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Forum
Andrew A Somogyi and Janet Hardy
Abstract
Analgesics, especially opioids, show remarkable inter-individual variability in both efficacy and adverse effect profile. There are many factors that contribute to this variability, including renal and liver function, co-morbidity and concomitant medications. Another source of interpatient variability in response to analgesics is the patients’ genetic profile that controls their drug metabolism, drug transport out of the brain and target site activity. The cytochrome P450 2D6 poor metaboliser phenotype reduces the effects of some opioids, such as tramadol. In contrast, in ultra-rapid metabolisers, adverse effects are seen with codeine and antidepressants. The efflux transporter p-glycoprotein located at the blood brain barrier limits the access of these drug classes to the brain. Genetic polymorphisms in ABCB1 result in enhanced efficacy, but also increased adverse effects to many drugs used widely in palliative care. For opioids, a mu receptor polymorphism leads to reduced efficacy and for Non Steroidal Anti-inflammatory Drugs, CYP2C9 polymorphisms are associated with a higher risk of bleeding. These genetic factors might explain why some drugs ‘don’t work’ or ‘work too well’ in routine clinical practice.
Christine Sanderson and Meera Agar
Abstract
Delirium is a distressing and under-diagnosed syndrome of acute alteration in mental state. It occurs frequently in patients with advanced cancer and is often associated with a worsening of prognosis and difficult challenges in symptom management. Given its associations with older age, recognition and management of delirious patients are likely to become an even more important aspect of oncological practice in the future. The potential for prevention of delirium is being studied, and protocols which involve modifications in hospital care, in addition to screening and rapid identification and treatment of precipitants, may reduce the burden of the condition. However, such approaches require further study and validation in an advanced cancer population. Routine use of appropriate and validated screening tools is a low burden strategy which is likely to improve diagnosis, care and understanding of delirium. The evidence to guide pharmacological management is not strong. Well designed clinical trials are urgently needed in order to improve supportive care outcomes for delirious patients and to clarify the role of antipsychotic and other medications in symptomatic management.
Bronwen Hewitt, Erin Bugden and Polly Levinson
Abstract
In palliative care, the presence of lymphoedema poses an interesting challenge for both patients and clinicians. When determining an appropriate management plan for a patient with advanced disease and lymphoedema, a number of factors need to be considered. These include: the extent of the oedema; the impact of the oedema and its management on other symptoms such as pain, breathlessness and fatigue; the expectations of the patient; and the patient’s tolerance of different treatment modalities. Current evidence suggests that combined with good skin care, the modalities most effective in the management of lymphoedema include massage (manual lymphatic drainage), compression (multilayer compression bandaging or compression garments) and exercise. This paper discusses how these modalities can be effectively modified for use in a palliative care setting and presents two case studies to illustrate some of the practical considerations of lymphoedema management in palliative care.
Patricia M Davidson and David C Currow
Abstract
Breathlessness is a common and distressing symptom in both malignant and non-malignant conditions. Both pharmacological and non-pharmacological strategies are necessary to minimise symptom burden and distress. Assessing the individual’s needs and clarifying the goals of treatment is an important first step in determining an effective treatment plan. Although the evidence supporting the use of some of these therapies is variable, there is an increasing evidence base to inform clinical decision making and treatment plans. Pharmacotherapy with opioids is a common and effective strategy for managing breathlessness, yet requires judicious titration and management. The adverse effects of opioid therapy, including constipation and drowsiness, can be anticipated and managed with adjunctive therapies. The use of oxygen in people who are hypoxaemic is supported, but is of limited value in people who are not hypoxaemic. Individualised strategies and advance care planning is important to avoid unnecessary hospitalisations and futile treatments at the end of life. There is a clear mismatch between the prevalence and burden of this problem and data to inform evidence-based guidelines. Refractory breathlessness is a fertile area for ongoing research and requires increased attention to address the burden of this highly prevalent symptom
Anne M Wilkinson
Abstract
Research into the experience of unpaid caregiving has been growing since the 1980s with the introduction of ‘community care’ policies in Australia and in other Western societies. There is now a large body of research that sheds light on various aspects of the experience of cancer end-of-life caregiving. The aim of this article is to explore what is known about the roles, needs, adverse impacts and concerns of family caregivers providing care to advanced cancer patients at the end of life. Reviewed literature, published between 1990 and 2010, focused on end-of-life cancer caring in the home, but includes in-patient palliative care interventions. Where relevant, general end-of-life caregiving literature to supplement the cancer specific research is included. Five major dimensions of the end-of-life cancer carer experience are identified: the end-of-life cancer carer role, impact of end-of-life caregiving; positive aspects of caregiving; carer perceptions of need; and access to palliative care.
Andrew MD Cole
Abstract
Rehabilitation has much to offer cancer patients with physical functioning issues related to nervous and musculoskeletal problems, as well as the general debility that may be a feature of advanced cancer. Individual members of the rehabilitation team bring their skills to bear to improve the ability of patients to live their daily lives as independently as possible. Rehabilitation outcomes can be measured with standardised assessments, including Barthel Index and the Functional Independence Measure, which may form part of casemix algorithms. There are no randomised control studies of rehabilitation in advanced cancer. However, there are observational studies that provide level III evidence for the efficacy of rehabilitation programs for residual physical disability that may be present in patients after acute treatment of brain tumours, spinal tumours, bony metastases with fractures, and in patients with debility. Patients with brain tumours and spinal tumours can expect a response to therapy that is entirely comparable with that seen in ‘benign’ lesions, such as strokes, brain trauma or spinal trauma in similar anatomical locations. Rehabilitation also has a useful role to play in the debility that may be a feature of advanced cancer. Particular attention must be paid to rehabilitation for return to safe driving of motor vehicles after treatment of brain tumours, and the program generally involves medical and psychological review, as well as occupational therapy assessment of the patient in off-road and on-road settings. There is no place for therapeutic nihilism in the presence of physical disability in cancer patients, any more than there is in the presence of disability due to ‘benign’ illnesses.
John H Kearsley
Abstract
Suffering is a universal human experience, which may be engendered by the onset of illness, especially if illness is perceived to be life threatening. This paper examines the essence of suffering and the common sources of suffering in the setting of illness and the health system. It is proposed that many health care professionals, despite mastering the diagnosis and treatment of physiologic dysfunction, may be at a loss when it comes to helping to relieve patient suffering. At an existential level, suffering arises from the meaning ascribed by patients to events of illness, and is commonly expressed as a personal narrative. In order to help alleviate suffering and to promote healing, clinicians are encouraged to recognise themselves as therapeutic tools in understanding the nature of suffering, listening proactively to the narratives that patients need to tell so that narratives with new meanings can be created.
This page was last updated on : Wednesday, 7 July 2010
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