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Professor David Currow

Biography

David Currow is Professor of Palliative Medicine at ImPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation), Faculty of Health, University of Technology Sydney.  He is Associate Director (Research) for the Wolfson Institute, Hull York Medical School, University of Hull. Research track record includes: better understanding and treating chronic breathlessness; phase II, III and IV clinical trials; population-based planning for palliative care; and codifying the evidence base underpinning palliative care.

He is the principal investigator for the Palliative Care Clinical Studies Collaborative (PaCCSC) which has randomised more than 1800 palliative care patients across 23 sites to adequately powered and rigorously designed phase III symptom control studies. He is a foundation partner in the Australian Palliative Care Outcomes Collaborative (PCOC), an initiative to improve systematically clinical outcomes in palliative care. Competitive funding has included the National Health and Medical Research Council (NHMRC) and the National Institutes of Health (NIH).

David has published more than 460 peer-reviewed articles, editorials and books. He is an editor on the 5th edition of the Oxford Textbook of Palliative Medicine. He is senior associate editor of Journal of Palliative Medicine and on the editorial boards of Journal of Pain and Symptom Management, BMJ Supportive and Palliative Care and the Journal of Oncology Practice. David is a former president of Palliative Care Australia and the Clinical Oncological Society of Australia. 

Professional

Awarded, 2016 British Medical Association (BMA) Medical Textbook of the year. ‘Oxford Textbook of Palliative Medicine.’ (5th Edition). Nathan Cherny, Stein Kaasa, Russell Portenoy, Marie Fallon, David Currow (Editors) Oxford University Press. (March, 2015) 

Tom Reeve Award for Outstanding Contribution to Cancer Care from the Clinical Oncological Society of Australia 2015

For a significant contribution to cancer care through research and clinical leadership

American Academy of Hospice and Palliative Care (AAHPM) 2015 Award for Excellence in Scientific Research in Palliative Care. The Award recognizes meaningful, exemplary research contributions to the field of hospice and palliative care. February, 2015 at the annual Academy meeting.

Palliative Care Council of South Australia Lifetime Achievement Award. 2013. The Lifetime Achievement Award recognizes excellence in mentorship, support, passion for their field of work, commitment to working in partnerships, respect for others, teamwork, persistence and pioneering developments/

University of Newcastle 2012 Alumni Medal (joint winner) Awarded annually to a graduate with an outstanding track record of professional excellence in leadership, knowledge and professional practice.

Royal College of Physicians and Surgeons of Canada, 2013 Balfour M. Mount Visiting Professorship in Palliative Medicine

National winner 2012 - Team Award – Postgraduate education Australian Learning and Teaching Centre

Flinders Offshore Palliative Care Program. In conjunction with the Lien Foundation (Singapore) and the Asia Pacific Hospice and Palliative Care Network, this was a program to provide Graduate Certificate post-graduate qualifications for health professionals in palliative care for resource challenged countries in South East Asia. More than 100 students have graduated to date.

Image of David Currow
Professor, Faculty of Health
BMed (N'cle), MPH, PhD
 

Research Interests

David is the Principal Investigator on the Australian government funded Palliative Care Clinical Studies Collaborative – the world’s largest clinical trials group in palliative care. He is also a co-founder of the Australian Palliative Care Outcomes Collaborative, the world’s largest point-of-care quality improvement program in palliative care.

Supervisory interests

  • Palliative care

Books

Currow, D.C. & Abernethy, A. 2009, Current Opinion in Supportive and Palliative Care: Editorial introductions.
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Chapters

Currow, D. & Phillips, J.L. 2016, 'Chronic Conditions and Cancer at the End of Life' in Cancer and Chronic Conditions, Springer, Germany, pp. 455-475.
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The majority of people diagnosed with cancer are older and therefore are likely to have co-morbidities at the time it is diagnosed and if the cancer progresses to advanced disease. Guidance in the process of managing long-term co-morbidities at the end of life requires clarity about the goals of care for the person's cancer, and for each of his/her co-morbidities. Why was a particular therapy started in the first place? What risk is the therapy mitigating, and does it need to be continued? Very few studies help to inform the process of ceasing medications. For example, with cachexia and its associated weight loss, frequently encountered in advanced cancer, the management of two of the most frequent conditions—hypertension and diabetes —will change. The need for anti-hypertensives will decrease or the person will risk postural symptoms and the need for lower doses of hypoglycaemic agents and liberalised diets will be hallmarks of managing diabetes in order to avoid hypoglycaemia. Mostly, this care is in the setting of multiple co-morbidities, making review a complex and continuing process. Changes in co-morbidities can also directly influence the anti-cancer therapies that are available to patients, because of characteristics of the drug itself or changes in metabolism or elimination. Adjusting chemotherapy in advanced disease also requires careful evaluation of the goals of palliative treatment—are there symptoms that can best be addressed by disease modifying treatments or are there other more direct, better tolerated symptom control therapies available? Not only will there be a need for active management of long-term co-morbidities, but people will need to adjust psychologically to these changes. Modifying the goals of treatment is often the most overt signal to people that their disease is progressing and therefore can be particularly confronting. Such changes will often precipitate, or are an opportunity for, much wider conversations about life, dying and dea...
Currow, D. & Phillips, J.L. 2015, 'Policies on palliative care for older people in Australia' in Palliative care for older people A public health perspective, OUP Oxford.
The book begins by outlining the range of policies towards palliative care for older people that are found worldwide.
LeBlanc, T.W., Currow, D., Phillips, J.L. & Abernethy, A.P. 2014, 'Management of dyspnea' in Palliative Care and Ethics, Common Ground and Cutting Edges, Oxford University Press, Oxford.
Currow, D. & Phillips, J.L. 2014, 'Models of care in palliative medicine' in Palliative Surgery, Springer-Verlag, Berlin.
Kamal, A., Maguire, J.M., Currow, D.C. & Abernethy, A.P. 2012, 'Should Bisphosphonates Be Used Routinely to Manage Pain and Skeletal Complications in Cancer?' in Evidence-Based Practice of Palliative Medicine, pp. 59-64.
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Maguire, J.M., Kamal, A., Currow, D.C. & Abernethy, A.P. 2012, 'Should Bisphosphonates Be Used Routinely to Manage Pain and Skeletal Complications in Other Conditions?' in Evidence-Based Practice of Palliative Medicine, pp. 65-69.
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Abernethy, A.P., Kamal, A., Maguire, J.M. & Currow, D.C. 2012, 'What Interventions Are Effective for Managing Dyspnea in Cancer?' in Evidence-Based Practice of Palliative Medicine, pp. 103-110.
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Abernethy, A.P., Kamal, A. & Currow, D.C. 2012, 'When Should Nonsteroidal Antiinflammatory Drugs Be Used to Manage Pain?' in Evidence-Based Practice of Palliative Medicine, pp. 49-53.
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Abernethy, A.P., Wheeler, J.L., Kamal, A. & Currow, D.C. 2012, 'When Should Corticosteroids Be Used to Manage Pain?' in Evidence-Based Practice of Palliative Medicine, pp. 44-48.
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Currow, D.C. & Abernethy, A.P. 2011, 'Dyspnea in supportive oncology' in Supportive Oncology, pp. 164-170.
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Conferences

Disler, R., Luckett, T., Phillips, J., Johnson, M., Garcia, M., Bhattarai, P., Hutchinson, A., Currow, D., Carrieri-Kohlman, V., Whelan, B., Newton, P., Agar, M., Chye, R., Sheehan, C., Ivynian, S. & Davidson, P. 2017, 'RESPIRATORY PATIENT EXPERIENCES IN SELF-MANAGING EMERGENCY DEPARTMENT 'NEAR-MISS' FOR BREATHLESSNESS: A STRENGTHS-BASED QUALITATIVE STUDY', RESPIROLOGY, WILEY, pp. 184-184.
Disler, R., Cui, Y., Luckett, T., Donesky, D., Irving, L., Currow, D., Horsfall, L. & Smallwood, N. 2017, 'RESPIRATORY NURSES' KNOWLEDGE AND PRACTICE BEHAVIOURS IN COPD-RELATED ADVANCE CARE PLANNING: PRELIMINARY FINDINGS FROM A CROSSSECTIONAL SURVEY STUDY', RESPIROLOGY, WILEY, pp. 20-20.
Stone, E., Rankin, N., Bewes, T., Kerr, S., Phillips, J., Fong, K., Currow, D. & Shaw, T. 2017, 'MDT V NON-MDT CARE IN LUNG CANCER: DOES CO-MORBIDITY STATUS HAVE AN IMPACT?', RESPIROLOGY, WILEY, pp. 29-29.
Disler, R., Luckett, T., Donesky, D., Irving, L., Currow, D., Horsfall, L., Cui, Y. & Smallwood, N. 2017, 'PALLIATIVE CARE NURSES' ATTITUDES AND PERCEIVED BARRIERS TO COPD-RELATED ADVANCE CARE PLANNING: PRELIMINARY FINDINGS FROM A CROSS-SECTIONAL SURVEY STUDY', RESPIROLOGY, WILEY, pp. 184-184.
King, M., Currow, D., Agar, M., Hardy, J., Fazekas, B. & McCaffrey, N. 2016, 'Assessing health-related quality of life (HRQOL) in palliative care settings: head-to-head comparison of the EORTC QLQ-C15-PAL, FACT-G7, FACIT-Pal and FACIT-Pal-14 patient-reported outcome measures (PROMs)', QUALITY OF LIFE RESEARCH, SPRINGER, pp. 75-76.
Agar, M., Lawlor, P., Quinn, S., Caplan, G., Draper, B., Rowett, D., Devilee, L., Fazekas, B., Sanderson, C., McCaffrey, N., Hardy, J., Le, B., Eckermann, S., Hill, M. & Currow, D. 2015, 'Phase III randomized double-blind controlled trial of oral risperidone, haloperidol or placebo with rescue subcutaneous midazolam for delirium management in palliative care', JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, pp. S99-S99.
Smith, A., Currow, D., Abernethy, A., Miao, Y. & Ritchie, C. 2015, 'Dyspnea in Older Adults: Epidemiology and Outcomes', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, pp. 455-456.
Currow, D., Temel, J., Fearon, K., Friend, J., Yan, Y. & Abernethy, A. 2015, 'ROMANA 3: A safety extension study of anamorelin in advanced non-small cell lung cancer (NSCLC) patients with cachexia', EUROPEAN JOURNAL OF CANCER, pp. S239-S239.
Lovell, M., Luckett, T., Phillips, J., Agar, M., Ryan, L., Lam, L., McCaffrey, N., Boyle, F., Stubbs, J., Shaw, T., Currow, D., Hosie, A. & Davidson, P. 2015, 'Clinical Trial Protocol - Implementing Clinical Practice Guidelines For Cancer Pain In Adults To Ensure Equitable, Cost-Effective, Evidence-Based, Person-Centred Care: A Phase III Pragmatic Stepped Wedge Cluster Randomised Controlled Trial Of Guidelines And Screening With Implementation Strategies Versus Guidelines And Screening Alone To Improve Pain In Adults With Cancer Attending Outpatients Oncology And Palliative Care Centres', Asia-Pacific Journal of Clinical Oncology, pp. 162-162.
Disler, R.T., Inglis, S.C., Newton, P.J., Currow, D.C., Macdonald, P., Glanville, A.R., Donesky, D., Carrieri-Kohlman, V. & Davidson, P.M. 2015, 'Perspectives Of Online Health Information And Support In Chronic Disease Respiratory Disease: Focus Group Study', AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE.
Disler, R.T., Inglis, S.C., Newton, P.J., Currow, D.C., Macdonald, P., Glanville, A.R., Donesky, D., Carrieri-Kohlman, V. & Davidson, P.M. 2015, 'Technology Use In Patients Attending A Cardiopulmonary Clinic', AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE.
Johnson, M.J., Bland, J.M., Gahbauer, E.A., Ekstrom, M., Sinnarajah, A., Gill, T.M. & Currow, D.C. 2015, 'Breathlessness In The Elderly During The Last Year Of Life Sufficient To Restrict Activity', AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE.
Young, J.M., Stacey, I., Dobbins, T., Dunlop, S., Dessaix, A. & Currow, D. 2015, 'How Can We Best Evaluate The Impact of Public Health Legislation? Use of Interrupted Time Series Analysis to Investigate the Introduction of Tobacco Plain Packaging Legislation in Australia', INTERNATIONAL JOURNAL OF EPIDEMIOLOGY, pp. 86-87.
Bonomi, P., Temel, J., Currow, D., Fearon, K., Gleich, L., Yan, Y., Friend, J. & Abernethy, A. 2014, 'Anamorelin for the Treatment of Cancer Anorexia-Cachexia in Advanced NSCLC Patients: Results From ROMANA 1, a Pivotal Phase 3 Study', INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS, pp. S3-S3.
Abernethy, A.P., Currow, D., Fearon, K., Gleich, L.L., Friend, J. & Temel, J.S. 2014, 'Anamorelin for the treatment of cancer anorexia-cachexia: Baseline characteristics from three phase III clinical trials (the ROMANA program)', JOURNAL OF CLINICAL ONCOLOGY.
Yee, J., Davis, G.M., Beith, J.M., Wilcken, N., Hui, R., Harrison, M.L., Currow, D., Emery, J., Phillips, J., Martin, A., Segelov, E. & Kilbreath, S.L. 2013, 'Physical activity and fitness in women with metastatic breast cancer.', JOURNAL OF CLINICAL ONCOLOGY.
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Abernethy, A.P., Temel, J.S., Currow, D., Gleich, L.L. & Friend, J. 2013, 'Phase III clinical trials with anamorelin HCl, a novel oral treatment for NSCLC cachexia.', JOURNAL OF CLINICAL ONCOLOGY.
Yee, J., Davis, G.M., Beith, J.M., Wilcken, N., Hui, R., Harrison, M.L., Currow, D., Emery, J., Phillips, J., Martin, A., Segelov, E. & Kilbreath, S.L. 2013, 'Physical activity and fitness in women with metastatic breast cancer.', JOURNAL OF CLINICAL ONCOLOGY, Breast Cancer Symposium, AMER SOC CLINICAL ONCOLOGY, San Francisco, CA.
Currow, D.C., Hardy, J., Quinn, S., Fazekas, B., Plummer, J., Eckermann, S., Agar, M., Spruyt, O. & Debra, R. 2012, 'A randomized, double-blind, placebo-controlled study to assess the efficacy and toxicity of subcutaneous ketamine in the management of cancer pain.', JOURNAL OF CLINICAL ONCOLOGY.
Currow, D.C., Hardy, J., Agar, M., Sanderson, C., Spruyt, O., Eckermann, S., Plummer, J. & Quinn, S. 2011, 'A Randomised, Double-blind, Placebo Controlled, Multi-site Study of Subcutaneous Ketamine in the Management of Cancer Pain', EUROPEAN JOURNAL OF CANCER, pp. S152-S152.
Phillips, J.L., Ramadge, J., Evans, R. & Currow, D. 2009, 'CanNET a new service model: linking regional and metropolitan cancer services into single networks', 10th National Rural Health Conference, National Rural Health Conference, National Rural Health Alliance, Cairns, Australia, pp. 1-11.
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Background: The treatment for cancer is often complex, involving many disciplines and therapies, which makes it difficult for Australians living in rural and remote areas to access the full range of care required within their local community. Aim: The Cancer Service Networks National Demonstration Program (CanNET) is a Commonwealth initiative which aimed to improve access to cancer care by linking regional and metropolitan cancer services. Method: Up to $7 million was made available across seven jurisdictions over a two year period from 2007 to 2009. This funding was to assist the development of sustainable links between cancer specialists and other leading health professionals in metropolitan cancer services and their colleagues in rural and regional centres. Each jurisdiction also made a contribution to the development of the cancer service networks. The cancer service network model is underpinned by: active consumer involvement; the development of agreed referral pathways; a multidisciplinary approach to cancer control; involvement of primary care and allied health professionals; championing of evidence-based practice; access to continuing professional development and training; and integration of rural and regional cancer services into a broad practice network.
Abernethy, A.P., Currow, D.C., Shelby-James, T., Williams, H., Roder-Allen, G., Hunt, R., Rowett, D., Esterman, A., May, F. & Phillips, P.A. 2006, 'Improving palliative care: A 2x2x2 factorial cluster randomized controlled trial of case conferencing and educational outreach visiting.', JOURNAL OF CLINICAL ONCOLOGY, pp. 472S-472S.

