service’s
development made possible by the use of the MRC
framework. This approach is recommended for other
service developments.
400. Minding the step between ward and home:
A multidisciplinary team makes it safer
Rosmarie Pohjanvuori, Camilla Wedenby
Sahlgrenska University hospital, Department of Geriatric
Medicine, Gothenburg, Sweden
Minding the step between ward and home:
A multidisciplinary team makes it safer
Occupational therapist Camilla Wedenby,
Physiotherapist RosMarie Pohjanvuori Sweden We work
as fulltime team members in Sahlgrenska hospital
Poster abstracts
401. “I wanted to die at home” A description of
patients experiences of palliative home care at
the end of life
Ing-Britt Cannerfelt 1, Birgitta Andershed 2
1
ASIH Langbro Park, Palliative Care, Stockholm, Sweden
2Department of Health Sciences, University, Department of
Health Sciences, University, örebro, Sweden
Background:
Many cancer patients wish to live and dye at home. The
palliative home care team need to provide a wellorganized structure of care to enable these patients and
their relatives to feel secure and in control of the
situation during the last period of life.
Aim:
The aim was to describe the patient’s experiences of
palliative home care.
Method:
This study includes seven patients. The Glaser & Strauss
method “Grounded Theory” was used for analyse of
interviews. They had all disrupted the home care and
moved to a palliative inpatients ward.
Results:
The patients regarded the home care as equivalent to a
job and it was very important to have a Self-image of
being capable. It was also important to have control over
the disease and knowledge of how the disease develops.
All these factors had a positive influence to the palliative
home care regime.In contrary no control over the
disease or insecurity in the relationship with relatives or
nursing staff decreased patient’s self-image and made it
difficult to stay at home.
402. Should respite care be offered in a Specialist
Palliative Care setting?
Joanna Bowden, Jennifer Pond
Marie Curie Hospice, Newcastle upon Tyne, United Kingdom
Aim:
To evaluate the respite service in a Specialist Palliative
Care Unit.
Method:
A questionnaire was devised following a survey
of professionals working within the service. Patients and
carers were interviewed about admissions that had taken
place over a six month period. The questionnaire
covered several domains, including the reason for
referral, how it had been beneficial, how things could
have been done better and whether there were
acceptable alternatives to respite in a specialist unit.
Results:
Two distinct groups of patients emerged from the
survey. There were those who felt that their needs could
only be met in a specialist unit, and often these patients
had complex needs and advanced disease. Others saw
the main benefit of their stay as the company and
support, and felt that they could be cared for adequatley
in a non-specialist setting.
Conclusions:
There is clear controversy about whether respite
should be offered in a Specialist Palliative Care Unit.
This survey highlights a group of patients for whom it
may be both appropriate and justifiable, given the
complexity of their needs.
We plan to undertake a more comprehensive,
multicentre study to investigate this further and hope
that from this we will be able to offer some local, and
potentially national guidelines.
403. The impossible challenge? Palliative care in
the Emergency department
Marie-france Couilliot 1, Mai Luu 2, Daniele Leboul 3
1
University Hospital, Public Health Sciences, Bobigny,
France
2University Hospital, Palliative Care Team, Bobigny, France
3
Medical Faculty, department of Social and Welfare studies,
brest, France
One of the main issues concerning the quality of care at
the end of life is rising in the Emergencies hospital
Departments (ED). This is a frequent place of death to
day.
The aim of the paper is to assess the main palliative
care issues and present a local response.
The method is based on the review of the scientific
press on “palliative* care in the ED and on various
fieldworks we conducted.
Scientific literature is poor on this subject.
Who are the “palliative patients”? Are clearly
identified as “palliative patients” those at the terminal
stage of a chronic illness and/or near agony. In the
literature as well as in our fieldwork observations, the
main physician’s concern is then to define gravity index
to anticipate the death time.
What are “palliativepractices»»? ED physicians are
concerned by the risk of futility care.
Palliative care means pain treatment, most of the
time via morphine and palliative sedation. There is no
collective decision making on palliative care among
doctors and nurses. Moreover the attitudes of individual
physicians differ strongly on this matter.
These results highlight a restrictive P C.
representation linked to the culture, the education and
the work organisation in the ED. These issues have led
ED caregivers and the Hospital Pain Control Committee
to constitute a working group to advance improvements
of the end of life care in the ED.
404. Dying of occupational cancer :what effects
has the compensation process on the caregivers ?
Marie-france Couilliot 1, Anne Claire Brisacier 2, Annie
Thebaud-Mony 1
1
INSERM Universite, CRESP, Bobigny, France
Centre de recherche en cancérologie, Bobigny,
2University,
France
Since March 2002, SCOP 93 has been a
multidisciplinary network investigating occupational
exposures to carcinogens of cancer patients in a suburb
of Paris, through job history reconstitution and
expertise, then providing an Initial Medical Certificate
necessary for the patient to claim for recognition and
compensation.
Aims: to assess the impact of the compensation process
on the care trajectory till death and on the socioeconomic family situation and bereavement process.
Method
1. Reconstitution of the care trajectory till death:
national mortality register enquiry, medical sheets and
interviews with the various care givers.
2. Interviews with families, 3 months after the death, to
assess the impact of the compensation process on the
financial situation and on the bereavement process,
according to the stage of the compensation process.
Results :
The mortality rate is high. At the end of 2005, 31% of
the 457 patients exposed to cancerigens were dead, 50%
had died before the compensation process achievement;
41% did not claim for compensation.
We will present the results of the caregivers’ survey :
reconstitution of the care trajectory till death,
knowledge of the compensation process of the
caregivers and impact according to the caregivers at the
end of life (cancer specialists, GP or palliative networks).
405. The Preferred Place of Care patient
assessment tool: Findings from the first 100 cases
undertaken in England
Justin Wood 1, Les Storey 2, David Clark 3
1
Lancaster University, International Observatory on End of
Life Care, Lancaster, United Kingdom
2
University of Central Lancashire, Faculty of Health,
Preston, United Kingdom
3
Background: Preferred Place of Care is an intervention
promoted within the NHS End of Life Initiative for
England. In offering terminally ill patients, their carers
and healthcare professionals the opportunity to
consider, discuss and record preferred priorities for care,
PPC aims to support patient choice and preferences at
the end of life. Aim: To analyse the first 100 PPC
assessments undertaken by healthcare professionals. To
summarise emerging patterns and variations in the
implementation of PPC. To consider the implications of
findings for national policy. Method: A quantitative &
spatial analysis of a Cancer Services Network PPC
dataset, along with a qualitative thematic analysis of free
text data from a 20% sample of returns. Result: PPC
identifies patients’ and carers’ preferences for care
location at the end of life. 73% of patients expressed the
wish to only die at home, of which 68% did so. 30% of
those assessed died within a week of assessment, 68%
within a month and 81% within 2 months.
Conclusions: Discussion about choice at the end of
life, personal wishes over place of care and death, and
issues of service access have far reaching implications for
healthcare providers and models of palliative care.
Findings have implications for consideration of the stage
of a terminal illness trajectory at which a PPC
assessment should be implemented, as well as how PPC
could be undertaken. PPC provides healthcare
professionals, patients and carers, internationally, with
an adaptable tool that could promote patient choice and
preferences.
406. Continuity of Care for Community Palliative
Services
Frances Legault 1, Kevin Brazil 2, Sheila Bauer 3, Pippa
Hall 4, Liliane Locke 5, Lynda Weaver 5, Barbara Cameron
3
1
University of Ottawa, School of Nursing, Ottawa, Canada
University, Epidemiology and biostatistics,
Hamilton, Canada
3Ottawa CCAC, Palliative Care at Home, Ottawa, Canada
4University of Ottawa, Faculty of Medicine, Ottawa,
Canada
5
SCO Health Service, Palliative Services, Ottawa, Canada
2McMaster
The aim of this study was to implement and evaluate
multiple interventions (service planning, physician
referral and support, and communication) to optimize
continuity of care in a community-based palliative care
program in Ottawa, Canada. Three types of continuity
were evaluated: 1) Management Continuity (consistency
of care and responsiveness to changing needs of the
client and family caregivers); 2) Relational Continuity
(on-going client-provider relationships and consistency
of provider); and 3) Informational Continuity (efficient
and effective transfer of information and accumulated
knowledge of the client). A case study research design
was utilized to systematically collect and synthesize
information to provide a complete description of the
contribution of the specific interventions on continuity
of care. Data collection included quantitative and
qualitative approaches incorporating six primary
sources: clients and family caregivers, home care nurses,
family physicians, home care case managers, program
documents, and client charts. Although there have been
several initiatives to promote continuity of care, there
has been little scientific research to develop and apply
direct measures of continuity from the client and
caregiver perspectives and to measure continuity over
time and across organizational boundaries. Findings and
recommendations for practice and policy will be
presented. (Funded by the Canadian Institutes of Health
Research.)
407. A spatial analysis of regional inequalities in
the location, organisation and availability of
adult inpatient hospices, and hospice inpatient
beds, across the United Kingdom and Ireland.
Justin Wood, David Clark
Background: United Kingdom hospices have
developed with the support of local communities, their
national coverage unplanned. There has been criticism
that such ad-hoc development has led to the
inappropriate location of some services
Aim: To summarise the location, organisation type,
availability and size (beds) of UK adult inpatient
hospices by region and the broad geographic areas for
which care is provided. To analyse regional variations in
availability against population & death data. To link
availability to measures of deprivation & hospice
neighbourhood geodemographics.
Method: A quantitative spatial& GIS map analysis of
adult inpatient hospices (an ongoing PhD).
Results: UK regions vary widely by geography, size,
population density, diversity & health. Hospices, with
notable exceptions, cover major conurbations. Wide
regional variations or inequalities in adult hospice &
bed availability are apparent, from 14.5 to 26.0 beds per
1000 cancer deaths across English regions. The
proportion of hospices located in the most deprived
50% of a region varies from 18% to 71%; such inequities
in availability, based on underlying deprivation,
highlight unanticipated differences.
Conclusion: Hospice accessibility has implications for
the establishment of further hospices and highlights the
need to consider the remit of alternative palliative care
services in areas without local access. The mapping of
services & catchments, when combined with analysis of
equity of access based on local need, provides policy
135
Poster abstracts
palliative care unit. The persons admitted to the ward
have usually made a significant loss in autonomy
compared to earlier on in their illness.
In our assessment and training we from the start
consider the possibilities for the person to return to
their home. The timing of interactions is of big
importance likewise how we present the solutions we
see possible. We often make a visit to the person’s home
during the stay in our ward. Assessing the person in
their home gives the team, the person and the family a
platform to plan from. Often adjustments to the home
environment and aid equipment can make living easier.
We strive to find the best possible solution for the
person and for the caretakers right now, in a few weeks
and in the future.
The whole teams resilience makes adjusting the plan or
the timing for discharge smooth, as well as our
knowledge of resources the persons district have
regarding palliative care. We find participating fulltime
in the team process of great value, making it easier to
help in making the step between hospital and home.
This is demonstrated by a case study.
Poster abstracts
makers internationally with a powerful tool
408. Development of a Municipal Palliative Care
Program in the Public Health Department in
Rosario, Argentina.
Hugo Fornells 1, Daniela MacGarrell 1, M Alvarez 1, A
Armando 1, A Kalbematter 1, M Padovani 1, David
Willems 1, Stella Binelli 1, Pablo Amigo 2
1 Municipal Palliative Care Program, Department of Public
Health Sciences, Rosario, Argentina, Argentina
2Palliative Care Program, Edmonton, Canada
Introduction: Rosario is a city in Argentina with a
million inhabitants. The municipal public health serves
300,000 people, with around 500 deaths per year due to
cancer. The Municipal Palliative Care Program was
created in 2004, consisting of the Adult Palliative Care
Unit (UCPAR), Pediatric Palliative Care Unit (UCPP) and
the Domiciliary Palliative Care Unit (UCPD). Methods:
Data from all patients admitted to the program from
2004 to 2005 was reviewed. Opioid consumption was
evaluated and compared to the year before the creation
of the program. The percentage of the palliative care
population seen, waiting time for admission to the
program, symptom control using the ESAS and home
death rate were also evaluated.Results: Opioid
consumption increased 341%, with 41.6% of the
palliative population seen by the Program. Waiting time
for admission was one day (mean). Adequate symptom
control was achieved in over 50% of the patients for
pain, dyspnea, nausea, anxiety and mood. Home visits
were provided to 41.82% of the patients, and home
death was achieved in 66% of the patients admitted to
the UCPD. Of note, 39% of the patients admitted to the
UCPAR and 100% of the patients admitted to the UCPP
died there.Conclusion: It was possible to provide
interdisciplinary palliative care services with little
waiting time, good home support and good symptom
control, increasing opioid consumption. The goals are
to increase access to the service and to extend this care
to non-cancer patients.
409. Better Late than Never? The Impact of Late
Referrals upon the provision of Community
Palliative Care
Philip Macaulay, Sylvia Spicer, Trish Sutton, Kath
Savona, Jane McGuire, Helen Vaz, Stephen Brooker
Poster abstracts
Sacred Heart, St Vincent’s Hospital, Palliative Care Centre,
Sydney, Australia
The Late Referral Project (LRP) is an initiative that
commenced at the beginning of 2006 to try to minimize
the often-stressful impact of a Late Referral to the
Community Palliative Care Team (CPCT) upon the
patient, the staff and the service as a whole. The LRP
sought to ascertain the external pathways for LR’s so that
they might be monitored and the reasons for lateness
examined. The assumption behind the LRP was that LR’s
are stressful for the staff involved, requiring complex
coordination and sometimes have a less than optimal
outcome for the patient . The aims of the LRP were to try
and improve the quality of service provided by staff, and
also the quality of support delivered to staff in difficult
and stressful situations. The LRP carried out a literature
search, a staff survey, a clinical file audit and together
made a series of practical arrangements within the
functioning of the team to deal with LR’s when they
arrive. In addition, the LRP, for the first time, collated the
results and defined a LR to a Palliative Care Service as
being “14 days from referral to death” and as”the inability
to optimally respond to the needs of the pt and family due to
the limited time available for best practice planning and
implementation prior to death.”
410. How do you persuade patients, staff and
volunteers in a successful Day Hospice attached to
an Acute In-patient Palliative Care Unit, that
service delivery processes must change to
accommodate a new economic reality?
Kate
Thompson 1,
Bee-Wee
Leung 2
1
Sir Michael Sobell House, Palliative care unit, Oxford,
United Kingdom
2Sir Michael Sobell House, Palliative Medicine, Oxford,
United Kingdom
MethodFollowing staff cuts, a step-wise iterative
approach using process mapping, focus groups and
working groups identified changes which are now being
implemented. Results Process mapping identified
bottlenecks, which interfered with patient flow, and
issues of equity regarding access to complementary
therapies and recreational activities. Whilst focus groups
highlighted the supportive environment, the sense of
belonging and the safe environment, they also
identified areas for improvement. Specifically, there
were opportunities for improvement in documentation
136
(concerning referral criteria, expectations of placement
and discharge), equity of access and staff skill
mix. DiscussionWhilst process mapping proved to be
efficient in demonstrating bottlenecks in patient flow
and equity, the process proved a challenging experience
for the team. Although an invitation was made to all
stakeholders to join relevant focus groups, bias may have
arisen through self selection. Nevertheless, suggestions
concerning changes in patient flow, practice and equity
of access have been approved and implemented. This is
a work in progress; new approved documentation (for
referral, invitation and assessment) and a reorganisation
of service delivery will begin in January 2007. Six month
follow up outcome data will be available for
presentation at the EAPC Congress
411. Support in palliative care for general
practitioners (GPs): a telephone advisory service
project by specialised GPs in the Netherlands
(2000-2003)
Florien Heest van 1, Ilora Finlay 2, Renee Otter 1, Betty
Meyboom-de Jong 3
1 Comprehensive cancer centre North-Netherlands, Palliaitve
Care, Groningen, Netherlands
2
University Medical Center Groningen, Department of
Oncology, Groningen, Netherlands
3
Family Medicine, Groningen, Netherlands
Many patients with a life-threatening disease wish to die
at home.
The region covered by the Comprehensive Cancer
Centre North-Netherlands (CCCN), is a predominantly
rural area with a population of 2.1 million, about 1000
GPs, 17 hospitals and 5500 cancer deaths per year.
Access to cancer therapy and disease modifying therapy
is well organised. 61% of all patient deaths in 1998-1999
occurred at home. In 2000 the area had neither hospices
nor nurses or doctors working as specialists in palliative
care.
The aim of this project was to organise rapid access to
palliative care advice for all GPs caring for patients dying
at home. We describe a novel type of support for GPs:
the establishment and evaluation of a telephone
advisory service for GPs, run by four regional working
GPs with a Special Interest (and training) in palliative
care (GPSI).
A growing number of GPs called for advice starting with
about 100 calls in 2000 up to almost 600 in 2003; 10%
during out of hours. Calls lasted 15 minutes (mean) and
sought advice on patients of all age-groups (mean age 62
yrs, range 0-100), usually in the last phase of
illness (prognosis days - weeks in 70%). Most advice
sought concerned symptom management, discussion
revealed more other problems. On evaluation, 85 % of
the GPs followed the advice.For instance the use of
subcutaneous infusions at home tripled.
Conclusion: the advisory service seemed to fulfil a need
for support of GPs caring for patients dying at home.
412. Palliative Mobile Team in a Shelter for
Homeless People
Katalin Muszbek 1, árpád Gajdátsy 2, Eszter Biró 1,
Adrienn Thuránszky 1
1
2Methodological Social Centre and Institutions, Budapest,
Hungary
Objective: After the fall of communism, the group of
homeless people emerged in Hungary in the wake of
radical changes in social life. This is the group in the
perhaps worst physical condition where illness is often
discovered at a highly advanced stage. The cooperation
of the Hungarian Hospice Foundation and the Budapest
Shelter for the Homeless is an effort to offer palliative
and hospice care for homeless people in the terminal
phase of their illness. Also, it seeks to change some of
the widespread confirmed attitudes of nurses towards
this highly disadvantegous group. Method: From 2004
on, members of the multi-disciplinary team of the
Hungarian Hospice Foundation visit the Shelter once a
week. Physicians, nurses, psychologists, physiotherapists
and voluntary workers offer palliative care to terminally
ill patients in an effort to preserve the dignity of life.
Once a week, we organize art therapy sessions for
outpatients of the night-shelter. We also organize
trainings for the local staff and the Foundation provides
the opportunity of field practice at the Budapest Hospice
House. Results: In the last years we nursed a total of 76
patients. 45 persons took part in the art therapy
sessions, and 10 professionals in our trainings and field
practices in the Budapest Hospice House.
Conclusions: The palliative mobile team is a new and
very effective kind of care for homeless people who
belong to the perhaps most disadvantegous group in
society. The palliative mobile team has established a
new attitude in the care of this helpless group.
413. How does proximity to a hospital/hospice
relate to place of death from cancer?
Philippa Hughes, 1, Manisha Mistry, 2, Peter Bath, 3, Bill
Noble, 1
1 University of Sheffield, Academic Unit of Supportive Care,
2
University of Sheffield, Medical School, Sheffield, United
Kingdom
3
University of Sheffield, Department of Information Studies,
Background: The percentage of UK home deaths has
decreased with more deaths in institutions. Many factors,
including social deprivation, which may influence this,
have been reported. Aim: To examine relationships
between place of death, deprivation index, and proximity
to an institution, for cancer deaths in Sheffield, UK.
Method: For the period 1997-2002, data was collated on
deaths at home, in a hospice, or elsewhere, for the 29
Sheffield electoral wards. Deprivation indices and
standard distances from each ward to the main city
hospitals and hospice were obtained. Spearman’s rho
correlations were calculated. Result: The correlation
between home deaths and deprivation index was weak
(Spearman’s rho: 0.312) and not statistically significant
(p=0.099). There were significant negative correlations
between death at the hospice and deprivation
(Spearman’s rho:-0.697, p=0.001); and death at the
hospice and distance from it (Spearman’s rho: 0.566,
p=0.001). A weak but significant correlation was seen
between distance to hospital and death in hospital or
other institutions (Spearman’s rho:-0.398, p=0.032).
Conclusion: Our findings did not confirm a negative
correlation between death at home and deprivation
index in Sheffield, but suggest that proximity to facilities,
particularly hospice, may influence place of death. Wider
ranging study may differentiate and quantify the
influence of proximity of hospices and hospitals on place
of death.
414. ONGOING PALLIATIVE CARE IN PRIMARY
HEALTH CLINICS
Yifat Rave 1, Sharon Wynne 2, Rivka Golan 3
1– 3 clalit health service, Community Health Service, haifa,
Israel
Rational
Oncology patients throughout all stages of the disease
suffer from a variety of symptoms requiring palliative
care. Despite the fact that they undergo treatment in
hospital, they spend most of their time at home.Contact
with their primary health care givers is usually minimal
at this time. Patients approach the hospital staff with all
their problems. Not all oncology patients are known to
the clinic nurses therefore the nurses are not able to
meet all their needs.
Aim Improve the connection between clinic nurses and
the oncology patients. Empower the nurses in taking
care of oncology patients.
Process Nurses from community health clinics were
chosen to manage the care of oncology patients. The
nurses underwent courses in palliative care to acquire
the required skills. Computer lists of oncology patients
were sent to these nurses twice a year. The nurses
coordinate the care according to the patients’ special
needs with the primary care physician and the hospital
staff as necessary. Data on the nurses’ activities is
reported back to the Head Oncology Nurse once a year.
Conclusion This project is now carried out in all clinics
in the region. Nurses report contact with about 90% of
the oncology patients. They feel satisfied and
empowered being capable of responding to most of the
patients’ needs. It was shown possible to give ongoing
palliative care throughout all stages of the disease in the
community.
415. Consultation in palliative care; how to
improve quality?
Erica Witkamp, Mathilde Van der breggen, Pascalle
Voerman, Janneke Koningswoud, Jorien Van der doel,
Lia Van zuylen
Erasmus MC University Medical Center, Department of
Medical Oncology, rotterdam, Netherlands
Introduction
In the Netherlands the Comprehensive Cancer Centres
(CCC) organises consultation in palliative care. To
develop and improve the quality of the consultation, the
CCC of Rotterdam (CCCR) recently set up the
Committee for Quality Improvement of Consultation in
Palliative Care (the Committee).
Method
Consultants from the region ,a representative of the
CCCR and the Erasmus MC participate in the
Committee. Target is to monitor and improve the
consultation by increasing knowledge and expertise of
regional consultants and by optimizing the
organisation.
Poster abstracts
416. Old and Given up for Dying?
Multidisciplinary Palliative Care Teamwork in
the Nursing Home
Aase Nordstroen 1, Georg Bollig 1, Stein Husebo 2, Bettina
Husebo 3
1
Red Cross Nursing Home, Bergen, Norway
University of Klagenfurt and Vienna, Department of
Palliative Care and Ethics, Klagenfurt and Vienna, Austria
3
University of Bergen, Department of Public Health and
Primary Health Care, Bergen, Norway
2
The palliative care unit in our nursing home (NH)
opened June 2000 to ensure excellent palliative care for
elderly with extraordinary needs and their relatives.
Physician and nurse have ward rounds daily. Once a
week, patients needs are discussed in a multidisciplinary
team, consisting of nurses, physicians, physiotherapists,
ergotherapists, priest, social worker, musictherapist and
volunteers. On long-term units, ward rounds are
organized once a week; palliative care needs are
discussed in the multidisciplinary team on demand.
Aim: A prospective study investigated multidisciplinary
needs of patients admitted to palliative care (n=68)
compared with those on long-term wards (n=82).
Method: Demographic data, need for multidisciplinary
teamwork and pain- and symptom management were
registered. Results: Basic palliative care can be
implemented on every NH ward. Patients with
extraordinary needs benefit from specialised services of
a multidisciplinary team. Conclusion: All NH
patients should have access to basic palliative care.
The challenge is the skill and training of the caring team
and the need for teaching is imminent. NH staff must
have basic knowledge and training in palliative care of
the elderly. Special units with experienced physicians,
nurses, etc. are helpful in caring for complicated cases
and can prevent the need for hospital care.
417. Family Physicians as an Enabler or BArrier to
Palliative Supportive Cancer CAre
Kevin Brazil 1, Jonathan Sussman 1, Daryl Bainbridge 1,
Tim Whelan 1
1 McMaster University, Clinical Epidemiology, Hamilton,
Canada
2McMaster University, Department of Medicine, Hamilton,
Canada
3McMaster University, Clinical Epidemiology, Hamilton,
Canada
4McMaster University, Department of Medicine, Hamilton,
Canada
Family physicians are in an ideal position to monitor the
supportive cancer care needs of their patients.
Considering this potential, it was questioned whether
family physicians act as enablers or barriers to their
palliative patients’ supportive cancer care needs being
met.
A mailed survey was sent to all non-oncologist
physicians in a representative region of Ontario,
Canada. The unadjusted response rate was 65%
(91/140). Just over two-thirds 68.2%) of physicians
reported assessing need and either providing or referring
pecifically for palliative care. While a majority of
physicians reported assessing need and either providing
or referring for pain and symptom management
(88.6%), emotional support (84.1%), nursing care
(86.4%), and homemaker services (86.4%), this extent of
care was not evident for needs such as hospice care
(36.4%), group counselling (47.7%), or professional
counselling (50.0%). A large number of physicians
neither assessed, provided, nor referred for hospice care
(43.2%), group counselling (27.3%), or professional
counselling (25.0%). For the other SCC needs examined,
most physicians reported assessing and either providing
or referring for needs related to equipment (81.8%),
nutrition (72.7%), treatment information (70.5%), and
supportive care information (79.5%). Implications of
these care practices as enablers or barriers to cancer
patients accessing needed SCC services are discussed.
418. Development of the Palliative Care (PC) in
Latvia (2004-2006)
Vilnis Sosars, Baiba Streinerte
National Cancer Center, Department of Palliative Medicine,
Riga, Latvia
Introduction. PC as a system in Latvia started in 2004.
Data base analysis is needed to plan 1) the number of
the in-patient beds, 2) outpatient service capacity, 3) the
budget.
Sources of the study. 4 data base sources were used: a)
Sickness Funds of Latvia, b) Registry of Cancer Patients,
c) Department of Information, LOC, d) data from 7 PC
units.
Results. In 2004 from all 52 022 cancer pts 9 395 or
18.05% needed active PC. From 9 395 pts, 1 132 or
12.1% were hospitalized at the PC units, not admitted 8
262 pts or 87.9%, receiving support either in general
hospitals or within the primary care by GPies.
From 18 to 20% of all cancer pts needed active PC
support; 4 000 pts in Riga, 6 000 outside Riga.
According the Masterplan until 2010 there should be
125 in-patient beds or 5 beds/ 100 000 inhabitants.
PC in-patient beds in Latvia:
2004 – 80 beds, admitted 1 132 pts,
2005 – 80, 1 588 pts,
2006 – 100, 1 503 pts ( during 8 months),
2006– 2010 + 25 in-patient beds.
From 25- 40% of PC pts are planned to be admitted at
the specialized units; from 60 to 75% should receive
active PC on outpatient or primary care basis. In Riga
about 25% out of 4000 pts were consulted on outpatient
basis in 2004 and 2005.
The budget in PC:
In 2005 it was EUR 280 205. 71.
In 2006 - EUR 752 615.71. The increase in the budget is
37.2% per year.
Conclusions. PC model should be planned taking into
account: 1) data base analysis, 2) current needs in PC, 3)
motivated financial background, 4) in-patient and
outpatient PC service balance.
before 2005 and in 2006 were 2 and 4, respectively.
Many symptoms that were neglected, underestimated
and untreated in the past, were now recognized,
recorded and treated. Some of them were managed
significantly better. Great improvement was achieved in
psychosocial and spiritual support for both, pts. and
their families.
Conclusion: High proportion of pts. is admitted for PC,
because a PC network is not in place in our country.
With implementation of state of the art principles of PC,
better assessment and management of symptoms can be
achieved.
421. Palliative Daycare in the Netherlands - a new
initiative
Arianne Brinkman 1, Marijke Wulp 1, Harry Finkenflugel
2
, Berend Buys-Ballot 2
1
Agora, Bunnik, Netherlands
Erasmus MC, institute of Health Policy and Management,
rotterdam, Netherlands
2
For some European countries palliative daycare is a well
known service. In the Netherlands it is a new
phenomenon. Agora, the Dutch support centre for
palliative care organized an invitational conference on
palliatieve daycare in May 2005. In 2006, five
organizations that are planning the set up a palliative
daycare service set out a questionnaire to investigate the
attitude towards palliative daycare amongst referrers in
their region.
Aim of the project: To determine the attitude towards
palliative daycare amongst referrers (mainly general
practitioners) and to determine their referral criteria.
Method: a questionnaire survey
Result: Amongst referrers is expected that daycare can be
a positive contribution to the existing palliative care
services in the region. They want to referrer patients to
daycare in case of physical, psychosocial and spiritual
needs and for respite for family and carers.
Conclusion: Referrers seem to have a positive attitude
towards palliative daycare services in which attention is
paid to physical, psychosocial and spiritual aspects.
419. Trends in Place of Death of Cancer Patients
in Taiwan
Ming-Hwai Lin 1, Heng-Liang Yeh 1, Chun-Kai Fang 2,
Tzeng-Ji Chen 1, Shinn-Jang Hwang 1
1 Taipei Veterans General Hospital, family medicine, Taipei,
Taiwan
2Mackay Memorial Hospital, Psychiatry, Taipei, Taiwan
Although many patients with cancer would prefer to die
at home, most die in hospital. We carried out a study to
describe the yearly trends in the place of death between
1981 till 2004 and to explore the associated factor of
home death for adults with cancer in Taiwan. In this
population-based study, we used administrative death
certificates data for all adults in Taiwan who died of
cancer between the periods. We used logistic regression
analysis to identify the odds of dying at home over time
and to identify factors predictive of home death. A total
of 2,620,284 adults died of cancer during the study
period. Among 563,153 who died of cancer (21.5%),
347,777 (61.8%) died at home, 204,952 (36.4%) died in
hospitals, and 10,424 (1.8%) died at other places. Over
the study period the proportion of people who died at
home fell by 16%, from 66.1% in 1981 to 57.0% in 2004.
Predictors associated with home death included year of
death, female sex, age of death, tumor group, and region
of death. Over time, more patients with cancer,
especially women, elderly people and people who lived
in the urban areas, would like die at home in Taiwan.
420. Building up a palliative care (PC) service in
Slovene cancer center Institute of Oncology (IO)
Ljubljana
Jasenka Gugic, Bostjan Seruga, Branko Zakotnik, Jozica
Cervek, Mojca Simoncic, Klelija Strancar, Dijana Jelec
422. Palliative care consultation in a Psychiatric
Department
Monia Guedira, Elisabeth Cabotte, Dominique Ducloux,
Laurence Derame, Huguette Guisado, Sophie Pautex
EMASP, CESCO, Rehabilitation and Geriatrics, Geneva,
Switzerland
Aim of the study: To determine the main
characteristics of patients hospitalized in the psychiatric
Department seen by the palliative care consultation
(PCC).
Method: review of the PCC records over a period of 6
years (2000-2006).
Results: 76 new consultations were reviewed. 53
patients were male. Mean age was 79 years (range 3496). 63 patients had severe dementia, 26 had cancer (16
had also dementia, 10 severe depression or anxiety).
Reasons to involve MPCT were the impact of pain on
behavioral troubles in patient with severe dementia
(37), symptom management (pain, dyspnea, anxiety
and fatigue) (21) in patient with advanced cancer,
transfer in a palliative care unit (10) and finally some
ethical questions about artificial nutrition and
hydration (3). Our recommendations concerned
introduction (30) or adaptation (17) of analgesic
treatment with careful pain assessment, introduction of
drugs for symptom relief like dyspnea, death rattle,
mouth care, constipation (19), transfer in palliative care
unit (4) and organization meeting with the whole team
to discuss the ethical questions (3)
Conclusion: These results should encourage the
development of palliative care in psychiatric
departments for patients for patients with severe
dementia, but also for patients with an advanced
oncological disease who suffer also from dementia or a
concomitant psychiatric disease.
Institute of Oncology, Ljubljana, Slovenia
Introduction: IO, established in 1937, is the only
comprehensive cancer center in Slovenia with
diagnostic, therapeutic (320 beds), research and
education facilities. All of these followed the state of art
treatments and technologies, but PC was neglected. To
improve PC, we started to implement modern principles
of PC in 2005. A multi professional team and
consultation services were established. Guidelines for
symptoms assessment and management were
introduced. Our aim is to report the burden of PC pts.
and the impact of PC programs.
Methods: We made a survey of the burden of PC pts. at
the Department of Radiotherapy (DRT) and Department
of Medical Oncology (DMO). We evaluated how
symptoms were recognized, recorded and managed
before and after the PC programs were established.
Results: In 2005 there were 30.000 inpatient admissions
at DRT and 21.500 at DMO, of them 40 % and 30 % for
PC, respectively. The median numbers of symptoms
423. Case Management in Palliative Care
Anne Düsterdiek 1, Reneé-Alfons Bostelaar 3, Christoph
Ostgathe 1, Jutta Mägdefrau 2, Norbert Huppertz 2,
Raymond Voltz 1
1 University Hospital of Cologne, Department of Palliative
2
University of Education, Department of Palliative
Medicine, Freiburg, Germany
3
University Hospital of Cologne, Department of Nursing,
Cologne, Germany
Aim of Project: Growing complexity of Palliative Care
(PC) services and patient needs lead to the necessity of
better coordination. Therefore a specific Case
Management (CM) position was created. This study
aimed to identify the range of tasks for CM in PC.
Method: A mixed methods approach was used:
137
Poster abstracts
Results
Main topic has been the operationalisation of three
spearheads of the national framework for quality in
palliative care consultation. A checklist for consultation
reports, requirements of expertise of consultants and
their team and guidelines concerning access to palliative
care advice were elaborated by consultants supported by
the Committee. Furthermore, activities were initiated to
develop education for the regional consultants as well as
for GPs and nurses. The Committee actively advised the
CCCR about changes in the organisation of the
palliative care consultation in the region.
Conclusion
The Committee stimulates the elaboration and
implementation of the national framework and the
development of educational courses. Initiative, structure
and coöperation with regional consultants are keywords
which make the Committee the motor of quality
improvement of consultation.
Poster abstracts
problem centred interviews with PC professionals and
Case Managers from other departments as well as case
studies by participant observation (three respectively)
were qualitatively analysed. Quantitatively, the new
contacts to CM by telephone-hotline were analysed by
descriptive statistics. Result: The range of tasks of CM in
PC can be subsumed in the theoretical model of CM
including intake, assessment, planning, intervention,
monitoring and evaluation. However, specific features of
CM in PC could be identified that result from limited
life expectancy, rapid changes and the multiprofessional
concept. The first 300 new contacts after
implementation of CM came from internal staff (40%),
patients/caregivers (38%) and external services (22%).
The range of contents included: admission (43%),
outpatient PC service (10%), hospital support team
(17%), information about hospice and PC (15%),
psychosocial problems (5%), pain and other
symptomcontrol (10%). Conclusion: CM meets a wide
spectrum of needs which has to be coordinated within a
multiprofessional team. This coordination can be
optimized by a specific CM position. The development
of an adequate qualification for CM in PC is essential.
open visiting. However, most patients felt the need for
some control over visiting and for a degree of formal
restriction to visiting times. There appeared to be some
links between the first two themes: both concern factors
that influence the enjoyment of the visiting experience,
e.g. the relationship between the patient and visitor
(theme 1) and the patient’s state of wellbeing at the
time of visit (theme 2).Conclusion The results suggest
that the present visiting policy should be reviewed. The
second strand of the study is in progress and will
ascertain staff’s perception of visiting.
426. Home Zoledronic Acid (HZA) treatment in
patients confined at home for bone metastases.
An observational trial.
Davide Tassinari 1, Barbara Poggi 1, Adriana Pecci 1,
Luciana Massa 1, Manuela Fantini 1, Cinzia Possenti 1,
Stefania Nicoletti 1, Emiliano Tamburini 1, Marco
Maltoni 2
1
City Hospital, Oncology and Palliative Care, Rimini, Italy
Hospital, Oncology and Palliative Care, forli’, Italy
2City
424. A National Survey of Patient Satisfaction
with Hospice Services in the UK
Jan Codling 1, Nick Pahl 2, Linda Jenkins 3, Charlotte
Hastie 4
1
Help the Hospices, ILD, London, United Kingdom
Kent University, Health & Social Survey Unit, Kent, United
Kingdom
4
Kent University, Health & Social Survey Unit, Kent, United
Kingdom
2
3
National Minimum Standards for Independent
Healthcare (DoH 2002), states hospices should conduct
annual patient surveys. The NICE Guidance “Improving
Supportive and Palliative Care for Adults with Cancer”
highlights the importance of patients informing the
delivery of services (NICE 2004).
A patient satisfaction survey was conducted across 53
UK hospice inpatient (IP) and daycare (DC) services, at
discharge from service, or after 2 months attendance at
daycare, for return to an independent academic
institution.
1398 questionnaires were returned from DC patients
and 926 from IP. High levels of satisfaction were
reported for the general environment (84-86%),
cleanliness (83-88%), catering (70-75%) and transport
(84%). 53% of DC and 62% of IP reported that
information leaflets were easy to understand and
helpful. 75% of DC and 68% of IPs always understood
explanations about their care, both expressing high
levels of confidence in staff. 78% of IP reported
sufficient opportunity to ask questions and 68% in
making decisions about their care. 7% DC patients felt
unsupported when a group member died or was
discharged.
Overall, patients reported high levels of satisfaction
with services, however hospices are encouraged to
identify action plans for areas of lower satisfaction,
compared to nationally benchmarked data. Examples of
resulting actions for service improvement will be
discussed. Future work includes development of a
questionnaire for clients with learning disabilities.
425. Open All Hours? A Study of Visiting in the
Hospice Setting
Poster abstracts
Helen Gray 1, Lesley Cooper 2, Joan Adam 3, Duncan
Brown 4, Patricia McLaughlin 5, Julie Watson 6
1 St Columba’s Hospice, Nursing, Edinburgh, United
Kingdom
2Queen Margaret University College, Nursing, Edinburgh,
United Kingdom
3St Columba’s Hospice, Education, Edinburgh, United
Kingdom
4St Columba’s Hospice, Medical, Edinburgh, United
Kingdom
5St Columba’s Hospice, Nursing, Edinburgh, United
Kingdom
6St Columba’s Hospice, Nursing, Edinburgh, United
Kingdom
Introduction A policy of open visiting, where no
restrictions are placed on visiting times, is often
advocated within palliative care. The visiting policy may
directly affect the care of a patient and may impact on
the family and the multidisciplinary team. Aim To
explore whether the current open visiting policy reflects
the needs of patients and staff in an inpatient hospice
unit. This abstract describes the patient strand of the
study. Method A qualitative approach was adopted.
Semi-structured interviews were carried out on a
purposive sample of ten patients. The data was
thematically analysed. Results Three main themes
emerged: 1. The importance of visiting; 2. The effect of
physical and psychosocial state on perception of
visiting; 3. Control of visiting. In general, patients
appreciated the benefits of visiting and the flexibility of
138
Background. To assess safety and feasibility of HZA, an
observational trial has recently concluded.Methods. All
the patients with bone metastases and confined to
home were included into the trial. All the patients were
treated with HZA 4 mg and included in a comprehensive
program of home care. Primary end point was safety of
the treatment at home; secondary one was time to
treatment failure (TTF) on the basis of patient’s
characteristics.Results. 42 patients were considered
eligible and enrolled into the trial. 220 home treatments
were administered in three years, with a median of 4
administrations per patient (range 1-28). TTF was 130
days; the main reasons of interruption were worsening
of performance status (71.4%), length of treatment>24
months (4.8%), hypocalcemia (2.4%), renal
failure (2.4%). No difference in TTF were observed
between patients with breast cancer, multiple myeloma
or the other tumors, nor a prognostic significance were
observed for the kind of tumors, age, sex and number of
extra-osseous sites of disease. No acute major side effects
were observed during the treatment, and the treatment
had to be interrupted for side effects in 2 patients
(4.8%). Jaw osteonecrosis was observed in 1 patient
(2.4%).Conclusions. Our experience seems to confirm
the safety of HZA, suggesting a possible new setting of
patients in which using the treatment. The
identification of a criterion to select patients that really
benefit by HZA will probably be needed to favor its
appropriate use in clinical practice.
427. Security box in out-of-hours palliative home
care - how does it work?
Lisbeth Johansson, Eva Thornberg
Palliative Care Team, Södra älvsborgs Hospital, Boras,
Sweden
Aim of study
Our hospital based palliative care team provides
palliative home care in collaboration with the
community nurses. The team works office hours but
there is a need for symtom management all around the
clock. We designed a box containing drugs for pain,
anxiety, nausea and excess secretions ie mainly
morphine/hydromorphone, lorazepam, midazolam,
metoclopramid and morphine-scopolamin. All drugs
could be given non-orally and individualized. A written
order followed the box. We wanted to know how the
community nurses perceived the box and how it was
used.
Method
A questionnaire was sent to the community nurses in
our area with the following questions: Do you find the
orders easy to understand? Do you miss any drug? Have
the drugs had the desired effect? Do you have enough
knowledge of the drugs? Have you received proper
information by the palliative care team concerning the
use of the box? We also recorded all used drugs.
Results and conclusions
77% of delivered boxes were used for symtom relief
during the last days or weeks of life. The most common
used medication was mouth-soluble lorazepam,
followed by morphine, hydromorphone, morphinescopolamin, midazolam and metoclopramid. No other
drugs were asked for except for a few requests for
diazepam due to unfamiliarity with midazolam. The
majority of nurses were content with the box. A security
box in the patient’s home seemed to be a prerequisite
for palliative home care and the content of the box
appropriate.
428. INPATIENT HOSPICE CARE FROM THE
RELATIVES’ POINT OF VIEW
Johann Baumgartner 1, Petra Wagner 2, Martin Boeker 3,
Brigitte Wagner 4
1 Stmk. KAGes, Coordination Palliative Care Styria, Graz,
Austria
2
Geriatric Health Center Graz, Coordination Palliative Care
Styria, Graz, Austria
3
Austrian Red Cross, Helga-Treichl-Hospice, Salzburg,
Austria
4
Socio-scientific studies, Consultant, Graz, Austria
The aim of the study was to evaluate two in-patient
hospices by interviewing relatives of patients who had
died there. Relevant topics were the decision about the
patients’ referral to the hospice, the previous knowledge
of family members of the cost sharing and the quality of
care as seen by the relatives. For every patient who had
died at the Albert Schweitzer Hospice and the Helga
Treichl Hospice in 2005 a close relative was identified.
Finally 100 available persons took part in the
standardized interview which was performed by
telephone in 2006.Results: 90% of family members were
involved in the decision about the patient’s referral to
the hospice, 31% were pressed for time. In about half of
the cases the in-patient hospice care had been
recommended by the staff of a referring hospital. Almost
all family members had previous knowledge of the cost
sharing and more than 90% of the relatives were satisfied
with the medical and emotional support the patient
received. However, there was a lack of information on
the support provided for relatives at the hospice in the
period after the patient’s death, so only the minority
benefited from it. Although there is uncertainty about
the extent to which the views of relatives reflect those of
the patients themselves, there is evidence of the high
quality of the patients’ care, but more information has to
be given to the relatives on the support provided at the
hospice after the patient has died.
429. Equity of access to community palliative care
services
Catherine Walshe 1, Ann Caress 1, Carolyn ChewGraham 2, Chris Todd 1
1 University of Manchester, School of Nursing, Midwifery
and Social Work, Manchester, United Kingdom
2University of Manchester, Division of Primary Care,
Manchester, United Kingdom
Aim: Access to palliative care services appears
inequitable, but for unclear reasons. This research
explored influences on palliative care referrals within
three UK primary care organisations.
Method: Three case study sites in NW England were
studied. Multiple sources of evidence included 57
interviews with patients and palliative care providers,
observation of referral meetings and analysis of case
notes and other documents. Framework analysis
techniques facilitated the development of a thematic
framework, the amendment of theoretical propositions,
and pattern matching within and across cases.
Results: Two issues appeared to affect professionals’
perceptions of equity:
1) ‘I treat everyone the same’ Palliative care
professionals presented themselves as approaching
everyone’s care equitably, without overt discrimination.
However, this approach did not mean that everyone
received the same care, rather that their way of ‘treating
everyone the same’ was to offer everyone individualised
care.
2) ‘It depends what they want’ Care given was
individualised, based on both the professionals’
assessment of care needs, and their interpretation of
patient and carer choice.
Conclusion: Palliative care professionals offered
different levels of care, conceptualised as responding to
needs in an equitable, yet individual way. Inequitable
access may therefore not be overt discrimination, but
related to different care needs.
430. “Ownership” of patients: does this affect
access to services?
Catherine Walshe 1, Ann Caress 1, Carolyn ChewGraham 2, Chris Todd 1
1 University of Manchester, School of Nursing, Midwifery
2
University of Manchester, Division of Primary Care,
Manchester, United Kingdom
Aim: Ownership is under-researched, yet could
potentially confer advantages to caring professionals, or
affect patient referrals. This research explored palliative
care referrals within three UK primary care
organisations.
Method: A qualitative case study strategy was adopted,
purposively selecting three sites in North West England
with different patterns of palliative care provision.
Poster abstracts
431. Hospice Casa Sperantei - A Beacon of Hope in
Romania
Alison Landon
Hospice, BRASOV, Romania
Hospice Casa Sperantei has led the development of
palliative care in Romania. It began as a local initiative
but is now an Eastern European centre of excellence.
The Hospice has evolved a range of local clinical
services: inpatient units, outpatient clinics, day centres
and home care teams for both adults and children;
breast prosthesis clinic, stoma therapy clinic, children’s
education project; and hospital support teams. The
education centre in Brasov and the national resource
centre in Bucharest actively promote palliative care
training for all members of multidisciplinary teams
both from Romania and other Eastern European
countries. The influence of the hospice on government
policy has resulted in national palliative care standards;
recognition of palliative care as a sub-speciality which is
now included in medical undergraduate education;
service contracts with local health authorities and most
recently new legislation covering the prescription of
opioids. Nationally palliative care services are expanding
but a coherent national strategy is still urgently needed.
Funding is the critical constraint.
also participate in palliative care process. Conclusions:
Organized approach to palliative care at our hospital
resulted in: 1. Better recognition of the importance of
palliative care among providers as well as patients and
their families; 2. Improvement in the integral/team
approach to treatment; 3. Increased amount of
information that patients and their families have about
the nature, course and treatment of the disease; 4.
Stimulation of more active participation of patients and
their families in the course of treatment and co-deciding
about the treatment; 5. Improvement of cooperation
with services at the primary level, and 6. Increased
satisfaction of both patients, families and care providers.
434. Integrated services to assure continuity of
care for patients and their families
Cristina Ghiran
Hospice, Palliative Care, BRASOV, Romania
In providing high quality multidisciplinary care to
patients and their families it may be overlooked that
each member of the team is a new face and each place of
care is a new setting where the patients and their
families may be traveling without a compass, map or
guide. To offer a safe journey, the organization must
promote continuity of care and ensure patients feel that
the team really cares about them. Hospice Casa
Sperantei offers a range of services to adult patients. In
each setting the team focuses on holistic care, striving to
offer high quality care, which to a certain extent
depends on continuity of care. This is achieved through
specific actions and by following certain procedures.
There is always scope for improvement and we have in
mind to develop a 24 hours service and to perfect
transfer of patients from one service to another. Not
least, we must strive to follow up promises made to the
patients and their families. Comprehensive coordinated
care reflects the complexity of human life with in all
respects: physically, socially, emotionally and spiritually
and drives our organization to fulfill the needs of
patients and families to a higher standard.
435. Monitoring Quality in an Acute HospitalBased Palliative Care Service - Adopting
‘Universal’ Indicators
Angel Lee, Huei yaw Wu, Koh Koh, Susan Chan, Tzer
Wee Ng
432. ‘Home Sweet Home’ Audit of all cancer
deaths across all health care settings
Tan Tock Seng Hospital, Palliative Care Service, Singapore,
Singapore
Marijtje Drijfhout, Karen Groves
Mortality rates, unsheduled readmissions and length of
stay are commonly used indicators to monitor quality of
care in acute hospitals. We reviewed the their use in the
context of a palliative care service. Mortality rates in
themselves were not useful as death is not an
unexpected outcome in the terminally ill. Instead,
mortality rounds were modified with emphasis on
determining (1) adequacy of symptom control,
(2) whether psychosocial needs were met and (3)
whether place of death was consistent with patient’s
preference. Lapses of care were addressed and staff
debriefing in challenging cases were also conducted as
appropriate. Unscheduled readmissions within 2 weeks
were also deemed to be an appropriate indicator with 3
areas commonly found to contribute to readmissions (1)
lapse in communication with community hospice
services (2) poor symptom control (3) unmet
psychosocial needs. Even as efforts to minimse
readmissions were put in place, length of stay is
concurrently monitored to ensure care remains
efficient and provided at the most appropriate site.
The NHS Cancer Plan 2000, included palliative care
education for District Nurses to support its aim of trying
to allow more people to die at home if that was their
wish.
In West Lancs, Southport & Formby area, despite
widespread education of District Nurses, GP Registrars,
Health Care Assistants and others integral to home care,
and good provision of community services, the number
of home cancer deaths continued to fall whilst the
number of hospital cancer deaths continued to rise.
A 6 month prospective audit was undertaken to look
at all cancer deaths across hospital, home, hospice and
care homes to establish the reasons why patients with
cancer did not die at home and whether their preferred
place of care was documented.
This poster outlines the results of this audit and the
actions required to address some of the local issues
arising from the results.
436. Good palliative care practice have impact on
the place of death
433. The development of palliative care at
University Clinic of Respiratory and Allergic
Diseases Golnik
Andreja Peternelj, Anja Simonic
University Clinic of Respiratory and Allergic Diseases,
Ljubljana, Slovenia
University Clinic of Respiratory and Allergic Diseases
Golnik is an institution specialized in the treatment of
pulmonary and allergic diseases. The chronic course of
these diseases requires the implementation of palliative
care, which in the past did not receive any special
attention in our hospital or elsewhere in Slovenia. Our
objective is implementation of organized palliative care
and improvement in the quality of patient’s and their
family’s lives. Implemented innovations (results) since
2003 are as follows: 1. Four beds set aside at the
department for non-acute treatment for patients who
need terminal palliative care; 2. Formation of a standing
palliative team; 3. Regular informative meetings for
patients and their families; 4. Establishment of a clinical
path for patients with small-cell lung cancer; 5.
Preparation of an educational programme for those who
Gunnar Eckerdal, Karin Ericson, Annelie Kilersjö, Benthe
Skale
ASIH Kungsbacka, Department of Palliative Medicine,
Kungsbacka, Sweden
Background: It is difficult to measure the overall effect of
establishing a new palliative care service. We wanted to
find out the impact for the whole population, not only
for persons dying of cancer. A simple way of
investigation is to describe the place of death in the
entire population. A well known fact is that many
persons prefer to be at home when they die. Problems
within health care, lack of relatives and limited access to
palliative homecare in many countries, reduce the
personal impact on preferred place of dying.
Method: In the town of Kungsbacka with 70 000
inhabitants a new palliative support team
was established in 2005. The place of all deaths was
studied in 2004 and 2005 (before and after the
introduction of the new team). The facts were collected
from death certificates. Places of death were categorized
as in hospital, nursing home, palliative care unit,
hospice and at home.
Results: The number of deaths in hospital and nursing
homes diminished, while the number of deaths in a
palliative care unit and at home rose. No great changes
in health organisation, demography or economy where
executed during the observation period. The data
suggests that establishing the new team explained the
observed changes.
Summary: In the palliative care it is interesting to study
all deaths in society. The goal is not only to give good
palliative care to persons registered in a palliative care
service, but to all dying persons as well. Specialized
palliative care services can have a strong impact. An
easily performed investigation of death certificates can
be used.
437. Dying for information: an evaluation of a
telephone helpline for patients with advanced
disease and their families
Susan Longhurst 1, Jonathan Koffman 2, Catherine
Shipman 3, Liz Taylor 4, Steve Dewar 5
1 King’s College London, Palliative Care, Policy and
2
King’s College London, Palliative Care, Policy and
3
4
NHS, Information, London, United Kingdom
5King’s Fund, Development, London, United Kingdom
Introduction: Up-take of palliative care services is low
among older people, black and minority ethnic groups
(BME), and the poor. This reflects poor knowledge of
relevant services. Telephone helplines (e.g. NHS Direct)
have potential to increase awareness of health
information and services. Research aim: To evaluate
‘COMPASS’, a free palliative care telephone helpline,
aimed at increasing awareness of palliative care to
patients with advanced disease and carers living in
South London. Methods: Audit of all calls received by
the helpline, measuring call patterns, caller
demographics and service requests. Results: The helpline
received 116 calls between Oct 05-Oct 06; call volume
declined over time. 84% of callers were female, 38%
were aged 45-65 years. 33% were from BME groups and
63% were from socially deprived areas. 41% of calls were
made by patients and carers seeking information about
issues including palliative care conditions, support
groups and financial benefits. 20% of calls were made
by health care professionals seeking information about
local specialist palliative care services. Conclusion:
COMPASS has been successful in providing an
innovative information source to previously
underserved population groups. It also provides an
important source of information for local health care
professionals, an unintended benefit. Dissemination of
publicity about the line remains challenging.
438. A learning curve: Developing and operating
a telephone helpline for patients with advanced
disease and their families and professional carers
Susan Longhurst 1, Jonathan Koffman 2, Catherine
Shipman 3, Liz Taylor 4, Steve Dewar 5
1 King’s College London, Palliative Care, Policy and
2King’s College London, Palliative Care, Policy and
3King’s College London, Palliative Care, Policy and
4NHS, Information, London, United Kingdom
5
King’s Fund, Development, London, United Kingdom
Introduction: Uptake of specialist and generic
palliative care is related to low awareness among certain
population groups. To address this, COMPASS, a
telephone helpline was established in October 2005 by
NHS Direct to provide information on end of life issues
and services. Research aim: To explore the
stakeholders’ views on the feasibility, development and
outcomes of the helpline. Methods: Semi-structured
face-to-face and telephone interviews with COMPASS
stakeholders including the management team, health
information advisors, and relevant external parties.
Results: Four main themes emerged from the
interviews: (i) recruitment of suitably qualified staff; (ii)
the challenge of developing an up-to-date database of
local services along with ‘response algorithms’ for call
handlers; (iii) while the service was widely publicised,
call numbers during the helpline’s first 12 months was
lower than expected; (iv) changes to NHS Direct’s
working policies encouraged regular review and
modification to the operational development of the
helpline. Conclusion: The helpline has faced many
challenges related to the nature of palliative care and to
external operating circumstances. The development of
this specialist telephone helpline has been an iterative
process which has demanded COMPASS react and
modify the service to a continually challenging external
backdrop.
139
Poster abstracts
Multiple sources of evidence included 57 interviews
with patients and palliative care providers, observation
of referral meetings and analysis of case notes and other
documents. Data were coded, charted, mapped and
interpreted, developing a thematic framework and
theoretical propositions. Framework analysis techniques
facilitated pattern matching within and across cases.
Results: Concepts of ownership were closely bound to
the interrelated issues of responsibility for, and
relationship building with patients. Medical
professionals highlighted a sense of responsibility
towards patients, whereas nursing professionals worked
to develop a relationship with patients. District nurses in
particular used possessive terms to outline ownership of
patients. This had variable effects, either leading them
to act to restrict others’ access to that patient, or giving
them a basis to share care.
Conclusion: Ownership was acknowledged as an
important concept by healthcare professionals, and
appeared to have an effect on how professionals referred
patients onto other services.
Poster abstracts
439. Social care interventions for hospice referral
in a university hospital without palliative care
unit
Sabine Prange 2, Ricarda Klein 3, Maike De Wit 1
1
University Clinic Hamburg Eppendorf, Internal Medicine
& Medical Oncology, Hamburg, Germany
2
University Clinic Hamburg Eppendorf, Department of
Social Work, Hamburg, Germany
3
University Clinic Hamburg Eppendorf, Patient Care,
Hamburg, Germany
The aim of this study was to evaluate the transfer rates to
a hospice for palliative patients of all departments of our
University Clinic Hamburg-Eppendorf without palliative
care unit or palliative care team.
The data base of the social care department
comprehends all in-patients in the year 2005 and from
January to October 2006 who were referred from
hospital to hospices or were advised about hospice care.
In 2005 118 consultations concerning hospice care were
performed.
20 patients received psychosocial and social judicial
interventions concerning palliative care and
information about the options of patient care outside
the hospital. In 98 consultations the intention of the
care givers was to discharge the patient to a hospice. 56
patients could be transferred to a hospice. 42 patients
died prior to discharge or could be cared for in the
family setting with the support of the social worker.
In 2005 32 patients and in 2006 (10 mths) 39
patients from the Department of Medical Oncology
were referred to a hospice. For 8 patients in 2005 and 12
patients in 2006 an alternative decision was made.
From January to October 2006 the social worker
received calls 118 times for hospice care, of these in 18
cases psychosocial and judicial interventions were
required and from 100 calls for referral to a hospice 61
patients were transferred from hospital to hospice.
Palliative care interventions for assistance
transferring patients to a hospice increased from 2005 to
2006.
440. The problems of transition from voluntary
hospice teams activities to modern hospice teams
integrated into the existing health care system
Gordana Spoljar 1, Ivana Bandovic Ozegovic 2, Anica
Jusic 3
Poster abstracts
1 Croatian Association of Hospice Friends, Paliative care
Service, Zagreb, Croatia, Republic of
2Croatian Association of Hospice Friends, Paliative care
3
Croatian Society for Hospice/Palliative Care, Paliative care
The Croatian Association of Hospice Friends (CAHF) was
founded in 1999 to provide logistic support, first of all to
the educative and promotive activities of the Croatian
Society for Hospice/Palliative Care,CMA. CAHF
endeavours to provide practical palliative medical,
psychosocial and spiritual care during hospice home
visits by interdisciplinary teams in Zagreb and Zagreb
region. As soon as a provision about palliative care was
included into the new health reform law in summer
2003, CAHF started the administrative procedure
necessary to establish an Institute for Palliative Care. - All
efforts were blocked by changes in the Government and
by the subsequent radical personal and organisational
reforms in autumn 2003. As. CAHF a civil association,
can’t conclude contracts with the Croatian Institute for
Health Insurance, we had to start with the procedure all
over again. Palliative care can’t develop on an almost
exclusively voluntary basis. It should be stressed
that our palliative care team is the only palliative care
unit in the modern sense in Croatia and has been
functioning for almost 7 years continuosly in
facilities rented by the city of Zagreb. So far, the
Association’s activities have been financed by projects
and national and foreign donations. From 12/1999 until
06/2006, palliative care services were provided for 879
people and their families.
441. Specialised palliative home care in Bonn which factors lead to referral to inpatient
settings previous to death
Martina Kern, Elke Ostgathe, Heike Wessel, Eberhard
Klaschik
University of Bonn, Department for Palliative Medicine,
Bonn, Germany
Introduction: Specialised palliative home care services
(SPHCS) aim at accomplishing that patients can die at
home. It is well acknowledged that this is not achieved
in all patients. This study analyses, which factors lead to
referral to inpatient settings (IS) previous to death.
Methods: Data of every patient of the SPHCS at the
Malteser Hospital in Bonn is documented in a
computerised data base. For this study, the period from
1/2002 to 6/2006 was analysed. Patients who died in IS
140
were compared to patients who died at home (DH) by
testing for differences (¯_Ç_) in symptom prevalence
and availability of family members as informal
carers.Results: Data sets of 567 patients were included,
of these 362 (64%) died at home and 205 (36%) did not
die at home. Higher symptom prevalence was detected
in IS patients for dyspnoea (27%, DH 19%; p=.028) and
nausea (13%, DH 7%; p=.019). No differences were
found for e.g. pain. Relatives as informal carers were less
common in IS patients (62%, DH 86%, p<.001).
Conclusion: The presented study shows that certain
factors have a significant influence on the place of
death. Social preconditions like lack of family structures
cannot be changed, but an improvement of symptom
management in the outpatient setting, e.g. better
qualification, closer cooperation (e.g. with physician)
and better coordination, may increase the number of
terminally ill patients in SPHCS in this area that can stay
at home for dying. This can be a focus for further
research.
442. PROJECT FOR SAFE DISCHARGE AND HOME
CARE SERVICE IN PALLIATIVE CARE BY THE 9th
ONCOLOGICAL PROVINCIAL INTERCOMPANY
DEPARTMENT OF LOMBARDIA (Italy)
Paola Castagnini 1, Raffaella Speranza 2, Gianstefano
Gardani 3
1 Azienda Ospedaliera Monza, Palliative care unit, Monza
(Milano) Italy, Italy
2
Azienda Ospedaliera Monza, Palliative care unit, Monza
(Milano) Italy, Italy
3Azienda Ospedaliera Monza, Department of Oncology,
Monza (Milano) Italy, Italy
Project Purpose:
Most of the home care oncological patients don’t need
any specialized oncological therapy. It is therefore
necessary to plan, set up and manage a service care
programm which allows the patients to enter a national
health insurance network with a territorial integration.
The network will provide the following :
the Hospital as promoter of safe discharge process
the Local Health Unit as guarantee of different territorial
social and health levels
The Municipal Social Services
Volountary Service
The project is for adult and paediatric patients with
oncological and oncohematological diseases. The aim of
the project is to promote a continuative relation
between the hospital and the region of the involved
patients by a safe discharge process from the hospital
and/or day-hospital or outpatient healthcare insurance.
Methods:
The continuity model of health care consists of:
-a computerized case report form . All the involved
professionals in the assistance can communicate
together easily and can be constantly updated.
-a specific training of all the involved professionals
-a pilot study for three years with a final inspection
using suitable markers.
Results:
The Lombardia Region has approved and sponsored the
project. Data processing systems have been
implemented and training being performed. The
effectiveness of the training will be evaluated after one
year and also the case recruiting will begin at that time.
443. Developing an early intervention supportive
and palliative care pathway for adults with
intellectual disabilities
Sally Stannard 1, Linda McEnhill 2
1 St. Christopher’s Hospice, Community and Hospice
Nursing, London, United Kingdom
2ST CHRISTOPHER HOSPICE, Education, London, United
Kingdom
Despite policy/legislation the healthcare needs of British
intellectually disabled people are poorly met and
particularly so within palliative care.Thus service
providers are often inexperienced in communicating
with and meeting the needs of this client group when
someone with an intellectual disability (ID) is referred to
them. Research has demonstrated that many people with
ID with life threatening conditions do not access
hospices or the full range of palliative interventions. This
is related to the late diagnosis of illness and a reluctance
to ‘hand over’ care to non ID professionals. It is clear that
late referral has a deleterious effect on all aspects of care,
not least the ability to develop trusting relationships with
the patient and those closest to them. This presentation
will detail work undertaken within a London hospice to
develop accessible and appropriate supportive and
palliative care for people with intellectual disabilities.
This endeavour is the consequence of developing
partnerships between community ID and palliative care
professionals; it has resulted in the development of a
patient pathway for early referral and intervention across
a continuum of supportive and palliative care. The
implementation of the pathway has highlighted
significant training and support needs for staff within
each area of care. The model of care developed is
transferable to a range of hospice and community
palliative care settings.
444. Accelerating Change In Complex, PublicFunded Health Systems: The Canadian Pallium
Project
Jose Pereira 1, Michael Aherne 2
1 University of Calgary, Palliative Medicine, Calgary,
Canada
2Pallium Project Canada, Edmonton, Canada
AIM: From 2004 - 2006, the Government of Canada
invested ¤ 2.8 million in the Canadian Pallium Project to
improve patient access through primary care renewal.
METHOD: The Project employed established social
science and educational research from the literature,
including; Action Research; Continuing Professional
Development informed by Situated Cognition/Learning,
Workplace Learning, Critical Reflection and Social
Constructivism theory; Communities of Practice;
Complexity Theory, and project management practices
informed by international capacity-building models.
Through development and change management projects
in outreach education and continuing professional
development; knowledge translation/ diffusion; and
health delivery system change, the Project (Phase II)
generated and catalyzed transferable lessons/innovations.
RESULT: Phase II of the Pallium Project completed 72
projects in a 24 month period with results including
demonstrable clinical practice change from local interprofessional education, a competency-based palliative
care courseware package being used in medical schools, a
nationally-validated, competency-based curriculum kit
for Spiritual Care, 12 other national education resources
and multiple innovations in e-learning and e-health to
support improved palliative care in community setting.
CONCLUSION: Phase II demonstrates the possibilities for
inter-sectoral collaboration among academic,
government, civil society (NGO) and health service
delivery partners to produce demonstrable change and
useful legacies for palliative care capacity-building.
445. What Affects Adherence by Internal
Medicine Nurses (IMNs) of Recommendations
Made by Palliative Care Consult Nurses in a Swiss
Tertiary Hospital
Fabienne Teike Lüthi
CHUV, Service de Soins Palliatifs, Lausanne, Switzerland
Aim: The goal was to explore the factors that influence
adherence by internal medicine nurses (IMNs) to
recommendations provided by a palliative care consult
nurses (PCN) in a Swiss teaching hospital. Method: A
qualitative approach, using case study design, was applied.
Following convenience sampling, IMNs were interviewed
one-on-one (semi-structured questions). Two conceptual
frameworks (Zay et al 1997 ; Sauve 2001) were used as a
starting point for data coding. New categories and themes
then emerged. Results: Data saturation was achieved
after 5 interviews. 5 categories emerged, including alterity;
transparency; communication; time; and sense of
ownership. Adherence requires a personal rapport and
trust between the IMNs and PCNs. Developing this
requires time. Frequent staff changes hinders this. IMNs
view the consultation at times as an intrusion by the
PCNs and feel that they are better acquainted with the
patients. Explicit recognition by the PCN of the personal
distress that IMN experience when caring for palliative
patients enhances the rapport. A focus on supporting the
IMNs rather than focussing only on the patient enhances
adherence. IMNs experience (whether real or perceived) a
sense of inferiority during the consultation process.
Conclusions: Our PC team needs to review its model of
consultation, possibly adopting one that focuses more on
supporting the primary teams. Formal and informal
strategies to improve the rapport with IMN will be sought.
Awareness by the PCN of the inferiority felt by the IMNs
may enhance rapport building.
446. CLINICAL AUDIT IN A HOME PALLIATIVE
CARE SERVICE:Auditing the audit
Maria Daud, Jorge Eisenchlas, Gustavo De Simone
Hospital B. Udaondo & Pallium Latinoamerica, Palliative
Care Service, Buenos Aires, Argentina
Clinical audit intends to improve current practice, use of
resources and team education. Therefore, it is essential
in the palliative care setting as a mean to reach an
excelent care.
Objectives Ensuring the effectiveness of an audit
project and discuss methodological issues able to impact
in the efficacy of the audit.
Methods The Pallium-Hostal de Malta Home PC Service
(HMHPCS), developed an organizational and clinical
audit programme based on standards developed by the
Trent Hospice Audit Group. In the first phase, the audit
Poster abstracts
447. National Palliative Care Outcomes
Collaboration (PCOC) - can it contribute to
improved standards and quality in palliative
care?
Tania Shelby-james 1, 2, Kathy Eager 3, Linda Kristjanson 4,
David Currow 1, Patsy Yates 5
1
Flinders University, Adelaide, Australia
Repatriation General Hospital, Southern Adelaide Palliative
Services, Adelaide, Australia
3
University of Wollongong, Centre for Health Service
Development, Perth, Australia
4
Curtin University of Technology, Perth, Australia
5Queensland University of Technology, Institute of Health
and Biomedical Innovation, Brisbane, Australia
2
Aim: PCOC aims to develop and support a voluntary
national benchmarking system to improve palliative
care outcomes. PCOC is working with palliative care
service providers to:
• Develop consistency in data collection
• Provide evidence through the collection and analysis
of data
• Assist with quality and standards reporting
• Provide a benchmarking service
• Promote and support palliative care research
Methods: The PCOC dataset includes demographic,
episode and phase data. When a service agrees to join
PCOC, Zone Coordinators meet with senior
administration staff followed by clinical staff.
Discussions with service providers include an
assessment of current data collection methods and how
extraction and mapping issues can be resolved. Training
programs ensure all data is collected in a rigourous and
consistent manner.
Results: To date approximately 30 services have been
recruited across Australia and have begun to collect data
and as practices become established, additional services
will be encouraged to join. Feedback from services
providers has led the PCOC team to conclude that the
Version 1 data set requires improved definitions and
guidelines.
The first half-yearly reports were circulated in early 2007.
providers.
Conclusion: The development of national
benchmarking program for palliative care in Australia
has the potential to make significant improvements on
the way we take care of people with a life-limiting
illness.
448. Activities of a Palliative Care Unit in Preah
Ket Melea Hospital Phnom Penh, Kingdom of
Cambodia
Khantey OM 1, Sokhun KAN 1, Kosal SOM 1, Cécile
BERNARD 3, Boren YI 1, Mikael GIRET 3, Phany AUK 3,
Philippe POULAIN 2
1
Preah Ket Mealea Hospital, Phnom Penh, Cambodia
sans frontieres, Paris, France
sans frontieres Cambodge, Phnom Penh,
Cambodia
2Douleurs
3Douleurs
Introduction: AIDS is one of the major public health
problems in Cambodia. Even if there is a national
program of antiretroviral therapy and prevention, the
mortality is high. Objectives:Describe the activity of the
only Palliative Care Unit in Cambodia. The Unit was
founded in 2003, has an inpatient ward of 30 beds, a
home care team and a Pain Clinic. It is part of a
governmental hospital. Material and methods: Since it is
openning, data has been prospectively collected on
demographic characteristics, diagnoses and symptoms
of all patients. Results :In 2005, the number of
admissions was 488: 412 patients with AIDS, 65 with
cancer and 11 with other pathologies. The mean lengtht
of stay was 16 days. For patients with AIDS, the mean
duration of their disease was 3 years. All these patients
were hospitalized for one or several opportunistic
infection and the most frequent reasons for admission
were pain (75%) and respiratory problem (22%).The
mortality rate was 24%. It is lower than in a classic
palliative care unit because a majority of patients are
very poor and arrive in very bad condition. After
treatment with antibiotics, symptom control and three
meals a day, most of them recover for a while and are
discharged at home. There is a follow-up by our home
care team.Tuberculosis and diarrhea are the most
common presenting conditions of AIDS and also the
most prevalent cause of death. Conclusion : The
Palliative Care Unit has proven its utility. In this 3rd year
of activity, we can see that the number of patient
referred by other health structure increase a lot.
449. Palliative Care for People living at Home:
Resources and Barriers
Katharina Heimerl, Klaus Wegleitner
University Klagenfurt, IFF-Department of Palliative Care and
Organisational Ethics, Vienna, Austria
Background: Despite a lack of systematic research data
there is evidence that the majority of the population
wishes to spend their last days and hours at home and to
die there. Nevertheless figures show that in middle
European countries only a minority actually does so.
The qualitative research project involving home care
services and families identifies resources and barriers to
palliative care at home. Methods: In three Austrian
pilotregions qualitative interviews with family members
and group discussions with nurses and managers of
home care services, family doctors and palliative care
teams were conducted and analysed. Results: Increasing
numbers of single households, the lack of experiences
with death and dying among family members the lack
of caring family, inadequate structures and resources of
home care services are the principle barriers whereas
cooperation between professionals (familiy doctors,
palliative care teams and home care services), adequate
processes and documentation of ethical decision
making, and quality in management of patient’s transfer
between hospital and home are reported as important
resources to enable people to die at home. Conclusions:
Departing form the analysis of resources and barriers for
palliative care at home the project is currently
developing a plan of action for home care services as
well as recommendations on a national and strategic
health policy level.
450. INDIVIDUALIZED MULTI-DISCIPLINARY
CASE CONFERENCES: CAN THEY BE
PRACTICALLY ADDED TO SPECIALIST
PALLIATIVE CARE?
Amy Abernethy 1, 2, 3, Tania Shelby-James 1, 2, David
Currow 1, 4, Helena Williams 5, Paddy Phillips 6
1 Flinders University, Department of Palliative and
Supportive Services, Adelaide, Australia
2
Repatriation General Hospital, Department of Palliative
and Supportive Services, Adelaide, Australia
3Duke University Medical Centre, Division of
Hematology/Oncology, Durham, United States
4Cancer Australia, Canberra, Australia
5
Southern Division of General Practice, Adelaide, Australia
6Flinders University, Department of Medicine, Adelaide,
Australia
Objective: Case conferences are multidisciplinary
meetings with the general practitioner (GP), patient, and
palliative care clinician, convened to plan care for the
patient. In a randomised controlled trial, the addition of
a single case conference to usual specialist palliative care
improved function and reduced hospitalisations. What
are the characteristics of case conferences? Can they be
incorporated into routine palliative practice? Participants
and Setting: Eligible participants were adults referred to a
regional specialised palliative care service in Adelaide
and their GPs. Results: 47% (167) of 358 patients
randomised to a conference had the intervention. 142
patients died before it could be arranged; 46 withdrew.
Conferences occurred median 52 days (range 6-288)
after enrolment, and 79 days (range 0-726) before death.
91% included patients/caregivers. 75% included 3
participants plus the patient/caregiver. Conference
lasted mean 39±13 min. Symptom control, function,
future care, social issues, and spirituality were discussed.
43% of conferences were claimed for GP reimbursement
through Australian Medicare; 99% were eligible. Nurses
reflected that conferences should be timed with
deteriorating patient function; organisation of
conferences was difficult and time consuming.
Discussion: Case conferences can be practically
incorporated into routine specialist palliative care.
Organisational difficulties were overcome through
administrative personnel.
451. HEALTH RESOURCE UTLISATION WITHIN
PALLIATIVE CARE. FINDINGS FROM A
PROSPECTIVE RANDOMISED CONTROLLED
TRIAL
Abernethy 1, 2, 3,
Background: Up-to-date, accurate data on the type and
costs of services provided in palliative care are required
for service planning and successful negotiation of health
system resources. Methods: The Palliative Care Trial was a
2x2x2 factorial randomised controlled trial that
evaluated case conferencing and educational
interventions. Eligible participants were adults referred to
a regional specialised palliative care service in Adelaide,
Australia, and their GPs. Longitudinal health resource
utilisation data were collected for each participant from
palliative care referral until death. Data included: 1)
palliative care service; 2) Australian Medicare; 3)
Department of Veteran Affairs; 4) private health insurors;
5) public and private hospitals; 6) aged care facilities; 7)
home nursing services; 8) domicillary care services; 9)
local ambulances; and, 10) hospital pharmacies. Data
were combined using probabilistic and deterministic
matching. Costs were attributed to all services and have
been used in economic analyses. Resource utilisation
mapping is underway. Results: 461 patients were enrolled.
Data matching and health resource utilisation analysis
will be completed by March 2007, enabling modelling of
resource use by demographics and disease profile.
Conclusions: These data will provide valuable insight into
the current needs of people with a life-limiting illness in
metropolitan Adelaide and can be used to inform the
policy making decisions for palliative care.
452. End-of-life decision-making in Belgium,
Denmark, Sweden and Switzerland: Does place of
death make a difference?
Joachim Cohen 1, Johan Bilsen 1, Suzanne Fischer 2,
Rurik Löfmark 3, Michael Norup 4, Agnes Van der Heide
5, Guido Miccinesi 6, Luc Deliens 1
1 Vrije Universiteit Brussel, End-of-Life Care Research Group,
Brussels, Belgium
2University of Zurich, Department of Health Sciences,
Zurich, Switzerland
3Karolinska Institutet and Uppsala University, Cantre for
Bioethics, LIME, Stockholm, Sweden
4University of Copenhagen, Department of Medical
Philosophy and Clinical Thery, Copenhagen, Denmark
5Erasmus MC, Department of Public Health Sciences,
6
Centre for Study and Prevention of Cancer, Florence, Italy
Objective: To examine differences in end-of-life
decision-making in patients dying at home, in a hospital
or in a care home.
Design: certifying physicians from representative
samples of death certificates, taken between 06/2001
and 02/2002, were sent questionnaires on end-of-life
decision-making preceding the patient’s death.
Setting: Belgium (Flanders), Denmark, Sweden, and
Switzerland (German-speaking part).
Main outcome measures: Incidence of and
communication in different end-of-life decisions
(ELDs): physician-assisted death, alleviation of
pain/symptoms with a possible life-shortening effect,
and non-treatment decisions.
Results: Response rates ranged from 59% in Belgium to
69% in Switzerland. Total number of deaths studied was
12492. Among all non-sudden deaths the incidence of
several ELDs varied by place of death. Physician-assisted
death occurred relatively more often at home (0.3%5.1%); non-treatment decisions more often in hospitals
(22.4%-41.3%), but also frequently in care homes in
Belgium (26.0%) and Switzerland (43.1%). Continuous
deep sedation until death was more likely in hospitals.
At home, ELDs were usually more often discussed with
the patients, but less often with other caregivers than in
hospitals or care homes.
Conclusion: End-of-life decision-making is possibly
related to the care setting where people die. This would
call for development of good end-of-life care options and
end-of-life communication guidelines in all settings.
453. HOME CARE AT THE END OF LIFE
MERCE LLAGOSTERA 1, MAGDALENA ESTEVA 2, JOANA
RIPOLL 2, MARTA VERDAGUER 1, ENRIQUE FERRER 1,
LLORENÇ ROIG 1, YOLANDA MUJOZ 1, MARTA
VERDAGUER 1, JOAN LLOBERA 2
1 Majorca Primary Care Department-Ibsalut, Unit of
Domiciliary Palliative Care, Palma de Mallorca, Spain
2Majorca Primary Care Department-Ibsalut, Unit of
Research, Palma de Mallorca, Spain
Shelby-James 1, 2,
Amy
Tania
David
Currow 1, 4, Andrew McAlindon 5, Darren Richardson 5
1
2
Repatriation General Hospital, Department of Palliative
and Supportive Services, Adelaide, Australia
3Duke University Medical Centre, Division of
Hematology/Oncology, Durham, United States
4
Cancer Australia, Canberra, Australia
5
Department of Human Services, Information Systems and
Modelling, Adelaide, Australia
Flinders University, Department of Palliative and
OBJECTIVES: Caregiver satisfaction of patients who has
received palliative home care (HC) vs those who have
not received it.
141
Poster abstracts
was directed to the evaluation of outcomes related to
symptom control and psychosocial and spiritual
support. Patients and families assisted at home by the
HMHCPC during a 15 month period, were interviewed
in deep and through semistructured questionnaires.
Results Data from 42 patients and 50 relatives was
audited and the outcomes analyzed under quantitative
and qualitative means. Advantages and barriers of the
audit method applied were identified, in terms of
patient involvement, interpretation of satisfaction
issues, participation/commitment of staff and resources
Discussion In spite of the highly positive reports of
patients and families, we wonder if the audit tools used
were appropriate for this low resource population. We
conclude that an effective clinical audit requires not
only detailed planning beforehand, but also continuous
review of the process and careful selection of the
instruments to use for collecting data.
Poster abstracts
Design: Terminal patients were included in hospitals,
primary care centres and HC teams. Follow-up study.
Main caregiver interview after 1-3 month of patient
death.
Setting: Majorca Island. Subjects: terminal cancer
patients that spend almost 15 days at home in the last
month of life, and caregivers.
Measurements: Caregivers satisfaction on health care
with SERQUAD questionnaire, validated for HC based
on likert responses (degree agreement 1 to 5).
RESULTS:107 patients, 88,8% caregivers women, aged
52.5 years (SD 10.6). 93 patients received some
palliative HC and 14 never received it. Of those who
NEVER received it 71.4% were totally satisfied with
health services vs 82.6% of those who did received.
71.4% of caregivers of those not treated at home
declared that patients were better attended at home than
hospital vs 86.7% of those with palliative HC. 43% of
patients with HC died at home vs 14.3% in those
without HC. Caregivers of those with some HC,
considered that the most important aspects were health
professionals humanity and trust, and at lesser extent
the capacity to offer safe health care, accessibility
and techniques.
CONCLUSIONS: Those caregivers of patients who
received some palliative HC were more satisfied with
health care received and think patient has been better
attended than in hospital. They value mainly humanity
and trust of health professionals.
