SYMPTOM CONTROL MEDICATION & THE DYING PERSON LITERATURE REVIEW, AUDIT RESULTS & NEW STANDARDS & GUIDELINES 27TH NOVEMBER 2014 SYMPTOM CONTROL MEDICATION & THE DYING PERSON GUIDELINE DEVELOPMENT GROUP RUTH CLARK MOIRA WATSON DR AVERIL FOUNTAIN DR AMARA NWOSU PHILIP GREEN CHRISTINE RILEY DEBORAH JONES DR CLAIRE ROBINSON DR ANDREW KHODABUKUS SESSION OUTLINE • Patient, Carer and Public Involvement • Literature Review • Existing Standards & Audit Results POWERPOINT • Updated StandardsPRESENTATION & Guidelines JULY 2012 V1.0 PROVENANCE • 2006 – initial guidelines produced • 6th March 2014 – Review meeting of CMPCNAG, majority quorate vote to review guidelines by e-Vote • Meetings of membership of Symptom Control Medication & the Dying Person Guideline Development Group POWERPOINT – 29th April 2014 – 27th May 2014 PRESENTATION th – 24 July 2014 JULY 2012 – 2nd September 2014 – 3rd October 2014 V1.0 – 7th November 2014 POWERPOINT PATIENT, CARERPRESENTATION AND PUBLIC INVOLVEMENTJULY 2012 V1.0 PATIENT, CARER & PUBLIC INVOLVEMENT • PCPI representative Christine Riley – Experience of family members dying including her sister – Involved in review of our proposal and perspectives of issues pertinent to PCPI POWERPOINT PRESENTATION JULY 2012 V1.0 PATIENT, CARER & PUBLIC INVOLVEMENT THE ROLE OF MEDICATION • Medications use is ‘part and parcel’ of management dying. • What the types of medications used are less important to PCPI • What is more important is that there is a plan in place that these would addressPOWERPOINT symptoms to make the patient comfortable and that what the medications were forPRESENTATION – which symptom groupsJULY 2012 were being addressed. is communicated well with V1.0 the family. PATIENT, CARER & PUBLIC INVOLVEMENT EXPERIENCE • Some families are distressed by the dying phase – they have no experience of it – no accurate POWERPOINT representation on the media of whatPRESENTATION it is actually like. JULY 2012 V1.0 PATIENT, CARER & PUBLIC INVOLVEMENT AN EXAMPLE • Respiratory tract secretions – many families are distressed by this as no- one told them about this. • Therefore, if discussing use (or potential use) of medications for secretions, this mustPOWERPOINT include: – a discussion withPRESENTATION the family about what secretions are – and how they willJULY be 2012 managed. V1.0 PATIENT, CARER & PUBLIC INVOLVEMENT RECOMMENDATIONS 1 • Compassion by the clinical team is important. • Guidelines about communication and the link to informing family about discussion of the dyingPOWERPOINT phase can be included in the standards and guidelines. PRESENTATION JULY 2012 V1.0 PATIENT, CARER & PUBLIC INVOLVEMENT RECOMMENDATIONS 2 • Dissemination of findings to public and patient groups was a positive thing. • Suggested ways that this could be facilitated, such as: – newsletters and talking/promotionPOWERPOINT of audit(s) at charity hospice events PRESENTATION – giving the public the opportunity to JULY 2012 participate/contribute in these. V1.0 CLAIRE ROBINSONPOWERPOINT AND AMARA NWOSU LITERATUREPRESENTATION REVIEW JULY 2012 V1.0 QUESTION “What is the evidence for the use of medications to effectively control symptoms (pain, dyspnoea, pyrexia, N&V, agitation and secretions) in adult dying patients?” POWERPOINT PRESENTATION JULY 2012 V1.0 LITERATURE REVIEW Participants Adult humans in the dying phase (last hours to days of life) Intervention Medications used for symptom control Comparator - Control - Alternative management POWERPOINT- No treatment - Comparisons with other PRESENTATIONmedications Outcome Good symptom control JULY 2012 V1.0 SEARCH STRATEGY • Pubmed • SCOPUS • CINALH • Cochrane database • Hand search(referencePOWERPOINT lists) PRESENTATION JULY 2012 V1.0 SEARCH STRATEGY 1. (((((("Seizures"[Mesh] OR ("Psychomotor Agitation/analysis"[Mesh] OR "Psychomotor Agitation/diagnosis"[Mesh] OR "Psychomotor Agitation/drug therapy"[Mesh] OR "Psychomotor Agitation/prevention and control"[Mesh] OR "Psychomotor Agitation/therapy"[Mesh])) 2. OR ("Fever/analysis"[Mesh] OR "Fever/classification"[Mesh] OR "Fever/drug therapy"[Mesh] OR "Fever/therapy"[Mesh])) 3. OR "Pain Management"[Mesh]) 4. OR ("Dyspnea/analysis"[Mesh] OR "Dyspnea/classification"[Mesh] OR "Dyspnea/drug therapy"[Mesh] OR "Dyspnea/prevention and control"[Mesh] OR "Dyspnea/therapy"[Mesh])) 5. OR ((("respiratory tract secretions"[All Fields] OR "tracheobronchial secretions"[All Fields]) OR "bronchial secretions"[All Fields]) OR "death rattle"[All Fields])) 6. OR "nausea and vomiting"[All Fields]) 7. AND ((("end of life"[All Fields] OR "end of life care"[All Fields]) OR dying[All Fields]) 8. AND ((("palliative care"[AllPOWERPOINT Fields] OR "palliative medicine"[All Fields]) OR "supportive care"[All Fields]) OR ("Terminal Care/classification"[Mesh] OR "Terminal