Background: Guidelines exist to direct end-of-life symptom management in COVID-19 patients. However, the real-world symptom patterns, and degree of concordance with guidelines on medication use, and palliative care involvement has received limited attention. 

Aim/Objectives: To describe the evolution of COVID-19 symptoms, medication used to alleviate these, and degree of palliative care involvement in the final week of life. 

Methods: This retrospective study reviewed all COVID-19 inpatient deaths across five metropolitan hospitals in Australia from 1 January – 31 December 2020. Outcome measures were collected at day of death, and days 1, 2, 5, and 7 before death. These were COVID-19 symptom severity (measured by the Palliative Care Outcome Scale), and use of supportive pharmacological and non-pharmacological therapies. Palliative care referral timepoint was also collected.

Results: Within the sample of 230 patients, commonest symptoms were breathlessness, agitation, pain, and respiratory secretions. On day of death, 79% (n=181) experienced at least one symptom, and 30% (n=68) experienced severe/extreme symptoms. The use of midazolam, glycopyrrolate, and infusions for symptom management occurred late, less frequently, and at lower doses than suggested in guidelines and other studies. Palliative care referrals were made late, at median 3 days before death (IQR 1-6 days), and for only half of people dying from COVID-19 (51%; n=118).

Conclusion: Symptoms peaked in final 3 days of life. Earlier use of infusional and breakthrough medications should be considered in anticipation of symptoms given high likelihood of dying in discomfort. Earlier palliative care referral for high-risk patients should be considered at hospital admission.

Background:  
Adequate and effective symptom control is essential to ensure quality of life. We present a case study demonstrating multiple teams working together to provide complex, patient centred, sustainable care, in the location of her choice.  

A 46yo woman from a remote town in WA, with metastatic breast cancer and significant pelvic bony involvement, was requiring multiple analgesics to manage her pain.  This led to significant toxicity, resulting in delirium and drowsiness.  

Method: 
She was transferred to Perth and an intrathecal catheter was placed, with significant improvement in her symptoms and decrease in opioid toxicity.  Addressing emotional distress and providing support from counselling also contributed significantly to her comfort. Counselling was also useful in supporting her family, enabling them to continue to be involved in her care.  

Upskilling and education for staff was essential to the safe use of this specialist technique.  Medical and nursing team members travelled to Perth to learn about the practical and clinical aspects of an intrathecal. The metropolitan team travelled to the region to deliver intensive education to ward and emergency staff across multiple disciplines and also to the ambulance team.  

Outcomes:  
The patient was successfully transferred back to her home, with an intrathecal insitu.  This continues to provide good symptom control, with ongoing care being provided by the local team with support from the metropolitan team. 

Lessons learnt:
·        education and support of the regional team created a confident and skilled workforce 

·        the use of technology enables pain specialists, palliative care specialists and rural team members to work together in a supported and sustainable way 

Conclusion:
This case study displays the success of collaboration of remote and metropolitan palliative care teams to achieve specialist sustainable patient-centred care in remote Western Australia.

Background: Breakthrough cancer pain (BtCP) is prevalent in cancer patients with advanced disease requiring clinical intervention. A systematic review undertaken by the authors as a part of a multiphase study, confirmed that limited peer-reviewed research has considered health professional perspectives of BtCP. 

Aim: This mixed-methods study aimed to assess clinician perspectives of BtCP, and particularly clarify (i) clinician understandings of BtCP,(ii) factors contributing to treatment decisions, and (ii) professional development.  

Methods: Participants included clinicians involved in the diagnosis and treatment of BtCP in Australia: medical oncologists, radiation oncologists, palliative medicine physicians, general practitioners who treat cancer patients, and nurses involved in the care of cancer patients. Initially, participants were invited to complete a cross-sectional survey which included nominal response option and open-ended questions aligned with study aims. After, those with interest, participated in a semi-structured interview to further explore clinician perspectives surrounding BtCP. Descriptive statistics were produced from survey data. Open-ended survey questions and interview transcripts were analysed using an inductive, grounded approach.   

Results: Findings include: (i) key characteristics which enable clinicians to establish that a patient is experiencing BtCP, (ii) factors which support and inhibit management of BtCP, and (iii) the extent of professional development received and professional development and training needs of clinicians. 

Conclusions: Diverse health professionals working to address BtCP engage with patients at different periods and contexts, thus prioritise diverse characteristics when establishing whether a patient is experiencing BtCP. Thus, barriers and facilitators to treatment and professional development requirements differ between health professionals. In part, ensuring that clinicians are aware of BtCP understandings and priorities across complementary health professions will support improved coordinated BtCP management. Professional development can assist in ensuring consistent interdisciplinary understandings of BtCP. 

Aim: We aimed to identify factors influencing dialysis withdrawal following modality change from peritoneal dialysis (PD) to haemodialysis (HD) using the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) between 2004-2019.