Journal articles

DiGiacomo, M., Hatano, Y., Phillips, J., Lewis, J., Abernathy, A. & Currow, D. 2017, 'Caregiver characteristics and bereavement needs: findings from a population study', Palliative Medicine, vol. 31, no. 5, pp. 465-474.
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Background: Globally, the majority of care for people with life-limiting illnesses is provided by informal caregivers. Identifying characteristics of caregivers that may have unmet needs and negative outcomes can enable provision of better support to facilitate their adjustment. Aim: We compared characteristics, expressed unmet needs, and outcomes for spousal caregivers, with other caregivers at the end of life, by gender and age. Design: The South Australian Health Omnibus is an annual, random, face-to-face, cross-sectional survey wherein respondents are asked about end-of-life care. Setting/Participants: Participants were aged over 15, resided in households in South Australia, and had someone close to them die from a terminal illness in the last five years. Results: Of the 1,540 respondents who provided hands-on care for someone close at the end of life, 155 were widows/widowers. Bereaved spousal caregivers were more likely to: be older, female, better educated, have lower incomes, less full-time work, English as second language, sought help with grief, and provided more day-to-day care for longer periods. Spousal caregivers were less likely to be willing to take on caregiving again, less able to 'move on' with life, and needed greater emotional support and more information about the illness and services. The only difference between widows and widowers was older age of spouse in women. Younger spousal caregivers perceived greater unmet emotional needs and were significantly less likely to be able to 'move on'. Conclusions: Spousal caregivers are different from other caregivers, with more intense needs that are not fully met. These have implications for bereavement, health, and social services.
Clark, K., Lam, L.T., Talley, N.J., Phillips, J.L. & Currow, D.C. 2017, 'Identifying Factors That Predict Worse Constipation Symptoms in Palliative Care Patients: A Secondary Analysis.', J Palliat Med, vol. 20, no. 5, pp. 528-532.
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OBJECTIVE: The aim of this work was to investigate whether variables identified as likely to impact the experience of constipation in other clinical settings similarly affected the experiences of constipated palliative care patients. BACKGROUND: The majority of palliative care patients with cancer are likely to be bothered by constipation symptoms at some point in their disease trajectory. Despite this, it remains unclear as to which factors predict more severe problems. METHODS: This study was conducted in a sample of 94 constipated palliative care patients who were asked to voluntarily complete a series of questions regarding their demographic and other characteristics, including whether they had chronic constipation symptoms, that is, constipation symptoms for 12 months. Other variables included age, body mass index, sex, performance status, and regular opioids and their doses. At the same time, they were asked to complete the Patient Assessment of Constipation Symptoms (PAC-SYM) and Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaires. RESULTS: Descriptive statistics summarized baseline data. Unadjusted associations between the selected variables on PAC-SYM were examined by using bi-variate analyses. Significant variables identified on bi-variate analyses were included in a multivariate analysis. The final results identified that only the chronicity of constipation symptoms predicted more severe symptoms. This relationship persisted when this single variable was retained in the final model, illustrating that PAC-SYM scores are 0.41 higher in patients with chronic constipation compared with those without it (p=0.02). In contrast, regular opioid use was not identified as a significant factor (p=0.56). DISCUSSION: This study suggests that the factor most likely to predict worse constipation symptoms was the duration that people had experienced problems. Further, those who perceived their constipation symptoms to be more severe had a po...
Collier, A., Breaden, K., Phillips, J.L., Agar, M., Litster, C. & Currow, D.C. 2017, 'Caregivers' Perspectives on the Use of Long-Term Oxygen Therapy for the Treatment of Refractory Breathlessness: A Qualitative Study.', J Pain Symptom Manage, vol. 53, no. 1, pp. 33-39.
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CONTEXT: Despite limited clinical evidence, long-term oxygen therapy (LTOT) is used for the management of refractory breathlessness in people with life-limiting illnesses who are not necessarily hypoxemic. OBJECTIVES: The aim of this study was to understand caregiver factors associated with caring for someone with LTOT from the perspectives and experiences of caregivers themselves. METHODS: The qualitative study used semistructured interviews. The study was conducted in two states in Australia. Participants (n = 20) were self-nominated caregivers of people receiving LTOT for refractory breathlessness in the palliative setting. RESULTS: Data analyses established one overarching theme titled: "Oxygen giveth (something to help caregivers relieve breathlessness) and oxygen taketh away (from patients who lose some autonomy)." The theme captured caregivers' feelings of extreme distress in response to witnessing refractory breathlessness, and oxygen fulfilling several critical and beneficial roles in this context. In parallel, caregivers also explicitly and implicitly articulated several downsides to the use of LTOT. CONCLUSION: Caregivers find caring for someone with refractory breathlessness extremely distressing. The benefits of LTOT are often overestimated, whereas its potential harms are underestimated. As significant stakeholders of people receiving LTOT, caregivers should be provided with opportunities to collaborate with clinicians in evidence-based decision making, efforts should be made to provide them with information and education about the most effective pharmacological and nonpharmacological strategies to manage refractory breathlessness in a palliative care setting including the appropriate use of LTOT to enable them to do so.
Agar, M., Lawlor, P., Quinn, S., Draper, B., Caplan, G., Rowett, D., Sanderson, C., Hardy, J., Le, B., Eckermann, S., McCaffrey, N., Devilee, L., Fazekas, B., Hill, M. & Currow, D. 2017, 'Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care A Randomized Clinical Trial', JAMA Internal Medicine, vol. 177, no. 1, pp. 34-42.
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Importance: Antipsychotics are widely used for distressing symptoms of delirium, but efficacy has not been established in placebo-controlled trials in palliative care. Objective: To determine efficacy of risperidone or haloperidol relative to placebo in relieving target symptoms of delirium associated with distress among patients receiving palliative care. Design, Setting, and Participants: A double-blind, parallel-arm, dose-titrated randomized clinical trial was conducted at 11 Australian inpatient hospice or hospital palliative care services between August 13, 2008, and April 2, 2014, among participants with life-limiting illness, delirium, and a delirium symptoms score (sum of Nursing Delirium Screening Scale behavioral, communication, and perceptual items) of 1 or more. Interventions: Age-adjusted titrated doses of oral risperidone, haloperidol, or placebo solution were administered every 12 hours for 72 hours, based on symptoms of delirium. Patients also received supportive care, individualized treatment of delirium precipitants, and subcutaneous midazolam hydrochloride as required for severe distress or safety. Main Outcome and Measures: Improvement in mean group difference of delirium symptom score (severity range, 0-6) between baseline and day 3. Five a priori secondary outcomes: delirium severity, midazolam use, extrapyramidal effects, sedation, and survival. Results: Two hundred forty-seven participants (mean [SD] age, 74.9 [9.8] years; 85 women [34.4%]; 218 with cancer [88.3%]) were included in intention-to-treat analysis (82 receiving risperidone, 81 receiving haloperidol, and 84 receiving placebo). In the primary intention-to-treat analysis, participants in the risperidone arm had delirium symptom scores that were significantly higher than those among participants in the placebo arm (on average 0.48 Units higher; 95% CI, 0.09-0.86; P = .02) at study end. Similarly, for those in the haloperidol arm, delirium symptom scores were on average 0.24 Units h...
Tervonen, H.E., Morrell, S., Aranda, S., Roder, D., You, H., Niyonsenga, T., Walton, R., Baker, D. & Currow, D. 2017, 'The impact of geographic unit of analysis on socioeconomic inequalities in cancer survival and distant summary stage - a population-based study.', Aust N Z J Public Health.
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OBJECTIVE: When using area-level disadvantage measures, size of geographic unit can have major effects on recorded socioeconomic cancer disparities. This study examined the extent of changes in recorded socioeconomic inequalities in cancer survival and distant stage when the measure of socioeconomic disadvantage was based on smaller Census Collection Districts (CDs) instead of Statistical Local Areas (SLAs). METHODS: Population-based New South Wales Cancer Registry data were used to identify cases diagnosed with primary invasive cancer in 2000-2008 (n=264,236). Logistic regression and competing risk regression modelling were performed to examine socioeconomic differences in odds of distant stage and hazard of cancer death for all sites combined and separately for breast, prostate, colorectal and lung cancers. RESULTS: For all sites collectively, associations between socioeconomic disadvantage and cancer survival and distant stage were stronger when the CD-based socioeconomic disadvantage measure was used compared with the SLA-based measure. The CD-based measure showed a more consistent socioeconomic gradient with a linear upward trend of risk of cancer death/distant stage with increasing socioeconomic disadvantage. Site-specific analyses provided similar findings for the risk of death but less consistent results for the likelihood of distant stage. CONCLUSIONS: The use of socioeconomic disadvantage measure based on the smallest available spatial unit should be encouraged in the future. Implications for Public Health: Disadvantage measures based on small spatial units can more accurately identify socioeconomic cancer disparities to inform priority settings in service planning.
Creighton, N., Walton, R., Roder, D.M., Aranda, S., Richardson, A.J., Merrett, N. & Currow, D. 2017, 'Pancreatectomy is underused in NSW regions with low institutional surgical volumes: a population data linkage study.', Med J Aust, vol. 206, no. 1, pp. 23-29.
OBJECTIVE: To examine differences in the proportions of people diagnosed with pancreatic cancer who underwent pancreatectomy, post-operative outcomes and 5-year survival in different New South Wales administrative health regions of residence. DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of NSW data on pancreatic cancer incidence and surgery, 2005-2013. MAIN OUTCOME MEASURES: The proportion of newly diagnosed patients with pancreatic cancer who were resected in each region; 90-day post-operative mortality; one-year post-operative survival; 5-year post-diagnosis survival. RESULTS: 14% of people diagnosed with pancreatic cancer during 2010-2013 (431 of 3064) underwent pancreatectomy, an average of 108 resections per year. After adjusting for age, sex and comorbidities, the proportion that underwent resection varied significantly between regions, ranging between 8% and 21% (P<0.001). Higher resection rates were not associated with higher post-operative 90-day mortality or lower one-year survival (unadjusted and risk-adjusted analyses). Higher resection rates were associated with higher 5-year post-diagnosis survival: the mean survival in regions with resection rates below 10% was 3.4%, compared with 7.2% in regions with rates greater than 15% (unadjusted and adjusted survival analyses; P<0.001). There was a positive association between regional resection rate and the pancreatectomy volume of hospitals during 2005-2009. An additional 32 people would be resected annually if resection rates in low rate regions were increased to the 80th percentile regional resection rate (18%). CONCLUSION: There is significant geographic variation in the proportion of people with pancreatic cancer undergoing pancreatectomy, and the 5-year survival rate is higher in regions where this proportion is higher.
Phillips, J.L. & Currow, D.C. 2017, 'Would reframing aged care facilities as a 'hospice' instead of a 'home' enable older people to get the care they need?', Collegian, vol. 24, no. 1, pp. 1-2.
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Pidgeon, T.M., Johnson, C.E., Lester, L., Currow, D., Yates, P., Allingham, S.F., Bird, S. & Eagar, K. 2017, 'Perceptions of the care received from Australian palliative care services: A caregiver perspective.', Palliat Support Care, pp. 1-11.
