Aim & Background: 
Renal patients, particularly those on dialysis, are known to have high morbidity and mortality risks, and their illness trajectory often leads to death in hospital. We aimed to identify the intensity of interventions and treatment renal patients experience during their final hospital admission.

Methods: 
Utilising electronic medical records and Rapid Response Team (RRT) data, we performed an audit of the terminal admissions of adult renal inpatients who died in a large tertiary hospital between January 2020 to September 2021 and their final 6 months of life. We collected demographic data and treatment information regarding their final 6 months as well as escalations of care during the terminal hospital admission prior to death, including time in intensive care, RRT data and number of invasive interventions such as surgery.

Results: 
We identified 90 patients who died in hospital during the specified period; 19% were from regional or rural areas. The majority were on haemodialysis (51/90, 56.7%) and had over 3 comorbidities (56.7%). Of those not on dialysis at presentation, 32% (8/25) were initiated on dialysis. During the final admission, 52.2% (47/90) had a RRT call, 38.9% (35/90) an intensive care stay, and 54.4% (49/90) underwent an invasive intervention. In the preceding 6 months, 44.4% (40/90) had had 2 or more hospital admissions and 23.3% (21/90) presented to the emergency department 4 or more times. Only 10% had completed an advanced care directive prior to the final admission.

Conclusion: 
Our audit highlights the treatment burdens renal patients can experience towards the end of life, and possible missed opportunities for identifying a patient’s values and achieving goal-concordant care. Being able to identify patients with terminal trajectories may facilitate advanced care planning, earlier involvement with palliative care, and help to reduce recurrent hospital presentations and unnecessary interventions.

Background: Use of methadone for the management of pain is increasing. Despite this there is variability in methods of prescription including: adjunctive vs. full opioid rotation, use for neuropathic vs. nociceptive pain, and opioid to methadone ratios.

Aim: To describe (1) patterns of methadone prescription for pain management by palliative care in a quaternary setting, (2) efficacy and tolerability of methadone and (3) optimal pain-type indications.

Methods: Details of methadone prescription by a palliative care consultation-liaison service in an acute hospital were analysed between 2019-2022. Prescriptions in outpatient settings, performed by non-palliative care clinicians, and for indications other than pain were excluded. Initial prescribing doses, adjuvant use, opioid rotation, or initial primary opioid, methadone conversion ratio, efficacy, and adverse events were recorded.

Results: Fifty seven patients were included; Rotation from another opioid occurred for 20 (35%) patients, adjunctive use of methadone for 35 (61%), and methadone as an initial opioid agent for two patients (4%). Improvement in pain occurred for 38 (72%) patients. For patients with nociceptive pain, 58% responded (14/24), compared to 80% for neuropathic pain (4/5), and 74% for mixed neuropathic/nociceptive (20/27). Titration of methadone to final dose required 14 days for adjuvants and 10 days for full rotation. Adverse events occurred in 16 (27%). Cessation was required in 5 (12%) of adjuvants and 1 (5%) in the rotational group. 

Conclusions:  Our findings support literature that methadone is safe and effective when used for pain in palliative care. Interestingly, our study challenges the notion that adjunctive methadone is better tolerated and faster to titrate than full methadone rotation. Prospective studies should further evaluate time taken to final methadone dose and tolerability for full rotation versus adjunctive methadone.

Background:

With the end in mind, families ask the “how long” question. They want to know what to expect, but importantly, how much time they have left with their loved-one. Understanding and predicting the length of time to death once the person with a life-limiting illness becomes unrousable and deemed to be imminently dying is crucial for clinicians and families. For clinicians, answers to this question will aid decision making, focus care and ensure appropriate support for the family.
 

Aim:

The research sought to determine the length of time between becoming unrousable and death.

Method:

This is a retrospective consecutive cohort study of 2449 patients between 2017 and 2021 who received specialist palliative care as hospice inpatients, or at home. 50,332 associated Australia-modified Karnofsky Performance Status (AKPS) scores were analysed. 
 

Using Kaplan-Meier survival analysis we analysed the time from the first AKPS 10 (unrousable) to death to determine the duration of patients’ terminal phase, considering variations across age, sex, diagnosis, and location of death. We examined the time from the first AKPS 20 to being unrousable (AKPS 10) to predict future decline. Survival curves were compared using the Wilcoxon (Breslow) test. 
 

Results:

From the first AKPS 10 score, 51% of patients were unrousable for longer than one day, with a mean of two days. Adjusting for covariates, the likelihood of death within four days of becoming unrousable is 80%. Four percent of outliers survived past seven days, the longest being 16 days. After recording an AKPS 20, there is 60% chance the patient will become unrousable within two weeks.  
 

