CHESHIRE AND MERSEYSIDE PALLIATIVE AND END OF LIFE … · JULY 2012 V1.0 IMPACT OF MORPHINE,...

CHESHIRE AND MERSEYSIDE PALLIATIVE

AND END OF LIFE CARE NETWORK

AUDIT GROUP MEETING

THURSDAY 3RD JULY 2014

AGENDA

2014/15 Audit Programme update

Development of psychological support services in palliative care

Updated Standards and Guidelines

Clinical update

Latest Cochrane reviews

NICE to see you, to see you NICE – Dr Grace Ting & Dr Kate Marley

Perfecting your poster – Dr Karen Groves

Closing remarks

UPDATE ON THE 2014/15

PROGRAMME

Date Topic Consultant

Lead(s)

Trainee Leads Other contributors

September

2014

Bowel obstruction

Neuropathic pain

S&G

Sarah Fradsham

Fawad Ahmad

Clare Jeffries

Emma Longford

Aileen Scott

Graham Holland

Rebecca Telfer

Helen Ferguson

Jenny Carlson

November

2014

End of life drugs Averil Fountain Andrew

Khodabukus

Ami Nwosu

Claire Robinson

Ruth Clark

Moira Watson

Phil Green

Debbie Jones

January

2015

Nausea and vomiting

Bowel obstruction

S&G

Richard Latten

Paula Powell

Seamus Coyle

Laura McGlynn

Jamie Barfield

Ann Griffiths

Agnes Noble

Tania Forrester

March

2015

Review meeting

End of life drugs S&G

May 2015 Bisphosphonates

Nausea and vomiting

S&G

Jenny Smith

Kate Smith

Kath Gaunt

Clare Horlick

Dan Monnery

Anthony Thompson

Barbara Humphries

Lynne Partington

Helen Thomas

Jess Hale

2014/15 PROGRAMME

Prescribing for Palliative Care Patients with Renal

Impairment

EAPC LLEIDA, 2014

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=RxnrIg4I0RFyIM&tbnid=QA44EfGx2xFTvM:&ved=0CAUQjRw&url=https://eapcnet.wordpress.com/page/2/&ei=53OsU-bSG7KV7Aal3ICIBA&bvm=bv.69837884,d.ZGU&psig=AFQjCNH7EDa8o0yV6Gn4D9eVwNNdQQ-Fjw&ust=1403897184565402

EAPC COPENHAGEN, MAY 2015

Abstracts open 15th July 2015

Deadline 15th October 2015

OTHER NEWS…

Audit website – Guidelines added!

Review meeting survey results

Audit data – localisation of results

Dissemination of information

POWERPOINT PRESENTATION

JULY 2012

V1.0

Specialist Palliative Care

Group

SPG Chair Audit Sub Group

Representative(s)

Aintree Julie Raj Catriona Mayland

Liverpool John Ellershaw Sarah Fradsham

Halton Averil Fountain Piet Geboers

Averil Fountain

Warrington Melanie Brooks Esraa Sulaivany

St Helens and Knowsley Alison Coackley Alison Coackley

Janet Lawton

East Cheshire Trevor Rimmer Trevor Rimmer

Central Cheshire Kate Smith Kate Smith

Lynne Partington

Western Cheshire Graham Leng Jenny Smith

Southport, Formby & West

Lancs

Karen Groves

Clare Finnegan

Steven Simpson

Wirral Cathy Lewis-Jones Fawad Ahmad

Isle of Man Ben Harris

DR ANDREW KHODABUKUS

DR AILEEN SCOTT

CLINICAL UPDATE

POWERPOINT

PRESENTATION JULY 2012

V1.0

COCHRANE REVIEWS

• Impact of morphine, fentanyl, oxycodone

or codeine on patient consciousness,

appetite and thirst when used to treat

cancer pain

• Medically-assisted nutrition to assist

palliative care patients

• Medically-assisted hydration to assist

palliative care patients

POWERPOINT


V1.0

IMPACT OF MORPHINE, FENTANYL,

OXYCODONE OR CODEINE ON

PATIENT CONSCIOUSNESS,

APPETITE OR THIRST WHEN USED

TO TREAT CANCER PAIN.