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BACKGROUND: Caregiver satisfaction and experience surveys help health professionals to understand, measure, and improve the quality of care provided for patients and their families. OBJECTIVE: Our aim was to explore caregiver perceptions of the care received from Australian specialist palliative care services. METHOD: Caregivers of patients receiving palliative care in services registered with Australia's Palliative Care Outcomes Collaboration were invited to participate in a caregiver survey. The survey included the FAMCARE-2 and four items from the Ongoing Needs Identification: Caregiver Profile questionnaire. RESULTS: Surveys were completed by 1,592 caregivers from 49 services. Most respondents reported high satisfaction and positive experiences. Caregivers receiving care from community-based palliative care teams were less satisfied with the management of physical symptoms and comfort (odds ratio [OR]&nbsp;=&nbsp;0.29; 95% confidence interval [CI 95%]&nbsp;=&nbsp;0.14, 0.59), with patient psychological care (OR&nbsp;=&nbsp;0.56; CI 95%&nbsp;=&nbsp;0.32, 0.98), and with family support (OR&nbsp;=&nbsp;0.52; CI 95%&nbsp;=&nbsp;0.35, 0.77) than caregivers of patients in an inpatient setting. If aged over 60 years, caregivers were less likely to have their information needs met regarding available support services (OR&nbsp;=&nbsp;0.98; CI 95%&nbsp;=&nbsp;0.97, 0.98) and carer payments (OR&nbsp;=&nbsp;0.99; CI 95%&nbsp;=&nbsp;0.98, 1.00). Also, caregivers were less likely to receive adequate information about carer payments if located in an outer regional area (OR&nbsp;=&nbsp;0.41; CI 95%&nbsp;=&nbsp;0.25, 0.64). With practical training, caregivers receiving care from community services reported inadequate information provision to support them in caring for patients (OR&nbsp;=&nbsp;0.60; CI 95%&nbsp;=&nbsp;0.45, 0.81). SIGNIFICANCE OF RESULTS: While our study identified caregivers as having positive and satisfactory experiences across all domains of care, there is room for improvement in the delivery of palliative care across symptom management, as well as patient and caregiver support, especially in c...
Boland, J.W., Allgar, V., Boland, E.G., Oviasu, O., Agar, M., Currow, D.C. & Johnson, M.J. 2017, 'Effect of Opioids and Benzodiazepines on Clinical Outcomes in Patients Receiving Palliative Care: An Exploratory Analysis.', J Palliat Med.
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BACKGROUND: Medications for symptom management in palliative care have associated, but poorly understood, harms. Drug-related harms have important clinical implications, may impact on patients' compliance and contribute to symptoms. OBJECTIVE: To explore the longitudinal relationship between oral morphine equivalent daily dose (MEDD) and oral diazepam equivalent daily dose (DEDD) with functional, cognitive, and symptom outcomes in patients receiving palliative care. DESIGN: Secondary longitudinal analysis of cancer decedents (n=235) was carried out from a palliative care randomized controlled trial with multiple outcome measures. At each time point, MEDD and DEDD were calculated. Multilevel modeling was used to investigate independent associations between MEDD and DEDD, and cognitive and gastrointestinal symptoms, quality of life (QoL), performance status, and survival. SETTING/SUBJECTS: Participants were recruited from a specialist palliative care program in southern Adelaide, were expected to live 48 hours, had pain in the previous 3 months, and a baseline Folstein Mini-Mental Status Examination score 25. RESULTS: Cognitive and gastrointestinal symptoms, performance status, and QoL worsened over time. In the adjusted multilevel analysis, statistically significant relationships remained between MEDD/DEDD and worsening performance status (p=0.001), DEDD and gastrointestinal effects (p<0.001), MEDD and QoL (p<0.022). CONCLUSIONS: Commonly used palliative medications were associated with deteriorating performance status. The lack of association between MEDD with gastrointestinal or cognitive symptoms underlines that these associations are not inevitable with close attention. This analysis highlights the importance of including other medications as confounders when exploring medication-related harms. An understanding of the risk-benefit balance of medications is needed to maximize net benefits for patients.
Tervonen, H.E., Walton, R., You, H., Baker, D., Roder, D., Currow, D. & Aranda, S. 2017, 'After accounting for competing causes of death and more advanced stage, do Aboriginal and Torres Strait Islander peoples with cancer still have worse survival? A population-based cohort study in New South Wales.', BMC Cancer, vol. 17, no. 1, p. 398.
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BACKGROUND: Aboriginal and Torres Strait Islander peoples in Australia have been found to have poorer cancer survival than non-Aboriginal people. However, use of conventional relative survival analyses is limited due to a lack of life tables. This cohort study examined whether poorer survival persist after accounting for competing risks of death from other causes and disparities in cancer stage at diagnosis, for all cancers collectively and by cancer site. METHODS: People diagnosed in 2000-2008 were extracted from the population-based New South Wales Cancer Registry. Aboriginal status was multiply imputed for people with missing information (12.9%). Logistic regression models were used to compute odds ratios (ORs) with 95% confidence intervals (CIs) for 'advanced stage' at diagnosis (separately for distant and distant/regional stage). Survival was examined using competing risk regression to compute subhazard ratios (SHRs) with 95%CIs. RESULTS: Of the 301,356 cases, 2517 (0.84%) identified as Aboriginal (0.94% after imputation). After adjusting for age, sex, year of diagnosis, socio-economic status, remoteness, and cancer site Aboriginal peoples were more likely to be diagnosed with distant (OR 1.30, 95%CI 1.17-1.44) or distant/regional stage (OR 1.29, 95%CI 1.18-1.40) for all cancers collectively. This applied to cancers of the female breast, uterus, prostate, kidney, others (those not included in other categories) and cervix (when analyses were restricted to cases with known stages/known Aboriginal status). Aboriginal peoples had a higher hazard of death than non-Aboriginal people after accounting for competing risks from other causes of death, socio-demographic factors, stage and cancer site (SHR 1.40, 95%CI 1.31-1.50 for all cancers collectively). Consistent results applied to colorectal, lung, breast, prostate and other cancers. CONCLUSIONS: Aboriginal peoples with cancer have an elevated hazard of cancer death compared with non-Aboriginal people, after accou...
Currow, D.C., Abernethy, A.P., Fallon, M. & Portenoy, R.K. 2017, 'Repurposing Medications for Hospice/Palliative Care Symptom Control Is No Longer Sufficient: A Manifesto for Change', Journal of Pain and Symptom Management, vol. 53, no. 3, pp. 533-539.
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Pidgeon, T., Johnson, C.E., Currow, D., Yates, P., Banfield, M., Lester, L., Allingham, S.F., Bird, S. & Eagar, K. 2016, 'A survey of patients' experience of pain and other symptoms while receiving care from palliative care services.', BMJ supportive & palliative care, vol. 6, no. 3, pp. 315-322.
In Australia, patients at the end of life with complex symptoms and needs are often referred to palliative care services (PCSs), but little is known about the symptoms of patients receiving palliative care in different settings.To explore patients' levels of pain and other symptoms while receiving care from PCSs.PCSs registered through Australia's national Palliative Care Outcomes Collaboration (PCOC) were invited to participate in a survey between 2008 and 2011. Patients (or if unable, a proxy) were invited to complete the Palliative Care Outcome Scale.Questionnaires were completed for 1800 patients. One-quarter of participants reported severe pain, 20% reported severe 'other symptoms', 20% reported severe patient anxiety, 45% reported severe family anxiety, 66% experienced depressed feelings and 19% reported severe problems with self-worth. Participants receiving care in major cities reported higher levels of depressed feelings than participants in inner regional areas. Participants receiving care in community and combined service settings reported higher levels of need for information, more concerns about wasted time, and lower levels of family anxiety and depressed feelings when compared to inpatients. Participants in community settings had lower levels of concern about practical matters than inpatients.Patients receiving care from Australian PCSs have physical and psychosocial concerns that are often complex and rated as 'severe'. Our findings highlight the importance of routine, comprehensive assessment of patients' concerns and the need for Specialist Palliative Care clinicians to be vigilant in addressing pain and other symptoms in a timely, systematic and holistic manner, whatever the care setting.
McCaffrey, N., Hardy, J., Fazekas, B., Agar, M., Devilee, L., Rowett, D. & Currow, D. 2016, 'Potential economic impact on hospitalisations of the Palliative Care Clinical Studies Collaborative (PaCCSC) ketamine randomised controlled trial', AUSTRALIAN HEALTH REVIEW, vol. 40, no. 1, pp. 100-105.
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Hui, D., Bansal, S., Strasser, F., Morita, T., Caraceni, A., Davis, M., Cherny, N., Kaasa, S., Currow, D., Abernethy, A., Nekolaichuk, C. & Bruera, E. 2016, 'Reply to the letter to the editor 'Integration between oncology and palliative care: does one size fit all?' by Verna et al.', ANNALS OF ONCOLOGY, vol. 27, no. 3, pp. 549-550.
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Masso, M., Allingham, S.F., Johnson, C.E., Pidgeon, T., Yates, P., Currow, D. & Eagar, K. 2016, 'Palliative Care Problem Severity Score: Reliability and acceptability in a national study', PALLIATIVE MEDICINE, vol. 30, no. 5, pp. 479-485.
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Langton, J., Reeve, R., Srasuebkul, P., Haas, M., Viney, R., Currow, D. & Pearson, S.-.A. 2016, 'Health service use and costs in the last six months of life in elderly decedents with a history of cancer: A comprehensive analysis from a health payer perspective', British Journal of Cancer, vol. 114, no. 11, pp. 1293-1302.
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Currow, D.C., Abernethy, A.P., Allcroft, P., Banzett, R.B., Bausewein, C., Booth, S., Carrieri-Kohlman, V., Davidson, P., Disler, R., Donesky, D., Dudgeon, D., Ekstrom, M., Farquhar, M., Higginson, I., Janssen, D., Jensen, D., Jolley, C., Krajnik, M., Laveneziana, P., McDonald, C., Maddocks, M., Morelot-Panzini, C., Moxham, J., Mularski, R.A., Noble, S., O'Donnell, D., Parshall, M.B., Pattinson, K., Phillips, J., Ross, J., Schwartzstein, R.M., Similowski, T., Simon, S.T., Smith, T., Wells, A., Yates, P., Yorke, J. & Johnson, M.J. 2016, 'The need to research refractory breathlessness', EUROPEAN RESPIRATORY JOURNAL, vol. 47, no. 1, pp. 342-343.
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Davidson, P.M., Phillips, J.L., Dennison-Himmelfarb, C., Thompson, S.C., Luckett, T. & Currow, D.C. 2016, 'Providing palliative care for cardiovascular disease from a perspective of sociocultural diversity: a global view', CURRENT OPINION IN SUPPORTIVE AND PALLIATIVE CARE, vol. 10, no. 1, pp. 11-17.
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Johnson, M.J., Allgar, V., Macleod, U., Jones, A., Oliver, S. & Currow, D. 2016, 'Family Caregivers Who Would Be Unwilling to Provide Care at the End of Life Again: Findings from the Health Survey for England Population Survey', PLOS ONE, vol. 11, no. 1.
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Johnson, M.J. & Currow, D.C. 2016, 'How much evidence isn't in evidence-based guidelines?', ANNALS OF ONCOLOGY, vol. 27, no. 1, pp. 205-205.
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Johnson, M.J., Booth, S., Currow, D.C., Lam, L.T. & Phillips, J.L. 2016, 'A Mixed-Methods, Randomized, Controlled Feasibility Trial to Inform the Design of a Phase III Trial to Test the Effect of the Handheld Fan on Physical Activity and Carer Anxiety in Patients With Refractory Breathlessness', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 51, no. 5, pp. 807-815.
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Nikles, J., Mitchell, G.K., Hardy, J., Senior, H., Carmont, S.-.A., Schluter, P.J., Vora, R., Currow, D. & Yelland, M. 2016, 'Single-patient multiple crossover studies to determine the effectiveness of paracetamol in relieving pain suffered by patients with advanced cancer taking regular opioids: A pilot study', PALLIATIVE MEDICINE, vol. 30, no. 8, pp. 800-802.
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Sanderson, C., Quinn, S.J., Agar, M., Chye, R., Clark, K., Doogue, M., Fazekas, B., Lee, J., Lovell, M.R., Rowett, D., Spruyt, O. & Currow, D.C. 2016, 'Pharmacovigilance in hospice/palliative care: net effect of pregabalin for neuropathic pain.', BMJ Supportive and Palliative Care, vol. 6, pp. 323-330.
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Real-world effectiveness of many medications has been poorly researched, including in hospice/palliative care. Directly extrapolating findings from other clinical settings may not yield robust clinical advice. Pharmacovigilance studies provide an opportunity to understand better the net impact of medications. The study aimed to examine immediate and short-term benefits and harms of pregabalin in routine practice for neuropathic pain in hospice/palliative care.A consecutive cohort of 155 patients from 62 centres in 5 countries was started on pregabalin and studied prospectively. Data were collected at three time points: baseline; day 7 (immediate, short-term harms); ad hoc reports of any harms 21days; and day 21 (short-term benefits).Median dose for 155 patients at day 21 was 150mg/24h. Benefits were reported by 61 patients (39%), of whom 11 (7%) experienced complete pain resolution. Harms were reported by 51 (35%) patients at or before 7days, the most frequent of which were somnolence, fatigue, cognitive disturbance and dizziness. 10 patients (6%) ceased pregabalin due to harms, but 82 patients (53%) were being treated at 21days. In regression modelling, people with worse baseline pain derived more benefit (OR=8.5 (95% CI 2.5 to 28.68).Pregabalin delivered benefit to many patients, with 4 of 10 experiencing pain reductions by 21days. Harms, occurring in 1 in 3 patients, may be difficult to detect in clinical practice, as they mostly involve worsening of symptoms prevalent at baseline.
Tervonen, H.E., Aranda, S., Roder, D., Walton, R., Baker, D., You, H. & Currow, D. 2016, 'Differences in impact of Aboriginal and Torres Strait Islander status on cancer stage and survival by level of socio-economic disadvantage and remoteness of residence-A population-based cohort study in Australia', CANCER EPIDEMIOLOGY, vol. 41, pp. 132-138.
