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Even in those with advanced, life-threatening disease, the prognosis is uncertain, and patients and relatives can derive benefit from involvement in planning care. Many patients undertake informal care planning in collaboration with healthcare professionals, but only a minority proceed to formal advance care planning. Better care planning is needed for frail patients with failing decision-making capacity,...
Oncological emergencies are common in patients with advanced cancer and may confer significant physical and psychological burden. Swift recognition of such events will allow rapid contextualized evaluation and management, which may need to be tailored according the individual patients circumstances. Wherever possible, the anticipation of a potential emergency allows clinicians to preempt potential...
Forty years on from the opening of St Christopher's Hospice and 20 years after palliative medicine was formally recognized as a medical specialty, it remains as diverse as ever. No longer a terminal care service, palliative medicine continues to evolve into supportive care and the management of non-malignant disease. Future challenges will include continuing partnership-working between the independent...
The last quarter of the 20th century produced considerable advances in hospice and palliative care. In many countries, specialist services developed, education programmes got underway and in some cases palliative care ideas began to infiltrate national health policies. Globally, however, palliative care still faces many challenges: lack of recognition and understanding on the part of the health professions...
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...
Pain is one of the most feared symptoms of advanced, progressive disease and dying. It is a common but not universal experience in both advanced malignant and non-malignant conditions. A patient-centred approach involving systematic and thorough assessment, management and regular review can provide pain relief for most patients. Even in advanced disease, it is important to identify the underlying...
A lack of access to specialist palliative care has led to a lack of clinicians' skills, knowledge and attitudes pertinent to the management of patients with chronic conditions such as end-stage heart failure, chronic obstructive pulmonary disease and renal failure. Recognition of the ‘end stage’ remains a key challenge. This article discusses how a palliative care approach can be incorporated into...
Care in the last hours and days of life is a vital part of medical practice and has recently been highlighted in the media following concerns over the use of the Liverpool Care Pathway for the Dying Patient and the subsequent review by Baroness Neuberger. Ensuring a dignified death for patients with appropriate support for carers is a core activity of all healthcare professionals. Once it has been...
Psychiatric conditions are common among patients with advanced illness who are 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 patients, it is necessary to diagnose psychiatric conditions and treat them appropriately. This brief review considers cognitive impairment, delirium, dementia,...
Nausea and vomiting are common problems in palliative care, occurring in 40–70% of patients with advanced incurable disease. Nausea and vomiting can be disease- or treatment-related and require a holistic approach to their management involving a careful assessment of the problem with a focused history and a limited range of key investigations. A knowledge of the likely receptors involved in this complex...
Spiritual and cultural issues are common at the end of life and are a natural part of the process of life and death. They often present as distress or agitation 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. Although it can be suggested that...
Symptom management is the cornerstone of good palliative care. Symptoms of advanced disease, such as pain, nausea and dyspnoea, are readily assessed and frequently the focus of both consultations and research studies. However, there are many other prevalent symptoms that remain unaddressed in clinical practice if not highlighted by the patient or specifically sought by the healthcare professional...
Many patients with cancer suffer from pain – caused by the cancer itself, its treatment or other causes. In the majority of patients, this can be managed by analgesics and adjuncts as recommended by the World Health Organization analgesic ladder. In a significant minority of around 10%, either the pain is not controlled by drugs or the adverse effects are intolerable; interventional procedures should...
Breathlessness is a distressing symptom that arises in many diseases. It has several pathophysiological causes involving peripheral and central receptors and modulated by cortical processing. Older people and patients with cachexia are more susceptible to breathlessness on exertion. Most patients can be assessed by physical examination, and simple investigations including haemoglobin concentration,...
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