Objectives:

To determine the impact of

opioid treatment on patient

consciousness, appetite and

thirst in randomised controlled

trials of morphine, fentanyl,

oxycodone or codeine for

treating cancer pain.

POWERPOINT


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Selection criteria:

RCTs using multiple doses of these opioids, taken from

four existing or ongoing Cochrane reviews.

Data collection and analysis:

Adverse event data (reduced consciousness, appetite

and thirst) was extracted and each study was assessed

for quality.

POWERPOINT


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Main results:

77 RCTs

5619 randomised participants

Several major problems with how adverse events were

reported

POWERPOINT


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Main results:

No direct evidence that opioids affected patient

consciousness, appetite or thirst when used to treat

cancer pain.

Adverse event incidence rates:

• Constipation 25% Nausea 21%

• Somnolence 23% Dry mouth 17%

• Vomiting, anorexia, dizziness 13%

POWERPOINT


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Authors’ conclusions:

No direct evidence that opioids affect consciousness, appetite or thirst,

but there are other common side effects

Need to develop definitions for adverse events and development of

appropriate measurement tools to record them

Need for further research in this area

http://summaries.cochrane.org/CD011056/impact-of-morphine-fentanyl-oxycodone-or-codeine-on-patient-

consciousness-appetite-and-thirst-when-used-to-treat-cancer-pain

POWERPOINT


V1.0

MEDICALLY ASSISTED NUTRITION

TO ASSIST PALLIATIVE CARE

PATIENTS

Objectives:

To determine the effect

of medically assisted

nutrition on the quality

and length of life of

palliative care patients.

POWERPOINT


V1.0



PATIENTS

Selection criteria:

All relevant randomised controlled trials (RCTs) or

prospective controlled trials (if no RCTs were found).


No RCTs or prospectively controlled trials met the

inclusion criteria.

Cochrane Database of Systematic Reviews

23 APR 2014 DOI: 10.1002/14651858.CD006274.pub3

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006274.pub3/full#CD006274-fig-0001

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006274.pub3/full






POWERPOINT


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PATIENTS

Main results:

• 5 prospective non-controlled trials (including

one qualitative study) that studied medically

assisted nutrition in palliative care

participants

• 1 Cochrane systematic review (on motor

neuron disease that found no RCTs), but no

RCTs or prospective controlled studies.

POWERPOINT


V1.0



PATIENTS

Authors' conclusions:

• insufficient good-quality trials to make

recommendations

• uncontrolled prospective studies suggest patients with a

good performance status and prognosis of months to

years may benefit from medically assisted nutrition.

• the evidence base to support this is weak and intention

to use this treatment should be monitored carefully and

ideally fed in to further research.

http://summaries.cochrane.org/CD006274/medically-assisted-nutrition-to-assist-palliative-care-

patients#sthash.NTaezt0O.dpuf

http://summaries.cochrane.org/CD006274/medically-assisted-nutrition-to-assist-palliative-care-patients

















POWERPOINT


V1.0

MEDICALLY ASSISTED HYDRATION


PATIENTS

Objectives:

To determine the effect

of medically assisted

hydration on the quality

and length of life of

palliative care patients.

POWERPOINT


V1.0



PATIENTS Selection criteria:

All relevant randomised controlled trials (RCTs) or prospective

controlled trials (if no RCTs were found) of medically assisted hydration

in palliative care patients.


• six relevant studies for this update

• three RCTs (222 participants),

• three prospective controlled trials (360 participants).

Cochrane Database of Systematic Reviews

23 APR 2014 DOI: 10.1002/14651858.CD006273.pub3

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006273.pub3/full#CD006273-fig-0001







POWERPOINT


V1.0



PATIENTS Main results:

• Bruera et al (2005) – sedation and myoclonus scores improved more in

the intervention group.