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Bausewein, C., Daveson, B.A., Currow, D.C., Downing, J., Deliens, L., Radbruch, L., Defilippi, K., Lopes Ferreira, P., Costantini, M., Harding, R. & Higginson, I.J. 2016, 'EAPC White Paper on outcome measurement in palliative care: Improving practice, attaining outcomes and delivering quality services - Recommendations from the European Association for Palliative Care (EAPC) Task Force on Outcome Measurement.', Palliative medicine, vol. 30, no. 1, pp. 6-22.
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Outcome measurement plays an increasing role in improving the quality, effectiveness, efficiency and availability of palliative care.To provide expert recommendations on outcome measurement in palliative care in clinical practice and research.Developed by a European Association for Palliative Care Task Force, based on literature searches, international expert workshop, development of outcome measurement guidance and international online survey. A subgroup drafted a first version and circulated it twice to the task force. The preliminary final version was circulated to wider expert panel and 28 international experts across 20 European Association for Palliative Care member associations and the European Association for Palliative Care Board of Directors and revised according to their feedback. The final version was approved by the European Association for Palliative Care Board for adoption as an official European Association for Palliative Care position paper.In all, 12 recommendations are proposed covering key parameters of measures, adequate measures for the task, introduction of outcome measurement into practice, and national and international outcome comparisons and benchmarking. Compared to other recommendations, the White Paper covers similar aspects but focuses more on outcome measurement in clinical care and the wider policy impact of implementing outcome measurement in clinical palliative care. Patient-reported outcome measure feedback improves awareness of unmet need and allows professionals to act to address patients' needs. However, barriers and facilitators have been identified when implementing outcome measurement in clinical care that should be addressed.The White Paper recommends the introduction of outcome measurement into practice and outcomes that allow for national and international comparisons. Outcome measurement is key to understanding different models of care across countries and, ultimately, patient outcome having controlled for differing p...
Currow, D.C., Phillips, J. & Clark, K. 2016, 'Using opioids in general practice for chronic non-cancer pain: an overview of current evidence.', Med J Aust, vol. 204, no. 8, pp. 305-309.
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Chronic non-cancer pain (lasting more than 3 months) is highly prevalent in Australia (17% of males and 20% of females) and its optimal management is crucial to the health and wellbeing of the community. For 5% of the population, such pain interferes markedly with daily function. Part of the treatment for acute non-cancer pain for many people will include opioid analgesics at least for days to weeks. However, as pain becomes chronic, evidence to support ongoing prescription of opioids is lacking. There is increasing pressure to ensure that prescribing opioid analgesics is minimised to reduce not only the risk of dependence and illicit diversion but also the potential harms associated with tolerance, side effects and complications. Frameworks for considering opioid prescribing include assessing suitability of the patient for opioids; initiating a trial of therapy; and monitoring long term use. There is limited evidence of the long term efficacy of opioids for chronic non-cancer pain, and documented clinical consequences beyond addiction include acceleration of loss of bone mineral density, hypogonadism and an association with increased risk of acute myocardial infarction. Careful clinical selection of patients can help optimise the evidence-based use of opioids for chronic non-cancer pain: only treat pain that has been as well defined as possible when non-opioid therapies have not been effective; consider referral to specialist services for assessment if doses are above 100 mg oral morphine equivalent per 24 hours or the duration of therapy is longer than 4 weeks; limit prescribing to only one practitioner; seek an agreement with the patient for the initiation and potential withdrawal of opioids if the therapeutic trial is not effective.
Luckett, T., Disler, R., Hosie, A., Johnson, M., Davidson, P., Currow, D., Sumah, A. & Phillips, J. 2016, 'Content and quality of websites supporting self-management of chronic breathlessness in advanced illness: a systematic review.', NPJ primary care respiratory medicine, vol. 26, p. 16025.
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Chronic breathlessness is a common, burdensome and distressing symptom in many advanced chronic illnesses. Self-management strategies are essential to optimise treatment, daily functioning and emotional coping. People with chronic illness commonly search the internet for advice on self-management. A review was undertaken in June 2015 to describe the content and quality of online advice on breathlessness self-management, to highlight under-served areas and to identify any unsafe content. Google was searched from Sydney, Australia, using the five most common search terms for breathlessness identified by Google Trends. We also hand-searched the websites of national associations. Websites were included if they were freely available in English and provided practical advice on self-management. Website quality was assessed using the American Medical Association Benchmarks. Readability was assessed using the Flesch-Kincaid grades, with grade 8 considered the maximum acceptable for enabling access. Ninety-one web pages from 44 websites met the inclusion criteria, including 14 national association websites not returned by Google searches. Most websites were generated in the USA (n=28, 64%) and focused on breathing techniques (n=38, 86%) and chronic obstructive pulmonary disease (n=27, 61%). No websites were found to offer unsafe advice. Adherence to quality benchmarks ranged from 9% for disclosure to 77% for currency. Fifteen (54%) of 28 written websites required grade 9 reading level. Future development should focus on advice and tools to support goal setting, problem solving and monitoring of breathlessness. National associations are encouraged to improve website visibility and comply with standards for quality and readability.
Clark, K., Lam, L.T., Talley, N.J., Quinn, J., Blight, A., Byfieldt, N. & Currow, D.C. 2016, 'Assessing the Presence and Severity of Constipation with Plain Radiographs in Constipated Palliative Care Patients.', Journal of palliative medicine, vol. 19, no. 6, pp. 617-621.
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Palliative care guidelines recommend plain radiographs to assess constipation based on the presumption that visible fecal shadowing represents stool retention. Despite this, using plain radiographs in this way is not well validated.This work's main aim was to compare clinicians' reports of fecal loading on radiographs. This study also compares clinicians' assessments with radio-opaque marker transit studies and patients' self-reported constipation symptoms.This study was conducted in a sample of 30 constipated palliative care patients taking laxatives who had all undergone colon transit studies and contemporaneous assessment of constipation symptoms with the Patient Assessment of Constipation Symptom (PAC-SYM) questionnaire. Four separate clinicians independently reported their opinions of fecal loading using a previously developed fecal loading scale. Participant details were summarized and pair-wise inter-rater agreement among all four raters were examined using the Bland-Altman approach. For the comparisons of the clinician-assigned fecal loading score between the radiographic assessment of the normal and slow colon transit time, the nonparametric approach of Mann-Whitney U tests were applied. Spearman's correlation analyses were employed to investigate the association between the clinician-assigned fecal loading score and the patient self-reported PAC-SYM score.The results of this study are very similar to other studies conducted in functional constipation, highlighting systematic disagreement between observers. Further poor correlations were noted between fecal loading scores and colon transit times and with patient self-reported symptoms.These results, when considered with other work in chronic constipation, question the ongoing use of radiographs in the diagnosis of constipation.
Crane, M., Scott, N., O'Hara, B.J., Aranda, S., Lafontaine, M., Stacey, I., Varlow, M. & Currow, D. 2016, 'Knowledge of the signs and symptoms and risk factors of lung cancer in Australia: mixed methods study', BMC PUBLIC HEALTH, vol. 16.
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Dunlop, S., Lyons, C., Dessaix, A. & Currow, D. 2016, 'How are tobacco smokers using e-cigarettes? Patterns of use, reasons for use and places of purchase in New South Wales', MEDICAL JOURNAL OF AUSTRALIA, vol. 204, no. 9, pp. 355-355.
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Hatano, Y., Moroni, M., Wilcock, A., Quinn, S., Csikós, Á., Allan, S.G., Agar, M., Clark, K., Clayton, J.M. & Currow, D.C. 2016, 'Pharmacovigilance in hospice/palliative care: the net immediate and short-term effects of dexamethasone for anorexia.', BMJ supportive & palliative care, vol. 6, no. 3, pp. 331-337.
Loss of appetite is prevalent in palliative care and distressing for patients and families. Therapies include corticosteroids or progestogens. This study explores the net effect of dexamethasone on anorexia.Prospective data were collected when dexamethasone was started for anorexia as part of routine care. The National Cancer Institute's Common Toxicity Criteria for Adverse Events (NCICTCAE) Likert scales assessed severity of anorexia and immediate and short-term harms at 2 time points: baseline and 7days.This study (41 sites, 8 countries) collected data (July 2013 to July 2014) from 114 patients (mean age 71 (SD 11), 96% with cancer). Median Australian-modified Karnofsky Performance Scale was 50% (range 20-70). Mean baseline NCICTCAE anorexia score was 2.7 (SD 0.6; median 3). 6 patients died by day 7. Of 108 evaluable patients, 74 (68.5%; 95% CI 59.0% to 76.7%) reported 1 reduction anorexia scores by day 7, of whom 30 were 0. Mean dexamethasone dose on day 7 was 4.1mg/day (SD 3.4; median 4; range 0-46mg). 24 patients reported 1 harms (32.4% CI 22.6% to 44.1%; insomnia n=10, depression n=7, euphoria n=7 and hyperglycaemia n=7). Of 24 patients with no benefit, 10 reported 1 harms.This study shows positive and negative effects of 7days of dexamethasone as an appetite stimulant in patients with advanced life-limiting illnesses. Identifying clinicodemographic characteristics of people most at risk of harms with no benefit is a crucial next step. Longer term follow-up will help to understand longer term and cumulative harms.
Agar, M.R., Quinn, S.J., Crawford, G.B., Ritchie, C.S., Phillips, J.L., Collier, A. & Currow, D.C. 2016, 'Predictors of Mortality for Delirium in Palliative Care', JOURNAL OF PALLIATIVE MEDICINE, vol. 19, no. 11, pp. 1205-1209.
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Delaney, G.P., Gandhidasan, S., Walton, R., Terlich, F., Baker, D. & Currow, D. 2016, 'The Pattern of Use of Hypofractionated Radiation Therapy for Early-Stage Breast Cancer in New South Wales, Australia, 2008 to 2012', INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS, vol. 96, no. 2, pp. 266-272.
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Kirby, S., Barlow, V., Saurman, E., Lyle, D., Passey, M. & Currow, D. 2016, 'Are rural and remote patients, families and caregivers needs in life-limiting illness different from those of urban dwellers? A narrative synthesis of the evidence', AUSTRALIAN JOURNAL OF RURAL HEALTH, vol. 24, no. 5, pp. 289-299.
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Creighton, N., Walton, R., Roder, D., Aranda, S. & Currow, D. 2016, 'Validation of administrative hospital data for identifying incident pancreatic and periampullary cancer cases: a population-based study using linked cancer registry and administrative hospital data in New South Wales, Australia', BMJ OPEN, vol. 6, no. 7.
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Luckett, T.R., Phillips, J., Lintzeris, N., Allsop, D., Lee, J., Solowij, N., Martin, J., Lam, L., Aggarwal, R., McCaffrey, N., Currow, D., Chye, R., Lovell, M., McGregor, I. & Agar, M. 2016, 'Clinical trials of medicinal cannabis for appetite-related symptoms from advanced cancer: A survey of preferences, attitudes and beliefs among patients willing to consider participation', Internal Medicine Journal, vol. 46, no. 11, pp. 1269-1275.
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Bush, S.H., Lacaze-Masmonteil, N., McNamara-Kilian, M.T., MacDonald, A.R., Tierney, S., Momoli, F., Agar, M., Currow, D.C. & Lawlor, P.G. 2016, 'The preventative role of exogenous melatonin administration to patients with advanced cancer who are at risk of delirium: study protocol for a randomized controlled trial', TRIALS, vol. 17.
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McCaffrey, N., Al-Janabi, H., Currow, D., Hoefman, R. & Ratcliffe, J. 2016, 'Protocol for a systematic review of preference-based instruments for measuring care-related outcomes and their suitability for the palliative care setting.', BMJ Open, vol. 6, no. 9, p. e012181.