Care/nursing"[Mesh] OR "Terminal Care/prevention and control"[Mesh]PRESENTATION OR "Terminal Care/therapy"[Mesh]))) 9. AND ((Clinical Trial[ptyp] OR Comparative Study[ptyp] OR Case Reports[ptyp] OR Meta- Analysis[ptyp] OR systematic[sbJULY]) 2012 10. AND "humans"[MeSH Terms] AND English[lang]) V1.0 SELECTION CRITERIA INCLUSION CRITERIA EXCLUSION CRITERIA Aged ≥ 18 years Aged ≤ 18 years Humans Animals Specifically about the dying Not specifically about dying phase. phase. Pharmacological Non-pharmacological management of symptoms. measures. Includes a patient related No patient related outcome outcome (e.g. POWERPOINTsymptom used (e.g. prevalence control, QOL, side effects, studies). survival) or to evaluate medication intervention.PRESENTATION Interventional, JULY 2012 Case reports, review observational, retrospective, articles, editorials,V1.0 letters. prospective, Delphi. English language. Non-English. Pubmed CINALH Scopus Cochrane References (n= 71) (n= 894) (n= 98) (n= 4) (n=24) Exclusions of abstracts (n=40) Duplicates (n= 22) Review article (n=4) Scope beyond care of the dying (n=23) Articles after Articles selected Case report (n=1) duplicates removed for abstract after German (n=2) (n= 1069) titles screened Not about medications (n=2) (n= 71) Textbook (n=5) Editorial (n=1) Web resource (n=2) POWERPOINTArticles selected for full text review Exclusions full text (n=20) (n= 31) PRESENTATIONReview article (n=8) Scope beyond care of the dying JULY 2012 Studies included in (n=5) the review (n=11) Case report (n=3) V1.0 Not about medications (n=4) RESULTS Symptom Number of articles Pain 1 Dyspnoea 0 Agitation 1 Respiratory tract secretions 8 Nausea and vomiting 0 Pyrexia 0 Generic aboutPOWERPOINT use of key 1 medications in the dying PRESENTATION JULY 2012 V1.0 QUALITY ASSESSMENT • Review included both quantitative and qualitative elements • Used a multi-methods assessment tool, devised by Hawker et al • The assessment tool consists of nine areas; Rated on a four-point scale from 1 (very poor) to 4 (good). – abstract and title – introduction and aims – methods and data; sampling – data analysis – ethics and bias – results; – transferability or generalizability – implications and usefulness. • Each paper scored (maximum of 36=good, and a minimum of 9=very poor) based on the methodological rigor. The POWERPOINTmethodological quality was assessed by A.C.N and CR. • Both authors agreed on the quality assessment of all studies. • Data were stored and analysedPRESENTATION using SPSS version 21. • The methodological quality scores are ordinal in nature; consequently Spearman JULY 2012 coefficient was chosen to measure pair-wise correlation of scoring between the assessors. V1.0 QUALITY ASSESSMENT Study Agreed score Back 2001 33 • Study quality ranged between 23 and 36. Bennett 1996 28 Campbell 2013 36 • Agreement between assessors Ellershaw 2002 34 was excellent. Hugel 2006 31 Hughes 2000 23 • Spearman coefficient = 0.9, p<0.0001). Kass 2003 28 POWERPOINT Lindqvist 2013 29 Stirling 1999 26 PRESENTATION Wildiers 2002 26 JULY 2012 Wildiers 2009 36 V1.0 Respiratory Tract Secretions POWERPOINT PRESENTATION JULY 2012 V1.0 BACK ET AL 2001 • DESIGN: Cohort study • PARTICIPANTS: Patients with death rattle. States similar age, diagnosis and gender both groups • SAMPLE: N =191, [Hyoscine (N= 128) compared with Glycopyrrolate (N= 63)] • METHOD: Scoring scale - noise volume initial, 30mins post drug, 1 hr post drug, every 4 hours. First group hyoscine hydrobromide 0.4mg. Second Group Glycopyrronium 0.2mg. Scale 0 = none, 1 = audible head of bed, 2 = end of bed, 3 = 10 steps away • RESULTS: Significant. P = 0.002 30min H HBr 56% improved vs Glyco 27%. Glyco group needed 2nd injection at 30mins. 1 hr and final scores similar. • LIMITATIONS: No exclusion criteria (could there be pseudo secretions in one group?). Groups separatedPOWERPOINT in time and less participants in second round. Increased chance of data collection bias. PRESENTATION • Hyoscine HydrobromideJULY 2012 more effective for secretions at 30minutes, no overall difference. 'There is some evidence that reduction of noise relieves carer distress'. Should we consider usingV1.0 Hyoscine Hydrobromide first line for death rattle? BACK CONT “Their literature review found that glycopyrrolate has a slower onset of action than hyoscine hydrobromide at equipotent doses (0.4mg vs 0.27 = equipotent). Increased use of diamorphine, midazolam and levomepromazine in glycopyyrolate group, therefore minimal cost saving in glycopyrrolate group (average £1.53 per patient). Possibly due to less sedative and anti-emetic effects of gylcopryyolate. To prove null hypothesis that both drugs are equally efficacious in 30 bedded unit would take 12 years or multi-centre study.” POWERPOINT PRESENTATION