Conclusion:

The research provides clinicians with confidence when responding to the “how long” question. This knowledge can be used to anticipate and plan for end-of-life care and provide families with the information they need to prepare for their loved one’s death.

Background: Psycho-existential symptoms may be overlooked in palliative care. Screening can be a helpful way to recognise these patients.

Aim: To discern the prevalence of psycho-existential symptoms identified through routine screening.

Methods: Through use of the Psycho-existential Symptom Assessment Scale (PeSAS), data were collected from 1405 patients across six palliative care services representing a mix of models of care, and the use of pencil and paper versus electronic medical records. Symptom prevalences were computed as frequencies, with the precision of measurement represented by the difference in 95% confidence intervals. A network structure was estimated through exploratory graph analysis portraying the strength of associations between individual symptoms when all other correlations are controlled for.

Results: Psycho-existential symptoms with clinically significant prevalence (scores ≥ 4/10) included anxiety 41.1%, discouragement 37.6%, hopelessness 35.8%, pointlessness 26.9%, depression 30.3%, and the wish to die 17%. A precision of measurement within 3% was found for severe ratings (score ≥ 8/10) including anxiety 10.6%, depression 10.2%, the wish to die 7.6%, and confusion 3.6%. Higher PeSAS scores were predicted by lower Karnofsky ratings and unstable/deteriorating/terminal phases of care. Network analysis revealed hopelessness as the most central symptom, pointlessness most strongly associated with the wish to die, and feeling trapped was associated with loss of control and loss of roles.

Conclusions: PeSAS screening helped the recognition of psycho-existential distress, and revealed symptom prevalences that are challenging to our efforts to ameliorate this form of suffering. Training is desirable to help clinicians grow in confidence to discuss and respond to these symptoms.

Background-The evidence for clonidine as an analgesic for cancer and non-cancer pain via the intravenous, intrathecal and epidural route is strong but systemic administration via the oral route is weak. Aims: The primary aim was to examine the effectiveness of oral clonidine as an analgesic in patients with complex cancer and non-cancer pain needs. The secondary aims include finding the median range in dosing and dosing intervals in patients where clonidine has been well tolerated, and establishing what side effects are experienced by these patients. Results-Twenty-one patients who were commenced on clonidine were identified. Thirteen patients were men and eight were women.  Average age was 51.77 years old. Mean duration of the patient’s pain was 74.45 days and median duration was 37.5 days. Average starting dose of clonidine per day administered was 83.5 micrograms per day, while the maximum total daily dose was 103.4micrograms. Of the patients, 14 had cancer related pain and the remaining non cancer related pain.  The most common site of pain were the legs. The average pain score prior to starting clonidine was 7.59 and the average pain score after starting clonidine was 5.59. Majority (15) patients demonstrated a decrease in their use of “as required analgesia” after clonidine introduction. Of the 22 patients included in the study, majority (15) patients demonstrated a decrease in their use of “as required analgesia” after clonidine introduction. Conclusion: The current study demonstrates that oral clonidine is an effective co- analgesic in resistant cancer and non-cancer pain, including in the treatment of OIH. Systemic side effects are uncommon when oral clonidine was used at dosages up-to 200mcg/day in divided doses. We would recommend more research into the use of clonidine as a co-analgesic in difficult to control pain. 

The management of pain for patients with a prior history of Substance Use Disorder Use (SUD) is challenging. This becomes more complex when the patient is actively using illicit substances, and an acute crisis and risk management concern when the patient is discovered injecting in the Hospice.

We describe a complex case of this situation and the strategies put in place to manage this.

A 46-year-old patient with metastatic melanoma with choroidal metastases, extensive leptomeningeal deposits, and spinal cord involvement with lower limb paralysis was admitted to our Hospice for control of severe pain. Large doses of opioids, methadone and adjuvants were being prescribed, with minimal benefit.  The patient was heavily sedated at times, however would wake and request further breakthrough doses of opioids. We discovered  that the patient was self-injecting extra opioids and methamphetamines consistent with long-term behaviours. 

Urgent planning was undertaken by treating medical and nursing clinicians and risk management. Open and frank conversations with the patient and family ensued, with an attempt to set strict limits around illicit use and appropriate behaviour. Management strategies were put in place for patient and visitors, and staff safety. 

Tension was evident between the abuse of the system, balancing safety for staff and other patients, mitigating risk for the health service, whilst aiming to provide the best care for a person who was suffering from the duality of an advanced malignancy with a short prognosis and  intractable drug addiction.

Staff were engaged in consultation, formal debriefing undertaken and a checklist developed for future patients with a life limiting illness and a SUD, which will guide proactive management of similar situations.

We hope our learnings from this clinically and ethically complex case can improve the care for this small but complex group of patients with a terminal illness and substance use disorder.