Background: Dialysis modality change is a frequent occurrence among patients on PD. Death attributed to dialysis withdrawal following a transition to HD is an under-researched area and this transition point may represent an opportunity for earlier engagement with palliative and supportive care.

Methods: Utilising the ANZDATA registry, which collects patient data from all renal units across Australia and New Zealand, we performed a retrospective observational cohort study to identify the risk factors for dialysis withdrawal following a switch from PD to HD. We included all adult patients (>18 years old) who initiated PD in Australia and New Zealand between 2004-2019 and subsequently transitioned to HD. The primary outcome was death attributable to HD withdrawal.

Results: We identified a total of 6342 patients who met inclusion criteria; of these, 1245 (19.6%) died following dialysis withdrawal. The survival probability of the dialysis withdrawal group was much lower: 0.67 versus 0.81 for death due to other causes at one year. We found that older age at PD initiation (subhazard ratio [SHR] 4.25, 95% confidence interval [CI] 2.97 – 6.06), the presence of a comorbidity, and remoteness of residence (SHR 1.22, 95% CI 1.06 – 1.40) were predictive of death due to dialysis withdrawal following modality change. 

Conclusion: Being able to recognise vulnerable patients at risk of dialysis withdrawal following a switch to HD from PD may facilitate greater shared decision-making during this transition period, prompting discussions regarding the most appropriate future pathway and opening other avenues for additional support, including early referral to palliative care.

Background
International research consistently demonstrates the benefits of integrating palliative care (PC) with advanced cancer, such as improved symptom control and higher levels of patient and caregiver satisfaction. Multiple Myeloma (MM) remains incurable, but survival rates have improved with new treatment modalities. Many MM patients experience high symptom burden and complex psychosocial needs. Care Plus is a new care pathway that directly addresses identified barriers to early integration of PC with Myeloma care and demonstrates how to implement such a practice change. 

Aim 

The aim is to explore the opportunities and challenges of implementing an early PC pathway for all MM patients at the time of diagnosis or relapse, from the vantage point of PC and Myeloma nurse practitioners. 

Methods 

‘Care Plus’ is a ‘whole of system’ practice change implemented in oncology services at four Australian metropolitan tertiary public hospitals for identified advanced cancers, whereby everyone reaching the nominated trigger point is automatically offered an ‘extra layer of care’ with specialist PC services, alongside their usual cancer care. 

Results 

Integrating PC within the oncology service hospital fostered a collaborative confidence and flexibility to address the complex care needs of advanced cancer patients, their families, and carers. This integration of care was notably well received by MM patients, carers, referring haematologists and PC teams. From November 2020 to May 2022, 45 MM patients received Care Plus.  

Conclusion 

The ‘Care Plus’ pathway includes the perspectives and experiences of both the Myeloma and PC teams regarding the challenges and strategies of establishing a referral pathway to PC in existing systems, introducing the activities and benefits of PC to MM patients, and developing an integrated service for supportive care within a shifting landscape of Myeloma treatment. 

Introduction: Vaporised medicinal cannabis has the potential to improve anorexia in people with advanced cancer however, pharmacokinetic studies are lacking. This Phase I study assessed the pharmacokinetics, safety and tolerability of vaporised botanical cannabis flower bud. 

Methods: In an advanced cancer population with anorexia, placebo/Bedrobinol® was vaporised three times a day, one hour before meals and escalated over seven days (average 0–6.96 mg delta-9-tetrahydrocannabinol (∆-9-THC)). Bloods were collected at pre-dose, 1, 5, 20, 40, 60 mins and 4 hours post dose. Safety was measured using a numerical rating scale (NRS), Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder Assessment (GAD-7) and National Cancer Institute Common Terminology for Adverse Events (NCICTCAE).  Vaporiser tolerability was surveyed.

Results: Twelve participants (7 females; mean age: 66.6 years) completed the study. The dose-concentration relationship of vaporised ∆-9-THC followed standard first order pharmacokinetics, with an exponential increase between 16 and 32 mg and displayed linear kinetics on elimination. A dose-exposure relationship became relatively linear after 16 mg, with significant inter- but not intra-participant variability. A two-compartment pharmacokinetics model identified ∆-9-THC dose as a significant covariate for bioavailability. The NRS reported grade 3 “intoxicated” for 48 mg, with a general increase for “relaxed” and “drowsy”. There was a significant decrease (p<0.05) for PHQ-9 at Days 8 and 14 compared to baseline. NCICTCAE reported grade 3 hypertension on Day 1, 6 (n=2), 8 and 14 (n=1) and grade 4 constipation on Day 14 (n=1). Overall tolerability was 99.2%.

Conclusions: These findings provide robust pharmacokinetic parameters for vaporised ∆-9-THC to guide future research and is relatively safe and well tolerated at these doses for people with advanced cancer.