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The WHO definition of palliative care for care ‘principles apply to other paediatric ‘Doctor, my pain is getting
children states that it begins when illness chronic disorders’. This is also true of adults worse. Please help me.’ Some
is diagnosed, and continues regardless of with chronic illness, but is a hospice the most thoughts on opioid-induced
whether a child receives treatment directed appropriate place of referral for patients with neurotoxicity
DavID caMeRoN, MB ChB,
South African palliative care practitioners, One of the benefits of palliative care is that it MPraxMed, MPhil (Pall Med), FCFP
the Hospice Palliative Care Association and can be provided in any setting – the patient (SA)
Associate Professor, Department of Family
endorse the WHO definition of palliative care facility to access such care. The palliative care Medicine, University of Pretoria and Senior
and provide such care to patients with life- practitioner can bring care to the patient – Consultant, Foundation for Professional
threatening illness from the time of referral to in the GP’s rooms, hospital, emergency unit, Development
a hospice or a palliative care service. Hospice ICU, frail care centre, hospice, and patient’s personnel frequently comment that patients home. The only requirement is that the health Correspondence to: David Cameron (david. are referred very late and do not experience care practitioner – doctor, nurse, oncologist, HIV clinician – is trained in palliative care and applies the appropriate principles to the There are a number of misconceptions with It is usual y possible to deal with severe regard to palliative care that limit access to pain in patients with advanced cancer by it. This article considers some of these and Palliative care personnel have identified following basic palliative care principles. then describes how one can improve access that, in order to provide appropriate care Occasional y, however, a patient whose pain to palliative care for those who need this to patients with progressive illness, it is had previously been well controlled suddenly important to discuss a person’s wishes while she/he is still able to have such conversations. Is palliative care only care of the dying It is also important to develop an appropriate ‘Doctor, my pain is getting worse. Please help patient? Palliative care practitioners and care plan – but how can one identify these me.’ This is a real challenge for any doctor. patients, given the recognised uncertainties Consider the following possible reasons for compassionate end-of-life care, with support dying. Hospices also provide bereavement The Gold Standards Framework3 in the UK, appropriate response would be to increase care to family members after the death of a which advises on establishing a palliative care loved one. However, palliative care personnel service in general practices, recommends • Coping with cancer is challenging. At of their treatment. The focus of palliative • the surprise question4 – would you be care is on control of distressing symptoms, surprised if the patient were to die within expressed in excessive somatic complaints that have no organic basis. Somatisation spiritual care with a goal of helping people with life-threatening illness ‘to live as actively • clinical indicators – specific indicators • The patient has developed pharmacological patients: cancer, organ failure, elderly frail/dementia. In South Africa we would companionship of dying patients? Palliative care is a clinical discipline involving careful assessment and active treatment of distressing treatment of the cause of the symptoms. It aims to relieve suffering, and the response title of this article is that palliative care can be offered from the time of diagnosis of a an interdisciplinary team of health carers life-threatening illness; it can be provided to respond to a particular person’s needs. by any health care practitioner trained in Palliative care is provided in conjunction the discipline; and it can be provided in any with appropriate disease-specific treatment, setting, including the patient’s home.
and hospice staff work in col aboration with the oncologist, GP, HIV clinic and other Palliative care may be provided from the time of diagnosis of a life-threatening illness.
Is palliative care only for cancer patients? Palliative care is appropriate for patients with Palliative care developed as a response to cancer patients experiencing severe pain as their disease progressed. The principles and Patients who could benefit from palliative practice of palliative care are effective in the care may be identified by considering the care of patients with any life-threatening ‘surprise’ question – would you be surprised illness, and many particular palliative care if the patient were to die within the next 6 - skil s and control of distressing symptoms are applicable in any health care setting. Patients with heart failure, progressive neurological disorders, renal failure, and advanced HIV also benefit from palliative care. The WHO References available at www.cmej.org.za
paediatric definition states that palliative 292 CME July 2011 Vol.29 No.7
the situation. ‘It’s the paradoxical pain of available here as that also works well in and the current dose is too low for such hyperalgesia,’ Dr Smith replies. She goes • ‘Encourage adequate hydration. If he additional physical activity. This patient on to explain that although morphine does needs a more flexible regimen to allow for not have the limitation of a maximum dose could give 1 litre of normal saline by like many other analgesics, sometimes OIN occurs. In some individuals, particularly over 24 hours.7 This is a simple procedure. deteriorating renal function, there is a build- abdomen and attach the IV solution to it. somatisation. Careful examination reveals morphine-3-glucuronide. These metabolites This is far less troublesome than an IV line no evidence of further disease progression. and you won’t get called out at 2 am to re- So you decide that the patient has developed analgesic effect of morphine. In addition pharmacological tolerance and you increase • ‘If Mr Jones is not already on paracetamol, hal ucinations. Sensitivity to light touch, consultant, Dr Mary Smith, whose lecture ‘That’s fascinating but what do I do now?’ The next day, much to your surprise, things you ask, ‘Should I give naloxone to reverse have deteriorated. ‘Mr Jones is not well the condition?’ Dr Smith calmly responds necessary yet as OIN usual y settles down today,’ says Sr Margaret, ‘he has become very ‘No, that would just make things worse drowsy. The night staff reported that he was as you would precipitate an acute opioid restless and complaining of strange animals withdrawal syndrome with severe pain and The next day Mr Jones is all smiles: he is eating in his room’. As you examine Mr Jones you and drinking wel . He is looking forward notice brief, irregular jerking of the muscles to watching the World Cup rugby final on of his right arm. There is also twitching of his ‘Here is what you can do,’ continues Dr Saturday. You are pleased that everything facial and abdominal muscles. He grimaces has turned out well but there is obviously even when you touch him lightly. ‘You’ve got • ‘Reduce the morphine by 50% or change more to learn about good palliative care and to help me, doc. This pain is unbearable.’ to a fentanyl patch. This will allow the you decide to register for the Diploma in Palliative Medicine at the University of Cape expert advised and now things are worse. References available at www.cmej.org.za
hours. It’s a pity we don’t have methadone SINGLE SUTURE
Red wine chemical unlocked at last
Fancy receiving the heart-protecting abilities of red wine without having to drink a glass every day? Soon you may be able to, thanks to the synthesis of chemicals derived from resveratrol, the molecule believed to give wine its protective powers. The chemicals have the potential to fight many diseases, including cancer.
Plants make a huge variety of chemicals, called polyphenols, from resveratrol to protect themselves against invaders, particularly fungi. But they only make tiny amounts of each chemical, making it extremely difficult for scientists to isolate and utilise them. The unstable nature of resveratrol has also hindered attempts at building new compounds from the chemical itself.
Scott Snyder and his team at Columbia University in New York have found a way around this: building polyphenols from compounds that resemble, but are subtly different to, resveratrol. These differences make the process much easier. Using these alternative starting materials, they have made dozens of natural polyphenols, including vaticanol C, which is known to kill cancer cel s.
‘It’s like a recipe book for the whole resveratrol family,’ says Snyder. ‘We’ve opened up a July 2011 Vol.29 No.7 CME 293
Die Fakten zur "Schweinegrippe" Was ist wirklich dran an der derzeit grassierenden Pandemie-Panikmache? 1. EINE STINKNORMALE VIRUSGRIPPE Die sogenannte Schweinegrippe ist selbst offiziellen Quellen zufolge noch harmloser als eine ganz normale Virusgrippe, wie wir sie jedes Jahr erleben. Schwere Verläufe treten nur dort auf, wo Hunger und Elend regieren. Auch eine Mutation zu eine