European journal of cancer : official journal for European Organization for Research and Treatment of Cancer (EORTC) [and] European Association for Cancer Research (EACR)
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Despite advances in cancer survival rates, end of life care remains a vital aspect of cancer management. The use of integrated care pathways can facilitate effective care of dying patients in a generalist setting. ⋯ The key symptoms at the end of life are restlessness, agitation, breathlessness, pain and noisy respiration from retained airway secretions. Ethical tensions arise from the assumptions that the use of opioids and sedatives hastens dying, but this is contradicted by available evidence.
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Breathlessness (or dyspnoea) is a common symptom experienced by cancer patients. It may be iatrogenic and is often caused or aggravated by co-morbidity. ⋯ The main approaches for palliation of dyspnoea include anti-cancer treatments; drugs; oxygen and airflow; non-medical approaches. Further research is needed to clarify the best pharmacological regimens and the place of more invasive interventions.
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We can anticipate that failure to assess cancer pain adequately will inevitably lead to inappropriate application of pain management options. However, it is not always standard practice to teach the limitations of the question 'How bad is the pain?', as well as the need to consider what may complicate pain management or be a poor prognostic factor for pain control. ⋯ Research dating back to the late 1980s has resulted in the development of the Edmonton Classification System for Cancer Pain. This includes many of the factors that may be prognostic for the complexity of cancer pain management and can assist an inexperienced clinician in anticipating the need for specialist advice.
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Randomized Controlled Trial Comparative Study
Subanaesthetic ketamine spares postoperative morphine and controls pain better than standard morphine does alone in orthopaedic-oncological patients.
Postoperative pain in patients with bone and soft tissue cancer is different from that of other surgical patients due to the severity of the pain generated during surgery and because many of them have already been in pain preoperatively. The search for optimal intravenous pharmacologic management for this population is an ongoing one. We conducted a 10-month prospective, randomised, double blind study to compare the effects of a standard morphine dose to a 35%-lower dose plus a subanaesthetic dose of ketamine for postoperative pain control in patients undergoing bone and soft tissue cancer surgery under standardised general anaesthesia. ⋯ The use of subanaesthetic ketamine plus 2/3 the standard dose of morphine following bone and tissue resections results in 1) lower and more stable pain score, 2) approximately 60% morphine sparing effect, 3) a shorter period of postoperative IV-PCA dependence. Such therapy is also associated with better early physical performance.
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Palliative care in children has been emerging as a clinical subspecialty of paediatrics for many years. It requires the knowledge and experience of a paediatrician, combined with the skills of a palliative care specialist. ⋯ This paper reviews recent literature and discusses advances in the development of palliative care services for children and young people with incurable cancer. It highlights key areas where paediatric palliative care differs from that of adults and outlines the barriers to providing palliation and conducting evidence-based research in children and young people dying from cancer.