454. Hospice-friendly-Hospitals: A national
approach to mainstreaming hospice principles in
hospital practice
Mervyn Taylor 1, Orla Keegan 2, Max Watson 3, David
Clark 4, Ginny Dunn 1
1
456. Cost analysis of patients admitted to an
inpatient Palliative Care Unit according to their
clinical complexity
Edna Goncalves 1, Lília Costa 2, Catarina Simees 3,
Cristina Pereira 4, Miguel Tavares 5, Margarida Alvarenga
6
, Cátia Ferreira 7
1– 6 Portuguese Oncology Institute, Paliative care Service,
Porto, Portugal
Aim: To derive a mean cost per day per inpatient
admitted to the Palliative Care Unit (PCU) of Portuguese
Institute of Cancer on Porto classified according to five
clinically meaningful “palliative care phases”.Methods:
Prospective study based on the detailed registration of
the clinical and service utilization profile for each
patient admitted to the PCU between 1 August 2006 and
31 January 2007. A purpose-designed software was
created to measure direct patient care costs on a daily
basis (staff time, drug treatment, diet and other
resources consumption were registered) and patients
were classified according to five “clinical phases of care”
adapted from the Palliative Care Phases of the Australian
Association for Hospice and Palliative Care (“acute”,
“stable”, “deteriorating”, “agonizing” and “social”)
Results: In a preliminary analysis of the first 2 months
of the study the mean daily cost per patient admitted to
the PCU was 352,41 ¤ (30% less than the mean daily
cost per patient admitted to the IPO-Porto), ranging
from 462, 91 ¤ for “deteriorating” patients to 204,80 ¤
for patients admitted predominantly for social reasons.
Almost 27% of total costs were associated with
therapeutics, 25% with staff, 25% with indirect costs
and 23% with other costs. Final and more detailed
results will be presented at the Congress
Irish Hospice Foundation, Dublin, Ireland
Irish Hospice Foundation, Dublin, Ireland
Northern Ireland Hospice, Belfast, United Kingdom
4University of Lancaster, Lancaser, United Kingdom
457. The environmental factors that impact on
quality of life in advanced cancer in-patients
BackgroundThe care of dying and bereaved people in
hospitals remains a challenge. Individual interventions
may improve care for subgroups of patients, or for
particular dimensions of experience. A “systems”
approach is also needed which acknowledges the
complex multi-dimensional nature of care and can be
generalized across hospitals. In Ireland a national
programme focuses on improving experience of
hospital care at the end of life, building on local and
international knowledge, a pilot study in one Irish
hospital and a series of strategy workshops. AimsTo
develop interventions and demonstrate improvement in
four areas of end of life care in hospitals: 1) Integrated
Care 2) Design and Dignity 3) Communications 4)
Personal Autonomy. ActionsA 3 year plan has been
devised and is in progress. 18 (50%) of Irish acute
hospitals are participating. Systematic literature reviews
on the 4 themes of the programme are underway. An
evaluation strategy is being developed. Three national
contextual studies have been commissioned covering:
ethical framework for “a good death”; national review of
quality of care for dying patients in hospitals and
nursing homes; review of the economic imperatives
impacting on end of life care. ProgressSubstantial
funding (Euros 4.7m) has been secured and the
programme has begun. The National Steering
Committee has met. International partnerships are
encouraged.
1 Velindre Hospital, Department for Palliative Medicine,
Cardiff, United Kingdom
2
Cardiff University, Department of Palliative Medicine,
Newport, Gwent, United Kingdom
2
3
Poster abstracts
455. Nurses work load with inpatients in a
Palliative Care Unit (PCU) for cancer patients.
Cristina Pereira 1, Lília Costa 2, Catarina Simees 3, Miguel
Tavares 4, Edna Goncalves 5, Cátia Ferreira 6, Margarida
Alvarenga 7
Julie Rowlands 1, Simon Noble 2
It has been suggested that the hospital environment
impacts on patient outcomes and quality of life. Single
rooms are standard in many hospitals and the design
of future facilities. However, the literature favours single
over multi-bedded rooms based on advantages with
respect to noise levels, infection control confidentiality
with very few studies addressing patient preference or
quality of life. We explored the views of palliative care
patients within a regional oncology centre.
Methods
Audio taped semi-structured interviews of palliative care
inpatients were conducted. Recurring themes were
identified and interviews conducted until theoretical
saturation reached.
Results
Major themes suggested that patients favoured wards
with a mix of single and multi-bedded rooms. Single
rooms were favoured when patients felt unwell and
needed quiet and privacy. Most patients found multibedded rooms offered additional support from patients,
eased boredom and improved emotions. People placed
in single rooms for due to infection control experienced
boredom, loneliness and distress. They also worried that
they would be forgotten and receive less attention.
Conclusions
Whilst single rooms offer several practical advantages in
healthcare management, they may have a detrimental
psychological effect on some palliative care inpatients.
When “well” patients prefer multi-bedded wards and
the interactions they offer. Unwell patients prefer the
privacy and quiet of single rooms. Implications for
future ward design are discussed.
1– 7Portuguese Oncology Institute, Paliative care Service,
Porto, Portugal
Aim: To determine nurses work load with inpatients in
a PCU of the Portuguese Cancer Institute of
Porto Method: A prospective quantitative study, was
conduted to analyze the nurses daily work with
patients/family admitted in the PCU (capacity of 20
beds) between May and December of 2006. The study
was performed in 4 phases: First- Identifying the main
activities performed by the nurses; Second – Creating
an information technological instrument to register and
record these activities; Third-Computer registration of
activities performed by nurses in their duties to the
inpatients/family; Fourth – Evaluation of the
results. Results: In a preliminary analysis, we concluded
that the physical cares took on average 20,6 min, the
bureaucratic activities 24,8 min, and psychologicalspiritual support 19,6 min.. Still in the period of
gathering data, the definite and more detailed results
will be presented at the congress.
142
458. How Family Physicians see their own roles
and that of palliative care specialists caring for
their patients, after referral to a metropolitan
home palliative care service
Erica Moran, Russell Goldman, Deborah Adams, Amna
Husain
The Temmy Latner Centre for Palliative Care, Toronto,
Canada
The 2001 National Family Physician (FP) Workforce
Survey showed that 62% of Canadian FPs provide after
hours care. Those providing palliative care were twice as
likely to provide after hours care. Purpose: To investigate
how Family Physicians (FPs) see their own roles and that
of palliative care specialists caring for their patients, after
referral to our metropolitan home palliative care service.
Method: From August 2005 to May 2006, we sent 1007
questionnaires to referring FPs, to ask whether they
wanted our palliative specialists to: 1) only act as
consultants, 2) share the care with FPs, or 3) act as
primary professional. We also asked the referring FPs
about after-hours service they could provide. Result:
Sixty-seven per cent of 489 unique respondents wanted
our specialists to act as primary attending (most
responsible) physicians. Of another 27% who wanted
the specialist to only consult or to share in care, 36%
could do urgent house calls, and 82% could do
scheduled house calls. Respondents’ answers were
unclear as to whether an effective after-hours coverage
system was in place. Conclusion: Most FPs who refer
patients to our home palliative care service see our role
as that of attending physician. Other FPs who are willing
to provide home palliative care to their patients may be
hindered by the need to have an after-hours coverage
system, or may defer to specialist service when it is
available.
459. Improving supportive and palliative care for
adults with cancer: A pilot study of general
practices in the UK
Bill Noble, Philippa Hughes, Nisar Ahmed
University of Sheffield, Academic Unit of Supportive Care,
Aims
The aim of this study was to measure validity,
acceptability, and response rate of a questionnaire
designed to assess progress in general practices towards
implementation of the UK National Institute for Clinical
Excellence guidance on supportive and palliative care of
adults with cancer.
Method
A postal survey using a self-complete questionnaire was
undertaken in 39 general practices of Rotherham,
England. Introductory letters were sent to General
Practitioners (GPs) before the study, followed by an
initial mailing and three carefully timed reminders (2
weekly intervals). Practice managers were then sent an
abridged version of the questionnaire using a similar
protocol. Independent sources of information were used
to access the accuracy of data. Respondents were asked
to comment on the questionnaire.
Results
The pilot study response rate from practices overall
(where either the GP or the Practice Manager, or both
replied) was 69.2%. Response rates from individual
groups were lower: 48.7% for GPs, and 43.6% for
Practice Managers. Little ambiguity, inaccuracy or
difficulty in answering questions was detected.
Conclusions
Respondents provided useful data and informed the
design of a national survey of UK general practice. A
combined approach and reminder letters yielded higher
response rates. General Practitioners and practice
managers were positive about the questionnaire design.
460. Can the clinical nurse specialist make a
difference for outpatients receiving palliative
care?
Ellen De Nijs 1, Saskia Teunissen 2, Ginette Hesselmann 3
1 University Medical Center Utrecht, Department of Medical
Oncology, utrecht, Netherlands
2University Medical Center Utrecht, Department of Medical
3University Medical Center Utrecht, Department of Medical
Introduction
To reach optimal palliative care structural involvement
of a clinical nurse specialist (CNS) in the outpatient
clinic is considered as a prerequisite. First, a literature
review was done concerning the needs of outpatients
receiving palliative care, the types of interventions
applied by the CNS and the effect of these interventions.
Secondly, a qualitative exploration of outpatients of the
department of medical oncology, who have been seen
by the CNS, concerning their needs and the nursing
interventions was done.
Results
The literature revealed that outpatients have needs
concerning symptom monitoring, dealing with
symptoms, the effects of treatment in every day live,
support in communication and emotional support. The
type of interventions used by the CNS is not always well
described. Interventions mentioned include emotional
support and support in communication. No effectstudies were found. The qualitative exploration of 12
patients seen by the CNS confirmed the needs and
interventions as found in the literature.
Conclusion
Research concerning the effect of the interventions by
the CNS on symptom burden, patient control and
quality of life of palliative care outpatients is needed.
.Interventions on symptom management, emotional
support, support in communication and support in
dealing with symptoms and the effects of treatment in
daily life must be included. A prospective study will be
performed.
Poster abstracts
Bea Van der vegt 1, 2, Carolina Van den Akker 1, Manda
Broekhuis 2, Renée Otter 1
1 Comprehensive cancer centre North-Netherlands, Palliative
Care, Groningen, Netherlands
2University of Groningen, Faculty of Management,
Groningen, Netherlands
Background and aim: Within the northern part of
the Netherlands several local palliative care teams exist.
These multidisciplinary teams are made up of
physicians and nurses from the local hospital, nursing
home, home care organisation and general
practitioners. They are supportive teams, which do not
take over the care itself. The aim of this project was to
evaluate the functioning of the teams, and investigate
how they contribute to optimal palliative care for the
patient, and support for care givers. Method: 8 teams
participated in this evaluative study. In 2 questionnaires
participants gave their view on several aspects of team
functioning. Results: The most prominent finding was
the great variety between teams in working method,
team composition, connection to organisations etc.
Whereas most teams aim to be palliative consultation
team in their region, the majority receives only very few
questions. Two teams do receive questions; however,
these teams have a more limited target group.
Conclusion: In the Netherlands we are looking for the
best way to support regular professionals in giving
palliative care. None of the teams in this study manages
to support the full range of care givers involved in
palliative care in their region. We propose a new
concept for palliative support teams, made up of official
representatives out of the organisations involved, with a
role in enhancing palliative knowledge among
professionals and promote optimal organisation of
palliative care.
462. Perceptions and practice of palliative care
amongst junior doctors and nurses
Jason Boland, Elaine Rogers, Sam Ahmedzai
Aim
Many referrals to Palliative Care Services are requested
too late or inappropriately, when earlier palliative care
input could have made a significant difference. We
decided to investigate and further understand factors
that influence the nature of referrals amongst junior
doctors and nurses.
Method
A semi-structured 16 item quantitative questionnaire
was developed, utilising Likert scales. The questionnaire
explored junior staffs’ awareness of the Palliative Care
Service, and their own individual and team practice of
making referrals.
Results
104 junior doctors and nurses were approached and 99
returned questionnaires.Only 53% respondents thought
that the PCS were contactable 24 hours a day.81% of
doctors, but only 39% of nurses had referred a patient.
To the question ‘What proportion of patients do you feel
would benefit from referral to palliative care’ most
respondents stated between 10-25%
Discussion
Our Palliative Care Service provides an open 24 hour
service to cancer and non-cancer patient with
symptoms. From this study it has been identified that
the PCS is not perceived as providing continuous 24
hour care. Doctors are currently more likely to refer
patients than nurses. Only a small proportion of
patients are perceived as potentially benefiting from
palliative care and even lowers figures are actually
referred.
always taken.Common suggestions/complaints ranged
from: different time slots for daily visits/out of hour
visits (5,7%); Waiting period for admission (2,8%);
further family support (2,9%); treatment variation
among staff physicians (1,3%). Results varied reflecting
difficult periods in staff recruitment. Family members
mostly underlined satisfaction for: being present at the
patient’s death at home (choice of place of death :
94,4%); greater consideration by staff for patient’s
comfort/family wishes; high levels of personal
communication. Conclusions. The postal
questionnaire is a useful audit tool; sources of
“dissatisfaction” and the possibility to anonymously
express opinions and concerns assists in planning and
implementing change. As a result of this lengthy study a
more comprehensive audit tool is being compiled.
464. Satisfaction with Home and Hospital
Palliative Care
Georgiana Gama, Filipe Barbosa, António Barbosa
Faculty of Medicine of Lisbon, Palliative Care/Bioethics
Centre, Lisbon, Portugal
We aim to compare the satisfaction with care in cancer
patients in two settings: home palliative care and
palliative care unit.
A sample of sequential cancer patients from two hospital
palliative care units (n=64) and from home palliative
care of a community health centre (n=26) were assessed
by the Portuguese versions of EORTC QLQ-C30 and
EORTC QLQ-IN-PATSAT32 (a comprehensive,
multidimensional assessment of satisfaction with care,
rated on a 5 level Likert scale, with scales regarding
doctors, nurses behaviour and services regarding
technical, communication and interpersonal skills,
availability and coordination, waiting time, access,
comfort, kindness and helpfulness of health care
professionals) validated for Portuguese population by
the authors. There were no significant differences in
satisfaction with care in what concerns the doctor’s
/nurse’s items except a significantly higher availability
of doctors in Hospital Palliative Care. In terms of
organizational aspects, Hospital Palliative Care group
showed a significantly higher satisfaction in all the
items (comfort, information, and availability) compared
with community home care. We discuss our results in
terms of the differential socio-demographic and clinical
characteristics of these two populations and we strongly
recommend the use of this scale of satisfaction with care
according to the good properties it showed on detecting
discrepancies on quality of palliative care and helping to
design and evaluate strategies to overcome some of the
difficulties in providing palliative care.
465. A new Palliative Care Counselling Service
(PCCS) in the university hospital of Aachen Germany
Norbert Krumm, Eckhardt Tielke, Birgit Klaßßen, Frank
Elsner, Lukas Radbruch
University Hospital of Aachen, Department of Palliative
Medicine, Aachen, Germany
Introduction: In April 2006 the consultation team of
the palliative care unit was augmented with a fulltime
specialist nurse to facilitate continuous counselling.
Methods: First evaluation of the PCCS was performed
after 6 month using a descriptive and evaluative
analysis. In addition acceptance of the counselling
service in other departments was assessed. Results: In
the first 6 months of the PCCS 78 patients were treated
(68 cancer, 10 non-cancer). The time of survival after
admission to the PCCS was less than 14 days for 23
patients and more than 14 days for 27 patients (no data
available: 25 pat.). Requests for consultation were for
symptom control (32 pat.), psychosocial counselling (5
pat.) and requests for referral to the palliative care unit
(32 pat.).
466. Why we do need palliative care
Madalena Feio 1, Manuel Marques 2
1 Instituto Portugues de Oncologia Francisco Gentil de
Lisboa, UAAD, Lisboa, Portugal
2Instituto Portugues de Oncologia Francisco Gentil de
Lisboa, Lisboa, Portugal
Aims- To assess what happened in the last month of life
to patients dying from an oncologic progressive disease
in évora, Portugal. Methods- Death certificates, from
3/2003 to 2/2004 were retrieved and identified those
who died of cancer.Those whose diagnosis was done
prior to one month and the cause of death was
progressive disease were selected. Retrospectively we
studied admittances to the “Hospital do Espírito Santo –
évora” (HES-évora), visits to the Emergency Department
(ED), External Consultations (EC), symptoms,
treatment, place of death.Results – From 235, 118
patients, 50%, obeyed the selection criteria: males, 82,
70%, and females 36, 30%, aged 69±11 years. The most
frequent primaries were the digestive system, 31%, and
lung, 20%.In the last month of life, 100 patients, 85%,
were admitted to the HES-évora; 74, 62%, attended the
ED, and 48, 40%, attended at least one consultation. The
most common symptoms were: drowsiness, 74%, pain,
69% and dyspnea, 62%. Fifty-seven patients had an
opioid prescribed, 60% of those with pain and 47% of
those with dyspnea.The place of death was the HESévora wards for 97 patients, 82%, the ED in 11 patients,
9%, nursing home in 2 patients, 1 patient at home and 1
patient in a private hospital.Conclusions- 91% of the
patients died in the Hospital. The number of
admittances and attendances in the ED was high..
Palliative care teams are needed in évora.
467. PIA - Palliative Care Inventory of the region
of Aachen
Frank Elsner, Norbert Krumm, Martina Pestinger, Verena
Jaust, Robin Joppich, Lukas Radbruch
Introduction: A Palliative Care Inventory of the region
of Aachen has been finalised to offer a quick and
comprehensive overview of care options for palliative
patients and their relatives. Methods: Data about inand outpatient palliative care (PC) options were
collected by questionnaires. Key-persons in the field
were interviewed about the quality of PC. Furthermore
focus-groups of relatives of deceased patients were
formed. Evaluation of the questionnaires and content
analysis of the comments in interviews and focusgroups were performed differentiating between levels of
PC specialisation. Results: In the greater area of Aachen
one hospice and two PC units were found on a
specialised level with an average of 56 beds per one
million inhabitants, as well as 7 volunteers and one
homecare service. On a basic level 76% of 25 nursing
services and 63% of 16 nursing homes offered specific
terminal care options, however, none of them had
specialised nursing staff. Key-persons pointed out that
PC developed well, however, with shortcomings in close
coordination of collaboration. Relatives underlined the
need of training in communication with their dying
family members.
Conclusion: The underlying inventory is a first step to
improve the quality of PC in the region of Aachen.
Networking can be initialised and promoted.
Continuous and regular work on the inventory will be
necessary to reach and keep a high standard of PC in
Aachen.
468. NURSING COORDINATION OF A HOSPITAL
SUPPORT TEAM OF PALLIATIVE CARE BASED ON
COMPLEXITY LEVELS OF PATIENTS.
NURIA CODRONIU, ALBERT TUCA
463. Retrospective evaluation of carer
satisfaction: 10 years experience
Francesca Bordin, Francesca Trasatti, Ofelia Bernarte,
Pasquale Benvenuto, Annette Welshman
Fondazione Sue Ryder Onlus, Palliative Care, ROMA, Italy
Carer satisfaction represents an important outcome
variable in improving quality of care. Our hospice at
home service sends an anonymous questionnaire
inclusive of self addressed stamped envelope to the carer
approximately 30 days following death.1351
questionnaires were sent from 1997- 4/2006, measuring
specific domains: staff organization/coordination,
communication, physical and psychological symptom
control, place of death, overall satisfaction. Choices were
“satisfactory/partially satisfactory/unsatisfactory”.
Response rate was 61%; caregivers were satisfied with
care provided to 97%, partial satisfaction-dissatisfaction
being reported respectively for 1,6 and 0,36%.
The opportunity to write feelings/advice was nearly
Agree
Satisfied
with PCCS
Multidisciplinary
PCCS is
important
PCCS felt to
be supportive
PCCS felt to
be a barrier
Care of dying is
better in PCU
Rather Do not Rather Disagree
agree know disagree
30
5
0
0
0
32
3
0
0
0
24
6
2
3
0
2
1
1
6
25
22
6
3
4
0
Conclusions: Nursing service in the counselling team
was met with high acceptance in other departments.
Regular follow-up contacts with a specialist nurse builds
up confidence for patients. The extension towards a
multi professional team was a valuable endorsement for
the palliative care unit’s position in the environment of
the university hospital.
Institut Catala d’Oncologia, Palliaitve Care, Barcelona,
Spain
Hospital support team activity is based in 2
premises:intervention based more on complexity than
immediate prognosis;responsibility shared with referent
team. PC nurse assesses the patient needs and agrees
level complexity and shared responsibility.We defined 3
levels: Low complexity, basic/advance advice (Nurse
Manag);Medium complexity, diagnosis-treatment
adjust, make decision (PC Co-responsibility);High
complexity (PC complete responsibility).Objective:
Describe nurse coordination based on level agreement.
Method: Observational, descriptive study. Comparative
analysis of data stratified according intervention
levels.Results:526 successive advanced cancer patients
(Jan-Nov 2006), 65% men and 35% women, mean age
65. According complexity-intervention level, 21%
patients were low, 49% medium and 30% high
complexity. Analysis of data stratified per level didn’t
show significant differences between groups in sex, VAS
143
Poster abstracts
461. Evaluation of local palliative care teams looking for a feasible concept to support care
givers
Poster abstracts
of pain, insomnia, asthenia, anorexia and depressive
trends. In medium complexity group we observed a
decrease of performance status and higher probability of
difficult pain (p< 0.01). In high complexity group we
found younger patients with higher probability of
comorbilty, impairment of performance status, difficult
pain, anxiety, cognitive failure, psychosocial risk,
complex nursing cures, and mortality <3 moths
(p<0.01).Conclusion: Differences between groups
demonstrate that is possible to define profiles of patient
complexity using a structured-multidimensional record.
An accurate nurse evaluation improves team
organisation
469. End-of-life care in a Swedish county during
last three months of life
Eva Jakobsson 1, 2
1 School of Life Scences, University of Skövde, Skövde,
Sweden
2Institute of Health and Care Sciences, Sahlgrenska
Academy at Göteborg University, Gothenburg, Sweden
This study aims to contribute to a broad understanding
of of the nature of end-of-life and end-of-life care for
individuals who access the health care system at this
period of life. The study was undertaken through
retrospective examinations of health care records in a
randomly selected sample of adults who died in a
Swedish county during 2001(n=229).
The mean age at time of death was 80 years. Onehalf, the less old, resided in private homes and one-half,
the oldest old, in residential care facilities. Use of
hospital care was higher in the former group than in the
latter group. Dementia, was associated with lesser use of
hospital care regardless of residence. Use of GP service
was higher among residents in residential care facilities
than among residents of private homes. Advancing age,
ADL-dependency and living alone increased the use of
care at residential care facilities. Specific diseases
increasaed the use of care care in private homes. The
most common places of death was hospitals. A range of
highly prevalent problems was identified. A turning
point reflecting onset of the dying process and
reorientation of care was found in three-quarters of the
records, of which two-thirds were documented within
the last week of life.
The content of end-of-life care should be based on
systematic insights into the identities of individuals
who access the health care system at the end of life,
where they receive care and the nature of their problems
and needs.
470. Community based palliative care services
(CB-PC) in developing countries (DeCo): A
systematic literature review
Shamsudeen Moideen 1, Suresh Kumar 1, Shabeer
Chenganakkattil 1, Florian Strasser 2
Poster abstracts
1 Institute of Palliative Medicine, WHO Demonstration
Project, Kerala, India
2Cantonal Hospital St.Gallen, Oncology & Palliative
Medicine, St.Gallen, Switzerland
Background: CB-PC may respond to local needs and
priorities and use untapped societal resources.
Information on variables of success and transferability is
scarce. We aim to explore characteristics of CB-PC in
DeCo.
Methods: A systematic literature search (Pubmed,
Cinahl), amended by handsearch and snowballing,
included as search strategy 1) PC [MeSH], 2) DeCo
[MeSH] and 3) community participation (consumer
participation, ‘society taking part in decision making
process’, voluntary workers [free text]). Inclusion criteria
were: 1. PC Services in DeCo, 2. CB-PC, 3. involvement
of CB groups in organizing and running PC units.
Results: 38 papers (28 from 240 citations) were found,
other databases (incl. grey literature) and experts are
pending.
Characteristics of 32 CB-PC in Africa (8), south America
(8), Asia (16):
- functioning: most CB-PC models are based at the
charity organization level;
- financing: In Africa six hospices are financed by
contributions, in south America one by government,
most others by fee for funding, in Asia 4 by government,
several by a microfunding system;
- difficulties: professional burn-out and opioid related
issues;
- sustainability: few centers independently exist with
local resources, frugal cost regimes could not be
maintained;
Conclusion: CB-models are reported as appropriate for
DeCo, lack of funding and low governmental priority
reduced PC coverage. Desire and attempts to develop an
indigenous sustainable model has persuaded groups to
try new experiments in delivery of care.
144
471. Where do People die at Portugal? Why?
“Algarve”s survey.
Primary Care, Cambridge, United Kingdom
5
University of Warwick, Centre for Primary Health Care
Studies/Warwick Medical School, Warwick, United Kingdom
Ivone Nabais, Graça Pedro, Ana Marques
1
Lisboa, Portugal
We are a multidisciplinary team, working in private
practice in Palliative Care (CP) at Portugal. For our team,
one of the biggest targets is the implementation of
Palliative Home Care in our geographic area, assuming
that it would be most people choice.
In the recent National Program for Palliative Care,
various levels and models of care are illustrated. Thus,
and giving the absence of data in Portugal about this
issue, we propose to investigate where people usually die
in this region of Portugal, what they prefer and what
they think are the necessary conditions to die at home.
Method: Phone questionnaires are applied to family
members - the formal career - of people who died in the
past 6 months with a diagnose of a chronic disease
(cancer/non cancer). We chose a regional sample of 100
persons (no restrictions about age, sex, race, etc).
Conclusion: We intent to have the profile of patients
and careers (social-demographic data). Different
nationalities are expected. Evaluation and analysis of the
results depending on littoral and interior home location
would be interesting.We expect to find that: 1) most
people died at hospitals (first position) and in nursing
homes (second position); 2) most people would prefer
to die at home, if they have the necessary condition; 3)
differences between Portuguese and foreigners living in
Algarve; and 4) the most important conditions to die at
home are: 1) the existence of medical home care, 2) 24h
assistance, and 3) availability of non Professional
careers.
472. Identifying the ‘key worker’ for patients
having palliative treatment - patient and
professional views in relation to patients with
bone metastases : A survey and prospective audit
Jamal 1,
Young 2,
Donaldson 3,
Humaira
Teresa
Alison
Elizabeth Lank 4, Clare Gwilliam 2, Lorraine Sloan 5,
Edward Chow 6, Jane Maher 2, 3
1
Mount Vernon Cancer Centre, Michel Sobel House,
Northwood, United Kingdom
2Mount Vernon Cancer Centre, Lynda Jackson Macmillan
Centre, Northwood, United Kingdom
3University of Hertfordshire, Complexity and Management
Centre, Business School, Hatfield, United Kingdom
4Think.plus.com, London, United Kingdom
5Macmillan Cancer Support, London, United Kingdom
6Sunnybrook Regional Cancer Centre, Toronto, Canada
Multiple professionals care for advanced cancer patients.
Both nurses and GPs think they are the “key worker”
whose role is to help patients with issues they
prioritised.
Method
300+ patients with bone mets prioritised their top issues.
40 professionals (10 disciplines) attended workshops
and rated the importance of their role in addressing
these issues. Service gaps were identified at interactive
workshops with patients and professionals. An audit of
100 patients having palliative RT was conducted.
Results
Patient’s priority issues included difficulties in
conducting meaningful activity, worry about becoming
dependent and financial burden. GPs and nurses scored
their role as “very important” for the largest number of
issues. Within-professional group variation was noted.
Service gaps identified included Out of Hours care
(OOH), information about finances, confusion as to
“who is in charge”, discussion about prognosis and poor
experience of crisis admission. Preliminary audit results
show that none recognise the term key worker, GPs were
“ first port of call” if symptoms deteriorated, <50% of
patients knew who to call OOH, <10 % had received
financial benefits information and only 50% of GPs had
registered patients as palliative and put them on a
supportive register.
Conclusion
The “palliative” phase of illness is confusing.
Professionals do not share an understanding as to what
is important for patients
473. What is End of Life Care? Definitions from a
national consultation and implications for
practice
Background:
The English Department of Health has defined ‘end of
life care’ as care for adults with any advanced,
progressive or incurable illness, in any care setting and
in the last year/s of life. A national consultation exercise
was commissioned to explore definitions and to identify
research priorities for generalist services.
Aim: To identify and explore meanings that health,
social care professionals and users attach to ‘end of life
care’
Methods:
Interviews and questionnaires to gain the views of policy
makers, commissioners, health professionals, user
groups and specialist palliative care; the ‘nominal group
technique’ to identify priorities; a thematic analysis to
identify key themes.
Results: Over 200 people are being consulted in the UK.
Initial results suggest a range of definitions of ‘end of life
care’ including the last days of life, the last 6 months,
the last year, or following a poor prognosis. Definitions
can relate to perceptions of palliative or terminal care
and to specific patient groups. For some respondents,
‘end of life care’ is a more socially acceptable phrase
than ‘terminal care’.
Conclusion
Professionals and user groups vary considerably in what
they understand by ‘end of life care.’ This holds
implications for advanced care planning, including
onward referral of patients to specialist support. The lack
of shared understanding might perpetuate inequitable
access. Definitions must be based in working practice if
they are to be widely adopted.
474. Complicated grief. A support group
intervention for family members
Yvonne Hajradinovic 1, Eva Erichsén 2, Lars Sundberg 3,
Monika Axmacher-Jonsson 4, Maria Jakobsson 5, Anna
Milberg 6, Maria Friedrichsen 7
1 Vrinnevisjukhuset, Clinic for Palliative Care Palliative
Consulting team, Norrköping, Sweden
2Vrinnevisjukhuset, Clinic for Palliative Care Palliative
3Vrinnevisjukhuset, Clinic for Palliative Care, Norrköping,
Sweden
Sweden
Sweden
6Department of Social and Welfare Studies, Pallaitive
Education and Research Center, Norrköping, Sweden
Abstract Complicated griefA support group
intervention for family members Yvonne Hajradinovic,
Eva Erichsen, Lars Sundberg, Monica AxmacherJonsson, Maria Jakobsson, Anna Milberg, Maria
Friedrichsen
Complicated grief is a debilitating disorder associated
with important negative health consequences. Aim: To
illuminate bereaved family members’ lived experience
of participation in a support group intervention for
complicated grief. Method: Participants were selected
according to specific inclusion criteria. Eleven interviews
were performed and analysed with Giorgi’s
phenomenological method. Findings: Five themes
emerged: Group cohesion: Family members experienced
the importance of sharing their experience with people
in a similar situation who understood them.
Confirmation: Family members felt confirmed when
being in focus one by one in the group. The feeling of
being respected, the frankness, and the allowing attitude
in the group influenced the participants? courage to tell
and to express feelings. Emotional and physical distress:
Relatives felt distressed in varying extension before,
during and after group meetings, for example
palpitations of the heart, anxiety and ache.
Comprehension: The process of work in the group
involved an increased understanding of one self and a
personal growth when learning from each other. Release
and strength: Finally, most family members felt released
and empowered after discontinuing the group. Some
did not want to separate. The essence of the phenomena
was described as a journey, travelling together over a
stormy ocean to a calm haven guided by safe hands.
Conclusion: The participants? felt satisfied with the
group intervention that gave them an understanding,
meaning and strategies to cope with their grief.
Cathy Shipman 1, Irene Higginson 1, Marjolein Gysels 1,
Patrick White 2, Allison Worth 3, Scott Murray 3, Stephen
Barclay 4, Sarah Forrest 4, Jonathan Shepherd 5, Jeremy
Dale 5
1 King’s College London, Department of Palliative
Care&Policy, London, United Kingdom
2King’s College London, Department of Palliative
3
University of Edinburgh, School of Clinical Sciences and
Community Health, Edinburgh, United Kingdom
4
University of Cambridge, Department of Public Health and
Poster abstracts
Poster abstracts
riday
June
CONNECTING
DIVERSITY
Poster abstracts
of pain, insomnia, asthenia, anorexia and depressive
trends. In medium complexity group we observed a
decrease of performance status and higher probability of
difficult pain (p< 0.01). In high complexity group we
found younger patients with higher probability of
comorbilty, impairment of performance status, difficult
pain, anxiety, cognitive failure, psychosocial risk,
complex nursing cures, and mortality <3 moths
(p<0.01).Conclusion: Differences between groups
demonstrate that is possible to define profiles of patient
complexity using a structured-multidimensional record.
An accurate nurse evaluation improves team
organisation
469. End-of-life care in a Swedish county during
last three months of life
Eva Jakobsson 1, 2
1
School of Life Scences, University of Skövde, Skövde,
Sweden
2
Institute of Health and Care Sciences, Sahlgrenska
Academy at Göteborg University, Gothenburg, Sweden
This study aims to contribute to a broad understanding
of of the nature of end-of-life and end-of-life care for
individuals who access the health care system at this
period of life. The study was undertaken through
retrospective examinations of health care records in a
randomly selected sample of adults who died in a
Swedish county during 2001(n=229).
The mean age at time of death was 80 years. Onehalf, the less old, resided in private homes and one-half,
the oldest old, in residential care facilities. Use of
hospital care was higher in the former group than in the
latter group. Dementia, was associated with lesser use of
hospital care regardless of residence. Use of GP service
was higher among residents in residential care facilities
than among residents of private homes. Advancing age,
ADL-dependency and living alone increased the use of
care at residential care facilities. Specific diseases
increasaed the use of care care in private homes. The
most common places of death was hospitals. A range of
highly prevalent problems was identified. A turning
point reflecting onset of the dying process and
reorientation of care was found in three-quarters of the
records, of which two-thirds were documented within
the last week of life.
The content of end-of-life care should be based on
systematic insights into the identities of individuals
who access the health care system at the end of life,
where they receive care and the nature of their problems
and needs.
470. Community based palliative care services
(CB-PC) in developing countries (DeCo): A
systematic literature review
Shamsudeen Moideen 1, Suresh Kumar 1, Shabeer
Chenganakkattil 1, Florian Strasser 2
Poster abstracts
1
Institute of Palliative Medicine, WHO Demonstration
Project, Kerala, India
2
Cantonal Hospital St.Gallen, Oncology & Palliative
Background: CB-PC may respond to local needs and
priorities and use untapped societal resources.
Information on variables of success and transferability is
scarce. We aim to explore characteristics of CB-PC in
DeCo.
Methods: A systematic literature search (Pubmed,
Cinahl), amended by handsearch and snowballing,
included as search strategy 1) PC [MeSH], 2) DeCo
[MeSH] and 3) community participation (consumer
participation, ‘society taking part in decision making
process’, voluntary workers [free text]). Inclusion criteria
were: 1. PC Services in DeCo, 2. CB-PC, 3. involvement
of CB groups in organizing and running PC units.
Results: 38 papers (28 from 240 citations) were found,
other databases (incl. grey literature) and experts are
pending.
Characteristics of 32 CB-PC in Africa (8), south America
(8), Asia (16):
- functioning: most CB-PC models are based at the
charity organization level;
- financing: In Africa six hospices are financed by
contributions, in south America one by government,
most others by fee for funding, in Asia 4 by government,
several by a microfunding system;
- difficulties: professional burn-out and opioid related
issues;
- sustainability: few centers independently exist with
local resources, frugal cost regimes could not be
maintained;
Conclusion: CB-models are reported as appropriate for
DeCo, lack of funding and low governmental priority
reduced PC coverage. Desire and attempts to develop an
indigenous sustainable model has persuaded groups to
try new experiments in delivery of care.
144
471. Where do People die at Portugal? Why?
“Algarve”s survey.
Primary Care, Cambridge, United Kingdom
5
University of Warwick, Centre for Primary Health Care
Studies/Warwick Medical School, Warwick, United Kingdom
Ivone Nabais, Graça Pedro, Ana Marques
1
Lisboa, Portugal
We are a multidisciplinary team, working in private
practice in Palliative Care (CP) at Portugal. For our team,
one of the biggest targets is the implementation of
Palliative Home Care in our geographic area, assuming
that it would be most people choice.
In the recent National Program for Palliative Care,
various levels and models of care are illustrated. Thus,
and giving the absence of data in Portugal about this
issue, we propose to investigate where people usually die
in this region of Portugal, what they prefer and what
they think are the necessary conditions to die at home.
Method: Phone questionnaires are applied to family
members - the formal career - of people who died in the
past 6 months with a diagnose of a chronic disease
(cancer/non cancer). We chose a regional sample of 100
persons (no restrictions about age, sex, race, etc).
Conclusion: We intent to have the profile of patients
and careers (social-demographic data). Different
nationalities are expected. Evaluation and analysis of the
results depending on littoral and interior home location
would be interesting.We expect to find that: 1) most
people died at hospitals (first position) and in nursing
homes (second position); 2) most people would prefer
to die at home, if they have the necessary condition; 3)
differences between Portuguese and foreigners living in
Algarve; and 4) the most important conditions to die at
home are: 1) the existence of medical home care, 2) 24h
assistance, and 3) availability of non Professional
careers.
472. Identifying the ‘key worker’ for patients
having palliative treatment - patient and
professional views in relation to patients with
bone metastases : A survey and prospective audit
Jamal 1,
Young 2,
Donaldson 3,
Humaira
Teresa
Alison
Elizabeth Lank 4, Clare Gwilliam 2, Lorraine Sloan 5,
Edward Chow 6, Jane Maher 2, 3
1
Mount Vernon Cancer Centre, Michel Sobel House,
Northwood, United Kingdom
2Mount Vernon Cancer Centre, Lynda Jackson Macmillan
3University of Hertfordshire, Complexity and Management
Centre, Business School, Hatfield, United Kingdom
4Think.plus.com, London, United Kingdom
5
Macmillan Cancer Support, London, United Kingdom
6Sunnybrook Regional Cancer Centre, Toronto, Canada
Multiple professionals care for advanced cancer patients.
Both nurses and GPs think they are the “key worker”
whose role is to help patients with issues they
prioritised.
Method
300+ patients with bone mets prioritised their top issues.
40 professionals (10 disciplines) attended workshops
and rated the importance of their role in addressing
these issues. Service gaps were identified at interactive
workshops with patients and professionals. An audit of
100 patients having palliative RT was conducted.
Results
Patient’s priority issues included difficulties in
conducting meaningful activity, worry about becoming
dependent and financial burden. GPs and nurses scored
their role as “very important” for the largest number of
issues. Within-professional group variation was noted.
Service gaps identified included Out of Hours care
(OOH), information about finances, confusion as to
“who is in charge”, discussion about prognosis and poor
experience of crisis admission. Preliminary audit results
show that none recognise the term key worker, GPs were
“ first port of call” if symptoms deteriorated, <50% of
patients knew who to call OOH, <10 % had received
financial benefits information and only 50% of GPs had
registered patients as palliative and put them on a
supportive register.
Conclusion
The “palliative” phase of illness is confusing.
Professionals do not share an understanding as to what
is important for patients
473. What is End of Life Care? Definitions from a
national consultation and implications for
practice
Background:
The English Department of Health has defined ‘end of
life care’ as care for adults with any advanced,
progressive or incurable illness, in any care setting and
in the last year/s of life. A national consultation exercise
was commissioned to explore definitions and to identify
research priorities for generalist services.
Aim: To identify and explore meanings that health,
social care professionals and users attach to ‘end of life
care’
Methods:
Interviews and questionnaires to gain the views of policy
makers, commissioners, health professionals, user
groups and specialist palliative care; the ‘nominal group
technique’ to identify priorities; a thematic analysis to
identify key themes.
Results: Over 200 people are being consulted in the UK.
Initial results suggest a range of definitions of ‘end of life
care’ including the last days of life, the last 6 months,
the last year, or following a poor prognosis. Definitions
can relate to perceptions of palliative or terminal care
and to specific patient groups. For some respondents,
‘end of life care’ is a more socially acceptable phrase
than ‘terminal care’.
Conclusion
Professionals and user groups vary considerably in what
they understand by ‘end of life care.’ This holds
implications for advanced care planning, including
onward referral of patients to specialist support. The lack
of shared understanding might perpetuate inequitable
access. Definitions must be based in working practice if
they are to be widely adopted.
474. Complicated grief. A support group
intervention for family members
Yvonne Hajradinovic 1, Eva Erichsén 2, Lars Sundberg 3,
Monika Axmacher-Jonsson 4, Maria Jakobsson 5, Anna
Milberg 6, Maria Friedrichsen 7
1
Vrinnevisjukhuset, Clinic for Palliative Care Palliative
2
Vrinnevisjukhuset, Clinic for Palliative Care Palliative
Sweden
Sweden
Sweden
6Department of Social and Welfare Studies, Pallaitive
Education and Research Center, Norrköping, Sweden
Abstract Complicated griefA support group
intervention for family members Yvonne Hajradinovic,
Eva Erichsen, Lars Sundberg, Monica AxmacherJonsson, Maria Jakobsson, Anna Milberg, Maria
Friedrichsen
Complicated grief is a debilitating disorder associated
with important negative health consequences. Aim: To
illuminate bereaved family members’ lived experience
of participation in a support group intervention for
complicated grief. Method: Participants were selected
according to specific inclusion criteria. Eleven interviews
were performed and analysed with Giorgi’s
phenomenological method. Findings: Five themes
emerged: Group cohesion: Family members experienced
the importance of sharing their experience with people
in a similar situation who understood them.
Confirmation: Family members felt confirmed when
being in focus one by one in the group. The feeling of
being respected, the frankness, and the allowing attitude
in the group influenced the participants? courage to tell
and to express feelings. Emotional and physical distress:
Relatives felt distressed in varying extension before,
during and after group meetings, for example
palpitations of the heart, anxiety and ache.
Comprehension: The process of work in the group
involved an increased understanding of one self and a
personal growth when learning from each other. Release
and strength: Finally, most family members felt released
and empowered after discontinuing the group. Some
did not want to separate. The essence of the phenomena
was described as a journey, travelling together over a
stormy ocean to a calm haven guided by safe hands.
Conclusion: The participants? felt satisfied with the
group intervention that gave them an understanding,
meaning and strategies to cope with their grief.
Cathy Shipman 1, Irene Higginson 1, Marjolein Gysels 1,
Patrick White 2, Allison Worth 3, Scott Murray 3, Stephen
Barclay 4, Sarah Forrest 4, Jonathan Shepherd 5, Jeremy
Dale 5
1
King’s College London, Department of Palliative
2
King’s College London, Department of Palliative
3
University of Edinburgh, School of Clinical Sciences and
Community Health, Edinburgh, United Kingdom
4University of Cambridge, Department of Public Health and
Poster abstracts
Sarah Barnes 1, Merryn Gott 1, Sheila Payne 2, David
Seamark 3, Chris Parker 1, Neil Small 4, Salah Gariballa 1
1
University of Sheffield, Sheffield Institute for Studies on
Ageing, Sheffield, United Kingdom
2
University of Lancaster, International Observatory on End
3University of Exeter, Peninsular Medical School, Exeter,
United Kingdom
4
University of Bradford, School of Health Studies, Bradford,
United Kingdom
Aim To explore family carers’ views on death and
bereavement in relation to UK heart failure patients.
Method 17 interviews were conducted with bereaved
carers of HF patients participating in a longitudinal
study. Carers were approached in writing 3 months after
the death of the patient. Interviews were transcribed
verbatim and analysed thematically with the assistance
of NUD*IST.
Results Findings fell into 3 areas: the period prior to
death; the death itself and; the bereavement period.
Most carer’s found discussions about end of life with
their family member prior to death difficult.
Dissatisfaction with the death itself was focused around
hospital care with deaths in the home considered
‘good’. Although carers reported satisfaction with
services during the bereavement period, many felt more
input from their GP would have been welcome. Most
carers adopted coping strategies to deal with grief
including ‘using their faith’ and ‘busying themselves’
with practicalities. Only a small number had taken up
counselling.
Conclusion Findings confirm that carers of people
with HF find it difficult to discuss the wishes of their
family members prior to death, and this lack of
communication can pose a barrier to advance care
planning. With death at home being both a preference
of family carers and a feature of HF due to its
unpredictable prognosis, GPs are well placed to provide
input during the end of life period and into
bereavement, although may require training to enable
them to do so.
476. The Experiences and Attitudes of Single
Bereaved Fathers in East London
Christina Mason, Gina Langley
This study investigates the experiences and attitudes of
single bereaved fathers in East London. Seven
participants who had experienced a significant
bereavement and were also in majority charge of one or
more child(ren) under eighteen were interviewed, and
the resulting data analysed using a grounded theory
approach. Experiences, coping strategies and subsequent
attitudes after bereavement were investigated. A key
process identified was a process of emotional evolution
for the fathers involved, and a merging of “masculine”
and “feminine” grieving styles. On the basis of this
finding, proposals were made for practice and further
research.
477. Bereaved spouses’ adjustment after the
patients’ death in palliative care
Ingrid Nilsson 1, Maria Carlsson 2
1
Sjukvardsteamet, Uppsala kommun, Uppsala, Sweden
Dept.Public Health and Caring Science, Uppsala University,
Uppsala, Sweden
478. An action research project concerning
bereavement support following the death of a
partner or close relative in the acute hospital
setting
Isabel Dosser
Napier University, Dept of Nursing, Edinburgh, United
Kingdom
Key Issues
• Bereavement support in acute settings is different
from that offered by hospices or palliative care units
• National as well as local strategies are required to
address issues around inequity of bereavement support
• Within Scotland (UK) bereavement support has
recently moved up the government policy agenda
The aim of this research study is to investigate the
bereavement care given by nursing staff to families
following a death in the acute hospital setting by using
an action research approach.
Ethics and access have been negotiated and this will
be discussed as well as phase one of the study, which
includes interviews with specialists currently working in
bereavement and bereaved carers known to them. Phase
two will involve interviewing bereaved carers who are
linked with a ward in the acute hospital, for their unique
experience, which will be utilised when working with
the ward team who have nominated themselves to
participate in this action research study.
479. Caregiving & Bereavement : The Family
Caregiver’s Journey
Isabelle Dumont
Memorial Sloan-Kettering Cancer Center, Psychiatry &
Behavioral Sciences, New York, USA, United States
Bacground: More than 3 million Canadians are
providing care for a close one with a terminal or longterm illness. Most patients would rather die at home.
Since we know that devoted family caregivers (FC) are of
outmost importance in providing home care, we must
take into account the considerable burden it often puts
on them, as they risk of becoming patients themselves.
It has been shown in the literature that, in many cases,
the caregivers of advanced cancer patients experience a
general worsening in their physical health and quality
of life, and considerable caregiving-related emotional
distress. Health professionals must, in order to identify
properly the FC at higher risk of emotional and physical
distress, benefit from a fuller understanding of the main
factors which influence the caregiving and bereavement
experiences. Goal: This study aims at fostering a better
understanding of the FC’s experience during the
palliative care and grief periods. Method: A
longitudinal study with a mixed method (quantitative
and qualitative) was carried out with 63 FC in Quebec
City. The relationship between the level of psychological
and emotional burden experienced during the
caregiving period and the complications of grief of
bereaved caregivers has been analysed. Results: Results
show that some factors related to the caregiver’s
experience such as the psychological burden and the
degree of depression experienced during palliative care
as well as the nature of the relationship with the patient
and the circumstances surrounding the death are more
likely to influence FC’s well-being during the palliative
care and bereavement phases. Conclusion: A
comprehensive understanding of the caregiving
experience during palliative care and its impacts on
bereavement is of crucial importance for helping health
professionals identifying the caregivers at higher risk of
experiencing distress and to intervene in a preventive
way to support them.
2
480. Bereavement in Old Age
In order to improve the support to bereaved spouses
during the year after the patient’s death, a project was
started consisting of three visits by a nurse (after 1, 3 and
13 month) with conversations about the patient’s death
and the spouse’s life situation. Goals: The aim of this
study was to describe the bereaved spouse’s situation
and adaptation during the first year after the loss.
Patients and methods: Spouses of patients cared for by
The Advanced Home Care Team (APHCT) in Uppsala,
Sweden, were invited to participate in the project. Each
participant was encouraged to talk freely about his or
her situation, but enough direction was given to ensure
that all items listed on a standardised questionnaire were
covered. Results: Fifty-one spouses met the inclusion
criteria and were invited to participate. The subjects felt
quite healthy but were tired and suffered from sleep
disturbance. The grief reactions had initially been high
but showed a significant decline from 1 to 13 months (p
<0.01). Forty-nine percent had experienced postbereavement hallucinations. Conclusions: The
participants’ adaptation to the new situation gave a
fairly encouraging picture. The majority of subjects felt
fairly healthy and had a relatively positive outlook to the
future. The visits have been highly appreciated and fulfil
a great need even when the bereaved spouse adopted
well and has good social support.
Katharina Heimerl, Marina Kojer
University Klagenfurt, Department of Palliative Care and
Ethics, Vienna, Austria
From early childhood on all human beings have to learn
to cope with losses. For those well advanced in years
however, the number of bereavements increases
enormously. The last period of life is characterized by
loss of health, of mobility, of beloved ones, of social
standing, of familiar surroundings and by loss of
autonomy. The growing number of bereavements
increases the fear of further losses and the fear of the
future. If additionally the aged person is struck by
dementia, he or she suffers even more: As the disease
advances the patient gets defenseless and unable to cope
with the burden of life. A meta-analysis of qualitative
interviews will be used to deliver evidence for these
statements.The issue of bereavement in old age has been
widely neglected as far as professional discussion and
research are concerned. This lack results in painful
experiences for the bereaved ones: Getting more and
more tired and frail the aged persons themselves are
often not able to gather the strength to demand respect
or to ask for help. If they do, they are frequently not
understood and/or not taken seriously. They seldom
encounter adequate comfort and empathy by those
around them, nor do they find professionals willing to
accompany them. Instead their needs are mostly met by
inadequate medicalization only. The paper therefore
identifies bereavement in old age as an important
subject for future research as well as for training in the
field of Palliative Care.
481. An aspect of organ-removal: grief reaction of
relatives of dead-donors
Smudla Aniko
Semmelweis Medical University, Institute of Behavioural
Aim of the study: Bereavement support of deaddonors’ relatives must begin at the bedside and
continue until it is no longer needed (Sque). This
support is only partly realized in Hungary. We studied
the effect of organ-removal on grief reaction and
psycho-social processes following transplantations.
Method: The target group of our investigation was
comprising relatives who approved of organ-removal.
They completed two self-completed psychometric
questionnaires: the Revised Grief Experience Inventory
(RGEI) and shortened version of the Beck Depression
Inventory (BDI), 3-5 months post donation. The other
part of the questions was asked about opinions
regarding donation and the communication of
physicians. Results: 15 relatives had completed our
questionnaire in pilot study. Family members who think
that the diagnosis of brain-death is unfailing had lower
score on BDI (p<0,01) and on RGEI (p<0,01) than those
who do not think so. The relatives for whom religion is
important had lower scores of RGEI (physical distress
subscale, p<0,05) than those who do not feel so. Higher
score of RGEI represents higher level of grief.
Conclusion: Bereavement support of dead-donors’
relatives begins at the bedside. The proper
communication of physicians is pivotal in this aspect as
it is an important factor in the evolvement of severe
grief reaction and depression. Based on our results we
wish to create an appropriate psycho-social background
for relatives.
482. How do caregivers in palliative care manage
their distress and how is the awareness of the
physician’s vulnerability and coping strategy in
France and the Netherlands?
Francine Hirszowski 1, Jaap Schuurmans 2, Judith Prins 3,
Jeroen Hasselaar 2, Kris C.P. Vissers 2
1
Hospital Paul Brousse, Palliative care unit, Paris, France
University Medical Centre, Palliative care unit, Nijmegen,
Netherlands
3University Medical Centre, Department of Psychology,
Nijmegen, Netherlands
4
University Medical Centre, Pallaitive Education and
Research Center, Nijmegen, Netherlands
5
University Medical Centre, Pallaitive Education and
Research Center, Nijmegen, Netherlands
2
Introduction There always have been reflections
focussing on the inner life of physicians facing their
seriously ill. These emotions can affect both the quality
of medical care and the physician’s owns sense of well
being. Epidemiological surveys show figures from 1020% of physicians receiving none or hardly ever
pleasure from their work. Models were described
showing increasing physician’s self awareness, which
includes working with emotions that may affect
patient’s care Aim 1)To measure the management of
distress among caregivers working in palliative care (PC).
2)To identify the awareness of the physician’s own
vulnerability and coping strategy. 3)What are significant
differences on this subject between France and the
Netherlands? Methodology 1) a written questionnaire
based on five questions focussing on the management
of distress was spread among caregivers visiting the
EAPC research forum in May 2006 at Venice. 2) a
structured telephone questionnaire based on 6 items is
being performed among doctors in France and in the
Netherlands Results Written questionnaire had a
response rate of 50% (n=64). Telephone questionnaire
rerults are awaited
Conclusion The majority of PC caregivers are aware of
the danger of burn out and are able to share experiences
and feelings within their professional team. With the
structured telephone questionnaire, we focus on the
cognitive dimension of the mourning of the physicians.
145
Poster abstracts
475. COPING WITH DEATH AND BEREAVEMENT:
VIEWS OF CARERS’ OF OLDER HEART FAILURE
PATIENTS IN THE UK
Poster abstracts
483. Thematic Issues in Parental Grief Identified
from a Retrospective Review of Pediatric
Bereavement Group Notes
Tanya St. John, M.A., Randi McAllister-Black, Ph.D.
City of Hope National Medical Center, Clinical Psychology,
Duarte, United States
This exploratory study was an examination of the
various themes that emerged during an open-ended,
monthly, bereavement support group for parents whose
children have died from cancer. AIM: The study’s
purpose was to identify the most salient issues discussed
by bereaved parents. METHOD: Progress notes from this
bereavement group, over twenty-four sessions and two
and half years, were reviewed. The patterns and contents
of these notes were analyzed using a thematic approach.
Then a comparative analysis was applied to identify and
emphasize important similarities and differences across
cases. RESULTS: In this group (n=26) five common
themes emerged (healing and acceptance, avoidance
and feelings of dissociation, faith and spirituality, guilt,
and remembering the death of the child). Other themes
included loving others and the parents changed
relationship with death. Furthermore, parents discussed
symptoms of re-experiencing, avoidance, and
dissociation possibly suggesting posttraumatic stress.
Posttraumatic stress symptoms appeared to decrease over
time as did guilt and anger. In contrast, certain themes
like healing and acceptance, and faith and spirituality,
were discussed no matter how long it had been since
their child’s death. CONCLUSION: This study offers
insights for clinical and medical staff working with
grieving parents, as well as for those who are grieving,
and may provide focus for areas of future research and
intervention.
484. Existential Distress of Physicians among
Caring Terminal Cancer Patients
Chun-Kai Fang 1, Ming-Liang Lai 2, Hsin-Chin Lu 3, Pei-Yi
Li 4, Haunn-Tarng Tseng 5, Ming-Hwai Lin 6
1
Mackay Memorial Hospital, Psychiatry, Taipei, Taiwan
National University Hospital, Department of
Neurology, Tainan, Taiwan
3Mackay Memorial Hospital, Department of Health
Sciences, Taipei, Taiwan
4National Taiwan Normal University, Department of
Educational Psychology and Counseling, Taipei, Taiwan
2Chungnam
5national
taipei college of nursing, Taipei, Taiwan
6Taipei
Poster abstracts
Veterans General Hospital, Department of Family
Medicine, Taipei, Taiwan
Aim of study The spiritual well-being of physicians is
important to terminal cancer patients. The physicians’
spiritual well-being shall be considered as a medical
ethic issue. To understand the existential distress of
physicians is important , because it could be the first
step of spiritual growth. In this study, we present the
existential distress of physicians among palliative
care. Method A qualitative phenomenological approach
based on Heidegger’s existentialism was used to guide
this study. There were 10 physicians from two general
hospitals. They received the in-depth interview by the
researcher with master degree. The average of being
physicians was 10 years.The method of analysis referred
to the Colaizzi method. ATLAS.ti 5.0 software was
further used to Result The themes of existential distress
among physicians are difficult therapeutic alliance,
dilemma of announcing patients’ condition, frustration
of treatment, confused meaning, disability of spiritual
care, grief reaction for patients’ death, anxiety for the
certainty of self death, overloading, and imbalance of
therapeutic team. Conclusion Physicians are human
beings who experience strong existential distress among
caring terminal cancer patients and among meeting
death of their patients. In the future, we should try to
develop the education courses of spiritual growth to
help physicians overcome their existential distress.
traumatic stress (HTQ), coping style (CSQ), attachment
style (RAAS), personality (NEO-PI) and depression (BDI).
Adult relatives to deceased patients treated in palliative
home care team were asked to participate one month
after their loss and for a period of 18 months
subsequently. So far 60 bereaved relatives (43 females
and 17 males) have been included. The study is
ongoing. Results: At baseline 27% of the relatives meet
the DSM-IV-criteria of PTSD (Post Traumatic Stress
Disorder) and 33% the criteria of a subclinical PTSDdiagnosis. The diagnosis of PTSD is not significantly
correlated with demografic data: sex, age, educational
level, marital status, number of children. Significantly
correlated with PTSD is however the feeling of
powerlessness at the time of death (p=0.03).
Conclusions: This study indicates that about 1/3 of
bereaved relatives suffer from acute traumatic stress. A
high level of experienced powerlessness at the time of
death appears to be an early predictor of the
development of traumatic stress and even PTSD. Further
results are in preparation concerning the identification
of other risk-factors that could complicate grieving and
predict the need for support.
Mai-Britt Guldin 1, Maja O’Connor 2, Anders Jensen 3
1
Aarhus University Hospital, Palliative Care Team, Aarhus,
Denmark
2
Aarhus University, Psychotraumatological Research Unit,
Aarhus, Denmark
3
Aarhus University Hospital, Department of Oncology,
Aarhus, Denmark
Aim: To study the impact of traumatic stress and other
personality related factors that could affect and
complicate grieving in bereaved relatives to patients
treated in a palliative home care team. Acute traumatic
stress has been shown to be treatable if diagnosed early
but may develop into a chronic disorder if left untreated.
Methods: A self-report questionnaire, measuering
146
488. The last days in life: experiences of family
members in a hospice
Gunilla Flodin 1, 2, Erika Lindqvist 1, 2, Birgit Rasmussen 1,
2
1
Axlagarden Hospice, Palliative Care, Umea, Sweden
2
486. “Hope and the possibility of free choice” - a
qualitative study among patients in palliative
care
Peter Strang 4, Maria Friedrichsen 2, Gunnel östlund 3,
Louise Olsson 1
1
Karolinska Institutet, Department of Oncology, Stockholm,
Sweden
2Linköping University, Pallaitive Education and Research
Center, Norrköping, Sweden
3
Linköping University, department of Social and Welfare
studies, Norrköping, Sweden
4Linköping University, department of Social and Welfare
studies, Norrköping, Sweden
Introduction
The aim of this study was to describe how patients in
palliative care themselves define and use hope.
Presented results are preliminary.
Methods
A theoretical sampling was used with inclusion and
exclusion criteria. Data were collected through recorded
semi-structured interviews and personal written diaries
during a period of four weeks. The collected data were
analysed using a constant comparative method. Until
today’s date, the sample consists of ten cancer patients
admitted to two palliative hospital based home care
units in two different counties in the south east of
Sweden. The data collection will continue until
saturation has been reached.
Preliminary results
Patients described hope as fundamental in life and as
being closely related to personal freedom and the ability
to make choices in life. Hope was something they had
not reached out to or used as a source until the day they
received the news about their fatal prognosis. After that
instant, hope became related to life and hopelessness to
death. Patients attempted to focus of hope on cure,
better quality of life, prolonged life expectancy, a good
way to end life, or a good future for their families. The
patients described hope according to one of the
following categories 1) Moments of hope, including the
knowledge that life was limited but with a wish to still
seize the day and capture moments of joy and pleasure
2) Convinced hope, with a focus on positive things, i.e.
treatment, journeys, in order to have something to look
forward to 3) Simulated hope, when patients were not
really convinced of hope being a reality, but still
attempted to believe in hope even if they knew it was
unrealistic, 4) Lost hope, were patients felt that they
where in a situation where they had no influence over
their life situation due to lack of energy or a sense of
time running out.
487. Meeting grieving people : prevention and
early diagnosis of difficult bereavement
FERREOL Mireille, BURUCOA Benoit
485. Screening for acute traumatic stress in
bereaved relatives to patients treated in a
palliative home care team - preliminary results
Results : 631 cards were sent, 60 meetings were
organised. 104 families were represented, 180 persons
attended these meetings. Other results will follow
according to systematic and thorough reading.
Discussion : The underlying psychological levels will be
explored. The impact of these meetings on the resilience
abilities of family members to live a normal
bereavement or to prevent a pathological one will be
discussed. The works of Parkes, Ferenczy and Bowlby
will help on this subject.
Conclusion : From this work, we seek to readjust as well
as possible these meetings and improve the family
members’ participation. A database may be done in
order to prospectively study these meetings.
Hôpital Saint-André, Palliative care unit, BORDEAUX,
France
Introduction : The prevention of difficult bereavement
is one of palliative care’s main targets. The mourning
process can be influenced by the dying conditions, and
therefore by care, treatment and support given to the
terminal patient. Besides, a bereavement follow up can
be organised. In our palliative care unit, a card is sent to
the next of kin one month after the death. On this one,
team members can sign and three meeting dates are
offered.
Objective : The objective is to describe the participants’
family relation with the deceased person, the modalities
of the meetings’ beginning and end, the interactions
during the exchanges.
Method : The communication is based on the analysis
of the content of the reports written after each meeting.
This study is only descriptive, retrospective, and is
considered as a preliminary work.
Background: Research that has been carried out shows
that the majority of family members feel weak and
helpless when faced with the suffering and deteriorating
condition of a loved one. Feelings of inadequacy,
anxiety, fear, anger and loneliness can be experienced, as
well as guilt.
Aim: The aim of this study is to shed light on the
experiences of family members during the final days of
a loved one’s life in a hospice. Method: In the spring of
2006, 7 family members of dying patients in a hospice
in Sweden were interviewed. Open questions such as
‘can you tell us about the last few days of your loved
ones’ were used so that they could share their personal
experiences and thoughts. The interviews were taped
and then printed out. The interviews were analysed
using the method of qualitative description inspired by
Sandelowski. Result: Since the data analysis is currently
being undertaken the final result and the discussion will
be presented at the conference. Preliminary results show
that the majority of family members need continuous
information and support over the course of their loved
one’s illness. Many feel guilty since they no longer can
cope with looking after the loved one themselves and
have to rely on healthcare services. The majority
considered that the symptoms and their treatment were
well dealt with but that information was lacking, for
example, in the administering of pain relief.
489. Palliative spiritual care at home.
Marijke Wulp, Henk Jochemsen
Agora, Bunnik, Netherlands
According to the WHO-definition spiritual care should
be an integrated part of palliative care. In the
Netherlands this care is only given structurally in
hospitals, nursing homes and homes for the elderly.
However most of the people in the Netherlands die at
home. Agora started a project to stimulate palliative
spiritual care at home. An inventory among the 73
networks palliative care shows the following: In
December 2005 there were 6 initiatives. After promoting
the item in February 2006 there were 12; 7 of them
focused on training of the caregivers who visit the
patient regularly at home, 2 networks started a local
inventory about the need for spiritual care and 3 were
trying to set up a point of support, some with a pool of
only chaplains and pastoral care workers, some with a
multidisciplinary team including volunteers. After a
conference on the topic and PR to the other networks,
in November there were 6 new initiatives, all of them
focusing on training of the care givers. In some other
networks participants made products to facilitate the
communication about dying and death, like a ‘lastwishes-booklet’ and a picture book for mentally
disabled people. Conclusion: Encouraging local
networks to pay (more) attention to spiritual care in
palliative care gave a significant impulse to new
initiatives. Most palliative care workers know in their
heart this kind of care is important, but they do not
know how to realize it and need support.
490. Bereavement Support at the Hungarian
Hospice Foundation
Magdolna Singer, Eszter Biró, ágnes Molnár, Adrienn
Thuránszky, Katalin Muszbek
1
Objective: The Hungarian Hospice Foundation
considers dying cancer patients and family members in
bereavement two equally important target groups for
psychological support. Our goal is to help people get
through the bereavement process, prevent the
development of a complicated bereavement process,
and, if already developed, offering therapeutical
intervention for their treatment.
Poster abstracts
491. Bereavement Therapy - Case Presentation Use of Art Therapy to treat the anguish of a
mother whose daughter died of cancer
during bereavement. Existing literature presents 3
modes of assessing risk by; questioning the bereaved,
intuition, or instruments. Drawing upon empirical
findings from a larger study, this discursive paper
explores whether literature informs the practice of risk
assessment and the extent to which intuitive assessment
avoids responsibility. 22 support providers completed 1
questionnaire per death over 3 months. This included;
whether the bereaved was risk assessed, the mode of
assessment, and whether this affected the support
provided. Of 595 deaths, 71% of bereaved were risk
assessed and 99% were then offered support. Only 8
services reported using an instrument with
conversations being the most common form of
assessment. In 69% of cases the risk assessment had no
effect, yet where it did this included advanced or
increased interventions. Yet services also noted that they
could not always respond to extra needs. The findings
suggest that informal assessments are favoured. Yet that
so great a number went on to receive support after
assessment implies that it was aimed at those at risk and
not to make a decision about whether to offer support
or not. The empirical findings and discussions
surrounding the ways of assessing suggest the
connection between literature and practice is complex
and rests on whether the service is aware that with
assessment comes responsibility.
Yael Bleich
Hospice Upper Galilee, Nursing, Rosh Pina, Israel
The paradox of suffering: “Healing, meaning,
consolation when and if they come, do so from within
the individual.” Dr Michael Kearney. As a nurse working
in Hospice Upper Galilee, I took car of Mira, a 28 year old
single woman with metastatic breast cancer. She died at
home in her mother’s arms. Shortly after the “shiva”
mourning period, I phoned Yona, Mira’s mother. She
depicted unbearable anguish. I suggested that I come
over and draw with her. Kubler Ross wrote: “Give him a
secure place to vent his anger, his sense of injustice and
his tremendous need for mourning. Only after he has
done so, can you begin working with him.” Art therapy
allows adults to overcome intellectual inhibitions which
normally distance them from their emotions. Through
the use of color combinations and shapes, it provides an
opportunity for expression of unconscious themes. It
requires no previous artistic experience. Furthermore, it
can lay the groundwork for a person to undergo intrinsic
adaptive changes more attuned to their new situation.
During my presentation, I will describe the therapeutic
process with Yona, through encounters over several
months. I will show the pictures, describe insights drawn
from then, and my role as a therapist. “You cannot teach
anything. All you can do is help a person discover that
which is within him.” Galileo
492. Support for the bereaved
Marie Macková
Masaryk University, Department of Nursing, Brno, Czech
Republic
Background: There is no coherent system of support
for the bereaved in the Czech Republic.Aim of survey:
To identify areas in which the bereaved feel the need for
support. In case they do feel the need for support, to
identify their expectations concerning which
professional groups this support should be provided
by.Methods: Structured interviews were conducted
with 170 bereaved individuals in hospices of the Czech
Republic. Results: Altogether 88 women and 48 men
took part in the interview. Most of them were between
41 and 50 years old, they were married or
widows/widowers, working or retired. More than one
half of them lived in town. They identically claimed the
need for support in all three offered areas – orientation
in the system of support, support in practical issues and
in coping with the loss. Most of them indicated that
support should be provided by a social worker or a
specially trained professional – a
counselor. Conclusion: The survey has demonstrated
that the bereaved do expect support.In every area they
expect support to be provided especially by a social
worker; in coping with the loss they expect support
provided by a specially trained professional - a
counselor. Due to insufficient participation of social
workers in the hospice care I recommend increase in the
number of existing social workers. There are no specially
trained professionals - counselors in the Czech Republic.
493. The extent to which literature exploring risk
assessment connects to the practice of
bereavement support.
Alison McNulty
University of Manchester, Psychology, Manchester, United
Kingdom
494. High prevalence of depressive symptoms
among Italian surviving caregivers. Results from
the Italian Survey of the dying of cancer (ISDOC)
Massimo Costantini 1, Gabriella Morasso 2, Monica
Beccaro 2
1
National Cancer Research Institute, Clinical Epidemiology,
Genoa, Italy
2National Cancer Research Institute, Psychology Service,
Genoa, Italy
Aim of this survey was to estimate prevalence and
determinants of severe depression among Italian nonprofessional caregivers after the cancer patient’s death.
Methods: ISDOC is a mortality follow-back survey
representative of all Italian adults cancer deaths.
Caregivers were identified and interviewed about the
problems encountered by the patient and the family
during their last 3 months of life. After the interview,
caregivers were evaluated for depressive symptoms using
the 20-item Center for Epidemiologic Studies
Depression (CES-D) scale.
Results: We obtained 1,231 valid interviews. The
median time between the patient’s death and the
interview was 234 days (range 103-374). CES-d was filled
in by 1181 caregivers (95.9%). According to the generally
used cut-off of 16 in the CES-D score, 64% of the
caregivers were classified as depressed; with a more
conservative cut-off of 23, still 39% resulted depressed.
After adjusting for a number of characteristics of the
patient, the disease and the caregiver, the highest
depression scores were observed for female caregiver,
aged 65 years or more and when he/she was the spousepartner.
Conclusions: This large, representative survey
confirmed a high rate of depression among surviving
caregivers of cancer patients. Intervention and support
are needed most before the patient’s death.
495. A thesaurus on bereavement
Denise Brady
St Christopher’s Hospice, London, United Kingdom
Introduction. A thesaurus is a tool for subject indexing
of documents. It consists of a structured list of terms in a
particular subject area. An indexer can use this to
describe documents so that end-users can retrieve
relevant items easily. In constructing a thesaurus, one is
also contributing to identifying the unique
characteristics of the subject and this presentation
reviews the subject headings on bereavement in the
library where the author works.
Methods. The subject headings will be reviewed and
separated like a true thesaurus, into facets. This means
that aspects of the subject are divided into fundamental
categories. These categories are functional in nature and
have some correspondence with grammatical forms. For
example, bereavement might be divided as
follows:relationship of bereaved person to the deceased
(bereaved child, widower), cause of bereavement (eg
suicide, illness, stillbirth), influences on bereavement
(psychological aspects, religious aspects, social aspects),
interventions (counselling, befriending, supporting),
agents of intervention (eg psychologists, volunteers)
management (recruitment, health and safety provision,
setting standards).
Outcomes. Elements of the thesaurus will be illustrated
and some difficulties of categorisation in bereavement
literature will be outlined.
Risk factors, characteristic or circumstantial, can
potentially affect both physical and mental health
496. Connecting Diversity in Bereavement
Services: Contrasting the Bereavement Services of
the Hôpital général juif de Montréal Palliative
Care Division with Services in UK and USA
Hugues Cormier 1, Bessy Bitzas 2, Michael Dworkind 3,
Bernard Lapointe 3, Sandy Lipkus 2, Francine Venne 2
1
University of Montreal, Montreal, Canada
Hôpital général juif de Montréal, Montreal, Canada
McGill, Montreal, Canada
2
3Université
In this paper, we will contrast bereavement services of
the Hôpital général juif de Montréal (HGJM) Palliative
Care Division with numerous bereavement services in
UK and USA. The similarities and differences will be
presented using the UK National Institute for Clinical
Excellence (NICE, 2004) three-tier model of bereavement
support in which all health-care providers should
provide information about local services to bereaved
people (level 1), in which those in need of more
comprehensive support should be offered support from
professionals and/or volunteers (level 2) and in which a
minority of people at risk of complicated bereavement
reactions should be referred to specialist services (level 3).
Other specific contrasts will be: age of services (HGJM :>
15 years), pre-bereavement support, continuity, risk
assessment of bereaved people, number of participants,
staffing, volunteers’ selection and supervision. The 2005
HGJM data were obtained through four staff members
interviews, whereas the USA and UK data were found in
published papers (US: survey by Demmer, 2003), (UK:
Volunteers selection and supervision by Relf, 1998;
survey by Field et al, 2004; in depth case studies of five
English hospice bereavement services by Reid et al,
2006a and Reid et al, 2006b). HGJM and the five English
services clearly met the first two NICE levels. The
integration of bereavement support as a more central
aspect of HGJM Palliative Care Division activity will be
recommended to improve support
497. Vulnerable families and individual risk
factors in a Swedish Palliative Care Setting
Bylund Grenklo 2, 3, 4, 5, Unnur Valdimarsdottir 1, 2, 3, 4, 5,
Carl Fürst 3, 4, 5
1
—-, Department of Medical Epidemiology and Biostatistics,
Stockholm, Sweden
2—-, Unit for Clinical Cancer Epidemiology, Stockholm,
Sweden
3
—-, Department of Oncology-Pathology, Stockholm, Sweden
4Stockholms Sjukhem Foundation, Stockholm, Sweden
5
Karolinska Institute, Stockholm, Sweden
Introduction. Support for relatives to patients in end
of life care is most effective if directed to those who run
the risk of long-term psychological complications.
Aim. To develop a checklist of risk factors for long term
grief complications and test it in the clinical setting.
Material and Methods. Based on a literature review
we identified factors indicating increased risk or
vulnerability for complicated grief related to family,
professional care and communication, and concurrent
life events. A checklist for professional assessment was
developed and tested in consecutive bereaved families at
our palliative care services.
Results. During 11 months (11/2005-09/2006) the aim
was to assess all consecutive families during palliative
care and/or after the death of the patient. 24 of 325
families were not assessed. In 48% of the families no risk
factors were identified. In 50% of families at least one
family member were identified to have at least one risk
factor. Out of these, 43% of the families were identified
to have one risk factor while 27% had 3 or more risk
factors. The most common risk factors identified were
children and young adults in the family (21 %) and the
perception of a fast disease progression and/or lack of
awareness of impending death (23%).
Conclusion. In 50% of families of patients in late
palliative phase, one or more family members were
assessed to be at risk for long-term morbidity. Young
families and fast disease progress and lack of awareness
seem to be a prevalent problem. We offer tailored
support for families at risk.
500. When the going gets tough....an exploration
of spirituality and palliative care
Barry Clark
University Hospital Birmingham, Chaplaincy, Birmingham,
United Kingdom
Despite increased awareness of the spiritual aspect of
palliative care it remains an under-resourced and poorly
understood element of care. It reaches far beyond
religious belief and embraces both those who can
identify with a particular faith or tradition and those
who seek alternative responses to the big questions such
as ‘Why are we here?’ and ‘What happens when we die?’
For the last 2 years, based upon recommendations in
the 2004 NICE guidelines for Improving Supportive and
Palliative Care for Adults with Cancer and with support
147
Poster abstracts
Method: In the last four years, well trained
bereavement advisors organised several bereavement
groups. They supported the family members of recently
deceased patients belonging to the home care
service. Individual, structured eight-session
psychotherapy is also available. The bereavement club
works as a self-support group that uses the power of
social support to positively affect the mental condition
of all participants. The number of clients involved in the
various forms of support are as follows: 40 clients in
bereavement groups, 35 clients in individual
psychotherapy and 26 clients in bereavement clubs.
Results: Our experience is that pain can be successfully
reduced and everyday living conditions improved. This
can be achieved first of all through the realization of the
nature of the bereavement process, the utilization of the
potential of social support and the possibility of sharing
their feelings with others .
Conclusions: Our therapeutical results clearly show the
importance of the professional support for the bereaved.
This support can have a significant impact on the
clients’ lives who are suffering from a great loss.
Poster abstracts
from the Pan Birmingham Palliative Care Network, I
have been drawing on the experiences of patients and
carers to develop a screening tool called ‘When the
going gets tough……’ It is designed to help patients
express their religious and spiritual expectations, to give
confidence to staff in addressing this area, and to ensure
that any specified needs are met.
What has become clear is that while patients are
quite willing to respond positively to this area when it is
raised, staff often remain reluctant. Tools such as The
Liverpool Care Pathway acknowledge the need to
address spiritual care but do not always offer sufficient
support to the staff.
It is hoped that ‘When the going gets tough…….’,
largely created and validated by patients, will enhance
patient care, encourage staff involvement and raise the
profile of appropriate spiritual care.
501. Culture and pain: a qualitative study of
Caribbean and white British patients with
advanced cancer living in London
Jonathan Koffman 1, Myfanwy Morgan 2, Polly Edmonds
1, Irene J. Higginson 1
1
2
King’s College London, Public Health Sciences, London,
United Kingdom
Background: Pain is common in advanced cancer.
Sociological and anthropological studies have shown
this symptom is socially and culturally patterned. Little,
however, is known about the experience of cancer pain
among Caribbeans living in the UK.
Aim: To explore and compare the meaning of this
symptom among Caribbean and white British patients.
Method: In-depth qualitative interviews with Caribbean
and white British patients with advanced cancer living
in south London. Patients were recruited from in-patient
and community-based palliative care teams and outpatient oncology and lung clinics. Interview
transcripts were analysed using Framework Analysis.
Results: 26 Caribbean and 19 white UK patients were
interviewed. Patients represented a range of cancer sites.
23 Caribbean and 15 white UK patients reported cancerrelated pain. Three major categories of the meaning of
pain were identified and included: pain as a test; pain as
an enemy; and pain as a punishment. More Caribbean
than white British patients believed their pain
corresponded with the meanings of pain as test or a
punishment. Further, these two tests were considered to
add meaning to their religious or spiritual beliefs.
Conclusions: The results of the study show that some
Caribbean patients who believe their pain is a test or
punishment do not perceive them as being negative
experiences. Current methods for assessing pain should
attempt to understand the cultural as well as the clinical
context of this symptom.
502. Holding onto holism
Lucinda Jarrett Jarrett
Poster abstracts
Rosetta Life, Health and Wellbeing, London, United
Kingdom
In a climate of increasing medical specialisation it is
increasingly important to address the spiritual and
psychosocial needs of the people using our services.
Rosetta Life is an artist led organisation that was set up
to enable hospice users to find their creative voice and
in so doing find meaning in their lives, leave a legacy for
friends and family and address the emotional and
spiritual pain that dying leaves. A unique website creates
a collective voice for those who are dying and includes
the works of over 500 people who use and have used
hospices over the past ten years.
Using creativity as an effective tool enables the
process of grief to begin with diagnosis and encourages
whole families to engage with the process of celebrating
the life of a loved one before their death. Celebration
events enable hospice uses and families to tell their
stories and share these with health care providers. This
process of storytelling fosters a healthy bereavement
process where a whole family witness how a loved
member chooses to be remembered and hold the legacy
of this.
Presentations in public enable a wider audience to
understand the lessons lived by those leaving life and
challenge contemporary taboos about death and
dying. This presentation of the spiritual and
psychosocial issues raised through creative interventions
demonstrates how whole communities can continue to
participate in the well being of the dying throughout
their care.
148
503. The Spirituality and the organic disease
Maria Custodio 1, Jose Cruz 2, Antonio Barbosa 3
1
Hospital CUF Descobertas, Department of Oncology,
Lisbon, Portugal
2Hospital CUF Descobertas, Chaplaincy, Lisbon, Portugal
3
Hospital de Santa Maria, Psychiatry Department, Palliative
Care Center of the Faculty of Medicine of Lisbon, Lisbon,
Portugal
Objective: We aim to understand the features that
oncologic patients with advanced disease recognize and
value in their experience of spiritual suffering using a
conceptual framework of authors from Christian and
Budist thougt.
Methods and patients: A qualitative study was
undertaken using Collaizi methodology. The knowledge
of the phenomena came from the experience of a patient
with advanced disease, interviewed in a semi-structured
profound way in order to know and understand the
experiences of the patient in it’s spiritual dimension.
Results: Relevant data showed that the patient with
spiritual suffering facing his oncologic reality, is focused
in the qualification of his spiritual pathway, assuring a
strong link to earthly things; for that, he recognizes and
values: 1- There is a spiritual implication in the organic
disease. The disease emerges in a circle of silence and
reclusion. 2- Disease has a place in the spiritual
dimension of human being. Emerging feelings of
compassion, courage/authenticity, hope-sense of life,
sharing-fraternity. 3- Genesis of the feeling of inner
peace, that encloses meditation, miracle and grace, sense
of eternity and faith. 4- The disease might be explored in
a spiritual way, through self knowledge and prayer.