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INTRODUCTION: Despite informal caregivers' integral role in supporting people affected by disease or disability, economic evaluations often ignore the costs and benefits experienced by this group, especially in the palliative setting. The purpose of this systematic review is to identify preference-based instruments for measuring care-related outcomes and provide guidance on the selection of instrument in palliative care economic evaluations. METHODS AND ANALYSIS: A comprehensive search of the literature will be conducted from database inception (ASSIA; CINAHL; Cochrane library including DARE, NHS EED, HTA; Econlit; Embase; PsychINFO; PubMed). Published peer-reviewed, English-language articles reporting preference-based instruments for measuring care-related outcomes in any clinical area will be included. One researcher will complete the searches and screen the results for potentially eligible studies. A randomly selected subset of 10% citations will be independently screened by two researchers. Any disagreement will be resolved by consensus among the research team. Subsequently, a supplementary search will identify studies detailing the development, valuation, validation and application of the identified instruments. The degree of suitability of the instruments for palliative economic evaluations will be assessed using criteria in the International Society for Quality of Life Research minimum standards for patient-reported outcome measures, the checklist for reporting valuation studies of multiattribute utility-based instruments and information on the development of the instrument in the palliative setting. A narrative summary of the included studies and instruments will be provided; similarities and differences will be described and possible reasons for variations explored. Recommendations for practice on selection of instruments in palliative care economic analyses will be provided. ETHICS AND DISSEMINATION: This is a planned systematic review of published lite...
Dunlop, S., Dessaix, A. & Currow, D. 2016, 'How are tobacco smokers using e-cigarettes? Patterns of use, reasons for use and places of purchase in New South Wales REPLY', MEDICAL JOURNAL OF AUSTRALIA, vol. 205, no. 7, pp. 336-336.
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Ekstrom, M., Johnson, M.J., Schioler, L., Kaasa, S., Hjermstad, M.J. & Currow, D.C. 2016, 'Who experiences higher and increasing breathlessness in advanced cancer? The longitudinal EPCCS Study', SUPPORTIVE CARE IN CANCER, vol. 24, no. 9, pp. 3803-3811.
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Currow, D. & Aranda, S. 2016, 'Financial toxicity in clinical care today: a "menu without prices"', MEDICAL JOURNAL OF AUSTRALIA, vol. 204, no. 11, pp. 397-397.
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Dunlop, S., Perez, D., Dessaix, A. & Currow, D. 2016, 'Australia's plain tobacco packs: anticipated and actual responses among adolescents and young adults 2010-2013.', Tob Control.
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BACKGROUND: In December 2012, Australia introduced world-first legislation mandating plain packaging for all tobacco products. To date, there is very little evidence on youth responses to the changed packs. AIM: To assess attitudes towards, and responses to, tobacco plain packs preimplementation and postimplementation. METHODS: The Tobacco Promotion Impact Study (TPIS) was a yearly cross-sectional telephone survey of adolescents and young adults (12-24years) from the states of New South Wales (NSW) and Queensland, conducted at three time points preimplementation (June 2010; June 2011; June 2012) and one time point postimplementation (June 2013; total n=8820). RESULTS: There were significant increases in support for plain packaging from preimplementation to postimplementation for: never smokers (56% in 2012 vs 63% in 2013; OR=0.77, 95% CI 0.65 to 0.90, p=0.001), experimenters/ex-smokers (55% in 2012 vs 72% in 2013; OR=0.51, 95% CI 0.38 to 0.68, p<0.001) and current smokers (35% in 2012 vs 55% in 2013; OR=0.49, 95% CI 0.32 to 0.75, p=0.001). At postimplementation, 16% of never smokers reported that plain packaging made them less likely to try smoking and 18% of experimenters/ex-smokers reported that plain packaging made them less likely to smoke again. Youth were significantly less likely to have anticipated these responses preimplementation (never smokers: 8% in 2011; OR=0.43, 95% CI 0.28 to 0.65, p<0.00; experimenters/ex-smokers: 11%; OR=0.65, 95% CI 0.52 to 0.82, p<0.001). At postimplementation, 34% of smokers reported a quitting-related response to plain packaging (tried to quit or thought about quitting); the proportion who anticipated such a response preimplementation was significantly less (14% in 2011; OR=0.33, 95% CI 0.20 to 0.53, p<0.001). 28% of smokers reported a social denormalisation response at postimplementation (hid their pack from view, used a case to cover their pack, felt embarrassed); the proportion who anticipated such a response preimplement...
Watts, G.J., Clark, K., Agar, M., Davidson, P.M., McDonald, C., Lam, L.T., Sajkov, D., McCaffrey, N., Doogue, M., Abernethy, A.P., Currow, D.C. & Australian national Palliative Care Clinical Studies Collaborative (PaCCSC) 2016, 'Study protocol: a phase III randomised, double-blind, parallel arm, stratified, block randomised, placebo-controlled trial investigating the clinical effect and cost-effectiveness of sertraline for the palliative relief of breathlessness in people with chronic breathlessness.', BMJ Open, vol. 6, no. 11, p. e013177.
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INTRODUCTION: Breathlessness remains a highly prevalent and distressing symptom for many patients with progressive life-limiting illnesses. Evidence-based interventions for chronic breathlessness are limited, and there is an ongoing need for high-quality research into developing management strategies for optimal palliation of this complex symptom. Previous studies have suggested that selective serotonin reuptake inhibitors such as sertraline may have a role in reducing breathlessness. This paper presents the protocol for a large, adequately powered randomised study evaluating the use of sertraline for chronic breathlessness in people with progressive life-limiting illnesses. METHODS AND ANALYSIS: A total of 240 participants with modified Medical Research Council Dyspnoea Scale breathlessness of level 2 or higher will be randomised to receive either sertraline or placebo for 28days in this multisite, double-blind study. The dose will be titrated up every 3days to a maximum of 100mg daily. The primary outcome will be to compare the efficacy of sertraline with placebo in relieving the intensity of worst breathlessness as assessed by a 0-100mm Visual Analogue Scale. A number of other outcome measures and descriptors of breathlessness as well as caregiver assessments will also be recorded to ensure adequate analysis of participant breathlessness and to allow an economic analysis to be performed. Participants will also be given the option of continuing blinded treatment until either study data collection is complete or net benefit ceases. Appropriate statistical analysis of primary and secondary outcomes will be used to describe the wealth of data obtained. ETHICS AND DISSEMINATION: Ethics approval was obtained at all participating sites. Results of the study will be submitted for publication in peer-reviewed journals and the key findings presented at national and international conferences. TRIAL REGISTRATION NUMBER: ACTRN12610000464066.
Aranda, S. & Currow, D. 2016, 'Financial toxicity in clinical care today: a "menu without prices".', Med J Aust, vol. 205, no. 11, pp. 529-530.
Ekstrom, M., Ahmadi, Z., Bornefalk-Hermansson, A., Abernethy, A. & Currow, D. 2016, 'Oxygen for breathlessness in patients with chronic obstructive pulmonary disease who do not qualify for home oxygen therapy', COCHRANE DATABASE OF SYSTEMATIC REVIEWS, no. 11.
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Johnston, A.K., Creighton, N. & Currow, D. 2016, 'Breast reconstruction following mastectomy in NSW, 2008-2011', Asia-Pacific Journal of Clinical Oncology, vol. 12, pp. 111-111.
Collins, A., Burchell, J., Sundararajan, V., Millar, J., Le, B., Currow, D., Hudson, P., McLachlan, S.-.A., Mileshkin, L. & Krishnasamy, M. 2016, 'Transition to Palliative Care for Patients with Metastatic Prostate Cancer: How Well Have We Integrated?', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 52, no. 6, pp. E150-E151.
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Clark, K., Connolly, A., Clapham, S., Quinsey, K. & Currow, D. 2016, 'The Prevalence and Intensity of People's Physical Symptoms at the Time That Dying Was Diagnosed: A Prospective Cohort Study', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 52, no. 6, pp. E17-E17.
Reigada, C., Fairhurst, C., Yorke, J., Ross, J., Boland, J., Hart, S., Currow, D., Grande, G., Bajwah, S., Wells, A., Macleod, U., Bland, M. & Johnson, M. 2016, 'Construct validity of the needs assessment tool progressive diseases for interstitial lung disease (nat: pd-ild) patients', Thorax, vol. 71, pp. A266-A266.
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Collins, A., Burchell, J., Ritchie, D., Le, B., Sundararajan, V., Hudson, P., McLachlan, S.-.A., Krishnasamy, M., Millar, J., Currow, D., Mileshkin, L. & Philip, J. 2016, 'Exploring the Landscape of Palliative Care for People with Non-Hodgkin's Lymphoma: Do They Receive Quality End-of-Life Care?', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 52, no. 6, pp. E151-E152.
Currow, D., Temel, J., Abernethy, A., Friend, J., Giorgino, R. & Fearon, K.C. 2016, 'Anamorelin in cachectic patients with non-small cell lung cancer (NSCLC) and acute phase protein reaction (APPR): Pooled analysis of two phase 3 trials (ROMANA 1 and ROMANA 2)', ANNALS OF ONCOLOGY, vol. 27.
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Philip, J., Collins, A., Burchell, J., Krishnasamy, M., Mileshkin, L., McLachlan, S.-.A., Le, B., Millar, J., Currow, D., Hudson, P. & Sundararajan, V. 2016, 'Integration of Palliative Care for Patients with Metastatic Breast Cancer: Have We Achieved Quality End-of-Life Care?', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 52, no. 6, pp. E152-E152.
Temel, J.S., Abernethy, A.P., Currow, D.C., Friend, J., Duus, E.M., Yan, Y. & Fearon, K.C. 2016, 'Anamorelin in patients with non-small-cell lung cancer and cachexia (ROMANA 1 and ROMANA 2): results from two randomised, double-blind, phase 3 trials.', Lancet Oncol, vol. 17, no. 4, pp. 519-531.
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BACKGROUND: Patients with advanced cancer frequently experience anorexia and cachexia, which are associated with reduced food intake, altered body composition, and decreased functionality. We assessed anamorelin, a novel ghrelin-receptor agonist, on cachexia in patients with advanced non-small-cell lung cancer and cachexia. METHODS: ROMANA 1 and ROMANA 2 were randomised, double-blind, placebo-controlled phase 3 trials done at 93 sites in 19 countries. Patients with inoperable stage III or IV non-small-cell lung cancer and cachexia (defined as 5% weight loss within 6 months or body-mass index <20 kg/m(2)) were randomly assigned 2:1 to anamorelin 100 mg orally once daily or placebo, with a computer-generated randomisation algorithm stratified by geographical region, cancer treatment status, and weight loss over the previous 6 months. Co-primary efficacy endpoints were the median change in lean body mass and handgrip strength over 12 weeks and were measured in all study participants (intention-to-treat population). Both trials are now completed and are registered with ClinicalTrials.gov, numbers NCT01387269 and NCT01387282. FINDINGS: From July 8, 2011, to Jan 28, 2014, 484 patients were enrolled in ROMANA 1 (323 to anamorelin, 161 to placebo), and from July 14, 2011, to Oct 31, 2013, 495 patients were enrolled in ROMANA 2 (330 to anamorelin, 165 to placebo). Over 12 weeks, lean body mass increased in patients assigned to anamorelin compared with those assigned to placebo in ROMANA 1 (median increase 099 kg [95% CI 061 to 136] vs -047 kg [-100 to 021], p<00001) and ROMANA 2 (065 kg [038 to 091] vs -098 kg [-149 to -041], p<00001). We noted no difference in handgrip strength in ROMANA 1 (-110 kg [-169 to -040] vs -158 kg [-299 to -114], p=015) or ROMANA 2 (-149 kg [-206 to -058] vs -095 kg [-156 to 004], p=065). There were no differences in grade 3-4 treatment-related adverse events between study groups; the most common grade 3-4 adverse e...
Currow, D.C. & Johnson, M.J. 2016, 'Chronic breathlessness', Current Opinion in Supportive and Palliative Care, vol. 10, no. 3, pp. 221-222.
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Ahmadi, Z., Wysham, N.G., Lundström, S., Janson, C., Currow, D.C. & Ekström, M. 2016, 'End-of-life care in oxygen-dependent ILD compared with lung cancer: a national population-based study.', Thorax, vol. 71, no. 6, pp. 510-516.
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RATIONALE: Advanced fibrosing interstitial lung disease (ILD) is often progressive and associated with a high burden of symptoms and poor prognosis. Little is known about the symptom prevalence and access to palliative care services at end of life (EOL). OBJECTIVES: Compare prevalence of symptoms and palliative treatments between patients dying with oxygen-dependent ILD and patients dying of lung cancer. METHODS: Nationwide registry-based cohort study of patients with oxygen-dependent ILD and patients with lung cancer who died between 1 January 2011 and 14 October 2013. Prevalence of symptoms and treatments during the last seven days of life were compared using data in Swedish Registry of Palliative Care. MEASUREMENTS AND MAIN RESULTS: 285 patients with ILD and 10822 with lung cancer were included. In ILD, death was more likely to be 'unexpected' (15% vs 4%), less likely to occur in a palliative care setting (17% vs 40%) and EOL discussions with the patients (41% vs 59%) were less common than in lung cancer. Patients with ILD suffered more from breathlessness (75% vs 42%) while patients with lung cancer had more pain (51% vs 73%) (p<0.005 for all comparisons). Patients with ILD had more unrelieved breathlessness, pain and anxiety. The survival time from initiation of oxygen therapy in ILD was a median 8.4months (IQR 3.4-19.2months). CONCLUSIONS: Patients with ILD receive poorer access to specialist EOL care services and experience more breathlessness than patients with lung cancer. This study highlights the need of better EOL care in oxygen-dependent ILD.
