J Palliat Care
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The lack of control of physical suffering among cancer patients in the last days or hours of life is a common medical problem but it is rarely discussed in an open fashion. We carried out a prospective study of the dying of 120 terminal cancer patients assisted by a home care team. We documented how long it was before death that physical symptoms, unendurable to the patient and controlled only by sedation-inducing sleep, appeared. ⋯ The most frequent symptoms were dyspnea in lung and head and neck disease; pain in breast, gastrointestinal tract, colon-rectum, and male genitourinary tract cancer; and vomiting in female genitourinary tract malignancies. Data reported emphasize the clinical relevance of physical symptoms in the last days of life in terminal cancer patients and how these serve to indicate imminent death. More than 50% of these patients die with physical suffering that is controllable only by means of sedation.
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The growth of various palliative care programs is continuing. The family unit is affected by the need for palliative care in one family member. It is critical, therefore, to know what models of palliative care are preferred by families who are experiencing the need for such services. ⋯ Five interrelated concepts explained this preference. The ability of families to realize their preference was dependent upon four factors. These concepts and factors are discussed, focusing on resultant implications for practice.
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It is possible that a physician who administers life-shortening palliative care, even to a terminally ill patient with the patient's consent, commits murder. The Law Reform Commission of Canada, as part of its proposals on recodifying criminal law, has recommended that criminal liability not attach to the administration of life-shortening palliative care "appropriate in the circumstances". The author submits that while the aim of the Commission's recommendation is good, the phrase "appropriate in the circumstances" should be replaced with more specific criteria for determining when life-shortening palliative care may be administered. Failure to do so would leave physicians in almost as uncertain a situation as is presently the case, preventing them from administering such care without fear of criminal liability.
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Morphine and hydromorphone infusions of 6 or more (average 25.75) days in duration were used with increasing frequency (up to 7%) by our oncology inpatients. Eighty-six percent of the 135 inpatients we reviewed realized good pain control with dose rates up to 700 morphine-equivalent (ME) mg/h. Local toxicity occurred on only 10 occasions. ⋯ Adjuvant therapies were not used as frequently as might be warranted. We believe that narcotic infusions, particularly subcutaneous ones, are safe and effective. Further prospective trials are needed to clarify how they should be combined with other therapies to control cancer pain that is poorly responsive to narcotics, and to better understand the etiology and management of serious side effects.
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To assess the necessity and feasibility of introducing a home-based palliative care program for children admitted to our neurosurgical unit and diagnosed as being terminally ill, we conducted an analysis of all such patients admitted to our unit over an 18-month period. Of a total of 30 patients, 22 (73.4%) had central nervous system tumors, 6 (20.0%) had myelomeningocele/hydrocephalus, and 2 (6.6%) had arteriovenous malformations. The mean duration +/- SEM of hospitalized days prior to death and the proportion of time spent hospitalized during the terminal phase of illness were 28.8 +/- 4.77 and 0.327 respectively, for the 23 patients who died and on whom adequate data were available. ⋯ The most troublesome symptoms in this subgroup were feeding difficulties, gastrointestinal symptoms, breathing difficulty, and seizures. These symptoms were managed either by (a) medications administered orally or by feeding tube or rectally, or by (b) noninvasive procedures carried out by a nurse under the direction of the admitting neurosurgeon. This study suggests that prolonged hospitalization for children diagnosed as being terminally ill can be avoided by introducing a home-based palliative program with involvement from a nurse and a physician familiar with drug therapy for terminally ill children.