• Morita et al (2005) – dehydration significantly higher in the non-hydration

group

– some fluid retention symptoms (pleural effusion, peripheral oedema and ascites) were significantly higher in the hydration group.

• The other four studies (including the three RCTs) did not show significant differences in outcomes between the two groups.

POWERPOINT


V1.0



PATIENTS

Main results continued:

• The only study that had survival as an

outcome (Bruera, 2013) found no

difference in survival between the

hydration and control arms

POWERPOINT


V1.0

Bruera et al. Parenteral hydration in patients with advanced cancer: a multicenter,

double-blind, placebo-controlled randomized trial.

Journal of Clinical Oncology 2013;21(1):111-8.

Methods Randomised, placebo-controlled, double-blind, multicentre study

Participants Advanced cancer (i.e. locally recurrent or metastatic disease) who

were:

•aged ≥ 18 years admitted to hospice

• reduced oral intake of fluids with evidence of mild or moderate

dehydration as defined by:

• decreased skin turgor in subclavicular region (2 seconds) and

• score of ≥ 2 of 5 in the clinical dehydration assessment

•intensity of ≥ 1 on a 0 to 10 scale for fatigue and 2 of the 3 other target

symptoms (hallucinations, sedation and myoclonus)

•life expectancy 1 week

•availability of a primary carer

•MDAS score < 13

•ability to give written informed consent

•geographic accessibility (within 60 miles of the University of Texas MD

Anderson Cancer Center)

Sample size: 905 patients assessed for eligibility

Excluded: 776

Included: 129

Underpowered - powered for 150 patients but recruitment stopped at

129 due to funding limitations

POWERPOINT


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Interventions 129 patients were randomised to 1 of 2 groups

1.Parenteral hydration (1000 mL normal saline administered

subcutaneously over 4 hours) (63 recruited, 49 completed and

analysed)

2.Placebo (100 mL normal saline administered subcutaneously over 4

hours) (66 recruited, 53 completed and analysed)

Outcomes Primary outcome:

1.Change in the sum of 4 dehydration symptoms (fatigue, myoclonus,

sedation and hallucinations) between day 4 and baseline - no

difference between groups

Secondary outcomes:

1.Delirium: MDAS - no difference, RASS - no difference, NuDESC - no

difference, except night-time NuDESC where placebo group

deteriorated more than intervention group (P value = 0.028)


sedation and hallucinations) between day seven and baseline: no


3.Global symptom evaluation: no difference between groups

4.Quality of life: day 7, using FACIT-F and FACIT-G: no difference

between groups

5.Hydration status: using dehydration assessment scale: no difference

between groups at day 4 and day 7

6.Survival: median survival 17 days, with no significant difference

between groups

POWERPOINT


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Outcomes Primary outcome:


sedation and hallucinations) between day 4 and baseline - no


Secondary outcomes:

1.Delirium: MDAS - no difference, RASS - no difference, NuDESC - no

difference, except night-time NuDESC where placebo group

deteriorated more than intervention group (P value = 0.028)


sedation and hallucinations) between day seven and baseline: no


3.Global symptom evaluation: no difference between groups

4.Quality of life: day 7, using FACIT-F and FACIT-G: no difference

between groups

5.Hydration status: using dehydration assessment scale: no difference

between groups at day 4 and day 7

6.Survival: median survival 17 days, with no significant difference

between groups

POWERPOINT


V1.0



PATIENTS Authors' conclusions:

• No significant benefit in the use of medically assisted hydration in palliative care patients

• However, there are insufficient good-quality studies to inform definitive recommendations for practice with regard to the use of medically assisted hydration in palliative care patients

- See more at: http://summaries.cochrane.org/CD006273/medically-assisted-hydration-to-assist-palliative-care-patients#sthash.qErhHfZR.dpuf

http://summaries.cochrane.org/CD006273/medically-assisted-hydration-to-assist-palliative-care-patients

















POWERPOINT


V1.0

REGIONAL GUIDELINES ON

HYDRATION

• All patients are entitled to food and drink as part of basic

care. You should satisfy yourself that oral hydration is being

provided in a way that meets the patients’ needs and that

any problems such as swallowing problems or risk of

choking are being managed effectively.