Johnson, M.J. & Currow, D.C. 2016, 'Treating breathlessness in lung cancer patients: the potential of breathing training.', Expert Rev Respir Med, vol. 10, no. 3, pp. 241-243.
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Allen, S.A., Dal Grande, E., Abernethy, A.P. & Currow, D.C. 2016, 'Two colliding epidemics - obesity is independently associated with chronic pain interfering with activities of daily living in adults 18 years and over; a cross-sectional, population-based study', BMC Public Health, vol. 16, no. 1, pp. 1-9.
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Soeberg, M.J., Creighton, N., Currow, D.C., Young, J.M. & van Zandwijk, N. 2016, 'Patterns in the incidence, mortality and survival of malignant pleural and peritoneal mesothelioma, New South Wales, 1972-2009.', Aust N Z J Public Health, vol. 40, no. 3, pp. 255-262.
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INTRODUCTION: Malignant pleural mesothelioma (MPM) and malignant peritoneal mesothelioma (MPeM) are often grouped together in descriptive epidemiological analyses, resulting in limited understanding of epidemiological patterns for these tumour types. METHODS: We studied patterns in the incidence, mortality and survival of people diagnosed with MPM (n=4,076) and MPeM (n=293) in New South Wales (NSW), Australia, 1972-2009. We also calculated 5-year relative survival for people diagnosed 1972-2006 followed up to 2007. We assessed patterns for each tumour type and histological subtype and, where possible, by combination of these categories. RESULTS: Annual MPM cases steadily increased over time (n=208 in 2009). There was an increasing trend in the MPM age-standardised incidence rate from 1972 up to 1994. This rate increase has levelled off in the past 10 years. Since 1999, 11 cases of MPeM were diagnosed each year, on average. Five-year relative survival remained stable for MPM and MPeM. However, 5-year relative survival in 2002-2006 was substantially higher for people with MPM epithelioid histological subtype (11.7% [95%CI 6.8-18.2%]) compared to all other non-epithelioid histological subtypes (6.9% [95%CI 5.0-9.1%]), a 70% difference. Survival was also greater for women with MPM (13.4% [95%CI 8.5-19.4%]) compared to men (7.0% [95%CI 5.1-9.2%]). INTERPRETATION: MPM incidence rates have stabilised since the mid-1990s, suggesting that maximum incidence levels have been reached. When more up-to-date data are available, survival estimates should be reanalysed to include people likely to benefit from the wide introduction of combination chemotherapy in 2007, including pemetrexed.
Johnson, M.J., Hui, D. & Currow, D.C. 2016, 'Opioids, Exertion, and Dyspnea: A Review of the Evidence.', Am J Hosp Palliat Care, vol. 33, no. 2, pp. 194-200.
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The aim of this paper is to review the evidence for a role for opioids as an intervention for exertion induced breathlessness with regard to exercise tolerance and breathlessness intensity. Current knowledge about exogenous opioids in exertion-induced breathlessness due to disease comes from a variety of phase 2 feasibility or pilot designs with differing duration, doses, drugs, exercise regimes, underlying aetiologies, and outcome measures. They provide interesting data but firm conclusions for either breathlessness severity or exercise endurance cannot be drawn. There are no adequately powered phase 3 trials of opioids which show improved exercise tolerance and/or exertion induced breathlessness. Low dose oral morphine seems well tolerated by most, and is beneficial for breathlessness intensity. Current work to investigate the effect on exercise tolerance is ongoing.
Currow, D.C., Ekström, M. & Johnson, M.J. 2016, 'Opioids in chronic obstructive pulmonary disease: the whole picture using all available evidence.', Br J Clin Pharmacol, vol. 81, no. 4, pp. 795-796.
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Hussain, J.A., White, I.R., Langan, D., Johnson, M.J., Currow, D.C., Torgerson, D.J. & Bland, M. 2016, 'Missing data in randomized controlled trials testing palliative interventions pose a significant risk of bias and loss of power: a systematic review and meta-analyses.', J Clin Epidemiol, vol. 74, pp. 57-65.
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OBJECTIVES: To assess the risk posed by missing data (MD) to the power and validity of trials evaluating palliative interventions. STUDY DESIGN AND SETTING: A systematic review of MD in published randomized controlled trials (RCTs) of palliative interventions in participants with life-limiting illnesses was conducted, and random-effects meta-analyses and metaregression were performed. CENTRAL, MEDLINE, and EMBASE (2009-2014) were searched with no language restrictions. RESULTS: One hundred and eight RCTs representing 15,560 patients were included. The weighted estimate for MD at the primary endpoint was 23.1% (95% confidence interval [CI] 19.3, 27.4). Larger MD proportions were associated with increasing numbers of questions/tests requested (odds ratio [OR], 1.19; 95% CI 1.05, 1.35) and with longer study duration (OR, 1.09; 95% CI 1.02, 1.17). Meta-analysis found evidence of differential rates of MD between trial arms, which varied in direction (OR, 1.04; 95% CI 0.90, 1.20; I(2) 35.9, P&nbsp;=&nbsp;0.001). Despite randomization, MD in the intervention arms (vs. control) were more likely to be attributed to disease progression unrelated to the intervention (OR, 1.31; 95% CI 1.02, 1.69). This was not the case for MD due to death (OR, 0.92; 95% CI 0.78, 1.08). CONCLUSION: The overall proportion and differential rates and reasons for MD reduce the power and potentially introduce bias to palliative care trials.
Johnson, M.J. & Currow, D.C. 2016, 'Minimal clinically important difference and Edmonton Symptom Assessment Scale.', Cancer, vol. 122, no. 1, pp. 158-159.
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Collier, A., Morgan, D.D., Swetenham, K., To, T.H.M., Currow, D.C. & Tieman, J.J. 2016, 'Implementation of a pilot telehealth programme in community palliative care: A qualitative study of clinicians' perspectives.', Palliat Med, vol. 30, no. 4, pp. 409-417.
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BACKGROUND: Telehealth technologies are an emerging resource opening up the possibility of greater support if they have utility for patients, carers and clinicians. They may also help to meet health systems' imperatives for improved service delivery within current budgets. Clinicians' experiences and attitudes play a key role in the implementation of any innovation in service delivery. AIM: To explore clinicians' perspectives on and experiences of the utilisation of a pilot telehealth model and its integration into a specialist community palliative care programme. DESIGN: Focus groups and interviews generated data that were analysed through the lens of a realistic evaluation theoretical framework. SETTING/PARTICIPANTS: The study was conducted in a metropolitan specialist palliative care service in South Australia. Participants (n=10) were clinicians involved in the delivery of community specialist palliative care and the piloting of a telehealth programme. RESULTS: Service providers consider telehealth resources as a means to augment current service provision in a complementary way rather than as a replacement for face-to-face assessments. Introducing this technology, however, challenged the team to critically explore aspects of current service provision. The introduction of technologies also has the potential to alter the dynamic of relationships between patients and families and community palliative care clinicians. CONCLUSION: Implementation of a pilot telehealth programme in a specialist palliative community team needs to involve clinical staff in service redesign from the outset. Reliable IT infrastructure and technical support is critical for telehealth models to be effective and will aid uptake.
McCaffrey, N., Kaambwa, B., Currow, D.C. & Ratcliffe, J. 2016, 'Health-related quality of life measured using the EQ-5D-5L: South Australian population norms.', Health and Quality of Life Outcomes, vol. 14, no. 1, pp. 1-12.
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BACKGROUND: Although a five level version of the widely-used EuroQol 5 dimensions (EQ-5D) instrument has been developed, population norms are not yet available for Australia to inform the future valuation of health in economic evaluations. The aim of this study was to estimate HrQOL normative values for the EQ-5D-5L preference-based measure in a large, randomly selected, community sample in South Australia. METHODS: The EQ-5D-5L instrument was included in the 2013 South Australian Health Omnibus Survey, an interviewer-administered, face-to-face, cross-sectional survey. Respondents rated their level of impairment across dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and global health rating on a visual analogue scale (EQ-VAS). Utility scores were derived using the newly-developed UK general population-based algorithm and relationships between utility and EQ-VAS scores and socio-demographic factors were also explored using multivariate regression analyses. RESULTS: Ultimately, 2,908 adults participated in the survey (63.4&nbsp;% participation rate). The mean utility and EQ-VAS scores were 0.91 (95 CI 0.90, 0.91) and 78.55 (95&nbsp;% CI 77.95, 79.15), respectively. Almost half of respondents reported no problems across all dimensions (42.8&nbsp;%), whereas only 7.2&nbsp;% rated their health >90 on the EQ-VAS (100=the best health you can imagine). Younger age, male gender, longer duration of education, higher annual household income, employment and marriage/de facto relationships were all independent, statistically significant predictors of better health status (p<0.01) measured with the EQ-VAS. Only age and employment status were associated with higher utility scores, indicating fundamental differences between these measures of health status. CONCLUSIONS: This is the first Australian study to apply the EQ-5D-5L in a large, community sample. Overall, findings are consistent with EQ-5D-5L utility and VAS scores reported for other countries...
Martins, R.T., Currow, D.C., Abernethy, A.P., Johnson, M.J., Toson, B. & Eckert, D.J. 2016, 'Effects of low-dose morphine on perceived sleep quality in patients with refractory breathlessness: A hypothesis generating study', Respirology, vol. 21, no. 2, pp. 386-391.
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Ekström, M., Allingham, S.F., Eagar, K., Yates, P., Johnson, C. & Currow, D.C. 2016, 'Breathlessness during the Last Week of Life in Palliative Care: An Australian Prospective, Longitudinal Study', Journal of Pain and Symptom Management, vol. 51, no. 5, pp. 816-823.
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McCaffrey, N., Fazekas, B., Cutri, N. & Currow, D.C. 2016, 'How Accurately Do Consecutive Cohort Audits Predict Phase III Multisite Clinical Trial Recruitment in Palliative Care?', Journal of Pain and Symptom Management, vol. 51, no. 4, pp. 748-755.
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CONTEXT: Audits have been proposed for estimating possible recruitment rates to randomized controlled trials (RCTs), but few studies have compared audit data with subsequent recruitment rates. OBJECTIVES: To compare the accuracy of estimates of potential recruitment from a retrospective consecutive cohort audit of actual participating sites and recruitment to four Phase III multisite clinical RCTs. METHODS: The proportion of potentially eligible study participants estimated from an inpatient chart review of people with life-limiting illnesses referred to six Australian specialist palliative care services was compared with recruitment data extracted from study prescreening information from three sites that participated fully in four Palliative Care Clinical Studies Collaborative RCTs. The predominant reasons for ineligibility in the audit and RCTs were analyzed. RESULTS: The audit overestimated the proportion of people referred to the palliative care services who could participate in the RCTs (pain 17.7% vs. 1.2%, delirium 5.8% vs. 0.6%, anorexia 5.1% vs. 0.8%, and bowel obstruction 2.8% vs. 0.5%). Approximately 2% of the referral base was potentially eligible for these effectiveness studies. Ineligibility for general criteria (language, cognition, and geographic proximity) varied between studies, whereas the reasons for exclusion were similar between the audit and pain and anorexia studies but not for delirium or bowel obstruction. CONCLUSION: The retrospective consecutive case note audit in participating sites did not predict realistic recruitment rates, mostly underestimating the impact of study-specific inclusion criteria. These findings have implications for the applicability of the results of RCTs. Prospective pilot studies are more likely to predict actual recruitment.
Tieman, J.J., Swetenham, K., Morgan, D.D., To, T.H. & Currow, D.C. 2016, 'Using telehealth to support end of life care in the community: a feasibility study', BMC Palliative Care, vol. 15, no. 1, pp. 1-7.
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Smith, A.K., Currow, D.C., Abernethy, A.P., Johnson, M.J., Miao, Y., Boscardin, W.J. & Ritchie, C.S. 2016, 'Prevalence and Outcomes of Breathlessness in Older Adults: A National Population Study', Journal of the American Geriatrics Society, vol. 64, no. 10, pp. 2035-2041.
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McCaffrey, N., Bradley, S., Ratcliffe, J. & Currow, D.C. 2016, 'What Aspects of Quality of Life Are Important From Palliative Care Patients' Perspectives? A Systematic Review of Qualitative Research', Journal of Pain and Symptom Management, vol. 52, no. 2, pp. 318-328.e5.