Conclusions: We discuss the repercussion of our praxis,
being aware of the real distance from what would ideally
be recommended for Palliative Care in order to have a
“Quality Sense of Life”.
504. DIIFICULTIES IN ADDRESSING SPIRITUAL
CARE OF THE PATIENTS: A QUALITATIVE STUDY
Syed Qamar Abbas 1, Simon Dein 2
1
St Clare Hospice, Palliative Medicine, Hastingwood, United
Kingdom
2St Clare Hospice, Psychiatry, Hastingwood, United
Kingdom
Introduction: Despite the recognition that spiritual
care provision is an integral part of Palliative care and
that patients generally desire spiritual care discussions
with healthcare professionals rather than just faith
leaders, there are reports that such discussions are
infrequent in clinical settings.Objectives: We
conducted a focus group study aimed at exploring the
difficulties; palliative care healthcare professionals have
come across while assessing the spiritual distress of the
patients Methods: Three focus groups of five
informants each (2 doctors, 8 nurses, 4 healthcare
assistants and 1 social worker) were interviewed in a
hospice. Participants were all healthcare professionals
working in the hospice in-patient unit. Interviews were
taped and later transcribed. Themes were evaluated and
are reported. Analysis and Results: The themes
elicited were acknowledgement of the difficulties
including patients’ and staff’s lack of vocabulary,
training issues, spirituality being a private matter, fear of
inability to resolve the problem, lack of time, difficulties
about own spirituality and mortality and lack of
standard spiritual care tool. Staff identified that they
would like support groups, specific training, audit,
reflection, supervision and dedicated slots for
discussions in hand-over. Conclusion: Although it is a
small study, it has generated useful data. The difficulties
were highlighted by the staff, but the productive
outcome was the staff’s own thought process to find
ways to deal with difficulties.
505. Where is palliative care in 2007: A
Hungarian-English comparison
Geraldine O’Meara 1, Katalin Muszbek 2
1
Sir Michael Sobell House, Macmillan Nurse Specialists,
Oxford, United Kingdom
2
Magyar Hospice Alapitvany, Palliative Care, Budapest,
Hungary
Sir Michael Sobell House, Oxford, and Magyar Hospice
Alapitvany, Budapest, are collaborating partners within
the Oxford International Centre for Palliative Care. Both
organizations have faced challenges and great changes
since their formation.
Aim and Method
With Sobell’s 30th anniversary celebrations in 2006/7,
the community nurse teams in both organizations have
undertaken a comparative piece of reflective work to
consider:
Where are we now?
What defines palliative care?
How is the philosophy of palliative care manifested in
each organization?
What can we learn from each other?
Result
In the UK, health policy subdivides palliative care into
‘specialist’ and ‘generalist’ services. Sobell House
Community Team is under increasing pressure to
demonstrate its specialist contribution to the care of the
most complex patients. This has caused soul-searching
for the team, fearing that the relationship-building that
traditionally formed a fundamental element of palliative
care - and that helps to prevent complex crises - is in
danger of being lost.
Hospice care is not yet an integrated part of the health
care system in Hungary. Nursing and physiotherapy are
strong, but palliative care is not yet part of the education
curriculum of Hungarian physicians
Conclusion
This poster will explore the different challenges faced by
the teams from both organizations, and identify the key
issues in the development of palliative care in each
country.
506. End-of-life services for Sikh and Muslim
patients and their families
Allison Worth 1, Aziz Sheikh 1, Tasneem Irshad 1, Scott
Murray 1, Marilyn Kendall 1, Elizabeth Grant 1, Raj
Bhopal 2, Julia Lawton 2, Duncan Brown 3, James Adam 4
1
University of Edinburgh, General Practice, Edinburgh,
United Kingdom
2
University of Edinburgh, Public Health Sciences,
3St Columba’s Hospice, Edinburgh, United Kingdom
4Marie Curie Hospice, Glasgow, United Kingdom
Aims of study
To construct a patient and family-carer centred account
of needs during the last year of life ··To understand the
barriers and facilitators to accessing services ··To
integrate findings to inform palliative care policy,
service delivery and professional education
Methods
Serial, longitudinal interviews with 25 Sikh and Muslim
patients with cancer or other long-term conditions,
their family-carers and key health professionals.
Results
Open discussion of death and dying was uncommon;
diagnosis and prognosis were withheld from some
patients. Few patients had access to specialist palliative
care. Basic needs, such as culturally acceptable food and
appropriate personal care, were often not provided by
hospital and community services. Emotional needs were
poorly recognised and addressed. Institutional and overt
personal racism were apparent at times in patients’ and
carers’ interactions with services. Standards of care
varied widely; some staff met the needs of Sikh and
Muslim patients effectively through a partnership
approach, effective advocacy and excellent care
coordination.
Conclusion
End-of-life services for minority groups are reactive and
often inflexible. Considerable policy, education and
service reforms are needed to reduce inequalities in end
of life care.
507. Anxiety, Depression and Spiritual Coping of
Cancer Clients Receiving Hospice Palliative Care
in the Maltese Islands
Antoinette Shah, Donia Baldacchino
A.V.A.P.O., Palliative Care at Home, Almada, Malta
Aims To identify differences in anxiety and depression
and spiritual coping between subgroups of clients. To
explore clients? perception of the Hospice Care being
provided.
Method A cross-sectional descriptive study was
conducted on a random sample of 52 clients with
cancer (male n=21, female n=31), aged between 30-89
years, who were referred to the Malta Hospice
Movement for Palliative Care. Home Care nurses
collected the data through face to face, structured
interviews using the Maltese translated version of the
Hospital Anxiety and Depression Scale (Baldacchino and
Buhagiar 2002, Zigmond and Snaith 1983). A semistructured self-administered questionnaire on
satisfaction with services was designed for the study. The
Cognitive Theory of Stress and Coping (Lazarus &
Folkman 1984) guided the study.
Result The majority of clients were found to have
normal anxiety (n=30) with few having mild (n=9),
moderate (n=8) and severe anxiety (n=4). Similarly, most
clients had normal depression (n=38) with some having
mild (n=6), moderate (n=5) and severe depression (n=2).
No significant differences were found in anxiety
between subgroups of clients such as gender, age,
marital status, living conditions, stage of illness and
awareness of diagnosis/prognosis. A significant
difference in depression (F=0.4236, p=0.006) was found
between clients who were stable (n=22, Mean=4.18,
SD=3.11) and those with a deteriorating physical
condition (n=11, Mean=9.36, SD=4.73).
Conclusion Low scores of anxiety and depression were
Poster abstracts
508. Good Death for Hospice Care Nurses in Japan
Mikiko Kawamura 1, Yoko Tsukamoto 1, Yukiko Sasaki 2
1
Health Sciences University of Hokkaido, Dept of Clinical
Nursing Study, Tobetsu, Japan
2
Health Sciences University of Hokkaido, Dept of Clinical
Nursing Study, Tobetsu, Japan
3Sapporo Minami-seishu hospital, hospice care unit,
Sapporo, Japan
Aim of study: Good death is influenced by individual
value and experience. Therefore, it is important to
understand the differences of good death between
nurses and patients to provide patient-centered end of
life care. Method and Results: Thirty-nine hospice care
nurses were asked about good death . The survey was
consisted of 44 items about good death and participants
rated the importance of each item on a 5-point scale.
Eight items were answered as important by more than
80 percent participants. Those items were: “Have a
someone who will listen”, “Be free with shortness
breath”, “Maintain one’s dignity”, “Presence of family”,
“ Share time with close friends”, “ Say goodbye to
important people”, “ Be free of pain”, and “Name a
decision maker”. Four items were answered as not
important by more than 30 percent participants. Those
items were: “Use all available treatments no matter what
chance recovery”, “Meet with a clergy member”, “Pray”,
and “Be at peace with God”.”Conclusions: In this study,
“Use all available treatments no matter what chance
recovery” was not considered as important for nurses
and this was consistent with the previous study result.
However, patients considered as an important factor.
Therefore, nurses need to recognize the differences and
it is important to emphasize to have more chances to
discuss with patients about their good death.
509. Mummies Exhibition and Hospice Movement
Mária Markó, Katalin Muszbek, Rita ádám
Objective: One of the main tasks of the Hungarian
Hospice Foundation is to enhance social awareness in
the topics of death, dying and bereavement. The main
purpose of the cooperation between the Foundation
and the Hungarian Museum of Science was to break the
taboo of death and seek to change the confirmed
attitudes of schoolchildren, teachers and adult visitors
towards this delicate subject.
Method: The Foundation has been working in Hungary
for fifteen years and has affected social attitudes. The
cooperation between the Foundation and the
Hungarian Museum of Science is a result of this impact.
Co-workers of the Foundation offered coaching to the
hostesses of the exhibition Mysteries, Fate, Mummies
from May to November 2006 to help them answer
questions concerning death and dying. This coaching
consisted of five lectures and respective practical
training. The lectures were dealing with the customs,
images concerning and attitudes toward death int he
various cultures.
Results: After the end of coaching, hostesses had 77
conversations with a sum of almost 1000 children and
adults. Children dealt with these delicate subjects in a
much more natural way than adults. The teachers
attending schoolchildren expressed their interest in
further similar forms of coaching in their own schools.
Conclusions: The cooperation was further evidence that
there is great social interest in subjects related to death
and dying. Adequate forms of communication can help
expand common knowledge and change confirmed
attitudes towards these topics.
510. A Population-based Study on the Specific
Locations of Cancer Deaths in Taiwan, 1997-2003
Herng-Ching Lin 1, Chia-Chin Lin 2
1
University, Department of Health Administration, Taipei,
Taiwan
2
University, Department of Nursing, Taipei, Taiwan
In traditional Taiwanese culture, home death is
generally regarded as implying a good death, since it is
believed that the spirit will not be left to wander. The
purpose of this study was to determine the place of
death and identify the predictors of home deaths for all
cancer patients in Taiwan. We undertook a populationbased study using death registration data on all cancer
deaths occurring in Taiwan between 1997 and 2003. A
total of 173,187 eligible cancer deaths occurring during
the period were under examination. Results reveal that
around 60% of all cancer deaths in Taiwan between
1997 and 2003 occurred at home. Female cancer
patients and those aged between 55 and 64, who were
either married or widowed, living in the less-urbanized
areas of Taiwan, and areas with a low density of hospital
beds, were found to be more likely to die at home.
Results from logistic regression revealed that predictors
of home death included being female, aged greater than
55, ever being married, being employed, having
respiratory cancer, living in central Taiwan, and living in
less urbanized areas. There is increased awareness on a
global scale of the desire among terminally-ill patients
to be able to die at home, and indeed, we are seeing
greater effort towards promoting home death; however,
more palliative home care services will be necessary if
home deaths are to become a feasible option in Taiwan.
511. Effective Cross Cultural End of Life Home
Care
Jim Shalom, Yaniv Ben Shoshan
Hospice Upper Galilee, Medical, Rosh Pina, Israel
Nancy Caroline Hospice Upper Galilee (HUG) is a home
hospice in the Upper Galilee in Israel. Our part time
team consists of 4 physicians, 5 nurses, 2 social workers,
a music thanatologist (harpist), art therapist, volunteer
psychologist and team of volunteers. The demographic
makeup of the 76 communities of the Upper Galilee
includes Jewish towns, villages, kibbutzim and
moshavim. We treat Arabs, Christians, Jews, Moslems
and Druze. Providing effective palliative care means
finding the balance between standardized care and
tailor made individualized care. This is particularly
daunting when the treatment population is
heterogeneous and our emphasis is not simply on
pharmacological symptom control but also provision of
relief from suffering in the broader sense. At any given
time HUG may be treating a holocaust survivor,
Ethiopian new immigrant, religious Moslem Arab father
with secular children, secular kibbutz member and
religious Moroccan Jew. In such a varied background
issues such as deciding on treatment location and
medication emphasis for symptom control must be
individualized and culturally contextual. Dealing
professionally with end of life is contingent upon both
familiarity with the issues at hand and awareness of the
family mores. Only when trans- cultural care is done
effectively can there be significant relief of suffering. We
will present several case vignettes illustrating our
approach.
512. The extent to which literature exploring
cultural differences connects to the practice of
bereavement support.
Alison McNulty
University of Manchester, Psychology, Manchester, United
Kingdom
Cultural diversity in the UK, along with increasing
home deaths, makes the question of how influential
culture is upon bereavement essential when
determining bereavement support provision.Moreover
to fully understand the role of culture the argument of
whether bereavement is universal and innate, or socially
derived and learnt must be explored.Drawing upon
empirical findings from a larger study, this discursive
paper explores whether literature can inform the
practice of provision depending upon whether culture is
deemed universal or otherwise.22 support providers
completed 1 questionnaire per death over 3
months.This included; whether support was culturally
sensitive, and whether guidelines were followed.Of 595
deaths, 67% of bereaved were offered support with 60%
being offered culturally sensitive support.Yet few
services followed guidelines and instead opted to
provide support by ‘being aware’ and ‘having
respect’.Above all culturally sensitive support was
viewed as not sacrificing the individual, nor being too
prescriptive.These findings imply a socially derived role
of culture, yet on closer analysis the responses reveal a
passive provision whereby a universal model is accepted
with little room for differences.The empirical findings
and discussions surrounding the influence of culture
suggest that literature can be connected to practice in a
cyclical way through changing passivity into clear,
evidence led guidelines, and subsequent practices.
513. Exploration of the spiritual dimension in
Palliative Care at home
Encarnacion Perez Bret 1, Ana De Santiago Ruiz 2,
Inmaculada Martin-Sierra Navarro 3, Dolores Puerta
Ardiz 4, Maria Victoria Rodriguez Blazquez 5, Belen De la
Haz Gan 6, Manuela Diaz Romero 7
1– 7
Centro de Cuidados Laguna, Palliative Care at Home,
madrid, Spain
OBJECTIVE
To know the perception about spiritual needs of
palliative care patients in our team, methods used to
explore it and main difficulties found by professionals.
METHOD
Making a questionnaire to professionals about
assessment of spiritual needs and methods of
evaluation.
Discussion group about the results of the survey.
RESULTS
Participants in this study: 2 doctors, 2 nurses, 2 social
workers and 1 nurse assistant, members of the home
palliative care teams .
All professionals consider important the spiritual needs
assessment, but only 71% of the members of the team
do it usually. The main problems found by professionals
to explore spirituality are patients in agony (85%),
patients with difficulties in communication (71%) and
the family opposition or fears (71%)
About the evaluation methodology, 43% of professionals
don’t use any particular methodology and 57%
professionals assess spirituality by listening and asking
open questions. About the aspects that should be
registered in medical records, 43% of the members would
register religious beliefs and human relations and 29%
not only this but also other aspects which can help other
professionals.
CONCLUSIONS
The professionals of the interdisciplinary team are
interested in giving support to spiritual needs of
palliative care patients.
It is necessary to unify the criteria of spiritual
assessment and the way to register this evaluation in the
medical records. In this way, we propose to elaborate a
protocol of spiritual needs evaluation.
514. The Orthodox Jewish Community and Endof-Life Care: Needs and Guidlines
David Wollner, Eliot Fishman, Barbara Hiney, Toby
Weiss, Jay Schwartz, Charles Rudansky
Palliative Care Program, PALLIATIVE CARE SERVICES, New
York, United States
Orthodox Judaism is a religious system that adheres to a
relatively strict interpretation and application of the
“Halacha”, the corpus of Jewish religious law as
canonized in religious texts beginning with the Old
Testament and continuing until the present.
Metropolitan Jewish Health System is a highly
integrated system that provides a continuum of care to
chronically ill individuals of all ages. It includes three
extended care facilities, hospice and palliative care
services and a network of home health agencies in the
New York City area.
There has been an ongoing strain between the
Orthodox Jewish Community and hospice and
palliative care services regarding end-of-life care.
Metropolitan Jewish Hospice offers an “Halachic
Pathway” to every Orthodox Jewish patient and family
upon admission. The Pathway gives the family an
opportunity to identify a rabbi who will work with the
hospice interdisciplinary team to judge all medical
decisions in end-of-life care. The hospice’s own Halachic
advisor is available to serve this role as may a rabbi
whom the family knows and trusts. Each family is
guided in constructing an “Halachic Living Will” to
clearly identify a unique advance directive.
The Pathway has permitted the catalysis of earlier
discussions of end-of-life care and has helped develop
bridges with the Orthodox Jewish Community.
515. Changing perspectives in the last stage of
disease. Differences in professional and cultural
settings between attendants of EAPC
Jeroen Hasselaar, Jaap Schuurmans, Stans Verhagen, Kris
Vissers
Radboud university hospital nijmegen, anesthesiologie, pain
and palliative medicine, Nijmegen, Netherlands
AIM OF STUDY: Attention for palliative care is growing.
Nevertheless different views concerning optimal care for
the incurable patient still exist.
METHODS: A vignette-study was developed, addressing
three vignettes that follow the same patient in
progressive stages of disease (last month, 4th month, and
8th month before death). For each vignette respondents
were asked to score the patient on a rate of 1-10 (1=total
curative stage; 10=total palliative stage). The
questionnaire was addressed at the EAPC meeting in
Venice 2006 (n=336).
RESULTS: The response rate of the questionnaire was
19%. Preliminary results showed that 8 months before
death, oncologists judged the incurable patient to be
more in a palliative stage and less in a curative stage
compared to specialists from palliative care and internal
medicine. No differences were found between countries.
Respondents from USA/UK less often offered palliative
options of last resort (e.g. palliative sedation) in the last
stage of life compared to respondents from mainland
European countries.
CONCLUSIONS AND DISCUSSION: In this study,
oncologists interpreted and classified the vignette
different compared to other physicians. Treatment of
the patient in the last stage of life shows differences
149
Poster abstracts
attributed mainly to strong family ties, spiritual coping
and support from family and friends. Their high
satisfaction with the care they were receiving from the
Hospice was another contributing factor
Poster abstracts
between countries. Further discussion as well as
education is needed to distinct when and how incurable
patients should be treated in a palliative care program.
516. APPROXIMATION TO AN OBJECTIVE “GOOD
DEATH”
Ramón Martín, Gracia Megías, María Jesús Elvira, Rafael
Vidaurreta, Martín Cuenca, Vicente De Luis
palliative terminal care in the home setting.
Method
Turkish, Arabic and Hindustan Surinam migrants are
approached through migrant key persons who are
trained to lead group discussions with elderly people,
informal caretakers of their own ethnic group. In these
groups the needs and wishes of terminal patients and
their families, and possible solutions will be discussed.
The most promising of these solutions will be tried in
community based pilot projects.
Results and conclusion will be presented at the congress.
Fundación Instituto San José, Madrid, Spain
Introduction: The Pastoral Team have tried an approach
to the subject carrying out a close monitoring assessing
how patients admitted to our PCU have died.Objectives:
1.To measure patients the “quality of death” in patients
admitted to the PCU. 2.To develop a standard
instrument for death’s evaluation.Method: We have
designed an instrument with five evaluation criteria
(each of them scoring between 0 and 2): 1. Pain control.
2. Control of other symptoms. 3. Control of anxiety. 4.
Presence of the family and/or the therapeutic team. 5.
Main carer’s support during the whole process.
Descriptive and quantitative study during the period
1/07/04 to 31/12/06.Preliminary Results: Total deaths:
700 Global score (0-10) for Good death’s (average and
range): Year 2004: 8,03 (5-10) Year 2005: 8,29 (5-10) Year
2006 (6 months): 8,20 (4-10)Conclusions: Patients
admitted to our PCU had had a satisfactory death’s
quality factor (>8/10). It is necessary to have more
information about other factors able to influence the
quality of the death moment.
517. Attitudes toward hospice-palliative care of
patients with terminal cancer
Su-Jin Koh, Kyoung Shick Lee, Young Seon Hong, JinHyoung Kang, Sang Ok Choi, In Sook Woo
Catholic University Kangnam St. Mary’s Hospital, Internal
Medicine & Medical Oncology, Seoul, Korea, South
Poster abstracts
Background: We evaluated the attitudes toward
hospice-palliative care of the terminal cancer patients
who refused hospice care, comparing them with patients
in the hospice center.
Methods: We enrolled the patients with advanced
cancer who did not take further anti-cancer therapy
(ECOG 3-4). The patients in general ward who refused
transfer to hospice unit and in the hospice center were
assessed using the questionnaire that was composed of 5
categories including the perception and attitude of
physical, psychological, social, spiritual aspects and
hospice.
Results: The patients in general ward (GW) were not
satisfied with their present status (GW vs HC: 31.8% vs
61.5%, respectively) and required anti-cancer
chemotherapy more than them in hospice center
(HC)(58.3% vs 13.3%). In terms of the anti-cancer
treatment, patients in GW needed more information of
new treatment than them in hospice center (66.7% vs
33.3%). The patients in HC did not expect that they
would get better and be relieved to cancer-related
symptom (6% vs 61.5%). Regarding psychosocial
aspects, the patients in GW had angrier feelings than
them in HC(41.7% vs 19.2%). In terms of attitude
toward the dying process, the patients in GW rarely
talked about death with their family, but the patients in
HC prepared for dying with their family members
(16.7% vs 64.3%). The patients in GW did not feel any
spiritual help, however, the patients in HC felt
comfortable with the spiritual support by hospice team
(33.3% vs 75%)
518. The community-based development of
culturally-sensitive voluntary palliative terminal
care
Jos Somsen, Hans Bart
Volunteers Palliative Terminal Care (VPTZ), National
Centre, Bunnik, Netherlands
Aim of project
Most Dutch citizens want to die at home. Although
health care professionals can do a lot in supporting this
wish, caring for a terminal patient is a demanding task
for informal carers. To ease the burden they may be
supported by trained VPTZ volunteers. Research suggests
that the burden on families of migrant terminal patients
is even higher, due to extra tasks such as interpreting,
and catering for the many visitors. Nevertheless,
migrant families seldom seek support from the VPTZ.
This may be due to a lack of information about VPTZ,
but research suggests that factors such as language
barriers, taboos on needing support outside the family,
and reluctance to allow more than one person in the
intimacy of the sickbed also play an important role. The
aim of this project is first to investigate which forms of
voluntary palliative terminal care would be helpful to
families of diverse migrant groups, with respect to their
customs and cultural values, and second to help
migrants develop culturally sensitive forms of voluntary
150
they didn’t go home any more. The authors describe
how an acceptance of death and its consequences 11
years after the change of regime will be necessary. We
also demonstrate how one might start to break down
the taboos related to this subject.
522. Improving quality of life. Towards a
normative framework of palliative care to
patients with a severe mental disability
Maaike Hermsen
519. Fateless and stateless
University Medical Centre, Medical Ethics, Nijmegen,
Netherlands
Denise Brady
St. Christopher’s Hospice, London, United Kingdom
Introduction. This presentation encompasses loss and
grief including links – bridges - that span generations,
countries and disciplines. It has a focus on migration
and emigration. It is particularly about Hungary and
visits Germany, Ireland, England and Australia.
Methods. Material is being collected about Hungary
linking its citizens and their migrations to other
countries. For example, it includes concentration camps
in Germany and Hungarian refugees in Ireland after the
Revolution of 1956. It finds some Hungarians who have
recently moved to England. Sources include newspapers
in Ireland and England, some academic texts and two
books of fiction written by and about Hungarians,
Sorstalansag (Fateless) by Imre Kertesz (1975) and
Stateless by Mark Collins (2006).
Outcomes. These are but fragments. However, delegates
will have more knowledge and information of
Hungarian people, especially of migration. This can
provide greater connectedness for health professionals in
palliative care, caring for Hungarians in other countries.
Accompanying issues of loss and migration are insights
on arrivals and departures, rootlessness and integration.
These are actions and metaphors closely related to
themes of listening to people near the end of their lives.
520. Documenting pastoral care: reflections on a
new IT-based protocol for hospital chaplains
Traugott Roser 1, 2, 3, Thomas Hagen 1, 2, 4, Thomas
Kammerer 2
1
Interdisciplinary Center for Palliative Medicine,
Psychosocial & Spiritual Resources, Munich, Germany
2University of Munich, Chaplaincy, Munich, Germany
3
University of Munich, Department of Theology, Munich,
Germany
4
Archdiocesis Munich Freising, Palliative and Hospice
Pastoral Care, Munich, Germany
Background
The exact institutional role of hospital pastoral care
services remains an open question in many countries.
Palliative Care includes spiritual care as part of its
approach. This requires an appropriate way of
documenting the work of spiritual care services.
Methodology
The ecumenical pastoral care team at our hospital
developed a computer-based protocol of documenting
services performed while on-call (24 h/day, 7 d/week).
For every call, date and time,, patient data and clinical
situation, religious affiliation, person requiring pastoral
care, and the type of service performed are recorded.
Results
In 2004 357 calls were reported, 517 calls in 2005. 76%
of all calls took place within a perimortal situation. Calls
during the night (10 pm to 8 am) rose by 50% from
2004 to 2005. Calls during day time (8 am to 5 pm) rose
by 63%. Compared to the total number of deaths within
the hospital (2005 n=865) pastoral care services were
involved at a rate of 46%. Many of the services
performed were rituals.
Discussion
Pastoral services are most often called in the context of
dying, death and bereavement. The data indicate the
importance of a standardized protocol for reporting
spiritual care services as part of organisational clinical
setting. A computer-based data report form can help the
multiprofessional team understand the work performed
by spiritual care professionals. It also offers a completely
new data pool for research in the field of spiritual care.
521. Hospice Care in Rural Hungary
Aim
The primary goal of palliative care is to improve the
quality of life of patients facing life-threatening illness. it
is accepted that assessment of quality of life is subjective:
what contributes to quality of life is a judgement made
by the patient himself. However, an alternative
perspective is needed when patients are not able to
articulate their own preferences and desires, as in the
case of severely mentally disabled (smd) patients. The
improvement of their quality of life must necessarily be
carried out by others. Patients with a smd are fully
dependent on others. Research has shown that this
responsibility weighs heavily upon caregivers. Caregivers
indicate to be in need of instruments that provide points
of reference to distinguish between harm and benefit,
and to confirm whether their interventions are indeed
improving quality of life. This study will contribute to
answering this need.
Method
Literature study
Results
A normative framework for the improvement of quality
of life of smd patients should not be based on the
independence of the patient but rather on relation,
closeness and presence.
Conclusion
It has been argued that the goal of palliative care remains
the same regardless of who the patient is. However, if the
improvement of quality of life for smd patients seems to
come under threat, palliative care is potentially less allinclusive than it presumes. This study contributes to the
clarification of the concept of quality of life and
palliative care.
524. Written information and signed consent
forms in palliative care: the ethical issues
Isabelle PLU 1, Grégoire MOUTEL 2, Christian HERVE 2,
Françoise ELLIEN 3, Irene PURSSELL-FRANCOIS 1
1
School of medicine/Faculté de médecine, Department of
forensic medicine and medical law/Médecine légale, Dijon,
France
2Faculté de Médecine, Université Paris V René Descartes,
Laboratoire d’Ethique Médicale et de Médecine Légale, Paris,
France
3
Réseau SPES, Champcueil, France
Introduction: French palliative care networks aim to
help healthcare workers to take care of patients at home
by improving coordination and the continuity of care.
French legislation in 2002 defined that an information
document explaining the functioning of the network
should be given to patients and signed when they enter
a healthcare network.
Objective: To study the ethical issues arising from the
application of this legislation in palliative care.
Discussion: The obligation to provide information
relating to palliative care contradicts the doctor’s
obligation to respect the patient’s wish not to know his
diagnosis or prognosis. From a legal viewpoint, the
signature of the document is contestable in such
circumstances because it does not necessarily indicate
that the patient is capable of making an informed
decision. Last, the signature of the consent form by a
guardian, the designated person of trust or a relative
transforms the doctor-patient relationship into a
triangular doctor-patient-third party relationship.
However, healthcare professionals must be aware that
the relationship with the patient is based on trust and
that decisions must always be made for the good of the
patient.
Conclusion: Compulsory written information and
signature of consent forms is not appropriate in the
practical realities of the doctor-patient relationship in
palliative care. Oral information must be preferred.
László Darvai 1, Ferencné Mihailov 2, Katalin Kádár 3
1– 3
Menedékhely Foundation, Novaj, Hungary
People became isolated from one other under Socialism
in Hungary. In these decades women had to go to work,
and families moved into tower blocks in urban housing
estates losing touch with their wider families and so the
tradition of living together in big families broke down.
People became estranged from the concepts of home
care and the proximity of death. Every incurable patient,
particulary in the towns was hospitalized and usually
525. Audit of appropriateness of resuscitation
and documentation of ‘Do not Resuscitate orders’
Tracy Anderson 1, Kiran Kaur 2
1– 2
Royal Victoria Hospital, Palliative Care Team, Belfast,
United Kingdom
Aim:
To identify what proportion of hospital deaths involved
resuscitation,whether any of these attempts were
Poster abstracts
526. Suffering induced by perseverance of
nursing care on terminal patients.
Raffaella Dobrina, Emanuele De Leo
These opinions may depend on the intensity and
quality of nurse-patient relation in end-of-life care.
support: the institution must provide the staff with the
support they need. The main differences are shown in
table 1.
528. ARTIFICIAL NUTRITION AND REHYDRATION
AT THE END OF LIFE:YES OR NO
Table 1. Differences between the guidelines of the
Geneva and Vaud nursing home associations
Geneva
Vaud
Policy of the nursing home:
Yes
Excessive
can object to AS as morally
inacceptable impediment to
personal freedom
Respect of self determination
Yes Consideration
of the values
of others
(residents, staff)
Staff can take part in AS
Yes
No
Natasa Milicevic, Leonida Mirilo
Centre for palliative care and palliative medicine
BELhospice, Belgrade, Yugoslavia
End of life care abounds with ethical dilemmas.One of
those concerns artificial nutrition and rehydration.
The aim of this presentation is to explore the opinion of
medical staff regarding this issue at the end of patients’
lives.
METHOD: All doctors (n= 131) and nurses (n= 223)
employed by one of the university hospitals in Belgrade,
Serbia, were asked to answer the following questions:
-Do you think that artificial nutrition is necessary at the
end of patients’ lives if they are not able to eat?
-Do you think that artificial rehydration is necessary at
the end of patients’ lives if they are not able to drink?
RESULTS: 85 doctors (64,9%) and 126 nurses (56,5%)
answered the questions.The answers regarding artificial
nutrition were as follows: 196 (92,9%) of them consider
that it is necessary, while 15 (7,1%) consider it as
inappropriate.Concerning the artificial rehydration 203
(96,2%) of them think that artificial rehydration, as a
minimum of end of life care, should be applied,
whether 8 (3,8%) consider it as
inappropriate.Correlation of these answers to
occupation, age, sex and faith will be presented in detail
at the Congress.
CONCLUSION: medical staff approaches in this hospital
are disease-oriented and not patient-oriented and
appropriate education concerning end of life care and
withholding and withdrawing treatment is necessary.
Antea palliative care unit, Palliative Care, rome, Italy
Do nurses stop when patients with very high rates of
asthenia and sleepiness in their last days of life say no to
baths, to painful management of wounds that will never
have the time heel, to mobilizing made to prevent
lesions that wont have time to form, to pills that are not
able to swallow and that remain in their mouths for
hours? If they do, would it be considered
neglecting?While wide literature is on futile treatment
and therapies, little is said on what is suffering caused by
nurses care when terminal patients say “please leave me
alone, I’m too tired..”A discussion has been provoked in
an Italian nursing forum on the subject “perseverance
of nursing care”. Interesting answers has been collected
and reported (with consensus) in this study, showing
that the problem is real and felt by nurses acting in
different fields (hospitals and hospices).
527. French hospital and district nurses: opinion
toward legalisation of euthanasia and medical
assisted suicide: A National Survey
MARC BENDIANE 1, 2, ANNE GALINIER 3, ANNE
BOUHNIK 1, 2, ROGER FAVRE 4, JEAN-MARC LAPIANA 5,
CLAUDE RIBIERE 6, JEAN-PAUL MOATTI 1, YOLANDE
OBADIA 1, 2, PATRICK PERETTI-WATEL 1, 2
1
Health and Medical Research National Institute,
RESEARCH UNIT 379, Marseilles, France
2
Southeastern Health Regional Observatory, ORS PACA,
Marseilles, France
3ASSISTANCE PUBLIQUE HOPITAUX DE MARSEILLE,
Service de médecine pénitentiaire, Marseilles, France
Service d’oncologie médicale, Marseilles, France
5
La Maison, Palliative care unit, Gardanne, France
6
ASSISTANCE PUBLIQUE HOPITAUX DE MARSEILLE,
Direction Générale, Marseilles, France
Aim: The ongoing debate about euthanasia is primarily
focused on physicians’ attitudes, while those of nurses
are seldom given much attention. Some studies
suggested that nurses perform patient-requested
euthanasia more frequently than physicians, and
occasionally without consulting one of them. This
report aims to assess French nurses’ opinions toward
Euthanasia (E) and Physician-Assisted Suicide (PAS),
using data from a nationwide survey conducted in 20052006. Method: An anonymous telephone survey carried
out among a national random sample of French district
and hospital nurses.Participants: 2,104 French nurses
agreed to participate (response rate: 68%).Main
outcomes measured: Opinion toward the legalisation
of E and PAS (Likert scale), attitudes toward terminal
patients, personal and professional characteristics,
opinions toward palliative care, pain treatment
knowledge.Results: Overall, 53% of respondents
supported the legalisation of E and 34% for PAS. District
nurses are more willing to uphold E and PAS legalisation
than hospital nurses. One controlled for confounding
factors, several personal characteristics (age, gender,
religiosity) and professional characteristics (training……)
remained associated with nurses’ opinion.Conclusion:
Factors associated with opinions toward E and PAS are
different among French district and hospital nurses.
529. Dignity for the Elderly in Nursing
Institutions and at Home in Europe - How can we
guarantee them Palliative Care?
Stein Husebo 1, Frode Jacobsen 2, Bettina Husebo 2,
Georg Bollig 3
1
University of Klagenfurt and Vienna, Department of
2University of Bergen, Department of Public Health and
3
Aim: The world-wide accepted concept of palliative care
includes cancer patients, mainly younger than 75 years
old. However, all elderly citizens desperately need this
offer. Their number is several tenfold higher than the
“lucky” severe ill and dying patients receiving proper
and competent palliative care. Our aim is to give a
European review of the present and future needs for
palliative care in the elderly, and to give access to the
necessary tools in institutional home care services and
care givers in all European countries. Methods: A
European project: “Dignity and Palliative Care for the
Frail Elderly” is established since 2003, cooperating in a
European network with professionals representing 12
countries, coordinated by University of Klagenfurt and
Vienna, Austria and University of Bergen, Norway. A
European survey on the situation and need for
action was collected for publishing in a textbook
(expected for publication 2007). Targets for
implementation of palliative care for the frail elderly
were identified. Results: Access to palliative care for
elderly patients in home care or nursing institutions
is extremely poor in all European countries. The need
will face a dramatic growth of the elderly population the
next fifty years and the need for national and local
implementation projects is imminent. Our program for
implementation will be available end of 2007. A
European congress is planned 2008.
530. Assisted suicide in nursing homes: a
comparative analysis of two guidelines.
Monica Escher
Geneva University Hospitals, Mobile Palliative Care Team,
Clinical Pharmacology and Toxicology, Geneva, Switzerland
Assisted suicide (AS) is authorised in Switzerland.
Nursing homes hold a unique position as they are both
the residents’ new homes and health care institutions.
The ethics committees of two regional associations
wrote guidelines about AS in nursing homes. Aim: to
determine the similarities and differences between the
guidelines of Geneva and Vaud, two French-speaking
neighbouring cantons. Results: both texts aim to serve as
a basis for a debate which should take place in each
nursing home. The main point is a person’s right to self
determination must be respected, also in a nursing
home, considering that it has become his life-place.
Decision-making capacity is a prerequisite. Emphasis is
put on: 1. time: the request must be persistent 2.
procedure: the various steps must be made clear 3.
Conclusion: The associations of nursing homes in
Geneva and Vaud acknowledge that the residents should
have access to assisted suicide. Their guidelines however
differ on substantial points.
531. Reasons palliative care patients desire
hastened death and the quality of clinical
guidelines to assist health professionals to
respond.
Peter Hudson 1, Linda Kristjanson 2, Michael Ashby 1,
Brian Kelly 3, Penelope Schofield 4, Rosalie Hudson 4,
Sanchia Aranda 4, Margaret O’Connor 5, Annette Street 6
1
St Vincent’s Health and The University of Melbourne,
Centre for Palliative Care, Melbourne, Australia
2
Curtin University, Perth, Australia
3University of Newcastle, Sydney, Australia
4University of Melbourne, Melbourne, Australia
5
Monash University, Melbourne, Australia
6
La Trobe University, Melbourne, Australia
Aim: We evaluated the research evidence related to the
reasons palliative care patients express a desire for a
hastened death and the quality of clinical guidelines in
this area. Methods: A systematic literature review was
undertaken using conventional processes. Results:
Thirty-five research studies met the inclusion criteria
related to reasons associated with a desire for hastened
death. The factors associated with a desire to die were
multifactorial, psychological, existential and social
reasons seemed to be more prominent than those
directly related to physical symptoms such as pain.
However, much of the evidence is based on patients’
perceptions of how they might feel in the future, and
health professionals’ and families’ interpretations of why
desire to die statements may have been made. In keeping
with this limited research base there is also a lack of
evidence-based guidelines for clinical care. Most
guidelines focus on discipline specific responses with
minimal exploration of how clinicians might respond
initially to a statement from a patient regarding a desire
to die. Conclusions: In order to increase understanding
of the complex issues regarding desire for hastened
death, research should focus on studies with patients
who have actually made a desire to die statement.
Furthermore, guidelines need to be developed to help
health professionals respond appropriately.
Recommendations for research in these two main areas
are described.
532. A prospective regional audit of the use of
artificial hydration (AH) in the dying phase
Jennifer Smith 1, Anita Roberts 2, Lynne Moorhead 3,
Catherine Wilcox 4, Kate Smith 5
1
Countess of Chester Hospital, Palliative Care Team,
2
Marie Curie Palliative Care Institute, Liverpool, Palliative
Care Team, Liverpool, United Kingdom
3HOSPICE OF THE GOOD SHEPHERD, Social work,
4West Lancs, Southport & Formby Palliative Care Services,
5St Lukes Hospice, Winsford, United Kingdom
Aim The use of artificial hydration (AH) in the dying
phase is an emotive and controversial issue.The Mental
Capacity Act (2005),enacted in April 2007 in England
and Wales,will influence decision-making around the
use of AH at the end of life for those who lack
capacity.The aim of this audit was to explore the use of
AH across the Merseyside and Cheshire Cancer Network
(MCCN) in the UK.
Methodology A literature review was performed and
evidence-based guidelines and standards were
formulated.Based on these a proforma was developed to
audit the use of AH in the dying phase over a ten-week
period within 2 integrated clinical networks of the
MCCN including community,hospital and hospice
settings.It focussed on demographics,decisionmaking,documentation,symptoms and compliance
with the recommended regimen.
Results 88 completed proformas were returned - 27
hospital,36 hospice,25 community. 42% of decisions
151
Poster abstracts
inappropriate,what proportion of patients had a DNAR
order and why,who it was discussed with and how it was
documented.
Method:
A retrospective audit was carried out in the Royal
Hospitals Trust of patients who died in March 2006.
The standards used were based on the trust policy on
do not resuscitate decisions.
Results:
31 charts were analysed.Death was expected in 84% of
patients but only 77% of patients had a DNAR
order.Resuscitation was attempted in 29% of
patients,but in more than half of these patients
resuscitation may have been inappropriate.87% of
patients were not involved in decisions about
resuscitation,the reasons for this were poorly
documented.Documentation was unclear in 41%.There
was no universal method of documentation and there
was poor documentation of discussion with consultant.
Conclusion:
Patients and families should be encouraged to be
involved in decisions regarding end of life care,with
timely discussions about resuscitation,where
appropriate.The reason for this is to decrease the
number of inappropriate CPR attempts,prevent
prolongation of death and to allow the patient and
family to prepare for death.Communication training
should be provided for medical staff.There should be
clear documentation of discussions,a suggestion was to
use a large coloured sticker in the clinical notes.The
decision should be reviewed by the consultant on a
regular basis.
Poster abstracts
regarding the use of AH involved MDT and 29% were
documented (missing n=13). 20 patients (18 from the
hospital setting) received AH with 50% following the
recommended regimen (missing n=4). AH was
continued until death in 8 patients.
Conclusions Decisions regarding the use of AH were
strongly influenced by care setting.It was not possible to
draw conclusions about the influence of symptoms due
to missing data.Guidelines and standards for the use of
AH in the dying phase were revised in the light of the
literature review and audit results.
533. Differences in experiences of nurses and
doctors with end of life decisions
Annelies De Vuyst 1, Bernadette Dierckx de Casterle 3,
Nancy Cannaerts 2, Walter Rombouts 2
1
A.Z. Virga Jesse, Geriatric, hasselt, Belgium
Gasthuisberg, Palliative Care Team, leuven, Belgium
University, Nursing, leuven, Belgium
2U.H.
3
Although end-of-life decisions recieve a lot of attention
these days, little scientific evidence exists about this
topic. Literature describes taking end-of-life decisions as
a complex process in which tensions between physicians
and nurses are perceived. In the first place these tensions
are attributed to disparity concerning role fulfilment
and role expectations.This qualitative study clarifies the
differences between nurses and physicians experiences
with end of life decisions. In depth interviews were
conducted with seven physicians and eight nurses
involved in five end-of-life decision cases in the
University Hospitals Leuven. Results show important
differences between nurses and physicians. Still nurses
as wel as physicians both start from a feeling of
involvement with the patient. They express this
common feeling in a different way: they handle a
different “role-expectation model” and “role fulfilment
pattern” about themselves and about one another. The
reason why especially nurses consider the decision
process as a very difficult one, is the lack of
communication about these role expectations and the
role fullfilment. Surprisingly physicians don’t seem to
notice this lack of communication nor the tensions
caused by this lack of communication. The findings of
this study underscores the importance of
communication in end of life decisions and the need for
development of a culture of interdisciplinary
communication.
534. TREATMENT USED IN THE LAST WEEK OF
LIFE IN AN ACUTE PALLIATIVE CARE UNIT(PCU) :
PRELIMINARY RESULTS.
Silvia Llorens 1, Jose Espinosa 1, Victoria Ma as 1, Xavi
Perez 2, Xavier Gomez-batiste 1
1
Poster abstracts
Institut Catala d’Oncologia, Palliative Care Service,
Barcelona, Spain
2
Institut Catala d’Oncologia, Clinical Research Unit,
Barcelona, Spain
AIM
METHOD Descriptive retrospective study.A randomised
sample of the 321 patients died in PCU in 2005
Variables
Age, sex, tumour, cognitive state, PPS, Barthel index and
awareness of an impending death. Drugs, way of
administration, treatment pharmacology and tests used
at 7, 3 and 1 day before death (BD).
RESULT
Clinical records of 185 patients were reviewed . Mean
age was 64,8 yrs. and 66,5% were male.The median of
Barthel was 35 and PPS 30. Mean stay was 9.7
daysRegarding via of adm. many simultaneous
parenteral ways were used even IV or SC.The IV route
was used in the 67,0% of the patients in day 7 BD
and 54,6% in the day 1 BD. The IV route was used in the
day 1BD for hydration in 14,21% of the patients and the
main reason for IV route was for continued infusion of
drug for symptom control.PO adm. falls from 72% in
day 7 to 15% in day 1 . Laboratory tests were requested to
a 1/5 in the 7th day falling till 2% in day 1 . Image tests
were seldom used. Concerning drugs an overall
reduction was observed, but still 10% pts. were on
antibiotics the day 1 BD & 20% were on prophylactic
Omeprazol.
CONCLUSIONS
Drugs, iv lines and laboratory test overuse can be seen as
a hazard for the quality of end-of-life care, this
description is the way to evaluate and improve the
quality.
Better recognition of the last days of life and the use
of specific pathways would be of help.
535. Is the published debate in palliative care
research ethics sufficient to guide sensitive
palliative care research?
Sue Duke 1, Helen Bennett 2
1
Southampton University, School of Nursing and Midwifery,
152
Southampton UK, United Kingdom
2
Naomi House, Winchester, United Kingdom
Introduction: Ethical research lies as much with the
design of a study as it does with its conduct and the
quality of the relationship between researcher and
participant (Lawton 2001).
Aim: To assess whether the published debate in
palliative care research ethics is sufficient to guide
sensitive palliative care research.
Method: A literature review of a diverse body of
published palliative care literature was undertaken
adopting the principles of a systematic review to manage
selection bias (Bennett et al 2005). Papers were
identified from a wide range of databases and search
engines (n=560 papers), subjected to explicit inclusion
and exclusion criteria and critically reviewed (n= 52
papers).
Findings: Several debates emerged - benefits and harms
of palliative care research; ethical challenges of palliative
care research; the need for research design to be rigorous
despite these challenges; argument that constraints in
palliative care research are less to do with ethics than
financial and external review issues. Assessed against
typical research governance standards the reviewed
literature fails to adequately address issues of participant
voice and research practice, although these are
emergently present in recent publications.
Discussion: Debates from the social science literature
are offered to contribute to the reviewed debate on voice
and supportive research practice, drawing on situated
ethics, democratic evaluation and feminist ethics.
536. An evaluation of film showing followed by
small group discussion in teaching medical
students dying with dignity vs. euthanasia
Maria Fidelis Manalo 1
1
Far Eastern University-NRMF Medical Center, Community
& Family Medicine, Quezon City, Philippines
2
Supportive, Palliative & Hospice Care, UP-PGH, Family &
Community Medicine, Manila, Philippines
Aim It is so important that medical students learn well
the bioethical principles early in their medical
education. Critical thinking skills are highly required in
particular when the students come face-to-face with
dying patients in the future. Instead of the usual
lectures, they need to be taught to be critical in their
decisions about death and dying, especially because of
the ethics involved. Film showing followed by small
group discussion is supposed to be excellent tool in
problem-based learning. We took a documentary film
for education on palliative care vs. euthanasia and
evaluated the effects on medical education. Methods A
film on “Euthanasia: Mercy or Murder?” was shown to
first year medical students attending a course on
Medical Ethics. The numbers of students were 80 per
section and they were divided into 10 groups/section.
The duration of the film was 30 minutes followed by
small group discussion for another 30 minutes. Each
group presented their output in a plenary session
facilitated by a moderator. We investigated into all
questionnaires, which were answered by each student
after the learning session. Results The percentage of
students who had good impressions on this filmshowing followed by small group discussion was 89%.
There were a good number of students who had a better
understanding of dying with dignity vs. euthanasia after
this activity. Conclusion Film-showing followed by
small group discussion enhances problem-based
learning on palliative care and ethical decision making
on end-of-life issues among medical students.
537. Ethical Guidelines on End-of-Life Decisions in
the Nursing Home
Anette Ester 1, 2, Georg Bollig 1, Stein Husebo 3, Bettina
Husebo 4
1
Regional Centre of Excellence for Palliative Care, Bergen,
Norway
3University of Klagenfurt and Vienna, Department of
4University of Bergen, Department of Public Health and
2
Worldwide 24 million people suffer from dementia; their
number has been estimated to increase to 81 million by
the year 2040. End of life decisions need to be balanced
between curative and palliative treatment. Hardly any
nursing home (NH) has ethical guidelines on end-of-life
decisions. In Norway, 40% of all deaths occur in a NH.
Aims: Study site was one of the largest NHs in Norway, a
174-bed facility with palliative care and long-term care
units. It was the aim to develop ethical guidelines based
on literature review and clinical experience regarding
informed and presumed consent, communication and
restraint of life prolonging treatment. Methods:
Guidelines were introduced for the staff and
implemented in clinical work by establishing an ethical
support team. Decision making processes were registered
in a qualitative observational trial. Results: It is necessary
to discuss and make individual arrangements before a
patients’ death. Guidelines on end-of-life decisions
emphasize starting the communication process early.
Most decisions are made during doctors’ rounds. Input
by the ethical support team was necessary more
frequently regarding patients with dementia or
multimorbidity. They include the patients, relatives and
staff. Conclusion: End-of-life decisions in NHs have to be
backed up by ethical guidelines. Guidelines and
preliminary results will be presented.
538. Ethical review committees and palliative
care research. Reflections on a multi-centre
application process.
Philip Larkin
University College Galway, Nursing & Midwifery Studies,
Galway, Ireland
This presentation describes the complexities of seeking
ethical approval for a palliative care qualitative study
into advanced cancer patients’ experiences of the
transition towards palliative care. 100 patients were
interviewed across 6 EU countries; UK, Ireland, Italy,
Spain, The Netherlands and Switzerland.This required
multiple ethical applications,sometimes duplicated at
local and regional level. Problems arising in negotiating
the differing requirements and demands made of the
researcher are reported. In particular, three issues are
discussed; paternalism around access to palliative care
patients, bureaucratic paperwork demands and a failure
to understand the potential impact of qualitative
research on patients. Poor feedback or follow-up from
research ethics committees (REC’s) questions how they
perceive their role and function. Despite positive
developments in the ethical assessment of research
protocols for RCT’s at a European level, there remain
serious limitations to be addressed where qualitative
methods are involved. We conclude that REC’s have a
responsiblity to explicate the decision-making
process by which they make judgments on the validity
and rigour of a study, in as much as the researcher has to
ensure that they abide by sound ethical principles in its
production and delivery.
539. Changing the treatment goal at the end of
life - the experience of a palliative care consult
service
Andreas Schaider, Ralf Jox, Gian Borasio
Interdisciplinary Center for Palliative Medicine, Palliative
Care Medicine, Munich, Germany
Aim. The study investigates the process of changing the
treatment goal from a curative to a palliative approach.
Methods. We analysed all case notes and protocols of
the adult palliative care consult service at Munich
University Hospital between Sep 2004 and Nov 2006 in
which the main question was change in the treatment
goal, using statistical assessment and Qualitative
Content Analysis.
Results. 13 of 17 cases (76%) happened on intensive or
intermediate care units. In 10 cases (59%) the question
could be solved by clarifying within the medical
profession that there was no longer any meaningful
indication for curative or life-prolonging treatment. In 5
cases, the treatment goal was changed in accordance
with the patient’s will. 12 out of these 15 cases entailed
discontinuation of life-sustaining measures. In the
remaining 2 cases, divergent family views on the
patient’s will led to the continuation of life-sustaining
treatment. Consult meetings comprised a median of 6
people (3 physicians, 2 relatives and one nurse), in half
of the meetings a chaplain was present. The patient’s
health care proxy was nearly always female (9 of 10).
Conclusions. The majority of cases were futility cases,
where the main challenge was clarifying the medical
indication. The second major problem is determining
the patient’s presumptive will in the absence of advance
directives. A specific protocol will be presented on how
to structure the process of changing the treatment goal
at the end of life.
540. Ethical decision-making in palliative care: a
prospective representative survey in Germany
Birgit Jaspers 1, 4, Friedemann Nauck 2, Christoph
Ostgathe 3, Norbert Krumm 4, Lukas Radbruch 4, None
HOPE Working Group0
1
Rheinische Friedrich Wilhelms University of Bonn,
Department of Science and Research, Centre for Palliative
Medicine, Bonn, Germany
2
University of Goettingen, Department of Palliative
Medicine, Goettingen, Germany
3
University of Cologne, Clinic for Palliative Medicine,
Cologne, Germany
4
RWTH Aachen University, Dept. of Palliative Medicine,
University Hospital of Aachen, Aachen, Germany
Poster abstracts
541. Physicians’ views on a possible legal
regulation of advance directives in Germany: a
survey
Birgit Jaspers, Katri Elina Clemens, Eberhard Klaschik
Rheinische Friedrich Wilhelms University of Bonn,
Department of Science and Research, Centre for Palliative
Background: A legal regulation of advance directives
(AD) is seen as a very promising instrument to achieve
both, patient autonomy and support of ethical decisionmaking of the treating physician. However, there has
been an ongoing controversial debate in Germany about
which aspects a possible regulation of AD should cover.
Aim of this study was to look into physicians’
experiences and wishes with regard to AD and legal
regulations of AD.
Method: 827 physician members of the German
Association for Palliative Medicine (DGP) were surveyed
using an anonymised e-mail questionnaire (17
questions/11 sub-questions) in 11/2006.
Results: 224 (27.1%) questionnaires were returned; up to
now 196 of these were evaluated. Of the physicians
(?133/67.9%) with an average work experience of 19.08.9(3-52) years, most found AD in the practical situation
helpful/rather helpful (36.1%/45.5%), 37.6% think a
regulation is desirable, 30.1% rather desirable. 44.7%
found it acceptable that AD should be applicable in all
patients, 20.5% only and 34.% rather applicable in
patients with incurable, life-limiting disease. 18.3%
thought regulations acceptable, where there is no
obligation to have received previous advice, 32.9%
found this unacceptable, 48.8% rather unacceptable.
Conclusions: A political/judicial agreement on the
wording of a legal regulation on AD should consider the
views of physicians, based on practical experience and
professional ethos. Further research is urgently needed.
542. “There is a time to be born and a time to die”
(Ecclesiastes 3,1-2). Jewish Perspectives on
Euthanasia.
Goedele Baeke 1, 2, Bert Broeckaert 1, 2
1
Katholieke Universiteit Leuven, Faculty of Theology,
leuven, Belgium
2
In most western societies the “medical revolution”
provoked considerable bioethical debate. However, in
these discussions the voices of religious minorities are
often absent. In answer to this challenge, we discuss in
this presentation Jewish opinions on euthanasia.
Although (Orthodox, Conservative, Reform) Rabbis
when dealing with an ethical challenge such as
euthanasia are appealing to the Halakha (Jewish law)
and usually base their judgments on common Jewish
sacred texts, a heterogeneity of interpretations emerge.
Basing themselves on the most important sources
(Avodah Zarah 18a, Ketubot 104 and the “laws of goses”,
Semahot 1,1-4), Orthodox Rabbi Bleich, Conservative
Rabbis Dorff and Reisner and the Reform Central
Conference of American Rabbis radically oppose
euthanasia. Using the same sources Conservative Rabbi
Sherwin and Reform Rabbis Knobel and Kravitz
discover, however, some openness for mercy-killing in
the traditional Jewish tradition. It is not surprising to
find some supporters of euthanasia on the liberal side.
After all, Reform Jews - Conservatives in a lesser degree perceive the Halakha as mainly the work of human
hands and having an advisory function. Orthodox Jews,
on the contrary, consider the Halakha as an absolute,
immutable and binding divine norm. Taking these
divergent perspectives into account, our conclusion is
that the Jewish stance on euthanasia does not exist.
Without neglecting this heterogeneity, it must be
stressed, however, that pro-euthanasia opinions are
exceptional voices, even within the Conservative and
Reform denomination.
543. “Two Jews, three opinions”. The Divergent
Specificity of Jewish End-of-Life Ethics.
Goedele Baeke 1, 2, Bert Broeckaert 1, 2
1
Katholieke Universiteit Leuven, Faculty of Theology,
leuven, Belgium
2
In this presentation, based on an extensive review of the
available literature, we discuss the divergent specificity
of Jewish end-of-life ethics. Though Jewish end-of-life
ethics is characterised by a typical halakhic
methodology - appealing to the Jewish religious law and a case-based approach, there is also wide diversity.
This is due to the fact that there is no central Jewish
authority and to the divergent ways in which the
Halakha is addressed, as either binding or rather guiding
and advising. This inner-Jewish (denominational)
heterogeneity can be duly illustrated through the debate
on sanctity of life versus quality of life. Although all are
valuing the Jewish mitzvah (commandment) of pikuah
nefesh - the preservation of human life - and the Jewish
conviction that human beings bear special worth as
being created as God’s stewards, Jewish ethicists take a
divergent stance in the debate. Whereas e.g. Orthodox
Rabbi David Bleich defends an absolute sanctity of life
approach, others are stressing the importance - instead
of the sacredness - of human life and see quality of life
as a criterion to be taken into account when dealing
with bioethical challenges. This debate is reflected in
rabbis’ opinions on end-of-life decisions, such as
withdrawing of life-sustaining treatment. Most rabbis
hold to the distinction between the preservation of
human life - which is commanded - and (artificially)
prolonging the death process and agony - which is
prohibited, though there are important differences of
opinion, e.g. regarding the withdrawing or withholding
of artificial nutrition and hydration.
544. Psychosocial support in Palliative Care
Irena Bildireva
Palliativ Care Unit, Cancer department, Sofia, Bulgaria
The purpose of this paper is to summarize and
rationalize the meaning of psychosocial support and its
crucial role in improving Supportive Care. Today the
literature is reach of empirical data enough for
defining the need to apply more systematically holistic
approach in Supportive Care as a component of routine
cancer care. Assessment the psychosocial variables are
an ongoing process that allows an evaluation of
response to the rapid changes caused by the advanced
disease. It is designed to lead health care practitioners to
understand better the medical and psychosocial
situation of the patient/family system so that the
effective intervention can be developed.Supportive
therapy as an integrative approach is effective model for
dealing with psychosocial distress and better quality of
life for patients in end-of-life.
Conclusions
- Psychosocial Support facilitate the sense of mutuality;
the feeling of being understood as well as
understanding; being empowered as well as
empowering.
- Psychosocial Support diminishes emotional distress
and improves quality of life of patients in the
patient/family system.
- Healthcare practitioners have to inquire about the
quality of psychological well being of their patients in
facing advanced illness and offer psychosocial
support.
546. Attitudes toward euthanasia and assisted
suicide of the Portuguese oncologists
José António Ferraz Gonçalves
doctors would practice euthanasia in the actual situation
illegality and would rise to 24% if it was legal. Only 29
doctors (21%) received requests for euthanasia in a
variable number and only 1 practiced euthanasia once.
The results about assisted suicide are similar; although
only 5 doctors received requests and no one accept any
of them.The only factor statistically significant
concerning the opinion about euthanasia and assisted
suicide was if the doctor was a practising catholic or not
with those being more often against. Relatively to
assisted suicide also doctors older than 65 were more
often against (p = 0.027)
Conclusion Only a small minority of Portuguese
oncologists seems favourable to the practice of
euthanasia and assisted suicide. Religion and age are the
only factors significantly associated to the attitudes
about those practices.
547. End-of-life Ethics in a Hindu Context: An
Analysis of the Difficulties Related to the
Determination of the Hindu Attitude
Joris Gielen, Bert Broeckaert
Aim of the Study: There exist only a few studies
dealing with ethical problems like euthanasia and
physician assisted suicide from a Hindu perspective.
These studies generally use a Western conceptualisation
of religion and fail to appreciate the diversity in
Hinduism. We investigate to what extent traditional
Hindu sources can help palliative care workers to
anticipate ethical end-of-life dilemmas whenever
Hindus are involved. Method: We performed a critical
analysis of authoritative Hindu sources from which
Hindus draw inspiration to determine their attitude
towards end-of-life issues. Result: There are several
Hindu concepts and ideas that could be connected with
euthanasia. These ideas are often contradictory. A
generally applicable Hindu end-of-life ethic does not
exist. This does not mean that ethical thinking is absent
in Hinduism. Hindus believe they are responsible for
their actions and that they have to live an ethically
correct life. But, there is no Hindu authority that can
concretely determine what an ethically correct life
amounts to in all circumstances. When making concrete
end-of-life decisions Hindus contextually draw from a
vast body of ethical injunctions and exemplary stories.
Conclusion: In the context of palliative care it must be
realised that Western ethical models are not universally
applicable. Awareness of the complex Hindu point of
view will also contribute to the development of a
contextually adapted model of palliative care for Hindu
patients.
548. Attitudes toward end-of-life situations other
than euthanasia and assisted suicide of the
Portuguese oncologists
José António Ferraz Gonçalves
Faculty of Medicine, Ethics, Porto, Portugal
Objective To examine what the Portuguese oncologists
think and do about end-of-life situations other than
euthanasia and assisted suicide.
Methods A questionnaire was mailed to Portuguese
oncologists registered in the Portuguese Oncology
Society and to other oncologists whose opinion was not
publicly known, with a reminder letter sent 3 weeks
later. A total of 450 questionnaires were mailed.
Results Of the 450 questionnaires 12 did not reach the
target, so there were 438 effectively delivered. Of those
143 (33%) were filled and sent back. Only 11 doctors
(7.7%) would give lethal doses of one or more drugs to
an incompetent patient. However, 70% would withdraw
life supportive treatments at the patients’ request, but
only 41% would withdraw feeding and hydration. Most
oncologists (96.5%) would give drugs, such morphine,
in order to control the suffering of a terminal patient
even if they foresaw that death could be hasten. About
80% believe that palliative care can prevent requests for
euthanasia and assisted suicide.
Conclusion Portuguese oncologists seem to value
patients’ autonomy and distinguish clearly euthanasia
from symptom control even when there is a risk of
hasten death. They also seem to value palliative care as
an adequate response to the suffering of terminal
patients.
Faculty of Medicine, Ethics, Porto, Portugal
Objective To examine what the Portuguese oncologists
think and do about euthanasia
and assisted suicide.
Methods A questionnaire was mailed to Portuguese
oncologists registered in the Portuguese Oncology
Society and to other oncologists whose opinion was not
publicly known, with a reminder letter sent 3 weeks
later. A total of 450 questionnaires were mailed.
Results Of the 450 questionnaires 12 did not reach the
target, so there were 438 effectively delivered. Of those
143 (33%) were filled and sent back. Only 13% of the
549. Measuring Attitudes toward End-of-Life
Issues: Presentation of a New Questionnaire
Bert Broeckaert, Joris Gielen, Trudie Van Iersel, Stef Van
den Branden
Aim of the Study: Several studies have already
investigated attitudes of medical professionals towards
153
Poster abstracts
Background: Ethical decisions play a major role in
palliative medicine. The aim of the study is to assess the
prevalence of ethically relevant issues in PC, such as
advance directives, palliative sedation or
discontinuation of therapies, which may need to be
discussed in the course of treatment.
Methods: The Hospice and Palliative Care Evaluation
(HOPE) was complemented with a checklist on matters
of ethical decision-making for use in two evaluation
periods (2004 and 2005) for patients treated in palliative
care services in Germany. Computerised data were
analysed descriptively. Results: For 1211 of 2214 (in
2004) and 779 of 1903 (in 2005) documented patients
the checklist was completed. Full information about
diagnosis was present in 87% in 2004 and 86% of the
patients in 2005. However, only 64% / 63% were
completely aware of the prognosis. Advance directives
were prepared by 17% / 21% of the patients. Waiving
treatment options was documented most frequently for
resuscitation (57% / 59%) and most scarcely for fluid
substitution (16% / 15%). Palliative sedation was
performed for 13% / 14% of the patients, either
continuous (5% / 5%) or intermittent (8% / 9%).
Requests for euthanasia were put forward by 3% / 1% of
the patients.
Conclusions: Palliative care patients have a high need
for clarification of various ethically relevant problems,
therefore palliative care teams should provide
appropriate counselling and communication skills.
Poster abstracts
end-of-life issues. Yet, often the questionnaires use
ambiguous concepts and are not in tune with recent
palliative care research. In 2006 the Interdisciplinary
Centre for the Study of Religion and World Views
(K.U.Leuven) and the Flemish Federation for Palliative
Care undertook a quantitative study of the attitudes of
palliative care physicians towards end-of-life issues. In
order to obtain reliable results, we developed a new
questionnaire. Method: We reviewed all recent
empirical studies dealing with attitudes of European
physicians towards euthanasia. Afterwards, we finalised
the questionnaire and sent it to all physicians (147)
professionally employed in palliative care in Flanders
(Belgium). Result: Our questionnaire was constructed
around six clearly distinct ethical categories
(withholding or withdrawing curative or life-prolonging
treatment, alleviation of pain and symptoms, palliative
sedation, voluntary euthanasia, involuntary euthanasia,
physician assisted suicide) each consisting of ethical
statements using a five-point Likert-scale. 67.3% of the
physicians (n=99) responded. Most physicians were
positive about the questionnaire. Conclusion:
Researchers should be more cautious while formulating
ethical questions to measure attitudes towards end-oflife issues. Our ethical questionnaire offers a promising
model for further use in other settings and countries.
550. English Sunni E-Fatwas on End-of-Life
Decisions
Stef Vanden branden, Bert Broeckaert
Migration and globalisation have changed the way
Muslims deal with their religion. Roy (2002) indicates a
more visible impact of these forces in the way Muslim
minorities in non-Muslim countries reposition
themselves towards their faith. English Sunni e-fatwas
form a little researched though very influential body of
Islamic knowledge for Muslim minorities, providing
guidance on a broad range of topics. End-of-life decision
making is increasingly being discussed on international
Islamic websites, predominantly through e-fatwas. We
searched for and studied (2002-2006) English Sunni efatwas dealing with end-of-life decisions. The first
characteristic of these fatwas is that the term euthanasia
is used to cover almost every form of end-of-life decision
making: withholding treatment, refusing treatment,
pain treatment with alleged life shortening effect and
voluntary direct active euthanasia are all framed as a
form of euthanasia. Secondly, the authors of the fatwas
unanimously declare direct active euthanasia to be
forbidden (haram) and frame it on the same level as
suicide or murder: life is sacred (Q5:32), suicide is
prohibited (Q4:29) and only Allah is to determine the
life span of man. Thirdly, withholding/withdrawing
treatment is generally conditionally allowed: a treatment
can be withdrawn only if medical specialists see no hope
for recovery at all. From our study we conclude that a
Sunni Islamic consensus on end-of-life decision making
is emerging through internet fatwas
551. The Attitudes of Practising Elderly Moroccan
Men Living in Antwerp (Belgium) Towards
Withholding/
Withdrawing Treatment Compared with the
Guidelines in English Sunni E-Fatwas.
Poster abstracts
Islamic End-of-Life decision making remains an under
developed research area both in Belgium and in Europe.
We compared the results of our review of 43 English
Sunni E-Fatwas on withholding/withdrawing therapy
with the results of our empirical study (Grounded
Theory Methodology) using in-depth interview
techniques (n=30) with Moroccan elderly (<60) men
living in Antwerp (Belgium) on End-of-Life decision
making. The fatwa material revealed the central
importance of the diagnosis of the treating physician:
since the medical expert knows best whether a patient
could recover or not, one is allowed to follow the advice
of the treating physician on withholding/withdrawing
treatment. Our interviewees expressed a parallel form of
reasoning with a more negative stance against
withdrawing treatment: the tradition (hadith) stresses
that man has the duty to look for treatment and that no
one except Allah should end a person’s life. As it is the
doctor’s duty to treat the patient, withholding/
withdrawing treatment is only possible if the medical
expert regards every form of medical treatment to be
futile, which for the interviewees means that the patient
has died. Both the e-fatwas and our interviewees did not
regard the withholding of artificial food and fluids as a
medical decision: it is forbidden to starve a patient to
death. We conclude that in both our sources we found
ideas on medical futility that diverged from established
Western views.
154
552. Integrating euthanasia in palliative care
Some suggestions for research, which in this area of
practice is badly needed, will also be made.
Luc Van imschoot, Gert Huysmans
coda hospice, Palliative care unit, wuustwezel, Belgium
During 2002 Belgium became the second country in the
world where euthanasia was introduced by law.
We describe the coping of all caregivers involved
during a period of adjustment , starting from a ‘non life
shortening palliative care’ to integration of euthanasia
in this palliative care .
A stepped care approach was developed.
1.Extensive detailed exploration of the wish of
euthanasia during several contacts with the patient (and
relatives) .
2Adjustment of the care integrating new elements
discovered during these contacts .
3.Clear deals about when (and when not!) ,where and
how euthanasia will be performed.
4.If euthanasia will be performed , standard holistic care
of the patiëënt and his family in the period before the
event.
5.Standard procedure of the medical - technical aspects
of euthanasia.
6.Debriefing of all involved.
During this process we encountered many difficulties :
repeated team meetings , open communication and
listening to our patiëënts were the keys to success.Less
then 3% of patients cared for choose euthanasia.
We do realise that the euthanasia law is only valid for a
minority of Europeans.
But we also believe that the process we went through
can be helpful for others to reflect on bounderies of care
, on autonomy of patients and on modisty in providing
care.
553. Supportgroups for relatives during late
palliative phase
555. Supporting children and families facing
parental death: case study presentation
Rosemary McIntyre, Catriona Kennedy
Napier University, School of nursing, Midwifery and Social
Care, Edinburgh, United Kingdom
This is one of two linked papers that evaluate a new
Children and Family Support Service in Palliative Care.
The other paper (Kennedy and McIntyre) explores
challenges in evaluation research at the end of life. The
support service, funded by Macmillan Cancer Support,
offers support, advice and counselling to parents,
children and other family members affected by a
parent’s terminal illness and death from cancer.
Interviews and observations with service users and
stakeholders were used to evaluate the impact of the
service and make recommendations. This paper will
draw on family case studies. A thematic framework,
from the interpretive processes, will illuminate the
experiences of children and families who accessed the
service. Data will be presented around five main themes;
thrown into chaos, lost in the panic, holding them steady,
journeying together and the road ahead. Interventions
used by the family support worker (FSW) in the
palliative phase and after the parent’s death, will be
reported. The scope of the service and expertise required
of the FSW will be reviewed. Outcomes, as described by
the children, families and stakeholders, will be
presented and issues of sustainability and transferability
discussed.
556. When the patient and family have different
goals for continued care -a method to find a
workable solution.
Anette Henriksson
Anne-marie Westman, Inger Benkel
Södra Stockholms Geriatriska Klinik, avd 60 ASIH,
Stockholm, Sweden
In a palliative care unit in Stockholm, Sweden there is
an ongoing intervention with supportgroups for
relatives during late palliative phase.the aim being to
offer a chance to meet others in a similar situation
under organised conditions, obtain collected
information and discuss their situation with
professionals. The group meets for an hour and a half a
week for six weeks.
The purpose of this study was to describe a
supportgroup program during late palliative phase and
to describe how relatives to severly ill and dying patients
experienced the participation and what impact the
support group had on their lives.
10 relatives were interviewed in form of open
dialogues and the analyse was inspired by the
phenomenological analysis method as described by
Giorgi.
The findings in this study was that relatives to severly
ill patients experienced a support and that the
participation in some way gave relief in their day to day
life. Their experiences are described in six key
constituents:Confirmation - to be seen and to count,
Insight to the gravity of the illness, Sense of belonging
created by similar experiences, participation in the care
of the patient, Being able to rest and Strenght to
constitute a support for the patient.This reulted in a
sense of safety.
Interventions of this kind initiated and carried
through by nurses may bear importence on relatives
possibilities to handle their situation in the care of a
severly ill person.
554. Mesothelioma: The financial aspects
Christina Mason, Roy Nightingale
Sahlgrenska University hospital, Geriatric, Gothenburg,
Sweden
Aim
A palliative patient, approaching end of life, may have a
different opinions with the family
on what form of care will be most suitable after hospitalstay. Complicated family relationships,
worry and anxiety concerning different aspects of the
illness both, emotional and physical,
specific nursing needs, and physical hindrances can
make it difficult to find out how future
care should be formed. On ward 71, palliative unit,
Sahlgrenska University Hospital, has a
method been worked out, in order to help patients and
family find a well planned discharge.
Method
The team designates a few staff members to be
responsible for the patient. They will take care
of all questions concerning arrangements about the
planning in order to lessen risks for misunderstanding
and to clearly explain different alternatives. The method
includes: Planned
and frequent discussions with the patient and family.
Information about different care facilities
outside the hospital. Allow time for contemplation. If
the illness changes, the process continues
from the patients new health status.
Result
The method help patient and family to find a common
solution they could accept.
Conclusion
Using this method, to letting a few staff members be
responsible for the future care plans
and information when patient and family has different
opinions, is very helpful. It gives also
the other staff members possibility to concentrate on
the care of the patient without being
involved in the difficult planning process.
When people are first diagnosed with any cancer, it is
often difficult for them to obtain the United Kingdom
welfare benefits to which they are entitled. This can be
for a number of reasons; for example, shortfalls in
information provision about benefits, lack of awareness
amongst staff, and problems in completing application
forms. Difficulties can be compounded in
mesothelioma. This disease has a number of specific
benefits associated with it. Specialist financial and also
legal advice are essential to enable patients to find their
way through complex systems and to obtain what are
sometimes very substantial sums of money as
compensation from industries in which they have been
working. Even though after 1980 there was little use of
asbestos, the incidence of mesothelioma and other
asbestos related illnesses is increasing, and the United
Kingdom, as well as Australia and South Africa are facing
an epidemic of these illnesses. The results of an Audit
Study carried out at St Joseph’s Hospice in East London
will be presented together with a case study of the
impact of financial hardship on people with the disease.
557. Assessing fatigue in relatives to patients
cared for in palliative care
Maria Carlsson
Dept.Public Health and Caring Science, Uppsala University,
Uppsala, Sweden
When inpatients care decrease and the care-time been
shorter, the responsibilities for the patients’ care
transfers to the relatives. This is apparent also in the
palliative care were a increasing numbers of dying
patients are cared for at home, often with help of an
advanced palliative home care team. The relatives’
burdens in palliative care are considerable and may
cause fatigue. However, few studies have examined
fatigue in relatives to patients in a palliative phase, with
validated instruments. Relatives fatigue is therefor an
important but overlooked subject in palliative research.
The overall aim of this study is to gain a greater
understanding of fatigue in relatives to patients cared for
Poster abstracts
558. A new tool to assess primary caregivers’
burden at end of life care
Serge Dumont, Lise Fillion, Pierre Gagnon, Nadine
Bernier
Université Laval, Centre de recherche en cancérologie,
Québec, Canada
Measuring the primary caregiver’s burden in the specific
context of palliative care is a great challenge. Existing
tools do not specifically target caregivers in a palliative
care context and their reliability is often problematic
due to underlying conceptual weaknesses. A new tool,
which specifically assesses the primary caregiver’s
burden in the palliative care context, was developed and
validated through qualitative and quantitative methods.
Purpose: To describe the steps taken to develop a new
tool and to examine its psychometric properties.
Methods: In order to develop and validate the
instrument, a series of studies were conducted among
different content experts and caregiver samples. Result:
The Caregiver’s Burden Scale in End of Life Care (CBSEOLC) is self-reported questionnaire. Internal-consistency
reliability: Cronbach’s alpha = 0.95. Construct validity:
Most inter-item associations were consistent with the
conceptual framework which emerged from qualitative
data analysis. Convergent validity: Interscale correlations:
a) Zarit’s Burden Interview (BI) = 0.72 (p<0.01); b) QOL =
- 0.41 (p<0.01); c) POMS (fatigue) = 0.69 (p<0.01) d)
POMS (vigor)= -0.27 (p<0,05). Social Desirability was
tested with the Crowne & Marlowe questionnaire (0.24). Responsiveness: Associations were consistent with
patient’s functional status (ECOG) and caregivers unmet
needs. Conclusion: The CBS-EOLC is a reliable and
valid measure, available in French and English.
559. Family caregivers of advanced cancer
patients: coping and burden
Judith Prins 1, Dore Broekhuis 2, Stans Verhagen 3,
Yolande Kuin 4
1
Radboud University Medical Centre, Medical Psychology,
2
Radboud University Medical Centre, Medical Psychology,
3
Radboud University Medical Centre, Palliative Care Centre,
4University of Nijmegen, Centre for Psychogerontology,
Aim of study Advanced cancer patients often wish to
receive palliative and terminal care at home. Mainly
qualitative and retrospective research showed care
related caregiver burden. Purpose of this quantitative
study was to investigate the relation between caregiver
burden and coping care during palliative care. Method
Twenty family caregivers, ten men and women, of
advanced cancer patients receiving treatment of a
Palliative Consultation Team in the Netherlands
participated, filling in eight validated self-report
questionnaires measuring perceived caregiver
symptoms, strain, burden and coping. Results Of the
participants 5% experienced no burden, 50% moderate
burden and 45% severe burden. Severe burden
correlated with high levels of psychological and physical
problems. Despite high levels of caregiver burden, 80%
of family caregivers reported to receive sufficient
practical help. Compared to coping of less distressed
family caregivers, those experiencing severe burden
were more focused on their negative emotions and
experienced less social support and self-confidence in
caring for the patient. Conclusions
Almost half of family caregivers in palliative care
experience severe burden, expressed in high levels of
fatigue and physical and psychological problems.
Coping is also affected. These problems were not
mentioned by caregivers in regular contacts with
members of the palliative team. Therefore, systematic
screening of caregiver burden is necessary in clinical
practice. A nine-item questionnaire (EDIZ) is appropriate
for screening caregiver burden in palliative care.
Preliminary data of (complicated) grief assessed in the
same sample will also be presented.
560. Appetite loss in advanced cancer - the
informal caregivers’ perspective.
Ginette Pilkington 1, Jonathan Koffman 2
1
University of Northampton, School of Health,
Northampton, United Kingdom
2
King’s College London, Department of Palliative care,
Background: To date, research on cancer induced
weight-related issues has focused on changes in weight
and interventions to increase appetite. Scant attention
has been paid to the informal caregivers’ perceptions of
the impact of weight and appetite loss among
dependants or loved ones with advanced cancer. Aim of
study: To explore informal caregivers’ perceptions of
caring for a spouse with loss of appetite, their coping
strategies, and perceptions of support. Method: Indepth qualitative interviews with informal caregivers of
deceased spouses with advanced cancer. Caregivers were
recruited from palliative care records. Interviews were
recorded and transcribed verbatim. Transcripts were
analysed using Framework analysis. Results: Eight
caregivers [4 male and 4 female] were interviewed
during the study period. The following themes emerged
from the transcripts (i) Informal caregivers expended
great energy attempting to overcome spousespoor
appetite; (ii) A mismatch was present between spouses’
and caregivers priorities regarding food in-take. This
resulted in tension and conflict; (iii) Informal caregivers
wanted information and advice on improving their
spouses’ appetite. Conclusions: Weight and appetite
loss results in high levels of stress among informal
caregivers. More research is required to develop
interventions to assist caregivers to manage this
situation more effectively.
561. Longitudinal caregiving impact on quality of
life for family caregivers of terminally ill caner
patients in Taiwan
143 patients died in our unit in 2004, of which 74
(51.7%) were men and 69 women (48.3%). The average
age was 68.30±13.14 years (67.89±11.85 in men and
68.74±14.47 in women (p= 0,074))
79 died at home (55.6%) and 63 (44.4%) at the hospital
(1 lost data). There were no sex related statistical
differences. However, we did see that 64.4 % of patients
over 65 died at home as against 40% of those under 65
(statistically significant difference p=0.004)
Average stay at the home care unit was 71.15 days, and
did not influence the place of death nor did age
influence the length of stay in the unit
Practically 91% of the patients lived at home and 96.9%
lived in a family environment. 56.2% of them had a
main carer and for 40% of them, this role was shared
between more than one person. We noted that the main
carer who appeared the most was the partner (57.3%),
followed by the children (36.4%) and, to a much lesser
extent, parents, siblings etc. Having one or more carers
had no influence on the location of death nor did the
existence of children under 18 at home.
The second most frequent cause for patients being
referred to hospital were abandonment by the families
(9.9% of the cases, with 14% due to poor control of
symptoms), and there was no association with the
existence of minors at home (p00.352). No statistically
significant differences were observed either in terms of
greater abandonment by sole carers. Conclusions:
1) Patient care must include taking care of the patient’s
environment by home care unit staff.
2) Staff must be on the alert for signals that might
indicate overload for the main carer and which could
cause the family to abandon.
3) For a small percentage of patients (3.3%) it is their
express wish to go into hospital, which speaks
favourably of the quality of the attention provided.
4) Age influences the location of patients’ death.
563. Decision Making, Spirituality, and Hope in
Grieving Neuroblastoma Parents
Joshua Rosenberg 1, Michelle Fleurat 2, Clarke Anderson 3
Siew Tzuh (Stephanie) Tang
Chung Gung University, School of Nursing, Taipei, Taiwan
Purpose: To (1) describe the patterns of caregiving and
impact of caregiving on Taiwanese CGs over time; and
(2) identify predictors for CGs’ QOL.
Methods: 167 CGs were interviewed every two weeks
until the patient died. Objective and subjective
caregiving burden was measured by total hours of
caregiving per day, care tasks and levels of care,
symptom distress and the Caregiver Reaction
Assessment (CRA). QOL was measured by the Caregiver
Quality of Life Index-Cancer. Generalized estimating
equation (GEE) models were used to examine the trends
and impact of caregiving over time.
