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Sudden changes in a patient’s condition that require urgent treatment are not uncommon during the last phase of a patient’s life. The diagnosis and management of spinal cord compression, shortness of breath, haemorrhage, metabolic disturbance, fractures and neurological conditions are discussed. Appropriate treatment can make a big difference to how the patient and family cope and anticipation of...
Nausea and vomiting are common problems in palliative care, occurring in 40–70% of patients with advanced incurable disease. They may be disease- or treatment-related, and require a holistic approach to their management. Careful assessment of the problem, with a focused history and a limited range of key investigations, is essential to effective management. Knowledge of the likely receptors involved...
Facing potential loss (of health, bodily functions, independence, a future, hope for a cure, control) can be overwhelming for all individuals involved, including healthcare professionals. However, understanding the profound impact of loss and how it can be managed enables those involved to gain a sense of control and hopefulness. Doctors can use their relationship with patient and family to help individuals...
In those with life-threatening disease, prognosis is unpredictable. Communication with the patient and family must guide the clinician, always weighing up the benefits against the risks and burdens of any intervention, and recognizing when interventions are futile in the face of irreversible deterioration. There is no evidence that patients’ lives are shortened when opioids and other drugs are used...
From 19th century roots, palliative care developed in the later part of the 20th century as a social movement and medical specialty. Dr Cicely Saunders was central to its modern development; her vision for improving the care of the dying encompassed the physical, psychological, social and spiritual domains whilst emphasizing the importance of rigorous clinical practice, training and research. St Christopher’s...
Care in the terminal phase is an important part of medical practice. Ensuring a dignified death for patients with appropriate support for carers is a core activity of all healthcare professionals. Once a patient has entered the dying phase it is important that pain and symptom control is managed appropriately. All medication that needs to be continued should be converted to the subcutaneous route...
Forty years on from the opening of St Christopher’s Hospice and twenty years after the specialty was formally recognized as a medical specialty, palliative medicine remains as diverse as ever. No longer a terminal care service, the specialty continues to evolve its role into supportive care and the management of non-malignant disease. Future challenges will include ongoing partnership working between...
A lack of access to specialist palliative care (SPC) has led to a lack of clinicians’ skills, knowledge and attitudes pertinent to the management of patients with end-stage heart failure, chronic obstructive pulmonary disease (COPD) and renal failure. Recognition of the ‘end-stage’ itself remains a key challenge. This article discusses how a palliative care approach can be incorporated into standard...
Psychiatric issues are common among those with advanced illness referred to palliative care services. Psychiatric illness can cause considerable distress to both patients and their families. In order to improve end-of-life care for palliative patients, it is necessary to diagnose psychiatric conditions and to treat them appropriately. This review considers the more common issues of delirium, dementia,...
Breathlessness is a distressing symptom which arises in many diseases and has several pathophysiological causes, involving the interplay between peripheral and central chemoreceptors, lung receptors, chest wall and diaphragmatic muscles and cortical processing. Older people and patients with cachexia are more susceptible to breathlessness on exertion. Most patients can be assessed with physical examination...
Anorexia, cachexia and malnutrition occur in many chronic disease states including cancer, chronic obstructive pulmonary disease, chronic heart failure, chronic renal failure, chronic liver failure, rheumatoid arthritis and AIDS. Despite the relative frequency of such symptoms and signs, they are often overlooked or managed inadequately. Cachexia is characterized by a negative nitrogen and energy...
About 10% of patients have pain that is difficult and they may benefit from interventions such as nerve blocks, intrathecal drug delivery (ITDD) or percutaneous cordotomy. Early referral for specialist pain management is needed if interventional techniques are being considered. It is important to manage pain with the simplest methods possible and to consider all available alternatives to an invasive...
Despite medical advances over the past 20 years, pain remains a problem in 60% of patients with advanced cancer and other fatal diseases. In this article, we focus on how to assess and diagnose pain, and explore basic pharmacological and other pain-relieving interventions. Important issues highlighted are the need for skilled assessment and timely decisions in getting to grips with pain control quickly...
Spiritual and cultural issues at the end of life are common and a natural part of the process of life and death. They often present as distress or agitation in the patient and should be considered when pain control is difficult to manage. Spirituality can be defined as our sense of meaning in life. It is often influenced by, and regularly confused with, religion and culture. While it can be suggested...
The most common symptoms of advanced disease, such as pain, nausea and dyspnoea, are readily assessed and often the focus of consultations. However, many prevalent symptoms remain that may be ignored if not specifically sought by the healthcare professional and, unaddressed, these symptoms may have a significant impact on remaining quality of life. This paper will focus on the assessment and management...
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