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Boland, J.W., Reigada, C., Yorke, J., Hart, S.P., Bajwah, S., Ross, J., Wells, A., Papadopoulos, A., Currow, D.C., Grande, G., Macleod, U. & Johnson, M.J. 2016, 'The Adaptation, Face, and Content Validation of a Needs Assessment Tool: Progressive Disease for People with Interstitial Lung Disease', Journal of Palliative Medicine, vol. 19, no. 5, pp. 549-555.
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Ahmadi, Z., Bernelid, E., Currow, D. & Ekström, M. 2016, 'Prescription of opioids for breathlessness in end-stage COPD: a national population-based study', International Journal of Chronic Obstructive Pulmonary Disease, vol. Volume 11, pp. 2651-2657.
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Obita, G.P., Boland, E.G., Currow, D.C., Johnson, M.J. & Boland, J.W. 2016, 'Somatostatin Analogues Compared With Placebo and Other Pharmacologic Agents in the Management of Symptoms of Inoperable Malignant Bowel Obstruction: A Systematic Review', Journal of Pain and Symptom Management, vol. 52, no. 6, pp. 901-919.e1.
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Clark, K., Connolly, A., Clapham, S., Quinsey, K., Eagar, K. & Currow, D.C. 2016, 'Physical Symptoms at the Time of Dying Was Diagnosed: A Consecutive Cohort Study to Describe the Prevalence and Intensity of Problems Experienced by Imminently Dying Palliative Care Patients by Diagnosis and Place of Care', Journal of Palliative Medicine, vol. 19, no. 12, pp. 1288-1295.
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Clark, K., Eagar, K. & Currow, D.C. 2016, 'Embedding Objective Measurements of Quality into Routine Practice in Hospice/Palliative Care', Journal of Pain and Symptom Management, vol. 52, no. 3, pp. e5-e7.
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To, T.H.M., To, L.B. & Currow, D.C. 2016, 'Can We Detect Transfusion Benefits in Palliative Care Patients?', Journal of Palliative Medicine, vol. 19, no. 10, pp. 1110-1113.
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Taylor, A., Morris, G., Tieman, J., Currow, D., Kidd, M. & Carati, C. 2016, 'Can Video Conferencing Be as Easy as Telephoning?—A Home Healthcare Case Study', E-Health Telecommunication Systems and Networks, vol. 05, no. 01, pp. 8-18.
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Hochman, M.J., Kamal, A.H., Wolf, S.P., Samsa, G.P., Currow, D.C., Abernethy, A.P. & LeBlanc, T.W. 2016, 'Anticholinergic Drug Burden in Noncancer Versus Cancer Patients Near the End of Life', Journal of Pain and Symptom Management, vol. 52, no. 5, pp. 737-743.e3.
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Wysham, N.G., Nipp, R.D., LeBlanc, T.W., Wolf, S.P., Ekstrom, M.P. & Currow, D.C. 2016, 'A practical measurement of thoracic sarcopenia: correlation with clinical parameters and outcomes in advanced lung cancer: TABLE 1', ERJ Open Research, vol. 2, no. 2, pp. 00085-2015-00085-2015.
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Ferreira, D.H., Silva, J.P., Quinn, S., Abernethy, A.P., Johnson, M.J., Oxberry, S.G. & Currow, D.C. 2016, 'Blinded Patient Preference for Morphine Compared to Placebo in the Setting of Chronic Refractory Breathlessness—An Exploratory Study', Journal of Pain and Symptom Management, vol. 51, no. 2, pp. 247-254.
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Ekström, M., Vergo, M.T., Ahmadi, Z. & Currow, D.C. 2016, 'Prevalence of Sudden Death in Palliative Care: Data From the Australian Palliative Care Outcomes Collaboration', Journal of Pain and Symptom Management, vol. 52, no. 2, pp. 272-283.
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Muircroft, W. & Currow, D. 2016, 'Palliative care in advanced pancreatic cancer', Cancer Forum, vol. 40, no. 1, pp. 62-65.
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Sanderson, C., Quinn, S.J., Agar, M., Chye, R., Clark, K., Doogue, M., Fazekas, B., Lee, J., Lovell, M.R., Rowett, D., Spruyt, O. & Currow, D.C. 2015, 'Pharmacovigilance in hospice/palliative care: net effect of gabapentin for neuropathic pain.', BMJ supportive & palliative care, vol. 5, no. 3, pp. 273-280.
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Hospice/palliative care patients may differ from better studied populations, and data from other populations cannot necessarily be extrapolated into hospice/palliative care clinical practice. Pharmacovigilance studies provide opportunities to understand the harms and benefits of medications in routine practice. Gabapentin, a -amino butyric acid analogue antiepileptic drug, is commonly prescribed for neuropathic pain in hospice/palliative care. Most of the evidence however relates to non-malignant, chronic pain syndromes (diabetic neuropathy, postherpetic neuralgia, central pain syndromes, fibromyalgia). The aim of this study was to quantify the immediate and short-term clinical benefits and harms of gabapentin in routine hospice/palliative care practice.Multisite, prospective, consecutive cohort.127 patients, 114 of whom had cancer, who started gabapentin for neuropathic pain as part of routine clinical care.42 centres from seven countries. Data were collected at three time points-at baseline, at day 7 (and at any time; immediate and short-term harms) and at day 21 (clinical benefits).At day 21, the average dose of gabapentin for those still using it (n=68) was 653mg/24h (range 0-1800mg) and 54 (42%) reported benefits, of whom 7 (6%) experienced complete pain resolution. Harms were reported in 39/127 (30%) patients at day 7, the most frequent of which were cognitive disturbance, somnolence, nausea and dizziness. Ten patients had their medication ceased due to harms. The presence of significant comorbidities, higher dose and increasing age increased the likelihood of harm.Overall, 42% of people experienced benefit at a level that resulted in continued use at 21days.
Dunlop, S., Kite, J., Grunseit, A.C., Rissel, C., Perez, D.A., Dessaix, A., Cotter, T., Bauman, A., Young, J. & Currow, D. 2015, 'Out of Sight and Out of Mind? Evaluating the Impact of Point-of-Sale Tobacco Display Bans on Smoking-Related Beliefs and Behaviors in a Sample of Australian Adolescents and Young Adults', NICOTINE & TOBACCO RESEARCH, vol. 17, no. 7, pp. 761-768.
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Young, J., Badgery-Parker, T., Dobbins, T., Jorgensen, M., Gibbs, P., Faragher, I., Jones, I. & Currow, D. 2015, 'Comparison of ECOG/WHO Performance Status and ASA Score as a Measure of Functional Status', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 49, no. 2, pp. 258-264.
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Holloway, K., Toye, C., McConigley, R., Tieman, J., Currow, D. & Hegarty, M. 2015, 'National consultation informing development of guidelines for a palliative approach for aged care in the community setting', AUSTRALASIAN JOURNAL ON AGEING, vol. 34, no. 1, pp. 21-26.
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Currow, D.C., Quinn, S., Agar, M., Fazekas, B., Hardy, J., McCaffrey, N., Eckermann, S., Abernethy, A.P. & Clark, K. 2015, 'Double-Blind, Placebo-Controlled, Randomized Trial of Octreotide in Malignant Bowel Obstruction', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 49, no. 5, pp. 814-821.
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Young, J.M., O'Halloran, A., McAulay, C., Pirotta, M., Forsdike, K., Stacey, I. & Currow, D. 2015, 'Unconditional and conditional incentives differentially improved general practitioners' participation in an online survey: randomized controlled trial', JOURNAL OF CLINICAL EPIDEMIOLOGY, vol. 68, no. 6, pp. 693-697.
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Hoefman, R., Al-Janabi, H., McCaffrey, N., Currow, D. & Ratcliffe, J. 2015, 'Measuring caregiver outcomes in palliative care: a construct validation study of two instruments for use in economic evaluations', QUALITY OF LIFE RESEARCH, vol. 24, no. 5, pp. 1255-1273.
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Phillips, J., Dal Grande, E., Ritchie, C., Abernethy, A.P. & Currow, D.C. 2015, 'A population-based cross-sectional study that defined normative population data for the Life-Space Mobility Assessment-composite score.', Journal of pain and symptom management, vol. 49, no. 5, pp. 885-893.
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Mobility is linked to health status and quality of life. Life-Space Mobility Assessment (LSMA; range 0-120) measures the spatial extent of people's excursion and physical support needs over the preceding month.The aim of this study was to generate normative population data for an LSMA-Composite (LSMA-C) score, irrespective of age or health service contact and explore the LSM of people with diabetes, current asthma, arthritis, and osteoporosis.LSMA questions were included in the 2011 South Australian Health Omnibus Survey, a multistage, systematic, and clustered sample of household face-to-face interviews. Sociodemographic and clinical variables were explored in relation to LSMA scores using descriptive, univariable, and multivariable analyses and receiver operator curves.For the 3032 respondents, the mean LSMA score was 98.3 (SD 20.3; median 100; interquartile range 34 [86-120]; range 6-120). Five percent of respondents scored <60, 11% scored between 60 and 79, 27% scored between 80 and 99, and the remainder scored between 100 and 120. After 55 years of age, LSMA-C scores declined, more so in females. In multivariable analysis, declining scores were associated with being female, being older, living in rural areas, lower educational attainment, not working, lower household income, and higher numbers of chronic conditions (R(2) = 0.35, P < 0.001). The receiver operator curve demonstrated a highly specific but relatively insensitive measure.Having controlled for known confounders, the male/female difference cannot be easily explained. These data will help to contextualize studies in the future that use the LSMA-C score.
Ekström, M., Bornefalk-Hermansson, A., Abernethy, A. & Currow, D. 2015, 'Low-dose opioids should be considered for symptom relief also in advanced chronic obstructive pulmonary disease (COPD).', Evidence-based medicine, vol. 20, no. 1, p. 39.
Clark, K. & Currow, D. 2015, 'Midazolam in Palliative Care: At What Cost?', JOURNAL OF PALLIATIVE MEDICINE, vol. 18, no. 2, pp. 96-97.
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Scott, N., Crane, M., Lafontaine, M., Seale, H. & Currow, D. 2015, 'Stigma as a barrier to diagnosis of lung cancer: patient and general practitioner perspectives', PRIMARY HEALTH CARE RESEARCH AND DEVELOPMENT, vol. 16, no. 6, pp. 618-622.
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Reigada, C., Bajwah, S., Ross, J., Boland, J., Wells, A., Yorke, J., Grande, G., Hart, S., Currow, D., Papadopoulos, T., Macleod, U. & Johnson, M. 2015, 'Adaptation, face and content validation of a palliative care needs assessment tool for people with interstitial lung disease.', BMJ supportive & palliative care, vol. 5, no. 1, pp. 111-112.
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INTRODUCTION: Interstitial lung disease (ILD) is a non-malignant progressive disease which causes breathlessness, cough, fatigue, psycho-social, financial and spiritual distress; difficult for patients and their family carers. The Needs Assessment Tool: Progressive Disease (NAT:PD-C) was developed as an "aide-memoire" to help clinicians identify a range of palliative care needs in people with cancer, and their carers, in daily practice. We have adapted this tool for people with ILD. AIMS AND METHODS: Our aim was to adapt, and then test face and content validity of the adapted version. The NAT:PD-C was adapted for people with ILD using data from a systematic review of the literature and previously completed qualitative interviews. Focus groups were held (patients [N=7], carers [N=3], clinicians [N=8] followed by an Expert Consensus Group to discuss face and content validity of the NAT:PD-ILD. The Expert Group also discussed issues regarding implementation in practice. The discussion was audio and video-recorded, and cognitive mapping was used. Data was analysed following the principles of inductive theory building. Further validation and reliability testing is ongoing. We present the preliminary results of the face/content validation. RESULTS: All sections ("red flags" for high risk patients; priority referral; patient wellbeing; ability of carer to provide care; carer wellbeing) of the tool were felt to be important. Some symptoms (voice, mucous and mobility) were added by patients. Clinicians identified training needs about "Spiritual or existential concerns". Carers highlighted the need for support for themselves. CONCLUSIONS: The NAT:PD-ILD appears to have face and content validity and the content and structure reflected the experience of all groups. *This research was funding by Marie Curie Care Cancer Research UK.
McCaffrey, N., Agar, M., Harlum, J., Karnon, J., Currow, D. & Eckermann, S. 2015, 'Better Informing Decision Making with Multiple Outcomes Cost-Effectiveness Analysis under Uncertainty in Cost-Disutility Space', PLOS ONE, vol. 10, no. 3.
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Disler, R.T., Inglis, S.C., Newton, P.J., Currow, D.C., Macdonald, P.S., Glanville, A.R., Donesky, D., Carrieri-Kohlman, V. & Davidson, P.M. 2015, 'Patterns of Technology Use in Patients Attending a Cardiopulmonary Outpatient Clinic: A Self-Report Survey', Interactive journal of medical research, vol. 4, no. 1, pp. e5-e5.
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Roder, D., Creighton, N., Baker, D., Walton, R., Aranda, S. & Currow, D. 2015, 'Changing roles of population-based cancer registries in Australia', AUSTRALIAN HEALTH REVIEW, vol. 39, no. 4, pp. 425-428.
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Currow, D.C., Clark, K., Kamal, A., Collier, A., Agar, M.R., Lovell, M.R., Phillips, J.L. & Ritchie, C. 2015, 'The Population Burden of Chronic Symptoms that Substantially Predate the Diagnosis of a Life-Limiting Illness', JOURNAL OF PALLIATIVE MEDICINE, vol. 18, no. 6, pp. 480-485.
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Nikles, J., Mitchell, G.K., Hardy, J., Agar, M., Senior, H., Carmont, S.-.A., Schluter, P.J., Good, P., Vora, R. & Currow, D. 2015, 'Testing pilocarpine drops for dry mouth in advanced cancer using n-of-1 trials: A feasibility study', PALLIATIVE MEDICINE, vol. 29, no. 10, pp. 967-974.