Results: As death approaching, patient symptom distress,
intensity of caregiving, and time spent in caregiving
increased significantly but caregivers did not gain more
confidence in their caregiving. Impact of caregiving on
family caregivers’ daily schedule, health, and QOL
grows substantially over time. Multivariate GEE analysis
indicated that the interval between assessments made
and the date of the patient’s death, CGs’ characteristics
and objective caregiving burden were not significant
predictors of CGs’ QOL. Patient symptom distress,
subjective caregiving burden, confidence in caregiving
and coping capacity played significant roles in
determining CGs’ QOL.
Conclusion: Development of interventions targeted on
improving CGs’ confidence of caregiving and their
coping capacity shall be able to reduce subjective
caregiving burden and improve QOL for CGs.
1
University of California-Irvine, School of Medicine, Irvine,
California, United States
2University of Southern California, Keck School of Medicine,
Los Angeles, United States
3City of Hope National Medical Center, Pediatric palliative
care/Pediatric oncology, Duarte, United States
AIMS/METHODS: The beliefs, attitudes, and collective
experience before, during and since their child’s death
were studied in 20 bereaved parents attending the
Children’s Neuroblastoma Cancer Foundation annual
meeting. The 6 hour study included a newly created
questionnaire combined with facilitated discussion on
decision making, ending therapy, and the impact of the
child’s death upon the family. RESULTS: Ages ranged
from 26-60 yrs, 12/19 had incomes > $35,000/yr and all
were Caucasian. Those bereaved < 12 months felt less
prepared to deal with their child’s suffering compared to
bereaved > 12 months (p= 0.03). A large role in the
decision making process led to less regrets/negative
feelings about the child’s care and most felt that the
option to stop curative therapy should be brought up
early. Likert scale questions (1 disagree to 5 agree)
showed a trend for decreased belief in God (mean 4.4 vs.
3.8, p=0.06) and the usefulness of prayer during
treatment vs. the time of the child’s death (mean 4.0 vs.
3.4; p = 0.09). After death, there was decreased belief in
miracles (p=0.04). Definition of hope changed
throughout the course of illness and focused upon
maintaining legacy after death.CONCLUSION: Parental
opinion is crucial in end of life decision making;
spiritual issues are strongly impacted by a child’s death
and maintaining a legacy for the child is an important
part of hope.
562. ROLE OF THE ENVIRONMENT IN THE DYING
PROCESS
Elena Oliete 1, María Piera 1, Rocío Romero 1, Paz Guilló 1,
Carmela Ara 1, Elena Romero 1, Ascensión Landete 1,
María josé Estellés 1, Marina Costa 1, Carmen Juarez 1
1
INSTITUTO VALENCIANO DE ONCOLOGIA, Unit of
advanced palliative home care, VALENCIA, Spain
2
3
INSTITUTO VALENCIANO DE ONCOLOGIA, Department
of Psychology, VALENCIA, Spain
4
INSTITUTO VALENCIANO DE ONCOLOGIA, Department
of Psychology, VALENCIA, Spain
5
6INSTITUTO VALENCIANO DE ONCOLOGIA, Unit of
Aim of the project Description of the demographic
characteristics of patients deceased in our unit (in 2004)
and also of their environment.Material and methods:
Retrospective descriptive survey done using the clinical
history of all patients deceased in 2004 seen at our unit.
The information was collected through an ad hoc form
and the results were analyzed using the software package
SPSS 12.0 for Windows.Results:
564. Caring for Families of Dying Patients - The
Nursing Experience
Anne - Marie Corroon
Trinity College Dublin, School of Nursing and Midwifery,
Dublin, Ireland
The terminal phase of the patients’ illness often results
in considerable psychological and social difficulty for
the patients’ family (Thomas & Morris, 2002). Nurses
find caring for families of dying patients stressful
(Costello, 2001; Main, 2002; McIntyre, 2002). This study
was undertaken to explore nurses’ lived experiences of
caring for families of terminally ill patients on oncology
wards. A hermeneutical phenomenological
methodology was employed using purposive
sampling to interview seven nurses to explore their
experience of this phenomenon. The analysis of the
transcripts was influenced by Gadamerian philosophy.
The level of support provided for families was directly
related to the relationship with the family. The
relationship involved an emotional engagement with
the family and the therapeutic value of the relationship
was dependent on the level of emotional engagement.
The relationship was noted to have a degree of
155
Poster abstracts
in palliative care settings
Methods: A descriptive, comparative and cross-sectional
design was employed. The sample consisted of relatives
to all patients care for in palliative care settings in a
Swedish county during a specific day. After giving
informed consent, all relatives were asked to complete a
questionnaire consisted of MFI-20, Karolinska Sleepiness
Scale, Karolinska Sleepiness Questionnaire and 15
demographic questions. There were also four openended questions encouraging the respondents to
expound on one’s views of fatigue, what gives the
fatigue, what consequences it gives and how the health
care could facilitate their situation.
Results: Data collection is now completed and 56/73
(77%) participated in the study.
Data is currently analysed and will be presented at the
congress.
Poster abstracts
reciprocity and the experience of caring for families was
simultaneously rewarding, sustaining and emotionally
draining. The nurses perceived that without this
emotional engagement, their ability to journey with
families was impaired and that therefore families
derived only minimal support from the relationship.
Further research exploring nurses’ and relatives’
experience of this relationship is required.
565. Informal care at the end of life
Geraldine Visser, Marijke Wulp
The Netherlands Institute for Care and Welfare / VILANS,
Client and Support, utrecht, Netherlands
In the coming years, increasingly more older people will
die following a long period of illness and physical
limitations. In the Netherlands informal care is an
increasingly important means of providing care during
the final stages of life or the palliative terminal stage.
Due to the complexity and severity of the care and the
large number of professional carers involved, informal
carers in this situation experience problems with burden
and with co-ordination between and communication
with professionals and family members. Most people
prefer to die at home, in their own familiar
surroundings, close to their loved ones. Unfortunately,
however, this is only possible for a small group of
people. Only one-third of people under the age of 80
and only one-fourth of those above the age of 80 die at
home. Informal care burden is often the reason for
admission to hospital or nursing homes. Patients who
receive support at home both from carers and
professional care providers are more likely to die at
home than people who receive only informal care or
only professional care. Professionals are often not well
enough informed about the potential types of support
for informal care and palliative care, such as support
centres for informal care, hospices and halfway homes,
volunteer palliative terminal home care or palliative
units in nursing homes. This poster presentation shows
recommendations for supporting these end-of-life
informal carers.
566. Employment and Family Caring in Palliative
Care settings: A review of the literature.
Paula Smith 1, Paul Ramcharan 2, Sheila Payne 3, Alice
Chapman 3
Poster abstracts
1
Sheffield Hallam University, School of Health and
2RMIT University, Health Sciences, Melbourne, Australia
3
Background As life expectancy and chronic illness
increase, the number of Family Carers who are juggling
employment and caring roles will rise. Issues of work
and care are firmly placed in the policy agenda in the
United Kingdom, but the impact of this on family carers
in palliative care settings is largely unknown. Aim To
explore the literature surrounding employment issues
for family caregivers in palliative care settings. Method
Drawing on the principles of a systematic review a
literature review was undertaken. Search terms relating
to palliative care, family caregivers, and employment
were used in six databases. Papers were independently
reviewed using the Hawker et al (2002) and SCIE (2002)
review process. Five empirical papers identified issues
relating to palliative care, carers and employment.
Findings A number of variables may impact on
combining caring and employment including;
variability in caring required, emotional impact of
situation, financial costs, relevant and accessible support
services, and flexibility in employment patterns. Caring
negatively impacted on carers work, however,
employment acted as a ‘buffer’ for carer stress for some.
Discussion Combining employment and caring for a
dying relative is highly varied. Current service delivery
and support may be inaccessible for some carers.
Identification of factors that negatively impact on
combining work and caring may enable a more focused
approach to care delivery and employment support.
568. High Prevalence of Caregiver’s Burden with
Palliative Care at Home
Antonio Noguera, Jesús Poveda, Mariant Lacasta,
Manuel Gonzalez-Barón
Clínica Universitaria de Navarra, Unidad de Medicina
Paliativa, PAMPLONA, Spain
Care of terminal patients demands high physical and
emotional overload. A study has been carried out to
evaluate caregivers’ burden and emotional stress when
palliative care home teams care for terminal patients.
A hundred caregivers completed the Zarit Burden
Interview (ZBI), the HADS, and an interview designed to
assess suffering levels.
Results:According to ZBI 21 caregivers showed severe
156
stress levels and 23 showed moderate stress levels.
According to the HADS, 12 caregivers suffered severe
depression and 20 moderate depression; 14 caregivers
suffered severe anxiety and 21 moderate anxiety.
Correlation (rho Spearman) was found between
depression and stress r 0,424 ·_<0,01, and between
anxiety and stress r 0,581 ·_< 0,01. The median value of
suffering on a 0 to 10 scale was 6.
Our results show high levels of stress, anxiety and
depression in caregivers of patients being attended at
home for palliative care teams . High overload on
caregivers of terminal patients is most likely the cause of
severe emotional morbidity.
569. Carers’ health, functional status and
caregiver burden in end of life care: trajectories,
interrelationships and relation to cancer
patients’ status.
Morag Farquhar 1, Gunn Grande 1, Stephen Barclay 2,
Chris Todd 1
1
University of Manchester, School of Nursing, Midwifery
2University of Cambridge, Department of Public Health and
Primary Health Care, Cambridge, United Kingdom
Background:
Current literature highlights the impact of caring on
carer health but says little about its trajectory or its
relationship to changing patient status. In addition, it
focuses on carers of those with long-term conditions,
the elderly and disabled children, and less on those with
advanced cancer, and mainly addresses carers’
psychological, rather than physical, health.
Aim:
To investigate carers’ health, functioning and perceived
caregiver burden, and these variables’ relationship with
patients’ health, functional status and health related
quality of life in lung and colo-rectal cancer.
Method:
Prospective longitudinal study of 100 lung and
colorectal cancer patients and their carers. Respondents
were interviewed once every two months from the point
at which patients became palliative until death.
Measures included patient and carer health related
quality of life (EORTC QLQ-C30 and SF-36) and Carers’
Assessment of Difficulties Index (CADI). Data are
analysed with death (as opposed to baseline interview)
as an anchor point.
Result:
We will describe carers? health, functioning (SF36) and
perceived burden (CADI) over time, and report on their
interrelationships and relation to patient status
(EORTC).
Conclusion:
The study will inform our understanding of the
trajectory of caregiver burden, functioning and health in
end of life care, the association of caregiver burden to
carer health and functioning, and how patient status
and closeness to death may impact on these.
570. Attitudes towards terminally ill cancer
patients
Aleksandra Modlinska 1, Magdalena Osinska 2, Justyna
Janiszewska 1, Tomasz Buss 1, Magdalena Osowicka 1,
Monika Lichodziejewska-Niemierko 1
1
Medical University of Gdansk, Department for Palliative
Medicine, Gdansk, Poland, Poland
2
Medical University of Gdansk, Department for Palliative
Medicine, Gdansk, Poland, Poland
The main idea of palliative care is to support a dying
patient with appropriate holistic care.The aim of the
study was to analyze the attitude towards dying patients
in the aspect of care that can be provided by a family
and health system. The survey was carried out in a group
of 130 patients hospitalized in the University Hospital in
Gdansk for minor health problems /Karnofsky PI- 90 100%/. Nearly half of the responders had had the cancer
patients in the family in the past. Half of these patients
died in hospital and another half at home. Only 2
patients died in hospice. 70% of responders were happy
with home care whereas only 30% were satisfied with
the hospital care. 74 of 130 responders indicated that
both a patient nad his family have the right to decide on
the place of terminal care, while only 35 replied that
this is the solely a patient’s decision. More than half of
responders believed that there is better care in the
institution-hospice rather than hospital. Almost 90%
assumed emotional bonds as the most important factor
influencing the decision of the family to care for a
patient.22% of the surveyed who hadn’t had an
experience with cancer did not know how they would
care over terminally ill family member. Majority of them
would have tried to look after their sick family at home
but they were afraid of not being able and not having
time to take care of the sick, not having enough help
from the health service and being anxious of the dying.
571. The role of an ambulatory Palliative Care
Team (PCT) during exacerbations in the final
stage of life of terminally ill cancer patients
Christoph Wiese, Utz Bartels, Andrea VoßßenWellmann, Hannah Morgenthal, Michael Bautz,
Margret Kriegler, Alexander Schultens, Friedemann
Nauck, Bernhard Graf, Gerd-Gunnar Hanekop
University Hospital Goettingen, Anaesthesiology, Göttingen,
Germany
Introduction: Terminal cancer patients suffer from
many symptoms, e.g. dyspnea, pain. These can be
shocking for next-of-kin causing helplessness, frequent
calls for emergency medical services (EMS) and
avoidable hospital readmissions thus making a peaceful
death impossible. Although nearly 2.5% of all EMS tasks
in Germany are calls to terminal cancer patients
Palliative Care Teams (PCT) rarely get involved [1]. Aim
of Study: To clarify whether Advanced Palliative Care
(APC) can reduce use of EMS in those cancer patients.
Methods: After informed consent 46 adults whose
partner had died from cancer while in APC completed
an anonymous survey. Results: In 19 cases (41%) EMS
had been called in the last six months of patient’s life.
Overall, 23 EMS visits were found (14x1, 4x2 and
1x3 visits), 16 led to hospital admission (69.6%). 21 calls
(91.3%) happened before vs. 2 during enrolment in APC.
Other causes for EMS use were: dyspnea (39.1%), pain
(26.1%), seizures (17.4%), unconsciousness (13%), and 1
fracture (4.4%). Conclusions: In their last 6 months
41% of patients used EMS at least once. 91% of these
calls occured before a PCT took over, only 2 visits
ensued subsequently. Like similar studies our data show
that PCTs can help to significantly reduce use of EMS,
number of hospital admissions, and stressful events for
patients and relatives thus aiding a peaceful death [2].
Literature: [1] Wiese CHR et al. (2006) Anästhesist
(suppl) [2] Brumley RD et al. (2003) J Pall Med: 715-24
572. CAREGIVERS BURDEN IN TAKING CARE OF
TERMINAL PATIENTS
MAGDALENA ESTEVA 1, JOANA RIPOLL 1, JOAN
LLOBERA 1, MERCE LLAGOSTERA 2, ADORACION
SANCHO 1, ENRIQUE FERRER 2, LLORENÇ ROIG 2,
MAGDALENA SEGUI 1
1
Majorca Primary Care Department-Ibsalut, Unit of
Research, Palma de Mallorca, Spain
2
Majorca Primary Care Department-Ibsalut, Unit of
Domiciliary Palliative Care, Palma de Mallorca, Spain
Objectives: To establish the consequences of the burden
of care in terminal cancer patients caregivers.
Design: observational follow-up study.Setting: Majorca
Island; 40 primary health teams, 5 Home Care Teams.
Measurements: Caregivers Interview included:
sociodemografic characteristics, frequency of care
activities, mental health during terminal period, help
received, changes in job .
Results: 107 caregivers, 88,8% women, mean age 52,5
years (SD=10,5), 45,8% offsprings, 37,4% the couple.
Worked 57 (53,3%), of those 40,4% declared changes in
their job. They stated that very often had to bath patient
(67,3%), bed moving (58,9%), feeding (43,9%), go for a
walk (77,6%), toilet (60,7%). They carry out frequently
other caring activities as healing (42,1%), give injections
(28,3%) and administering drugs (91,6%). About a third
had domestic help and 69% had other help to take care
of the patient. Always or nearly always felt nervous
(43%), very low moral (62%), exhausted at night (57,5%)
and surpassed (45,8%). Nine in ten caregivers stated that
doing all they could makes them to feel good. Number
of caring activities is related with being exhausted
(P=0,001) and with feeling surpassed (P=0,005). Those
who had somebody else to care patient were more
relaxed (P=0,07) but also more exhausted (P=0,04) and
surpassed (P=0,04).
Conclusions: Terminal patient represents a considerable
burden for caregivers. Those who have either domestic
help or other caregivers feel more relaxed but at the
same time this fact represents more tiredness.
573. Dissatisfaction with home and hospital care
during the last three months of life of Italian
cancer patients.
Elena Rapisarda 1, Gabriella Bertone 2, Monica Beccaro 3,
Massimo Costantini 3
1
ASL 3 genovese, Cure domiciliari, Genoa, Italy
Martino Hospital, Direzione Sanitaria, Genoa, Italy
National Cancer Research Institute, Clinical Epidemiology,
Genoa, Italy
2S.
3
Aims: this study aims at investigating domains and subdomains of dissatisfaction with home and hospital care
received by cancer patients in their last three months of
life.
Methods: The Italian Survey of the dying of cancer
(ISDOC) is a mortality follow-back survey of a
representative sample of Italian cancer deaths.
Poster abstracts
574. Quality of Life in next-of-kin caring for
terminal cancer patients with support from a
Palliative Home Care Team
Christoph Wiese, Utz Bartels, Hannah Morgenthal,
Andrea Voßßen-Wellmann, Margret Kriegler, Michael
Bautz, Friedemann Nauck, Bernhard Graf, Gerd-Gunnar
Hanekop
University Hospital Goettingen, Anaesthesiology, Goettingen,
Germany
Introduction: Next-of-kin caring for dying cancer
patients at home may experience impaired Quality of
Life (QoL) due to frequent feelings of helplessness. In
Germany data on this problem is scarce. Aim of Study:
To retrospectively assess QoL in next-of-kin who had
given care to terminal cancer patients with support from
a Palliative Care Team (PCT) and compare it to subjects
who had to give such care without such
support.Methods: A consecutive sample of 50 persons
whose spouse had died from was selected as the study
group. These subjects had given home care to their
partner with help from our PCT. A control group
consisted of 50 persons who had provided similar care
but had to do so without professional support. After
informed consent we questioned the two groups using a
structured interview. Also, the SF-12 subscales for
“mental” (MCS 12) and “physical” (PCS 12) aspects of
QoL were applied. Results: 46 subjects in the study
group could be evaluated. They had significantly lower
than norm values in both QoL subscales. QoL values
were even lower in the control group. Conclusions:
Next-of-kin caring for terminal cancer patients at home
feel better QoL when they have professional support
from a PCT. Still, they show significantly lower QoL
values than the norm population. Outpatient PCT seem
to benefit QoL in relatives giving home care but clearly
more assistance is needed for people in these
demanding situations. Literature: [1] Sheman DW et
al. (2006) J Palliat Med 9: 948-63 [2] Mc Millan SC et al.
(2006) Cancer 106: 214-22
575. INTERVENTIONS FOR SEXUAL DYSFUNCTION
(SD) FOLLOWING TREATMENT FOR CANCER: A
COCHRANE SYSTEMATIC REVIEW.
Clare Miles9, Louise Jones9, Adrian Tookman9, Michael
King9, Bridget Candy9
1– 4
University College London, Mental Health Sciences,
5University College London, Medical, London, United
Kingdom
AIMS: i) To evaluate the effectiveness of interventions
(psychological, pharmacological, mechanical or
complementary) for Sexual Dysfunction (SD) following
treatments for cancer. ii) To assess adverse events
associated with therapy.
METHOD:
We searched Cochrane Pain, Palliative & Supportive Care
Register (current issue), Medline, Embase, PsycInfo,
AMED, Cinahl, databases of grey literature, such as
Dissertation Abstracts and National Health Service
Research Register. Only randomised controlled trials were
included. The study population comprised adult patients
of both sexes receiving any treatment for cancer, who are
now experiencing SD resulting from treatment.
ANALYSIS:
Data were extracted independently by two reviewers.
The major findings of studies retrieved and graded in
terms of quality and strength of evidence were
summarised and described using Forest plots. Metaanalysis was used for those studies with comparable
outcome measures.
RESULTS:
8940 articles were retrieved, of which 8 RCTs met the
inclusion criteria. 1100 participants were included. The
main findings follow:
1. In men who had erectile dysfunction (ED) after
radical retropubic prostatectomy (RRP) and
radiotherapy (RT), Phosphodiesterase type 5 (PHE5)
inhibitors were effective in improving erections.
Higher doses were more effective and side effects were
mild to moderate (headache and flushing).
2. Alprostadil was successful in restoring erections after
RRP.
3. Cognitive Behavioural Therapy (CBT) improved both
psychological and physical problems associated with
ED.
4. Dyadic support partners helped to reduce the bother
associated with SD after RRP.
CONCLUSIONS:
The studies retrieved are not representative of the whole
spectrum of SD interventions that have been used in
non-cancer populations. More research is needed to fill
the following gaps identified in this review:1. Efficacy
and safety of PDE5 inhibitors in female cancer
patients.2. Sexual issues of patients with metastatic
cancer.3. SD resulting from disfigurements associated
with neck and head cancer.
576. HIGH MORTALITY IN A PALLIATIVE CARE
UNIT AMONG PATIENTS WITH
TRACHEOSTOMIES DISCHARGED FROM THE
INTENSIVE CARE UNITS
Jose Garcia-Garcia 1, Alfonso Aguirre-Palacio 2, Rafael
Lopez-Alonso 3, Eduardo Gomez-Camacho 4
1– 4
Hospital Universitario de Valme, Unidad de
Continuidad Asistencial. Servicio de Medicina Interna,
Seville, Spain
OBJECTIVE: To document the mortality and related
factors of patients discharged from the intensive care
unit (ICU) with tracheostomies. METHODS: This was a
retrospective study conducted in a palliative care unit
(UCA) in southern Spain. All patients discharged from
the ICU with tracheostomies over a period of one year
from 1 January to 31 December 2005. The main
outcome studied was the mortality after ICU period.
Mortality related factors were also analysed. RESULTS:
Twenty-six patients were discharged with
tracheostomies during the study period. Twenty-one
were males and the median (Q1-Q3) age was 70.1 (54.774.4) years. The post-ICU mortality was 61.5%. Six
(37.5%) patients died after 24 hours the ICU discharged.
Survivors had a long duration of hospitalisation in UCA:
66.5 (19-93.25) days. The 8 surviving patients were
decannulated before discharge from hospital. The
mortality rate was higher if the tracheostomy was
performed for a low Glasgow Coma Scale (GCS) than
when it was performed for reasons other than a low GCS
(p < 0.001). In the multivariate analysis, an older age, a
low GCS as a reason of perform the tracheostomy and a
severe clinical dysfunction on the day of discharge from
the ICU using a objective scale to measure outcome in
critical illness. CONCLUSION: There is a high early
mortality among patients discharged from the ICU with
tracheostomies. A low GCS is a good predictor of poor
outcome.
577. Evaluation of a combination of low-dose
ketamine & low-dose midazolam in terminal
dyspnea, attenuation of “double-effect”
Abhijit Dam 2, Jagadish Mishra 2
1, 2
Bokaro General Hospital, Anaesthesiology & Critical care,
Bokaro Steel City, INDIA, India
Introduction: Dyspnoea is the sensation of difficulty or
distress in breathing. It is very frightening and occurs in
about 21 to 78.6% of all patients for palliative care.
Reticence about the use of morphine for palliation of
dyspnoea is common, especially in non-malignant
disease, as there is fear of causing respiratory depression,
particularly where COPD exists. Also, morphine can
cause histamine release & thus aggravate bronchospasm
especially in COPD patients & thus can also lead to
hypotension. This factor is also compounded by the lack
of availability of morphine in parts of developing
countries & the consideration of “double-effect”.
Ketamine has excellent anaesthetic & analgesic effects &
also produces bronchodilatation & does not produce
respiratory or cardiovascular depression. However it has
a propensity to produce “emergence phenomenon”
which can be attenuated by the addition of low—dose
midazolam.
Aims & Objectives:
To assess the efficacy of a combination of low-dose
(0.2mg/kg) ketamine & low-dose midazolam
(0.02mg/kg), given intravenously, in relieving terminal
dyspnea
To note adverse effects, if any, associated with the use of
this combination
Study design: Prospective study duly approved by the
hospital ethics committee
Materials & methods: Patients with terminal dyspnea
admitted to the critical care unit which included cancer
& non-cancer patients. Patients having evidence of SIRS
were excluded from the study. Only adult patients were
enrolled. Dyspnea was assessed using the Modified
dyspnea scale, which has a value from 0 – 10, 10 being
maximium dyspnea, along with dyspnea facies. Each
patient received one low-dose ketamine & midazolam
for relief of dyspnea. All patients received low-flow
(2lit./min.) oxygen therapy via a variable performance
device.
Patients needing ventilatory support were excluded
from the study.
Monitoring: Pulse, ECG, SpO2, NIBP, RR
Results & conclusions : Will be discussed
578. Management of death rattle: what
influences the decision making of palliative
medicine doctors and clinical nurse specialists?
Keiron Bradley
Sir Michael Sobell House, Palliative Care, Oxford, United
Kingdom
Death rattle or noisy, rattling breathing occurs
commonly in dying patients and yet there has been
only minimal research into this symptom. This study
explores the death rattle management practices of
palliative medicine doctors and clinical nurse specialists,
whilst also considering factors that may influence these
practices.
The study involved semi-structured interviews with
15 palliative medicine doctors and clinical nurse
specialists working with inpatients. A brief questionnaire
was employed to gather basic demographic data. The
demographic data was analysed using simple
quantitative methods, and the interview data using
thematic content analysis.
Of the 15 participants, 73% were female, 67% were in
the age range 36-50 and 53% were doctors. The years of
experience working in palliative care ranged from 2-19.
All participants utilised both drug and non drug
management, though the management approaches
differed between the two sites studied. Management
practice was influenced by local policy, patient, family
and staff distress and consideration of benefit versus
harm to the patient. Other factors influenced decision
making to a lesser extent.
The information gained from this study contributes
to our understanding of the management of this
important symptom, with particular focus on what is
influencing these management decisions.
579. The use of Kinesio Tex Tape: The Experience
of One Hospice
Stephen Rumford
St Joseph’s Hospice, Patient Care, London, United Kingdom
In May 2006 St Joseph’s Hospice set up a Lymphoedema
clinic as a pilot scheme to assess the need for a service in
the east end of London. The clinic offered advice and
treatment for patients already known to St Joseph’s
community care teams. Treatment consisted in skin
care, simple lymphatic drainage and the measuring and
fitting of pressure garments. The team running the
clinic had recently been using a novel type of treatment
for the management of lymphoedema; Kinesio Tex tape.
This is a pre-stretched tape that when applied to the
skin gently lifts the first dermal layer allowing the free
flow of congested lymph. It also appears to have
applications for managing fibrotic areas in chronic
lymphoedema.
The purpose of this poster is to use a case/ contrast to
demonstrate the effectiveness of the tape and suggest its
usefulness in the palliative care setting
The advantages of Kinesio Tex include: the
management of mid-line oedemas (breast, trunk,
scrotal). These are typically difficult to manage and
often require time consuming massage as the only
means of treatment. The relative low cost of the tape
and the possibility of patient self management are a
further two benefits of the tape. Lastly, its effectiveness is
a huge benefit of the tape.
580. Sealed boxes with medicine and utensils for
treating typical symptoms arising the last days of
life developed for palliative care patients dying at
home.
Tove Vejlgaard, Jette Pedersen, Grethe Hansen, Anita
Duedahl
Vejle Sygehus, Det Palliative Team, Vejle, Denmark
When patients approach death typical changes and
symptoms may occur. It is important to be prepared for
these changes, to assure the optimal care for the patients
who are dying at home to evite unnecessary stress and
possible admission to hospital the last days.In
Denmark patients at home have to have medicine
prescribed by a physician to a pharmacy, and not all
pharmacies have the necessary medicine in stock.
Subcutaneous administration form is not yet common
157
Poster abstracts
Information on patients’ experience was gathered from
the non-professional caregiver interviewed after the
patient’s death. The interview included 26 open-ended
questions on the care provided to the patients and their
caregivers (10 for home section, 8 for hospital section, 8
for the general section). All comments transcribed by
the interviewers were typed on to a computer database.
Data were analysed by two independent researchers
according to the classical content analysis methodology.
Results: valid interviews were obtained from
1231 caregivers. Thirty-nine patients who never were in
hospital or at home were excluded. Overall, 7035
comments were collected from 1084 caregivers (91%). A
total of 2804 dissatisfactions were expressed from 754
caregivers (70% of those with at least one comment). A
preliminary classification of the contents identified six
major domains and 41 sub-domains.
Most dissatisfactions were in the domain of quality of
care and in the domain of communication.
Conclusions: This study suggests that terminal cancer
patients and their non-professional caregivers
experience a wide spectrum of dissatisfactions, most in
the areas where effective palliative care interventions are
available.
Poster abstracts
in Denmark, and not all home care teams have the
utensils.We developed a box containing the necessary
medicine and utensils for treating the most typical
symptoms at the end of life by subcutaneous route. We
leave a box in the home when the patient starts to
deteriorate. The boxes are sealed and with each box
there is a patient identification and a prescription signed
by a physician for the medicine to be given as
needed.Content of the box; Midazolam, Morphine,
Haloperidol, glycopyrrolate, furosemide, necessary
utensils and sodiumchloride. With each box there is a
stamped envelope and a questionnaire that the
responsible home care nurse has to fill in. Questions
regard the use of the box, evaluation of the box and to
what extend the use of the box prevented call for
physician assistance or admission to the hospital. The
box and the results from the evaluation, which was
overall very positive, will be presented at the conference.
581. A RETROSPECTIVE REVIEW OF THE USE OF
PROMETHAZINE FOR CONTROL OF NAUSEA AND
VOMITING
Frank Formby 1, Andrew Dickman 2
1
ILLAWARRA AREA HEALTH SERVICE, PALLIATIVE
CARE SERVICES, WOLLONGONG, Australia
2Marie
Curie Palliative Care Insitute Liverpool, Liverpool,
United Kingdom
Aims: To review the use of subcutaneous promethazine
in the Illawarra Area Health Service in palliative care
patients with nausea and/or vomiting.
Method: Over the period of 1 year, this restrospective
study identified 123 patients who had received
promethazine. A proforma collecting demographic data,
cause of the nausea and vomiting, anti-emetic therapy
and route of administration was completed for all
patients. Data on the efficacy, side-effects and
complications of promethazine therapy was also
recorded.
Results: The majority of patients were given
promethazine via a subcutaneous infusion at a starting
dose of 50mg over 24 hours. Most patients were on
promethazine for less than three weeks and
commonly promethazine was given until death. It was
generally used as a second or third line anti-emetic.
There was indirect evidence of the effectiveness of
promethazine in 38 patients, in whom no other antiemetics were added after the commencement of
promethazine. The most common side effect of
promethazine was drowsiness and a local skin reaction
was noted in two patients.
Conclusion: Within the limits of analysis of a
retrospective chart review study, it appears that
promethazine is an effective and well-tolerated
medication for nausea and vomiting in a palliative care
patient population.
582. The influence of adenosine triphosphate on
nutritional status in patients with advanced
pancreatic cancer: results of a randomized
controlled trial
Maxim Petrov, Arcady Anosov, Nikolay Emelyanov
Poster abstracts
Nizhny Novgorod State Medical Academy, Oncology and
Palliative Care, Nizhny Novgorod, Russian Federation
Background: The majority of patients with pancreatic
cancer are not resectable for cure at the time of
presentation. The complex syndrome of cancer cachexia
is a main contributor to the morbidity and mortality of
these patients. The aim of present randomized clinical
trial was to assess the efficacy of adenosine 5’triphosphate (ATP) in attenuating weight loss in patients
with advanced pancreatic cancer.Patients and Methods:
Patients admitted with unresectable pancreatic cancer
were eligible for study. Patients were excluded if they
had undergone surgery, endoscopic stenting,
radiotherapy, or chemotherapy during the previous four
weeks, had other active medical conditions or received
medication which could profoundly modulate
metabolism or weight. Patients who met the entry
criteria were randomized to receive either 5 intravenous
ATP infusions every 2 weeks or no ATP. Results: Thirty
patients were randomized to the ATP (n = 15) or control
group (n = 15). The two groups were comparable for
baseline characteristics. At 16 weeks, patients in the ATP
group had lost 0.9 kg in weight and 1.2 cm(3) in AMA
compared with a loss of 4.1 kg (p<0.05) and 9.2 cm(3)
(p<0.05) in the control group. Appetite remained stable
in the ATP group but decreased significantly in the
control group (P<0.01). Conclusion: ATP was well
tolerated and effective at attenuating loss of weight and
lean body mass in patients with cachexia due to
advanced pancreatic cancer.
158
583. Pleurodesis for malignant pleural effusion: a
procedure too long at the end of life
Anna Reyners 1, Margot Scheer 2
1
University Medical Center Groningen, Internal Medicine,
section of Palliative Medicine, Groningen, Netherlands
2
Pulmonology, Groningen, Netherlands
Introduction
In 2004, 9 patients of the department of medical
oncology underwent pleurodesis for dyspnoea caused
by malignant pleural effusion. Pleurodesis was
considered to be successful if dyspnoea did not reoccur
within 30 days. The median stay in the hospital for the
procedure was 11 days (range 7-27), whereas the median
survival was 54 days (range 14-133) after the pleurodesis.
Although the procedure succeeded in 7 patients, the
duration of hospital admission was considered too long.
Aim
To introduce a new protocol, with the aim to shorten
the hospital stay.
Methods
Within a 1-day protocol, patients are admitted to the
hospital early in the morning. A chest tube for drainage
is inserted. At 15 pm a chest X-ray is performed and
pleurodesis with 5 g talc is carried out if approximation
of the pleural leaves has been achieved. Thereafter, the
drain is removed and the patient goes home the same
day.
Results
Since the introduction of this protocol, 10 pleurodeses
have been performed. The procedure was successful in 8
patients. The median duration of admission was 9 days
(range 3-19). Median survival after pleurodesis was 40
days (range 6-188).
Conclusion
Pleurodesis for malignant pleural effusions is frequently
performed at the end of life. With the introduction of a
1-day protocol, the median duration of admission
diminished unsatisfactory. Other management plans
should be sought.
584. Malignant Fungating Wounds: An Analysis
of the Lived Experience
Catherine Piggin 1, Vanessa Jones 2
1
Prospect Hospice, PALLIATIVE CARE SERVICES, Swindon,
United Kingdom
2Cardiff University, Cardiff, United Kingdom
Aim: This study aimed to illuminate the meaning of
living with a malignant fungating wound.
Background: The current understanding of living with
a fungating wound is derived from professionals’ rather
than the patient’s perspective. Through analysing the
lived experience, an opportunity arises to return to the
experience itself and explore its meaning. An
appreciation of the lived experience may assist in the
development of empathic approaches towards the
support of patients living with fungating wounds.
Method: A Heideggerian hermeneutic
phenomenological approach was utilised to guide the
method. Five participants were interviewed and content
hermeneutic analysis was adopted to analyse the data.
Results: Four themes illuminated the meaning of living
with a fungating wound:
_The wound representing the worst part of living with
cancer
_Living within a body that cannot be trusted
_A changing relationship with family and friends
_A loss of identity whilst continuously striving to be
normal, yet feeling different
Conclusion: The study imparts the new meanings for
individuals living with cancer following the
development of a fungating wound. The need for
professionals to consider the impact of variable
symptoms upon day to day living in terms of self
identity, purpose and relationships is suggested. The
value of focusing more upon the subjective meaning of
a changing wound rather than objective measurement is
explored.
585. Well being, drowsiness, decreased appetite,
and anxiety are predictors of fatigue in patients
with advanced cancer.
Sriram Yennurajalingam 1, Lynn Palmer 2, Tao Zhang 3,
Eduardo Bruera 4
1– 4
UT MD Anderson cancer center, Palliative care and
Rehabiliation Medicine, Houston, United States
Background: Despite its high prevalence, there is little
research on the predictors of fatigue in advanced cancer.
The aim of this study was to determine association
between fatigue measured by the Functional assessment
of cancer therapy-fatigue (FACIT-F), age, gender, cancer
symptoms measured by the Edmonton symptom
assessment scale (ESAS) and to determine the
association between fatigue and clinical predictors by
the backward elimination process.
Methods: We reviewed the results of scores of ESAS, and
FACIT-F in a cohort of 253 advanced cancer patients
admitted in prior clinical studies on the management of
fatigue. Results: We found no univariate associations
between fatigue (FACIT-F) and gender (p=0.22), race
(p=0.31), cancer type (p=0.72). Performance status was
associated with fatigue (p<0.0001). There was a negative
correlation between fatigue and pain (r=-0.20,
p=0.0012), nausea (r=-0.13, p =0.04), anxiety (r=-0.27,
p<.0001), drowsiness (r=-0.24, p=0.0002), dyspnea (r=0.17, p=0.007), anorexia (r=-0.29, p =<.0001), insomnia
(r=-0.25, p<.0001), wellbeing (r=-0.36, p<.0001). Using
backward stepwise analysis, independent predictive
factors associated with fatigue include well being
(p=0003), drowsiness (0.006), anorexia (0.01), and
anxiety (0.03). However this model only explained 21%
of the variation in fatigue intensity. Conclusions: Well
being, drowsiness, decreased appetite, and anxiety are
predictive of fatigue in advanced cancer patients.
586. TENS at P6 should be included in treatment
algorithms for nausea and vomiting
Georg Bollig, Bettina Husebo
Aim of projekt: To investigate the importance of TENS at
P6 as non-pharmacological treatment of nausea and
vomiting. Previous studies have shown that acupuncture
point stimulation of the point P6 (using acupuncture,
acupressure and transcutaneous electrical nerve
stimulation=TENS) is an effective treatment for nausea
and vomiting, in pregnancy, cancer, chemotherapy and
the postoperative period Method: 3 case reports from
our department show that the use of TENS is effective in
the treatment of nausea as well as vomiting in palliative
patients. TENS was applied at the acupuncture point P6
with 2 Hertz at for at least 30 minutes every day. A
review of non-pharmacologic treatment of nausea and
vomiting is presented. Results: We report the cases of 3
patients who had very god effect of TENS in the
treatment of nausea and vomiting. To of these patients
with advanced cancer diseases had tried various drugs
without effect, but had effect after 10-20 minutes of
TENS treatment at P6. One patient suffered from
vomiting without nausea several times a day. After TENS
treatment vomiting was just occasionally. Conclusion:
TENS-stimulation at P6 is an effective treatment option
and showed to be effective in patients who could not be
treated effectively by pharmacological antiemetic
therapy alone. TENS should be included as a basic nonpharmacologic therapy in the treatment algorithms for
nausea and vomiting.
588. The Management of Malignant Bowel
Obstruction
Ruth Flockton 1, Jenny Doherty 2, Jenny Wiseman 3
1
United Kingdom
2
Aintree University Hospital, Liverpool, United Kingdom
3
Willowbrook Hospice, Liverpool, United Kingdom
Aim
Malignant bowel obstruction occurs in 3% of all patients
who are in the last stages of malignant disease. The
symptoms of nausea, vomiting and abdominal pain may
be very distressing and difficult to control. This project
aimed to review the management of bowel obstruction
by specialist palliative care teams.
Method
We collected data prospectively on all patients with
malignant bowel obstruction in the Mersey and
Cheshire Cancer Network.
Results
Specialist palliative care teams managed 66 patient
episodes of malignant bowel obstruction over the ninemonth data collection period. 34.8% of patients had
colorectal malignancy. 25.8% had an ovarian
malignancy. 76% of episodes of malignant bowel
obstruction were thought due to progressive disease.
53.0% of patients were cared for in the acute hospital
setting. 43.9% of patients had a nasogastric tube and
15.2% underwent a surgical procedure to palliate their
symptoms. Although the majority of patients were in
complete bowel obstruction an improvement in
symptom control was achieved in 76.7% of the patients.
48.5% of the patients died during the audit period.
Conclusion
Malignant bowel obstruction causes symptoms that may
be very distressing and achieving symptom control must
be a priority for all those involved in the patients care. A
multi-professional approach to the management is
essential to optimising the care of this group of patients.
Poster abstracts
Jordanka Kirkova 1, Mellar Davis 1, Declan Walsh 1, Tony
Jin 2, Jade Homsi 1, Nilo Rivera 1, Lisa Rybicki 2, Kristine
Nelson 1, Susan LeGrand 1, Michael Naughton 1
1
States
2Cleveland Clinic, Health Sciences, Cleveland, United States
Aim
To study how demographic characteristics and primary
cancer site influence symptom severity and distress.
Methods
48 symptoms were assessed on 181 cancer patients. Chisquare analysis or Fisher’s exact test compared symptom
severity and distress by age(≤65 v older), gender,
ECOG(PS),and cancer site.Logistic regression analysis
evaluated distress while controlling for severity.
Results
Younger patients had more moderate/severe anorexia,
dysphagia, early satiety, heartburn, numbness, pain,
sleep problems, urinary incontinence (10-58% v 1-40%),
and distressing anxiety, fever, numbness, sleep
problems, sore mouth(44-88% v 0–57%). Females had
more moderate/severe anxiety, headache, vision
problems(7-19% v 1-11%), and distressing
itch(12%v8%). Poor PS was associated with
moderate/severe confusion, depression, dysphagia,
dyspnea, myoclonus, and distressing dry mouth and
hoarseness. Moderate/severe itch, dysphagia, myoclonus
and skin problems were common for Head &Neck
cancer (22-33%), while edema for Breast, GU,
Hematologic, and Other cancers (18-36%). Belching was
distressful for all (29-80%), except for Head &Neck,
Lung, and Other cancers.After controlling for symptom
severity, cancer site did not influence distress. Females
were more distressed by anxiety, depression, sweating.
Conclusions
Younger patients, those with poor PS and females have
more severe and distressing cancer symptoms.Gender,
age, and PS influence distress independent of symptom
severity.
590. DEMOGRAPHIC INFLUENCES ON CANCER
SYMPTOM PREVALENCE
Jordanka Kirkova 1, Declan Walsh 1, Lisa Rybicki 2
1
States
2
Cleveland Clinic, Health Sciences, Cleveland, United States
Aim
To study the influence of age, gender, and performance
status (PS) on 8 symptoms.
Methods
38 symptoms were assessed on 1000 cancer patients.
Pain, constipation, sleep problems, nausea, anxiety,
vomiting, sedation, and blackout were significantly
influenced by > 1 demographic factor. A probability
model by gender, age (45, 65, 85 y old) and ECOG PS
identified prevalence patterns (magnitude, direction of
change) due to all three factors. Demographic
influences were arbitrarily defined as large (> 20%),
moderate (10-20%), or small 10%.
Results
Sleep problems were more prevalent among males;
anxiety, nausea and vomiting among females.
Prevalence decreased with aging for all eight symptoms.
The magnitude of age influence was: 1.large for
vomiting (females), 2. moderate for anxiety (females),
constipation, nausea, sleep problems, vomiting (males),
3. small to moderate for the rest symptoms. Five
symptoms were associated with worsening PS: anxiety
and pain prevalence decreased; blackout, constipation,
and sedation increased. The magnitude of PS influence
was: 1. large for sedation; 2. moderate for pain, anxiety,
constipation, blackout (males), 3. small for blackout
(females).
Conclusions
Common and rare symptoms decreased in prevalence
with aging. PS determined two prevalence patterns. PS
and age influenced symptoms in both genders in a
similar direction, but age influenced more gender
related prevalence differences. Age, PS, and gender must
be considered in symptom screening.
591. The Akathisic Cyclist- An unusual
symptomatic treatment
Mark Taubert, Ian Back
Marie Curie Centre Penarth, Palliative Medicine, Cardiff,
United Kingdom
A 47 year old woman was admitted to a palliative care
unit with anxiety and agitation. She had metastatic
carcinoma of the ovary and suffered with episodes of
subacute intestinal obstruction, as well as anxiety and
depression. Four days prior to admission, she began
vomiting, associated with mild intestinal colic.
On admission, she displayed classic acute akathisia,
continuously pacing the corridor, and describing a sense
of restlessness only relieved by movement. Pacing
continued throughout the night and caused her a lot of
distress and discomfort.
She continued to show signs of severe restlessness for
a further 3 days, with complete resolution after one
week. Pacing made her exhausted, and prevented her
from sitting down to meals, or enjoying time with
relatives.
A set of exercise pedals was offered to her, and she
found that by continuous pedalling in her chair, she was
able to relieve the distressing urge to move, whilst still
able to watch television, do crossword-puzzles, speak
with relatives, and eat meals.
Three drugs are considered in this case of akathisia:
haloperidol, fluoxetine and levomepromazine. We
describe the changes we made to her medication in our
case-report, stopping or substituting the offending
drugs.
The introduction of the exercise pedals made a great
impact on our patient’s quality of life, and gave relief
from the distress of her condition. A literature search
found no reference to any such non-drug management
of akathisia, and yet the benefit for this patient was
profound.
We suggest that light, repetitive exercises such as
treading exercise pedals could make the unpleasant
effects of akathisia more bearable in some patients and
that this simple intervention can have a profound effect
on a patient’s quality of life.
592. Palliative sedation in the last days of life:
indication ,duration and dosages of propofol and
lorazepam
Filip GEURS, Veerle DE VOS, Sarah HEYMANS, Muriel
DE DECKER, Lieve SOETAERT, Anne GHYSELS, Peggy
VILLE, Leen DEPYPERE, Isabelle LEBBE, Ann CORYN
Regionaal Z.H. St-Maria, Department for Palliative
Medicine, halle, Belgium
Introduction: palliative sedation (PS) is meant to relieve
otherwise uncontrollable symptoms like pain,
delirium/agitation and dyspnea. Most authors advocate
the use of benzodiazepins (mostly midazolam) or
propofol. The dosage of both drugs vary enormously
according to these authors.
Patients and methods: this retrospective chart review
evaluated the indication, dosage of drugs and duration
for all patients admitted to the palliative care ward from
1.11.2005 to 1.11.2006 and for whom PS was indicated.
Results: the doses of both drugs were gradually increased
and the level at which effective sedation was obtained, is
noted.
pt
duration dose
pt duration dose
number (d) required: number (d)
required:
propofol
lorazepam
(mg/h)
mg/24h
1
1
40
11
4
4
2
5
40
12
2
8
4
7
200
13
8
8
5
3
10
14
2
4
6
5
50
15
3
4
7
6
120
16
3
4
8
4
80
17
2
4
9
1
10
18
2
2
10
3
30
19
2
8
11/19pts had PS for anxiety, 4/19 for delirium and
agitation and 2/19 for pain; 2 /19 for hemorrage
Conclusions
1. PS can be obtained with ‘low dose’ (<50mg/h)
propofol and ‘ standard’ dose lorazepam.
2. median duration of PS is 3 days (range 1-8days)
3. clinically significant side effects from propofol like
hypotension and bradycardia were never noted in this
series.
593. A randomized phase III clinical study with
an integrated treatment in cancer-related
anorexia/cachexia: Evaluation of laboratory
variables of treatment efficacy
Giovanni Mantovani, Antonio Maccio’, Clelia Madeddu,
Giulia Gramignano, Roberto Serpe, Elena Massa, Giorgio
Astara
University of Cagliari, Department of Medical Oncology,
Cagliari, Italy
We are currently conducting a Phase III randomized
study which aims to demonstrate which is the safest and
most effective treatment for cancer-related
anorexia/cachexia and oxidative stress (CACS/OS). All
patients enrolled receive as basic treatment poliphenols
+ antioxidant agents. Patients are then randomised to
one of the following treatment (p.o.) arms: Arm 1.
Medroxyprogesterone Acetate (MPA) 500 mg/day; Arm
2. Energy-dense and high protein content pharmaconutritional support containing eicosapentaenoic acid ( 2
gr) + DHA, 2 briks/day;Arm 3. L-carnitine 4 g/day;Arm 4.
Thalidomide 200 mg/day;Arm 5. MPA + Pharmaconutritional support + L-carnitine +
Thalidomide.Treatment duration: 16 weeks. According
to statistical requirements 95 patients should be enrolled
for each arm (475 patients). From March 2005 to
November 2006, 116 patients were enrolled (M/F ratio
69/47, 94.6% stage IV). The patients were well balanced
for their characteristics between arms. An optimal
compliance was achieved and no significant side effects
were observed. As for laboratory variables, an interim
analysis on 91 patients evaluable at November 2006
showed: a significant decrease of reactive oxygen species
in arm 3, 4 and 5; a significant decrease of IL-6 in arm 3
and 5 and of TNF-in arm 3; a significant increase of
gluthatione peroxidase in arm 2 and 5. These changes
may reflect treatment efficacy. The study is ongoing.
Work supported by:MIUR National Research Project
No.2004067078
594. Palliative sedation therapy in the last weeks
of life: a literature review and recommendations
for standards
Alexander De Graeff 1, Mervyn Dean 2
1
university medical centre utrecht, Department of Medical
2
Western Memorial Regional Hospital, Corner Brook,
Canada
Background: Palliative sedation therapy (PST) is a
controversial issue. There is a need for internationally
accepted definitions and standards.Aim: To develop
internationally accepted definitions and
recommendations based on the published
literature.Method: A systematic review of the literature
on PST by an international panel of 29 palliative care
experts from 15 countries all over the world. After
extensive e-mail discussions and two meetings at the
EAPC in The Hague and Aachen, recommendations
were formulated, based on the level of evidence of the
published literature.Results: 17 recommendations on
the following topics: definitions of PST, intolerable
suffering and refractory symptoms, aim of PST,
indications and conditions, decision-making and
informed consent, cultural issues, types of sedation,
drug selection, dosing and titration, nutrition and
hydration, ethical aspects and outcomes and
monitoring. Conclusion: When other treatments fail to
relieve suffering in the imminently dying patient, PST is
a valid palliative care option, but only after a full
multidimensional assessment of the symptom(s) and
expertise of the professional caregivers involved.
Provided that the level of sedation is titrated to the relief
of the symptom(s), the decision to offer the use of PST
to relieve intolerable suffering of terminally ill patients
should be regarded as acceptable medical practice and
presents no distinct ethical problem.
595. A 44-year old breast cancer patient with
refractory vomiting due to neoplastic meningitis:
profound symptom relief by intrathecal
chemotherapy
Bernd Alt-Epping, Friedemann Nauck
University Hospital Goettingen, Department of Palliative
Medicine, Goettingen, Greenland
Background: Meningeal metastases occur in 2-3% of
all breast cancer patients. Symptoms comprise
headache, impaired consciousness, ataxia, fits, cranial
nerve palsies and myelopathic pain syndromes. Casereport: Here we report about a 44-year old female
patient diagnosed for breast cancer in 03/2005 (ER+,
PR+, Her2/neu 1+), with primary bone and liver
metastases and bone marrow infiltration. Opioid
analgesia, ablative hormone therapy, tamoxifen,
bisphosphonates and radiotherapy were delivered,
followed by systemic chemotherapy with moderate
clinical response. 6 months later, cervical pain,
dysphagia and heavy vomiting developed. MRI scans
and GI studies remained without explanation. Intensive
analgetic or antiemetic therapy showed no symptom
control.Progressive paraplegia occurred; a lumbar MRI
scan showed intraspinal nodular enhancement. The
patient became fully immobilized and unable to eat or
drink due to vomiting. Method: A Rickham reservoir
was inserted and Methotrexate 15mg was applied on an
outpatient basis. For the second i.th. application on day
5, the patient came walking; vomiting had sustained
completely and dietary intake resumed. I.th.
chemotherapy was switched to liposomal cytosine
arabinoside 50mg q2w because of mnestic disturbances.
The patient remained in sufficient symptom control for
8 weeks, when she died after a short period of general
deterioration. Conclusions: Refractory vomiting might
be associated with neoplastic meningits. Intrathecal
chemotherapy can lead to profound and sustained
symptom control. A Rickham reservoir allows safe drug
application. Possible benefits of antineoplastic therapy
159
Poster abstracts
589. THE INFLUENCE OF AGE, GENDER,
PERFORMANCE STATUS AND PRIMARY CANCER
SITE ON SYMPTOM SEVERITY AND DISTRESS
Poster abstracts
with regard to symptom control should be further
investigated.
3.-It is also important to take care of the carer to avoid
the family from abandoning
596. METHYLPHENIDATE SIDE EFFECTS AND
BENEFITS IN ADVANCED CANCER
598. Less gastrointestinal symptoms under
hydromorphone or morphine? A prospective
randomized open-labeled investigation on cancer
pain with a long-term opioid therapy.
WAEL LASHEEN, DECLAN WALSH, MELLAR DAVIS,
DILARA KHOSHKNABI, FADE MAHMOUD, NILO
RIVERA
States
Aim: Methylphenidate(MP) appears effective for
depression and fatigue in advanced cancer. Fear of side
effects(S/E) may discourage MP use.We analyzed MP S/E
observed in 3 published trials in depression and fatigue
in advanced cancer. Methods:Data from two cohort
series and a phase 2 study in advanced cancer were
pooled and assessed. All had identical dosing schedules
and follow up assessments. Results:62 patients were
evaluable; median age 69(range 30-90) years.7(11%)
withdrew due to intolerable S/E:insomnia(n=3),both
agitation and insomnia(n=2),nausea and tremor(n=1),
and agitation (n=1). 5(8%) refused to continue for
unspecified reasons. 50 completed 7 days of MP
treatment:35 were on 10 mg/d, one 15 mg/d, thirteen 20
mg/d, and one 30 mg/d.Of the 50 S/E occurred in 26%:
insomnia(14%), dry mouth(12%), nausea(12%),
agitation(10%), anorexia(8%), tremors(8%),
dizziness(4%), headache(4%), palpitations(2%), and
vomiting(2%). Some had multiple S/E. 49(98%) had
improvement in depression and/or fatigue. Most were
maintained on 10 mg/day. 3non-targeted symptoms
decreased in severity one week after MP therapy:
agitation(P<0.029), anorexia (P<0.008), and dizziness
(P<0.011). Conclusions:1)MP was 98% effective for
depression and fatigue in advanced cancer 2)A minority
experienced predictable S/E, but most had a low risk for
severe S/E.3)Therapeutic response was seen at doses
lower than in other reports.4)Improvement in nontarget
symptoms may be secondary to less fatigue and
depression
597. HOME CARE UNIT: A CHALLENGE.
Elena Oliete 1, Virtudes Soriano 1, Vicente Guillem 1,
Antonio Manche o 1, Silvia Zafra 1, Manuel Modesto 1
Poster abstracts
1
Aim of project: Profile survey of the patients deceased in
2004 seen at our Home Care Unit
Material and methods: Retrospective descriptive survey
done through the clinical history of all the patients who
died in 2004 seen at our unit. The information was
collected through an ad hoc form and the results were
analyzed using the software package SPSS 12.0 for
Windows.
Results:
In 2004, the Unity had 80 bed capacity. Average
occupation was 75 patients/day and there were 1160
admissions, of which 548 were new patients.
152 of the patients seen during 2004 died. Of the 143
patients 51.7% were men and 48.3% women. Average
age was 68.30±13.14 years.
Incidence of tumour pathology was: C. genitourinary
22.4%; C. gastrointestinal 20.7%; C. breast 18.6%; C lung
13.6%. 85% of the patients had metastasis. By order of
frequency metastasis was located, in: bone, liver, lung
and ganglio. 24.6% were given active palliative care on
admission to UHD.The main symptoms on admission to
the unit were: pain (46.5%), lack of energy (57.5%),
weight loss (35.4%), dyspnea (13%), dry mouth,
constipation, early satiety, sleep problems, coughing,
nausea and vomiting, edema, depression and anxiety.
No differences between the sexes were found.Lack of
energy was associated more to gastrointestinal tract
tumours, and no other statistically significant
associations between symptomatology and pathology
were found.In the treatment prescribed on admission to
the unit, the most commonly used drugs were morphic
(45.9%), anxiolytic (47.4%), gastro-protective (81.2%)
and laxative (90.8%). There was a good correlation
between drugs and secondary effects prevention like
corticoid-gastro-protective and morphic-laxative
associations. 79 died at home (55.6%) and 63 (44.4%) at
hospital. There were no sex related statistical differences.
64.4 % of patients over 65 died at home, however in the
under 65 age group 40% (p=0.004) died at home. No
statistically significant difference was found between the
place of death and the main diagnosis and/or the
location of metastasis.The most frequent reason for
referring patients to hospital were poor control of
symptoms (14%) and family abandonment (9.9%).
Other, less frequent causes were the patient’s express,
wish (3.3%), or problems with the
environment. Conclusions:
1.-Dyspnoea was the most difficult symptom to control
at our unit and the only one that showed a significant
association with place of death.
2.-The main carer has a very important role in correct
symptom control and the good quality attention.
160
Stefan Wirz, Hans-Christian Wartenberg, Joachim
Nadstawek
University of Bonn, Anaesthesiology & Critical care, Bonn,
Germany
IntroductionGastrointestinal symptoms such as
nausea, emesis and constipation are generally
considered by many cancer patients to be among the
most distressing adverse events associated with opioid
therapy The purpose of the present study was to evaluate
the effect of long term-treatment with either oral
sustained release hydromorphone or morphine and
concomitant medication on gastrointestinal symptoms
such as nausea, emesis and constipation. Patients and
MethodsIn a prospective, randomised, open-labeled,
controlled trial, 100 outpatients with cancer pain and
preceding long term treatment with either oral
sustained release hydromorphone or morphine were
enrolled. Prior opiod therapy had a duration for at least
28 days. During an observation period of 5 subsequent
days mobility, pain, nausea, emesis, and constipation
were assessed by the ECOG performance status, selected
items of the EORTC questionnaire and Numerical
Rating Scales (NRS). Data were analyzed using
descriptive and confirmatory statistics (paired t-test, chi
square test, poisson regression). ResultsDemographic
and medical data were comparable in both treatment
groups. Nausea and emesis did not attenuate in 33 % of
patients with a long term opioid therapy. Despite higher
morphine equivalent doses of hydromorphone the
severity of nausea (NRS 2.5 vs. 1.5; p = 0.01), incidence
of emesis (0.7/d vs. 0.1/d, p = 0.0001) and the
consumption of antiemetics was higher in the
morphine group (26 vs. 14, p = 0.01). In the morphine
treatment group an extended use of substances with
potentially constipating effects (31 vs. 13, p = 0.0003)
was associated with an increase of patients with a stool
free interval of more than 72 hours (8 vs. 2, p = 0.04).
There was no statistical significant difference in NRS for
constipation (2.7 vs. 2.2, p = 0.35) and for dosing of
laxatives (32 vs. 35, p = 0.52). ConclusionSymptom
control in outpatients with cancer pain may be
complicated by a symptom controlling medication.
More attention has to be drawn to potentially
constipating effects of antiemetics.
599. MRSA in the Palliative Care Unit ? A New
Challenge
Aoife Gleeson, Jan Kiely, Carol Moloney, Liam O’Siorain
Our Lady’s Hospice, Harold’s Cross, Palliative care unit,
Dublin, Ireland
The aims of this study were threefold: Firstly, to identify
the methicillin-resistant staphylococcus aureus (MRSA)
prevalence in patients transferred to hospice from other
health care institutions. Secondly, to determine the
accuracy of information relating to the MRSA status of
patients at the time of transfer to the hospice. Thirdly,
to determine whether the hospice policy of screening
all patients transferred from other health care
institutions was being carried out and to what extent
the screening identified new MRSA cases. A
retrospective chart review of all patients admitted to a
36 bed specialist Palliative Care Unit over a 12 month
period, from other health care institutions was
undertaken. All patients transferred were screened for
MRSA within 48hrs of transfer. Prevalence of MRSA
colonisation, site of colonisation and clinically
significant infection were documented. All transfer
documentation, referral forms and available MRSA
screening results were reviewed on each transfer patient
to determine whether they were already known to be
MRSA positive before transfer. Results: Will present data
pertaining to the sample of approximately 200 patients
transferred to the Palliative Care Unit from other health
care institutions. Prevalence of MRSA, site of
colonisation, clinically significant infection and
accuracy of transfer information will be presented.
600. HYPERCALCEMIA AT PATIENTS WITH
BREAST CANCER AND GENERALIZED BONES
METASTASIS
Lidija Veterovska Miljkovik
Gerantology Institution 13 Noemvri, Hospice Sue Ryder,
Skopje, Macedonia
Aim of the abstract: explanation of the case of,
woman, age 57 with recurrent hypercalcemia, because
of breast cancer and generalized bones metastasis.
Method: She had verified cancer on left breast in
09/97. The same month, mastectomia was done and left
adnexectomia. In 1997/98, post surgical radiation and
chemotherapy. In 12/97, there were appearances of pain
at the patient in the area of collar part, right hip and at
backbone (with Rtg and scan verified secondary deposits
in many bones), as well as pathological fractures of L4
and L5. In 2002, the statement of inability to move, pain
and dyspnea. Symptoms linked with hypercalcemia at
the patient occurred in 2002 with intense nausea and
throwing up, anorexia, polyuria: 3-4 l/24 hours,
dehidratation, forgetfulness, headache, sleepiness, and
later disorientation and hallucinations.
Treatment at our institution: She was subject to
rehydratation with 0,9% NaCl I.V., amp.
Miacalcic,amp.Dexamethason.. Symptoms of
disorientation, confusion and hallucination were
increasing rapidly, and these were the reasons to give
bisphosphonate i.v.There was continuation of the
treatment with 0,9% NaCl i.v.amp. Dexamethason, and
after seven days the value of serum Ca was 3,4 mmol/l.
The dose of bisphophonate was repeated.
Conclusion: Hypercalcemia is often at the patients
with generalized bones metastasis. Treatment of
hypercalcemia leads to decrease of symptoms at
terminally ill patients.
601. Coping with breathlessness through selfmanagement by COPD patients
Marjolein Gysels 1, Irene Higginson 2
1
2King’s College London, Department of Palliative care,
Background: Studies of COPD patients’ experience of
care have documented poor service delivery. Most of the
effort of controlling breathlessness happens at home.
Aim: To understand how patients and carers respond to
breathlessness, what their self-care entails and what they
experience as helpful.
Methods: A qualitative design based on Grounded
Theory and part of a wider programme “Improving
Breathlessness”. A purposive sample of 18 COPD
patients were included. Data were collected through
participant observation during outpatient consultations
and in-depth interviews at a large hospital, and the
community in London.
Results: As information regarding the management of
breathlessness was lacking and access to treatment was
difficult, patients reverted to alternative strategies. Some
patients developed considerable expertise and managed
their symptoms competently within the limits of
current care. Patients who coped successfully were
involved in pulmonary rehabilitation and had adopted
this as a way of life. Benefits and challenges to
participation in these programmes were identified.
Conclusion: Not all patients suffer from poor service
delivery; they practice self-management and maintain
an acceptable quality of life through self-acquired
expertise relating to symptoms, medication and helpseeking, and through a changed outlook on life. The
findings have implications for patient-involvement,
responsibility and adherence in the management of
COPD.
602. Modafinil and Methylphenidate improve
Fatigue and Quality of Life in Terminally Ill
Cancer Patients on Opiods
Stefan Schild, Andreas Lübbe
Karl-Hansen Klinik, Palliative care unit, Bad Lippspringe,
Germany
Objectives:Many cancer patients suffer from fatigue. The
fatigue-syndrome implies cognitive/mental aspects
and/or physical tiredness (asthenia) and negatively
impacts on quality of life (QL). Therefore, we tested if
methylphenidate (G1), modafinil (G2) improve the
fatigue-syndrome. Methods:In a randomized,
prospective, double blind study, 31 advanced cancer
patients with opiods against pain were separated into
G1(5 mg bid), G2 (100 mg bid) or placebo (G3, one pill
bid) for up to 28 days. Fatigue and QL were measured on
days 0,7,14,28 via the MFI-20 and QLQ-C30. Results:QL
decreased over 28 days in G3 (-39%), but increased in G2
(+17%) and G1 (+23%). Physical functioning increased
more in G2 (+12%) and in G1 (+5%) than in G3 (+2%).
MFI-20 presents variable results. General fatigue could
be hold steady from day 0 to day 28 in G1(+1%), while
fatigue increased with placebo (+6%) and modafinil (+
17%). Physical fatigue declined from day 0 to day 7 in
G1 (-12%), as well as with placebo (-4%) and remained
steady with modafinil (+2%). Surprisingly, placebo kept
mental fatigue constant from day 0 to 28, whereas it
increased in G2 (+10%) and G1 (+37%). “Activity”
decreased in all three groups over 28 days.
Conclusions:There is an overall trend for improved QL
and general/physical fatigue with methylphenidate and
less with modafinil. Placebo did not have a significant
influence on fatigue. Key words: Fatigue, quality of life,
modafinil, methlyphenidate, cancer.
Poster abstracts
Ilya Tsimafeyeu, Lev Demidov, Galina Kharkevich
N.N.Blokhin Russian Cancer Research Center, Dept.of
Biotherapy, Moscow, Russian Federation
Objective:
In most cases PV has been associated with hematologic
malignancies, and only rarely with solid tumors. There
is no standard supportive therapy. Various principles of
PV treatment have been proposed for tumor-associated
vasculitis, including prednisolone and cytostatic drugs.
Unfortunately, prednisolone does not guarantee stable
effect. We describe cases of low dose IL-2 efficacy in
MRCC pts with PV.
Methods:
5 from 102 MRCC examined pts had PV (4.9%).
Clinically, there were erythematous macules and
palpable purpura occurring on the lower legs
(leukocytoclastic vasculitis). In all cases PV presented
together with tumor. 1 patient had previous prednisone
therapy without prolonged effect. 3 pts were with
thrombocytosis (up to 500x109/l). As a standard for
MRCC they received IL-2, 1 MIU, 3 t.i.w., during 3
weeks.
Results:
Objective anticancer response was seen in the only 1
from 5 PV pts. Nevertheless, we revealed anti-PV action
of IL-2 in all pts. Partial regression of eruption was
dedicated after the first IL-2 infusion and complete
regression was observed towards end of
immunotherapy. Duration of effect was permanent
without relapse of PV symptoms.
Conclusions:
PV is not very rare symptom of kidney cancer. Low dose
IL-2 can be effective in PV pts and possibly in pts with
other paraneoplastic autoimmune disorders.
604. Reducing nausea and vomiting
Carina Rundstrom 1, Susanne Carlsson Bennet 1,
AnnaLena Sandell Blomqvist 2, Katarina Landstedt 2,
Erica Neumann 2
1
Karolinska University Hospital, oncology, Stockholm,
Sweden
2Lowet Narvard, Palliaitve Care, Stockholm, Sweden
The purpose of this project is to reduce nausea and
vomiting in patients affiliated to the division of palliative
incare and homecare in Löwet Närvård.Patients with
cancer in advanced stages often suffers from nausea. The
cause of this could either be the oncology treatment or
be related to the disease itself. In order to find the right
and the best treatment it is necessary to have basic
knowledge of different causes itself.Löwet Närvård has
during many years been having regular meetings with
the oncology consulting team from the Karolinska
University Hospital. Because of that it was natural to
contact the oncology clinic when planning to draw up
and introduce an assessment form for nausea. Within
the oncology clinic there is an antiemetical project going
on. The purpose of this project is to draw up evidence
based guidelines regarding antiemetic treatment in
cancer patients. Löwet Närvård drew up an assessment
form regarding nausea which was thouroughly looked
through the oncology consulting team. The different
professions from the consulting team educated the entire
staff within Löwet Närvård regarding physiology,
pharmacology, nursing and complementary treatments
for nausea in cancer patients. After the education the
assessment form will be introduced to all patients in
Löwet Närvård. Regular follow up will take place in the
form of team conferences with the oncology consulting
team.
605. Dyspnoea: A bad prognosis symptom at the
end of life
Miguel Angel Cuervo_Pinna 1, Maria José
Redondo_Moralo 2, Miguel ángel Sánchez_Correas 3,
Rafael Mota Mota_Vargas 4, Guillem Pera 5
1– 4
Regional Palliative Care Program of Extremadura,
Badajoz, Spain
5Centre of Public Health, Mataró, Spain
Purpose:survival since dyspnoea appears and if this
symptom reduces the prognosis. To analyze the
relationship between dyspnoea and wherever the
patient died and dyspnoea is such a cause of sedation.
Method: It’s a retrospective, longitudinal study with
patients included in a Palliative Care Program(n=195).
All of them died in 2005. We studied : dyspnoea in
terminal patients. The average of survival since its
presence to the death , where is the place of this
symptom as a cause of sedation and the cause of death.
We used the STATA-9 statistic software and a logistic
regression to value the sedation caused by dyspnoea and
the place of death.In the survival analysis, we used the
Kaplan- Meyer model and the Cox model. Results:
.Dyspnoea is the most frequently symptom in our
population that conduce us to practice the palliative
sedation (37%)Suffering dyspnoea like an isolated
symptom supposed a high risk factor of sedation. (O.R.:
5.13). This probability was highly significant. (p:
0.0002).The odds about dying in hospital was more
than double in patients with dyspnoea. (O.R.: 2.13; p:
0.0001).The survival analysis showed 22 days (median)
in dyspnoea population and 26 days in patients without
the symptom. Conclusions:We observed a clear
association between dyspnoea and the possibility of
practising a sedation. Patients with dyspnoea died more
frequently in hospital. The survival analysis identified
patients without dyspnoea had more life
expectancy;otherwise, it was a light difference.
606. Dyspnea: Etiology Factors in patients with
terminal disease
Miguel ángel Cuervo-Pinna, Rafael Mota-Vargas, Miguel
ángel Sánchez-Correas, MJosé Redondo-Moralo,
Guillem Pera
Palliativ Care Unit, Internal Medicine & Medical Oncology,
Barcelona, Spain
Objectives Analize the etiology factors(EF) of dyspnea
in a population treated by a support team of palliative
care Methodology It is a retrospective longitudinal
study of patients included in a palliative care
programme in Badajoz in 2005. 195 patients were
recruited . The following variables were studied: Age,
Sex,% patients with dyspnea,Kind of terminal
disease,Location of cancer,EF of dyspnea: 1. Local
cardiology and Lung.2. Asociated disease 3. Sistemic
causes, 4-Oxygen saturation(SatO2) - Hemoglobin
level (Hb) Analysis was achieved with Statistical STATA9
Method. To Know the relationship between the dyspnea
and the EF we haved used logistic regresion models.
Results:110 presented dyspnea (56%). Oncology disease
representated the 88% of all the cases. Lung cancer was
the most frecuently one . Regression logistic study
showed that “odds” of present dyspnea in patients with
cardiac and lung diseases direct (1) and indirect(2) was
higher than the others diseases (OR1=0.1 OR2=0.05,
p=0,0001). SatO2 was lower in patients with dyspnea
(OR=0,53 ; p=0,0003). Hb was associated with dyspnea
(OR=0,78 p=0,02) ConclusionsThe presence of cardiac
and lung disease was associated in a significant way with
dyspnea. Systemic causes were associated with dyspnea
but not significantly. Hipoxemic patients and those who
had low levels of hb showed higher probability to suffer
dyspnea.
607. MANAGEMENT IN HOPITAL OF MALIGNANG
PLEURAL EFFUSION, TROMBOEMBOLIC LUNG
DISEASE AND INTESTINAL OCCLUSION.
EXPERIENCE IN OUR CENTRE.
Isabel Blancas, Jesus david Cumplido, Pablo Iglesias,
Nuria Cardenas, Javier Angel Garcia, Teresa Delgado,
Belen Rios, Jose luis García-Puche
Hospital Clinico San Cecilio, Unidad de Oncologia,
Granada, Spain
INTRODUCTION:The oncologic patients suffer
complications, specially severe are the malignant pleural
effusion (MPE), tromboembolic lung disease(TlD) and
intestinal occlusion(IO)OBJETIVE:To describe the
epidemiological patter of these complications, the
treatment applied and the evolution of the income
patients in our Unit.PATIENTSMETHODS:Observational retrospective study, we
reviewed all the medical history of all income patients
in our Oncology Unit that suffered MPE, TLD and IO
during 2004 and 2005.Characteristics: 25 women/12
men, mean age: 61 years(27-82). Primary tumor:
gynecologic 12, digestive 10, lung 8, breast 4, others 3
RESULTS: MPE: thoracocentesis to 9 patients,
providing relief in 8.Pleurodesis was not performed after
first thoracocentesis. Six patients (66%) suffered a
relapse, to 4 of these were made a pleurodesis (with talc)
without posterior relapse. Five (55%) patients died
because MPE. Mean overall survival since the diagnose
of MPE: 4 months(1-16). TLD: 13 patients,all received
low weight heparins.A filter of cava vein was inserted in
one. 4 dead because TLD. Mean stay at hospital: 13 days
(2-24). IO: 15 patients, 93% received medical treatment
and surgery was performed in one, 33% required a
nasogastric sounding and 27% parenteral
nutrition.Seven patients(60%) suffered a relapse Mean
stay 11 days (4-35)CONCLUSIONS: MPE should be
treated definitively at the time of initial diagnosis in
order to avoid the relapse.The evolution of TID and IO is
determined by the tumor, what usually provides a worse
evolution and a longer mean stay at the hospital
608. TREATMENT OF ANOREXIA: ASSESMENT OF
OUR CLINICAL PRACTICE
Isabel Blancas, David Cumplido, Jose Luis García-Puche
Granada, Spain
Objective: To look at anorexia in cancer patients being
entered on an oncology service and to assess our clinical
practice in the treatment of anorexia.Patients and
Methods: transversal and prospective study with all the
oncologic patients who were admitted in our service in
one month, measuring the symptom of anorexia and
the treatment that they received when they were
admitted in the hospital and while they were at the
hospital. There were 50 patients. Results: On the first
day in our unit anorexia was found in 22 patients (44%).
The intensity was: light: 15, moderate: 5, and severe: 2.
15% of the patients with anorexia received already
appetite stimulants: 1 megestrol acetate and 2
corticosteroids. During the stay nutritional counselling
was provided by physicians in all the patients. Appetite
stimulants were prescribed in 5 : 4 megestrol acetate and
1 corticosteroids. Enteral or parenteral nutrition was not
administrated. Evolution: 87% of the patients who
receibed appetite stimulants became better.28% patients
developed anorexia during the time in the hospital
(related with the food in the hospital or with the
administration of chemotherapy), none of them
received treatment. Conclusions: The anorexia is a
common problem in cancer patients, even more
frequent when they are income in the hospital. Most of
the times are not properly treated, especially when it
occurs during the time that the patient is in the hospital
or it is related with the administration of the
chemotherapy
609. Symptom Clusters in Newly Diagnosed
Patients with Lung Cancer in Taiwan
Shu-Yi Wang 1, Chun-Ming Tsai 2, Bing-Chang Chen 3,
Chia-Chin Lin 4
1– 4
University, Department of Medicine, Taipei, Taiwan
The number one cause of cancer deaths in Taiwan is
lung cancer. Of the few studies describing the
experience of patients living with lung cancer, most use
bivariate analyses to test associations between individual
symptoms. Few have systematically investigated
multiple symptoms. This study was undertaken to
explore both the phenomenon of symptom distress, and
the presence of symptom clusters in Taiwanese lung
cancer patients. The design is both descriptive and
correlational. We collected data from a sample (n=108)
of lung cancer patients using the MD Anderson
Symptom Inventory-Taiwan form, analyzed with
hierarchical cluster analysis, factor analysis, Pearson
correlation, and descriptive statistics. The top five mostsevere symptoms were fatigue, sleep disturbance, lack of
appetite, shortness of breath, and general distress. All
symptoms could be factored into two groups, general
and gastrointestinal symptoms. Cluster analysis also
indicated two cluster groups. The first included pain,
fatigue, sleep disturbance, distress, shortness of breath,
difficulty remembering, lack of appetite, drowsiness, dry
mouth, sadness, and numbness. Cluster two included
nausea and vomiting. These results provide an
important basis for developing novel strategies to
manage multiple symptoms in lung cancer patients,
therefore improving their well-being.
Key Words: Symptom cluster, lung cancer, Taiwan
610. Fatigue in Breast Cancer Survivors
SUSANNA ALEXANDER 1, PATRICK STONE 2, PAUL
ANDREWS 3
1
2St George’s, University of London, Division of Mental
3
St George’s, University of London, Medical School, London,
United Kingdom
Objectives: To determine the prevalence of Cancer
Related Fatigue Syndrome (CRFS) in a population of
disease free breast cancer survivors. To investigate the
relationship between fatigue,activity,sleep
disturbance,haematological,biochemical and endocrine
indices.
Methods: 115 Breast cancer survivors were recruited and
completed (i) an interview for diagnosis of CRFS (ii)a
validated semi-structured psychiatric interview
(iii)questionnaires assessing (a)fatigue (b)quality of life
(c)coping strategies and (d)psychological status.
Screening blood tests were completed and a 24 hour
urinary collection for assay of urinary cortisol was
undertaken. Objective physiological data was obtained
using specialised activity monitors - actigraphs. In a
subgroup of patients (30) an endocrine challenge test
was completed in order to assess the functionality of the
hypothalamic pituitary adrenal axis.
161
Poster abstracts
603. Paraneoplastic vasculitis (PV) associated
with metastatic renal cell carcinoma (MRCC).
Interleukin-2 (IL-2) has anti-PV efficacy.
Poster abstracts
Preliminary results: There was a high recruitment rate
with 65% of eligible patients entering the 1st part of the
study. Completion rates of various parts of the study
were high (98%). The prevalence rate for CRFS was 31%.
The expected rise in prolactin and cortisol was
demonstrated in the 2nd part of the study and there was
a low attrition rate (97%).
Conclusion: Initial actigraphy looks very different with
CRFS subject less daytime activity and sleep pattern
significantly affected when compared with the control
subject. Buspirone challenge showing emerging
differences.
611. The Management of Nausea in the Last Days
of Life
Ruth Flockton 1, Helen Ferguson 1, Melanie Brooks 2,
Andrew Dickman 1, Karen Groves 3
1
United Kingdom
2
3
Aim
Nausea and vomiting develop in the last days of life in
10% of patients. The cause of the symptoms may not be
clear. The symptoms need to be managed quickly to
ensure the patient is not distressed. We aimed to
establish the anti-emetics suggested by specialist
palliative care (SPC) professionals for the management
of nausea and vomiting in the last days of life.
Method
A questionnaire survey was distributed to all senior
medical and nursing staff who work within SPC in the
Mersey and Cheshire Cancer Network. They were
required to state the drugs they would use to manage
symptoms arising in the last days of life.
Results
37% suggest cyclizine as the first line anti-emetic for
patients in the last days of life. 35% of respondents
would suggest levomepromazine in this situation.
Haloperidol was suggested as a second line anti-emetic
by 29% of respondents. The dose of levomepromazine
suggested varies from 3.125mg to 25mg with 85%
suggesting 6.25mg initially. The most commonly
suggested combination is cyclizine and haloperidol
which is recommended by 64%.
Conclusion
It is important to fully relieve all symptoms that cause the
patient distress in the last days of life. There is a paucity of
evidence to guide the use of anti-emetics for patients who
become nauseous in the last days of life and this is an area
which needs further evaluation to find the most effective
drug treatment to achieve symptom control.
612. The Management of Agitation at the End of
Life
Ruth Flockton 1, Helen Ferguson 1, Melanie Brooks 2,
Andrew Dickman 1, Karen Groves 3
Poster abstracts
1
United Kingdom
2
3
Aim
We aimed to establish the prescribing intentions of
specialist palliative care (SPC) professionals when
managing patients who are agitated in the last days of
life.
Method
A questionnaire survey was distributed to all senior
healthcare professionals in SPC across the Mersey and
Cheshire Cancer Network. We required respondents to
state the drugs they would usually suggest when
managing patients who are in the last days of life.
Results
89% of those who completed the questionnaire suggest
midazolam first line for the management of agitation.
61% suggest levomepromazine and 17% suggest
haloperidol as second line drugs. 87% suggest 2.5mg as
the initial dose of midazolam. 29% suggest a continuous
subcutaneous infusion of midazolam is commenced at
5mg and 63% suggest 10mg. 57% suggest 6.25mg as the
initial dose of levomepromazine but the dose varies
from 3.125mg to 50mg. The initial dose of haloperidol
suggested varies from 0.5mg to 5mg with 50% of SPC
professionals suggesting 1.5mg initially.
Conclusions
The management of agitation in the last days of life
varies across the cancer network. Healthcare
professionals suggest the same drugs but the doses
suggested vary significantly. The production of
guidelines for the management of agitation in the last
days of life facilitates a more integrated and cohesive
approach.
162
613. PILOT STUDY OF APPLICATION OF A
CLINICAL TYPOLOGY FOR TERMINAL
RESTLESSNESS
Christine Sanderson 1, Meera Agar 1
1
Flinders University, Deapartment of Palliative and
2
Flinders University, Deapartment of Palliative and
Introduction: Terminal restlessness describes a
distressing symptom cluster of fluctuating
consciousness, motor agitation, myoclonus, cognitive
change, anxiety, and sleep disturbance in the last
days/hours of life. It is often aggressively managed, so
that patients lose ability to interact or make decisions.
