Palliative medicine education—Bed Race, The End of Life Board Game in undergraduates

BackgroundEducational board games facilitate active learning to conceptualise knowledge, and, promote collaborative learning and team work. Despite increasing interest in them, use in palliative and end of life care has been very limited to date.MethodIn ‘Bed race, The End of Life Game’, participants are divided into four teams who move a model hospital bed around a board to collect items (syringe driver; Do Not Attempt Resuscitation form; oral hydration gel; a ‘heart’; Just In Case medicines). To obtain items at themed ‘checkpoints’, each team needs to answer quiz questions, which require application of clinical knowledge and/or communication skills. Pregame and postgame quiz scores and feedback were collected from 12 game sessions involving 251 year 5 medical students.Results169 (67%) of students completed pregame and postgame anonymous quiz questions and free-text feedback. Postgame quiz scores were higher for each topic, and the difference in the paired pregame and postgame questionnaires was statistically significant (p<0.05). Themes from the free-text feedback included ‘engaging and fun’; ‘relevant learning’; ‘peer learning and team work’.ConclusionsEducational board games are not a new panacea for education, but the concept can be successfully applied in palliative care.

Seizures in palliative medicine: brivaracetam

Seizures occur in around 13% of patients with cancer and can be distressing for family members to witness. In those unable to manage regular antiepileptic medications, midazolam can be administered subcutaneously using a syringe driver, but this may cause sedation. Brivaracetam is a newer drug licensed as an adjunctive therapy in the treatment of partial-onset seizures with or without secondary generalisation and for restricted use in those with refractory epilepsy. It is associated with fewer behavioural or psychiatric side effects than levetiracetam, has a very low incidence of drug interactions and the maximal dose can be accommodated in a single syringe driver. We present three cases from 2019 to 2020 where subcutaneous brivaracetam has been successfully used in a Specialist Inpatient Palliative Care setting to manage seizures. Brivaracetam dosing is 1:1 conversion from oral:subcutaneous, with syringe driver doses ranging from 150 mg to 300 mg/24 hours being successfully used, with no adverse effects observed.

Subcutaneous vitamin B12 administration using a portable infusion pump in cobalamin-related remethylation disorders: a gentle and easy to use alternative to intramuscular injections

Background Cobalamin (cbl)-related remethylation disorders are a heterogeneous group of inherited disorders comprising the remethylation of homocysteine to methionine and affecting multiple organ systems, most prominently the nervous system and the bone marrow. To date, the parenteral, generally intramuscular, lifelong administration of hydroxycobalamin (OHCbl) is the mainstay of therapy in these disorders. The dosage and frequency of OHCbl is titrated in each patient to the minimum effective dose in order to account for the painful injections. This may result in undertreatment, a possible risk factor for disease progression and disease-related complications. Results We describe parenteral administration of OHCbl using a subcutaneous catheter together with a portable infusion pump in a home therapy setting in four pediatric patients with remethylation disorders, two patients with cblC, one patient with cblG, and one patient with cblE deficiency, in whom intramuscular injections were not or no longer feasible. The placement of the subcutaneous catheters and handling of the infusion pump were readily accomplished and well accepted by the patients and their families. No adverse events occurred. The use of a small, portable syringe driver pump allowed for a most flexible administration of OHCbl in everyday life. The concentrations of total homocysteine levels were determined at regular patient visits and remained within the therapeutic target range. This approach allowed for the continuation of OHCbl therapy or the adjustment of therapy required to improve metabolic control in our patients. Conclusions Subcutaneous infusion using a subcutaneous catheter system and a portable pump for OHCbl administration in combined and isolated remethylation disorders is safe, acceptable, and effective. It decreases disease burden in preventing frequent single injections and providing patient independence. Thus, it may promote long-term adherence to therapy in patients and parents.

Effect of microaggregate filter passage on feline whole blood stored for 35 days

Objectives The aim of this study was to compare the characteristics of fresh and stored feline red blood cells (RBCs) after passage through an 18 μm microaggregate filter. Methods Nine cats were recruited for a single blood donation using an open collection system. A simulated transfusion using a syringe driver and microaggregate filter was performed over 2 h with half the blood on the day of donation and the other half after 35 days of storage. Differences in haematological parameters, haemolysis percentage and osmotic fragility (OF) were compared on the day of donation pre-filter passage (D0–) vs day of donation post-filter (D0+) or day 35 storage pre-filter (D35–) and post-filter (D35+). Blood was cultured at D0+ and D35+. Results There were no statistically significant differences in the D0– vs D0+ comparisons. There were statistically significant ( P <0.05) increases in haemolysis percentage, red cell distribution width (RDW) percentage and mean OF, and decreases in packed cell volume (PCV), RBC count, haemoglobin and haematocrit for D0– vs D35–. The same was found for D0– vs D35+ with the addition of a significant increase in mean cell haemoglobin (MCH). For D35– vs D35+ only MCH significantly increased. At day 35, 6/9 units had haemolysis percentages that exceeded 1%. This increased to 8/9 of stored units post-filter passage. All blood units cultured negative. Conclusions and relevance Fresh RBCs exhibited no in vitro evidence of injury following passage through an 18 μm microaggregate filter. Increased MCH was observed in the stored blood and may represent haemolysis induced by the filter. All other changes can be explained by storage lesion rather than filter passage. The findings highlight the importance of blood banking quality controls and the need for further research to assess the effects of transfusion technique, specifically filter passage, on storage lesion-affected feline blood.