• Decisions surrounding the use of CAH should be discussed

with the multi-professional team, patients and relatives in

accordance with the Mental Capacity Act.

POWERPOINT


V1.0

REGIONAL GUIDELINES ON

HYDRATION

• Decisions regarding the use of CAH should take into consideration the potential harms and benefits to the patient.

• Hydration decisions should be individualised and include the participation of the family, patient and other disciplines

• A time-limited trial of CAH to assess if it improves symptoms may be appropriate in some patients

POWERPOINT


V1.0

REGIONAL STANDARDS IN

HYDRATION

• Decisions surrounding the use of CAH in dying patients should

involve the multi-professional team and be clearly documented in

the case notes

• If CAH is continued in the dying phase, the appropriateness and

benefits of its use should be reviewed on a daily basis

• If artificial hydration is continued in the dying phase, a rate of 1 litre

over 24 hours intravenously or subcutaneously (or via a PEG/PEJ)

is the recommended regimen

DR GRACE TING

DR KATE MARLEY

CANCER-RELATED NEUROPATHIC PAIN AUDIT GROUP

NICE TO SEE YOU, TO SEE YOU NICE!

POWERPOINT


V1.0

WHAT WE DID WELL…

• Defining the clinical question.

• “Breaking it down”.

• Working in pairs to search, review & grade

evidence.

• Information gathering between meetings.

• Deadlines / Timelines.

POWERPOINT


V1.0

CHALLENGES

• Grading the evidence

– classifying study design

– where 2 could not agree, a 3rd opinion (or

group opinion) was sought.

POWERPOINT


V1.0

Guideline Development Manual March 2014,

p11

POWERPOINT


V1.0

http://www.sign.ac.uk/pdf/studydesign.pdf

POWERPOINT


V1.0

CHALLENGES

• Grading the evidence

– classifying study design

– where 2 could not agree, a 3rd opinion (or

group opinion) was sought.

• Added time & workload of literature review

• Patient involvement

POWERPOINT


V1.0

WHAT WOULD WE DO DIFFERENTLY?

POWERPOINT


V1.0

WHAT WOULD WE DO

DIFFERENTLY?

Audit Manual March 2014, p30

POWERPOINT


V1.0

WHAT WOULD WE DO

DIFFERENTLY?

POWERPOINT


V1.0

HINTS & TIPS

• Recruit enough members to the group from the outset and ensure everyone knows what they need to do.

• Have a plan for patient and carer involvement from the outset. Patient forums may be useful as well as approaching individual patients.

• Agree the scope of the guideline – e.g. if it is about cancer, stick to cancer; are you going to look at diagnosis, assessment, and/or treatments?

POWERPOINT


V1.0

HINTS & TIPS

• Ensure you have a good list of relevant

clinical questions.

– Do not be tempted to deviate from these

without the rest of the group’s agreement

• Audit questionnaire

– Be clear about what you want to know

– Keep it user friendly

POWERPOINT


V1.0

HINTS & TIPS

• Discuss how you are going to grade

papers in advance and ensure everyone

using same method.

• Make sure meetings are scheduled well in

advance.

• Someone to take responsibility for

coordinating and collating findings into

presentation.

POWERPOINT


V1.0

THANK YOU.

NEXT MEETING:

THURSDAY 25TH SEPTEMBER

BOWEL OBSTRUCTION AUDIT

CHESHIRE AND MERSEYSIDE PALLIATIVE AND END OF LIFE … · JULY 2012 V1.0 IMPACT OF MORPHINE,...

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