However lucidity at the end of life remains important
for patients and families. We present pilot data of a
proposed typology of terminal restlessness, describing
changes in domains of cognition, consciousness, mood,
motor and existential distress in actively dying patients,
aiming to promote consistency in clinical practice and
research. Methods: A cross sectional study of the
typology was conducted in 100 palliative care inpatients
in Sydney, Australia. A nurse rated the five domains to
allow classification with the typology which was
compared to blinded ratings using validated measures of
cognition, conscious state, and delirium. In a subset of
patients 2 blinded raters classified the patient to provide
preliminary data on inter-rater reliability. Results and
discussion: We report prevalence in this hospice
population of subcategories in the typology (delirium
subtypes, drug toxicity, psychological distress and
symptoms of the dying trajectory). Comparison and
agreement with classification using other validated tools
is presented. Its potential as a diagnostic and research
tool is discussed, with evidence for targeted
interventions and supportive care of each subgroup.
614. Parenteral Hydration and distressing
symptoms in terminally ill cancer patients: a
preliminary study.
Claudio Ritossa 1, Silvia Cedrino 1, Eugenia Malinverni 1
1
Luce per la vita, Home Care Team, Rivalta (Turin), Italy
Most terminally ill patients decrease their oral fluids
intake in the last days of life. This study aimed to
evaluate differences in symptoms control in patients
artificially hydrated. 34 cancer patients, with aestimated
survival of 7 days, cared by three different teams,
a home care team, an hospice team and a medical team
of a public hospital, were involved. Symptoms in
relation to hydration level were recorded at day 1, 4 and
7, according to ESAS scale scores, patients were divided
in three groups, in relation to fluids administered:
<1000ml, >1000 < 2000, > 2000 ml. Results. In the last
24 hours of life dyspnoea, sleepiness, delirium, nausea
get worse in patients with higher quantity of
fluids, thirst seems to be improved. Nausea improves
when fluids are reduced. Thirst was harder to evaluate in
the last 24 hours. Vomiting improves in patients treated
with less fluids. Delirium decreases in relation to
reduced fluids. Sleepiness is present in half of the
patients observed whatever the quantity of
fluids. Palliative care teams are prone to reduce fluids in
the last days, while doctors without training in palliative
care have opposite tendency. This preliminary study,
limited by the absence of clear statistical evidence,
seems to confirm some previous reports which
demonstrate worsening of the majority of distressing
symptoms in the last days of life in relation to fluids
given. Further controlled studies are required, in spite of
the difficulties of research in the last days of life.
615. THC as an antiemetic in palliative care
patients: A prospective trial
Isabella Blum 1, Friedemann Nauck 2, Eberhard Klaschik
1, Elina Clemens 1, Ulrike Stamer 3
1
Malteser Hospital, Centre for Palliative Medicine,
University of Bonn, Department of Science and Research,
Bonn, Germany
2University of Göttingen, Department of Palliative Medicine,
Göttingen, Germany
3University of Bonn, Department of Anaesthesiology and
Intensive Care Medicine, Bonn, Germany
Aim of the study: Nausea and vomiting are distressing
symptoms in patients with advanced cancer.
Cannabinoids may be effective in the management of
nausea (1). A pilot study was initiated to evaluate a
titrating regime, efficacy, and side effects of THC (delta9-tetrahydrocannabinol).
Methods: Patients complaining of nausea/ vomiting
were included in this prospective study and received
THC according to a standardized protocol (3x0.8 mg/d,
dose escalation to 3x3.2 mg/d; rescue medication:).
Demographic and cancer related data, number of daily
episodes of nausea, severity of nausea / vomiting and
need for rescue medication were documented.
Results: 14 patients (Karnofsky-Index: 30-90) suffering
from far advanced cancer were included. Nausea and
vomiting was induced by gastrointestinal problems,
drugs, chemotherapy or radiation therapy. 12 patients
were pre-treated with WHO III opioids (20-240 mg
morphine equivalents). Individual maximum THC
doses varied between 2.4-7.2 mg/d. 93 Treatment days
could be evaluated. In 6 patients additional rescue
medication was needed at 14 different treatment days.
THC (median 9(3-14) days was discontinued due to
lacking efficacy in 3 and good symptom control in 1
patient. One patient complained of diplopic images and
THC dose had to be reduced.
Conclusions: The low doses of THC were well tolerated
by the majority of the patients. Need of dose escalation
was common. Further patients have to be enrolled in
the ongoing study.
616. Problems and care needs in patients with
incurable esophageal or hepato-pancreaticobiliary cancer.
Madeleen Uitdehaag 1, Ate Van der Gaast 2, Casper Van
Eijck 3, Els Verschuur 1, Karin Van der Rijt 2, Rob De Man
1, Ewout Steyerberg 4, Ernst Kuipers 1, Peter Siersema 1
1
Erasmus MC University Medical Center Rotterdam, Dept.
of Gastroenterology and Hepatology, rotterdam, Netherlands
2Erasmus MC University Medical Center Rotterdam, Dept.
of Medical Oncology, rotterdam, Netherlands
3
Erasmus MC University Medical Center Rotterdam, Dept.
of Surgery, rotterdam, Netherlands
4Erasmus MC University Medical Center Rotterdam, Dept.
of Public Health, rotterdam, Netherlands
Aim: To investigate which problems patients with
incurable esophageal (EC) and hepatico-pancreaticobiliary cancer (HPBC) experience and how often
patients expect care for these problems to devise a
follow-up policy tailored to this group of patients.
Methods: Fifty-seven patients with incurable EC or
HPBC from our outpatient clinic filled out a validated
questionnaire “Problems and Needs for Palliative Care”.
Patient and disease characteristics, patient problems,
and care needs for these problems were recorded.
Results: The majority of the 57 patients experienced
physical problems, such as fatigue (51(90%)), pain (41
(72%)) and lack of appetite (38 (67%)). Similarly,
patients experienced psychological problems, such as
fear for physical suffering (45 (79%)) and fear for
metastases (40 (70%)). Social problems, such as being
dependent on others (41 (72%)) and problems with
delegating tasks to others (35 (61%)) were also frequent
in these patients. Less dominant were spiritual issues,
such as questions regarding the meaning of death (28
(49%)). Professional care was expected for physical and
psychological problems in 40-65% of patients. In
contrast, patients preferred to deal with social and
spiritual problems by themselves or in their own social
network. Conclusions: Professional care for patients
with incurable EC or HPBC should mainly be directed
towards the encountered physical and psychological
problems and to a lesser extent towards social and
spiritual problems.
617. Non-pharmacological interventions for
breathlessness in advanced stages of malignant
and non-malignant diseases: a Cochrane Review
Claudia Bausewein, Sara Booth, Marjolein Gysels, Irene
Higginson
King’s College London, Department of Palliative care, Policy
and Rehabilitation, London, United Kingdom
Background: Non-pharmacological interventions are
often recommended for the treatment of breathlessness.
However, their role and effectiveness remain unclear.
Aim: To determine the effectiveness of nonpharmacological and non-invasive interventions to
relieve breathlessness in patients with advanced disease.
Secondary objectives were to determine which
intervention strategies exist, were most effective and
most efficient for whom. Method: Systematic literature
search in 11 data bases and hand searches of relevant
textbooks, websites and articles. Studies were graded for
their evidence and methodological quality. Analysis
included interventions, conditions, effect of outcomes
and outcome measures. Results: We identified 24
studies which we classified as follows: acupuncture
(n=5), music (n=6), nursing intervention (n=4),
relaxation (n=3), psychotherapy (n=2), use of rollator
(n=2), other (n=2). 18/24 interventions were tested in
COPD, only those in nursing interventions were
predominantly tested in cancer patients. There were
mixed findings for the effect of acupuncture, music and
relaxation. Nursing interventions and the use of a
rollator seemed to have positive effects on
breathlessness. Conclusion: A variety of nonpharmacological interventions has been tested mainly
with COPD and rarely with cancer patients. Evidence is
supportive only of nursing interventions and the use of
a rollator.
Poster abstracts
Jaime Sanz 1, Almudena García 2, M Victoria Rodríguez 3
1
H universitario Marqués de Valdecilla, Oncología Médica,
Spain, Spain
2H universitario Marqués de Valdecilla, Oncología Médica,
Spain, Spain
3
H universitario Marqués de Valdecilla, Palliaitve Care,
Spain, Spain
Background. Providing palliative care in the end of life
we found that the incidence of refractory symptoms is
15-52%. In these cases palliative terminal sedation is
necessary. Objectives. 1.Analyse the incidence of
terminal sedation from 2003 to 2006 in a medical
oncology unit and assistant home care. 2. Identify the
refractory symptoms. 3. Survival time from sedation to
death. 4. Drugs used to induce sedation. Design.
Descriptive retrospective study of the incidence terminal
sedation in patients dead in our oncology unit.
Results.1. 1146 patients dead from 2003 to 2006. 512
patients (44.6%) were sedated. 2. The most common
refractory symptoms were: 40% dispnea, 41% pain, 26%
delirium, 26% terminal anxiety, 13% digestive disorders.
3. Median time from sedation to death was 1.9 days (1 to
5). 4. Drugs used were: 80% midazolam, 75% morphine,
10% haloperidol, 2% rohipnol. Propofol and
fenobarbital were no necessary. Conclusions.1. Terminal
sedation is indicated in 40-45% of patients at the end of
life. 2. The most common refractory symptoms are
dispnea, pain, delirium and terminal anxiety. 3. Survival
time from terminal sedation to dead is short. 4.
Midazolan and morphine are the drugs more useful
alone or in combination. 5. Terminal sedation allow to
make comfortable the last trip of life.
619. Results of different therapeutic approaches
for leptomeningeal metastases
Viktoria Lange-Brock 1, Carsten Bokemeyer 1, Andreas
Kruell 2, Maike De Wit 1
1
University Clinic Hamburg Eppendorf, Internal Medicine
& Medical Oncology, Hamburg, Germany
2University Clinic Hamburg Eppendorf, RADIOTHERAPY,
Hamburg, Germany
The aim of this study was to compare treatment options
for patients with leptomeningeal metastases (LM).
In this retrospective single center study all patients
(n=135) between 1985 and 2005 with malignant cells in
the cerebrospinal fluid (CSF) were evaluated.
These 80 females and 55 males, were treated for LM,
73 patients with solid tumors and 62 patients with
haematological malignancies. Of the total 135 patients
33% received combined chemotherapy and intrathecal
chemotherapy (ITC), 25% only TC, 5 % received only
systemic chemotherapy, 18% radiochemotherapy and 2
% radiotherapy only. 13% patients were treated with
supportive therapy only and in 4% therapy could not be
evaluated.
Median overall survival (OS) was 2.5 months.
According to univariante analysis age >50 years and
Karnofsky status <80 were predictors of poor survival.
Response to therapy and application of systemic therapy
were correlated with longer survival. The median OS of
5.6 months for NHL and 7.0 months for breast cancer
following systemic therapy compared to 2.5 months for
NHL and 1.4 for breast cancer without systemic
treatment demonstrated a significant better OS using
systemic therapy.
The results suggest that systemic chemotherapy
alone as well as in combination with other therapeutic
modalities may improve survival in patients with LM.
Unfortunately no QoL assessment could be included in
this retrospective trial. Changes of neurological
symptoms will be presented.
620. Wich word is better for depression and
anxiety screening with a simple question
Antonio Noguera, Marina Martínez, Ana Carvajal, Julia
Urdiroz, Cristina Arellano, Uxue Arzoz, Carlos Centeno
Clínica Universitaria de Navarra, Unidad de Medicina
Paliativa, PAMPLONA, Spain
The goal of this study was to determine the best word to
explore anxiety and depression with a simple question.
A hundred cancer patients completed HADS and
Verbal Numerical Scales (VNS) 0 to 10 about their level
of anxiety with ‘anxious/ansiedad’, ‘nervous/nervioso’
or ‘disquiet/intranquilo’, and their level of depression
with ‘depressed/deprimido’, ‘discouraged/desanimado’
or ‘sad/triste’. An HADS score of 8 or more was used to
diagnose mild anxiety or depression. A score of 11 or
more was used for moderate/severe anxiety or
depression. The correlation, regression, sensitivity and
specificity of all the VNS were analysed.
Correlation (rho Spearman) between HADS and
anxiety VNS were r0,557 with ‘anxious’, r0,603 with
‘nervous’ and r0,594 with ‘disquiet’. Correlation with
the depression VNS were r0,662 with ‘depressed’, r
0,759 with ‘discouraged’, and r0,596 with ‘sad’, ·_ <0,01
was used in all the VNS. Regression estimated
‘discouraged’ and ‘disquiet’ as best predictors’ models
for depression and anxiety respectively. A cut off 3 out of
10 for anxiety and 2 out of 10 for depression
reached best sensitivity and specificity levels.
In Spanish the term ‘discouraged’ seems to be more
proper to assess depression and the term ‘disquiet’ to
assess anxiety.
621. The impact of exercise on the level of fatigue
and quality of life in advanced cancer patients
under hospice care : preliminary report.
Tomasz Buss, Aleksandra Modlinska, Krystyna De
walden-Galuszko, Magdalena Osowicka, Justyna
Janiszewska, Monika Lichodziejewska-Niemierko
Medical University of Gdansk, Department of Palliative
Medicine, Gdansk, Poland
Cancer related fatigue (CRF) is experienced by most
patients in advanced cancer remaining under hospice
care. Fatigue is one of the most distressing problem
decreasing Quality of life (QL) in these patients. There is
almost no evidence that exercise can help to combat
CRF and QL in cancer patients in terminal stage of
disease.
Aim:
to asses the impact of schedule of exercises on the level
of fatigue and QL in advanced cancer patients under
hospice care.
Material and methods:
We examined 30 cancer patients in terminal state
remaining under hospice care in Gdansk and Gdynia. 15
patients in experimental group participated 3 times a
week during 4 weeks in exercise schedule comprised
isometric, breathing and active exercises supervised by
physical therapist. Control group (n=15) was only
observed. Both were treated with Best Supportive Care
rules. Once a week the CRF intensity and QL with VASfatigue scale, Brief Fatigue Inventory (BFI) and
Rotterdam Symptom Checklist (RSCL) were assessed.
Results:
Preliminary findings reveal that exercises can decrease
the intensity of CRF and prevent from decreasing of QL
over the time. We observed also improvement in
physical scores in RSCL in exercised group. In our
opinion the results are promising. Further investigations
are needed to establish the efficacy of exercise therapy in
decreasing CRF intensity in advanced cancer patients
under hospice care.
622. The R.I.S.S. experience; Dealing with
infections in palliative care settings
Jaume Canal 1, Marta Gabernet 2, Blas Sanchez 3, Marcos
Serrano 4, Neus Albanell 5, Jesus Lopez 1, Fernando
Barcenilla 6
1
Hospital Jaume d’Urgell, PALIATIVE CARE UNIT,
Balaguer, Spain
2
iNSTITUT CATALA DE SALUT, sociosanitary service,
Lleida, Spain
3
Hospitau Val d’Aran, sociosanitary service, Vielha, Spain
4
Hospital Santa Maria, sociosanitary service, Lleida, Spain
5
Fundació Sant Hospital, sociosanitary service, La Seu
d’Urgell, Spain
6
Hospital Universitari Arnau de Vilanova, Unitat Funcional
d’Infecció Nosocomial, Lleida, Spain
INTRODUCTION
Patients admitted to a palliative care unit can suffer from
infections, mainly adquired in the hospital.As advanced
diseases down regulate immunological system, severe
infections can be dramatic for both oncological and non
oncological patients.
METHODS
Descriptive, retrospective and multicentric study carried
out from january 2001 to april 2006. The R.I.S.S. group (
Registre Infeccions SocioSanitaries ) was set up in order
to detect and then to propose the appropriate mesures to
cut down infections in palliative care settings in the
sanitary region of Lleida (Catalonia).
RESULTS
4308 patients were admitted to the sociosanitary
program in Lleida in 7 different hospitals. 981 of them
were admitted to specific palliative care units. 349
patients were admitted with cancer.258 of them died in
the hospitals.135 of them had, at least, one episode of
infection. 218 specific treatments were recorded ( 1,6
treatment per patient ). The mean of stay was 19,7 days.
In 83/135 patients the end of the treatment took place <
7days of death. Urinary and respiratory infections were
the most prevalents.56% of the infections were adquired
in the same hospital.60% of infections physicians did
not undertake further laboratory tests. E.Coli and
C.Albicans were the patogens more detected.
CONCLUSIONS
Infections are involved with the patient’s death in
palliative care settings. Most of treatments are carried
out without laboratory test and treatments initiated
empirically.
623. Outcome of acute bleeding in Palliative Care
Manuel Castillo, Nart Keituqwa, Ignacio Fernández,
Miguel Benitez
Hospital Universitario Ntra Sra Candelaria, Unidad de
Cuidados Paliativos, Santa Cruz de Tenerife, Spain
Aim of study: To assess the outcome of acute bleeding in
terminally ill patients. Method: Review of the charts of
every patient affected by a major acute haemorrhage
treated in our Palliative Care Unit between March 2005
and October 2006. Age, gender, type of cancer and
haemorrhage, consumption of opioids, the indication
of palliative sedation and midazolam (MDZ) doses, and
other potential causes of suffering were collected.Result:
31 (80% men) patients suffered major acute
haemorrhage (median age 65 years). 64.5% of patients
without previous episodes. Type of cancer: head and
neck 35.5%, lungs 13%, oesophagus 13%, others 38.5 %.
The origin of bleeding was: gastrointestinal 48.4%,
upper respiratory 29%, others 22.6%. Bleeding was
considered to be associated with dying process in 64.5%
of patients (median survival 3 days), 70% of these
receiving a palliative sedation to relieve suffering. MDZ
(median 60 mg/d; range 52,5 -200 mg/day), was chosen
for sedation in all cases. Head and neck cancer patients
needing more MDZ (median 130 mg/d; p=0.02 U-MW
test). 19.4% of patients were able to return home, with a
median survival of 63 days (2-295). Opioid treatment
was present in all patients, most frequently morphine
(74%; median oral dose 65mg/day). Conclusion:
Bleeding was a severe complication associated with
imminent death. Their treatment should be oriented
primarily to achieve symptom control, needing many of
these patients palliative sedation to relieve their
suffering.
624. Managing fungating wounds : the challenge
for nurses, patients and families
Vicky Robinson 1, Jane McManus 1, Patricia Grocott 2
1
St Christopher’s Hospice, Nursing, London, United
Kingdom
2King’s College London, Nursing, London, United Kingdom
The issue of hard to heal and never to heal wounds is an
under-researched, yet not unusual area of clinical
nursing in palliative care. Experience tells that as a
clinical problem this is marginalised, and that the needs
presented by patients for effective dressing regimes and
products are largely unmet.
The subject of fungating wounds is complex, and can
stretch practitioners in every area of expertise. Patients
face living with disfigurement, chronic illness, pain,
malodour, difficulties in coping, poor quality of life,
and, of course impending death.
Drawing largely on the work of Grocott and Rowan,
and our experience at St. Christopher’s Hospice, we seek
to address some of these difficulties and offer some
nursing care strategies. Theoretical frameworks for
palliative wound care and management differ from
those where the aim is to heal. These frameworks will
form the basis from which the nursing management
strategies will be discussed.
Particular emphasis will be placed on the practical
management of pain and discomfort, infection, exudate,
bleeding, odour. A set of management algorithms
developed by our Palliative Wound Care Network will be
presented.
Finally the work of WRAP (Woundcare Research for
Appropriate Products) and the TELER (Treatment
Evaluation by Le Roux’s method) will be discussed,
together with the challenges for future nursing research.
625. PALLIATIVE TERMINAL SEDATION: THE
EXPERIENCE OF THE PALLIATIVE CARE SERVICES
OF TRENTO
Giampaolo Rama, Isabella Caracristi, Luciana Fontana,
Loreta Rocchetti, Luca Ottolini, Carlo Abati
Palliative sedation (PS) is a therapeutic procedure that is
used to control refractory symptoms to specific
treatments.There are generally well codified approach
procedures and technical procedures,but on the other
hand there is a great deal of variability in terms of the
frequency with which they are used and the
subscription.To compare the experiences of the
Palliative Care Services of Trento(PCS),with those of
similar services.Since Jan.2005 the PCS has put into use
a form to gather data regarding patients (P) that require
PS.
RESULTS: from Jan.1st to December 31st 2005, the PCS
has cared for 193 P at home up until the moment of
death:28 (14,5%)requested PS.
Indicators:dyspnea39%,delirium21%,agitation/
anxiety18%,pain18%,hemorrhage4%.P consent had
been previously received in 3(11%),just before
beginning the procedure in 7(25%);in 18(64%) the P
was not able to express his/her opinion due to a state of
163
Poster abstracts
618. Terminal sedation in Medical Oncology
Poster abstracts
delirium or due to other clinical conditions.In all cases
the consent of a family member was given.In
100%midazolam was the drug that was used.Death
occurred between 40 to 6 days (an average of 27
hours).PS was begun by sc administration using a bolus
dose that varied from 2, 5 to10mg, (an average of 6
mg).It was maintained via sc infusion.In more than half
of the cases, the P was not able to express his/her
consent: this is why since June 2006 all patients, that
the healthcare professionals believe will require sedation
in the future, are monitored to ensure that their consent
is given in advance.
626. Do guidelines for the management of fatigue
in advanced cancer improve practitioner ability
to assess and manage the symptom in practice?
Karen Satchwith 1, 2, Lorraine Dixon 2
1
Sir Michael Sobell House, palliative ward, Oxford, United
Kingdom
2
oxford brookes university, school of health and social care,
Oxford, United Kingdom
Fatigue, the most commonly described symptom by
cancer patients (Winningham et al 1994), has a major
effect on quality of life among individuals with cancer
(Stone et al 1999). Fatigue is acknowledged in practice
but, assessment and management lack consistency and
structure. This work determines whether the guidelines
developed by Coackley et al (2002) can provide a
structured and consistent approach.
A literature review (search terms: assess*; fatigue,
lethargy, exhaustion; palliative care, and terminal care in
databases Cinahl, Medline, AMED and BNI) identified:
majority of research focused on general oncology;
assessment tools were generally developed for research
puposes not clinical use; and debated the number of
dimensions for assessment. Coackley et al (2002)
guidelines were applicable to assessing fatigue within
the palliative care setting, providing an informative, and
logical approach.
This work presents the preliminary audit findings of
practitioner views and reviews medical and nursing
documentation before and after the introduction of the
‘Guidelines for the management of fatigue in patients
with advanced cancer’ (Coackley et al 2002) within the
palliative care in-patient unit.
Coackley A, Hutchinson T, Saltmarsh P, Kelly A,
Ellershaw JE, Marshall E, Brunston H (2000) Assessment
and management of fatigue in patients with advanced
cancer: developing guidelines, International Journal of
Palliative Nursing, 8,8, p381-388
627. Audit of the use of prophylactic
anticoagulants in cancer patients referred to
Specialist Palliative Care
Vandana Vora 1, Sam Ahmedzai 2
1
Sheffield Teaching Hospitals NHS Foundation Trust,
Paliative care Service, Sheffield, United Kingdom
Poster abstracts
2
Sheffield, Turks and Caicos Islands
Aim Although there are generic guidelines on the use of
anticoagulant prophylaxis, there is no specific guidance
for cancer patients receiving palliative or terminal care.
The aim was to assess current practice as well as to
review it with a view to formulating future guidelines.
Methods Retrospective analysis of the data from
patients referred to hospital palliative care team between
January to April 2002. Findings Notes of 110(83.9%)
referrals were available. 25 were excluded. Of remaining
85, 37 (43.52%)patients received prophylactic
anticoagulation. There was no significant difference in
the median age, site, extent or duration of cancer
between two groups i.e. with or without prophylactic
anticoagulation. In both groups 10 patients died after
admission and the median length of survival in days
was13 (without prophylactic clexane) and 16 (with
prophylactic clexane). 27 out of 37 patients who
received thromboprophylaxis were discharged from the
hospital. In all cases clexane was discontinued on
discharge. When current practice of
thromboprophylaxis was compared against standard,
only in 30% cases platelet count was monitored. In 70%
cases thromboprophylaxis was never reviewed.
Conclusion This audit showed that
thromboprophylaxis is not routinely reviewed when
patient reaches a terminal phase. Also this treatment is
given only during hospital stay even when underlying
risk factors for thrombosis have continued on discharge.
628. Efficacy of Granisetron in the Antiemetic
Control of Non-surgical Intestinal Occlusion in
Advanced Cancer: A Phase II Clinical Trial
(Definitive Results)
ALBERT TUCA 1, ROSA ROCA 2, JOSEP PORTA 1, GALA
SERRANO 1, XAVIER GOMEZ BATISTE 1
1
Institut Catala d’Oncologia, Palliaitve Care, Barcelona,
Spain
2Hospital Santa Caterine, Palliative Care, Girona, Spain
Intestinal obstruction is a frequent complication in
patients with advanced cancer and frequently it
provokes refractory symptoms. Objective: Determine
efficacy of granisetron in control of nausea and
vomiting provoked by non-surgical intestinal occlusion
in advanced cancer patients. Method: Open and
prospective study (Phase II Clinical Trial). Experimental
treatment was granisetron 3 mg and dexametasone 8
mg / day without gastric tubes. Rescue treatment was
Haloperidol. We record the number of episodes of
vomiting, and visual analogue scale (VAS) was used to
evaluate nausea, pain, asthenia and anorexia at baseline
visit and every 24h up to the completion of 4 days of
treatment (final visit). We assessed previous consensus
of response and investigator opinion. Results: 24
advanced cancer patients was included (mean age: 61.3;
10 males, 14 females) with intestinal obstruction
refractory to previous anti-emetics. Obstruction was
upper intestine in 6 patients, lower intestine in 3 and
multiple in 15. During treatment we observed a
significant decrease in: severity of nausea (VAS 6.7 vs.
2.6; p<0.001), number of episodes of vomiting (4.1 vs.
1.1; p<0.001), abdominal pain (VAS 4.4 vs. 1.8; p<0.001).
Symptom response was maintained throughout the
treatment period. The efficacy based on previouslyestablished consensus showed a high rate of response
(85%). Conclusion: Granisetron is highly efficacious in
the control of emesis provoked by non-surgical bowel
occlusion in advanced cancer patients, and can be used
effectively in patient refractory to other anti-emetics.
629. DELIRIUM AT HOME
RAMONA GONZALEZ 1 8 5 1, NURIA ARRARAS 1 7 1 7,
ANGELES RAMOS 2 4 6 3, MARIAN SANZ 1 1 1 1, MARIBEL
ESQUERDO 5 4 3
1
Hospital Santa Maria, Home Care Team, Lleida, Spain
Santa Maria, Home Care Team, Lleida, Spain
Hospital Santa Maria, Home Care Team, Lleida, Spain
4Hospital Santa Maria, Home Care Team, Barcelona, Spain
5
Hospital Santa Maria, HOME HOSPITALIZACION UNIT,
Barcelona, Spain
6
Hospital Santa Maria, Department of Geriatric Medicine,
Lleida, Spain
2Hospital
3
Delirium is a frequent symptom developed in advanced
cancer patients. However, delirium diagnosis and
cognitive disturbance are often under-diagnosed and
inadequately documented.Objective:Describing design
and implementation of a health education intervention
so as to determine its effectiveness in detecting delirium
in patients with a current house-called palliative
treatment that have been diagnosed with terminal
cancer disease. Description of the health education
instrument,intervention methodology.Intervention
methodology:PADES house-called-patients complying
with the admission inclusion criteria will be recruited
consecutively in a randomized case-control study.Health
education will be developed in the intervention
group.All patients will receive an informed consent
form of participation.Caregivers will receive official
health education to facilitate the earlier detection of
delirium.We are interested in stating the utility of such
health education instrument. This instrument consists
of written instructions and the corresponding
explanation of the health professional at the moment of
the house-call. In order to configure the health
education instrument, patient records were revised to
register the most frequently used expressions by our
patients’ caregivers to define the patient’s behaviour in a
possible delirium outbreak. These expressions could be
compared to those of the DSM-IV criteria.
630. Phase I/II Clinical Study of Octreotide
Acetate (SMS201-995) in Terminally Ill Japanese
Cancer Patients with Malignant Bowel
Obstruction
Yasuo Shima 1, Atsushi Otsu 2, Kuniaki Shirao 3,
Yasutsuna Sasaki 4
1
Palliative Care Service, Department of Palliative Medicine,
Tsukuba, Japan
2
National Cancer Center, Department of Medical Oncology,
Chiba, Japan
3
National Cancer Center, Department of Oncology, Tokyo,
Japan
4Saitama Medical Center Saitama Medical University,
Department of Medical Oncology, Saitama, Latvia
In patients with advanced cancer, malignant bowel
164
obstruction (MBO) causes gastrointestinal symptoms
such as nausea and vomiting and reduces or prevents
oral intake. Thus, MBO markedly impairs the quality of
life (QOL) of these patients. Many studies have shown
that octreotide acetate (SMS 201-995; SMS ), a synthetic
analog of somatostatin, is effective for controlling the
symptoms of MBO. The purpose of this phase I/II
clinical study of SMS was to establish its efficacy and
safety for the management of MBO in Japanese patients
with advanced cancer. The subjects were patients with
MBO refractory to other medical treatment who had
suffered at least two vomiting episodes per day for 2 days
or had required a nasogastric tube. Among 25 patients
who were enrolled, 11 (44.0%) responded to treatment
with resolution or improvement of nausea/vomiting.
Their symptomatic improvement was reflected by the
clinical benefit of SMS (assessed using a selfadministered QOL questionnaire) in terms of patient
satisfaction with the control of nausea/vomiting and the
proportion of patients enjoying recreational activities.
SMS was well tolerated, and nausea and agitation were
the only adverse events potentially related to this drug.
These findings suggest that SMS is both safe and
effective for the management of MBO refractory to
other medical therapy, and that symptomatic
improvement by SMS therapy may be of clinical benefit
for patients with MBO.
631. Literature Review of the Pharmacological
Management of Opioid Induced Bowel
Dysfunction
Jason Boland, Sam Ahmedzai
Opioids are widely used in the management of both
cancer and non-cancer pain. Although generally
efficacious for these indications they have a range of
adverse effects, the most prevalent and troublesome
probably being opioid induced bowel dysfunction
(OBD).
The evidence for laxatives and opioid antagonists in
the management of OBD was evaluated with a
systematic literature search using: Medline, Embase, The
Cochrane Database of Systematic Reviews and Cochrane
Central Register of Controlled Clinical Trials, Centre for
Reviews and Dissemination (CRD) - for Database of
Abstracts of Reviews of Effects (DARE) and Health
Technology Assessment (HTA), Turning Research into
Practice (TRIP), and National Institute for Health and
Clinical Excellence (NICE).
The results showed a lack of good quality trial
evidence for the majority of laxatives in OBD. There was
limited clinical trial evidence for lactulose, senna and
polyethylene glycol; these were similar in term of
efficacy and toxicity.
There was more evidence for the opioid antagonists,
which not only reversed the constipation but also the
other symptoms of bowel dysfunction associated with
opioids.
There is limited clinical trial evidence to choose one
laxative over another. However, the evidence for
peripheral opioid antagonists is superior both in terms
of efficacy and toxicity. These drugs could be used more
in the future.
632. Dyspnea as a prevalence symptom
Enrique Ferrer 1, Antonio Amengual 2
1
Institut Balear de la Salut, Atenció Prim ria, Palma de
Mallorca, Spain
2
Institut Balear de la Salut, Hospital Universitari Son
Dureta, Palma de Mallorca, Spain
Introduction The aim of this study was to describe the
clinical, pharmacological and general issues assessed in
a group of patients visited between January 96 and
December 98 referring dyspnea as a symptom registered
in the first visit. Material and methods Retrospective
study registered with DBaseV from the general database
of the palliative care unit in the Hospital Son Dureta,
Mallorca, Spain.Cross data search through Spss7
program. Results Prevalence of dyspnea shows similarity
to other studies with a 22,8% of incidence ( 381 from a
total of 1673 patients ). Survival varies from a median of
20 days in the general group and 15 days in the group
with dyspnea.Higher rate of death in hospital when
breathlessness is related (72,7% versus
65,4%).Predominance of men (76,6%) due to a 50,7% of
lung cancer as a main diagnosis and probably due a
higher abuse of tobacco in men.Other symptoms and
their incidences in both groups refer some differences.
Pain, dry mouth, constipation, delirium, nausea and
sickness show a higher rate of incidence in the group
control. Hemoptysis and cough are increased in the
dyspnea group.Use of morphine, steroids and
benzodiacepines are described. Conclusions The aim was
to define those characteristics. Although the study is
descriptive there are some interesting differences like
median survival, higher rate of stay and death in
hospital.
Poster abstracts
Wojciech Leppert 1, Jacek Luczak 1, Woêniak Woêniak 2
1
Palliative Care Unit, Chair and Department of Palliative
Medicine, Poznan, Poland
2
Palliaitve Care Unit, Department of Oncology, Wroclaw,
Poland
3Palliative Care Unit, Chair and Department of Palliative
Introduction: Three step antiemetic ladder for chronic
n & v: first metoclopramide, haloperidol,
tiethylperazine, second dimenhydrynate, promethazine,
dexamethasone, hyoscine derivatives, third
levomepromazine, setrons, for inoperable bowel
obstruction (IBO) first metoclopramide, haloperidol,
dexamethasone, second dimenhydrynate,
promethazine, hyoscine derivatives, third step
levomepromazine and octreotide. Material and
methods: 510 patients with chronic n & v, including
105 with IBO. Symptoms 0 = lack 1 = weak 2 = moderate
3 = strong n & v assessed (1) at beginning of care, (2)
during symptomatic treatment and (3) at last week of
life. Treatment beneficial decrease from strong or
moderate to mild or no symptoms and maintaining
mild or complete disappearence. Treatment failure
increase from no or mild to moderate or strong and
moderate or strong n & v maintained. Results: In all
patients comparing (2) to (1) beneficial results in 418
(82%) lack of effect in 92 (18%) patients. Comparing (3)
to (2) benefits in 434 (85%) lack of effect in 76 (15%)
patients. In patients with IBO comparing (2) to (1)
benefits in 62 (59%) patients most frequently decrease
to weak intensity. Comparing (3) to (2) benefits in 54
(51%) patients. Conclusions: Treatment of n & v by
antiemetic ladder is beneficial in over 80% patients.
However in over 40% patients with IBO control of n & v
was unsatisfactory, which indicates for more intensive
treatment
634. Gastro-duodenal dysmotility (GDD) in nonoperated advanced cancer patients (ac-pts):
systematic review of its frequency and causes
Aurelius Omlin, Florian Strasser
Background: GDD seems common in ac-pts
impacting appetite and weight. We aim to characterize
frequency and causes of GDD in pts without former
operation of the gastrointestinal tract (GIT).
Method: GD-GID was defined as motility problems of
the whole GIT resulting in altered GD-motility. A
systematic literature review used ([MeSH], free text): 1.
GI-motility, gastric emptying, gastroparesis, 2.
autonomic dysfunction, neurologic GI paraneoplastic
syndromes, and 3. symptoms (early satiety, bloating,
postprandial fullness or epigastric pain), all three
combined with neoplasm and excluding surgical
procedures.
Inclusion criteria were: 1) cancer, 2) original work, and
endpoints on 3.1) frequency or 3.2) causes of GDD or
3.3) defined symptoms, or 4) GDD-tailored
interventions.
Results: 238 articles from 1088 MEDLINE citations
were included, further searches (other databases, hand,
snowballing) are ongoing.
The frequency of GDD is indirectly reported from
symptom prevalence (>1050 ac-pts, early satiety > 50%)
and autonomic dysfunction studies (>100 ac-pts, >1/3).
The main causes of GDD can be summoned as: cytokine
associated, paraneoplastic, tumour infiltration, drugs
(i.e., opiods, antineoplastic agents), radiation, GIinfections, electrolytes, and constipation (cologastric
inhibitory reflex).
Conclusions: GDD seems frequent as the symptom
early satiety suggests, but understanding of its complex
neuro-humoral-inflammatory causes - leading to
tailored treatments - is poor, calling for focused research.
Final results will be presented.
635. Psychooncological interventions in an
interdisciplinary palliative outpatient clinic
focused on nutrition and fatigue: A pilot study
Rahel Graf, Susanne Wiedmer, Nina Schmitz, Liselotte
Dietrich, Florian Strasser
Background: In an interdisciplinary palliative care
(PC) clinic focused on nutrition and fatigue (ID-NF)
psychosocial and spiritual assessments contribute to
team-based (nurse, nutritionist, physiotherapist,
physician) care plan decisions. We aim to characterize
the themes identified and interventions provided by the
psycho-oncological nurse, who uses FICA for spiritual, a
checklist for social and coping, and HADS for anxiety
and depression assessment.
Methods: Data were collected from ID-NF reports and
analysed by coding of themes, applying constant
comparison methodology involving ID team members
until saturation.
Results: From 43 patients three groups of interventions
were identified: 1) structured assessment and awarenessenhancing interventions, 2) counselling of patient and
families according to identified needs for support, 3)
and psychosocial support by acknowledging emotions
and normalising them, sustaining helpful coping
strategies and utilizing resources. These interventions
tackled 17 themes: consequences of anorexia, eatingrelated distress, changed roles and coping with them in
marriage and self, supporting the partner, social
withdrawal; social support for patients and proxies in
out- and inpatient settings, finances, sexuality, sociolegal issues; coping with difficult emotions and
uncertainty, preserve wellbeing, supporting resources of
patients, fatigue, dealing with anxiety, coping with pain,
death and dying, and unfinished business.
Conclusions: These psychooncological interventions
cover a wide spectrum of themes reflecting
multidimensional needs of patients and partners,
maybe influenced by the team composition. Specific
interventions tackling eating-related distress of patients
and partners were identified.
636. Late Effects After Pelvic Radiotherapy - A
Significant & Invisible Problem
Ian Watson 1, Wendy Makin 2, Lorraine Sloan 1, Jervoise
Andreyev 3, Jane Maher 4
1
Macmillan Cancer Support, London, United Kingdom
Christie Hospital, Manchester, United Kingdom
Marsden Hospital, London, United Kingdom
4
Mount Vernon Cancer Centre, Lynda Jackson Macmillan
2
3Royal
Half of patients cured of cancer receive RT. Annually,
15,000 UK patients receive pelvic RT. Studies suggest
10% will develop serious consequences of treatment
after 10 years presenting to their primary care physicians
(GPs). Macmillan Cancer Support supports a
community of GPs interested in cancer, supportive care
and treatment related problems.
Design
60 GPs were asked how they would manage late effects
of radiotherapy in the community. Four workshops held
jointly with affected patients clarified priorities for
intervention.
Results
67% had seen a signficant problem related to pelvic
radiotherapy e.g. proctitis, diarrhoea, incontinence,
bleeding, pelvic pain & fistula . <10% systematically
recorded RT on computer records, had information as to
signs and symptoms or had a care plan for late effects.
None knew the prevalence of treatment related
problems in their practice population. GPs generated 18
suggestions to improve integrated care. Focus groups
prioritised information for patients & carers to support
self management & navigation to appropriate services &
revealed GP’s lack of confidence in investigations, use of
antidiarrhoeal agents, and analgesia.
Conclusion
Chronic survivorship illness is increasing but invisible.
Palliative/supportive care is needed at the severe end of
the spectrum. A community based audit in 2007 should
uncover the prevalence of severe problems and test the
utility of written information and navigation.
637. Art at home for children with lifethreatening illnesses
Mona Trudel 1, Suzanne Mongeau 2
1
Université du Québec in Montreal, Visual art, Montreal,
Canada
2
Université du Québec in Montreal, Social work, Montreal,
Canada
Introduction: The Lighthouse, Children and Families
is an organisation who provide respite services to
families and palliative care to children. The
organisation, in collaboration with a Montreal
university, offers a program where art students visit sick
children in their homes. The project includes a public
year-end exhibition of artwork. The problem: Sick
children are often socially isolated. They have little
access to art and therefore cannot enjoy their benefits.
The program seeks to remedy this situation. Objective:
The objective of this study is to identify the outcome of
this intervention on the child, his parents, the
organisation and the art student. Methodology: Semistructured interviews were conducted with children,
their parents, art students and the
organisation staff. Audio recordings were made of the
interviews and a verbatim transcription was produced.
All of the data were subjected to a qualitative analysis.
Results: Art offers an entry point into a world where
sickness and death, though never denied, are relegated
to the background. Access to art and culture allows a sick
child and his or her family to be connected to the
outside world, lessening their feelings of exclusion. This
project allows the participating art students to discover
art’s role in the community. Conclusion: This program
has benefits for all participants.
638. Emergency conditions during last 100 days of
life among pediatric cancer patients with solid
tumors
Bilal Moaed 1, Sergey Postovsky 2, Ruth Ofir 3, Myriam
Weyl Ben Arush 4
1– 4
Technion - Israel Institute of Technology, Haematology &
Oncology, haifa, Israel
Background: despite that 80% of children with cancer
become long-term survivors, remaining 20% die and
encounter problems while approaching death
Aim of the study: evaluate the epidemiology of
emergency conditions (EC) among children with cancer
during last 100 days
Patients & methods: retrospective review of medical
charts of patients (pts) who died of their disease since
01.01.95 to 01.10.06. Totally, 70pts died. Among those
who developed EC, there were 31 boys and 17 girls with
median age 16y (range, 0.5-22). 24pts had sarcomas (S),
16pts -brain tumors (BT), 6pts – neuroblastoma and two
pts carcinoma Results: 76 EC were registered. 25pts had
seizures, spinal cord compression (SCC)–15pts, 9pts respiratory failure, sepsis–6pts, obstructive
hydrocephalus (OH)– 5pts, 3pts-bleeding, 3pts-renal
failure, 3 pts - metabolic problems, 2pts-GI obstruction,
2pts-urinary obstruction, 2 pts -heart problems, brain
edema-1pt. The efficacy of treatment for EC was
satisfactory in 18/25 cases of seizures, in 9/15 cases of
SCC, in 1/9 cases of respiratory EC, in 0/6 cases of
sepsis, OH- in 1/5 cases. Most seizures were in pts with
BT and SCC – in pts with S
Conclusions: 1. Incidence of EC is high (69 % of all
dying pts) 2. Prevalence of various EC depends on the
specific diagnosis of cancer 3. Satisfactory treatment of
EC is difficult 4.Knowledge of epidemiology of EC may
facilitate better management of this problematic group
of pts
639. NEW PERSPECTIVES IN PHYSICAL THERAPY
MANAGEMENT FOR HYDROCEPHALUS CHILDREN
Constantin Ciucurel 1, Ioana Iconaru 2, Horia Traila 3
1
St. Andrei Center Pitesti, Children in distress, Pitesti,
Romania
3
2
Aim of study
The goal of the palliative care for hydrocephalus
children (HC) is to maximize physical independence by
improving motor function.
Method
We applied a physical therapy protocol (PTP) on 5 HC
(sex ratio 4:1 for boys) aged 7 to 10 years, at St. Andrei
Center Pitesti, during 12 months. We utilized the case
studies model with a qualitative approach.
The PTP consisted on passive mobilizations, depending
on the response at muscle stretching. If the muscle
control was partial conserved, we used the technique of
hold/relax, the stretching time being increased by
conserving of some postures.
The HC evaluation consisted in nutritional status, skin
integrity (Norton scale), functional evaluation (GMFM
Gross Motor Function Measure, PSATH Pain, Spasm,
Armchair, Transfer and Hygiene), mobility (ROM),
muscle tonus (Ashworth scale).
Results
Unfortunately one of HC died after one year. For the rest
of HC we recorded a functional optimization (medium
GMFM raised with 20%, PSATH with 15%);
improvement of nutritional status (medium growth of
weight and BMI 10%) and of skin trophicity (35%
growth of Norton index); spasticity reduction (medium
improvement of Ashworth index of 25%) and the
increase of ROM (30o for upper limb, 20o for hip, 10o for
knee, 20o for ankle).
Conclusions
The management of HC must focus on a global program
of neuromotor rehabilitation as part of general palliative
care. The most important factors that can reduce the
efficiency of PTP are fatigability and convulsions.
165
Poster abstracts
633. Three step antiemetic ladder in the
treatment of chronic nausea and vomiting and
inoperable bowel obstruction in patients with
advanced cancer
Poster abstracts
640. COPING STRATEGIES, COHESION AND
PERCEIVED SOCIAL SUPPORT IN CHILDREN
WITH AIDS AND LEUKEMIA
Ovidiu Popa-Velea 1, Iuliana Pantelimon 2, Raluca Fatu 2,
Andreea Icleanu 2, Mara Jidveian 2, Madalina Radulescu 2,
Aida Rascanu 2
1
University of Medicine and Pharmacy, Medical Psychology,
Bucharest, Romania
2University of Medicine and Pharmacy, Bucharest, Romania
This study aimed to investigate the possible differences
regarding coping strategies, perceived social support and
group cohesion in children suffering from AIDS and
leukemia, in an advanced stage of their disease. Two
groups of 20 and 32 10-14 years old children, diagnosed
with advanced AIDS and acute leukemia, respectively,
and admitted in the same pediatric palliative facility,
were tested for the above mentioned variables, using
Duke Social Support, COPE and Group Cohesion
Evaluation Questionnaires. Successive t-tests for
independent samples showed significant differences
regarding perceived cohesion and social support, both
higher in leukemia group (24,8 vs. 29,27, p < 0,05) (34,4
vs. 45,5, p < 0,02). There were also noticed significant
differences in terms of coping strategies, namely the use
of instrumental social support, more frequent in
leukemia patients (12,01 vs. 12,4, p < 0,01), religious
coping, also more prevalent in leukemia patients (12,06
vs. 15,09, p < 0,01) and remarkably, substance use, more
frequent in AIDS patients (12,00 vs. 4,59; p < 0,001). The
latest finding is consistent to the specific of HIV
infection in Romania, often related to drug use, even at
a very early age.
These results could offer some more specific targets for
efficient psychological interventions in this category of
patients.
641. THE CHARACTERISTICS OF KINESITHERAPY
PROGRAM FOR CHILDREN WITH
MICROCEPHALY AND CEREBRAL PALSY
Stefan Toma 1, Constantin Ciucurel 2, Ioana Iconaru 3
1
Andrei Center Pitesti, Children in distress, Pitesti,
Romania
2
Poster abstracts
3St.
Aim of study
The aim of this study is to evaluate a kinesitherapy
program (KP) for children with genetic microcephaly
and cerebral palsy using two criterions: methodological
exigencies and practical applicability.
Method
The research implied 3 children with the mentioned
pathology, residents of St. Andrei Center Pitesti.We
realized 3 case studies, using 2 evaluation instruments:
Pediatric Motor Activity Log (PMAL) and Pediatric
Evaluation of Disability Inventory (PEDI).Anticipated
goals of KP included: improving motor control, increase
physical independence, normalize tone, minimize
abnormal movement patterns, maximize balance and
stability in different positions, with or without assistive
device (associated with splinting for reducing the
spasticity), maximize safety awareness with all
functional mobility.The KP took place during 12
months, once a day and it last initially 20 minutes, then
progressively increasing to 40 minutes.
Results
We have continually assessed the children’s abilities and
adjusted the treatment appropriately. The medium
scores had the following evolution: PMAL, HO item
(how often) from 11,2 to 13,2, HW item (how well) from
10 to 11.3; PEDI from 56,7 to 62,7.
Conclusions
Children improved their motor control and physical
independence through the facilitation of motor control
and skill acquisition.Thus KP can prevent the
orthopedic complications and improve the functional
status by reducing the spasticity, which set free the
residual motor potential.
642. Advantages and limits of a palliative care
meeting in a Pediatric Hematology /Oncology
Ward
MICHEL
VIGNES 1,
AGNES
SUC 2
1
HOPITAL DES ENFANTS, Psychooncology, Toulouse,
France
2
HOPITAL DES ENFANTS, Pediatric palliative care/Pediatric
oncology, Toulouse, France
Health care providers’ support is recognised as an
important part of end of life care. In pediatrics, the
practical aspects of this support are still badly set out.
This presentation aims to describe the author’s
experience of four years of emotional support group
open to the whole team. This ward includes traditional
hospital stays and day hospital with one hundred new
cancer- cases each year. The functioning modalities and
the evolution of this group will be described together
166
with its dynamic supervised and enlightened by a
competent professional advisor. The group improved
the nurse’s well being as assessed by an internal audit. It
was also useful as a basis for the implementation of a
unique medical file common to both teams (hematology-oncology and palliative care- ) . End of life
procedures for taking care of children in hospital or at
home were also improved. In spite of these positive
outcomings, this group is the target of attacks and
criticisms who can be considered as a warrant of its
efficiency. Indeed, it is the only place where one can
become aware of the intense emotional response and
defense mechanisms associated with children’ s death .
As such, those conflicts should not be seen as
competing with good clinical practices but on the
contrary insures that the latter are dynamic and
constantly renewed
643. A Multidisciplinary Team Approach to
Adolescent/Young Adult Palliative Care
Clarke Anderson 1, Randi McAllister-Black 2
1
City of Hope National Medical Center, Pediatric palliative
2City of Hope National Medical Center, Psychology, Duarte,
United States
AIMS/METHODS: A Multi-disciplinary Team (MDT) of
11 pediatric professionals with palliative care expertise
were given a newly developed 68 question survey
covering the physical, cultural, spiritual and
psychological domains of end of life (EOL) care for the
adolescent and young adult (AYA). The MDT also
participated in a 60 minute focus group after
completing the survey. RESULTS: Pain and fatigue were
recognized as the most common physical issues faced by
dying AYAs with loss of independence as the major
psychosocial issue. Feedback on pain revealed barriers to
good control (communication, patient’s lack of
information, perception of instructions, use of pain
medications to cover other symptoms such as anxiety or
depression). The MDT felt that end of life care is focused
upon physical symptoms in the AYA and that additional
effort needs to be made to address the emotional and
psychological components of end of life. . Existential
issues (lost hope, lost worth, lost future) were also
identified as important but neglected. Interestingly, the
MDT felt that chemical abuse, suicide, and loss of a
formal educational environment were of minimal
importance and that AYA sexuality was largely ignored.
CONCLUSION: For AYA there needs to be more staff
education with an emphasis on communication,
compassionate delivery of emotional/physical symptom
relief and a shift of treatment towards a comfort/care
model from the traditional therapeutic model.
644. Ethical approach in case of terminally ill
child
Silviya Aleksandrova
Medical School, Public Health Sciences, Plovdiv, Bulgaria,
Bulgaria
A diagnosis of terminal illness of a child brings a new
dimension in family life. What is the child’s role in the
decision-making in that particular situation? How to
approach the child? What has to be said? This paper
aims at presenting the existing communicative methods
in the care for terminally ill children, raising related
questions for discussion and proposing an ethical
approach to children as patients. Traditionally, parents
and physicians have made all medical decisions on
behalf of children. Nowadays, though, the child, the
parents and the physician are involved in a “triadic”
relationship. Children can be approached either
through the parents or directly. The basis for an ethical
approach in case of terminally ill children would be the
focus on the experience itself. Children do not
understand what is going on with them. Keeping silence
means leaving children alone with their worries. So
communication is not only of utmost importance but
also there should be place for death as an option in the
discussions. We will never understand completely how
the terminally ill children and their parents feel. Neither
will it ever be easy to see children suffering and dying.
But that does not mean that we have to avoid talking
about death. This is the right moment to respect our
children as persons. Key words: death, decision-making,
ethical approach, terminally ill children
645. Professional perceptions of pain in children
with severe neurological impairments prior to
the implementation of a parent-held pain
assessment tool.
Anne Hunt 1, Susan Robertson 2, Kate Seers 2, Nicola
Crichton 3
1
University of Central Lancashire, Nursing, Preston, United
Kingdom
2Royal College of Nursing Institute, Nursing, Oxford, United
Kingdom
3
South Bank University, Health Studies, London, United
Kingdom
Children with severe/profound disability are unable to
self-report pain. The Paediatric Pain Profile (PPP) has
been developed for this group. AIMS: To implement the
PPP and evaluate its acceptability and feasibility for
parents and professionals. METHODS: Prior to
implementation of the PPP, researcher asked
consenting parents for names of professionals involved
in child’s care. Professionals were notified of family’s
entrance to study and asked to complete questionnaire
on pain in this group. RESULTS: Parents of 56 children
agreed to use PPP and named 386 professionals, 29%
(n=110) of whom completed the survey. Professionals
including 36% doctors, 36% nurses, 9% physiotherapists
had seen from 1 to 500 (median 30) children in the last
year. Proportion children thought to have significant
pain varied from 0 to 100% (median 30%). Number
children seen and the proportion believed to have pain
were negatively correlated (rs = -0.280, p< 0.008). Muscle
spasms, constipation and gastro-oesophageal reflux pain
were reported to be the most common pains. Assessing
pain was ‘quite difficult’ for 50%, ‘very difficult’ for
38%. Providing effective treatment was ‘quite
difficult’ for 44% and ‘very difficult’ for 15%. 82%
thought a pain assessment tool would be useful.
CONCLUSIONS: Professionals recognise difficulty in
assessing and treating pains in this group and are
receptive to a pain assessment tool.
646. Paediatric palliative care drug boxes;
facilitating safe & effective symptom
management at home at end of life.
Lynda Brook, Jan Vickers, Caroline Osbourne
Alder Hey Children’s Hospital, Paediatric Palliative Care,
Background: Palliative care drug boxes were developed
to avoid delays initiating infusions for symptom
management at end of life. The boxes contain pre
prescribed medication necessary
for continuous intravenous or subcutaneous infusion.
Methods: Retrospective review of the drug box
prescriptions during a 5 year period. Results: 74 boxes
(34 intravenous) were prescribed for 69 children: 50
with cancer. 21 palliative care prescriptions were not
used (8 oncology). Most common combinations were;
diamorphine, midazolam & leveomepromazine (N=13);
diamorphine, midazolam & cyclizine (N=11);
diamorphine & cyclizine (N=9). Contents of the syringe
were renewed every 24 hours and continued for a
median of 75 hours (inter-quartile range 17 - 256 hours).
78% of symptoms were controlled with a combination
of one or more of the following: a strong opiate,
cyclizine, haloperidol, levomepromazine, midazolam
and hyoscine hydrobromide. Where medication other
than these 6 “essential drugs” was required to control
symptoms this had usually been started before end of
life care. Drug boxes remained in the house a median of
4 days (range <1 to 106 days). Despite several families
with known substance abusers all medication was
accounted for except 1 instance. Conclusions:
Paediatric palliative care drug boxes containing 6
“essential drugs” are effective in controlling the
majority of symptoms at end of life.
647. Progress in pediatric palliative care in the
Netherlands
Conny Molenkamp 1, Marijke Wulp 2
1
University of Maastricht, Nursing Sciences, Maastricht,
Netherlands
2Agora, Bunnik, Netherlands
The interest in pediatric care in the Netherlands is
growing. From 2000 – 2004 a research project was
established to investigate the parental needs and
carefacilities for children in the palliative phase.
Results: Parents want ‘to be there for their child’ and are
in need for care adjusted to their specific family situation.
The amount of carefacilities and the diversity is growing.
But parents and caregivers experience often one or more
problems in the palliative phase. A structure for pediatric
palliative care is missing. One of the proposals of the
parents and caregivers was to form a nationwide
‘network’ to inform and educate people about pediatric
palliative care. As a follow-up of the project in 2005
organisations related to and caregivers working in
Poster abstracts
648. Paediatric hospice care (PHC): Successful
interaction between hospital and home care
providers
Matthias Schell 1, Maité Castaing 1, Thierry Philip 1,
Didier Frappaz 1, Yves Devaux 2
1
Centre Léon Bérard, paediatric oncology, LYON, France
Léon Bérard, Home Care Team, LYON, France
2Centre
PHC is a rare event for conventional home care
providers. Aim: to describe our innovative and
structured organisation for the implementation and
coordination of paediatric hospice care with emphasis
on interactions between our hospital-based paediatric
oncology team and conventional home care providers.
Results: First, we investigated the availability of local
home care providers to deliver paediatric hospice care.
For a large majority of local home-based care providers,
PHC was a first experience. Providers often felt uneasy,
isolated and not properly trained. Our hospital-based
team offered a first formal meeting with local home care
providers at the provider’s office. We discussed the
patient’s current status, explained the expected
symptoms and the palliative treatment options. We
clarified the respective roles of health care professionals
and the interactions between them. Finally we discussed
psychological issues that may arise for each care giver.
We then visited the child and his family and explained
the new organisation. Evaluation demonstrates that our
initial meeting with local health care professionals
initiates an interactive collaboration and facilitates
further discussions between care givers. Families report
increased reassurance by what they appreciate as an
extension of their primary, familiar hospital-based
paediatric team. This collaborative approach also
provides local care givers with improved consideration
by families.
649. Anticipating non-resuscitation orders in
paediatric palliative home care.
Matthias Schell 1, Maité Castaing 1, Parrine Marec-Berard
2, Nago Humbert 4, Christophe Bergeron 2, Thierry Philip
2
, Yves Devaux 3
1
Centre Léon Bérard, Pediatric palliative care/Pediatric
oncology, LYON, France
2Centre Léon Bérard, paediatric oncology, LYON, France
3
Centre Léon Bérard, Home Care Team, LYON, France
4
HOPITAL DES ENFANTS, Pain and Palliative Care Unit,
Montreal, Canada
families whose unborn baby is diagnosed with a
possible lethal condition.
Abstract: In the United States more children die prior
to birth or in the first month of life than at any other
time in childhood. The majority of these deaths are due
to Congenital Anomalies often diagnosed early in a
pregnancy. Palliative Care and support for decision
making is an essential option of care when a fetal
diagnosis may mean death of a baby or uncertainty
regarding the results of a pregnancy. Families are asked
to make agonizing choices concerning their baby ‘s well
being while receiving little guidance, education or how
to prepare for the birth and possible death of their baby.
At the University of Colorado Health Science Center,
Maternal Fetal Medicine specialist, Neonatologist and
Palliative Care nurses have developed a comprehensive
Palliative Care service, ‘Fetal Concerns.’ This session will
describe the outcome of pregnancy for thirty-five
families and the support they received for decision
making and anticipatory guidance during pregnancy
and after the birth of their baby.
651. Children’s Hospice Home Care in Germany
Marcel Globisch
German Children’s Hospice Society, Hospice Care, Olpe,
Germany, Germany
In 1990 a group of 6 families with children suffering
from life-shortening diseases joined together to form the
German Children’s Hospice Society. In 1997 Germany’s
first children’s hospice was opened in Olpe. Today 7
children’s Hospices provide care for families. Three
more are in the planning.In 1999 the first two pediatric
mobile hospice services were founded in Berlin and
Kirchheim/Teck. In 2004 the German Children’s
Hospice Society began building up a network of mobile
children’s hospice services in Germany. It operates
according to the needs of the sick children and their
families, extending beyond the services inpatient
children’s hospices offer. 15 mobile children’s services
are run by the society today. In total, there are 44
services in Germany. The service offered is at no cost to
the parents. The volunteers take part in and complete a
specially-tailored course to on how to accompany
families, and are then themselves supervised in their
work by a professional coordinator. The expansion of
the mobile children’s hospice services in German helps
with concept and the carrying out of mobile children’s
hospice service in one’s own area, networks with other
mobile hospice services assists to secure legal
financing. It’s exceptional that family
representatives and professionals together constantly
evaluate and develop existing and new concepts.
652. DEVELOPING AN INTERNATIONAL
CHILDREN’S PALLIATIVE CARE NETWORK FOR
THE SHARING OF EXPERTISE AND SKILL, AND
THE DEVELOPMENT OF PAEDITRIC PALLIATIVE
CARE IN THE DEVELOPING WORLD
Joan Marston, Barbara Gelb, Lizzie Chambers
Major challenge in paediatric palliative home care is to
anticipate management of future events. Aim: To avoid
medical futility especially resuscitation attempts in
terminally-ill children.Methods: We prospectively
discussed with proxi what should be attempted (e.g;
treat symptoms of pain or discomfort) and what should
be avoided for the sake of the child. A crucial part of the
discussion included anticipating non resuscitation of
the child. We informed local emergency unit on results
of the discussion and suggested a procedure in case of an
emergency call. Results and discussion: Two
situations may occur: 1/parental panic while facing
difficult terminal symptoms: we recommend that the
local emergency unit coordinator dispatches an
emergency team to the child’s home in order to manage
symptoms (seizures, pain, etc.) but avoid any futile
resuscitation attempt. Parental decision to maintain the
child at home should be re-evaluated. 2/ parents who
wish to stay at home as long as possible, but refusingthe
idea of home-based death of their child. We
recommend that the family doctor decides when to refer
the child to the hospital. Emergency team may be called
upon based on the child’s status and need for
medicalised transport. Conclusion: Anticipating nonresuscitation recommendations is a key approach in
paediatric palliative home care. This complex discussion
should not be avoided as parental/medical panic may
induce unrealistic requests for futile medical procedures.
Hospice Palliative Care Association of South Africa,
Paediatric Palliative Care, Cape Town, South Africa
The need for personnel skilled and knowledgable in
paediatric palliative care, and paediatric palliative care
resources, is increasing with the rising number of
children suffering from HIV and AIDS in the developing
world.
To meet this need an International Children’s Palliative
Care Network (ICPCN) was established by paediatric
palliative care advocates from all regions of the world ,
in Seoul, South Korea in March 2005.
The ICPCN advocates for the development of palliative
care resources, and the sharing of knowledge and skill,
to improve the quality of life of children with lifelimiting and life-threatening conditions, in a respectful
and culturally -sensitive manner, and to allow the voices
of these children to be heard.
A steering group with representation from all regions
leads the development of the international network ,
and continental and in-country networks are being
established.
A Paediatric Outcome Scale to measure quality of life in
children, is to be developed and researched in Africa, for
possible use around the world.
653. In-house training for Pediatric Palliative
Care in a University Hospital
650. Perinatal Palliative Care for families when a
fetal diagnosis has uncertain outcomes
Nancy English
University of Colorado School of Medicine, Denver, United
States
Objective of session: To describe our experience in
providing a program of structured interdisciplinary
palliative care and support for decision-making for
Ayda Duroux 1, Bernadette Fittkau-Toennesmann 2,
Kinast Kinast 1, Gian Domenico Borasio 2, Monika
Fuehrer 3
1
Interdisciplinary Centre for Palliative Medicine,
Coordination Centre for Pediatric Palliative Care, Munich,
Germany
2
Interdisciplinary Centre for Palliative Medicine,
Coordination Centre for Pediatric Palliative Care, Munich,
Germany
3
Dr. von Haunersches Kinderspital, Pediatric Oncology and
Hematology, Munich, Germany
Background: In Germany, specific professional training
for pediatric palliative care (PPC) is rare. In the PPC
Working Group at the Munich University Hospital,
professionals from pediatric inpatient wards and
intensive care units expressed their need for training on
Palliative Care and end of life issues.
Methods: Following a needs assessment, in-house
training courses (32 hrs each) for pediatric palliative care
were designed. The participants filled out an
anonymous pre- and post-course evaluation
questionnaire, rating (0-10) their self-perceived attitude,
knowledge and skills in the following areas: family
support, decision-making at the end of life,
communication, bereavement and symptom control.
Results: Seven trainings with 145 participants took place
from 1/05 to 12/06. 89% of the participants were
female, 70% were nurses, 20% physicians and 10% came
from other professions (physiotherapists, psychologists,
social workers, chaplains or teachers). All participants
rated their attitude, knowledge and skills in all domains
significantly higher (P<.001) at the end of the course.
The opportunity for inter-professional exchange was
particularly appreciated.
Conclusion: Multi-professional in-house trainings for
PPC were highly accepted and increased the
participants’ selfperceived competence in the care of
severely ill children. Further studies with longer
observation periods and objective outcome measures are
required to assess the effect of these courses on patient
care.
654. Change in the Patients’ Satisfaction with
Pain Control after Using the Korean Cancer Pain
Assessment Tool (KCPAT) in Korea
Youn Seon Choi 1, Su hyun Kim 2, Jun suk Kim 3,
Juneyoung Lee 4
1
Korea University Guro Hospital, family medicine, Seoul,
Korea, South
2
Korea University Guro Hospital, family medicine, Seoul,
Korea, South
3
Korea University Guro Hospital, Haematology & Oncology,
Seoul, Korea, South
4
Korea University Guro Hospital, Preventive Medicine, Seoul,
Korea, South
Appropriate pain assessment is very important for
managing the cancer pain. This study was purposed to
evaluate the utility of the Korean Cancer Pain
Assessment Tool (KCPAT) by assessing the changes in
the management of cancer pain. The changes in the
pain intensity, the pattern of drug prescriptions, and the
patients’ satisfaction with the pain controls were
analyzed after using the KCPAT. The results indicated
that the prescriptions were changed in 194 (51.5%) cases
after using the KCPAT and 69.5% of these changes were
affected by the KCPAT. After the KCPAT, pain intensity
by the Visual Analogue Scale (VAS, 0-10 cm) had
decreased (before:4.31-2.35 vs after:3.60-2.45, P<0.0001),
and the presence of associated symptoms and
psychosocial items were significantly reduced. The
patients’ satisfaction with the pain controls was
improved. Forty-four physicians (89.8%) thought that
the KCPAT was useful. The KCPAT improved the
patients’ satisfaction with pain control and was a useful
assessment tool for evaluating and managing cancer
pain.
655. PROVISION FOR ADVANCED PAIN
MANAGEMENT TECHNIQUES IN ADULT
PALLIATIVE CARE: A NATIONAL SURVEY OF
ANAESTHETIC PAIN SPECIALISTS
Emma Husbands 1, Samantha Kay 2, James Antrobus 3,
Daniel Munday 2
1
St. Michaels Hospice, Palliative care unit, Hereford, United
Kingdom
2Myton Hospice, Palliative care unit, West Midlands, United
Kingdom
3Warwick Hospital, Anes.Dept., Warwick, United Kingdom
Introduction:Evidence shows around 8% adult cancer
patients may benefit from advanced pain management
techniques, equating to 12,000 patients/yr in the UK. In
2002, Linklater et al surveyed palliative medicine
consultants, assessing their access and attitude to such
techniques. They found significant under-utilization of
these services and a lack of formal arrangements for
accessing them. Palliative care consultants’ experiences
and attitudes were suggested as contributory factors. For
comparison, we conducted a survey of anaesthetists
with an interest in pain management to assess their
experience of and attitudes towards treating cancer
patients. Method:A postal questionnaire was sent to
lead anaesthetists in UK pain clinics. Results:Of 170
questionnaires sent, 106(62%) responses were received.
Referral rates were low; only 31.1% received >12
palliative care referrals annually. Formal joint
consultations were rare but where they existed, more
167
Poster abstracts
pediatric palliative care were brought together, which led
to the development of a Dutch Forum for Pediatric
Palliative Care. In this forum 15 persons and the
organisations they represent (chidrens hospices,
hospitals, policy makers, specialized nurses, parent
groups, researchers, and others) participate. We will
inform the participants of the EAPC-congress about the
final results of the research and the development of the
forum.
Poster abstracts
referrals were received. Only 25.5% pain specialists had
time within their job plan for palliative care referrals.
Total interventions were estimated at <1000/yr. Most
respondents (76.4%) felt their role should include
advice on medications as well as performing procedures.
Discussion:There is under-referral of patients for
advanced pain management techniques. This survey
identifies factors including a lack of service integration,
inadequate allocation of hours within job-plans and a
wide variation in training and facilities available.
656. An audit of advanced pain management
techniques carried out on inpatients at Myton
Hamlet Hospice.
Samantha Kay 1, Hugh Antrobus 2, Daniel Munday 3
1
Myton Hospice, Palliative care unit, West Midlands,
United Kingdom
2Warwick Hospital, Anes.Dept., West Midlands, United
Kingdom
3
Myton Hospice, Palliative care unit, West Midlands, United
Kingdom
Introduction: Evidence suggests approximately 8%
adult cancer patients could benefit from advanced pain
management (APM) techniques. Current UK guidelines
recommend that all specialist palliative care teams
should have access to pain specialists with expertise in
nerve blocking and neuromodulation techniques.
Myton Hospice provides such a service in partnership
with a local pain specialist. However the utilisation and
effectiveness of APM for hospice inpatients was unclear.
Method: Hospice inpatients who had undergone APM
between July 2004 and December 2005 were audited.
Subjective pain assessments as well as the 24 hour preand post procedure morphine equivalent doses were
recorded. Results: 9 patients received neurolytic blocks
and 4 had non-neurolytic blocks. Patients having
undergone a neurolytic block demonstrated a larger
decrease in opiates post procedure than those who had
non-neurolytic blocks. The range of reduction of opiate
requirements was 0-50% with a median reduction of
14%. Subjectively both groups felt their pain had
improved. Complications encountered were recorded.
Discussion: Although analgesic requirements did not
always decrease after treatment, a subjective and
functional improvement was often reported.
Furthermore, the selection of both patients and
appropriate APM may best be undertaken as a joint
consultation between the hospice and the pain
specialists. This study suggests that such an approach is
an effective way of providing an APM service.
657. Rational Prescribing of Transdermal
Fentanyl in a DGH - a retrospective audit
Cate O’Neill, Wendy Prentice, Tim Peel
Poster abstracts
North Tyneside General Hospital, Palliative Medicine, Tyne
& Wear, United Kingdom
Local guidelines for the use of transdermal Fentanyl
(TDF) include its indications, dose conversion from
other opioids, and appropriate resuce medications.
We have audited the use of TDF in medical and surgical
inpatients in the two main hospitals of Northumbria
NHS Trust (North Tyneside and Wansbeck Genral
Hospitals).
The case notes of 30 patients were identified. There were
26 females, the mean age was 75 (range 37-92). 11
patients were prescribed TDF for cancer pain, and 19 for
non malignant pain (mostly for rheumatological or
osteoporotic pain).
The indication for TDF was not documented in 11. Of
the remainder, 7 (23%) had unacceptable opioid side
effects, 2 (6%) stable pain (ease of use). The remainder
had poor pain control on alternative opioids. Dose
conversion was appropriate in 13 cases (43%).
Rescue analgesia was prescribed in 2/3 (20 patients). The
dose of rescue analgesia was inappropriately low in 11 of
these people.
The only two pateints to have been correctly prescribeed
TDF in terms of indication, conversion and rescue
anlagesia had had this done undeer the guidance of the
palliative care team.
It is concluded that the prescribing of TDF was poorly
practiced in the setting of a DGH.
658. Audit of Resource Utilization in a Regional
Palliative Care Program Using the Edmonton
Classification System for Cancer Pain (ECS-CP)
Pablo Amigo, Robin Fainsinger, Hue Quan
Capital Health Palliative Care Program, Edmonton, Canada
Introduction: Patients younger than 60, neuropathic
pain, incident pain, and psychological distress alone or
with addictive behaviour require longer time to achieve
stable pain control and a higher MEDD. Neuropathic or
incident pain use significantly more modalities to
achieve stable pain control.
168
Hypothesis: Patients admitted to a Tertiary Palliative
Care Unit (TPCU) would have a higher percentage of
neuropathic pain, incident pain, psychological distress,
& addiction when comparing their ECS-CP profile with
other areas of the program.
Methods: The ECS-CP scores for the TPCU, community
and two consult services at the Royal Alexandra (RAH) &
University of Alberta (UAH) hospitals from July 2005
until October 2006 were analyzed.
Results: Neuropathic pain was higher in TPCU at 29.9%
vs. consult services (RAH & UAH) at 7% and 7.2%,
and community at 14%. Incident pain was higher
in TPCU at 52.5% vs. consult services at 19.8% and
37.6% and community at 49%. Psychological distress
was present in 49.2% of TPCU patients vs. 12.9%, 30.3%
and 20.9% respectively. Addictive behaviour was not
different among sites. Cognitively intact patients
in TPCU were 71.7% compared to 53.8%, 64.6%, and
59.4% respectively.
Conclusion: Patients in the TPCU had higher
neuropathic, incident pain & psychological distress; and
were adequately identified by the ECS-CP. The ECS-CP is
useful for auditing purposes.
659. Pharmacokinetic study of transdermal
fentanyl patch in Japanese patients with cancer
pain
Hideya Kokubun 1, Motohiro Matoba 2, Sumio Hoka 2,
Kazuo Yago 1
1
Kitasato University Hospital, Department of Pharmacy
Services, Sagamihara, Japan
2Kitasato University Hospital, Deapartments of Anaesthesia,
Sagamihara, Japan
Background: It has been reported that fentanyl is
released from transdermal fentanyl patches(Durotep®
JANSSEN PHARMACEUTICAL K.K. the same as
DURAGESIC®) at a constant specified rate, and a
constant serum concentration can be maintained by
replacing the patch every 3 days. On the other hand, we
have experienced a number of patients that complained
of pain on the third day after patch applications. In this
study, we determined the serum concentration levels of
fentanyl to elucidate it’s pharmacokinetics in patients
with cancer pain. Methods: The study was conducted
on 38 cancer patients hospitalized in the Department of
Anesthesiology, using fentanyl patches for pain
management. Blood samples were collected at 24, 48,
and 72 hours after patch applications. Plasma
concentrations were measured by LC/MS/MS method.
Results: The results of the correlation analysis between
the dose of fentanyl and the fentanyl serum
concentrations were as follows: r = 0.9565, 0.8785, and
0.9351. Also, it was found that the fentanyl serum
concentration decreased between 24 and 72 hours after
the patch application. Conclusions: These findings
indicate that in the normal state, fentanyl serum
concentrations may not be maintained at a constant
level for 3 days following the application of fentanyl
patches.
660. Pain and Asthenia in Advanced Cancer
Patients
661. Topical lidocaine in silver sulfadiazine
cream. In the treatment of painful, cancerrelated skin lesions
Jan Meeuse, An Reyners
Topical analgesics might reduce the need for systemic
analgesia, which use can be hampered by side effects.
Topical applicated lidocaine is an interesting option, as
lidocaine is effective in nociceptive as well as
neuropathic pain. As a result, it might be effective in
pain with a complex origin, such as painful cancerrelated skin conditions. Silver sulfadiazine, a topical
antimicrobial agent, could be of additional benefit, as
sustained inflammation can amplify nociceptive
stimulation.Lidocaine in silver sulfadiazine cream (SSC)
was used in five patients with painful cancer-related skin
conditions. Lidocaine (5%) in SSC (q.i.d.) was sufficient
in one patient for pain control; in another patient
systemic pain therapy could be delayed with lidocaine
2% in SSC b.i.d. In two others the pain was controlled
after adding this cream to systemic pain therapy.
Increasing the lidocaine percentage to 5% reduced the
need for systemic therapy in one of these patients,
resulting in improvement of the opioid induced
obstipation. In the fifth patient pain could not be
controlled with lidocaine 3% in SSC in combination
with systemic pain therapy.
662. Long term sequelae of a cordotomy
Jan Meeuse, An Reyners
Percutaneous cervical cordotomy (PCC) results in
immediate complete pain relief in 64 – 90% of the
patients. After 2 years, only 40% remain pain free. PCC
can result in complications (respiratory dysfunction,
autonomic dysfunction (Horner’s syndrome,
hypotension, bladder dysfunction), ataxia and paresis)
and side effects (loss of vital and sexual sensory
functions).We evaluated a patient, born in 1947, with a
history of diabetes mellitus type 2 (DM-2), who
underwent 5 years ago a PCC for intractable pain of
malignant origin. Evaluation revealed seminoma testis
stage IIIc. He was treated with cyclofosfamide, vincristin
and carboplatin. In 5 years, no recurrence was
shown.Immediately after the cordotomy total pain relief
was achieved. Complete numbness and absence of
temperature awareness was induced in the whole left
side of the body (upper border: the jaw). The touch
sensation improved, but never returned to normal. The
vital sensory functions are still absent. Shortly after the
PCC, tingling sensations in the left arm and leg were
present. These sensory dysfunctions interfere with the
patient’s daily work. Furthermore, the libido is absent
due to loss of penile sensation. The erectile function is
intact.Neurophysiologic testing to quantify these
sequellae and differentiate them from DM-2 or
chemotherapy induced neuropathy will be presented.
Mikheil Shavdia 1, Ioseb Abesadze 2, Rema Ghvamichava
3, Memed Jincharadze 4, Miranda Gogishvli 5
663. Access to Pain Relief : An essential Human
Righ - The State of the World
1– 4
Cancer Prevention Center, Palliative Care, Tbilisi,
Georgia
5
Cancer Prevention Center, Palliative care unit, Tbilisi,
Georgia
Vanessa Adams, Nick Pahl
Cancer Preventive Center Palliative Care Clinic,
Adjarian Cancer Center (Georgia)Objectives: Pain
and asthenia are main characteristic symptoms in
advanced cancer care, which highly influence patient ‘s
quality of life, especially at the last stages. The objective
of the study was to define the correlation between pain
and asthenia in cancer patients at different stages;.
Methods: ECOG performance status (I-IV scale) has
been used to define symptoms in 638 advanced cancer
patients. Various statistical methods have been used for
elaboration of the results. Results: In 267 patients at
ECOG scale I-II gradation asthenia was reveiled in 198
patients (74,2%), pain (various severity)- in 200 patients
(74,9%); In 242 patients at ECOG scale III gradation ,
asthenia was revealed in 218 cases ( 90,1 %), pain - in
191 (78,9% ). In 129 patients at ECOG scale IV gradation
asthenia as revealed in 127 cases (98,4%), pain in - 110
(85,3 %). As a whole, 543 cases of asthenia (85,1 %) and
501 cases of pain (78,5 %) in 638 patients with advanced
cancer (ECOG I-IV scale) has been revealed. The figures
shows high correlation (r= + 0,9) between two
symptoms. Conclusion: Strong correlation between
the symptoms and causal interactions are complex and
multidirectional, that should be taken into
consideration in palliative care, especially in pain
management .
Help the Hospices, London, United Kingdom
Pain relief is essential for palliative care. Freedom from
pain allows the highest quality of life possible for as long
as possible. Many patients with advanced disease
experience pain: cancer (70%), AIDS, COPD, heart and
renal disease (50%).
In 2005, the WHA and ECOSOC adopted resolutions
highlighting in access to analgesics. The WHO is
reviewing palliative care drugs on its EML in 2007.
Questionnaires on analgesic access (Likert scale) and
in access were e-mailed to Hospice Information, the
African Palliative Care Association and Asociación
Argentina de Medicina y Cuidados Paliativos contacts in
Asia, Africa and Latin America.
69 questionnaires were returned (23% response); Asia
(24), Africa (28) and Latin America (17), with 6 - 1,000
patients per month.
Access was poor:
Only 55% had 1 weak opioid always available
Over 20% in Africa never access a “strong opioid”
35% in Latin America cannot always access a “strong
opioid”
Unable to “always access” any anticonvulsant (37%),
”tricyclic” (~30%) and dexamethasone (25%)
Reasons:
Restrictive laws
Fear of addiction, tolerance and side effects
Underdeveloped health systems
Poor knowledge
Millions of patients are suffering pain which can be
alleviated. A number of interlinking factors need
Poster abstracts
664. A randomised, placebo-controlled study of
nasal and intravenous fentanyl in patients with
post operative pain
Lars Popper 1, Lona Christrup 2
1
Nycomed Group, International Medical Affairs, Roskilde,
Denmark
2
Danish University of Pharmaceutical Sciences,
Pharmacology and Pharmacotherapy, Copenhagen,
Denmark
Aims
The aims of the study were to compare the
pharmacokinetic profile, onset and duration of
analgesic action after intranasal (IN) and intravenous
(IV) administration of fentanyl in patients undergoing
third molar extraction.
Methods
The study was performed after a randomised, double
blind, double dummy, balanced two way cross-over
design using IN and IV administration. The following
doses were given twice to each 5 patients: 75, 100, 150
and 200 ug.
Recordings of pain intensity were done using a 11-point
NRS at selected time points up to 4 hours after drug
administration. Blood samples were drawn at selected
time points up to 3 hours after drug administration.
Further, patients were asked to record time to onset and
duration of action.
Results
The bioavailability after IN administration was 100 %.
Tmax was found to be 13.0 and 5.8 min after IN and IV
administration, respectively. Time to onset af analgesia
was 7 and 1 min and duration of action 56 and 49
minutes after IN and IV administration, respectively. No
difference in overall analgesia between IN and IV
administration could be demonstrated.