Verification of administrative data to measure palliative care at terminal hospital stays

Background: Administrative data and clinician documentation have not been directly compared for reporting palliative care, despite concerns about under-reporting. Objective: The aim of this study was to verify the use of routinely collected administrative data for reporting in-hospital palliation and to examine factors associated with coded palliative care in hospital administrative data. Method: Hospital administrative data and inpatient palliative care activity documented in medical records were compared for patients dying in hospital between 1 July 2017 and 31 December 2017. Coding of palliative care in administrative data is based on hospital care type coded as “palliative care” and/or assignment of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) palliative care diagnosis code Z51.5. Medical records were searched for specified keywords, which, read in context, indicated a palliative approach to care. The list of keywords (palliative, end of life, comfort care, cease observations, crisis medications, comfort medications, syringe driver, pain or symptom management, no cardiopulmonary resuscitation, advance medical plan/resuscitation plan, deteriorating, agitation, restless and delirium) was developed in consultation with seven local clinicians specialising in palliative care or geriatric medicine. Results: Of the 576 patients who died in hospital, 246 were coded as having received palliative care, either solely by the ICD-10-AM diagnosis code Z51.5 (42%) or in combination with a “palliative care” care type (58%). Just over one-third of dying patients had a palliative care specialist involved in their hospital care. Involvement of a palliative care specialist and a cancer diagnosis substantially increased the odds of a Z51.5 code (odds ratio = 11 and 4, respectively). The majority of patients with a “syringe driver” or identified as being at the “end of life” were assigned a Z51.5 code (73.5% and 70.5%, respectively), compared to 53.8% and 54.7%, respectively, for “palliative” or “comfort care.” For each keyword indicating a palliative approach to care, the Z51.5 code was more likely to be assigned if the patient had specialist palliative care input or if they had cancer. Conclusion: Our results suggest administrative data under-represented in-hospital palliative care, at least partly due to medical record documentation that failed to meet ICD-10-AM coding criteria. Collaboration between clinicians and coders can enhance the quality of records and, consequently, administrative data.

Advance care planning and syringe drivers in palliative and end-of-life care

This article discusses the practicalities of syringe drivers (subcutaneous continuous infusion pumps) for symptom control in patients requiring palliative or end-of-life care, which may form part of an advance care plan. It includes a discussion of palliative and end-of-life care, advance care planning, and when a syringe driver might be beneficial for the patient. It also provides step-by-step clinical guidance on setting up a syringe driver.

P57 Continuous drug delivery is significantly affected by relative height changes between patient and syringe driver

AimsSyringe drivers are the principle method of giving continuous infusions of important drugs to patients. Many of these drugs are critical for the maintenance of normal physiology. Anecdotal evidence abounds of severe patient instability on movement of syringe drivers during infusion. Our objective was to define the variation in drug delivery seen in three different syringe drivers, with changes in relative height between the syringe driver and the end of the giving set.MethodsThree syringe drivers (Alaris CC (Becton Dickinson), Perfusor Space (B Braun), and Synamed μSP6000 (Arcomed)) were analysed for reliability of flow at 0.5, 1, 2, and 5 ml/hr. A small air bubble was introduced into the giving set, and the progression of this was documented before and after a vertical movement of the syringe driver by 25 or 50 cm upwards or downwards relative to the delivery port.ResultsFor all pumps, delivery was interrupted on movement of the pumps downwards, and a bolus was given with movement of the pump upwards. Delivery halted at lower pump speeds for longer than higher pump speeds. The maximum delivery interruption was 11.8 minutes. Boluses given on moving the pump up were calculated as the equivalent number of minutes needed to deliver the bolus volume at steady state. The maximum bolus given was equivalent to 15.8 minutes of delivery. We were unable to eliminate the effects seen by very slow, steady movement of the pumps up or down. Static height differences made no difference to delivery.ConclusionsSyringe drivers should not be moved vertically in relation to the patient. Critical drug delivery is interrupted for up to 12 minutes with relative downward movements, and significant boluses of drugs are given with relative upward movements. As far as possible, elimination of relative height movements is advised, and extreme caution is necessary if any movements are unavoidable.