EAPC - ipac

404 EAPC Abstracts
larger study of 100 patients newly referred to a hospice community palliative
care service in Central Scotland. A grounded theory and narrative approach
was taken to analysis. Results: Key themes were physical (debility, dependence
and expectations); psychological (understanding, uncertainty and vulnerability);
social (communication and family) and spiritual (faith, reflection
and hope). The unifying theme was control. Over the time from referral to
death, patients’ perspectives evolved in a positive direction: Patients adapted
and became reconciled to death. Despite this positive trend, all of the patients
suffered transient negative episodes related to acute, unpredictable exacerbations
of distress in any one of the physical, psychological, social or spiritual
domains. The distress was induced by a sudden change in circumstances
inconsistent with the established and familiar pattern of change.
Conclusions: For patients with advanced cancer, perspectives on illness
relate to physical, psychological, social and spiritual factors. The fundamental
issue is control maintenance. Patients appear to become reconciled to
death, facing it positively, despite experiencing periodic, unpredictable, acute
exacerbations of distress. These episodes, which occurred throughout the
final journey, reflected the transient loss of control associated with unexpected
change. The process of adaptation continued once control was regained.
16 Oral Presentation
End of life care and quality of death
How effective is the control of and communication about agitation
and distress in the last 48 hours of life
Authors: Joanna Dunn Medicine St Christopher’s Hospice UNITED
KINGDOM
Emma Hall St Christopher’s Hospice London UNITED KINGDOM
Jane McManus St Christopher’s Hospice London UNITED KINGDOM
Holly Young St Christopher’s Hospice London UNITED KINGDOM
Background: The prevalence of end of life sedation appears to be increasing.
There is insufficient evidence about effectiveness of medication and communication
with patients/families. Aims: Relate sedative dose titration and drug
review to effectiveness of relief of agitation in the last 48 hours of life.
Identify areas for improvement. Methods: Retrospective case-note review of
last 48 hours of life of 100 consecutive hospice deaths. Results: 99 evaluable
patients. Median age 73 years (range 33–93). 49 males. 90 had cancer. 69/99
(69%) patients were agitated at some time in the last 48 hours of life. 117/273
(43%) stat doses were recorded as effective. 46/115 (40%) stat doses of sedative
at 48–24 hours pre death and 76/158 (48%) in the last 24 hours were
given simultaneously with another drug, usually analgesia. The median number
of stat doses per patient was 2 (range 1–10) at 48–24 hours and 2 (range
1–9) in the last 24 hours. 29/99 (29%) required 3 or more stat doses in the last
48 hours.57/99 (58%) patients received continuous infusions of sedatives in
the last 48 hours of life, of whom 22/57 (39%) had an increase or change in
the last 24 hours and 11/57 (19%) required combinations of sedatives.
Midazolam was the most frequently used drug for both continuous (median
20mg; range 5–100mg) and stat use (median 2.5mg; range 1.25–20mg), followed
by levomepromazine (median continuous dose 25mg; range
6.25–250mg, median stat dose 12.5mg; range 6.25–50mg). 3 patients
required phenobarbital. There were discussions about sedation with families
in 30/68 (44%) cases. Conclusions: Agitation was common in the last
48 hours of life, sometimes intermittently. Documentation of communication
and drug effectiveness could be improved. Doses were similar to previous
studies. Issues for further investigation include co-administration of sedatives
and analgesics, dose titration of stat and continuous doses and the use of
sedative drugs in combination for more resistant agitation.
17 Oral Presentation
End of life care and quality of death
Palliative Care in Dutch Nursing Homes: Dying with Dignity
Authors: Luc Deliens Dept. of Social Med. Vrije Universiteit Amsterdam-
VUMC CANADA
Dr. H Brandt VU Free University Medical Center Amsterdam
NETHERLANDS
Miel W Ribbe VU Free University Medical Center Amsterdam
NETHERLANDS
Background: Nursing homes (NHs) are less well studied than hospices or
hospitals regarding palliative care. For palliative care information is
≠needed about the patients, symptoms, direct causes and underlying diseases,
and incidence of terminal ill NH patients. Methods: Prospective
observational cohort study in 16 NHs in the Netherlands. All long-term
care patients assessed by an NH physician to have a life expectancy of
6 weeks or less were enrolled (n=516). The symptoms-and-signs list was
constructed from the MDS-RAI2.0. The validated Dutch Classification of
Diseases for Nursing Home Medicine (CvZ-V)16 was used for registration
of the direct cause of the terminal phase and the underlying disease.
Results: The terminal disease phase was marked with symptoms of low
fluid and food intake, general weakness, and respiratory problems or dyspnea.
Patients were frequently in a state of somnolence and experienced
recurrent fever. Direct causes of these conditions were diseases of the respiratory
system and general disorders. The 2 main underlying diseases of
the terminal phase were mental disorders (dementia) and circulatory
diseases. For both groups, symptoms of (very) little/no fluid intake, generalized
weakness, somnolence and cachexia/anorexia were common. For
patients with mental disorders (mainly dementia) the beginning of the terminal
phase was marked with problems of nutritional intake, and recurrent
fever. In the circulatory group, this beginning was mostly the presence of
respiratory problems and/or dyspnea. Cancer was the underlying disease in
only 12% of the patients, showing a different pattern of symptoms compared
to residents without cancer. Conclusions: A wide variety of burdensome
signs and symptoms are seen in the terminal phase of nursing home
patients with fluid and food intake-problems, general weakness, and dyspnea,
as the most important. For patients without cancer in Dutch NHs, the
terminal disease phase is difficult to predict, and once diagnosed, patient
survival time is short.
18 Oral Presentation
End of life care and quality of death
Care for patients in the last three months of life: findings from
the nationwide SENTI-MELC study in Belgium
Authors: Lieve Van den Block End-of-Life Care Research Group Vrije
Universiteit Brussel BELGIUM
Nathalie Bossuyt Wetenschappelijk Instituut Volksgezondheid Brussels
BELGIUM
Viviane Van Casteren Wetenschappelijk Instituut Volksgezondheid Brussels
BELGIUM
Katrien Drieskens Vrije Universiteit Brussel, End-of-Life Care Research
Group Brussels BELGIUM
Sabien Bauwens Vrije Universiteit Brussel Brussels BELGIUM
Reginald Deschepper Vrije Universiteit Brussel, End-of-Life Care Research
Group Brussels BELGIUM
Luc Deliens Vrije Universiteit Brussel, End-of-Life Care Research Group
Brussels BELGIUM
Background: The WHO has identified palliative care as an issue of great
clinical and public health importance. However, data describing end-of-life
care on a societal or population-based level are lacking. This is the first
nationwide study to measure end-of-life care in a representative sample of
dying persons, in terms of involvement of caregivers, access to specialist
palliative care, treatment goals, and physical-psychosocial-spiritual components
of care. Methods: We performed a one-year nationwide mortality follow-back
study in 2005, Belgium. Data were collected within the Sentinel
Network Monitoring End-of-Life Care (SENTI-MELC) study. All 205 general
practitioners within the Sentinel Network of GPs, an existing epidemiological
surveillance system representative of all Belgian GPs, reported
weekly on the final three months of life of every patient in their practice who
died non-suddenly. Results: We studied 892 deaths. GPs, nurses/geriatric