Conclusion
Onset of pain relief within few minutes and the limited
duration of action as seen in this study are important
benefits in treating breakthrough or episodic pain. Thus
IN administration of fentanyl might be a promising new
way of treating breakthrough pain.
665. Opiophobia: Knowledge and attitudes to
strong pain killers in palliative care patients.
Katherine Lambert 1, Stephen Oxberry 1, William Hulme
1
, Kirsten Saharia 1, Alan Rigby 3, Miriam Johnson 2
1
Leeds Teaching Hospitals Trust, Palliative Medicine, Leeds,
United Kingdom
2
Hull-York Medical School, Palliative Medicine, hULL,
United Kingdom
3University of Hull, Statistics, hULL, United Kingdom
Aim
To assess the knowledge and attitudes to strong
painkillers (opioids) of patients known to Specialist
Palliative Care (SPC) services.
Method
Questionnaire study of adult cancer patients known to
SPC services in Leeds. The questionnaire was designed
using themes from the “Barriers Questionnaire” to
assess knowledge and attitudes to opioids. Statements
pertinent to palliative care were added.
Results
Twenty patients were recruited; 12 were taking strong
opioids, 2 weak opioids and 6 none. Only 31% of
knowledge questions were answered correctly. Questions
regarding maximum doses of opioids, use of alcohol
and ability to drive were the most poorly answered
knowledge questions. Addiction to opioids (45% of
patients) and fear that opioids may mask changes in a
disease (40%) were the most common anxieties. The
majority of patients’ information was based on their
own experience (80%) or from talking to doctors and
nurses (50%). Few patients had gained information
from patient information leaflets (25%).
Conclusion
The results of this study suggest that SPC patients lack
knowledge and hold beliefs that could be considered
barriers to effective pain relief. Future studies need to
address how best to improve patients’ knowledge and
allay anxieties with emphasis on how patients would
prefer to receive this information.
666. Baclofen as an adjuvant analgesic for cancer
pain
Kinomi Yomiya 1, Naoki Matsuo 1, Shiro Tomiyasu 2,
Tetsusuke Yoshimoto 3, Tomohiro Tamaki 4, Tsutomu
Suzuki 5, Motohiro Matoba 6
1
Saitama Cancer Center, Palliative care unit, Kitaadachigun, Japan
2
Nagasaki Municipal Hospital, Palliative care unit,
Nagasaki, Japan
3Social Insurance Chukyo Hospital, Palliative Care Team,
Nagoya, Japan
4
Minami-Seishu Medical Center, Palliative care unit,
Sapporo, Japan
5Hoshi University School of Pharmacy and Pharmaceutical
Sciences, Toxicology, Shinagawa, Japan
6
National Cancer Center, Palliative Care Team, Chuo,
Japan
-aminobutyric acid (GABA) B receptor agonist approved
for the treatment of spasticity and commonly used for
managing many types of neuropathic pain. The effect of
baclofen on cancer pain has not previously been
studied. This retrospective study evaluated the efficacy
of baclofen in patients with cancer pain. Methods: We
reviewed the medical records of all patients given
baclofen orally as an analgesic for cancer pain between
February 2003 and August 2006 at 5 institutions with a
palliative care unit or palliative care team. We evaluated
the data the day after administration of baclofen. Result:
Twenty-six patients received 10-40mg of baclofen for
cancer pain relief. Twenty-one patients have undergone
neuropathic pain such as paroxysmal or lancing, sharp,
or like an electric shock. Baclofen was effective in 21 of
26 patients and significantly reduced Numeric Rating
Scale (NRS; pain score, 0-10) (p<0.0001). Nine patients
reported mild adverse events: six complained of
sleepiness, two of nausea and one of leg weakness; none
of these nine patients had to discontinue baclofen due
to adverse events. Conclusion: Our findings suggest that
baclofen may be a useful adjuvant analgesic in the
treatment of cancer pain.
667. A research protocol for evalutating possible
genetic predictors of the analgesic response to
oral morphine in patients with cancer pain
Benedetta Terziroli Beretta-Piccoli, Sistiana Nava, Mauro
Bianchi, Hans Neuenschwander
Oncology Institue of Southern Switzerland, Palliative Care
Service, Lugano, Switzerland
Background: Morphine is the cornerstone in the
pharmacological treatment of cancer pain. However,
there are a number of poor responders in this patient
population. Specifically designed clinical trials are
needed to elucidate the underlying mechanisms of
interindividual variation in response to morphine. Aim:
To evaluate how the polymorphisms in the specific
receptors, metabolizing enzymes and transporters can
affect the clinical response to oral morphine in cancer
patients. Method: In an observational multicentric study
in Southern Switzerland, adult cancer patients who start
therapy with oral morphine for the treatment of
moderate to severe cancer pain, will be observed during
10 days. The patients will be divided in responders and
poor responders, according to the morphine escalation
index percent, the analgesic response (recorded by the
VAS), and the appearance of signs and symptoms of
morphine toxicity. After genotype stratification, the two
groups will be compared, in order to define a possible
relationship between the genotype and the clinical
response to morphine. The plasma concentrations of
morphine and its main metabolite (M6G) will be also
measured and correlated with the clinical outcome.
Results: The study was opened to acquisition in October
2006. We estimate an acquisition rate of 60
patients/year. Considerations on feasibility and
preliminary results on pharmacogenetic and
pharmacological parameters will be
presented. Conclusion: The possibility to obtain a preemptive identification of patients non-responders to
morphine on the basis of genetic predictive factors will
result in those patients starting on an alternate opioid as
first-line treatment for pain, minimizing the distress
related to the titration phase.
668. LOWER INTRATHECAL MORPHINE DOSES
VS. CONVERSION DOSES IN CANCER PAIN
Francesco Amato 1, Bruno Carenzi 2, Monica Loizzo 3,
Roberto Siciliano 4
1– 4
Azienda Ospedaliera Cosenza, Emergenza, Cosenza, Italy
for different morphine administrating routes were given
by Foley et all (1985). Those doses and concentrations
are now recommended as a starting dose guideline for
the initial phase of treatment. Dosage indicators should
be assessed and individualized based on patient
response, analgesic requirements and side
effects.Therefore, we are herewith presenting findings
from a study regarding morphine doses compared to
conversion doses (as per our algorithm) in chronic
cancer pain during drug-administration by spinal
route. METHODS: In this study, 36 patients have been
randomized to receive either morphine conversion
doses (M group), or lower morphine doses compared to
conversion doses (Low M group) (as per our
algorithm).RESULTS: After using neuro-axial analgesia
there has been a significant reduction in the number of
patients with severe pain ( defined as ”the worst pain”
score in a pain intensity range of 7-8 ), from 81,3 % to
23,7 % . The incidence rate of nausea and vomiting is
approximately 30 % in the group (M group) receiving
morphine conversion doses and 7 % in the other group
(Low M group). CONCLUSIONS: Patients treated with
continuous morphine Low doses needed less morphine
during all follow-up periods and experienced less side
effects such as nausea, vomiting hypotension,
somnolence (drowsiness) as well as early respiratory
depression.
669. Breakthrough pain in palliative patients is
dependent on the level of background pain:
results of a prospective cohort study
Dietmar Beck 1, 2, José Hinz 2, Joachim Strube 2, Berhard
Graf 2
1
Hospiz Stuttgart, Palliative Care Centre, Stuttgart,
Germany
2University Hospital Goettingen, Palliative Care Centre,
Goettingen, Germany
Aim of study: Despite pain treatment in accordance with
the guidelines breakthrough pain occurs frequently in
palliative patients, impairing their quality of life. The
correlation between the level of background pain and
the intensity, frequency, duration and treatment of
breakthrough pain is examined.
Method: Patients on a palliative care unit filled in
questionnaires for self-assessment on a daily basis.
Results: Based on the average level of background pain,
183 palliative patients were divided into a group of 134
patients (73%) with lower pain level (NRS < 2, group
one) and a group of 49 patients (27%) with higher pain
level (NRS 2, group two). The intensity of breakthrough
pain amounted to NRS = 1 in group one and NRS = 6 in
group two (p < 0.001). The number of daily pain attacks
amounted to 0.5 in group one and 2.0 in group two (p <
0.001). The duration of the pain attacks was the same,
lasting up to ten minutes in both groups (median). The
number of daily rescue doses amounted to 0.5 in group
one and 1.5 in group two (p < 0.001). In the course of
treatment the intensity of background pain as well as of
breakthrough pain was reduced in both groups
significantly.
Conclusion: A high level of background pain is an
indicator for a complex pain syndrome with frequent
severe breakthrough pain in need of treatment. 50 % of
the pain attacks last up to 10 minutes and are therefore
pharmacologically difficult to treat.
670. Safe pain therapy and improvement of
quality of life for elderly patients with
polypathia. Sustained-release hydromorphone in
ambulatory pain therapy
Sohn Wolfgang
pain specialist, Dorfstraßße 5-7, Schwalmtal, Germany
A pain therapy which is effective and well tolerated by
elderly patients, of which many suffer of more than one
disease, has to consider physiological changes depending
on age. For analgesia of strong pain the strong opioid
hydromorphone in sustained-release form offers
pharmacokinetic advantages. In this observational study
1615 mostly elderly patients with polypathia were treated
ambulatory with sustained-release hydromorphone due
to cancer- and non-cancer pain. After 2 to 3 weeks of
flexible and individual dosing with sustained-release
hydromorphone, pain was reduced by about 68.5% 21.3%. The requirement of rescue-medication diminished
and compared to prior therapy the percentage of patients
with opioid-typical side effects decreased considerably.
Correspondingly, the quality of life (assessed by the
parameters general activity, mood, walking ability, work
and endurance, social contacts, sleep and joy of life) was
improved by an average of 53.2%.
Advanced studies in cancer related pain have
demonstrated that intrathecal administration of opioids
has been much more effective than other drugadministrating routes (1-5). The most frequently used
drug has been morphine which is the first opioid
approved by the US Food and Drug Administration
(FDA) for intra-spinal use (6).Practical conversion rules
169
Poster abstracts
addressing urgently along with support for International
efforts to increase access to analgesics.
Poster abstracts
671. Documentation of paclitaxel-induced
peripheral neuropathy (PIPN) in patients with
ovarian cancer
Jayne Wood, Joy Ross, Gabriella Brogan, Julia Riley
674. Trend in Opioids use for Chronic Pain
Treatment at Clalit Health Services HMO in Israel
676. Pain and pain management in older people
with cancer
Pesach Shvartzman 1, Tami Freud 2, Silviu Brill 1, Michael
Sherf 3
Mike Bennett 1, John Chatwin 2, Jose Closs 2
1
Royal Marsden Hospital, Palliative Medicine, London,
United Kingdom
Introduction: Paclitaxel is an effective anti-tumour agent
for ovarian cancer. A common dose-limiting side-effect
is peripheral neuropathy. Neuropathic symptoms occur
in 79% of patients at standard doses.
Aim: To review the documentation of PIPN in the Trust.
Methodology: Retrospective review of electronic patient
record (EPR) and paper notes of 59 consecutive patients
with ovarian malignancy, who received paclitaxel. Data
was extracted by 2 clinicians using a standardised
proforma. Neuropathy scored according to ECOG scale.
Results: Full notes were available for 43 patients. Age:
mean(range) 60(28-76) years). 72.1% of patients had Stage
III disease. 69.8% received combination therapy with
carboplatin. During the 6 cycle course, presence/absence
of neuropathy was documented for 90.7 % of patients,
most commonly following the 2nd cycle (33.3%). At 12
months, documentation had fallen to 30.2%.
Documentation was most commonly on the EPR
(94.9%), rarely in the clinical notes (2.6%). 61.5% had
documentation on specified toxicity proformas. Most
neuropathy was grade 1 (66.7%); 12.5% was grade 3. No
neuropathic agents had been commenced for treatment.
Conclusion:
PIPN is a significant problem resulting in impaired
function for 12.5% patients. Clinical documentation
needs to be improved with ongoing education of
oncology teams to identify and treat such patients.
Further research into the prophylaxis and treatment of
paclitaxel-induced chemotherapy is recommended.
672. Dosage changes in cancer patients with
TransDermal Fentanyl(TDF)
Biljana Eftimova 1, Biljana Lazarova 2
1
General Hospital Stip, Anesthesia,reanimation,ICU,
Stip,Macedonia, Macedonia
2
Background and Aim-The purpose of this study is to
evaluate the results of dosage increases in cancer
patients with TDF and qualitatively asses dosage changes
during therapy with TDF in cancer patients.
Methods-We covering patients for one year,
2005January-2006 January ,in 36 patients on long-term
treatment, more than 200days with TDF,who can
comparable pain intensity as assessed by analgesic
premedications.
Results-Mean dosage increases per day was 0,4% TDF in
cancer patients. Despite the overall dosage increases,
qualitative evaluations revealed a high percentage of
TDF with alternating dosage changes, ie dosage
adjustment with TDF in cancer patients is 30%.
Conclusion-The pronounced dosage increase in patients
with TransDermal Fentanyl .Also suggest a high
tolerance development .
673. Episodic pain in hospitalized cancer
patients(breakthrough)
Biljana Lazarova 1, Biljana Eftimova 2
1
Poster abstracts
2
Background and Aim-Breakthrough pain is present in
50-75% of cancer patients and is associated with
inadequate pain control.
Methods-In our hospital we study 66 cancer patients
hospitalized for one-day treatment.Thay have to answer
the questions regarding to episodic pain and to asses
pain on VAS from 1-10.
Results-39 patients reported cancer-related pain,
21patients reported episodic pain with rate of 4 episodes
in one day. There were no differences regarding age and
sex in the incidence of episodic pain.Also, patients with
episodic pain more analgesics in general and they had
higher pain-intensities than patients with out episodic
pain. Men pain 4,8 vs. 3,1 and worst pain 5,9 vs. 4,1 last
24 hours.Mpre pain influence on general activity like
mood, walking ability, working etc. in patients with
episodic pain and more pronounced difference between
average pain and worst pain.Thay more often reported
abnormal skin sensibility in the area of pain.
Conclusions-61% of hospitalized cancer pain patients
report episodic pain and in general are more impaired in
their daily life activities and have worse pain experience.
170
1
Ben-Gurion University of the Negev, Pain and Palliative
Care Unit, Beer-Sheva, Israel
2
Ben-Gurion University of the Negev, Department of Family
Medicine, Beer-Sheva, Israel
3clalit health service, Beer-Sheva, Israel
Background Chronic pain is recognized as a common
problem within the community, and is known to affect
general health, psychological health, and social and
economic well being. Opioids are considered as a
cornerstone in the treatment of pain in non-cancer and
cancer patients. The WHO considers a country’s
morphine consumption to be an important indicator of
the quality of pain control. There is a little or no use of
morphine in nearly half of the countries in the
world. Objective To assess the change in opioids use
trends for chronic pain treatment during five years
(2000-2004) among members of Clalit Health Services
(CHS) the largest HMO in Israel. Method Potent opioid
analgesic drugs that were authorized to use in Israel
during the years 2000-2004 were obtained from the
computerized data bases of CHS. The data included:
opioid brand name, dose, date of administration, and
pharmacologic group. In addition patient’s
demographic details and cancer morbidity were also
extracted. To make the patient’s use of opiods
comparable we analyzed the data by translating all
opioids data (fentanyl patch, oxycodone, methadone
,hydromorphone ,meperidine) to oral morphine
equivalents. Results An increase of 68% in total
morphine consumption was found between the years
2000 and 2004 (from 56.2Kg to 94.9Kg). The mg
morphine per prescription increased from 840.75 to
895.19. The total number of patients who received
opioid prescription multiplied by 1.55 (from 18,370 to
28,462) while the growth in total number of CHS
members was significantly smaller. No significant
differences were found during the years in patients
characteristics who received opioids; regarding gender
(58% were woman) and age (about 80% were 65 years
old and above). A preliminary examination during the
year 2003 of opiods of consumption comparison
between cancer and non-cancer patients showed that
cancer patients used almost threefold the dosage than
non cancer patients (6084.77 vs. 2180.33
mg/patients/year). Conclusions There is a growing
trend in opioids use at CHS in Israel during the 5 year
period evaluated. This trend may be an indication for
the improvement in treatment for chronic pain
675. French nurses’ knowledge on pain
management: A National Survey
MARC BENDIANE 1, 2, PATRICK PERETTI 1, 2, ANNE
GALINIER 3, ROGER FAVRE 4, JEAN-PAUL MOATTI 1
1
Health and Medical Research National Institute,
rESEARCH UNIT 379, Marseilles, France
2
Southeastern Health Regional Observatory, ORS PACA,
Marseilles, France
3
ASSISTANCE PUBLIQUE HOPITAUX DE MARSEILLE,
Service de médecine pénitentiaire, Marseilles, France
Service d’oncologie médicale, Marseilles, Finland
Aim: Since 2002, a new French health legislation gives
nurses a crucial role in pain management. Pain control
is an important issue of palliative care and frequently
involves use of strong medication such as morphine or
other level 3 opioids. It is important to assess nurses’
knowledge and attitudes regarding pain management at
the end of life.Method: An anonymous telephone survey
carried out among a national random sample of French
district and hospital nurses in 2006.Participants: 2,104
French nurses agreed to participate (response rate:
68%).Main outcomes measured: a pain knowledge test
based on 27 items questionnaire and a short vignette
related to pain management for a dying patient,
personal and professional characteristics, opinions on
palliative care.Results: Average score was 15.6,
significantly higher for hospital nurses (16.2) than for
district nurses (14.0). This score was correlated to age
and training. Concerning the vignette, only 50% of
nurses supported the prescription of an analgesic
recommended by international guidelines. This support
depended on objective skills in pain management, but
was also weaker if the patient was a woman, or an old
person.Conclusion: Attitudes toward pain management
at the end of life do not only depend on learned skills.
They are also influenced by more subjective factors that
may cause inequality in care for some patients (women
and the older ones). Nurses’ training programs should
take into account such factors.
St-Gemma’s Hospice, Leeds, United Kingdom
of Leeds, School of Healthcare, Leeds, United
Kingdom
2University
Background: Cancer is predominantly a disease of older
people and is frequently painful. Research in older
people with chronic non-cancer pain suggests that this
group experience less effective control of their pain than
those in younger age groups.
Aim: To determine whether community based older
people with cancer pain experience differences in pain
and pain management compared to younger people.
Design: Prospective interview study.
Method: Patients with cancer pain, aged over 75 years,
or under 60 years, and newly referred to community
based palliative care services in Leeds were interviewed.
Pain and pain related variables were assessed using five
clinical measures: the Brief Pain Inventory; the Hospital
Anxiety and Depression Scale; Self-complete Leeds
Assessment of Neuropathic Symptoms and Signs;
EuroQol ‘thermometer’; and Karnofsky Performance
Status. Qualitative data relating to use of healthcare
resources and service access was also collected.
Results: Preliminary analysis (n=60) shows that pain
type and intensity, and levels of satisfaction with cancer
pain management are similar in younger and older
patients. Younger patients experience higher levels of
interference relating to their mood, and are more likely
to be affected by depression as a result of their pain.
Older patients display greater reticence about the use
of pain killers, and are likely to regard cancer pain as
unavoidable.
677. A RETROSPECTIVE STUDY ON THE USE OF
NEFOPEM IN CANCER-RELATED PAIN IN A
HOSPICE SETTING
Syed Qamar Abbas
Kingdom
Introduction: Nefopam Hydrochloride is a
benzoxacine analgesic with similar properties to
orphenadrine and diphenhydramine. It has neither
opioid nor NSAID like properties and therefore is devoid
of anti-inflammatory and anti-pyretic action. It has
antimuscarinic properties and works in brain. It is
rapidly absorbed and has half-life of 4 hours. It is
extensively metabolised by hepatic oxidation and
glucuronidation.
Objectives: In our hospice, we used Nefopam in
patients who developed intolerance to Opioids or were
not keen to try stronger Opioids. We retrospectively
studied our practice and its affectivity.
Methods: The duration of data collection was two
years. In this time there were 9 (7 males, 2 females)
patients, who were prescribed Nefopam as either they
could not tolerate Opioids due to sleepiness (7/9) or
they were reluctant to take stronger Opioids (2/9). All of
them were on step 2 of WHO Ladder. The pain was
assessed using a simple visual analogue score (VAS)
between 0-10 (0=asymptomatic).
Analysis and Results: The average age was 67.8 (42 –
81) years. All the patients had nocipcetive type of pain.
Their mean pain on VAS dropped from 7.5 to 4.3. Their
mean requirement for breakthrough analgesia per day
dropped from 2.8 to 1.7. 1 patient stopped Nefopam due
to lack of efficacy and 1 patient stopped due to sideeffects.
Conclusion: Nefopam is a useful analgesic, which can
be used to help cancer pain. However, the data to
support its use is lacking and prospective studies are
needed to determine its use in Cancer pain.
678. METHADONE BY CONTINUOUS
SUBCUTANEOUS INFUSION FOR THE
MANAGEMENT OF CANCER PAIN: A CASE REPORT
Costanza Calia 1, Carla Roero 1, Maddalena Castellano 1,
Libero Ciuffreda 2, Marina Torresan 1, Carla Forlano 1,
Margherita Mauro 1, Anna De Luca 1
1
Hospital, Palliative care unit, Turin, Italy
Hospital, Department of Medical Oncology, Turin, Italy
2
Clinical case
62 years old male patient.
March 2004 subtotal gastrectomy and adjuvant CT for
gastric carcinoma. June 2006 strong pain in the
dorsolumbar region of the back (NRS 8) for widespread
back metastasis.
Therapy: increasing doses Fentanyl TD up to 125 mcg/h
every 72 hours, without satisfying reduction in pain
intensity. Clinical conditions worsen and the patient is
admitted in hospital setting in an oncology department.
CT with 5- FU continuous infusion intravenous by CVC
is starting.Opioid switching from Fentanyl TD 125
mcg/h every 72 hours to Morphine 120 mg/day
Poster abstracts
679. A study on views on pain management in
palliative care
Marten Van Wijhe, Gerbrig Versteegen
University Medical Center Groningen, Anaesthesiology &
Critical care, Groningen, Netherlands
We interviewed general practitioners, oncologists,
nursing home physicians, nurses, and patients and their
family, using the focusgroup interview method to clarify
the perceptions of the quality of care. Oncologists wished
to have the role of palliative support teams clarified and
expressed the value of one reference point for pain.
Nurses felt they needed additional training, and
perceived poor communication between caregivers to be
a source of difficulties. Nursing home physicians pointed
out the need for instruments assisting medical and pain
history taking, improved communication with hospital
physicians and the presence of opiofobia in the nursing
profession. General practitioners felt that additional
schooling was urgently needed. The general
practitioners concluded that their own attitudes and
communicative skills play an important role in the
quality of the care they give.The patients and their
families had problems getting adequate care out of
hours and had experienced unnecessary pain during
diagnostic procedures. Conclusion:The perceptions of
the quality of pain management in palliative care
differed among the groups of professionals. All
mentioned the need for improved communication
however. Most importantly patients mention matters
not realised by professionals. The focus group method is
an efficient way of assessing quality and needs of care,
which we recommend to all groups of professionals in
palliative care.
680. Ketamine as an analgesic. Outcomes of
ketamine use in the palliative care setting from 3
surveys.
Rachel Quibell
St Oswalds Hospice, Palliaitve Care, Newcastle, United
Kingdom
Aim
To review outcomes and adverse effects of ketamine use
as an analgesic for refractory pain in the palliative care
patients
Method
Mixed prospective and retrospective data was collected
on all patients commenced on ketamine during the
three survey periods (2002, 2004, 2005). Information
was recorded on the route of administration, pain type,
outcome and side effects
There were 5 outcome categories in all surveys
• Successful
• Partially successful (requiring further intervention for
pain but some benefit from ketamine)
• Stopped due to ineffectiveness
• Stopped due to side effects
• Outcome not available
Results
Total of 73 patients commenced ketamine for 76
different pains. 65 malignant and 8 non malignant
diagnoses.
Age range 23-81.
70 orally (9 patients initially commenced on sublingual
ketamine then switched to oral), 3 subcutaneously.
Successful 42%. Partially successful 33%. Stopped due to
ineffectiveness 13%. Stopped due to side effects 1%
Outcome not available 11%. 26% patients experienced
side effects
11% had ketamine stopped due to side effects
Conclusion
The results confirm the place for ketamine as an
analgesic for refractory pain both malignant and non
malignant, in particular neuropathic pain, bone pain
and ischaemic pain. More robust evidence is required to
support the use of ketamine as analgesic
681. Alternative Opioid Use
Steven Simpson
Integrated Palliative Care Services, Southport, United
Kingdom
Morphine is considered the strong opioid of choice by
both WHO and the EAPC. Alternative opioids have a
special place either for those who are intolerant of
morphine or those unable to comply with or take oral
dosage forms of controlled release morphine.
A retrospective audit of opioid use across all specialist
palliative care settings was undertaken to establish how
the alternative opioids were being prescribed in the light
of this recommendation.
272 new referrals were identified over a period of 3
months. The key clinician completed an audit form
outlining the opioid use and reasons for any alternative
opioid chosen.
58% patients were using an opioid. 70% of those
using an opioid were taking morphine. The most
commonly used alternative opioid was fentanyl 16%,
then oxycodone 9%, alfentanil 4% hydromorphone 1%.
Nearly 50% of those taking an alternative had no
documented reason for it.
The poster describes the audit and the actions taken
as a result to ensure that health professionals have the
evidence required to make informed treatment
decisions if changes to the pain management are
required.
682. CHRONIC CANCER PAIN TREATMENT IN
RUSSIA: CURRENT STATUS AND PERSPECTIVES
Georgiy Novikov, Valeriy Samoylenko, Sergey Rudoy,
Mark Waisman, Michael Efimov
Sechenov Moscow Medical Academy, Oncology department,
PC trainig center, Moscow, Russian Federation
More than 300.000 patients annually die of cancer in
Russia, and about 70% from them suffer from chronic
pain during end-of-life. Historically, palliative care has
been developed in Russia as part of cancer care, and in
the past 15 years of development, over 200
institutions/services providing inpatient and/or
outpatient palliative care (organizing centers, inpatient
palliative care units, hospices, pain clinics, palliative care
community-based teams) have emerged throughout
Russia. In the past decade significant progress in the
opioids availability was made due to Regulations No.
53/9-96 of 17.12.1996 of the Narcotics Control
Committee and Regulations No 330 of 12.11.1997 and
No 2 & No 3 of 09.01.2001 of the Russian Ministry of
Health on the level of opioids used in hospices and
prescribed to home care patients. Nowadays, many
pharmacotherapeutic choices are available for the
management of cancer pain. However, there are strict
and rigid regulations on the prescription of strong
opioids, and very close control of their use involving
police requirements and much medical administration.
Perspectives in the complex approach to control chronic
cancer pain are determine, and include increase in
opiods availability, preferable use of noninvasive longacting formulations and adequate selection of
adjunctive medications and other modalities combined
with opioid therapy. Transdermal fentanyl (Durogesic)
introduction in clinical practice was successful, and in
the past 5 year more than 20.000 cancer patients from
62 cities relieved their suffering with this opiod. Opioid
treatment, including transdermal forms, is free of charge
in Russia.
683. How do physicians and nurses document the
symptom “pain” in palliative care? Difficulties
and obstacles. A questionnaire study
Lars Welin, Ann-Christine Berglund, Gunilla Olsson
ASIH, Langbro Park, Stockholm, Sweden
Background:In order to evaluate different aspects of
adequate pain relief in palliative care, it is essential that
both physicians and nurses completely and correctly
document their pain assessments both before and after
measures have been taken.
Aim: This questionnaire study wishes to survey what
physicians and nurses regard as difficulties and obstacles
for making a correct documentation of pain, in a
computerised patient record system.
Method:Questionnaires were distributed to 95 nurses
and 13 physicians, working either at a palliative care
ward, within three advanced home care teams or at four
nursing homes for demented elderly. Each question had
three alternative answers, either “yes”, “no” or “don’t
know” and a possibility to write down own reflections.
The different items of the questionnaire will be analysed
both with quantitative and qualitative methods,
respectively.
Results: Preliminary results indicate that 60 %
answered, ”no” to the question regarding if the
computerised patient record system per se was an
obstacle. Furthermore, this study will demonstrate the
most prominent factors, for not making an adequate
documentation of pain. Whether it is lack of
communication between patient and personnel, ethical
issues, the oblivion of the staff members, or simply lack
of time, will be interesting to know in order to improve
this very essential issue.
684. Mobility - Observation - Behaviour - Intensity
- Dementia Pain Scale (MOBID): Development and
Validation of a Nurse-Administered Pain
Assessment Tool for Use in Elderly Patients in Pain
and Dementia
Bettina Husebo 1, Liv Strand 1, Rolf Moe-Nilssen 1, Stein
Husebo 2, Anne Ljunggren 1
1
University of Bergen, Department of Public Health and
2University of Klagenfurt and Vienna, Department of
Advancing age is associated with increased prevalence of
pain. Elderly with severe cognitive impairment (SCI) are
at risk for under-diagnosed and untreated pain. Several
pain behavioural scales have been developed but
standardized movement protocols are not investigated
in this context. Aim: Mobilization - Observation Behaviour - Intensity - Dementia Pain Scale (MOBID) is
the first nurse-administered instrument in SCI, where
pain behaviour indicators are observed during
standardized active, guided movements, and inferred to
pain intensity. The study describes the development,
reliability and validity of MOBID. Method: Elderly with
SCI were included in video uptakes. Primary caregivers
rated pain intensity during morning care, and by
MOBID, at bedside and from video uptakes. External
raters completed MOBID by video rating regarding interand intra-rater reliability. Results: Internal consistency
was high (=0.90). MOBID disclosed significantly more
pain than pain scorings during morning care; video
observation demonstrated higher pain intensity than
bedside scoring. Inter-rater reliability for inferred pain
intensity was high to excellent (ICC=0.70-0.96), but
varied between poor to excellent for pain behaviour
indicators (=0.05-0.84). Conclusion: Registration of pain
behaviour indicators during active, guided movements
disclose reliable and valid pain intensity scores in
patients with SCI.
685. Evaluation of a pain education program for
cancer patients in district nursing care.
Mathilde Baan 1, 2, Rianne Wit, de 3, 4, Caren Rijt, van der
2
1
Erasmus MC, Department of Pain Expertise Centre,
2Erasmus MC - Daniel den Hoed, Department of Medical
Oncology, rotterdam, Netherlands
3
Maastricht University, Department of Nursing Science,
Maastricht, Netherlands
4
University Hospital, Maastricht, Netherlands
Introduction: Pain Education Programs (PEPs) have
been used in oncology practice to educate patients on
the principles of pain management thereby improving
patients’ knowledge and pain. Up till now PEP was
studied in the hospital setting. We report the results of a
tailored pain education program in district nursing care.
Methods: The PEP was inplemented in 6 home care
settings in the Netherlands. District nurses were
educated about pain and pain management and were
trained how to use the PEP. Patients’ present and worst
pain intensity (NRS 0 – 10) and patients’ knowledge of
pain management were measured before and 2 months
after receiving the PEP.
Results: PEP was used by 24 nurses for 93 cancer patients
with pain: 44 men (47.3%) and 49 women (52.7%)
mean age 69.3 years (sd 11.1) and mean pain duration
over 10 months (sd 23.2). 67.6% of patients experienced
substantial pain (pain ≥ 4). 34 patients (36.6%) could be
evaluated at 2 months; the other patients were too ill or
had died. Worst pain decreased significantly from 7.8 to
6.6. Present pain decreased from 4.6 to 3.8. Patients’
knowledge increased from 58.8 to 64.8.
Conclusion: In district nursing care, a substantial
number of patients suffer from severe pain. Nurses use
PEP in patients with severe pain at the end of life. PEP
seems to decrease patients’ pain intensity and increase
patients’ knowledge. Further research is needed on the
feasibility and the effects of implementing PEP in
district nursing care.
171
Poster abstracts
continuous subcutaneous infusion. After 24 hours
improvement in pain intensity but the patient develops
enteroplegia and somnolence. The patient is switched
from Morphine 120 mg/day to Methadone 15 mg/day
continous subcutaneous infusion. After 24 hours the
dose of Methadone is increased to 25 mg/day and after
48 hours to 40 mg/day, with complete resolution
enteroplegia, complete relief of pain (NRS 0), satisfying
reduction of somnolence.
Conclusions
This case report suggest that Methadone is an analgesic
with similar efficacy to morphine and may significantly
improve pain intensity without relevant adverse effects.
The process of reaching an optimal dose should be
highly individualized, particularly when patients are
switched from high doses of opioids. Today, after 4
months from the beginning of therapy with unchanged
doses of Methadone continuous subcutaneous infusion,
the patient has still a good pain control without
significant side effects.
Poster abstracts
686. Coadministration of Metamizole (Dipyrone),
Midazolam and Morphine: Compatibility and
stability
Constanze Remi 1 2, Bausewein Bausewein 2
1
University Medical Centre, pHARMACY, Munich,
Germany
2
University Medical Center, Interdisciplinary Center for
Palliative Medicine, Munich, Germany
Background
Metamizole sodium (Dipyrone) is the most widely used
non-opioid analgesic in palliative medicine in Germany.
It is often used with Morphine and other drugs such as
midazolam in the same syringe driver. However, there is
no data concerning the stability and compatibility of
admixtures of Metamizole, Midazolam and Morphine so
far. Incompatibility is not only associated with a loss of
effectiveness but also with i.e. the formation of invisual
crystals which might lead to complications such as
thrombophlebitis or embolism.
Aim
The aim of this study is to evaluate the stability and
compatibility of Metamizole-Morphin and MetamizoleMidazolam-Morphine mixtures in sodium chloride to
provide safe and effective drug therapy.
Methods
Test solutions of the drugs in common concentrations
are prepared in polypropylene syringes in triplicate and
stored at 22 and 40 °C, with and without light
protection. Samples are analyzed immediately and at 6,
12 and 48h. Compatibility is assessed by visual
inspection, pH measurement and by determining the
concentration of each drug with high-performance
liquid chromatography (HPLC).
Results and Conclusion
Morphin and Metamizol admixtures were stable
throughout the study with minimal changes in drug
concentration. The final concentrations of both drugs
after 48 h were > 90 %. An elevated temperature proved
to be the major influencing factor for Metamizole
degradation.
As the analyses of the Metamizole-MidazolamMorphine mixtures is ongoing, data will be presented at
the conference.
687. Codeine/Acetaminophen and
Hydrocodone/Acetaminophen Combination
Tablets for the Management of Chronic Cancer
Pain: A Double-Blind Comparative Trial
Rene Rodriguez, Javier Castillo, Maria Castillo, Paola
Daza, Mario Rodriguez, Jose Restrepo, Jorge Rodriguez,
Yamileth Ortiz
Poster abstracts
Universidad Libre Seccional Cali, Pain and Palliative Care,
Cali, Colombia
With the objective of comparing the analgesic efficacy
and tolerability of the opioids codeine and hydrocodone
in the relief of cancer pain, we conducted a randomized
controlled trial in which cancer patients were randomly
assigned according to a computer-generated schedule to
receive one of the two opioids. Of the 121 patients who
participated, 62 patients received hydrocodone and 59
patients received codeine. At the first visit, 88% of the
patients described pain intensity as moderate (4-6/10),
with the remaining 12% of the patients describing their
pain as severe (7-10/10). The symptoms most associated
with pain were weakness, insomnia and anorexia. In
74% of the total number of cases, the patient was aware
of his/her diagnosis prior to admittance to the palliative
care unit. Of the total number of cases, 59% fell in the
age range of 60-89 years old and 55% of the participants
were male. Hydrocodone/acetaminophen was effective
in relieving pain in 56.5% of the patients at the starting
dose of 25 mg/2500 mg day. An additional 14.5% of the
patients responded to a double dose, and the remaining
29% of patients did not experience any pain relief from
hydrocodone administration. 58% of the patients who
received codeine/acetaminophen experienced pain
relief at the initial dose of 150/2500 mg day, and 8% of
the patients responded to a double dose. 34% of the
patients, however, did not have any relief from their
pain using codeine. No significant statistical difference
in the analgesic efficacy and side effects of the two
opioids was found
688. Long term methadone for chronic pain: a
pilot study of pharmacokinetic aspects.
Fredheim 1, 3
Olav
, Petter Borchgrevink
1, 4, Stein Kaasa 2, 5, Ola Dale 1, 4
1, 4
, Paal Klepstad
1
Norwegian University of science and Technology, Pain and
Palliation Research Group, Department of Circulation and
Medical Imaging, Trondheim, Norway
2
Palliation Research Group, Department of Cancer Research
and Molecular Medicine, Faculty of Medicine, Trondheim,
Norway
3
Sandnessjoen Hospital, Department of Surgery,
Sandnessjoen, Norway
172
4
St. Olav University Hospital, Department of Anaesthesia,
Trondheim, Norway
5
St. Olav University Hospital, Palliative Medicine Unit,
Department of Oncology, Trondheim, Norway
Aim: Little is known about the pharmacokinetics of
switching from morphine to long term methadone
treatment for pain. It has been suggested that
autoinduction of methadone metabolism may occur. In
this study the time course of serum concentrations of
methadone and its metabolite EDDP and the decay of
morphine and metabolites were examined after
switching from morphine to methadone.
Methods: Twelve patients with unsatisfactory pain
control during morphine for chronic non-malignant
pain were switched to methadone. Morphine was
substituted with methadone stepwise over three days
and the switch was followed by a week of dose titration.
Serum concentrations of morphine, methadone and
their metabolites were measured at baseline, day one
and two, after dose titration and one week, five weeks,
three months and nine months after the end of dose
titration.
Results: Seven patients completed the study period of
nine months with only minor dose adjustments. Serum
concentrations of methadone and EDDP were stable
from the end of dose titration and throughout the nine
months (repeated measures ANOVA: p=0.88 and
p=0.06). No significant correlation between dose ratios
and serum concentration ratios between morphine and
methadone was observed (R=0.52, p=0.19). Serum
concentrations of methadone varied five-fold and were
not explained by total daily oral methadone dose (R
2
=0.06, p=0.61).
Conclusions: No sign of autoinduction of methadone
metabolism was seen during long term treatment.
689. Drug treatment of nociceptive cancer pain: a
systematic review and recommendations for
clinical practice
Alexander De Graeff 1, Frank Jansman 2, Michel
Wagemans 3, Kris Vissers 4
1
University Medical Center Utrecht, Department of Medical
2
Isala Hospitals, Department of Medical Oncology, Zwolle,
Netherlands
3
Reinier de Graaf Hospital, Department of Anaesthesiology,
Delft, Netherlands
4
University Medical Center St. Radboud, Department of
Palliative Medicine, Nijmegen, Netherlands
Background: This review was performed as part of the
development of a Dutch national guideline on
assessment and treatment of cancer pain.
Aim of the study: To perform a systematic review of the
literature on drug treatment of nociceptive cancer pain
and to give recommendations for clinical practice.
Method: Systematic literature search of two databases
(Medline and Embase) for meta-analyses, systematic
reviews and randomized trials of paracetamol, NSAID’s,
cannabinoids and opioids for non-neuropathic pain in
patients with cancer.
Results: We used 7 Cochrane analyses, 6 systematic
reviews and several additional studies, including a total
of 118 randomized studies. Based on the literature and,
where not available, on expert opinion, 28 evidencerated conclusions and 18 recommendations on the
effect and use of paracetamol (acetaminophen),
NSAID’s, cannabinoids, weak opioids (codein and
tramadol) and strong opioids (morphine, fentanyl,
oxycodone, hydromorphone and methadone) were
formulated and will be presented at the meeting.
Conclusion: These results will be used for an evidencebased national guideline on cancer pain. Optimal
treatment of cancer pain may increasingly be based on
the results of meta-analyses and randomized trials.
690. Spiritual Pain in Palliative Care: A
Multidimensional Approach
SHANNON POPPITO 1, KATHLEEN GALEK 2
1
Behavioral Sciences, New York, United States
2Health Care Centre, Chaplaincy, New York, United States
Purpose: The current study explores the
multidimensional nature of spiritual pain in end-stage
cancer patients located in an urban-based palliative care
setting.
Methods: Fifty-seven advanced stage cancer patients in
a palliative care hospital were interviewed by chaplains.
The study combines a quantitative evaluation of
participants’ intensity of spiritual suffering, physical
pain, depression, and intensity of illness, with a
qualitative focus on the multidimensional nature of
patients’ spiritual pain as delineated by five patientgenerated domains (e.g., physical, existential,
emotional, religious and mental).
Results: Overall, 96% of the patients reported
experiencing spiritual pain, but they expressed it in
different ways: (1) as an intra-psychic conflict, (2) as
interpersonal loss or conflict, or (3) in relation to the
divine. Patient-generated spiritual pain domains are
examined in light of these dimensions. Intensity of
spiritual pain was correlated with depression (r = .43, p <
.001), but not physical pain or severity of illness. The
intensity of spiritual pain did not vary by age, gender,
disease course or religious affiliation. Conclusions:
Given both the universality of spiritual pain and the
multi-faceted nature of “pain,” we propose that when
patients report the experience of pain, more
consideration be given to the complexity of the
phenomena and that spiritual pain be considered an
important contributing factor in palliative care.
691. Refractory Neurological Pain in a home care
patient, treated with intravenous Ketamine.
Lauren Shaiova 1, Eugene Perlov 1
1
Memorial Sloan-Kettering Cancer Center, Department of
Neurology, New York City, United States
2
Visiting Nurse Service of NY, HOSPICE, New York City,
United States
Palliative Care Presentation:
Brief case report; Refractory Neurological Pain in a 81
YO male with Hepatitis C, Hepatocellular Carcinoma,
cared for at home on Intravenous methadone and
Intravenous Ketamine.
Refractory Neuropathic pain continues to be one of
the most challenging cancer pain syndromes existing
currently. Although there are many treatments available
for neuropathic pain there are some patients who do
not respond to conventional therapies such as first line
opioid pharmacology and typical adjuvants. We report a
case of a 81 yo male of eastern European descent with
history of hepatitis C and a 2 year history of
Hepatocellular carcinoma.with diffuse spinal cord
metastatic disease. The patient presented to VNS
Hospice home care after being treated in hospital with
radiation therapy and long acting oxycodone for
bilateral and symmetrical lower extremity pain,
characterized by burning, dysesthesias, cramping with
an inability to ambulate secondary to intense,
unrelenting pain.
After several weeks of at home the patient began to
experience a crescendo pain flare which was
intermittent, sharp with intense burning. The patients
was evaluated at home by the hospice physician and
commenced on methadone and Ketamine orally
then rotated to a parenteral infusion of ketamine for the
treatment of severe neuropathic pain
692. Why Does It Hurt So Bad: Some Thoughts on
Pain Control in Hungary
Krisztina Tóth 1, Judit Maghera 1, Katalin Muszbek 1
1
Objective: In this lecture, we are attempting to explore
general issues of pain control. The main problem is that
although modern means of palliative care are all
available in Hungary, pain control remains insufficient.
Method: In the search for the reasons for a deficient
pain control, we first sought to explore the functional
and organizational characteristics of the Hungarian
medical system as well as the special features and
deficiencies in the training of medical staff. After an
exchange of experience with both medical doctors and
patients, we discovered an almost „„mythical” fear of
the utilization of morphine. For patients, this attitude
keeps them from accepting their medication and even
physicians do not prescribe the most effective medicine
in pain control.
Results: The medical system in Hungary has only been
financing hospice care for the last two years, thus, the
palliative approach has found its way neither in the
training of medical staff nor in the everyday practice of
medical care. Patients, and often even physicians, in a
lack of information, develop false concepts on
morphine products. Data on this will be demonstrated.
Conclusions: We urgently need a comprehensive
informative campaign that seeks not only to inform
patients but also to offer continuing palliative care
education for physicians and other health care
professionals. This is, thus, the only way to effectively
reduce the suffering of terminally ill cancer patients
which is an eminent goal of hospice care.
693. MERITO Study: Starting therapy with
Immediate Release oral Morphine (IRM) in
patients with cancer pain. Predictive factors of
analgesic response.
Franco De Conno 1, Carla Ripamonti 1, Elena Fagnoni 1,
Cinzia Brunelli 1, Tiziana Campa 2, Group Merito 1, Oscar
Bertetto 2
1
National Cancer Center, Palliative care and Rehabiliation
Medicine, Milan Italy, Italy
2
molinette, Cancer department, torino, Italy
Background According to EAPC clinical
Poster abstracts
694. Pharmacokinetics of nasal fentanyl.
Moksnes Husby 1, Olav Magnus Fredheim 2, Paal
Klepstad 2, 3, Stein Kaasa 2, 4, Jorn Lotsch 5, Anders
Angelsen 2, 6, Turid Nilsen 2, Ola Dale 1, 3
1
Norwegian University of science and Technology,
Department of Circulation and Medical imaging,
Trondheim, Norway
2
Norwegian University of science and Technology,
Department of Circulation and Medical imaging,
Trondheim, Norway
3
St. Olav University Hospital, Department of
Anaesthesiology, Trondheim, Norway
4St. Olav University Hospital, Palliative Care Medicine
Section, Trondheim, Norway
5Johann Wolfgang Goethe-University, Institute of Clinical
Pharmacology, Frankfurt am Main, Germany
6
St. Olav University Hospital, Department of Urology,
Trondheim, Norway
Aim:To determine pharmacokinetic parameters after
nasal administration of a low dose of fentanyl and to
evaluate the safety in opioid naïïve patients.
Methods:
12 patients (47 to 84 years) scheduled for transurethral
resection of the prostate gland received an intranasal
dose of 50 Ì_g fentanyl citrate. Simultaneous arterial and
venous blood samples for analyses of fentanyl were
drawn at baseline and 1, 3, 5, 7, 9, 13, 15, 20, 25, 35, 45
and 60 min after drug administration. Vital signs
including sedation were recorded.
Results:
The arterial AUC0-60 of 21 (5,7) min*ng/ml was
approximately 30% larger than the venous (15 (4,1)
min*ng/ml), arterial Cmax (0,83 (0,26)ng/ml) nearly
twice as high the venous (0,47 (0,15) ng/ml) , and the
arterial Tmax (7,0 (1,3) min) about five minutes shorter
compared to the venous (11,6 (3,3)min) (all p-values
≤0.005). No significant adverse events were observed.
Conclusion:
With reference to breakthrough pain, the most
important period is the first hour after administration of
the opioid. This study has shown that venous sampling
significantly underestimates the most important
pharmacokinetic parameters relevant for the clinical
outcome in this period. 50μμg of nasal fentanyl was well
tolerated by opioid naïïve middle aged to elderly male
patients.
695. TREATMENT OF PAIN IN ONCOLOGIC
PATIENTS INCOME IN OUR HOSPITAL:
ASSESMENT OF OUR CLINICAL PRACTICE
Isabel Blancas, David Cumplido, Jose Luis Garcia-Puche
Granada, Spain
Objective: To look at pain in cancer patients being
entered on an oncology service and to assess our clinical
practice in the treatment of anorexiaPatients and
Methods: transversal study with all the oncologic
inpatients that were in our service while a month.We
used to measure the pain the visual analog scale (VAS)
where 0 is no pain and 10 the worst pain. There were 50
patientsResults: The 52% of patients had pain, VAS 1-3:
19 patients, VAS 4-6: 3 patients, VAS 7-10: 4 patients.
Kind of pain: somatic: 19 (38%), neuropathic: 6 (12%),
visceral: 3 (6%) The pain was related to the tumor or its
metastasis in 16 patientsTthe first day in the hospital 5
patients had not any kind of treatment for the pain
(20% of the patients with pain, 3 of them with VAS
superior to 4). Drugs for the somatic pain were: 9 non
opioid analgesics, 4 tramadol, 4 morphine or fentanyl.
The 6 patients with neuropathic pain received: non
steroids anti-inflamatory drugs, corticoids and tramadol,
one received gabapentin. The 3 patients with visceral
pain had not any kind of treatment. During the time in
the hospital in 22 patients the analgesic drugs were
modified. After 6 days: VAS (1-3):5 patients, VAS (4-6):1
patient, EVA (7-10): none. 7 patients had prescribed
drugs to avoid the side effects (constipation 5, sedation
2, vomiting 1 and cushing habit 1 patient).
Conclusions: pain is a frequent symptom in the
majority is produced by the direct effect of the tumor or
its metastasis.It is not always properly assessed and that
could lead us to a deficient treatment
696. Combination of strong opioids in treatment
of cancer pain: synergic effect?!
Johan Van den Eynde
Network Palliative Care, Sint-Niklaas, Belgium
Background: most guidelines tell us to avoid the
combination of strong opioids because of possible
antagonism. Aim: to evaluate the effect of the
combination of Buprenorphine TTS (BUP TTS) and
Fentanyl TTS (FEN TTS) on pain scores in patients with
severe cancer pain. Method: cancer patients were
treated with FEN TTS. The dose was up titrated in
proportion to the pain score. When the normal increase
of dose did not give the expected decrease in pain score,
we didn’t rotate to an other opioid, but FEN TTS was
diminished to the previous dose (=inclusion dose) and
BUP TTS was added in an equivalent dose. Results: 7 pts
were included.Starting doses FEN/BUP varied from
25μg/17.5μμg to 200μg/105μg (av. 65/42.5).
Doses FEN/BUP at study end varied from 25μg/17.5μg to
200μg/140μg (av.67.9/52.5).
Observation period varied from 3 to 20 wk (av.10wk).
Pain scores could be kept under 3, by titrating the doses
of FEN: 4.5% increase, but mainly by titrating the doses
of BUP: 24% doses increase. Conclusion: instead of the
general believe that combination of strong opioids is to
be avoided, we find no clinical evidence of antagonism,
but we find an synergic effect of FEN TTS and BUP TTS.
This opens new possibilities to treat severe cancer pain.
More research is needed to optimize the combination
and conversion rate.
697. USE OF HIGHER THAN NORMAL DOSES OF
BUPRENORPHINE (BUP TTS) TO TREAT SEVERE
CANCER RELATED PAIN WITHOUT
ENCOUNTERING AN ANALGESIC CEILING EFFECT
Johan Van den Eynde 1, Johan Menten 2, Annemie
Delaruelle 3
1
De Plataan, Sint-Niklaas, Belgium
U.H. Gasthuisberg, leuven, Belgium
De Plataan, Sint-Niklaas, Belgium
2
3
Background: One of the misconceptions with regard
to buprenorphine is the belief an analgesic ceiling effect
exists within the therapeutic dose range.
Aim: to explore the maximal effective dose of
buprenorphine
Case: pt previously treated with fentanyl TTS 75g/h and
then with hydromorphone po 24mg bid. Still suffering
(VAS 8) from shooting pain with hyperalgesia, pt was
switched to 2 patches BUP TTS 70g/h with 230 mg
morphine sc . The next days morphine dose was
reduced and diclofenac 75mg bid sc added. VAS
decreased to 4. On day 4 (VAS 5,5) BUP TTS was up
titrated to 3 x 70g/h. The pain decreased (VAS 1.5).
When the pain increased again (VAS 6) BUP TTS was
increased to 4 x 70ug/h plus morphine sc. 120-200
mg/d. The pt died pain free on day 14.
Results: Severe cancer pain, with a neuropathic
component, was successfully treated with BUP TTS,
combined with morphine sc and diclofenac. Until this
moment we could treat 6 pts with high doses BUP TTS
instead of rotating to another opioid, confirming the
results of this case report.
Conclusion: The increasing pain was managed
efficiently by a gradual increase of the BUP TTS dose to 4
patches of 70g/h (=double of recommended maximal
dose) without increase in side effects, nor the
appearance of clinical toxicity. No ceiling effect on the
analgesic dose was encountered. BUP TTS in
combination with high doses of morphine sc was
effective and safe in the treatment of cancer pain with a
neuropathic component.
698. Transdermal Fentanyl (TF) and Slow
Releasing Oral Morphine (SROM) in front line
treatment of Moderate-Severe Pain (MSP). Metaanalysis of Randomized Clinical Trials (RCTs).
Davide Tassinari 1, Emanuela Scarpi 2, Emiliano
Tamburini 1, Cinzia Possenti 1, Stefania Nicoletti 1,
William Raffaeli 1, Marco Maltoni 2
1
City Hospital, Oncology and Palliative Care, Rimini, Italy
Hospital, Oncology and Palliative Care, forli’, Italy
2City
Background. To assess the differences of TF and SROM
in front line approach against MSP, we performed a
systematic review of literature and a meta-analysis of
RCTs.Methods. All the RCTs comparing SROM and TF
in front line treatment of MSP were considered eligible
and included into the analysis. Overall Safety (OS) was
the primary end point; Overall Neurological (ONS) and
Gastrointestinal Safety (OGS), Constipation (C), Laxative
Use (LU) and Patient’s Preference (PP) were the
secondary ones. RCTs enrolling patients with oncologic
and non-oncologic pain were included into the analysis.
Heterogeneity was assessed using the Mantel-Haenszel
test, and the Odds analysis was performed with the fixed
effect model. Results. Five trials, with 1305 patients
were considered eligible and included into the analysis.
Three trials investigated cancer pain, and 2 trials benign
pain. No differences were observed in the Odds Ratios of
OS (HR=0.96, p=0.83), ONS (HR=0.98, p=0.90) and OGS
(HR=0.85, p=0.313), nor any differences were observed
in the oncologic and in the benign subgroups of
patients. A significant difference in favor of TF was
observed in C rate (HR=0.576, p<0.0001), LU (HR=0.60,
p=0.001) and PP rate (HR=0.39, p<0.0001) both in
oncologic and non-oncologic pain.Conclusions. The
different safety profiles of TF and SROM seem to suggest
a differential approach to the patient with MSP, favoring
the selection of the front line approach on the basis of
the patient characteristics, to reduce side effects, and to
favor a personalization of analgesic approach.
699. Pharmacokinetics of double dose of
immediately released morphine and two singledose of 4 hours interval in cancer patient
Ola Dale 1, Pal Klepstad 1, Trine Andreassen 2, Stein Kaasa
2
1
Palliation Research Group, Department of Circulation and
Medical Imaging, Trondheim, Norway
2
Palliation Research Group, Department of Cancer Research
and Molecular Medicine, Faculty of Medicine, Trondheim,
Norway
Aim
The EAPC guidelines for treatment of cancer pain
recommend a double dose (DD) of immediate release
morphine (M) at bedtime instead of 4-hourly single
doses nightly (SD). This study was a follow up of
patients that had been included in a clinical study
comparing DD and SD of IR-morphine during night, in
which DD made it slightly better. The aim was to
explore pharmacokinetic aspects of these treatments
procedures.
Methods
Consenting patients were randomly given SD or DD
(same doses as during the clinical study) at two
occasions in this crossover study. Blood was sampled at
0, 15, 30; 45 min and 1, 1.5, 2, 3, 4, 5, 6, 7 and 8 h (DD),
with two additional samples at 4.5 and 5.5 h during SD.
M and M6G were measured with liquid-chromatography
tandem mass-spectrometry.
Results
Eleven patients participated; two completed one session
only. Times to maximum serum concentrations were 1
and 1.5 h for M and M6G. Maximum serum
concentrations (Cmax) for M and M6G for DD were about
twice as high as for those of the two Cmax of SD (p= 0.004
and 0.03, respectively). The total AUC (area under the
curve) for the 8-hour study period were similar for M
and M6G after SD and DD. However, the 0-4 h AUC for
M6G of DD was significantly higher (p=0.002) than
the0-4 h AUC of SD.
Conclusion
We hypothesize that M6G, due to a higher Cmax and
larger AUC in the 0-4 h period, by a possible late night
action, may play a role for the trend favouring DD in the
clinical study.
700. Evolution of Oxycodone Use in a Palliative
Medicine Unit
LAURA Santiso, MANUEL GÓMEZ, MARÍA SOCORRO
MARRERO, ELADIO DARIO GARCÍA, JULIA FRAQUET
HOSPITAL DR. NEGRíN, CUIDADOS PALIATIVOS, LAS
PALMAS DE GRAN CANARIA, Spain
Introduction : It has been demonstrated that pain
control and the use of strong opioids is a fundamental
aspect in improving quality of life in terminal patients.
Objectives: Use of strong opioids, and oxycodone in
particular, in pain control, as a fundamental factor in
improving quality of life. Material and methods:
Prospective, one-year study on 130 patients, considering
diagnosis, sex, symptom control, use of step three
analgesics and evolution of oxycodone use.Results:
Population studied: 130 patients, 85 of which were men
and 45 were men. Mean age was 67; minimum age 37,
maximum age 86. The following was studied: normal
pain control and breakthrough pain control, which is
fundamental for the patient to feel in an acceptable
state. Parameters were assessed at baseline and one
month after palliative intervention. CONCLUSIONS: 1)
Diagnoses per sex and age correspond in general with
173
Poster abstracts
recommendations immediate release oral morphine
(IRM) is the strong opioid of choice in the starting
therapy for patients with cancer pain.Aim of the present
study is to identify the prognostic factors of analgesic
response in the first five days of IRM therapy.Methods
159 consecutive strong opioid naïïve patients with
moderate to severe cancer pain were administered IRM
5mg/4 h or 10 mg/4h as starting therapy. Responders
were defined as patients a) who achieved the first pain
control (pain reduced of at least 50% with respect to
baseline) within the first 48 hours of treatment; b) had
pain controlled for at least 80% of their follow-up
period; c) took IRM for at least 4 of the 5 follow-up days;
d) took a maximum of 2 extra-doses of IRM a day; e)
showed no severe side effects. Results Data from 151 out
of 159 enrolled patients are available. 71 patients (47%)
resulted as responders and,among all the factors
examined,the absence of episodes of pain in the 24
hours before beginning treatment (OR=2.8 95%CI 1.45.5) and a KPS>50 (OR=3.3 95%CI 1.03-11.0) showed to
be independent prognostic factors of a good analgesic
response. Conclusions This study shows that patients
with cancer pain and a KPS > 50 before starting IRM
therapy are more likely to have better pain control than
patients with cancer pain and a KPS
Poster abstracts
that described in literature. 2) According to the graph,
there was fairly good control of symptoms after one
month of intervention, and a spectacular reduction in
pain control (including breakthrough pain). 3)
Significant increase after use of step 3 analgesics (strong
opioids). 4) A significant increase (almost four-fold) in
the use of oxycodone can be observed on the table and
in the graph. 5) The oxycodone presentation in solution
is significant in breakthrough pain control, because it is
fast acting, easy to administer, and is well accepted by
patients. 6) Use of Oxycodone was particularly
important in neuropathic pain control.
701. Effectivness of oral methadone for
neuropathic pain resistant to conventional
treatment. A revue of 5 cases.
Aurelie Laurent, Murielle Ruer, Henri Nahapetian, Mario
Barmaki, Marilene Filbet
CENTRE HOSPITALIER LYON SUD, Department of
Palliative Medicine, Lyon, France, France
Objective : Evaluate the effectivness of oral methadone
associated to conventional treatment of neuropathic
pain (tricyclic antidepressant, antiepileptic) compared to
other opioids associated to conventional treatment of
neuropathic pain for 5 consecutive patients suffuring of
a neuropathic cancer pain, resistant to this second
association.
Methods : We examined retrospectively during a onemonth study period the clinical response of all 5
patients at our palliative unit who were prescribed
methadone at the place of the previous opioid while
continuing the conventional treatment of neuropathic
pain. The neuropathic pain was linked to cancer for all
5. We have studied the VAS score before introducing
methadone, 4 to 7 days after and one month after, and
the relief of pain. The criteria of effectivness were
defined as a decrease of at least 50% for the mean VAS
score and of at least 50% for relief.
Results : Before rotation the mean dose of opioid was
344mg/24h and the mean dose of methadone was
38,58mg/24h the first day after rotation. Before rotation
the mean VAS score was 7,70. 4 to 7 days after rotation
the mean VAS score was 3,82 (decrease : 50,33%) and
2,82 one month after (decrease : 63,32%). The average
pain relief was 52%.
Discussion : These findings suggest that oral methadone
associated to conventional treatment of neuropathic
pain could be more effectiv than the association with
other opioids for resistant patients. A prospective study
is now needed to examine more rigorously the benefits
of methadone for neuropathic cancer pain resistant to
conventional analgesics.
702. Title: Incidence of oral mucositis study, and
treatment pain management in patients in
radiation oncology services
Ana Ma as 1, Amalia Palacios 2, Pilar Blanco 3, Isabel
Sanchez- Magro 4
1
Hospital La Paz, Oncología Radioterápica, madrid, Spain
Hospital Reina Sofía, Oncología Radioterápica, Córdoba,
Spain
3
Grünenthal Group, scientific, Madrid, Spain
4Grünenthal Group, scientific, Madrid, Spain
Poster abstracts
2
Background: Patients who receive radiation to the headneck cancer have an Incidence of oral mucositis of 3060%. Severe oral mucositis can strongly affect the
nutritional situation of the patient resulting in severe
damage to the quality of life. Methods: Two phase
epidemiological Study. Phase A cross- sectional to
determine incidence, all patients over 18 years of age
seen in outpatient radiation oncology services during
five consecutive working days. Phase B descriptive,
longitudinal and prospective study. Enrolment and two
month follow up of patients with oral mucositis ( grades
III- IV). This study was approved by an ethical
committee Objectives: Phase A: to determine the
incidence of oral mucositis in each of its grades within
Radiation Oncology services. Phase B: to describe
treatments given for pain management , to assess the
degree of management of pain , satisfaction and
compliance with the treatment given in patients with
oral mucositis grades III-IV . Results: The study
recruitment started in August 2006. 55 investigators
participated in phase A, 2233 patients have been
evaluated; 465 suffer from oral mucositis. Phase B
started in October 2006, currently we are finishing the
evaluation of the follow up period. The database will
close in December 2006. The results and conclusions
will be available during the congress.
174
703. Evaluation of Symptom Control
Adequateness Among the End-of-life Patients
Receiving Home-Based Palliative Care in Georgia
Tamari Rukhadze, Dimitri Kordzaya, Irina Tsirkvadze,
Marine Turkadze
Palliative Care Association Humanist’s Union (AHU), Home
Care Team, Tbilisi, Georgia
Aim of study: To evaluate the adequateness of
symptoms control among the home-based palliative
care suitable patients in Georgia and analyze the ways of
its improvement.Methods: Symptom control
adequateness was evaluated by using of especially
worked out questionnaires. 300 questionnaires filled by
patients (and their family members) curried by mobile
team of Palliative Care Association “Humanists’ Union”
(AHU) underwent to analysis. Complete relieve of
symptoms was considered as an indicator for the
successful control. The method of inferential statistics
was used. Results: During the 2004-2006 by the mobile
team of AHU have been provided care of 318 end-of life
patients in Tbilisi. Pain was revealed as the most
unresolved symptom for control (p<0.001). Its
management was insufficient in 136 cases (42.8%): it
was not reduced till 3-4 score (of 10-scores pain
intensivity scale) in spite of usage of all available
medications by AHU mobile team medical stuff.
Conclusion: The problems of pain management of
end-of life patients in Georgia should be caused by
lacking of: 1) legislative bases, 2) list and forms of
opioids and their availability, 3) knowledge and
experience of health care professionals.
704. Differential therapy with sustained-release
(SR) hydromorphone*and transdermal (TD)
Fentanyl** - results of a pilot study
Nolte Thomas
Schmerz- und Palliativzentrum, wiesbaden, Germany
Aim of study Efficacy, tolerability and quality of life
under therapy with HM or TF Method Open,
comparator, multi-centre cohort study with cancer pain
patients under ongoing HM or TF therapy. Assessment
of pain intensity (NRS: 0-100; no - most severe pain),
sleep at night, general activity, normal work (NRS: 0-100;
no-most severe impairment), wellbeing (+100=very good
- -100=very bad), rescue medication, laxatives with the
patients diary of the German Society for Pain Therapy
(DGS). Doctors assessed efficacy, tolerability and
compliance. Result 32 HM patients resp. 44 TF patients
were included. Both groups were comparable
concerning age, anamnesis, mean pain intensity, dose of
morphine equivalents. More TF patients needed
additional pain medication. A double amount of TF
patients needed rescue medication. Laxative use was
comparable. In the TF group more adverse events
occurred (2 vs 13): 50% in the GI duct (HM 2 vs TF 6).
QoL was comparable except for impairment of daily
activities and sleep at night: better in the HM group. A
significant increase of wellbeing in the HM group was
remarkable, even though it was in contrast to the
prognosis of the main disease. Doctors evaluated
efficacy and tolerability better for HM, compliance was
comparable. Conclusion Data do not show the often
mentioned better GI tolerability of transdermal opioids.
Doctors’ general preference of transdermal systems -in
contrast to recommendations by pain societies - has not
been proven - neither in this study.
(* Palladon®, Mundipharma GmbH, ** Durogesic SMAT,
Janssen-Cilag GmbH)
705. Pain management in opioid treated cancer
patients in hospital settings
Lena Lundorff 1, Vera Peuckmann 2, Per Sjogren 2
1
Regionshospitalet Herning, Palliative Care Team, Herning,
Denmark
2
National Hospital, Multidisciplinary Pain Centre,
Copenhagen, Denmark
Aim : To evaluate the performance and quality of cancer
pain management in hospital settings.Methods:
Specialists in pain medicine studied pain management
in departments of oncology and surgery. Information
regarding pain aetiology, mechanisms, medications and
treatment of opioid side effects were registered from the
medical records. The pain specialists examined and
interviewed the patients assessing pain aetiology, pain
mechanisms and opioid side effects. Pain intensity was
assessed using the Brief Pain Inventory.Results: In total
59 cancer patients were included. Pain aetiology was
assessed by 83% and pain mechanisms were assessed by
only 32% of the doctors. 78% of the patients received
opioids at adequate regular intervals according to
duration of action. In 88% oral opioids were given prn
and the median oral prn dose was 16.5% of the daily
dose. Only 12% of the patients with neuropathic pain
received adjuvant drugs whereas 10% of patients with
non-neuropathic pain received adjuvant drugs.
Constipation and nausea were adequately treated,
however, dryness of mouth, sedation and cognitive
dysfunction were only treated in a minority of
patients.Conclusion: Cancer pain is still prevalent and
serious in opioid treated patients in hospital settings.
Pain mechanisms were seldom examined and adjuvant
drugs are not specifically used for neuropathic pain in
departments of oncology and surgery. Opioid dosing
intervals and prn doses were most often adequate.
However, opioid side effects were highly prevalent and
most side effects were left untreated.
706. Use of patient-controlled analgesia for pain
control in dying children
Christine Schiessl 1, Chara Gravou 2, Reinhard Sittl 1,
Boris Zernikow 3, Norbert Griessinger 1
1
University of Erlangen, Department of Anaesthesiology,
Erlangen, Germany
2
University Hospital for Children and Adolescents,
Department of Peadiatric Oncology, Erlangen, Germany
3
Witten/Herdecke University, Vodafone Stiftungsinstitut für
Kinderschmerztherapie und Pädiatrische Palliativmedizin,
Datteln, Germany
Introduction. In the last week of life the daily opioid
dose in children is highly variable making the use of
patient-controlled analgesia (PCA) a useful therapy
option. Methods. Retrospective chart review over a
seven year period (Jan 1998 - Jan 2005) of children
dying of cancer. Results. Eight children were on PCA
for a median duration of nine days (range, 1 to 50). The
daily median intravenous morphine equivalent dose
referenced to body weight increased significantly when
PCA was initiated and during the last week of life. In the
last week of life the median daily number of
positive/negative bolus requests ranged from 7.5-21/04.5). Thirty-nine PCA parameter changes on 22
opportunities were observed. Daily median intravenous
morphine equivalent dose referenced to body weight
increased significantly when PCA was initiated and
during the last week of life. Median daily mean pain
scores remained low (range, 0-3) throughout the period.
Conclusion. PCA proved an ideal, dependable and
feasible mode of analgesic administration for the
individual titration of dose to effect.
707. Safety and efficacy of a german model for
opioid conversion to oral levomethadone
Jan Gaertner 1, Friedemann Nauck 2, Annika Bruhnke 1,
Raymond Voltz 1, Christoph Ostgathe 1
1
University Hospital of Cologne, Department of Palliative
2
University Hospital Goettingen, Department of Palliative
Medicine, Göttingen, Germany
Aim of Project: Difficult dose finding and challenging
management caused by delayed toxicity has restricted
the use of Levomethadone. To simplify the conversion,
a regimen with a strict scheme (titration phase first
72h: starting with 6 x 2.5 –5 mg independent from dose
of opioid in pre-treatment / maintenance phase >72 h,
3 x daily the dose reached after titration) has been
developed. To examine the effectiveness, safety and
feasibility, the “German Model” (GM) was analysed
retrospectively.
Method: A retrospective, systematic chart review on
patients (pts) receiving Levomethadon (LM) on the
palliative care unit was performed.
Results: From 1/2005 to 10/2006 LM therapy was
initiated in 33 pts (32 cancer, 1 non cancer) suffering
from difficult pain syndromes (neuropathic 42%,
breakthrough 73%) despite of opioid therapy (oral
morphine equivalent [mg] before conversion: mean 461
/ range 0-1200). 85% of pts could be discharged in good
pain control (mean dose [mg] of LM 31, range 7-120
mg). LM had to be discontinued in 15% of pts (no
sufficient pain relief in 2, side effects - sedation,
myoclonus - in 1, no more oral intake possible 2 pts).
Conclusion: The GM is a safe and effective approach for
conversion to Levomethadone. Further research should
compare safety and efficacy profiles of Levomethadone,
which is used in Germany, to racemic Methadone that is
used in other countries.
708. Regional cooperation in palliative pain
control needs attention!
Monique Van den broek 1, Hedi Ter braak 2, Gertie
Filippinie 3, Herlin Woldberg 4, Cootje Van der lans 5,
Sylvia Verhage 6
1
Network Palliative Care, Oss-Uden-Veghel, Netherlands
Network Palliative Care, Oss-Uden-Veghel, Netherlands
Hospital Bernhoven, Oss-Veghel, Netherlands
4
Palliative Consulting Team, ‘s-Hertogenbosch, Netherlands
5Home care Vivent, ‘s-Hertogenbosch, Netherlands
6
Hospital Jeroen Bosch, ‘s-Hertogenbosch, Netherlands
2
3
IntroductionThis became evident from the qualitative
Poster abstracts
709. PALLADONE SLOW RELEASE
(HYDROMORPHONE SR) TREATMENT EFFECTIVE
AND WELL-TOLERATED IN BELGIUM.
Luc De Colvenaer 1, Pierre Duquenne 2, Sophie Blockx 3,
Yvonne Van Megen 3
1
AZ St. Blasius, anesthesiology, Dendermonde, Belgium
CHC, anesthesiology, Liege, Belgium
Medical, Mechelen, Belgium
2
3Mundipharma,
Aim: The aim of this prospective observational study
was to evaluate patterns of use, safety and efficacy of
Palladone® Slow Release in daily clinical practice.
Methods: This open prospective, non-randomized
observational study was designed according to the
SAMM guidelines (Waller et al., Br. J. Pharmacol
38(2):95, 1994).
Results: A total of 1181 evaluable patients (mean 64
years) were included. The mean pain VAS score was 75
mm at inclusion. Patients were treated for severe
cancer (35%) or non cancer pain (65%) like low back
pain, osteoarthritis, sciatic pain. Patients were pretreated with step 1 (12%), step 2 (48%), or step 3 opioids
(39%) or co-analgesics (1%). The average daily start dose
was 11 mg Palladone® Slow Release. This dose increased
during treatment to 15 mg and 16 mg at the second
(mean 21 days) and third evaluation (mean 46 days)
respectively. After the last evaluation the VAS scores were
reduced for pain (53%), effect of pain on work (48%),
daily activities (53%) and quality of life (53%). The
efficacy was evaluated as ‘satisfactory’ to ‘very good’ for
88% of the patients. The most frequently reported
adverse events (nausea (23%), constipation (22%),
sedation (9%), dizziness (9%)) were common opioidrelated events.
Conclusion: In Belgium, Palladone® Slow Release was
effective and well-tolerated for the treatment of severe
cancer and non cancer pain in daily clinical practice.
710. OXYCONTIN (CONTROLLED RELEASE
OXYCODONE) TREATMENT EFFECTIVE AND
WELL-TOLERATED IN THE NETHERLANDS.
Ed Rouwet 1, Fergus Rooyer 2, Yvonne Van Megen 3
1
Medisch Spectrum Twente, anesthesiology, Enschede,
Netherlands
2Maasland ziekenhuis, Neurology, Sittard, Netherlands
3
Mundipharma, Medical, Hoevelaken, Netherlands
Aim: The aim of this observational study was to
evaluate patterns of use, safety, and efficacy of
OxyContin® in daily clinical practice.
Methods: This open prospective, non-randomised
observational study was designed in line with the SAMM
guidelines (Walter et al., Br. J. Pharmacol. 38(2):95,
1994).
Results: 2500 evaluable patients were included in this
study. Patients were treated for severe cancer (26%) and
non cancer pain (arthrosis, hernia, low back pain). The
majority of patients were pretreated with NSAIDs and/or
paracetamol (70%), less than 7% of the patients with a
strong opioid (WHO step 3). The mean pain VAS score
was 76 mm at their first visit. The average daily dose of
OxyContin® was 18 mg (mean) for a treatment of 59
days (mean). After 1 week of treatment the pain VAS
score was significantly reduced by 34 mm compared to
start of treatment. The efficacy was evaluated as
‘satisfactory’ to ‘very good’ for 79% (average) of the
patients during any time of evaluation. Patients treated
with the lowest dose of OxyContin® (2x5mg) also
experienced good pain relief. Overall, 29% of the
patients reported one or more side effects. The adverse
effects most frequently reported were common opioid
related events.
Conclusion: OxyContin® was effective and welltolerated for the treatment of severe pain in daily
clinical practice. The majority of patients evaluated the
OxyContin® therapy as ‘satisfactory’ to ‘very good’.
711. Nasalfent , a novel intranasal formulation of
fentanyl, is rapidly effective and well-tolerated
during treatment of breakthrough cancer pain
Geoffrey Davis 1, Andrew Knight 2, Robin Love 1,
Anthony Fisher 1
1 St. Josephs Hospital, PALIATIVE CARE UNIT, Thunder
Bay, On, Canada, Canada
2
Régional de Sudbury Regional Hospital, Ontario, Canada
3Nanaimo Regional General Hospital, British Columbia,
Canada
4
Archimedes Development Ltd., Nottingham, United
Kingdom
Aim: To determine the acceptability and tolerability of
fentanyl citrate nasal spray (FCNS [Nasalfent]) in the
treatment of breakthrough cancer pain (BTCP) in
opioid-tolerant patients.
Method: FCNS is a novel formulation of fentanyl, using
PecSys TM a proprietary system designed to deliver
lipophilic molecules to the nasal mucosa, administered
via a conventional nasal spray. A Phase II, open-label,
multi-centre inpatient study titrated 18 patients to
identify an effective dose of FCNS (25-800g fentanyl
citrate) for episodes of BTCP, despite adequate opioid
treatment of background pain. 15 patients were then
treated and assessed for up to four BTCP episodes.
Acceptability and tolerability were assessed through a
patient satisfaction questionnaire.
Results: 13 patients completed an overall satisfaction
score questionnaire. All strengths of FCNS (0.25, 1.0 and
4.0mg/ml) were well tolerated in the dose range (25800g). A total of 18 incidents of adverse events were
reported; these were transient and 84% were rated
“slight”. The majority of patients reported no local
symptoms after the application of FCNS; no significant
nasal findings or symptoms of irritation were seen at
any dose. 77% of patients rated FCNS as “good” or
“better”.
Conclusion: BTCP is a significant clinical problem,
complicated by common oral problems that restrict oral
drug application. Nasal delivery overcomes these
problems. This study provides clinical evidence for
FCNS as an acceptable and well-tolerated treatment for
BTCP in opioid-tolerant patients.
712. Rapid pain relief with fentanyl citrate nasal
spray (Nasalfent) in cancer patients with
breakthrough pain
Geoffrey Davis 1, Andrew Knight 2, Robin Love 3, Fisher
Fisher 4
1
St. Josephs Hospital, Thunder Bay, Canada
Régional de Sudbury Regional Hospital, Thunder Bay,
Canada
3
Nanaimo Regional General Hospital, British Columbia,
Canada
4Archimedes Development Ltd., Nottingham, United
Kingdom
2
Aim: To determine the utility of fentanyl citrate nasal
spray (FCNS [Nasalfent ]) in the treatment of
breakthrough cancer pain (BTCP).
Method: A Phase II, open-label, multicentre inpatient
study titrated 18 patients to identify an effective dose of
FCNS (25-800g fentanyl citrate) for episodes of BTCP,
occurring in patients on opioids for background pain.
15 patients were then treated and assessed for up to 4
BTCP episodes.
Results: Significant improvements in mean pain relief
(PR) and pain intensity difference (PID) scores were seen
from 5 min after dosing (both p<0.05). Mean PR score
and mean change in PID score for patients who
identified an effective dose reached a clinically
meaningful level approx 16 and 24 min after dosing,
respectively. PR was reported in 96% of BTCP episodes
and meaningful PR achieved in 73% of patients. Mean
duration of meaningful PR was 86 min.
Conclusion: BTCP is a significant clinical problem that
requires a drug with a fast onset and high patient
acceptability. This study provides the first clinical
evidence for FCNS (Nasalfent) as a consistent, rapidlyeffective treatment for BTCP. FCNS contains a
proprietary pectin drug-enabling system (PecSysTM)
designed for the fast delivery of lipophilic molecules to
the highly vascularised nasal mucosa to enhance drug
performance and acceptability.
713. Pregabalin in Patients with Central
neuropathic pain: A randomized, double-blind,
placebo-controlled trial of a flexible-dose
regimen.
Jan Vranken 1, Marinus Van der vegt 1, Marcel Dijkgraaf 2,
Ronald Kruis 1, Markus Hollman 1, Michael Heesen 3
1
Academic Medical Center, University of Amsterdam,
Anaesthesiology, Amsterdam, Netherlands
2Academic Medical Center, University of Amsterdam,
Clinical Epidemiology & Biostatistics & Bio-informatics,
Amsterdam, Netherlands
3
Bamberg hospital, Anaesthesiology, Bamberg, Germany
Introduction: The effective treatment of patients
suffering from central neuropathic pain remains a
clinical challenge, despite a standard pharmacological
approach.In this 4-week,randomized,doubleblind,placebo-controlled trial, the effects of pregabaline
on pain relief,health status and quality of life in these
patients were evaluated. Methods:Forty patients
received escalating doses of either pregabalin (daily 150,
300 or 600 mg) or matching placebo capsules.The
primary efficacy parameter was a pain intensity
score using a VAS.Health status (EQ-5D) and quality of
life (Pain Disability Index, SF36) questionnaires were
completed before and after 4 weeks. Results.There was
a statistically significant decrease in pain score at
endpoint for pregabaline treatment,compared with
placebo.Follow-up observation showed no significant
difference in PDI scores.The pregabalin group showed a
statistically significant improvement for the EQ-5D
utility and VAS score.Pregabalin treatment led to a
significant improvement only in the bodily pain
domain of the SF36.Discussion. Pregabalin produced
clinically significant reductions in pain and
improvements in health status in central neuropathic
pain patients.The results from the secondary outcome
parameters are not surprising because these patients
experience impairments in both physical and
psychological functioning.These issues may have a
profoundly adverse impact on patients‘QOL despite
improved pain control.
714. Cannabis use in palliative medicine : clinical
aspects
Rudolf Likar, Ernst Rupacher, Mario Molnar, Daniela
Jakob-Fuchs
Anaesthesiology, Klagenfurt and Vienna, Austria
There are Type 1 cannabinoid – receptors in the central
nervous system, in the peripheral nervous system and in
the reproductive organs. Type 2 Cannabinoid –
receptors are found in the immune system, in the
microglia and in the brainstem.
The endocannabinoid – system in the CNS is
responsible for pain processing, thought- and motor
processes, learning processes, appetite, mobility,
resolution of fear, sleep induction and
immunomodulation.
Dronabinol is used in palliative medicine to treat nausea
and vomiting and as an appetite inducer. We dosed
dronabinol as follows: We started with dronabinol
2.5mg twice daily. If the improvement in symptoms was
not sufficient by the third day, the dose was increased to
5mg twice daily. If by the sixth day there was still
insufficient relief of symptoms, the dose was increased
to 10mg twice daily. The side-effects of nausea, vomiting
and anorexia were documented and quantified on a 5
level scale. Summary
We were able to document a significant improvement in
the symptoms of anorexia, nausea and vomiting
through the use of dronabinol.
