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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
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
PRESENTATION JULY 2012
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
PRESENTATION JULY 2012
V1.0
IMPACT OF MORPHINE, FENTANYL,
OXYCODONE OR CODEINE ON
PATIENT CONSCIOUSNESS,
APPETITE OR THIRST WHEN USED
TO TREAT CANCER PAIN.
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
PRESENTATION JULY 2012
V1.0
IMPACT OF MORPHINE, FENTANYL,
OXYCODONE OR CODEINE ON
PATIENT CONSCIOUSNESS,
APPETITE OR THIRST WHEN USED
TO TREAT CANCER PAIN.
Main results:
77 RCTs
5619 randomised participants
Several major problems with how adverse events were
reported
POWERPOINT
PRESENTATION JULY 2012
V1.0
IMPACT OF MORPHINE, FENTANYL,
OXYCODONE OR CODEINE ON
PATIENT CONSCIOUSNESS,
APPETITE OR THIRST WHEN USED
TO TREAT CANCER PAIN.
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
PRESENTATION JULY 2012
V1.0
IMPACT OF MORPHINE, FENTANYL,
OXYCODONE OR CODEINE ON
PATIENT CONSCIOUSNESS,
APPETITE OR THIRST WHEN USED
TO TREAT CANCER PAIN.
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
PRESENTATION JULY 2012
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
PRESENTATION JULY 2012
V1.0
MEDICALLY ASSISTED NUTRITION
TO ASSIST PALLIATIVE CARE
PATIENTS
Selection criteria:
All relevant randomised controlled trials (RCTs) or
prospective controlled trials (if no RCTs were found).
Data collection and analysis:
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
POWERPOINT
PRESENTATION JULY 2012
V1.0
MEDICALLY ASSISTED NUTRITION
TO ASSIST PALLIATIVE CARE
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
PRESENTATION JULY 2012
V1.0
MEDICALLY ASSISTED NUTRITION
TO ASSIST PALLIATIVE CARE
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
POWERPOINT
PRESENTATION JULY 2012
V1.0
MEDICALLY ASSISTED HYDRATION
TO ASSIST PALLIATIVE CARE
PATIENTS
Objectives:
To determine the effect
of medically assisted
hydration on the quality
and length of life of
palliative care patients.
POWERPOINT
PRESENTATION JULY 2012
V1.0
MEDICALLY ASSISTED HYDRATION
TO ASSIST PALLIATIVE CARE
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.
Data collection and analysis:
• 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
PRESENTATION JULY 2012
V1.0
MEDICALLY ASSISTED HYDRATION
TO ASSIST PALLIATIVE CARE
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
PRESENTATION JULY 2012
V1.0
MEDICALLY ASSISTED HYDRATION
TO ASSIST PALLIATIVE CARE
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
PRESENTATION JULY 2012
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
PRESENTATION JULY 2012
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.
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)
2.Change in the sum of 4 dehydration symptoms (fatigue, myoclonus,
sedation and hallucinations) between day seven and baseline: no
difference between groups
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
PRESENTATION JULY 2012
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.
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)
2.Change in the sum of 4 dehydration symptoms (fatigue, myoclonus,
sedation and hallucinations) between day seven and baseline: no
difference between groups
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
PRESENTATION JULY 2012
V1.0
MEDICALLY ASSISTED HYDRATION
TO ASSIST PALLIATIVE CARE
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
POWERPOINT
PRESENTATION JULY 2012
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
PRESENTATION JULY 2012
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
PRESENTATION JULY 2012
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
PRESENTATION JULY 2012
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
PRESENTATION JULY 2012
V1.0
CHALLENGES
• Grading the evidence
– classifying study design
– where 2 could not agree, a 3rd opinion (or
group opinion) was sought.
POWERPOINT
PRESENTATION JULY 2012
V1.0
Guideline Development Manual March 2014,
p11
POWERPOINT
PRESENTATION JULY 2012
V1.0
http://www.sign.ac.uk/pdf/studydesign.pdf
POWERPOINT
PRESENTATION JULY 2012
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
PRESENTATION JULY 2012
V1.0
WHAT WOULD WE DO DIFFERENTLY?
POWERPOINT
PRESENTATION JULY 2012
V1.0
WHAT WOULD WE DO
DIFFERENTLY?
Audit Manual March 2014, p30
POWERPOINT
PRESENTATION JULY 2012
V1.0
WHAT WOULD WE DO
DIFFERENTLY?
POWERPOINT
PRESENTATION JULY 2012
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
PRESENTATION JULY 2012
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
PRESENTATION JULY 2012
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
PRESENTATION JULY 2012
V1.0
THANK YOU.
NEXT MEETING:
THURSDAY 25TH SEPTEMBER
BOWEL OBSTRUCTION AUDIT
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