715. A retrospective review of opioid prescribing
in a specialist palliative care unit
Campbell Murdoch 1, Jason Ward 2
1
Mid Yorkshire NHS Trust, Department of Palliative
Medicine, Dewsbury, United Kingdom
2
Mid Yorkshire NHS Trust, Department of Palliative
Medicine, Dewsbury, United Kingdom
Introduction
Opioid prescribing and switching between different
opoids is common in patients with cancer.
Aims
1 Incidence of opioid prescribing on admission
2 Incidence of, and reasons for opioid switching
3 Adherence to regional evidence-based guidelines
Method
Data was extracted from clinical notes and prescription
charts of 50 consecutive admissions to a 10-bedded
specialist palliative care unit.
Results
Median age 69.5 years (35-86 years), 19 men and 31
women, 46 had cancer (most commonly lung and
gastrointestinal cancers).
31 patients on strong opioids for pain on admission; oral
175
Poster abstracts
measurement carried out by the health care
organisations in the North-eastern Brabant Region. The
Regional Pain Centre had the ambition for a more
prominent role across the health organisational borders
in controlling pain. The Palliative Consulting Team also
received a lot of queries in relation to pain control. This
is the reason why both Palliative Networks in the region
started a project about this matter.ApproachA
multidisciplinary project group. The project goals are: At
a patient level: uniformity, continuity of the treatment
of pain and a VAS/NRS <4.At a health professional level:
uniformity, recognition of each others expertise,
expectations and availability. ResultsA regional
cooperative agreement about Palliative Pain Control is
realised. The project group made use of existing national
and regional guidelines: National Guideline Pain 2006.
National multidimensional Pain Assessment Tool, NRS
/VASREPOS – Rotterdam Elderly Pain Observation
ScalePOKIS – Pain Observational Scale for Young
ChildrenTo ensure quality assurance amongst the
diverse organisations, it is important that an
organisational team in relation to pain control is
realised. In the North-eastern Brabant Region,
committees and project groups are already organised,
consisting of health professionals from hospitals and
from home care.ConclusionExcellent communication
and recognition of each others expertise, increases
cooperation and quality of care for the patient.
Regional cooperation in palliative pain control
has our attention!
Poster abstracts
morphine 17, transdermal fentanyl 5, subcutaneous
diamorphine 3, oral oxycodone 2, subcutaneous
oxycodone 2, subcutaneous morphine 2.
18 patients on opioids (58%) underwent 22 switches.
Reasons (may be multiple) were; change of route 13, lack
of effectiveness 9, side-effects 7, other 1. Details will be
discussed in detail. 19 of 22 switches adhered to the
guidelines.
Conclusion
The incidence of opioid prescribing and switching is
consistent with other studies.
716. Pain in cancer. An Outcome Research Project
to evaluate the epidemiology, the quality and the
effects of pain treatment in cancer patients.
Giovanni Apolone 1, Oscar Bertetto 2, Augusto Caraceni 3,
Oscar Corli 4, Franco De Conno 3, Roberto Labianca 5,
Marco Maltoni 6, Mariaflavia Nicora 1, Valter Torri 1,
Furio Zucco 1
1
Istituto Mario Negri, Department of Oncology, Milan, Italy
molinette, Department of Oncology, Turin, Italy
3 National Cancer Research Institute, Palliative care unit,
Milan, Italy
4 Hospital V. Buzzi, Palliative care unit, Milan, Italy
5
Ospedali Riuniti BG, Medical Oncology, Bergamo, Italy
6
ASL Forl , Hospice Forlimpopoli, Forl , Italy
2
In the context of a wide multidisciplinary project
coordinated by the Mario Negri Institute (J Ambulatory
Care Manage 29:332-41,2006), a nationwide outcome
research study was launched in Italy. The multicenter
prospective study has the objective to investigate the
epidemiology of cancer pain, the quality of analgesicdrug therapies and the effectiveness of alternative
analgesic strategies in cancer patients using the state-ofthe art of patient-reported-outcomes. About 100 Italian
centers are actively recruiting eligible patients. Subject
evaluation and follow-up will be for 3 months. After 9
months of recruitment, about 1450 patients were
included by 100 centers. At inclusion, most patients
(54%) had bone metastasis, were treated at ambulatory
level (27%), had a level of pain classified as moderatesevere (67%), and were on treatment with a strong
opioid (55%). When we computed the Index of Pain
Management, by subtracting the pain level (intensity of
pain) from the analgesic level (the WHO analgesic scale)
to provide a rough estimate of how pain is treated in this
sample, 24% of patients had negative values suggesting a
possible analgesic under-treatment. In the sub-sample
with data at one month of follow-up, all outcomes did
improve, with variations according to case mix, type of
treatments and type of recruiting centers.
717. Administration of Somatostatin in Ascites
Rudolf Likar, Simone Hombach-Smole, Mario Molnar
Poster abstracts
Anaesthesiology, Klagenfurt and Vienna, Austria
Octreotid is a synthetic analogue of somatostatin with
various characteristics and modes of action. It inhibits the
secretion of peptide hormones and growth hormone.
We used Sandostatin® for the following indications:
Ascites, ileus, intestinal obstruction and diarrhea in a
dose of 200ug three times a day subcutaneously. In
addition, anorexia, nausea, vomiting and diarrhea were
quantified on a 5 level scale. Ascites reduction was
documented by measuring abdominal circumference.
The patients treated with Sandostatin® were assessed.
Case example: 81 year old female patient
The patient was referred to the palliative medicine ward
in an advanced stage of disease. The patient had an
adenocarcinoma of the ovary with carcinosis peritonei
and ascites. She essentially complained of general
weakness, lack of appetite, nausea and increasing
discomfort from her ascites. In addition she complained
of increasing dyspnea due to an accompanying
pneumonia, which was under control with antibiotic
treatment.
Two and a half liters of ascites were drained
whereupon her dyspnea resolved. During her stay on
the ward the ascites again increased. Treatment with
subcutaneously injected octreotid was carried out in a
dose of 200ug three times daily. At the beginning of
treatment the circumference was 102 cm. By the 6th day
of treatment the circumference had fallen to 98-99 cm.
The patient could then be transferred without the
initial dyspnea due to ascites to a chronic care facility.
No side-effects with octreotid were noted.
718. PALLIATIVE CARE AND STRONG OPPIATES Trento’s experienceLuca Ottolini, Luciana Fontana, Giampaolo Rama,
Helmut Menestrina, Carlo Abati
Even in 2005, Italy ranked second-last with regards to the
use of strong opiates (O) (Morphine-M,Fentanyl
176
Transdermal-FTD),with 3 DDD/1000,with a preferential
use of FTD, followed by M.In the health district of
Trento(160,000 inhabitants),in which,since
2000,Palliative Care Services (PCS)exist, the use has been
4,16 DDD,similar to that of France and Sweden.Even
though this information is comforting to know, it does
not sufficiently indicate a correct use of the drugs that are
part of the O category.We created an Access database, in
which all the information regarding the ”prescriptive
history of O” for each patient (P)that received care from
the PCS since 2005 is included.262 P were cared for in
this year,193 up to the moment of death,188 received O
for diverse symptoms but only 105 for pain.In the present
study we will limit ourselves to examining these last P.
Discussion:1) At the moment in which the study began
47(44%) received an O for pain:76% FTD.2) At the same
time, treatment with O was begun or modified in 26%
(28 P):50% rotated towards or begun to take M;39%
FTD;11% oxycodone 3)While care was being
provided,41(70%) of P that had not previously received
treatment, needed treatment with O: 56% with M,43%
with FTD,1% with oxycodone 4)At the moment of death
all 105 P were receiving O:58% M, alone or with FTD,35%
only FTD,6% oxycodone, methadone for 1 P.Conclusion:
the presence of PCS has influenced the territory, not only
with regards to an increase of the use of O, but also its use
has become more coherent to international guidelines.
719. Pain Education Programs in cancer pain: an
evidence-based intervention.
Wendy Oldenmenger 1, Silvia Van Dooren 1, 2, Carin Van
der Rijt 1
1 Erasmus MC - Daniel den Hoed, Medical Oncology,
2
Erasmus MC, Faculty of Psychology and Psychotherapy,
Pain remains one of the most important symptoms in
cancer, although effective treatment strategies should be
available for most patients. Patients’ insufficient
knowledge of pain and unrealistic concerns about
analgesics have been reported to cause nonadherence
and inadequate pain control. To overcome patients’
knowledge deficits, Pain Education Programs (PEP) have
been developed. A literature search was conducted to
explore the effect of PEP on pain.
Method
PubMed was searched for the period 1985-June 2006 for
randomized clinical trials (RCTs) on PEP. Only studies in
which the type of pain was defined were included.
Results
Seven RCTs on PEP were found which had defined pain.
The sample size varied between 30-313. All interventions
consisted of an education session (E). In 5 studies one or
more follow-up contacts were added (E+FU). In 3 studies
(2 E, 1 E+FU) the effect was tested ≤ 4 wks: a sign.
decrease in pain was found (average pain in 2, worst
pain in 1). In 4 studies (E+FU) the effect was tested > 4
wks: a sign. decrease in pain was found in the two largest
studies (worst(1) and average pain(2)). In 2 other studies
no effect was measured for worst pain.
Conclusions
We conclude that high quality studies on PEP are scarce.
PEP differs between the studies, especially with respect
to follow-up contacts. Studies on PEP with study
duration > 4 wks and a clear definition of the type of
measured pain are needed to provide data on the
effectiveness on pain control.
720. Study of the procedural pain in a cancer
population in university hospital
Marilene FILBET 1, Henri NAHAPETIAN 2, Mario
BARMAKI 1, Aurelie LAURENT 1, Isabelle BRABANT 1,
Marlene NABITZ 2, Wadih RHONDALI 1
1
CENTRE HOSPITALIER LYON SUD, Centre for Palliative
Medicine, LYON, France
2
HCL hôpitaux nord CHU de lyon, SUPPORT TEAM, LYON,
France
Introduction
The news guidelines for the procedural pain are
published in France in 2005.
Goal
The goal of the study was to assess the frequency of the
procedural pain in the cancer in-patient in two units in
university hospital
Methodology:
A questionnaire was given to each patient with the
cancer diagnosis in two unit of the University
hospital: the unit of gastroenterology specialty and the
unit of chest disease speciality. The questionnaire ask
about
-The pain until the admission
-The maximal pain during the stay
-The acts which is causing the pain i.e. venous puncture,
X ray,
The support team and the comity against the pain of
this hospital approved this questionnaire
Results:
100 patients where included in the study in each unit
(200 patients) the results are similar in the Two units
with
89% of the patient felt pain during the hospitalization
3% weak pain
63% middle pain
35% severe pain
The procedural pain are mostly linked with
-40% venous ponction
-27% mobilization
-36% X-Ray, endoscopies procedures
The only difference between the two-unit sis the high
frequency of pain during the dressing (32%) in the
gastroenterogy ward
Conclusion: this study shows that the procedural pain is
very common. This kind of pain can very easily be
prevented and treated. This study shows the needs for a
specific training implementation of the validated
guidelines.
721. Telemedicine in outpatient cancer pain
Christine Schiessl 1, Ulrich Grossmann 2, Susanne
Guenther 1, Stefan Lindner 3, Juergen Schuettler 1
1
University of Erlangen, Department of Anaesthesiology,
Erlangen, Greece
2
University of Karlsruhe, Institute for Information Processing
Technology, Karlsruhe, Germany
3Visionet GmbH, Erlangen, Germany
It is possible to provide high quality palliative care for
patients at home, even if parenteral application systems
have to be used to provide sufficient pain relief. To
overcome the distance between care-provider and
patient for the gathering of therapy-relevant
informations and controlling of therapeutic measures,
new technologies of data collection and transfer
(Bluetooth™, Internet) can be applied. Data supplied by
the PCA-pump are sent via Bluetooth™ to a
Smartphone, which transfers the data to a central
database. The bidirectional connectivity of the system
make it possible for authorised persons to receive the
data immediately and to adapt the patient’s therapy
adequately. These new possibilities should be
investigated for the home care of palliative care patients
with electronic pca-pumps and new solutions are to be
implemented. Currently we are conducting a pilot-study
with volunteers to test the system for reliability, safety
and feasibility under every-day-conditions.
Results will be presented.
722. Cognitive function of patients in cancer pain
treatment: a comparative study*
Geana Kurita, Cibele Pimenta
University of Sao Paulo, School of Nursing, Sao Paulo, Brazil
The possible negative effects on daily routine caused by
cognitive impairment encouraged the elaboration of
this study which objective was to compare cognitive
function of patients with cancer pain receiving
treatment with opioids (n=14) with that of patients
receiving treatment without opioids (n=12). Relations
between cognitive function, pain intensity and opioids
dose were also analyzed. The convenience sample was
composed by outpatients attended at oncologic and
pain clinics in Sao Paulo, Brazil. They were assessed
three times during a month, using Trail Making Test,
Mini-mental State Examination, Digit Span and Brief
Cognitive Screening Battery. The comparison between
groups showed better performance in attention/working
memory (p=.029) and executive functions (p=.023) in
patients receiving treatment without opioids. There
were correlations between less intense pain and higher
scores in Mini-mental (p=.001) and some tests of Brief
Cognitive Screening Battery (incidental recall,
immediate recall and late recall; p≤.042) in the group
receiving opioids. There were no correlations between
opioid dose and cognitive performance. The patients
who did not receive opioids had better performance in
some tests and correlations indicated that less pain
intensity was important to better cognitive performance.
Additional studies are desirable to further explore this
issue.
*Study supported by The State of São Paulo Research
Foundation.
723. Toward a More Complete Indicator of Opioid
Consumption Trends
Karen Ryan, David Joranson, Aaron Gilson
University of Wisconsin Comprehensive Cancer Center, Pain
& Policy Studies Group, Madison, United States
Background: Pain management is a critical component
of palliative care, especially in low and middle income
countries where most citizens are diagnosed with cancer
at the late stage. International bodies are calling for
improved pain management and access to opioid
analgesics.
Project aim: The WHO considers a country’s annual
Poster abstracts
724. Neuropathic pain:What are we doing?
Declan Cawley, Wendy Makin, Delphine Corgie
Christie Hospital, Department of Palliative and Supportive
Services, Manchester, United Kingdom
Background: Cancer patients with pain frequently
have underlying neuropathic mechanisms.New
classification of pain suggests two broad categories:that
of tissue injury or nervous system injury, both of which
encompass a number of universal
mechanisms.Therefore the way in which we
assess,classify and subsequently manage ‘pain’
irrespective of its etiology should have a universal
approach. Aim: To assess documentary evidence of pain
assessment,taxonomy and prescribing habits. Method:
Retrospective case note review of identified inpatients in
a tertiary cancer referral centre. Results: Documented
assessment of pain(64%)mentioned
site(100%),type(71%),duration(64%),frequency(36%)an
d sensory changes(29%) with only 32% of cases
supporting a diagnosis of neuropathic pain. Potential
causes were disease related(59%), treatment
related(12%) and non-malignant(18%).Medications
included oxycodone(7/29), morphine (5/29) and
fentanyl(4/29) with gabapentin(15/29) and tricyclic
antidepressants(10/29) as neuropathic agents;35% of
patients had 2 or more of these agents
prescribed.Patients with palliative care input(41%)had
better evidence of pain assessment(92%),reference to
the opioid responsiveness of their pain(75%)and had
more medication changes(27vs14). Conclusions:
Findings shaped the development of a guideline on
managing pain associated with nerve damage, adopting
a step-wise approach to assessment, taxonomy and
therapeutics.An aide memoir/pocket guide summaries
the salient points to help both in education and
prescribing.
725. Pain Management in the Elderly Patient - a
Concept
Roland Kunz 1, Markus Felder 2, Stephan Krähenbühl 3,
Markus Lampert 4, Friedrich Stiefel 5
1
Bezirksspital Affoltern a A, Geriatrie, Affoltern, Switzerland
Rheumatologie, Zurich, Switzerland
University Hospital, Clinical Pharmacology and Toxicology,
Basel, Switzerland
4
University Hospital, Clinical Pharmacology and Toxicology,
Lausanne, Switzerland
5
CHUV, Service Psychiatrie de Liaison, Lausanne,
Switzerland
2Praxis,
3
The mean life expectancy in Switzerland in 1900 was
some 50 years. In 2005 it was 83.9 years for women and
78.7 years for men. With increasing age the frequency of
chronic diseases often associated with pain is escalating.
An investigation “Pain in Europe” showed that older
people are more often in pain and suffer a considerable
reduction of quality of life.
Diagnosis and therapy have special requirements and
aspects that are most important for the treatment of
elderly patients but are insufficiently taken into
consideration. Very often findings that were made in
studies involving younger patients are transferred
uncritically into the treatment of elderly patients.
Neuropsychological changes, multimorbidity,
polypharmacy with the risk of interactions, changes in
pharmacodynamics and pharmacokinetics as a result of
kidney and liver malfunction, as well as the patient’s
fateful acceptance of his pain etc. are not taken into
account at all or to a limited extent only.
This alarming situation was the reason for the
formation of a group of Swiss experts “Pain in the
Elderly”. Its aim was to tackle this topic largely neglected
by medical care and research, to compile the actual state
of knowledge, to point out the specific problems and to
develop a concept of pain management in elderly
patients. The concept is the basis of modules for the
instruction and training of care givers for elderly pain
patients.
726. The European Pain in Cancer Survey (EPIC)
Sarah Phillips 1, Rob Cohen 2, Lara Dow 3
1
Research International, London, United Kingdom
Mundipharma International Limited, Cambridge, United
Kingdom
3Mundipharma International Limited, Cambridge, United
Kingdom
2
Aim: Assess current patient perceptions of pain in
cancer, the impact of cancer pain on quality of life and
identify the gaps in the provision of effective pain
management of cancer patients across Europe.
Methods:Between 100 and 400 cancer patients (except
skin cancer) suffering all stages of disease will be
recruited in each of 12 European countries. The
recruitment process will vary from country to country,
but will be conducted by advertising and enrolment
from cancer centres, primary care physician surgeries,
and patient advocacy groups. Patients will participate in
an initial screening process to ensure that they meet the
selection criteria for the study. These include
patients:who have suffered pain due to their cancer in
the last month; who experience a particular level of
pain; >18 years. Following screening, approximately 50
patients per country will participate in a computerassisted telephone interview survey. Survey
questionnaire feedback will be reviewed by third-party
organisations. A pilot study was conducted in the UK
and Ireland during November and December 2006. In
total, 500 patients were screened (400 from the UK and
100 from Ireland) and 50 in-depth questionnaires
completed. Fieldwork for the study will be conducted in
January and February 2007 upon completion of the
pilot. Results:Presentation of findings is expected in
June 2007. The EPIC survey is sponsored by
Mundipharma International Limited, Cambridge, UK.
727. Impact of a new Palliative Care Consultant
Team on opioid consumption at the Oncology
Department in a University Hospital
Antonio Noguera, María Angustias Portela, Julia Urdiroz,
Ana Carvajal, Antonio Idoate, Jesús García-Foncillas,
Carlos Centeno
Clínica Universitaria de Navarra, Unidad de Cuidados
Paliativos, PAMPLONA, Spain
In 2004 the Palliative Care Unit (PCU) of the University
Clinic of Navarre was established. This is a consultant
team, which supports the activity of 21 specialists of the
Oncology Department.
A retrospective observational study was done to
evaluate the impact of PCU on opioid consumption at
the Oncology Inpatient Unit. Consumption was
measured from data reported by the Pharmacy
Department between 2001-2006, and quantified as
number of defined daily doses (DDD) per thousand
hospital stays per year.
At the establishment of the PCU, opioid
consumption was 622 DDD. After two years it increased
to 817 DDD. The variation in consumption of different
opioids (DDD) in this two year period was: parenteral
Morphine went from 111 to 217(95%), oral Morphine
went from 50 to 76(52%), parenteral Methadone went
from 6 to 1(-90%), oral Methadone went from 8 to
45(446%), transdermal Fentanyl went from 427 to 299(30%), transmucosal Fentanyl went from 20 to
149(636%). Oxycodone was introduced in 2005; the
2006 consumption was 32 DDD. Cochrane-Orcutt
function estimation with a significant Rho statistic was
found since 2004, showing an external effect in the
predictive model that in our case was the establishment
of a PCU.
Since the PCU was set up, there has been a significant
increase in opioid consumption, coupled to an
optimization of their use. Therefore, there is increased
use of opioids that produce fast analgesic adjustment,
which is appropriate for a tertiary care hospital such as
ours.
728. Cancer Tales Workbook
Patricia Macnair 1, Rob Cohen 2, Lara Dow 2
1
Royal Surrey County Hospital Trust, Guildford, United
Kingdom
2Mundipharma International Limited, Cambridge, United
Kingdom
Aim: Improve communication with cancer patients and
ameliorate their overall experience of the disease by
providing healthcare professionals (HCPs) with a novel
educational tool.
Method: Cancer Tales is an emotive play developed
from a collection of cancer patients’ personal stories.
The Cancer Tales workbook uses themes from the play to
highlight key areas for improvement in communication
around cancer, its diagnosis and treatment. The
workbook provides guidance and practical exercises to
help primary care and specialist nurses, general
practitioners and secondary care physicians improve
their communication with patients. The original text of
Cancer Tales was reproduced with added educational
chapters and a foreword by the play’s author, Nell
Dunn. The workbook was reviewed by a European
editorial board of palliative care, pain management,
oncology, nursing and communications specialists.
Result: Over 10,000 copies of the workbook will be
translated and distributed to HCPs in Europe by June
2007. Copies will be available via email request.
Conclusion: The workbook will provide HCPs in
Europe with a resource to further develop their
understanding of the emotional and psychological
impact of cancer for patients, and to improve
communication with patients, carers and families.
The preparation of the Cancer Tales Workbook was
sponsored by an educational grant from Mundipharma
International Limited, Cambridge, UK, under the
auspices of the European Oncology Nursing Society and
the European Association for Palliative Care.
729. MERITO Study: Starting therapy with
immediate release oral morphine (IRM) in
patients with cancer pain. Evidence for a fixed
dose posology.
Franco De Conno 1, Carla Ripamonti 1, Elena Fagnoni 1,
Cinzia Brunelli 1, Tiziana Campa 1, Group Merito 1, Oscar
Bertetto 2
1
National Cancer Center, Palliative care and Rehabiliation
Medicine, Milan, Italy
2
molinette, Cancer department, Torino, Italy
Background Starting therapy with IRM in patients
with cancer pain is well established and supported by a
number of guidelines. Aim of the present study is to
suggest a fixed dosing posology for IRM. Methods
According to EAPC recommendation patients with
cancer pain, opioid naive, were administered with IRM 5
mg/4 h (pts previously on Step I WHO Ladder-Group A)
or 10 mg/4 h (pts previously on Step II WHO LadderGroup B) as starting therapy. Pain intensity was
evaluated 5/day throughout a self compiled diary and
the main outcome measurement was the percentage of
time with pain control in the 5 days of treatment.
Results The mean percentage of time with pain control
during the 5 days of treatment was 74% (CI: 0.69-0.78)
in 151 out of 159 patients for which data is available.
IRM was administered at 5 mg/4 h in 29% (Group
A) and 10 mg/4 h in 71% (Group B) of patients,
respectively. Rescue doses of IRM were administered
according to the EAPC Guidelines. Average daily dose
(regular dose + rescue doses) of IRM taken by Group A
patients was 30 mg/die for 5 days, while for Group B the
average daily dose was 60 mg/die for the first 2 days, 70
mg/die for the following 2 days, and 80 mg/die in the
5th day. Conclusion MERITO data suggests the
evidence IRM as starting therapy in patients with cancer
pain could be administered by following a fixed dose
posology. Further investigations are needed.
730. P.A.I.N. Workshop - International
Interdisciplinary Consensus on Evidence-Based
Clinical Pathways for the Management of Cancer
Pain
Bart Van den Eynden 1, Gabriel Yihune 2, Dirk Schrijvers
3
1
University of Antwerp, Chair and Centre of Palliative Care,
Antwerpen (B), Belgium
2
Grünenthal GmbH, Chair and Centre of Palliative Care,
Aachen, Germany
3ziekenhuisnetwerk Antwerpen-Middelheim, oncology,
Antwerpen (B), Belgium
Aim
Pain is the most prevalent symptom related to
cancer.The objective of the P.A.I.N. workshop was to
produce a clinical pathway that a general practitioner
could use to devise a care plan for a patient with cancer
pain during a 10-minute consultation.
Method
Twenty-three experts in pain, palliative care, oncology
and general practice from 12 European countries met for
a two-day workshop in Brussels, Belgium. During
3 workgroup sessions, clinical pathways regarding pain
assessment, treatment elements and treatment
implementation were developed for patients with
cancer-related, cancer-associated and therapy-related
pain. Content was evidence-based whenever possible; if
evidence was lacking, clinical experience was used to
derive “educated guesses”. Consensus was achieved via
the Delphi method. After feedback from participants,
results were finalised by an editorial team.
Results
The clinical pathway created by combining the results
from all 3 sessions conducts general practitioners
through a consultation, with guidance on the questions
to ask, assessments to make, conclusions to draw and
177
Poster abstracts
consumption of morphine to be an indicator of the
extent that opioids are used to treat moderate to severe
cancer pain. Globally, pain is inadequately treated as
reflected in the great disparity in morphine
consumption between countries. However, recognizing
that other newer opioid analgesic medications and
formulations have emerged in global markets, the WHO
Collaborating Center for Policy and Communications in
Cancer Care is developing an indicator, called morphine
equivalence (ME), that includes the principal opioid
analgesics used to treat severe pain.
Results: Trends in global opioid consumption calculated
in ME are greater than morphine alone, especially since
the mid-1990s, but the disparity between higher income
countries and lower income countries continues. In
some countries morphine consumption alone may have
been a valid indicator of access to medicines that can
relieve severe pain until other opioids were introduced.
What other events might have influenced the changes
in the consumption of strong opioids? What are the
strong opioids that account for most of the global and
regional increase in consumption?
Poster abstracts
conditions that necessitate referral.
Conclusion
Developing an international interdisciplinary clinical
pathway for managing cancer pain at a two-day
workshop is feasible. The pathway will now be evaluated
and implemented. The results will be published both in
appropriate professional journals and on-line at.
731. Views of Practising Moroccan Elderly
Muslims in Antwerp (Belgium) on Pain
Treatment
Studies demonstrate the influence of culture and
religion in experiencing and dealing with pain. But very
few address the issue in terms of end-of-life care. We
conducted a study on the influence of religion on
attitudes of Antwerp Muslims on pain medication with –
alleged – life shortening effect. We interviewed
(Grounded Theory Methodology, n=30) male Moroccan
elderly (<60) Muslims living in Antwerp, local imams,
Moroccan GP’s practising in Antwerp and a Moroccan
nurse working in a palliative care ward of an Antwerp
hospital. Pain treatment generally does not pose any
form of ethical dilemma: it is ultimately Allah and Allah
only who will determine whether the life of a patient is
shortened or not when taking heavy pain medication.
In this view, pain medication is permitted, even
necessary, as it helps the patient to stay focused on his
religion and his trust in God. Only one respondent
asserted that pain medication is not acceptable to
Muslims in those (rare) cases where it has a possible life
sustaining effect. If alternative forms of pain medication
are absent, Muslims should still be patient and put their
fate and faith in God, without taking any pain
medication. The occurrence of both these views suggests
the danger of generalising common held views and
stresses the importance of in-depth talks with Muslim
patients on how they experience pain.
732. Comparison of controlled release tramadol
and dihydrocodeine - a prospective, randomized,
cross - over study
Wojciech Leppert
Poster abstracts
Palliative Care Unit, Chair and Department of Palliative
AIM OF STUDY: Assessment analgesia, side effects,
quality of life in patients with cancer pain treated
controlled release dihydrocodeine (DHC Continus® 60,
90, 120 mg) and tramadol (Tramundin® 100 mg, Tramal
Retard® 100, 150, 200 mg). PATIENTS AND METHODS:
30 opioid – naive patients with moderate to severe
nociceptive cancer pain – prospective, randomised, cross
– over, 7 days, without wash – out. 23 moderate (NRS 4 –
6), 7 patients severe (NRS > 6) pain assessed by Brief Pain
Inventory, side effects verbal scale, ESAS, quality of life
EORTC QLQ C 30. Doses: DHC Continus® 2 x 60, 2 x 90,
2 x 120, 2 x 180, 3 x 120 mg, tramadol: 2 x 100, 2 x 150,
2 x 200, 2 x 300, 3 x 200 mg. RESULTS: Dihydrocodeine:
daily doses 120 – 360 mg, good analgesia (NRS < 4) 24
(80%), partial (NRS 4 – 5) 3 (10%), ineffective (NRS > 5)
3 (10%) patients, side effects: constipation 12 (40%),
drowsiness 5 (17%). Tramadol: daily doses 100 – 600
mg, good analgesia 21 (70%), partial 3 (10%), ineffective
6 (20%) patients, side effects: nausea 5 (17%),
constipation 3 (10%), sweating 3 (10%). No respiratory
depression appeared. Quality of life similar in both
groups. CONCLUSIONS: 1. Controlled release
dihydrocodeine and tramadol are effective and well
tolerated in moderate cancer pain. 2. The second step of
the WHO analgesic ladder is important for patients with
moderate cancer pain
733. TOPICAL ADMINISTRATED PREPARATIONS
CONTAINING OPIOIDS - MORPHINE SULPHATE
CLINICAL EFFICACY
Aleksandra Cialkowska-Rysz 1, Sylwia KazmierczakLukaszewicz 1, Bozena Misiewicz 2, Grazyna Samczewska
3
1
Palliative Care Unit Madical University of Lodz, Oncology
Department, Lodz, Poland
2
M.Copernic Hospital, Oncology Department, Lodz, Poland
3
Applied Pharmacy Department Medical University of Lodz,
Pharmacy Department, Lodz, Poland
Background: Opioids (morphine sulphate) may
successfully modulate the experience of pain by binding
to the opioid receptors on sensory nerve terminals
located at the inflamed peripheral tissues. Inflammation
probable alters the tissues epithelial barrier and
improves the topical opioid absorption. Opioids
receptors in non-inflamed tissues are naturally inactive.
Mechanism of immune cells activation is also involved
in such mechanism of pain inhibition. Our Palliative
178
Unit has carried out the researches of topical opioids
containing morphine sulphate in cancer pain.Aims: In
this randomised double blind placebo-controlled trial
we try to estimated efficacy of local analgesic effect of
morphine sulphate hydrogels and ointments compared
with placebo hydrogels and ointments. We have such
parameters as: time of duration , tolerance and presence
of side effects under our deep observation.Materials
and methods: The preparations containing morphine
sulphate hydrogels and ointments – 0,2% or placebo
were produced at the Applied Pharmacy Department
Medical University of Lodz. Observation – 7 days –
ointments or hydrogels (morphine) v ointments or
hydrogels (placebo). The study comprised patients
(study is still in the process) with painful skin
ulcerations and neoplasmatic infiltrations with intact of
skin surface. Frequency of application: 1-3
times/day.Results: So far all patients accepted therapy.
Conclusions:The data of this trial is still being
analysed.
enrolled. 65% had Burkitt’s lymphoma, 8.8 %
rhabdomyosarcoma, 6.9 % nephroblastoma. 25% had
lost one parent and 5% both. 42% required financial
help to meet basic needs. Pain 83.3% complained of at
least one pain, and 24 % of 3 or more. 47% were of
severe intensity. 35% were receiving no analgesia. Mean
number of symptoms was 4.7 (range 0-14). Commonest
symptoms: Cough (35.3%), Anorexia (29.4%), Weight
loss (28.4%), Fatigue (24.5%), Fever (22.5%), Nausea
(19.6%) and Vomiting (17.6%). Discussion: Majority of
children had pain and multiple symptoms. One third
were receiving no analgesia. Undertreatment may be
due to multiple factors: inability to assess pain, myths
about analgesia in children, lack of resources/
medications. The review confirms that children with
cancer in Uganda are often poverty-stricken, experience
multiple symptoms and significant pain which is
undertreated even in institutions accustomed to these
conditions, highlighting need for palliative care and
training in meeting the needs of children.
734. Polish experience with methadone in cancer
pain treatment
737. Our experience from Jan.1.2004 to jan.1.2006
Wojciech Leppert
Adnan Delibegovic
Palliaitve Care Unit, Chair and Department of Palliative
Clinical centre Tuzla, Palliative care-hospice Tuzla, Tuzla,
Bosnia and Herzegovina
Background: To assess analgesia, side effects of
methadone, calculation equianalgesic doses of oral
morphine to methadone. Patients and methods: 21
opioid – tolerant patients with cancer bone and
neuropathic pain received methadone: inadequate
analgesia (VAS > 5) on morphine (10), transdermal
fentanyl (TF) (4), morphine with ketamine and TF (3),
tramadol (1), pethidine (1), pain with drowsiness on
morphine with ketamine (1), pain with nausea on
morphine (1). Daily dose oral morphine (ddom) to daily
dose oral methadone (ddomet): 4 : 1 (ddom to 100 mg),
6 : 1 (100 – 300 mg), 12 : 1 (300 – 1000 mg), 20 : 1
(ddom over 1000 mg). Previous opioid stopped in 19, 2
patients on methadone and other opioids. Mean ddom
before switch 812 ± 486 mg. Methadone 3 times a day,
20 patients oral methadone, 1 rectally. Results:
Treatment time 38.3 ± 27.1 (range 3 – 95) days, daily
dose range 9 – 400 mg, mean daily doses 48.1 ± 19.7
beginning, maximal 148.5 ± 104.1, end 131.1 ± 104.3
mg. Good analgesia (NRS < 4) 11 patients, partial (NRS 4
– 5) 8, unsatisfactory 2 (NRS > 5). Side effects drowsiness
(6 patients), constipation (4), nausea and vomiting (2),
one respiratory depression (methadone alprazolam
interaction) disappeared after naloxone and methadone
cessation. Conclusions: Results confirmed analgesic
efficacy, safe and effective dose calculation, one
serious adverse event observed
Definition of palliative care:
Palliative care is incurable fatal nature of the illness, the
predictably short prognosis and that the focus of
palliative care is quality of life is true rehabilitation.
Palliative care:
Affirms life and regards dying as a normal process
Provides relief from pain and other symptoms
Integrates the psychological and spiritual aspects of
patient care
Offers a support system to help patients live as active as
possible until death
Rehabilitatin aims to:
Help patients to gain opportonity,control,indepedence
and dignity
Respond quickly to help people to adopt to their illness
Take realistic approach to defined goals
Take the pace from the individual
735. Hip Stretching on Patients with Malignant
Psoas Syndrome
Csaba Simkó, Annamária Breznai
AIM OF WORK -TO SHOW NUMBERS OF TREATED IN OUR DEPARTMENT FROM
O1.O1.2004 TO O1.O1.2006
NUMBERS OF DEATHS AND RECOVERED
ACCORDING TO SEX
ACCORDING TO AGE
LOCATION OF PRIMARY TUMOR
TOTAL NUMBER O TREATED PATIENTS 488
NUMBER OF DEATHS AND RECOVERED IN THE
PERIOD FROM O1.O1.2004 TO O1.O1.2006
CONCLUSION
FROM TOTAL NUMBER OF TREATED PATIENTS 54%
WERE DEATHS AND 46% WERE RECOVRED.MOSTLY
WERE MAN,AGE 60-70 YEARS,WITH MOST FREQUENT
LOCATION LUNG CANCER IN MAN,AND BREASST
CANCER IN WOMEN.
Semmelweis Hospital, Elizabeth Hospice, Miskolc, Hungary
Authors present this hardly known condition and its
treatment possibilities by their 4 patients cared in the
past 2 years at Elizabeth Hospice. Malignant psoas
syndrome (MPS) is characterized by proximal
lumbosacral plexopathy, painful contracture of the
ipsilateral hip and malignant involvement of the psoas
major muscle. Aim of the study was to evaluate the
effectiveness of stretching made by physiotherapiest
mainly in slight anaesthesia. Method: 4 patients with
MPS was investigated on the basis of pain VAS score and
angle of hip flexion before and after the stretching.
Results: Hip flexion was improved by 20 degree in
average after a stretching series. Conclusion: our
method, stretching of the fixed hip in MPS results in
temporary improvement of its function and moderate
decrease of pain. Stretching in slight anaesthesia is a
good example of multidisciplinary team members’
cooperation in palliative care. The process of stretching
and its functional result is shown by a short videoclip.
736. Pain and symptom burden among children
with cancer referred to a palliative care service in
Kampala, Uganda
Harnett Harnett, Emma Mathieson
Hospice Africa Uganda, Kampala, Uganda
Background:Multiple Western studies have confirmed
significant symptom burden among children with
cancer. Access to treatment and palliative care are
severely limited in sub-Saharan Africa. Hospice Africa
Uganda, Kampala provides palliative care for
children/adults living with cancer and HIV/AIDS. We
wished to assess symptom burden among children
referred from Cancer Institute, and the extent to which
they were receiving adequate analgesia prior to
referral.Methods:Retrospective chart review of children
enrolled Jan-Dec 2005 Results:102 children were
738. A Study of the Experience of Living with
Secondary Breast Cancer
Elizabeth Reed 1, 2, Jessica Corner 2, Peter Simmonds 2,
Timothy Gulliford 2
1
Breast Cancer Care, Policy and Research, London, United
Kingdom
2University of Southampton, Nursing, Midwifery and
Postgraduate Medicine, Southampton UK, United Kingdom
Despite much work being done to improve the physical
wellbeing of people with metastatic breast cancer,
surprisingly little is known about the practical and
emotional effects of living with advancing disease or
about the support needs of those with it.
Study aims:
1. To identify the physical, emotional and social
problems for people living with metastatic breast
cancer.
2. To explore in detail the physical and social
consequences of metastatic breast disease as
illuminated through people’s stories of their illness
experience over time.
3. To identify measures that might be taken to offer
greater support to this population.
Methodology:
Phase 1- a survey of people with metastatic breast cancer
from two cancer centres and the Breast Cancer Care
website.
Phase 2 - a sub sample of 30 people have been followed
over time through a series of interviews using narrative
enquiry.
Interview analysis - Narratives are considered as a whole
and also broken down into small units of text under
category headings relevant to the physical, social and
emotional or other issues. From these a broader
thematic structure has been developed.
Implications - the overall aim of the study is to improve
the experience of living with metastatic breast cancer.
Poster abstracts
Analysis of the first year of follow up in phase two of this
study will be presented at the EAPC conference. The
findings also inform the work of the Breast Cancer
Care’s Secondary Breast Cancer Taskforce ().
742. Sacred Space:Support for the staff of an
inner city hospice
Maria Coates
St Joseph’s Hospice, Chaplaincy, London, United Kingdom
739. Brave Heart
Miroslav Bojadzijevski
Gerontologic Institute, Hospice Sue Ryder, Skopje, Macedonia
Aims of project: Case reportI want to present the case of
one brave woman who struggled with cancer over 34
years.First the breast cancer was recognized in 1972.
After the mastectomies she received chemotherapy and
radio therapy. By her count, she received over 83
minutes of radiotherapy. She had a bone metastasis
more than five times. Now she is in the terminal stage of
diseases with mediastinal metastasis and stricture
esophagi after last radiotherapy. She lost in weight, has
serious problem with feeding, and has intensive back
pain. Now our services provide a domiciliary palliative
care for her.
740. Voluntary Work Overseas: pioneering
inpatient care at Hospice Casa Sperantei,
Romania
At St Joseph’s Hospice, East London, we value the hard
work and commitment of our staff. To show
appreciation for their commitment and dedication we
provide the opportunity for them to spend time
together in friendship, to think, pray, or simply to be.
Twice a year a group of 20, under the direction of the
chaplaincy team, use the facilities of Eden Hall,
Edenbridge - a retreat centre run by the Sisters of St
Andrew. This is a special time where joy and laughter
resonate throughout the whole group. It is also a time to
reflect on one’s own journey. During the weekend staff
get to know each other from a different perspective, and
this forms the basis of many lasting friendships. The
quality of our working relationship is also enhanced
which ultimately touches the people we care for with
faith, hope and love. These weekends are much valued
by staff and there is always a waiting list. The poster
presentation will describe and illustrate the different
activities that take place during these weekends and
their evaluation by the participants.
743. Innovative personnel practice
Alison Landon
professionals, augmented by a support staff (SS)
consisting of a heterogenous group of personnel such as
financial counselors, volunteers, secretaries, and other
individuals not involved in the direct delivery of
medical care, yet develop substantial, direct interactions
with dying children and their families. Prior research in
PC has neglected this population of providers. Our study
(combination of focus group and a 4 page survey)
investigated the impact of end-of-life care upon SS and
included quantitation of patient interaction, grief and
coping strategies, perceptions about symptom control,
and spirituality/cultural issues. RESULTS: 65
participants were studied (mean age 33.3 yrs, F:M 53:12,
42% with some college, White:Black:Latino:Asian
13%:18%:53%:16%). Despite 78% of SS spending > 4
hours/day with direct patient contact, end of life
experiences caused worry about multiple issues
(depression 43%, family arguments 21%, decreased sex
life 8%) and impacted ability to perform job 25%. Most
had minimal knowledge about PC issues nor training
(26%) to alleviate the stresses of dealing with dying
children. SS demonstrated noteworthy opinions about
symptoms and cultural/spiritual issues.
CONCLUSIONS: Support Staff play a key role in the PC
team and additional resources are need to enhance their
education, training, and emotional support.
746. Working to improve palliative care and endof-life care: Challenging the attitudes of health
professionals
Fraser Meek
Hospice, BRASOV, Romania
741. An integrative review of at-homeness: a
challenging conceptualization of wellbeing for
palliative care
Joakim öhlén 1, 2, Inger Ekman 1, Eva Benzein 3
1
Sahlgrenska Academy at Göteborg University, Institute of
Health and Care Sciences, Gothenburg, Sweden
2Karolinska Institutet, Institute of Health and Care Sciences,
Stockholm, Sweden
3University of Kalmar, Dep. of Health and Behavioural
Sciences, Kalmar, Sweden
Studies on lived experiences have suggested symbolic
meanings of “being at home” to be of significance for
people at the end-of-life. For this reason, an integrative
review utilizing a metasynthesis-like process was
conducted on research related to “at-homeness”. The
aim was to amplify the interpretive possibilities of
research on at-homeness in order to move towards its
conceptual clarification and to reflect upon its relevance
for palliative care. Twenty-three studies were included.
The results show that at-homeness captures the
symbolic meaning of wellbeing. At-homeness is
situational and appears on a continuum from being
symbolically at-home to its opposite, being symbolically
homeless. At-homeness can be characterized by three
interrelated aspects; being safe despite manifestations of
illness, being connected, and being centred. Four
processes that enhance as well as hamper at-homeness
are described in relation to these three aspects:
expanding–limiting experiences of illness and time,
reunifying–detaching ways of relating,
recognition–non-recognition of one’s self in the
experience, and others giving–withdrawing place for
oneself. We found “at-homeness” as a challenging
concept in the field of palliative care, particularly with
its inductive development out of clinical research, and
we particularly suggest the exploration of possibilities
for operationalization of at-homeness.
Aim: To identify the effectiveness of the approach to
personnel recruitment and selection within a new
purpose-built in-patient hospice unit.
Method: An audit of key indicators was carried out six
months after the opening of the hospice to judge the
success of the approach to personnel management.
Result: The findings provided useful information about
quality palliative practice in relation to staff selection
and recruitment. In addition it provided some helpful
indicators for auditing approaches to staff management.
Conclusion: The development of a bespoke approach
to health care staff management with palliative care is
appropriate in order to ensure that the philosophy of
the hospice is reflected in practice. The approach that
was taken and the audit of it provides a sound position
from which to reflect on common approaches to
personnel management and their appropriateness to the
hospice movement.
744. ‘Colour my working day’. Enhancing the self
esteem of nursing staff
Catherine Baldry 1, 2, Linda Dutton 1, Karen Groves 1, 2,
Cliff Bashforth 3
1
Queenscourt Hospice, Palliative care unit, Southport,
United Kingdom
2
3
Colour Me Beautiful, Penwortham, United Kingdom
Maslow’s hierarchy of needs puts self esteem/self respect
above homeostasis, safety/security and belonging. As an
organisation we believed we met the needs of our staff in
the first three layers of the hierarchy and wanted to
address the fourth to demonstrate to staff their value and
how much they were appreciated. Staff who had personal
experience of “having their colours done” described the
life changing effect on their confidence and self assurance
of wearing colours and styles which projected their image.
The current drab uniforms drained staff of colour and
made them look less healthy than their own clothes.
We consulted a colour analysis and image
organisation who gave advice about universal colours
which enhance the natural colouring of all colour types
and give them renewed pride in the way they looked in
their professional uniform.
This poster describes the process and the results of a
staff survey which showed the positive effects on staff
morale and self esteem. This gave impetus to then
consider other areas where we could use colour to make
people feel energised and invigorated and by upgrading
staff facilities make them feel more valued.
745. Support Staff in Pediatric Palliative Care:
Their Perceptions, Training, and Available
Resources
Ryan Swinney 1, Lu Yin 1, Andrew Lee 1, David Rubin 1,
Clarke Anderson 2
1
University of Southern California, Keck School of Medicine,
Los Angeles, United States
2
City of Hope National Medical Center, Pediatric palliative
BACKGROUND/AIMS/METHODS: Pediatric palliative
care (PC) requires a multidisciplinary team (MDT) of
National University of Ireland, Maynooth, Psychology,
Maynooth, Co. Kildare, Ireland
Background: Little is known about health professionals’
attitudes to palliative care and/or terminal illness. This is
an important topic and it has been suggested that
improving end of life care requires a shift in health
professionals’ attitudes. Aims: This, the first stage of a
two-part study investigating the fear and stigma
surrounding palliative care, aims to examine the attitudes
of a wide range of Irish health professionals toward
terminal illness and palliative care. Method: A large
postal survey was undertaken using a detailed Health
Professional Attitude Questionnaire (HPAQ) Results: The
findings suggest low levels of knowledge regarding service
availability and high levels of fear and stigma associated
with palliative care. Younger health professionals and
those with training were more positive in their attitudes.
Significant differences were found by occupational group.
A principal component analysis revealed a five factor
solution, explaining approximately 34% of the variance
in attitudinal scores. Conclusion: These findings,
consistent with a small pool of international research,
present a challenge to health systems worldwide working
to improve palliative care and the quality of life of
palliative care patients. Further work will examine service
users’ attitudes and the collective findings will inform the
development of a pilot health promoting palliative care
program.
747. Burn Out Syndrom Among Hospice Nurses
Zsuzsanna Kerekes 1, Ferencné Pálfi 2, Melinda Hidegné
Müller 2
1
University of Pécs, Institute of Behavioral Sciences, Pécs,
Hungary
2University of Pécs, Institute of Clinical Practice and Nursing
Sciences, Pécs, Hungary
The purpose of the investigation that was carried out in
4 Hungarian hospices, was to statistically estimate the
intensity and the frequency of burnout among nurses
who work directly with patients. A further purpose was
to highlight the opportunities of prevention, and also to
highlight the primary areas of the interventions that can
be provided by experts for hospice workers by the
practical application of the biopsychosocial and the
behavioral medical approaches. Protective steps should
be made against burnout from the very beginning of
career socialization, and the results of the investigation
give support for making these steps.
The randomized sample was constituted by nurses from
4 Hungarian hospice-hospitals. 50 questionnaires were
analysed.
Method: During the investigation we used selfcompleted and anonymous questionnaires, in which
the standardized version of Maslach Burnout Inventory
was completed by questions concerning job satisfaction
and by sociodemographical questions.
Results, conclusion: The results show significant
differences in connection with the three following
elements: the emotional and depersonalizational
exhaustion and the decrease of personal performance.
Furthermore, considering the sociodemographical data
and the question of job satisfaction the results highlight
numerous important areas of prevention, from which
the organization of effective team work and the
acquisition of the skills of effective communication are
the central factors.
179
Poster abstracts
As a medical student it was my ambition to do voluntary
work overseas. When I had the chance to join the
pioneering team at Hospice Casa Sperantei, I was eager
to be involved. The hospice was Romania’s first
palliative care in-patient unit adopting a
multidisciplinary approach with a holistic concept.
Working abroad, in a less developed country, is an
extremely rewarding and character-building experience.
It is a privilege to be part of the team leading palliative
care, initially in Romania but now in Eastern Europe
generally. I am involved in a wide range of clinical and
non-clinical activities that have not only honed my
professional expertise but also developed life skills such
as adaptability, perseverance and self-confidence.
Working abroad is also challenging and frustrating. One
obvious challenge is the language, but with the help and
tolerance of the team, the patients and their families I
can now speak effective Romanian. An obvious
frustration is the lack of resources and infrastructure in
the health care system. Many patients present in the late
stages of disease when treatment options are limited and
effective palliative care is even more important. My time
in Romania has fired my enthusiasm for palliative
medicine. I have given a lot to the hospice but gained so
much more. I have learnt to think laterally and to look
further than the narrow horizons of the UK and its NHS.
My initial commitment was for six months but I am still
there five years later!
Kathleen McLoughlin, Sinead McGilloway
St Richards Hospice, Palliative care unit, Worcester, United
Kingdom
Poster abstracts
748. TEST FOR CAREGIVERS: FORMULA OF HOPE
Galina Kuznecova, Klara Jegina
Preventive medicine Society, Cancer patient advocacy
bureau, Riga, Latvia
Introduction: Personnel in hospice is the primary
caregiver and the main provider of physical and
emotional support for patients. The present study was
designed to assess personal aptitude to be a carrier of
hope for cancer patients. Methods: 126 cancer nurses
looking for job in hospices, supportive care units and
cancer patient advocacy bureau from 3 countries of the
former SU during 1996-2006 were requested to design
the formula of hope. The completed task were subjected
to statistic handling with the focus on the mnemonic
device.Results: Respondents have defined the
prioritaties of cancer nursing as follows: Education treatment options side effects, patient and family
implications. Adaptation: adjusting to physical changes;
setting priorities and conserving energy;. Support:
counseling for the patient and family; affiliating with
support groups; obtaining needed entitlements.
Enhancement: enhancement of self-care skills,
facilitation of communication about needs and
concerns.Conclusion: Cancer nursing is an avocation.
Less than 10% of nurses have an aptitude to be a carrier
of hope. This is a problem for cancer care. Realistic hope
is a vital need of all patients with advanced cancer.
Dealing with cancer and hope must be based on
accurate information and appropriate expectations. This
can be obtained by acronymic formula:
HOPE=E(Education)+A(Adaptation)+S(Support)+E(Enha
ncement).
749. Networks of resource nurses as a tool to
improve cooperation and disseminate expertise
in palliative care
Dagny Faksvag Haugen, Ragnhild Helgesen
Haukeland University Hospital, Regional Centre of
Excellence for Palliative Care, Western Norway, Bergen,
Norway
Poster abstracts
Western Norway Health Care Region covers 86 local
communities and a population of 960,000. The region
has 11 somatic hospitals and is divided into
4 administrative areas. We wanted to build regional
networks to improve cooperation and disseminate
expertise in PC.
Aim: To establish a network of resource nurses in cancer
care and PC in each of the 4 areas.
Methods: A network plan, an executive committee, and
a binding agreement between the parties were
developed in each area in collaboration between
hospitals and health authorities, communities, the
Norwegian Cancer Society, and the Regional PC Centre.
The resource nurses have a defined responsibility and
function in PC: Clinical services in their work place,
cooperation and system work, advice and instruction.
Results: By the end of 2006, networks have been
formally established in 3 areas, and the 4th is under way.
All hospitals and 64 out of 67 communities have signed
the agreement so far, and 175 resource nurses have been
appointed. The nurses are divided into 14 geographical
groups, meeting at least 3 times a year. A common
teaching plan is developed. A number of nurses have
had observation practice or started specializing in
oncology or PC, several communities are engaged in
quality improvement in PC, and 13 have received
government funding for PC projects.
Conclusion: Networks of resource nurses may further
cooperation and strengthen expertise in PC.
750. DACUM: A Non-Prescriptive Process to
Standardize Practice and Enhance Professional
Development of Community-Based Palliative Care
Consult Teams (EMSP teams).
José Pereira 1, Thierry Currat 2, Catherine Hoenger 3,
Joëëlle Michel 2, Sylviane Bigler 4, Francoise Porchet 5,
Gisele Schärrer 6
1
University of Lausanne, Service de Soins Palliatifs,
2
CHUV, Service de Soins Palliatifs, Lausanne, Switzerland
3Sante Publique, Cantonale Program, Soins Palliatifs,
4Rife Neuve, Soins Palliatifs, Villeneuve (VD)-Suisse,
Switzerland
5
CHUV, Formation Continue, Lausanne, Switzerland
6HUGE, Soins Palliatifs, Geneva, Switzerland
Aim: The 6 interdisciplinary EMSP teams in the Swiss
cantons of Vaud and Geneva vary in their practice
models, experience and education. The goals of this
project were to develop a coordinated, level-appropriate
professional development strategy, and standardize
practice. Method: DACUM (Developing A Curriculum),
a non-prescriptive process that analyzes the tasks and
competencies required in a specific role, was used.
Skilled workers and experts in that role identify the
180
competencies through a consensus process. These are
codified. 14 team members (8 physicians, 5 nurses, 1
psychologist) and 3 experts participated in a 2-day
workshop which was facilitated by 5 trained local
facilitators. A survey was conducted to evaluate the
process. The Vaud Health Ministry sponsored the
project. Results: 144 distinct tasks within 14 domains,
covering a wide spectrum of competencies, were
identified. These related to symptom control,
psychosocialspiritual support, communication,
pedagogy, evidence-based practice, adherence to
consultant and shared-care models, clinical audit, and
self-care. All participants expressed satisfaction with the
process, its efficiency and reproducibility. The process
itself developed a closer rapport between the
participants. Conclusions: DACUM is a validating
process that promotes early stakeholder buy-in and
enhances collaboration. The results demonstrate good
face and content validity and are being used to guide the
development of appropriate education programs and an
evaluation tool for internal and external audit.
751. STRESS IN PALLIATIVE CARE - HOSPICE Trento’s experienceCarlo Abati, Carlo Tenni, Monica Gabrielli, Ornella
Isacco
The nursing staff that occupies itself with providing care
for oncological patients has often been identified as one
of the categories of professions that are most under
stress due to their job. MATERIALS AND METHODS: In
1990 Pamela S. Hindins et al. presented a questionnaire
(Q) whose purpose was to determine and quantify
stressful events within pediatric oncology called Stressor
Scale for Pediatric Oncology Nurses (SSPON). In 2005,
the same Q was used to evaluate stressful factors that
were present in oncological nursing staff that did not
work exclusively with pediatric patients.For this study,
after having translated the SSPON scale into Italian and
after having eliminated the items that refer specifically
to the pediatric field, it will be given to the nursing staff
that provide palliative care at home and at a hospice.
Each item is given a score from 0 (non stressful factor) to
10 (very stressful factor) an average score of five will
consider the factor in question as being
stressful.OBJECTIVE: Being able to precisely identify
which factors are considered stressful, which will be
carried out by a work group, is the first step that must be
taken in order to understand what must be done to
modify these factors, or if possible, eliminate
them.RESULTS: the results regarding the experience in
Trento are described in the detailed study and are
encouraging due to the possibility of being able to apply
the questionnaire and the ”good conditions” that were
found of both the health care professionals that provide
at home care and those that work in a hospice.
752. Patients with either Chronic Pain Syndromes
or Terminal Cancer Stages Together on a
Palliative Care Unit “ Does This Make Sense”
Thomas Jehser, Christof Müller-Busch
Gemeinschaftskrankenhaus Havelhöhe, Zentrum Schmerzund Palliativmedizin, Berlin, Germany
Aim of Investigation:In palliative care for dying patients
pain control is one of the main goals to maintain the
patient’s quality of life (WHO).A few German PCUs offer
a multidimensional pain therapy as well as a complex
palliative care setting to patients with either chronic
non-cancer pain or terminal and symptomatic
disease.What is the benefit of this combination
Methods:We sent a questionaire considering psychosocial, spiritual and medical aspects to German PCUs
who also admit patients with benign chronic
pain.Results:Pain patients get in touch with the
experience of the end of life care, weakness and
bereavement without suffering from terminal disease
themselves.This supports the ability of pain control and
useful interpretation of own suffering.Terminally ill
patients in community with healthier patients get the
chance to reflect the individual suffering and to
communicate about it.Physicians and nurses are
confronted with the need of high flexibility in
providing closeness and keeping distance as appropiate
to meet the needs of these groups of patients.Pain
suffering as well as terminal ill patients need intensive
communication about management of depressing
situations which can be provided by a PCU team with a
higher personell patient relation compared to regular
departments.Conclusions:Combined care for pain and
palliative patients is a beneficial setting for hospital
treatment.Effects and consequences for the health
maintainance need further investigation.
753. Stress in non clinical palliative care staff: the
medical secretary’s experience
Christine Lloyd-Richards 1, Annmarie Nelson 2, Simon
Noble 3
1
Dep Palliative Med, Royal Gwent Hospital, Newport,
Gwent, United Kingdom
2
Marie Curie Centre Penarth, Palliative Care Service, Cardiff,
United Kingdom
3Cardiff University, Palliative Medicine Unit, Department of
Oncology, Cardiff, United Kingdom
Introduction
Stress and burnout are recognised amongst palliative
healthcare professionals and formal support systems are
integral to many teams. Recent work identified sources
of stress and support needs of non clinicians such as
hospice volunteers. Secretarial staffs are essential in
a palliative care service and may be exposed to clinical
stressors, which they are inadequately prepared for. We
conducted a qualitative study to explore the sources of
stress experienced by palliative care secretarial staff.
Study Design
Semi structured audio taped interviews of palliative care
secretaries were conducted and transcribed. Transcripts
were analysed for recurring themes until theoretical
saturation was reached.
Results
Saturation was reached after 11 interviews. Participants
were aged between 32 and 59 and had worked in the
current post between 4 and 20 years (mean=9). Major
themes suggested secretaries had no prior experience of
palliative care and no formal induction on
commencement of the job. Contact with distressed
patients / carers was common and they were frequently
exposed to distressing clinical situations. No formal
support process existed for any participants. Coping
mechanisms included depersonalisation, self accessing
peer support and approaching managers for help
Conclusion
Stress in palliative care is not exclusive to doctors and
nurses and the impact of stressors likely to be greater in
non clinical staff. Induction, training and ongoing
clinical supervision of team secretaries must be an
integral part of all job plans.
754. RELATION BETWEEN JOB STRESS AND
SATISFACTION AMONG PALLIATIVE CARE
PROFESSIONALS
Mihaela Ciucurel 1, Carmen Tedor 2
1
University of Pitesti, Faculty of Social Sciences, Pitesti,
Romania
2
Children in Distress Foundation, Saint Andrew Centre,
Pitesti, Romania
The aim of this study is to identify the job stress implied
in palliative care for children and his relation with job
satisfaction of the professionals.
Started from these points we intend to design
training programs that will increase the efficiency of
palliative care. We realized an co-relational study on
professionals group (N = , sex ratio ), who are working in
palliative care units for children. For job satisfaction
evaluation we used an SP Questionnaire with 4 factors
(Ticu, 2004); for job stress evaluation we realized a semistructured interview, concerning specific work related
distress or “burnout”.
Death and dying represent a major source of job
stress among professionals because the patients are
children and the professionals has formed a close
relationship with them. Other sources of stress are:
several deaths of children occuring in a short space of
time, resource limitations, difficulties in relationships
with other professionals, a lack of understanding of
roles difficulties in building a culture of palliative care
despite. Concerning the job satisfaction, the
professionals have a significantly lower level of job
satisfaction (62%) or a medium level (38%), which are
correlated with a higher level of job stress.
The professionals must benefit from more effective
training in communication skills, including helping
patients through controlling symptoms and having
good relationships with patients, relatives and other
professionals.
755. The experience, knowledge and perceptions
of Slovenian health care professionals and their
cooperators about palliative care
Anja Simonic, Andreja Peternelj
University Clinic of Respiratory and Allergic Diseases,
Psychosocial Oncology and Palliative Care, Ljubljana,
Slovenia
Development of palliative care in Slovenia, which will
hold the presidency of the European Union in 2008,
falls greatly behind that of all other Western European
countries and even some Eastern European ones. The
implementation of palliative care lies in the hands of
eager individuals and institutions which believe in its
Poster abstracts
756. “Doctor, how can you cope with...every
day...”: personality traits of professional carers in
Palliative Care using the Wartegg Test
Giuseppina Schembri 1, Francesca Bordin 1, Marianna
Galassi 1, Annette Welshman 1
1
Fondazione Sue Ryder Onlus, Palliative Care, Rome, Italy
Palliative care team members constantly confront the
heavy emotional burden of sharing the anxieties of
family and patient, whilst doing their best to avoid
being overcome by the intense suffering.
Aim: to identify common personality traits in our
hospice at home team in urban italy, who encounter
patients/family on a daily basis.
Fifteen team members (doctors, nurses, psychologists,
bereavement officers) compiled the Wartegg (1) test to
measure the evolution of psychic organisation. The test
is diagnostic, semi structured and graphically
representative, involving complex graphical stimulus
requiring the interpretation of a well trained expert. To
our knowledge this is the first occasion that this has
been evaluated in a palliative care setting.
Results: Some personality traits resulted to be common
in all cases: difficulty in managing internal conflicts and
high levels of anxiety and emotions. One peculiarity which
emerged was the excessive emphasis of positivism especially
on behalf of more experienced staff (13%).The common
personality traits enhanced maintaining a healthy
psychological equilibrium when dealing upfront with
the emotionally unstable state of family and
patient.Conclusions: High emotional and anxiety levels,
combined with difficulty in managing internal conflicts
appeared to be necessary in order to achieve a
satisfactory working environment whilst maintaining
an efficient style of defence mechanisms. (1)
www.wartegg.com
757. Staying healthy at work: sense of coherence
and hardiness in palliative care nurses.
Janice Ablett 1, 2, Robert Jones 3
1
University of Liverpool, Division of Clinical Psychology,
2
Marie Curie Palliative Care Insitute Liverpool, Psychological
and Social Care Team, Liverpool, United Kingdom
3
University of Wales Bangor, School of Psychology, Bangor,
United Kingdom
The aims of this qualitative study were twofold. Firstly,
to describe palliative care nurses’ experiences of their
work in order to understand the antecedent factors
that promote resilience and mitigate the effects of
workplace stress, and secondly, to explore the processes
whereby nurses continue to work in palliative care and
maintain a sense of well-being.
Semi-structured interviews were carried out with 14
palliative care nurses working in community, hospital
and hospice settings. These were recorded and
transcribed verbatim, and the transcripts were analysed
using interpretative phenomenological analysis (IPA) to
identify themes that reflected the nurses’ experiences of
their work.
During the analysis several themes emerged which
related to the underlying personal factors that influenced
the nurses’ decisions to work in palliative care, and their
attitudes towards life and work. When the emergent
themes were compared with the personality constructs
of sense of coherence and hardiness, there were many
similarities. The nurses showed high levels of
commitment and found a sense of meaning and purpose
in their work. An area of difference was their response to
change, and this is discussed in relation to sense of
coherence and hardiness. Increasing our understanding
of resilience in palliative care has implications for
individual staff well-being, and, in turn, may also impact
on the quality of care provided.
758. An outline of developing a local volunteer
organization of palliative care in a rural area into
a national structure
Marjolijn Buitink 1
(3.3 times), and for the longest periods (35 days).
Conclusions: Patients with lung cancer are a particular
important target group for reducing hospitalization at
the end of live.
761. Intrathecal Use of Hydromorphone in
Palliative Care Patients: A Case Report
1
University Hospital North Norway, Cancer department,
Tromso, Norway
2TERMIK organization, VOLOUNTARY ORGANIZATION,
Vefsn, Norway
In 1996 the “TERMIK” organization was founded in
Vefsn, Norway. In due course the need for an
organization, training of volunteers and schooling of
coordinators popped up.Therefore we applied for 3
projects.
1998 – Developing and trying out a local model how to
organize, train and utilize volunteers
2002 - Developing guidelines “How to start a local
organization”
- Advice and practical support to requests for starting
local organizations
2006 - Developing guidelines and quality control
systems for coordinators
- Developing and organizing introductory and basic
courses for coordinators
As a result of these projects a database was established
.Today the database contents 25 titles and e-mail
addresses of municipalities or organizations which
involves volunteers in palliative care.The database is an
important tool in establishing a supporting network for
coordinators within all official health regions in
Norway .
759. Patients’ views of cancer support groups:
what may be barriers to attendance?
Gunn Grande, Janine Arnott
University of Manchester, School of Nursing, Midwifery and
Social Work, Manchester, United Kingdom
Background
Trials have shown support groups to be beneficial for
cancer patients. However, only a small minority of
patients attend groups, suggesting this may be an
underused resource.
Aim
To explore patients’ perceptions of cancer support
groups that may affect their likelihood of attending.
Method:
36 cancer patients (14 lung, 18 colorectal, 4 bladder)
were purposively sampled from hospital outpatients
clinics and support groups; 16 attended support groups,
20 did not. Semi-structured interviews were conducted
about patients’ views of support groups. These were
transcribed and subjected to Framework analysis.
Result
Preliminary analysis suggests that main factors
attracting patients to groups were their role as providers
of information and of access to fellow patients for
comparison and sharing of experiences. Negative factors
were fear of “too much” information and “negative”
patient comparisons, and perceptions of support group
members as isolated people who coped badly. The
presence of a health professional or expert to ensure the
validity of information and to keep control of the group
was seen as important.
Conclusion
Patients may see information as helpful or threatening
and patient contact as useful or detrimental. Attracting
patients to support groups may involve ensuring that
patient feel that these aspects are managed at a “safe”
level for their manner of coping.
760. Hospitalization of cancer patients in
Germany. Who is particularly concerned?
Katri Elina Clemens, Ines Quednau, Helmut HoffmanMenzel, Eberhard Klaschik
Rhenische Friedrich-Wilhems-University of Bonn,
Depratment of Science and Research, Centre for Palliative
Background Hydromorphone (HM) is a semi-synthetic
opioid for the treatment of malignant and nonmalignant chronic pain. Its pharmacokinetics and
pharmacodynamics have been well studied. In palliative
care patients, it is rarely used as a solo intrathecal
analgesic in clinical practice. The purpose of this case
report is to describe the safety and efficacy of
continuous intrathecal HM in the management of
difficult cancer pain in patients with failure of
continuous intrathecal morphine (M) therapy. Methods
Case report of a patient with chronic cancer pain
managed with intrathecal HM after insufficient pain
relief with intrathecal M.Results Male patient, 76 years
old, with prostata carcinoma and diffuse bone
metastases in os sacrum, os ischii and os ileum, severe
somatic pain with neuropathic pain components. Pretreatment with high dose intrathecal M (50 mg/die for
88 days) was switched to intrathecal HM because of sideeffects and inadequate analgesic response. Nausea and
vomiting, pruritus and sedation were significantly
reduced by use of HM. Analgesic response clearly
improved. Pain scores (NRS 0-10) at rest / on exertion at
admission vs. discharge were 5/10 vs. 1/2. Intrathecal
HM was continuously administered for 393 days. Mean
HM dose was 3.7±1.65 (2.60-5.60) mg/die.Conclusions
HM can be a safe analgesic alternative for long-term
intrathecal management of chronic cancer pain in
patients with pharmacological side effects or inadequate
pain relief under M treatment.
762. The last 24 hours of life, how could it be
when palliative care is undeveloped?
Ivan Justo Roll, Yobanys Rodriguez Tellez, María Luisa
Torres Páez
Tomás Romay, Palliative Care Team, Havana City,
Western Sahara
The last 24-48 hours of life is one of the fields that
constitute a capital reason for research in the attention to
the terminally ill, an ubiquitous subject of interest of
palliative medicine. Based on the observations of the
palliative care team members in the Old Havana, Cuba
we monitored the evolution of a small group of eleven
patients and their families during the last hours of life.
Using semistructured interviews regarding the patient
care and patients-families concerns, made able to record
data for different general domains including the
following: general demographic information, symptom
prevalence, patient performance status, patients and
family main concerns; the only criteria used to enter the
study was dying from a terminal disease. Patients were
dying from cancer, none of them new that they was
actually dying and avoided to discussed that issue, family
members were totally disoriented about the patient care,
in one hand they would like to try more medical
procedures to help their love one (5,45.4%) , in the other
they felt there was nothing else to do(4, 36.7%). Some
would like to take patients to the hospital (7, 63.6%); and
others were dubious about staying at home. Some family
members would like to introduce alternative ways for
nourish and hydrate the patients (8, 72.7%), others think
morphine could hasten patients’ death.
Nils Schneider, Maren Dreier
Aim: To evaluate the quantity and duration of hospital
stays of cancer patients in an advanced stage of disease
with respect to differences between the most frequent
cancer diagnoses. Method: Patients with the diagnoses
of lung, colon, breast and prostate cancer were included,
if they died from cancer in the year 2004. Using
routinely compiled data of the largest health insurance
company in the State of Lower Saxony, Germany, the
parameters of frequency (case numbers) and duration
(days) of inpatient hospital stays were examined for the
five-year period of 2000-2004, with special focus on the
years 2003/2004. Results: 355 patients were included.
On average, the number of inpatient hospital stays
amounted to 2.7 cases and 29 days per patient. 87.5% of
the hospital stays occurred in 2003/2004. The patient
groups differed significantly both in the average number
of cases and in the duration of hospital stays (KruskalWallis test: p<0.001), whereby patients with lung cancer
underwent inpatient hospital treatment most frequently
763. A feasibility study of the use of Cognitive
Behavioural Therapy (CBT) techniques for
anxiety and depression in hospice patients
Tracy Anderson 1, Max Watson 2, Robin Davidson 3
1
Belfast City Hospital, Palliative Medicine, Belfast, United
Kingdom
2
Northern Ireland Hospice, Palliative Medicine, Belfast,
United Kingdom
3
Belfast City Hospital, Clinical Psychology, Belfast, United
Kingdom
Aim:
To look at whether using CBT techniques for anxiety
and depression in a palliative care population is an
acceptable intervention, and whether a palliative care
professional, with short training can learn to use CBT
techniques which are helpful for hospice patients.
Method:
11 patients with scores of 8 or more in either aspect of
the HADS scale were recruited from Northern Ireland
Hospice and had 3-4 short sessions using CBT
181
Poster abstracts
importance. The aim of the study is to examine
current situation regarding experience, knowledge and
perceptions that Slovenian health care professionals and
their cooperators, who work in health and social
security institutions and hospice care, have about
palliative care. Method: We used the Questionnaire on
experience, knowledge and perceptions of Slovenian
health care professionals and their cooperators. The
questionnaire was translated and adopted from two
Australian questionnaires on the evaluation of work of
palliative care providers and other health professionals
who do not work in palliative care (Eagar etc., 2003).
Results: Considering various factors (e.g. job
occupation and area of work), health care professionals
and their cooperators differ in experience, knowledge
and perceptions they have about palliative care. Both of
them have the need for education in palliative care.
Conclusion: The collected data are the foundation for:
1. Preparation and organisation of quality education in
palliative care for health care professionals and their
cooperators who are usually a part of a palliative team, 2.
Evaluation of the national palliative care programme
which is currently being developed at the Ministry of
Health.
Poster abstracts
Poster abstracts
Saturday 9 June
CONNECTING
DIVERSITY
Poster abstracts
756. “Doctor, how can you cope with...every
day...”: personality traits of professional carers in
Palliative Care using the Wartegg Test
Giuseppina Schembri 1, Francesca Bordin 1, Marianna
Galassi 1, Annette Welshman 1
1
Fondazione Sue Ryder Onlus, Palliative Care, Rome, Italy
Palliative care team members constantly confront the
heavy emotional burden of sharing the anxieties of
family and patient, whilst doing their best to avoid
being overcome by the intense suffering.
Aim: to identify common personality traits in our
hospice at home team in urban italy, who encounter
patients/family on a daily basis.
Fifteen team members (doctors, nurses, psychologists,
bereavement officers) compiled the Wartegg (1) test to
measure the evolution of psychic organisation. The test
is diagnostic, semi structured and graphically
representative, involving complex graphical stimulus
requiring the interpretation of a well trained expert. To
our knowledge this is the first occasion that this has
been evaluated in a palliative care setting.
Results: Some personality traits resulted to be common
in all cases: difficulty in managing internal conflicts and
high levels of anxiety and emotions. One peculiarity which
emerged was the excessive emphasis of positivism especially
on behalf of more experienced staff (13%).The common
personality traits enhanced maintaining a healthy
psychological equilibrium when dealing upfront with
the emotionally unstable state of family and
patient.Conclusions: High emotional and anxiety levels,
combined with difficulty in managing internal conflicts
appeared to be necessary in order to achieve a
satisfactory working environment whilst maintaining
an efficient style of defence mechanisms. (1)
www.wartegg.com
757. Staying healthy at work: sense of coherence
and hardiness in palliative care nurses.
Janice Ablett 1, 2, Robert Jones 3
1
University of Liverpool, Division of Clinical Psychology,
2
Marie Curie Palliative Care Insitute Liverpool, Psychological
and Social Care Team, Liverpool, United Kingdom
3
University of Wales Bangor, School of Psychology, Bangor,
United Kingdom
The aims of this qualitative study were twofold. Firstly,
to describe palliative care nurses’ experiences of their
work in order to understand the antecedent factors
that promote resilience and mitigate the effects of
workplace stress, and secondly, to explore the processes
whereby nurses continue to work in palliative care and
maintain a sense of well-being.
Semi-structured interviews were carried out with 14
palliative care nurses working in community, hospital
and hospice settings. These were recorded and
transcribed verbatim, and the transcripts were analysed
using interpretative phenomenological analysis (IPA) to
identify themes that reflected the nurses’ experiences of
their work.
During the analysis several themes emerged which
related to the underlying personal factors that influenced
the nurses’ decisions to work in palliative care, and their
attitudes towards life and work. When the emergent
themes were compared with the personality constructs
of sense of coherence and hardiness, there were many
similarities. The nurses showed high levels of
commitment and found a sense of meaning and purpose
in their work. An area of difference was their response to
change, and this is discussed in relation to sense of
coherence and hardiness. Increasing our understanding
of resilience in palliative care has implications for
individual staff well-being, and, in turn, may also impact
on the quality of care provided.
758. An outline of developing a local volunteer
organization of palliative care in a rural area into
a national structure
Marjolijn Buitink 1
(3.3 times), and for the longest periods (35 days).
Conclusions: Patients with lung cancer are a particular
important target group for reducing hospitalization at
the end of live.
761. Intrathecal Use of Hydromorphone in
Palliative Care Patients: A Case Report
1
University Hospital North Norway, Cancer department,
Tromso, Norway
2TERMIK organization, VOLOUNTARY ORGANIZATION,
Vefsn, Norway
In 1996 the “TERMIK” organization was founded in
Vefsn, Norway. In due course the need for an
organization, training of volunteers and schooling of
coordinators popped up.Therefore we applied for 3
projects.
1998 – Developing and trying out a local model how to
organize, train and utilize volunteers
2002 - Developing guidelines “How to start a local
organization”
- Advice and practical support to requests for starting
local organizations
2006 - Developing guidelines and quality control
systems for coordinators
- Developing and organizing introductory and basic
courses for coordinators
As a result of these projects a database was established
.Today the database contents 25 titles and e-mail
addresses of municipalities or organizations which
involves volunteers in palliative care.The database is an
important tool in establishing a supporting network for
coordinators within all official health regions in
Norway .
759. Patients’ views of cancer support groups:
what may be barriers to attendance?
Gunn Grande, Janine Arnott
University of Manchester, School of Nursing, Midwifery and
Social Work, Manchester, United Kingdom
Background
Trials have shown support groups to be beneficial for
cancer patients. However, only a small minority of
patients attend groups, suggesting this may be an
underused resource.
Aim
To explore patients’ perceptions of cancer support
groups that may affect their likelihood of attending.
Method:
36 cancer patients (14 lung, 18 colorectal, 4 bladder)
were purposively sampled from hospital outpatients
clinics and support groups; 16 attended support groups,
20 did not. Semi-structured interviews were conducted
about patients’ views of support groups. These were
transcribed and subjected to Framework analysis.
Result
Preliminary analysis suggests that main factors
attracting patients to groups were their role as providers
of information and of access to fellow patients for
comparison and sharing of experiences. Negative factors
were fear of “too much” information and “negative”
patient comparisons, and perceptions of support group
members as isolated people who coped badly. The
presence of a health professional or expert to ensure the
validity of information and to keep control of the group
was seen as important.
Conclusion
Patients may see information as helpful or threatening
and patient contact as useful or detrimental. Attracting
patients to support groups may involve ensuring that
patient feel that these aspects are managed at a “safe”
level for their manner of coping.
760. Hospitalization of cancer patients in
Germany. Who is particularly concerned?
Katri Elina Clemens, Ines Quednau, Helmut HoffmanMenzel, Eberhard Klaschik
Rhenische Friedrich-Wilhems-University of Bonn,
Depratment of Science and Research, Centre for Palliative
Background Hydromorphone (HM) is a semi-synthetic
opioid for the treatment of malignant and nonmalignant chronic pain. Its pharmacokinetics and
pharmacodynamics have been well studied. In palliative
care patients, it is rarely used as a solo intrathecal
analgesic in clinical practice. The purpose of this case
report is to describe the safety and efficacy of
continuous intrathecal HM in the management of
difficult cancer pain in patients with failure of
continuous intrathecal morphine (M) therapy. Methods
Case report of a patient with chronic cancer pain
managed with intrathecal HM after insufficient pain
relief with intrathecal M.Results Male patient, 76 years
old, with prostata carcinoma and diffuse bone
metastases in os sacrum, os ischii and os ileum, severe
somatic pain with neuropathic pain components. Pretreatment with high dose intrathecal M (50 mg/die for
88 days) was switched to intrathecal HM because of sideeffects and inadequate analgesic response. Nausea and
vomiting, pruritus and sedation were significantly
reduced by use of HM. Analgesic response clearly
improved. Pain scores (NRS 0-10) at rest / on exertion at
admission vs. discharge were 5/10 vs. 1/2. Intrathecal
HM was continuously administered for 393 days. Mean
HM dose was 3.7±1.65 (2.60-5.60) mg/die.Conclusions
HM can be a safe analgesic alternative for long-term
intrathecal management of chronic cancer pain in
patients with pharmacological side effects or inadequate
pain relief under M treatment.
762. The last 24 hours of life, how could it be
when palliative care is undeveloped?
Ivan Justo Roll, Yobanys Rodriguez Tellez, María Luisa
Torres Páez
Tomás Romay, Palliative Care Team, Havana City,
Western Sahara
The last 24-48 hours of life is one of the fields that
constitute a capital reason for research in the attention to
the terminally ill, an ubiquitous subject of interest of
palliative medicine. Based on the observations of the
palliative care team members in the Old Havana, Cuba
we monitored the evolution of a small group of eleven
patients and their families during the last hours of life.
Using semistructured interviews regarding the patient
care and patients-families concerns, made able to record
data for different general domains including the
following: general demographic information, symptom
prevalence, patient performance status, patients and
family main concerns; the only criteria used to enter the
study was dying from a terminal disease. Patients were
dying from cancer, none of them new that they was
actually dying and avoided to discussed that issue, family
members were totally disoriented about the patient care,
in one hand they would like to try more medical
procedures to help their love one (5,45.4%) , in the other
they felt there was nothing else to do(4, 36.7%). Some
would like to take patients to the hospital (7, 63.6%); and
others were dubious about staying at home. Some family
members would like to introduce alternative ways for
nourish and hydrate the patients (8, 72.7%), others think
morphine could hasten patients’ death.
Nils Schneider, Maren Dreier
Aim: To evaluate the quantity and duration of hospital
stays of cancer patients in an advanced stage of disease
with respect to differences between the most frequent
cancer diagnoses. Method: Patients with the diagnoses
of lung, colon, breast and prostate cancer were included,
if they died from cancer in the year 2004. Using
routinely compiled data of the largest health insurance
company in the State of Lower Saxony, Germany, the
parameters of frequency (case numbers) and duration
(days) of inpatient hospital stays were examined for the
five-year period of 2000-2004, with special focus on the
years 2003/2004. Results: 355 patients were included.
On average, the number of inpatient hospital stays
amounted to 2.7 cases and 29 days per patient. 87.5% of
the hospital stays occurred in 2003/2004. The patient
groups differed significantly both in the average number
of cases and in the duration of hospital stays (KruskalWallis test: p<0.001), whereby patients with lung cancer
underwent inpatient hospital treatment most frequently
763. A feasibility study of the use of Cognitive
Behavioural Therapy (CBT) techniques for
anxiety and depression in hospice patients
Tracy Anderson 1, Max Watson 2, Robin Davidson 3
1
Belfast City Hospital, Palliative Medicine, Belfast, United
Kingdom
2
Northern Ireland Hospice, Palliative Medicine, Belfast,
United Kingdom
3
Belfast City Hospital, Clinical Psychology, Belfast, United
Kingdom
Aim:
To look at whether using CBT techniques for anxiety
and depression in a palliative care population is an
acceptable intervention, and whether a palliative care
professional, with short training can learn to use CBT
techniques which are helpful for hospice patients.
Method:
11 patients with scores of 8 or more in either aspect of
the HADS scale were recruited from Northern Ireland
Hospice and had 3-4 short sessions using CBT
181
Poster abstracts
importance. The aim of the study is to examine
current situation regarding experience, knowledge and
perceptions that Slovenian health care professionals and
their cooperators, who work in health and social
security institutions and hospice care, have about
palliative care. Method: We used the Questionnaire on
experience, knowledge and perceptions of Slovenian
health care professionals and their cooperators. The
questionnaire was translated and adopted from two
Australian questionnaires on the evaluation of work of
palliative care providers and other health professionals
who do not work in palliative care (Eagar etc., 2003).
Results: Considering various factors (e.g. job
occupation and area of work), health care professionals
and their cooperators differ in experience, knowledge
and perceptions they have about palliative care. Both of
them have the need for education in palliative care.
Conclusion: The collected data are the foundation for:
1. Preparation and organisation of quality education in
palliative care for health care professionals and their
cooperators who are usually a part of a palliative team, 2.
Evaluation of the national palliative care programme
which is currently being developed at the Ministry of
Health.
Poster abstracts
techniques. Visual analogue and HADS scales pre and
post intervention were analysed statistically. Thematic
analysis was carried out on themes arising during the
sessions and on semistructured interviews conducted at
the end of the study.
Results:
Quantitative analysis showed significant improvement
in anxiety, depression, relaxation, pain and energy.
Qualitative analysis revealed that the patients found
their thinking was more structured and positive, and
they coped better as a result of the intervention. They
benefited from creating alternative statements, using
diaries, weighing up advantages and disadvantages,
prioritising activities and setting goals. It was felt that
the relationship with the therapist was an important
factor.
Conclusion:
The content, timing and number of sessions were
acceptable for most patients. Only one patient found it
unacceptable, due to advanced disease. One other found
sessions tiring, but still beneficial. Patients
recommended it for others providing they were not too
tired, unwell or too advanced in their illness.
764. How Far the Population in Bulgaria is
Informed About Hospice and Palliative Care
Penka Kolchakova, Petroniya Karamitreva
College of Medicine Plovdiv, Plovdiv, Bulgaria, Bulgaria
The aim of the present study is to find out how far
people are informed about hospice and palliative care
and the need of it.
Methods and material: the study was conducted among
805 people /random selection/ of the population of
Plovdiv during 2004 - 2005 (including data gathered on
the First World Hospice and Palliative Care Day. An
anonymous inquiry specially developed for the purpose
was used. Alternative analysis was applied; statistical
significance p<.05.
Results: 85% of the people state that they have not heard
about palliative care at all; 98% point out that special
care has to be provided for people with incurable
diseases and for their relatives; 67% express potential
readiness to be involved as volunteers; 67% of the
people point out that in cases they needed such a help
and support, they had turned to their family doctors, to
friends - 61% and to a hospice - 3%.
Conclusions: There is a lack of information for the
population in Bulgaria about hospice and palliative care
and where they can receive it. There is a need to develop
palliative care, supported by the fact that 98% of the
people consider that suffering patients and their
relatives need such a help. The potential readiness of the
people (67%) to act as volunteers is a promising premise
for organising and involving volunteers at palliative care
in Bulgaria. It is necessary to develop a system to give
people information about palliative care and where they
can receive it.
765. Status ofPalliative Care in Lithuania Today
Arvydas Seskevicius
Poster abstracts
Kaunas University of Medicine, Kaunas, Lithuania
BackgroundThe Palliative Care (PC) is only making its
first steps in Lithuania. As a consequence, in the period
of last 10 years is marked with significant changes in PC
service in Lithuania: opioid therapy is accessible for all
the terminally ill patients, the first palliative treatment
department was opened, the most important
documents defining the legislative status of palliative
care were issued, research studies in palliative care were
initiated. ObjectiveTo define the strengths and
weaknesses, current status and future development goals
of palliative care system in Lithuania.MethodsAnalysis
of demographic data, legislative documents, reports
from Department of Statistics at Ministry of Health,
current health politics guidelines and
recommendations.ResultsEpidemiological Data. The
prevalence of oncological diseases is increasing every
year: it was 375/100.000 inhabitants in 1999 and
464/100.000 inhabitants in 2004. Cancer related
mortality was 208/100.000 inhabitants in 1999, while it
reached 238/100.000 inhabitants in 2005. Palliative Care
Service. PC services are provided by 69 supportive
treatment and nursing hospitals, 3 day care centers, 5
pain clinics. Therefore, a new PC Department (30 beds)
was established in KMU Oncology Department in
January 2006. Opiod Availbility. Opioids (and some other
analgesics) for all receiving outpatient and inpatient
palliative care are free. Regulation. The Palliative
Medicine Association created the special PC Group,
which in 2006 produced the document Criteria and
costs of palliative care services’ defining the legislative
status and appropriate funding of palliative care.
Conclusion
Strengths:
• Criteria and costs of palliative care services were
issued by Ministry of Health;
• Narcotic analgesics are available free of additional
costs for all palliative care receiving patients.
182
Weaknesses:
• A unified palliative care system is not yet available;
769. RADIATION INDUCED SECOND
MALIGNANCIES:
Andrew Broadbent, Abigail Walton
766. Survival in Hospice Patients
Hope Health Care, Palliative Care, Sydney, Australia
Stephen Connor
National Hospice and Palliative Care Org, Research and
International Development, Alexandria, VA USA, United
States
There is a widespread belief by some healthcare
providers and the wider community that medications
used to alleviate symptoms may hasten death in hospice
patients. Conversely, there is a clinical impression
among hospice providers that hospice might extend
some patients’ lives. We studied the difference of
survival periods of terminally ill patients between those
using hospices and not using hospices. We performed
retrospective statistical analysis on selected cohorts from
large paid claim databases of Medicare beneficiaries for
5 types of cancer and CHF patients. We analyzed the
survival of 4,493 patients from a sample of 5% of the
entire Medicare beneficiary population for 1998-2002
associated with 6 narrowly defined indicative markers.
For the 6 patient populations combined, the mean
survival was 29 days longer for hospice patients than for
non-hospice patients. The mean survival period was also
significantly longer for the hospice patients with CHF,
lung cancer, pancreatic cancer, and marginally
significant for colon cancer (p=0.08). Mean survival was
not significantly different (statistically) for hospice
versus non-hospice patients with breast or prostate
cancer. Across groups studied, hospice enrollment is not
significantly associated with shorter survival, but for
certain terminally ill patients, hospice is associated with
longer survival times.
There have been significant improvements in cancer
treatment in the last few decades. The use of radiation in
the treatment of cancer is widespread and has increased.
Up to 40% of cancer pts will receive radiotherapy as part
of their management.
More successful treatment has meant improved
survival rates, but conversely patients are living longer
and encountering more treatment-induced
complications.
The development of a second primary malignancy,
often many years later, is one of the more sinister
complications.
The American National Cancer Institute published
data in 2006 reporting that ‘Cancer survivors constitute
3.5% of the US population’ but that ‘second
malignancies among high risk groups now accounts for
16% of all cancer incidence.
The timescale between completion of the
radiotherapy and the development of a second
malignancy, known as the latent period, can vary widely
from as little as 5 years up to 50 years later.
In this poster we will present three cases of radiationinduced second malignancies seen in the Palliative Care
setting and then give an over-view radiation induced
second malignancies, looking at the aetiology, genetics
and the palliative care implications for these patients.
770. Polypharmacy in palliative care
Andrew Broadbent, Sunitha Razu
767. PALLIATION AND LIVER FAILURE:
PALLIATIVE MEDICATIONS DOSAGE GUIDELINES
Andrew Broadbent, Charles Rhee
Good symptom control is one of the most important
goals in palliative care. It often requires precision in the
prescribing of drugs in the presence of comcomittant
illness and organ failure. One of the most important
factors, from a pharmacokinetic point of view are the
dosage requirments and/or adjustments necessary in the
presence of liver failure. This poster summerises the
literature and suggests guidelines for use common
pallaitve care medications such as
opioids,antiarrythmics, antidepressants, aperients, and
other medications as selected by use at a Sydney
institution Comments about the metabolism and
excretion indicate how the metabolism is effected, and
also the important and/or pharmacologically active
metabolites. The normal dose intervals or ranges are
given, along with the suggested dose or dosage interval
changes depending on the degree of liver failure.
Common side effects from drug or metabolite
accumulation are noted. Palliation of symptoms is
important in a variety of conditions, both malignant
and non-malignant. These symptoms can be present in
patients with chronic or acute liver failure. The further
development of this information may help limit
difficulties in choice of medication and reduce potential
complications and improve palliation.
Polypharmacy can be considered as “the prescription,
administration, or use of more medications than are
clinically indicated
It is known that elderly patients take on average four
or five prescription medications, and two over-thecounter medications. In combination with advancing
cancer and co-morbidities such as hypertension and
insulin resistance that may fluctuate as the disease
progresses, medication interactions may be very
complex. Complications from the development of liver
or renal failure may also alter pharmacodynamics and
pharmacokinetics of drugs.
Some agents could easily be ceased in palliative
patients with a short prognosis, such as lipid therapy,
anti-glycaemic therapy, and antihypertensives, especially
in those patients who have reduced appetites or lost
weight.
Polypharmacy may be required to achieve good
symptom control and improving quality of life. In
patients with advanced cancer it may be difficult to find
a good balance between reducing polypharmacy and
achieving good symptom control
A prospective audit was designed of 75 consecutive
patients admitted to a palliative care unit between
September and November 2005.
This poster presents the findings of this study and
considers the implications of its results.
771. Are palliative care issues different in patients
with Primary Brain Tumours ? Data from the
German Hospice and Palliative Care Evaluation
(HOPE) 2002-2005
768. Cutaneous metastates of prostate cancer
Andrew Broadbent, Catherine Bailey
Cutaneous metastases are a rare but documented site of
distant prostatic metastases and account for less than 1%
of skin metastases from all cancers[1]. There have been
no published case reports in the palliative care literature.
The first reported cases were in the 1970s.
Almost 1 man in every 10 will develop prostate
cancer in his lifetime and is the 2nd largest cause of
cancer related death in men in Australia. In Australia,
approximately 10,000 men are diagnosed each year and
around 2,500 men will die of this disease. Half of those
diagnosed will already have evidence of distant
metastases. Cutaneous metastases are generally a late
feature and are therefore a poor prognostic indicator.
Here we describe a patient with known carcinoma of
the prostate who went on to develop cutaneous
manifestations of his disease and then discuss
epidemiology and palliative treatments.
Christoph Ostgathe 1, Sebastian Klein 1, Lukas Radbruch
2
, Gabriele Lindena 3, Raymond Voltz 1
1
2
3CLARA,
Berlin, Germany
Introduction: Little is known about symptoms and
needs of patients with primary brain tumours (PBT).
Therefore data from the German Hospice and Palliative
Care Evaluation (HOPE) was analysed.
Methods: Since 1999, an annually, three months
census is conducted in different palliative care settings.
Pooled data from 2002-2005 was analysed to test for
differences between patients with PBT and other
patients (OP). Symptoms/problems (grade 0-3) were
categorized, sum scores calculated (max. score physical
24, nursing: 6, psychological: 12, social: 6) and
categories compared (ANOVA). Symptom/problem
frequencies were tested for differences (¯_Ç_).
Results: 5684 patients were documented, 153 (2.7%)
with PBT. Physical symptoms were less intense and
prevalent in PBT (average sum score physical: PBT 7.1 /
OP 9.4, p<.001; e.g. dyspnea: prevalence 15% / 50 %,
p<.001 or pain: 53% / 76%, p<.001). Higher intensity and
prevalence of problems were found in nursing (3.1 / 2.7,
p=.002; e.g. activities of daily life: 95% / 87%, p=.003), in
psychological (4.7 / 4.0; p=.007; e.g. disorientation: 68% /
Poster abstracts
772. Are Needs Changing? A Retrospective Study
Identifying Changes in a Palliative Patient
Population Over the Last Decade.
Susan Pennington, Paul Paes
Marie Curie Hospice, Newcastle upon Tyne, United Kingdom
AIM
To identify any changes in the patient population
within a specialist palliative care unit over the last
10years
BACKGROUND
There is a perception within Palliative Care that patient
characteristics have changed over the last decade. It is
believed that palliative care services are seeing
increasing proportions of younger patients, and patients
with a different range of diagnoses.
METHOD
A retrospective longitudinal study was undertaken
looking at patient demographics within a large specialist
palliative care unit. Patient demographics were extracted
from the palliative care computer database for the years
1996, 2001, 2006. A number of parameters were
compared including age, sex, marital status, occupation,
length of stay and time between first admission and date
of death.
RESULTS
There are an increasing number of younger patients
being admitted to the specialist palliative care unit.
There has been a significant rise in the number of
patients with tumours of unknown primary, brain
tumours, and non-malignant conditions.
CONCLUSIONS
This study supports the hypothesis that the population
requiring specialist palliative care is changing. As well as
increasing numbers of patients with non - malignant
conditions, the nature of malignant disease is also
changing. It is important to recognise the evolving
nature of this patient population in the development of
specialist palliative care services.
773. THE NEEDS AND EXPERIENCES OF
PALLIATIVE CARE PATIENTS IN SOUTH AFRICA
AND UGANDA
Lucy Selman 1, Godfrey Agupio 2, Clare Gillespie 3,
Thandi Mashao 4, Keletso Mmoledi 5, Patricia Ndlovu 6,
Natalya Dinat 5, Liz Gwyther 4, Lydia Mpanga-Sebuyira 2,
Barbara Panatovic 3
1
2
Hospice Africa Uganda, Kampala, Uganda
3
South Coast Hospice, Durban, South Africa
4
University of Cape Town, Cape Town, South Africa
5
Witwatersand Palliative Care, Johannesburg, South Africa
6
Philanjalo Hospice, Tugela Ferry, South Africa
Aim: To investigate the needs and experiences of a
large sample (N=128) of palliative care patients and
their informal carers in South Africa and Uganda.
Method: Qualitative study involving single semistructured interviews with 92 patients and 36 carers
across 5 services.
Analysis: Interviews transcribed verbatim, translated into
English where necessary and content analysed in NVivo
v7. Demographic data analysed in SPSS.
Sample statistics: 128 interviews were conducted in 8
different languages across rural, urban and peri-urban
locations. Patients had a mean age of 43.1 (range 18-84);
59 (64.1%) were female. 63 (68.5%) were HIV+; of these,
55 (87.3%) had AIDS and 40 (63.5%) were on antiretroviral therapy. 34 (37%) had cancer. Carers had a
mean age of 44.8 (range 19-77); 33 (91.7%) were female.
Results: Psychological symptoms (anxiety, fear of the
future, sadness/ depression) were highly reported
amongst patients. Carers were concerned with planning
for the future care of children, and often wished to be
better informed about the patient’s disease. Stigma and
poverty were major concerns. Culturally specific
challenges around discussing death, dying and disease
were identified.
Conclusions: This large data-set provides valuable
guidance for palliative care services in South Africa and
Uganda. In particular, it provides evidence for palliative
care need in HIV, whether or not patients are on ART.
774. Patients’ Satisfaction with the Quality of Life
in Hospice
Zsuzsanna Kerekes 1, Ferencné Pálfi 2, Melinda Hidegné
Müller 2
1
University of Pécs, Institute of Behavioral Sciences, Pécs,
Hungary
2
University of Pécs, Institute of Clinical Practice and Nursing
Sciences, Pécs, Hungary
Hospice patients were investigated for determining the
possibly influencing factors of their daily life quality.
Factors like fear, anxiety, as well as physical and
emotional needs received special interest in this study.
Participants: 122 patients at the Hospice Department
Pécs, Hungary.
Methods: First, participants were asked on a
questionnaire, including both open-ended and closed
questions, about their socio-demographic details,
information and knowing about resources for the
terminally ill, and medical attendance. Thus, items
referred, for example, to the experience with pain, the
expectation on future, and the importance of religion
and social live. In addition, in order to detect our
participants’ depressive symptoms, the Beck Depression
Inventory was administered to all participants.
Results and Conclusion: In sum, our results were as
follows. Forty-nine participants rejected the thought of
death, 27 participants showed a mild level of depression,
and 108 participants have clear plans for the future.
These results are in line with previous results in the
analgesic literature. In a broader view, our findings
clearly indicate that the effectiveness of Hospice
attendance requires a highly cooperative,
multidisciplinary and holistic team work.
775. THE EFFECT OF OCTENIDYNE 775. THE
EFFECT OF OCTENIDYNE DICHLORIDE ON
MICROBIOLOGICAL BURDEN OF NEOPLASTIC
ULCERS IN ADVANCED CANCER PATIENTS.
of home care teams offering palliative care services at
home have also increased from 3 to 5.
METHODS
Retrospective and descriptive study carried out from
1977 to 2005. data were obtained from database of the
sanitary region of Lleida (Catalonia ).Diagnosis from
both oncologial and non oncologial diseases are based
on the Internationat Disease Classification-10.The aims
of our study are:
1. Relation oncological / non-oncological diagnosis ( in
number and % ).
2. Five more prevalent oncological diagnosis.
3. Five more prevalent non-oncological diagnosis
RESULTS
No
ONC
ONC
Total
1997
43
21%
162
205
1998
66
28%
168
234
1999
67
30%
160
227
2000
62
26%
177
239
2001
79
27%
218
297
2002
66
21%
242
308
2003
67
22%
236
303
2004
82
24%
256
338
2005
68
24%
227
285
CONCLUSIONS
Most prevalent oncological diagnosis: Lung,colon,breast
and prostate cancer. Most prevalent non oncological
diagnosis: cerebrovascular accidents,dementia,coma and
respiratory failure.
The total number of patients attended in the different
palliative care units located in hospitals show an slow
increment over the period 1997-2005 while the relation
oncological/non-oncological diagnosis remain almost
invariable,below the 30%.
777. LATE DIAGNOSIS OF CANCER - MAJOR
PROBLEM IN SERBIA
Ana Jovicevic Bekic 1, Natasa Milicevic 2
1
Institute for Oncology and Radiology of Serbia,
Epidemiology and prevention, Belgrade, Serbia
2
Maciej Sopata 1, Maria Ciupinska 2, Anna Glowacka 1,
Elzbieta Tomaszewska 1, Zygmunt Muszynski 2
1
University of Medical Sciences, Chair and Department of
Palliative Medicine, Poznan, Poland
2University of Medical Sciences, Chair and Unit of
Pharmaceutical Bacteriology, Poznan, Poland
INTRODUCTION:
Ulcers in patients with advanced malignant diseases are
a very important problem in view of difficulties in
treatment and questions of nursing care. They are
frequently the cause of additional pain, unpleasent
odour, bleeding and significantly affect patients quality
of life
THE AIM OF THE STUDY was an assessment of
octenidyne dichloride - Octenisept/Schulke & Mayr/ and
of its effect on the clinical condition and bacterial flora
of neoplastic ulcers.
MATERIAL AND METHODS:
This study were carried out at the PCW in february 2005
- august 2006 involved 42 pts aged 24-90 years with
neoplastic ulcers. Gauze dressings with octenisept were
changed twice daily. Observations were made on the
clinical status of the ulcerations: presence of necrosis,
amount of exudate, reddening, oedema and changes of
bacterial flora documented by bacteriological sampling
on the begining and after 3 weeks of treatment.
RESULTS:
In all 65 bacteriological strains were cultured. After 3
weeks of treatment the tests were repeated in 38 pts.
Based on observations, an improvement was found of
the clinical condition of the wounds - reduction of
necrosis, amount of exudate, reddening and oedema
and changes of bacterial flora including eradication of
Gram-positive bacteria: S. aureus and S. epidermidis and
Gram-negative bacteria: P. aeruginosa and P. mirabilis.
In 3 pts E. faecalis and in 1 pt E. coli organisms persisted.
The octenidyne dichloride looks very effective in
erradication of bacterial flora, help to control syptoms of
neoplastic ulcers and improve quality of life in such
patients.
776. ACTIVITY IN THE PALLIATIVE CARE
SERVICES IN THE SANITARY REGION OF LLEIDA
FROM 1997 TO 2005
JAUME CANAL 1, MARTA GABERNET 2, EVA BARALLAT 3,
NURIA FONTANET 2
1
Hospital Jaume d’Urgell, Unitat de Cures Pal.liatives,
Balaguer, Spain
2
Hospital de Santa Maria, Unitat de Cures Pal.liatives,
Lleida, Spain
3
iNSTITUT CATALA DE SALUT, SOCIOSANITARI, Lleida,
Spain
INTRODUCTION
Palliative care services in the sanitary region of lleida are
offered both in hospitals and domiciliary settings. Since
1997, the number of beds located in acute and long term
care hospitals has increased from 23 to 26. The number
BELhospice, Belgrade, Serbia
Stage at diagnosis influences prognosis of cancer and
the necessity for palliative care in cancer patients.
AIM: Aim of the study was to assess the epidemiological
situation of cancer and the needs for palliative cancer
care in Serbia .
METHOD: Data from national cancer registries, vital
statistics and hospital registries is analyzed to asses the
current epidemiological situation of cancer.
RESULTS: In Serbia, there are 30,000 newly registered
cancer cases and 19,000 cancer deaths per year. Cancer
incidence and mortality rates are constantly increasing.
Lung, breast, colorectal and cervical cancer are leading
cancer sites comprising for almost half of all cancer
cases. Lung cancer is responsible for a third of all cancers
in males and among leading cancers in females. The
majority of breast cancer patients are already with a
regional spread or distant metastases (50% and 10%,
respectively). Incidence and mortality rates of cervical
cancer in Serbia are the highest in Europe. Only 35% of
patients are with early stage (Figo I or IIa) cancers.
Precise epidemiology data for these leading cancer sites
will be presented in detail at the Congress.
CONCLUSION: The absence of cancer prevention/early
detection strategies and inadequate diagnostic capacities
have resulted in late stage at diagnosis for major cancers,
high cancer mortality and increased necessity for
palliative care in Serbia .
778. Symptom prevalence and factors associated
with burden indices among palliative care
patients: a multicentre study in 2 Sub-Saharan
African countries
Liz Gwyther 1, Richard Harding 2, Lucy Selman 2, Thandi
Mashao 1, Natalya Dinat 1, Lydia Mpanga-sebuyira 3,
Keletso Mmoledi 1, Godfrey Agupio 3, Claire Gillespie 1,
Barbara Panatovic 1
1
Hospice Palliative Care Association of South Africa, Cape
Town, South Africa
2King’s College London, London, United Kingdom
3
African Palliative Care Association, Kampala, Uganda
Aim This study aimed to measure pain, symptom
prevalence and burden in 5 specialist centres in South
Africa and Uganda. Method The Memorial Symptom
Assessment Schedule with additional African-specific
items was nurse-administered cross-sectionally.
Additional data: age/gender, ECOG functional status,
antiretroviral therapy [ART] use. Data were entered into
SPSS and prevalence/burden variables were compared
using non-parametric comparison of means across
diagnoses. For HIV patients, 3 regression models with
dependent variables of (1) Global distress, (20
Psychological distress and (3) Physical distress indices
were run with age, gender, ART use and ECOG as
independent variables. Results 315 participants (mean
age 43.5, 69.8% female), 71.1% had HIV and 35.6%
cancer. Of 41 symptoms, 15 had a prevalence ≥50%.
Most significant symptom is pain reported by 83.5% of
participants. Psychological symptoms were highly
183
Poster abstracts
31%, p<.001) and in social categories (3.7 /2.8, p<.001;
e.g. caregiver burden: 81% / 71%, p=.007).
Conclusion: The presented study is the first to show
that palliative care patients with primary brain tumours
suffer a variety of problems that differ significantly in
prevalence and intensity. These needs have to be met to
achieve an adequate provision of care. Further
prospective research is essential.
Poster abstracts
prevalent. Psychological distress burden was
significantly higher for HIV patients (p=0.010). In
regressions, being on ART and age were not significant
in any of the 3 models.
Conclusion The high psychological burden of
progressive disease has not been previously reported in
Africa. The differences in symptom prevalence and
burden across HIV & cancer should direct assessment
and management. It is noteworthy that being on ART
does not affect symptom burden, therefore quality
palliative care is needed alongside treatment.
779. The Gold Standards Framework. Improving
the quality of end-of-life care in UK primary
health care teams.
Karen Shaw 1, Keri Thomas 2, Collette Clifford 1, Frances
Badger 1
1
University of Birmingham, School of Health Sciences,
2
National Clinical lead, NHS End of Life Care Programme,
Department of Primary Care and General Practice,
Aim The Gold Standards Framework (GSF) provides
primary care health teams (PCHTs) with a practice-based
model to support end of life care. GSF has been
implemented by a third of PCHTs in the UK. Evaluation
of GSF in 200 general practices is reported.
Method Repeated measures design was used. Practices
completed questionnaires before & 9 months after
implementation of GSF. These assessed end-of-life care
in relation to: communication; co-ordination; control of
symptoms; continuity; continued learning; carer
support and care in the dying phase. Outcome changes
were calculated using appropriate statistical tests.
Statistical significance was set at p<0.01.
Results Questionnaires were completed by 94 (36%) and
106 (32%) PCHTs in GSF Phases 7 and 8 respectively. In
both Phases practices showed significant improvements
in: Patient identification and review; Assignment of a
nominated co-ordinator; Co-working with palliative care
specialists; Advanced care planning; Symptom
management, including anticipatory prescribing;
Record keeping; Communication with out of hours
providers; Practice based-education; Carer support; Use
of agreed protocol for terminal phase; Home-death rate
(Phase 7 only).
Conclusion The GSF is an effective framework to
improve quality of end of life care in PCHTs. Future
research should be directed at identifying the most
effective components of the programme and ensuring
that all practices can implement the GSF successfully.
780. NATIONAL MULTI-CENTER
EPIDEMIOLOGICAL STUDY ON PREVALENCE AND
TREATMENT OF CANCER-RELATED SYMPTOMS
Andrei Novik 1, Tatyana Ionova 2, Svetlana Kalyadina 2,
Anton Kishtovich 2, Shelly Wang 3, Charles Cleeland 3
Poster abstracts
1
Pirogov Medical Surgical Center, Moscow, Russian
Federation
2
Multinational Center for Quality of Life Research, Saint
Petersburg, Russian Federation
3
UT MD Anderson cancer center, Houston, TX, United
States
To have a better understanding of the current status of
symptom management, the national multi-center
epidemiological study among patients with advanced
cancer was initiated in Russia in 2005.
The analysis of data from 480 advanced cancer patients
(male/female - 206/274, mean age 53.6), included in the
study from 10 cancer centers across Russia, is presented.
Symptom status was assessed using the M.D. Anderson
Symptom Inventory at two time points.
The following distribution of patients was observed:
breast (31%), hematological malignancies (30%), lung
cancer (19%), gastrointestinal tumors (13%),
gynecological tumors (8,4%), others (3%). The most
severe symptom was fatigue (4.2) with its prevalence of
85 %. Other pronounced symptoms were pain (3.4),
distress (3.0), sadness (2.9), and sleep disturbance (2.9)
with their prevalence of 65.8%, 71.8%, 71.6%, and
70.0% respectively. Out of the total sample, 126 patients
had only mild symptoms and 344 – at least one
symptom as moderate-to-severe. Among them 131
patients had 5 or more moderate-to-severe symptoms
and 13 patients experienced 10 or more such symptoms.
Fatigue was treated only in 121 patients (30%); among
them the decrease in fatigue level was achieved in 35%
patients.
In conclusion, the results of this symptom outcome
study will provide the initial data on symptom control
in Russia and will establish the framework for
identifying the patients who experience poor symptom
assessment and management.
184
781. Audit of the Use of Antibiotics in a Specialist
Palliatiev Care Unit
Lorraine Lester, Richella Ryan, Natasha Michael, Tony
O’Brien
Marymount Hospice, Palliative Medicine, Cork, Ireland
The use of antibiotics in the palliative care is
challenging, involving complex decision making and
an individualised approach to care. The rate of
bacterial infections is has been described as being
between 28% -55%, with 60% -72% of a hospice
population at a time documented as having received
antibiotics. Bacterial infections are one of the leading
causes of morbidity and mortality but benefits of
antibiotics with regards to outcome and quality of life
is difficult to predict.
Method. A retrospective audit of antibiotic use over 2
months. Data was collected on demographics, number,
site of infective episodes, sensitivities and antibiotic
use in comparisons with local guidelines. 54 (66%) of
82 patient charts were reviewed. The average length of
stay was 16 days and 34 separate infective episodes
were recorded. Antibiotics were prescribed for 46% of
patients. 73% of the antibiotics were prescribed
empirically, with bacterial confirmation only obtained
on 44% of cases. 80% of drugs were prescribed for oral
administration. The dosing schedule for intravenous
antibiotics was variable and reflected the lack of an in
house intravenous policy. There was no clear symptom
appreciable in 59% of cases. 78% of patients survived
for more than 7 days post commencing antibiotics.
Conclusion The use of antibiotics should take into
account characteristics of infections, goals of care,
performance status, expected palliative benefit and
local guidelines.. Greater emphasis needs to be placed
on defining outcome measure and to ensure optimal
benefit from treatment.
782. The nonconvulsive status epilepticus in
terminally ill patients - a medical dilemma
Stefan Lorenzl 1, Simon Mayer 1, Gian Borasio 3
1
Institute of Palliative Medicine, Centre for Palliative
Medicine, Munich, Germany
2Institute of Palliative Medicine, Centre for Palliative Care,
Munich, Germany
3Institute of Palliative Medicine, Centre for Palliative
Medicine, Department of Sciene and Research, Munich,
Greece
Most convulsive epileptic seizures are brief because of
endogenous anticonvulsant mechanisms. In contrast,
nonconvulsive status epilepticus (NCSE) is characterized
by progressive sequential or simultaneous failure of
these endogenous anticonvulsant barriers. It does not
cease without therapeutic intervention. NSCE has been
reported in approximately 6% of patients with systemic
cancer. NSCE may be difficult to diagnose because of the
various clinical presentation ranging from altered
mental status to comatose patients. Here we report the
preliminary data of a prospective study evaluating the
underlying disease, clinical presentation, therapeutic
intervention and outcome of patients with NSCE in a
palliative care setting. So far, 8 patients with NSCE have
been included. Five patients were diagnosed with NSCE
lasting for longer than three days before admission to
the hospital. Five had never been treated with
antiepileptic drugs previously. Patients who presented
only with altered mental status (n=2) responded well to
treatment, whereas the other patients died during
antiepileptic drug treatment. Two of these regained
consciousness during treatment for at least one day.
Our study intends to discuss the treatment options of
NSCE in terminally ill patients and evaluate clinical and
electrophysiological parameters related to the outcome
of the patients to provide a useful score for treatment
decisions.
783. Sedation in palliative care - hardly disguised
euthanasia in Sweden
Anders Birr 1, Gunnar Eckerdal 2, Staffan Lundström 3
1
University hospital of Malmö, Oncology, palliative care,
Malmö, Sweden
2ASIH Kungsbacka, Kungsbacka, Sweden
3
Stockholms Sjukhem Foundation, Department of Palliative
Medicine, Stockholm, Sweden
sedation to achieve symptom control. 16 patients were
treated in an in-patient unit. Five patients were sedated
only during part of the day. Midazolam was the most
commonly used drug; Propofol and diazepam were also
used. In 15 patients the indication for treatment was
severe anxiety. Seven patients were treated due to
confusion/delirium and six patients due to intractable
pain. All patients were evaluated as having symptom
control. 12 patients had a lowered consciousness, but
only one patient had a continuous deep sedation. No
cases were reported were treatment was given at the
request of the patient for the purpose of shortening life.
Conclusion: Sedation in end of life care is rare within
specialised palliative care in Sweden. Severe anxiety is the
most common indication and midazolam is the most
commonly used drug.
784. STUDY ON DEATH ATTITUDE WITH THE
LESTER ATTITUDE TOWARD DEATH SCALE
Agnes Zana, Katalin Hegedus, Gabor Szabo
Semmelweis University, Institute of Behavioural Sciences,
Budapest, Hungary
Aim:
The topic of our study is a comparative investigation in
death attitude among the different age groups in the
Hungarian population. Our aim was to examine the
concepts and the attitudes towards death, primarily
relevant to the certain age groups.
Method:
We used the Lester Attitude toward Death Scale (1991) and
the Multidimensional Fear of Death Scale (MFODS,
Neimeyer and Moore 1994, Zana 2006). The Lester scale
is different from the other fear of death scales by not
only measuring fear, but even the inconsistencies in
attitudes. Our sample, 178 person was divided into three
subgroups: young group (N=118, average age: 18 ys), adult
group (N=38, av. age: 35 ys) and elderly group (N=22, av.
age 66 ys). Distribution by sex: 120 women, 56 men.
Results:
The fear of death is highest in the young age group (we
have the same results with the MFODS) lower in elderly
group and lowest in the adult group. Negative attitude
towards death does not show high value, neither
significant difference among the age groups.
Remarkable result is the specially dismissive attitude
against some items of the scalecharacteristically of
elderly group e.g.: ‘I don’t want to die right now, but I’m
glad that I will die someday’.
Conclusion:
The exploration of these causes will be the subject of our
further study.
785. Retrospective review of one hundred
consecutive discharges from a specialist palliative
care unit.
Kathleen Cronin, Sinead Buckley, Mary Jane O’Leary,
Natasha Michael, Tony O’Brien, Finnuala McSweeney
1– 5
Marymount Hospice, Palliative care unit, Cork, Ireland
Discharge planning is important in palliative care
because the complexity of hospice patients. This is due
to the severity of disease, symptomatic problems, carer
support, financial constraints, and lack of community
services. Very little has been written regarding the
discharge of hospice patients. This review examines 100
consecutive patients discharged from a specialist
palliative care unit, focusing on their in-patient clinical
course, discharge process, and clinical outcome three
months post discharge. PalCare, a hospice computer
database, and chart review were used to collect the
following data: patient demographics, type of
malignant/ non-malignant disease, source of referral,
discharge location, the main carer, and number of
occupants in the household. As an indication of
symptom control, the higest ESAS score on admission
and this score on discharge was noted. Investigations
conducted, medical referrals, and interdisciplinary input
were recorded. Length of stay and the interval between
the family meeting and discharge was obtained.
Outcomes three months post discharge were defined as
death or readmission. Place of death was determined. In
patients readmitted, the reason and interval from
original discharge was recorded. This is a work in
progress which will clarify inpatient demographics, their
clinical course, and the discharge process within this
special palliative care unit.
Aim: The question about sedation in end of life care has
been discussed within the Swedish Palliative Research
Network (PANIS). The aim of the study was to estimate
the occurrence of sedation in end of life care, indications
and drugs used.Method: A cross-sectional study was
performed within the network using a patient specific
questionnaire. All patients enrolled at each participating
unit were registered on a specific day. The questionnaire
comprised questions on diagnosis, age, gender, sedation,
indications and drugs used.Result: 2021 patients on 51
palliative care units were registered. 22 patients (1%) had
ongoing treatment with the purpose of producing
Poster abstracts
Friedemann Nauck 1, Norbert Krumm 2, Christoph
Ostgathe 3, Gabriele Lindena 4, Frank Elsner 2, Lukas
Radbruch 2
1
University of Göttingen, Department of Palliative
2University Hospital of Aachen, Department of Palliative
3
4CLARA, Berlin, Germany
Introduction: Enabling patients to stay home in the
terminal phase is considered an important goal of
palliative medicine. However, for some patients
inpatient treatment in specialised palliative care units is
required until the time of death. We evaluated factors
related to the percentage of patients discharged or
treated until time of death. Methods: Pooled data from
annual three months census from the years 2002-2005
were analysed. Demographic and disease-related factors
were compared for patients discharged and patients
treated until the time of death. ANOVA was used to
compare continuous data and Chi2-tests for categorical
data. Results: Inpatient treatment was documented for
4182 patients in palliative care units. Discharge or
transfer to other services was possible for 55.5% (DI),
43.3% required inpatient treatment until time of death
(DE). There were no significant differences for sex, age
or diagnosis between the two groups. Metastases in lung
(DE 30% of patients, DI 25%) or liver (DE 38%, DI 30%)
were more frequent in DE (p<.001) whereas bone
metastases were more frequent in DI (DE 27%, DI 34%).
No difference was found for brain metastases.
Performance status at time of admission was
significantly worse in DE (p<.001, ECOG 4: DE 58%, DI
24%). Conclusion: We found a clear pattern of
metastases distribution and performance status between
discharged and dying patients. The prognostic value of
these indicators has to be evaluated in subsequent trials.
787. Organisation and quality of physiciandelivered care in inpatient hospices in the state of
North Rhine Westphalia, Germany
Stefan John 1, Christoph Ostgathe 2, Eberhard Klaschik 3,
Friedemann Nauck 1
1
University Hospital Goettingen, Department for Palliative
2
3
Malteser Hospital, Centre for Palliative Medicine, Bonn,
Germany
4University Hospital Goettingen, Department of Palliative
Introduction: In Germany, palliative care units (PCU)
and inpatient hospices (HO) represent two different
settings of care with similar philosophy, but different
payment systems and organisation of services. Patients
are admitted to HO when sufficient care at home is not
achievable but referral to hospital/PCU in not necessary.
Medical care in HO is usually ensured by the GP. The
aim of this study is to assess organisation and quality of
physician-delivered care in HO in the state of North
Rhine Westphalia.Methods: A questionnaire covering
11 fields of interest was sent out to 52 heads of hospices
(HH) and to 92 physicians (PH) who see the patients in
these HO. Returned questionnaires were anonymised
and evaluated.Results: Return rate was 63% for HH and
PH. 58% of HO have 7-10 beds. 53% of PH and 73% of
HH agreed that a cooperation of general practitioners
(GP) with a consultant in palliative medicine is the best
possible organisation of medical care. However, in no
more than 36% HO such cooperation was provided.
59% of PH specialised in palliative medicine and 19% in
pain therapy. PH stated to have deficits in
communication and psychosocial skills and their
expertise in use of analgesics.Conclusion: The survey
shows that good medical care is delivered by PH in HO
in most fields covered by this study. In order to facilitate
high-quality PH care in HO, the usually GP-based care
needs to complemented by specialists in palliative
medicine.
788. PHARMACOLOGICAL MIXTURES FOR
CONTINUOUS SUBCUTANEOUS INFUSION FOR
PALLIATIVE CARE -Evidence in literatureMassimo Destro, Luciana Fontana, Cecilia Dal ri, Luca
Ottolini, Carlo Abati
Servizio cure palliative, Distretto sanitario, Trento, Italy
Background: cancer patients in the final stages of the
disease suffer multiple symptoms and require numerous
drug therapies. In certain cases it is not possible to
administer these drugs orally due to certain conditions
(intestinal obstruction, vomiting, agonal state). In these
cases it is necessary to administer drugs via a parenteral
method. Administering these drugs in a subcutaneous
manner has become quite important in providing
palliative care due to the simplicity of handling the site
and the equipment needed for infusion and the
possibility to simultaneously and in a constant manner,
administer more than one drug, resulting in clinical
effectiveness that is equal to that of intravenous
methods. Objective: the analysis of literature in order to
analyze information regarding the use of continuous
subcutaneous infusion and to study data regarding the
chemical-physical compatibility and stability of drug
mixtures (opiates, adjuvants and other symptomatics)
that are commonly used in Italy via continuous
subcutaneous infusion. Research was carried out on the
Meline, Pub-Med database, and other internet sites:
Palliative Care Matters, Pallmed and Palliativedrug.
Conclusion: the pharmacological compatibility of the
drugs described in the literature are limited to a certain
number of drugs and the concentrations of the mixtures
components, therefore if strictly applied they are
restrictive for daily use. The palliative care services of
Trento have begun experimentation in order to discover
other possible compatible drug mixtures.
789. Surgical Site Infections (SSI) after surgery in
advanced colon cancer patients, main complaint
affecting the quality of life
Horia Traila 1, Constantin Ciucurel 2, Manuela Ciucurel 3
1
of Pitesti, Kinesitherapy, Pitesti, Romania
of Pitesti, Psychology, Pitesti, Romania
2University
3University
Aim of study
Palliative surgery in cancer patients is meant to improve
the quality of life (physical and psychological aspects).
But their complex medical condition puts them at high
risk for SSI. The study is trying to asses at what level the
SSI are reducing the quality of life we aim to improve.
Method
A simple, non-randomized, retrospective study
conducted over a 2 year period 2001-2002. Out of 116
colon resections performed in a surgery clinic, 68 were
performed for advanced stages of colon cancer, 8 of
them suffering a SSI in the postoperative hospitalization
period, or soon post discharge. The SSI diagnostic was
based on the CDC criteria, and their quality of
postoperative life was evaluated based on our own
mailed in follow-up questionnaire, developed upon
studying the literature data and similar to those
internationally in use by the de EORTC.
Results
Of the 8 cases 3 of them were superficial SSI, 3 deep SSI
and 2 were organ-space SSI. Comparatively with the
control group, who had not developed a SSI, the
infection group scored very high on our assessment
scale, with major complaints in physical, social and
psychological aspects of life.
Conclusions
Given the high risk for infection this particular patient
group has, very careful selection of the patients
benefiting from palliative surgery needs to be
conducted, with careful prophylactic methods in place
in order to obtain the maximum reduction of the
operative infection risk.
790. Palliative specialists advice in a consult
setting: Is the reason of request matching with
the real problem?
Claudia Pesenti 1, Silvia Walther 2, Manuela Colla Züger
3
, Luisella Manzambi-Maggi 4, Piero Sanna 5, Hans
Neuenschwander 6
1– 6
Institute of Oncology of Southern Switzerland, Palliative
Care Service, Lugano, Switzerland
Background: The Palliative Care Service (SCP) is part of
the Institute of Oncology in Southern Switzerland
(IOSI) and has been operating through pluriprofessional
teams in a multisite-hospital since 1996. Its core tasks
are to give a consulting service and training in five
different hospitals in the whole area of Southern
Switzerland. Rational: In the first years of activity we
often felt that physicians and nurses are not really aware
about what SCP could offer, neither are they always able
to focus on the real palliative problems. Aim: We would
like to try to match the reasons of the requests
forwarded with the real palliative issues encountered
during the visit of SCP. Method: Our “patients list”
(database) has been reviewed from 1996 to 2006
specially focusing on the mentioned points. Results: In a
significant number of clinical situations the reason for
seeking a specialist advice did not match with the real
problem. Matching degrees will be quantified and
situations with specially weak correlations will be
highlighted. Conclusion: Our data suggest that
physicians and nurses without specific training in
palliative care are at high risk to fail in identifying
complex palliative issues. This may result in an
underuse of the available palliative care resources. The
result will be helpful to underline the evidence that SCP
is a real need, but that general sensibility must be
empowered and educational programs for physicians
and nurses better promoted.
791. Ten years of activity - Time to look back:
What kind of informations and conclusions is
possible to extract from our “patients list” and
should this collecting tool be modified?
Claudia Pesenti 1, Silvia Walther 2, Manuela Colla Züger
3
, Luisella Manzambi-Maggi 4, Piero Sanna 5, Hans
Neuenschwander 6
1– 6
Institute of Oncology of Southern Switzerland, Palliative
Care Service, Lugano, Switzerland
Background: The Palliative Care Service is integrated in
the Institute of Oncology of Southern Switzerland. Its
activity started in 1996 in a multisite-hospital with a
physician, a nurse and a secretary. Today there are nine
of us working in little interdisciplinary consulting teams
distributed in five hospitals in the whole area of
Southern Switzerland. Rational: Data of patients are
collected in a database (“patients list”), which has been
only slightly modified from the beginning ten years ago.
Aim: Describe the patients population, identify changes
over the time and verify if the method of data collection
is still helpful. Method: The “patients list” reports the
following data: identification (name, sex, age,.),
diagnosis, including other topics as: who advanced the
request and why, patient-information status,..Results:We
are going to present the results in detail and to put them
in relationship with the availability of the human
resources. Comment: The collected data are helpful to
endorse our request to increase the resources of our
team. On the other hand it is failing in identifying
specific areas where is worthwhile to improve our
competences. The development of a more sophisticated
data collecting tool is therefore crucial. Future: That will
be an opportunity to modify the way of collecting data
and the content of our “patients list” for a more
practical and easier extraction of informations to use in
future scientific activities.
792. Defining the palliative care population in
Extremadura
Javier Rocafort 1, Félix Fernández 2, Miguel ángel Cuervo
3, Maria Jesús Rangel 4, Fátima Díaz 5, Emilio Herrera 6
1
2Extremaduran Health Service, Regional Palliative Care
3
(RPCPEx), Badajoz, Spain
4
Extremaduran Health Service, Primary Care, Badajoz,
Spain
5
(RPCPEx), Badajoz, Spain
6
Extremaduran Health Service, Mérida, Spain
Background:
Which is the Extremaduran palliative care population?.
Different surveys (McNamara, Franks, Rosenwax, etc)
have previously looked at the question: how much
palliative care do we need?. The answer is complex and
probably depends on multiple visions like the literature
review, the local mortality rates and the consensus of
professionals and administrators.
Method:
After reading related scientific articles, a group of
professionals working in different levels of palliative
care provision, identified and agreed a minimum,
medium and maximum ratio of incident terminally ill
patients per million inhabitants and year. These ratio
were used to calculate the number of patients
susceptible to receive palliative care in every health
district of the region.
Results:
The group agreed a minimum of 2400, a mid-range of
3500 and a maximum of 5200 patients pM/ year. Noncancer diseases ratios were calculated as 600, 1500 and
3000 pM/ year, and cancer ratios as 1800, 2000 and
2200, respectively. Considering 1083879 inhabitants
living in Extremadura last year, we conclude that the
mid-range expected number of terminally ill patients
was 3794. Distribution of these ratios per Health
Districts will be shown in a map.
Discussion:
Ratios agreed in our regions, don’t differ very much
with other suggested by other authors. Knowing the
number of potentially users of palliative care services
constitute an indispensable tool for health services
administrators.
185
Poster abstracts
786. Outcome of inpatient treatment in palliative
care units in Germany Data from the German
Hospice and Palliative Care Evaluation (HOPE)
2002-2005
Poster abstracts
793. Delirium: evaluating age as a risk factor in
cancer patients
795. Methicillin-resistent Staphylococceus Areus
infections, a problem for palliative care patients?
Marjolein Bannink 1, Hetty Van Veluw 2, Lia Van Zuylen
2
, Carin Van der Rijt 2
Bart Van den Eynden 1, 2, Annick Vanderoost 1, Peter
Demeulenaere 1, Paul Van Royen 2
1
Erasmus MC - Daniel den Hoed, Psychiatry, rotterdam,
Netherlands
2
Erasmus MC - Daniel den Hoed, Medical Oncology,
1
University of Antwerp, Chair and Centre of Palliative Care,
Antwerpen, Belgium
2
University of Antwerp, Centre for General Practice,
Interdisciplinary Care and Geriatrics, Antwerpen, Belgium
Aim
Delirium is a common complication in the palliative
phase of cancer patients and is often related to opioid
use. According to the literature, age > 70 yrs is one of
the most consistently found risk factors for its
development. At the Palliative Care Unit (PCU) of our
cancer center, we monitor patients with a risk of
developing a delirium for 72 hrs using the Delirium
Observation Screening scale aiming to diagnose and
eventually treat a delirium as early as possible. Insight
in the relevance of age as a risk factor in developing a
delirium at the PCU is important to determine which
patients should be monitored.
Method
Medical records of all patients admitted to the PCU
between February 2004 and March 2006 were studied
for a reported diagnosis of delirium. The incidence of
delirium was assessed separately for patients aged < 70
and ≥ 70 yrs.
Medical records of all patients admitted to the PCU
between February 2004 and March 2006 were studied
for a reported diagnosis of delirium. The incidence of
delirium was assessed separately for patients aged < 70
and ≥ 70 yrs.
Results
In total 524 admissions of 400 different patients were
found: male/female: 204/320, age 22-89 yrs. In the 453
admissions of patients < 70 yrs, a delirium was found in
46 (10.2%; CI: 7.5-13.3%). In the 71 admissions of
patients aged ≥ 70 yrs, 6 patients (8.5%; CI: 3.2-17.5%)
developed a delirium. None of the patients developed a
delirium in different admissions.
In total 524 admissions of 400 different patients were
found: male/female: 204/320, age 22-89 yrs. In the 453
admissions of patients < 70 yrs, a delirium was found in
46 (10.2%; CI: 7.5-13.3%). In the 71 admissions of
patients aged ≥ 70 yrs, 6 patients (8.5%; CI: 3.2-17.5%)
developed a delirium. None of the patients developed a
delirium in different admissions.
Conclusion
In contrast to the literature, age was not a risk factor for
the development of a delirium in cancer patients at our
PCU. In these patients, advanced disease and necessary
symptom management e.g. by opioids, may be more
important factors in developing a delirium.
Introduction
Methicillin-resistent Staphylococceus Areus infections
are a huge problem for health care, especially in hospital
and caring homes. These infections are mainly
transmitted by direct skin contact, doctors and nurses
playing an important role. Therefore a large set of
measures is worked out like rigorous hand hygiene,
nurses wearing special clothes and masks while caring
patient’s wounds, and even isolation.
Aim
These measures are an obstacle for good palliative care:
they construct “a barrier” making a serene and intimate
saying goodbye impossible for patients and relatives. As
a first step we would like to know what the extent of this
problem is in palliative care.
Methodology
Fifty consecutive patients were screened for MRSAinfections at the moment of their transfer to the
palliative care unit by taking a nose swab. Demographic
data, referring place and data of a known MRSAinfection were registered.
Results
First results reveal an incidence of MRSA-infections of 10
% for patients admitted at a PCU. A more detailed
analyse will be presented.
Conclusions
It seems important to study incidence and prevalence of
MRSA-infections in different palliative care settings. The
analyse of the significance of such infections for
patients and their environment and of their feelings the
prevention measures evoke is another step. All this will
facilitate the development of a modified more
‘dignified’ prevention procedure.
794. Validation of the Arabic Version of the M. D.
Anderson Symptom Inventory (MDASI-A)
Nejmi EL MATI 1, Ibrahima GNING 2, Xin Shelley WANG
2
, Tito MENDOZA 2, Charles CLEELAND 2
Poster abstracts
1
INSTITUT NATIONAL D’ONCOLOGIE,
ANESTHESIOLOGIE ET RAITEMENT DE LA DOULEUR,
Rabat, Morocco
2
UT MD Anderson cancer center, Internal Medicine,
Houston, Texas, United States
This work was supported in part by Hwan Foundation.
Objective:
this study was to test the validity and reliability of an
Arabic version of the M.D. Anderson Symptom
Inventory (MDASI-A),
Methods:
The MDASI-A was developed using forward-backward
translation method,We enrolled 165 Arabic speaking
patients with different types of cancer,
Results:
Patients (68%) had advanced cancers. , age was 49 (+/14) years , 56% female,62% had an ECOG performance
3 or 4. h. In a forced 2-factor solution for the 13 items
factor analysis, there was a general symptom factor and a
GI factor as seen in other studies. A significant
correlation between the MDASI-A summary scores for
the symptom and interference subscales and ECOG 0 to
4 grades (P<0.001) provided a good concurrent validity
of the MDASI-A. Significant differences in overall mean
symptom severity and interference by independent
sample and Mann-Whitney t-tests between patients with
poor ( 0 - 2) and those with good ( 3 - 4) ECOG (P<0.01)
demonstrated the known-group validity. Internal
consistency was satisfied for the MDASI-A. Alpha values
were 0.85 for the 19 total items, and 0.78 and 0.79 for
the symptom and interference subscales.
Conclusion:
An Arabic version of the MDASI is a valid and reliable
patient reported outcome instrument
796. Hungarian Family Physicians - Knowledge,
Attitudes, and Perceived Barriers related to
Hospice Care
Agnes Csikos 2, John Mastrojohn 1, Csilla Busa 3
1
National Hospice and Palliative Care Org, Quality,
Alexandria, VA USA, United States
2
University of Pécs, Institute of Family Medicine, Pécs,
Hungary
3
University of Pécs, Department of Political Science, Pécs,
Hungary
BACKGROUND: A critical factor related to patient
access to hospice of care is the physicians’
understanding and acceptance of hospice as appropriate
care for patients with a terminal illness.
OBJECTIVE: The knowledge and attitude of physicians
and perceived barriers related to hospice care were
studied in Baranya County, Hungary in 2005. The study
gathered information and provided insight concerning
hospice as an accepted philosophy of care.
METHOD: A cross-sectional survey using a selfadministered, anonymous questionnaire.
PARTICIPANTS: Family Physicians working in Baranya
County.
OUTCOME MEASURES: Data were analysed using SPSS
10.0.
RESULTS: The majority of Family Physicians agreed
hospice care was appropriate for terminally ill patients.
Of those who responded, 91% had cared for a terminally
ill patient within the last year and 84% agreed that the
best setting for terminally ill patients was their home.
However, research results also revealed perceived
barriers to care that were related to family and resource
issues. Due to identified barriers, a majority of
physicians disagreed or were unsure families were able
to provide appropriate care in the home.
CONCLUSION: If addressed, the perceived barriers have
substantial potential to improve access for hospice
patients and their families. Future applications of this
research may be the development of a national survey
tool and utilization of the tool in other countries as a
means to enhance access to hospice services.
797. Cytokine gene polymorphisms and Cancerrelated symptoms in
Cielito Reyes-Gibby 1, Sanjay Shete 1, Xifeng Wu 1,
Eduardo Bruera 2, Margaret Spitz 1
symptoms. We hypothesize that functional variations in
cytokine genes could explain variability in self-reported
pain and depressed mood in lung cancer patients. Pain,
depressed mood, clinical and demographic variables
were assessed at presentation, and prior to initiating any
cancer treatment in 514 patients with non-small cell
lung cancer (NSCLC). Using the TaqMan method, we
genotyped single nucleotide polymorphisms in
interleukin (IL) -6 (–174 G C), IL-8 (–251 T A), and tumor
necrosis factor-alpha (TNF- ; –308 G A), and determined
their associations with pain and depressed mood.
Results showed that 16% of the respondents reported
severe pain (score >=7/10) and 7% reported depressed
mood. The severity of pain and depressed mood
predictably varied by disease-related variables and comorbidities. Multivariable analyses showed that carriers
of variant alleles in IL8-251TA had a higher risk
(OR=2;p<0.03) for severe pain. Carriers of the wildtype
allele in IL6 –174GC had higher risk (OR=2.0;p<0.05) for
depressed mood. We also observed a significant geneenvironment interaction for severe pain: patients with
variant alleles in IL8-251TA and early age of onset (< 50
years) had an OR=2.00 for severe pain. Classification and
Regression Tree analyses showed the same distinct
patterns for these symptoms. Future studies are needed
to validate these findings.
798. Caregivers’ communication with terminal
cancer patients about illness and death: An
explanatory model
Yaacov Bachner, Sara Carmel
Ben-Gurion University of the Negev, Sociology of Health,
Beer-Sheva, Israel
Aim: To examine the relative contribution of three
groups of variables - socio-demographic, personal and
treatment characteristics - to the explanation of primary
caregivers’ level of communication with terminal cancer
patients.
Method: A total of 236 primary caregivers of terminal
cancer patients participated in the study. The
questionnaire included measures of caregiver’s
communication, socio-demographic characteristics (i.e.
the caregiver’s age, family status, education level),
personal characteristics (i.e. optimism, sense of
coherence, self-efficacy) and treatment characteristics
(i.e. duration and intensity of care).
Results: Caregivers reported of law levels of
communication with patients. The study model
accounted for 28% of the explained variance. Six
variables emerged as significant contributors to
caregivers’ level of communication: family status (
=0.25, p<0.001), economic status ( =0.22, p<0.001),
duration of caregiving ( =0.21, p<0.001), level of
education ( =0.20, p<0.01), self-efficacy ( =0.18, p<0.02)
and intensity of caregiving ( =0.01, p<0.01).
Conclusion: Caregivers’ socio-demographic variables
as well as treatment characteristics play an important
role in the explanation of caregivers’ communication
level with patients. These variables should be considered
by professionals when developing intervention
programs for increasing caregivers’ communication
with dying patients.
799. Student Nurses’ thoughts on communicating
with Cancer Patients
Julie MacDonald
University of Hull, hEALTH AND sOCIAL CARE, hULL,
United Kingdom
Those who communicate with Cancer patients should
have enhanced skills or be supported by someone who
has those skills (NICE 2000). Student nurses feel isolated
when communicating with cancer patients, being afraid
of making mistakes by saying or doing the wrong thing.
Aim To investigate student nurses thoughts on
communicating with cancer patients Outcomes To
determine how prepared students feel when
communicating with cancer patients and how
supported they feel in practice. Methodology
Qualitative, convenience sample. Ethical approval
granted. Data from focus group taaped and analysis
followed Colaizzi’s procedural steps. Results Grouped in
theme clusters which included Verbal& non verbal
communication, caring ability, personal attributes and
practice issues. Implications for practice Keep
communication within pre and post registration
curricula Utilise role play as a teaching and learning
strategy Link to competencies in practice NICE
(2004)Supportive and Palliative care needs of adults
with cancer NICE London
1
The University of Texas M. D. Anderson Cancer Center,
Department of Epidemiology, Houston, Texas, United States
2
The University of Texas M. D. Anderson Cancer Center,
Department of Palliative and Supportive Services, Houston,
Texas, United States
Cytokines, aberrantly produced by cancer cells, have
recently been implicated in the severity of cancer-related
186
Poster abstracts
Darin Jaturapatporn 1, Jirapat Jaturapatporn 2, Albert
Kirshen 3
1
University of Toronto, family medicine, Toronto, Canada
University of Toronto, General Practice, Toronto, Canada
University of Toronto, Palliative Care, Toronto, Canada
2
3
Background: This study researched a group of Thai
people coming to a pharmacy regarding their attitudes
toward truth telling of cancer.
Methods: Self-answered survey of 80 participants
coming to a pharmacy in Thailand. four questions used
to collect the data included the attitude toward truth
telling of cancer whether they would like to know or
not, whether they will accept the result, their feeling in
case they have to know the results and whether they will
tell their relatives.
Results: In case of diagnoses with cancer, 95.00% of the
participants preferred being told the truth about their
diagnosis and 5.00% did not want to be told. The most
emotional response is anxiety. A total of 52.50% of the
participants preferred that doctors tell a beloved relative
the truth about their cancer diagnosis, while 47.50%
preferred that doctors not tell a relative the truth. The
distributions of gender and age did not significantly
differ between disclosure and nondisclosure group,
however, women (100.00%) preferred being told the
truth comparing to men (90.00%). Women (92.50) also
had higher acceptance of their cancer status than men
(82.50%).
Conclusions: Most of subjects in Thailand would prefer
to know the truth if diagnosed by a cancer disease.
Furthermore, attitudes toward truth telling of cancer
differed between patients toward their relatives and the
patients themselves.
802. Reducing team anxiety and increasing team
skills: Learning from audit review of a hospice
CPR policy
Corinna Midgley, Patricia Sealy, Helen Sullivan
St Francis Hospice, Palliative Medicine, Romford, United
Kingdom
aim was to determine the average duration of time from
discharge to dictation.
Methods
We retrospectively audited consecutive discharge letters
from the palliative care unit from July 1st to September
30th 2005 (n=29). Information contained in each letter
across a number of parameters, was recorded in a
standardised data sheet. This included demographic
details, diagnoses, admission details, inpatient course
and discharge details. We noted whether reference was
made to multidisciplinary or family meetings and
recorded those professionals to whom copies of
discharge summaries were forwarded.
Results
29 patients were discharged from the unit during the
study period; however only 22 letters were obtainable,
implying 25% of patients did not have a letter dictated
post discharge. There was an average of 8.5 days between
time of patient discharge and date of dictation (0-63
days).All letters contained accurate patient demographic
details in addition to primary and secondary diagnoses.
In 5 of the 22 letters, details concerning the place of care
prior to admission were lacking. Inpatient course was
referred to in all dictations; however there was a
predominance of biomedical information. There was
minimal mention of psychosocial information such as
family meetings, multidisciplinary input, insight,
bereavement and coping issues. Reference was made to
family meetings in only 9 of the 22 letters. 5 of the 22
letters had significant omissions in discharge
medications. In 4 letters, no reference was made to any
follow up arrangements.
Conclusions
There are significant deficits in the quality of
information contained in letters currently, with a
paucity of psychosocial information. We plan to pilot a
new discharge letter pro forma to 20 local General
Practitioners in order to assess its usefulness in terms of
content, style, and information conveyed. A chart
tracking will be implemented to reduce the number of
patients for whom no letter is dictated. We plan to
implement this for a period of 3 months, re-audit and
will present the final results at the meeting.
804. CANCER PATIENT-DOCTOR
COMMUNICATION: PATIENT RELATED BARRIERS
IN TELLING THE TRUTH PROCCESS
Stefanel Vlad, Liliana Visu
Abstract
St. Francis Hospice (an independent hospice)
implemented a cardiopulmonary resuscitation (CPR)
policy in October 2002. A year later it was clear that “for
CPR attempt in the event of” decisions were provoking
much care-team anxiety, despite the guidance. Using the
policy as the standard, a retrospective review of case
notes of patients who had been deemed “for CPR
attempt” was performed, the aim being to identify what
was and wasn’t being done, and to try and pinpoint
problem or confusing areas.
Youth and non-malignant diagnosis were common
features in patients with a “for CPR attempt” plan.
Problems identified fell within two key areas. Firstly, lack
of a clear review plan and secondly, lack of useful
communication with professional colleagues in the
primary and hospital care teams to support our own
team in CPR discussions and decision making. Review
guidance and the importance of shared discussion have
now been highlighted in the policy, supporting
documentation, and training programmes. The aim is to
leave the care team much clearer and more secure in
their “for CPR attempt” discussions and follow up.
803. An audit of the content of discharge letters
from a specialist Palliative Medicine facility
CENTRAL CLINICAL EMERGENCY MILITARY HOSPITAL,
RADIOTHERAPY, Bucharest, Romania
Telling the truth is the first step in cancer treatment
according to many physicians’ opinion. Patients should
be told when cancer is diagnosed, but handling of these
breaking bad news regarding their diagnosis and
prognosis is still a problem for many doctors. On the
other hand, in our country, many times cancer patients
do not want to know much about their disease, and the
physician is judging medical choices for their patients and
is manipulating the truth about the prognosis and
treatment alternatives.We consider a group of 60 new
cases of cancer patients referred to our Radiotherapy
Department. All of them were diagnosed with cancer
(breast, rectal, prostate, lung, cervical carcinoma) 2 weeks
to 6 months before the start of irradiation. Based on a
specific questionnaire we analysed the effect of patient’s
age, sex, education and socioeconomic status on
perception of:
telling the truth about cancer diagnosis and prognosis;
• patient-doctor relationship (relationship centred on
doctors vs. doctors and patients being equal partners);
• needs for information provided after cancer is
diagnosed;
• family’s involvement in the decision-making process.
(study still in progress)
Breffni Hannon, Natasha Michael, Tony O’Brien
Marymount Hospice, Department of Palliative Medicine,
Cork, Ireland
Background:
Discharge planning is an important part in the effective
coordination of services in palliative medicine, but can
be complex and challenging. Effective planning and
communication is important to ensure a seamless
continuation of treatment received in an inpatient unit
and the care in the community. Discharge letters usually
form the mainstay of communication between
professionals, but often lack a structured, coherent
framework. There is a high level of variation in terms of
writing style, format and content of letters. Letters
predominantly have a biomedical focus, often omitting
valuable psychosocial and interdisciplinary information.
There can be a significant time lag between patient
discharge and receipt of discharge letter by General
Practitioners, further compromising patient care. We
decided to undertake a larger review of the discharge
process in our palliative care unit, of which this audit
forms part.
Objectives
To assess the content of discharge letters from a
specialist palliative care unit over a three month interval
across a number of predefined parameters. A secondary
805. Can the use of videos of people who have had
a positive experience of hospice help patients to
make a decision about admission?
Paul Perkins 1, Sarah Grove 2, Mark Moughton 3, Sally
Thornton 4, Sarah Vowler 5
1
Hinchingbrooke Hospital, Palliative Medicine,
Huntingdon, United Kingdom
2
Hinchingbrooke Hospital, Palliative Medicine, Huntingdon,
United Kingdom
3
Hinchingbrooke Hospital, Information, Huntingdon,
United Kingdom
4
Hinchingbrooke Hospital, Palliative Medicine, Huntingdon,
United Kingdom
5University of Cambridge, Public Health and Primary Care,
Cambridge, United Kingdom
Objective: To determine whether watching a video of
hospice inpatients talking about their experiences
would be acceptable to prospective hospice patients.
Design: Prospective pilot study
Setting: District general hospital and 3 local hospices.
Participants: District general hospital inpatients that the
hospital palliative care team thought would benefit
from a hospice admission.
Methods: An interactive DVD was produced featuring
interviews with patients who had stayed in a local
hospice talking about their experiences.
Prospective patients who watched the DVD were asked
to complete a questionnaire at 3 time points – prior to
watching; after watching; and after admission to
hospice.
Main Outcome Measure: Patient satisfaction with DVD.
Results: All 15 patients who watched the DVD thought
that videos like this were a good idea.
13/15 thought it was useful for them to have seen it.
For patients who were concerned about hospices prior
to watching the DVD there appeared to be a change in
attitude:
6 patients’ opinions regarding ‘never going into a
hospice’ and 5 patients’ opinions regarding ‘what will
happen to me in a hospice’ changed after watching the
DVD, shifting towards feeling more favourable about
hospice admission.
Conclusion: The video was acceptable and can help
patients when faced with this difficult decision.
806. What do palliative patients know about
their diagnosis and prognosis in Belgium at the
moment the hospital based palliative support
team is brought in.
Nancy Cannaerts, Mieke De Pril, Inge Bossuyt, Walter
Rombouts, Annick Van Laeren, Johan Menten
U.H. Gasthuisberg, Palliative Care Team, leuven, Benin
This prospective study analyses the patients’
understanding of diagnosis/prognosis and the reasons
for non-disclosure. Data about the patient’s (non)
understanding of diagnosis/prognosis and the reasons
for not being informed were registered for 503
consecutive palliative patients hospitalised in 4
hospitals.
In the group of patients view of prognosis, 47% is
informed, 33% is not informed and in 20% there is
uncertainty about the degree of patients’
understanding of prognosis. Still 15% does not know
the diagnosis.
Reasons for not informing are the physical or mental state
of the patient inhibiting informing the patient
and family’s and physicians’ fear of talking about a life
threatening illness.
Young patients and patients staying on an oncological
ward are better informed. Patients receiving palliative
therapy are less informed about their prognosis. Patients
being discharged home with palliative home care
support are better informed than patients without
support. Of the patients for whom the palliative care
team is asked to prepare the transfer to the palliative care
unit, 30% is not aware of the prognosis.
Many palliative patients do not fully know their
diagnosis/prognosis. This is due to the mental and
physical condition of the patients, the fear of caregivers
and family members to disclose the thruth. Knowing
these variables will help the PST to support the
caregivers in communicating bad news.
807. ATTITUDES OF PAKISTANI DOCTORS
TOWARDS BREAKING BAD NEWS (BBN) - A
QUESTIONNAIRE SURVEY
Syed Abbas 1, Syed Muhammad 2, Syed Abbas 3
1
Kingdom
2
Muhammad Medical College & Hospital, General Surgery,
Mirpurkhas, Pakistan
3
Muhammad Medical College & Hospital, Department of
Medicine, Mirpurkhas, Pakistan
Objectives: Although there is increasing evidence that
more patients want to know their diagnosis and
prognosis, evidence suggests that BBN has been treated
differently in different settings. We assessed the attitude
of Pakistani doctors towards BBN with the help of a
questionnaire.
Methods: A questionnaire was distributed among
doctors of a teaching hospital. The questions included
demographic details, their experience of BBN, their view
on importance of BBN and the important components
of such discussion with patients and their families.
Analysis and Results: 76/120 doctors returned the
questionnaires. They were from varying disciplines and
experience (33 <5years). All (76/76) acknowledged that it
was very important for patients to know their disease
status. 30/76 had broken bad news in last year less than
10 times whereas further 38/76 had dealt with patients
with Bad news. 40/76 felt that BBN was done well. 61/76
felt that Bad news should be told to relatives first. 47/76
felt that it should be done by doctor in-charge
personally. Main components identified as important
part of discussion were whole truth-telling (48/76),
empathy (44/76), family involvement (35/76), follow-up
support (20/76), acceptance as will of God (17/76),
prognosis time (15/76), preparation with information
(12/76) and Palliative care (9/76).
Conclusion: Although there is understanding that BBN
is important, there was lack of consistency in approach.
187
Poster abstracts
800. The attitude and feeling toward truth-telling
of cancer: a public survey from a pharmacy in
Bangkok, Thailand
Poster abstracts
Family involvement was felt very important by the
doctors.
808. Accompanying the family in extremis : use of
the genosociogram and a database in a Palliative
Care Unit PCU
BURUCOA Benoit 2, MILON Julie 2
1
Hôpital Saint-André, Palliative care unit, BORDEAUX,
France
2
Hôpital Saint-André, palliative unit, BORDEAUX, France
To support the entourage in our PCU, are used a
genosociogram (adapted family tree) and a weekly onehour meeting between social worker, psychologist, head
nurse, physician.
To study three items: *the concept of the
“trustworthy person” *the fragilities of the family
system *the work of the team.
An evaluation and computerised follow-up form
elaborated in 2002 has been used during weekly
meeting during 2004. 90 patients were concerned. The
trustworthy person is: *at the emotional level: Spouse
35 times, Child 23, Several persons 23 *at the
time/space and material availability level: Spouse 32
times, Child 20, Several 15.
Concerning family fragilities : 37 % Infants, 21%
Conflicts, 18% Distance, 11 % Exclusion, 11% Difficult
mourning, 21% Social assistance, 20% Merging
relationship, 10% Material precariousness, 10% Legal
protection.
Projects: 63% End of life within the PCU, 17% Home
return, 14% Temporary leave project, 12% Other
structure.
Team-family meetings: 235, 68 professional and close
relation, 67 professional and several close relations.
Familial fragilities are weighty. Projects looking into
leaving the PCU are frequent. Families’ accompaniment
is time-consuming. Intrusion must be avoided and
confidentiality observed. The finality is preventing
difficult bereavements. The following are considered: a
study on accompanying the children close to the sick
persons, a multi-centric study.
809. Meaning-Centered Psychotherapies in
Advanced Cancer: Helping Patients Find &
Maintain Meaning in Life
SHANNON POPPITO, WILLIAM BREITBART
Poster abstracts
Behavioral Sciences, New York, United States
Purpose: This presentation will give an overview of
Meaning-Centered Psychotherapies for advanced stage
cancer patients. It will provide preliminary evidence for
the feasibility and efficacy of both Meaning-Centered
Group Therapy (MCGP), as well as Individual MeaningCentered Psychotherapy (IMCP) for enhancing spiritual
well-being and quality of life and reducing
psychological distress in patients with advanced cancer.
It will also explore the essential facets of these novel
interventions by highlighting the basic sources of
meaning that patients are taught, in order to enhance
meaning and spiritual well-being.
Overview: Both Meaning-Centered Psychotherapy
studies utilized a randomized, controlled, repeated
measures design to investigate the impact of MeaningCentered Psychotherapy on spiritual well-being,
psychological distress, and quality of life in patients with
stage III-IV cancer (solid tumors or Non-Hodgkin’s
Lymphomas). Patients were recruited from the
ambulatory care facilities of Memorial Sloan-Kettering
Cancer Center, under the leadership of Dr. William
Brietbart. Both group and individual Meaning-Centered
Psychotherapies are manualized treatments (Breitbart,
Poppito, 2005), based on Viktor Frankl’s existential
work. This psycho-educational intervention encourages
patients to explore basic sources of meaning (e.g.,
historical, attitudinal, creative and experiential), which
are intended to help them find, maintain and enhance a
sense of meaning and purpose in life.
810. ‘Shocking talk’ - Communication skills
training improves rates of resuscitation
discussions with patients on admission to hospice
Suzanne Ford-Dunn
St Barnabas House, Medical, Worthing, United Kingdom
Introduction
National guidelines recommend patient involvement in
discussions regarding resuscitation status
(RS) however, a single day survey of hospice in-patient
case notes (Oct 05) revealed only 2/15 patients had been
involved in discussions.
Aim
To improve communication/discussion about RS with
hospice in-patients through development of a
communication skills training programme.
Method
188
Multi-professional (hospice doctors, staff nurses,
community specialist palliative care nurses) training was
arranged involving role play scenarios, feedback and
sharing of ideas. Participants self-rated their confidence
in discussing RS prior to and immediately after the
training and again 6-9 months later. A repeat random
single-day case note survey was performed in Oct 06.
Results
Oct 05 2/15 patients (13 %) had been involved in
discussions. Oct 06, following instigation of
communication skills training 11/14 patients (78%
P<0.001) had been involved in discussions
surrounding RS and were aware of their RS. Confidence
levels for staff rose immediately following the training
and this was maintained 6 months later.
Conclusion
Communication skills training regarding RS improves
confidence of healthcare professionals in these
discussions and improves rates of involvement of
patients. Annual training in communicating RS
decisions now accompanies basic life support training in
our unit.
811. TRUTH-TELLING AND THE DIAGNOSIS OF
CANCER
José Díaz-Benito, Ana Sola-Larraza, Ignacio Pérez-Litago,
María Hernández-Espinosa, Clint Jean-Louis, María
León-Díaz, Maite Salinas-Vidondo
Servicio Navarro de Salud, Atención Primaria, PAMPLONA,
Spain
Aim
To determine the prevalence of primary care patients
who would want to know their diagnosis if they were
suffering from cancer, and to investigate the factors
determining their decision.
Method
Design: cross-sectional descriptive study. Setting: public
urban primary health care. Main measurements:
questionnaire survey was administered to 247 patients
selected by consecutive sampling.
Result
Mean age was 51.3 years (SD 18.7). Most patients
(85.4%) would wish to know themselves if they were
suffering from cancer (95% confidence interval, 81–89.8). However, persons appear more reluctant to
disclose diagnostic information to family members with
cancer: less than two-thirds (62.8%) thought the patient
should be informed of cancer diagnosis. Forty-eight per
cent thought the family doctor was the most appropiate
person to tell a patient their diagnosis of cancer, 32%
the hospital physician, and 20% the family members.
The greatest fear of the primary care patients with regard
to cancer disease is the fear of pain (43.9%). The patient’
preferences regarding truth disclosure were significantly
associated with younger age (p=0.024). The patients’
preferences for nonhospital deaths (69.6%) were
significantly associated with higher academic education
(p=0.028) and younger age (p<0.001).
Conclusion
The majority of primary care patients (85.4%) would
want to know the truth if they were suffering from
cancer: they want to be informed of cancer diagnosis.
However, when a family member has cancer, only
62.8% would prefer telling the truth.
812. Why we don’t understand each other?
Jadranka Lakicevic
Clinic Center of Montenegro, Clinic of Oncology, Podgorica,
Montenegro
Communication is one of the most important parts of
professional–patient relationship, having special
meaning in cancer care. Cancer brings fears, concerns
and uncertanity about future. Health care professionals
deal with cancer patients all the way: from diagnosis,
during period of anticancer treatments, up to the
terminal phase of disease and palliative care. There are
many contacts with patient and family members. Good
communication is a complex process and means more
than delivering information. It is because of influence
of different psychological, emotional and social factors
as well as because of personality of both patient and
professionals. Meaning of information might be
transformed and lead to misunderstandings. Source of
obstacles and problems for good communication might
be any of these: patients, professionals and family
members. Regarding patient, the issue is about what
does he/she want to know about diagnosis, prognosis,
outcome of disease and willing to take part in treatment
decission. These questions have background in patient’s
psychologic profile, educational level, as social and
cultural milieux. It is considered that professionals’
problems in communication are due to lack of formal
education and trainings, skills, and time to talk. Family
members have supportive role in process, but
sometimes they are too protective. It is mandatory to
establish an atmosphere of confidence and empathy,
with tailor-made communication for each patient.
813. The palliative cancer patient, his next-to-kin
and his doctor: What is important? Interview
study of patients and next-of-kin
Birgit Aabom 1, Per Pfeiffer 2
1
University of Southern Denmark, Institute of Public
Health, Odense, Denmark
2
University Hospital of Odense, Department of Oncology,
Odense, Denmark
Background: To achieve a “good quality death”
various physical, structural, emotional and spiritual
issues are important. Our hypothesis is that the relation
between oncologist, general practitioner, cancer patient
and his next-of-kin is of outmost importance for
creating a fertile soil for successful end-of-life cancer
care.Aim: To investigate cancer patients’ on-going
experience of the relation with doctors in the oncology
department and their general practitioner throughout
palliative chemotherapy letting the patients define the
”good” doctor. Methods:15 patients and their next-tokin participated in 2 consecutive face-to-face semistructured interviews in the patients’ home. Interview
transcripts were subjects to phenomenological analysis
using theories from the science of philosophy and
psychology.Results:12 men, 3 women (age 50-80)
participated in the interviews. Professionalism and
competence were highly valued. Patients valued honest
ness about the course of the disease in an atmosphere of
hope or “not knowing”. Hope was not an assurance of
total cure, however, a hopeful attitude in speak and
body language. A majority missed a guiding in psychosocial issues which could be fulfilled by their general
practitioner Conclusion: To be able to meet the
patients with empathy and fostering hope for the near
future, the skills of handing over issues of psycho-social
character need to be developed.
814. Searching for answers
Ruth Sladek 1, Jennifer Tieman 1, Amy Abernethy 1, 2,
David Currow 1
1
Flinders University, Adelaide, Australia
Duke University Medical Centre, Durham, United States
2
Aims of the project
To describe and quantify issues associated with
searching and retrieving literature relevant to palliative
care
Method
Three bibliographic studies were conducted.
1. Validating a search strategy to retrieve palliative care
literature from general biomedical journals by
comparing electronic search results against a dataset
created by a hand search
2. Estimating indexing rates of core palliative journals
within CINAHL, Embase, PsycINFO and Ovid
Medline
3. Determining conversion rates of conference abstracts
to publication for three palliative care conferences
held in 2001 in Australia, Europe and Australia.
Results
Less than half the literature identified as relevant to
palliative care was retrieved using a Master Search
comprising 9 MeSH terms and three text words. Over
30% of literature within core palliative care journals was
not indexed on the major bibliographic databases.
Publication rates for the palliative care conference in
Australia, Europe and US were 8.9%, 23.7% and 35.1%
respectively.
Conclusion
Literature relevant to palliative care is not
comprehensively retrieved with simple searches in a
single database. Further, unless research and observation
is published it can not be retrieved using electronic
bibliographic searches.
815. Cultural Aspects in the Role of Truth in
Relation to the Respect for Autonomy in
Palliative Care
Thomas Jehser, Christof Müller-busch
Gemeinschaftskrankenhaus Havelhöhe, Zentrum Schmerzund Palliativmedizin, Berlin, Germany
Aim of Investigation: Even in an advanced and lifethreatening illness patients have a need for information
and truth telling. Relatives sometimes demand for
avoidance of breaking onerous news towards their
beloved ones in order to protect them from “unuseful”
depressive reactions. The existance of different
languages sometimes amplify an assymmetri

Poster abstracts

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