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Luckett, T., Bhattarai, P., Phillips, J., Agar, M., Currow, D., Krastev, Y. & Davidson, P.M. 2015, 'Advance care planning in 21st century Australia: a systematic review and appraisal of online advance care directive templates against national framework criteria', AUSTRALIAN HEALTH REVIEW, vol. 39, no. 5, pp. 552-560.
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Agar, M., Lawlor, P., Quinn, S., Caplan, G., Draper, B., Rowett, D., Devilee, L., Fazekas, B., Sanderson, C., McCaffery, N., Hardy, J., Le, B., Eckermann, S., Hill, M. & Currow, D. 2015, 'Phase III randomised double-blind controlled trial of oral risperidone, haloperidol or placebo with rescue subcutaneous midazolam for delirium management in palliative care', AUSTRALASIAN JOURNAL ON AGEING, vol. 34, no. S1, pp. 33-33.
Guidelines recommend targeted use of antipsychotics indelirium for specic symptoms however this approach has notbeen evaluated in randomised trials. To compare the efcacyof risperidone relative to placebo in the control of specicdelirium symptoms in palliative care patients (communica-tion, behaviour and/or perceptual disturbances on NursingDelirium Screening Scale) at 72 hours after study commence-ment. Secondary aims were to compare haloperidol andplacebo; and risperidone and haloperidol
Disler, R., Inglis, S., Newton, P., Currow, D., Macdonald, P., Glanville, A., Donesky, D., Carrieri-Kohlman, V. & Davidson, P. 2015, 'USE OF TECHNOLOGY IN CARDIOPULMONARY PATIENTS', RESPIROLOGY, vol. 20, pp. 13-13.
Disler, R., Inglis, S., Newton, P., Currow, D., Macdonald, P., Glanville, A., Donesky, D., Carrieri-Kohlman, V. & Davidson, P. 2015, 'ATTITUDES TO ONLINE DELIVERY OF HEALTH INFORMATION AND CHRONIC DISEASE MANAGEMENT IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE: FOCUS GROUP STUDY', RESPIROLOGY, vol. 20, pp. 105-105.
Disler, R., Spiliopoulos, N., Inglis, S., Currow, D. & Davidson, P. 2015, 'INDIVIDUALS ATTITUDES TO COGNITIVE IMPAIRMENT AND IMPACT IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE: FOCUS GROUP STUDY', RESPIROLOGY, vol. 20, pp. 105-105.
Hui, D., Bansal, S., Strasser, F., Morita, T., Caraceni, A., Davis, M., Cherny, N., Kaasa, S., Currow, D., Abernethy, A., Nekolaichuk, C. & Bruera, E. 2015, 'Indicators of integration of oncology and palliative care programs: an international consensus', ANNALS OF ONCOLOGY, vol. 26, no. 9, pp. 1953-1959.
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Clark, K., Quinn, S.J., Doogue, M., Sanderson, C., Lovell, M. & Currow, D.C. 2015, 'Routine prescribing of gabapentin or pregabalin in supportive and palliative care: what are the comparative performances of the medications in a palliative care population?', SUPPORTIVE CARE IN CANCER, vol. 23, no. 9, pp. 2517-2520.
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Brewer, C., Abernethy, A., Currow, D., Fearon, K., Friend, J. & Temel, J. 2015, 'EVALUATION OF ANOREXIA-CACHEXIA SYMPTOMS/CONCERNS FROM ROMANA 2, A PHASE III TRIAL OF ANAMORELIN IN NON-SMALL CELL LUNG CANCER PATIENTS WITH CACHEXIA.', ONCOLOGY NURSING FORUM, vol. 42, no. 2, pp. E229-E229.
Nipp, R.D., Currow, D.C., Cherny, N.I., Strasser, F., Abernethy, A.P. & Zafar, S.Y. 2015, 'Best supportive care in clinical trials: review of the inconsistency in control arm design', BRITISH JOURNAL OF CANCER, vol. 113, no. 1, pp. 6-11.
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Hutchinson, A., Booth, S., Currow, D., Higginson, I. & Johnson, M. 2015, 'Invisible suffering: breathlessness in and beyond the clinic-a reply', LANCET RESPIRATORY MEDICINE, vol. 3, no. 8, pp. E29-E29.
Smallwood, N., Le, B., Currow, D., Irving, L. & Philip, J. 2015, 'Management of refractory breathlessness with morphine in patients with chronic obstructive pulmonary disease', INTERNAL MEDICINE JOURNAL, vol. 45, no. 9, pp. 898-904.
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McLoughlin, K., Rhatigan, J., McGilloway, S., Kellehear, A., Lucey, M., Twomey, F., Conroy, M., Herrera-Molina, E., Kumar, S., Furlong, M., Callinan, J., Watson, M., Currow, D. & Bailey, C. 2015, 'INSPIRE (INvestigating Social and PractIcal suppoRts at the End of life): Pilot randomised trial of a community social and practical support intervention for adults with life-limiting illness', BMC PALLIATIVE CARE, vol. 14.
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Swetenham, K., Tieman, J., Butow, P. & Currow, D. 2015, 'Communication differences when patients and caregivers are seen separately or together.', International journal of palliative nursing, vol. 21, no. 11, pp. 557-563.
Southern Adelaide Palliative Care Services introduced a nurse-led early introduction to a palliative care clinic in 2011. The clinic offers a thorough psychosocial assessment and the provision of information and an introduction to future care planning. The patients and their caregivers are seen together by the nurse practitioner initially for a physical assessment. They are then seen by a social worker to focus on advanced care planning and assessment of social and emotional factors. After the social work visit, the patient and caregiver are separated, and the patient sees the psychosocial nurse for coping and adjustment to illness and the carer sees the caregiver network facilitator to assess their informal supports to assist in the role of community-based caregiving. The pilot study looks at the nature of communication in the clinic where patient and carer are together and compares that to when they are separated.A total of 33 patients and their caregivers agreed for their coversations to be tape recorded between May and November of 2013. All tape recordings were transcribed verbatim. Ten patient transcripts (n=40) have been coded for quantitative analysis. The codes identify content and function of speech, cues for information and emotion and whether they are responded to by clinicians.Pilot results reveal that caregivers contribute little in the combined clinics and dominate the conversation in the private clinic. Patients, when seen alone, predominantly express emotion related cues, opposed to cues for information. The clinicians focus on their area of specialty, which results in little duplication in this clinic setting.An earlier evaluation of this clinic found that patients and their caregivers appreciate being separated in the clinic setting to have time and privacy to reveal fears and feelings related to end-of-life care. This current study quantifies the patient and caregiver experience and confirms those earlier findings.
Tervonen, H., Aranda, S., Walton, R., Baker, D., Currow, D., Morrell, S., You, H. & Roder, D. 2015, 'HOW CAN WE BETTER MEASURE AND ADDRESS SOCIO-DEMOGRAPHIC DISADVANTAGE IN CANCER OUTCOMES?', Asia-Pacific Journal of Clinical Oncology, vol. 11, pp. 65-65.
Hudson, P.L., Girgis, A., Mitchell, G.K., Philip, J., Parker, D., Currow, D., Liew, D., Thomas, K., Le, B., Moran, J. & Brand, C. 2015, 'Benefits and resource implications of family meetings for hospitalized palliative care patients: research protocol', BMC PALLIATIVE CARE, vol. 14.
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Abernethy, A., Fearon, K., Friend, J., Yan, Y., Duus, E. & Currow, D. 2015, 'Results From Phase III Trials of Anamorelin in Advanced Non-Small Cell Lung Cancer Patients with Cachexia: ROMANA 1 and 2', JOURNAL OF THORACIC ONCOLOGY, vol. 10, no. 9, pp. S791-S792.
Phillips, J.L., Johnson, M. & Currow, D. 2015, 'Heart failure and palliative care: Are we there yet?', Cardiology Today, vol. 5, no. 1, pp. 13-16.
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Morgan, N.A., Rowett, D. & Currow, D.C. 2015, 'Analysis of drug interactions at the end of life.', BMJ Support Palliat Care, vol. 5, no. 3, pp. 281-286.
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BACKGROUND: As death approaches, patients are at their most frail, but an increasing symptom burden often necessitates an increase in medications, putting them at higher risk for drug-drug interactions. OBJECTIVES: To assess the potential for drug-drug interactions in routine prescribing at the end of life. METHODS: An Australian retrospective multicentre case-note review of 266 consecutive adult patients who were referred to specialist palliative care, with data available on 166. Medications used in the last 2weeks of life were screened for potential interactions using the 'Stockley's Drug Interactions' software. RESULTS: The mean number of medications prescribed was 10.8, median 9 (IQR 6-14); all patients received at least one medication. In this study, 72% of patients were at risk of 1 or more potential drug-drug interaction. The mean number of potential interactions was 4.4, with a median of 2.5 (IQR 0-7) per patient. There were only 4/166 (2.4%) prescribed medications with an associated clinical record of an adverse drug reaction. CONCLUSIONS: Potential drug-drug interactions are common for this group of patients. Some interactions may be recognised as an acceptable risk when the prescription is written. Further research is necessary to determine the best way to improve recognition of potential drug-drug interactions and the rates of morbidity or accelerated mortality associated with this. It is likely that palliative care services will need to implement multiple strategies including greater use of computerised prescribing software, and greater closer liaison with clinical pharmacists.
Currow, D.C., Quinn, S., Ekstrom, M., Kaasa, S., Johnson, M.J., Somogyi, A.A. & Klepstad, P. 2015, 'Can variability in the effect of opioids on refractory breathlessness be explained by genetic factors?', BMJ Open, vol. 5, no. 5, p. e006818.
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OBJECTIVES: Opioids modulate the perception of breathlessness with a considerable variation in response, with poor correlation between the required opioid dose and symptom severity. The objective of this hypothesis-generating, secondary analysis was to identify candidate single nucleotide polymorphisms (SNP) from those associated with opioid receptors, signalling or pain modulation to identify any related to intensity of breathlessness while on opioids. This can help to inform prospective studies and potentially lead to better tailoring of opioid therapy for refractory breathlessness. SETTING: 17 hospice/palliative care services (tertiary services) in 11 European countries. PARTICIPANTS: 2294 people over 18years of age on regular opioids for pain related to cancer or its treatment. PRIMARY OUTCOME MEASURES: The relationship between morphine dose, breathlessness intensity (European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire; EORTCQLQC30 question 8) and 112 candidate SNPs from 25 genes (n=588). SECONDARY OUTCOME MEASURES: The same measures for people on oxycodone (n=402) or fentanyl (n=429). RESULTS: SNPs not in Hardy-Weinberg equilibrium or with allele frequencies (<5%) were removed. Univariate associations between each SNP and breathlessness intensity were determined with Benjamini-Hochberg false discovery rate set at 20%. Multivariable ordinal logistic regression, clustering over country and adjusting for available confounders, was conducted with remaining SNPs. For univariate morphine associations, 1 variant on the 5-hydroxytryptamine type 3B (HTR3B) gene, and 4 on the -2-arrestin gene (ARRB2) were associated with more intense breathlessness. 1 SNP remained significant in the multivariable model: people with rs7103572 SNP (HTR3B gene; present in 8.4% of the population) were three times more likely to have more intense breathlessness (OR 2.86; 95% CIs 1.46 to 5.62; p=0.002). No associations were seen with fentanyl nor ...
Boland, J., Currow, D.C., Wilcock, A., Tieman, J., Hussain, J.A., Pitsillides, C., Abernethy, A.P. & Johnson, M.J. 2015, 'A systematic review of strategies used to increase recruitment of people with cancer or organ failure into clinical trials: implications for palliative care research.', J Pain Symptom Manage, vol. 49, no. 4, pp. 762-772.e5.
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CONTEXT: The challenges of palliative care clinical trial recruitment are well documented. OBJECTIVES: The aim of the study was to review tested strategies to improve recruitment to trials of people with a range of conditions who may access palliative care services but are not explicitly stated to be "palliative." METHODS: This was a systematic review with narrative description. The Cochrane, Embase, PubMed, PsycINFO, and CINAHL electronic databases were searched (English; January 2002 to February 2014) for quasi-experimental and randomized controlled trials (RCTs) testing the effect of recruitment strategies on accrual to clinical trials of people with organ failure and cancer. Titles, abstracts, and retrieved articles were screened by two researchers and categorized by recruitment challenge: 1) patients with reduced cognition, 2) those requiring emergency treatment, and 3) willingness of patients and clinical staff to contribute to trials. RESULTS: Of 549 articles identified, 15 were included. Thirteen reported RCTs and two papers reported three quasi-experimental studies. Five were cluster RCTs of recruiting sites/institutions. One was a randomized cluster, crossover, feasibility study. Seven studies recruited patients with cancer. Others included patients with dementia, stroke, cardiovascular disease, diabetes, frail elderly, and bereaved carers. Some interventions improved recruitment: memory aid, contact before arrival, cluster consent, "opt out" consent. Others either reduced recruitment (formal mental capacity assessment) or made no difference (advance research directive; a variety of educational, supportive, and advertising interventions). CONCLUSION: Successful strategies from other disciplines could be considered by palliative care researchers. Tailored, efficient, evidence-based strategies must be developed, acknowledging that strategies with face validity are not necessarily the most effective.
McConigley, R., Shelby-James, T. & Currow, D.C. 2015, 'Promoting the consumer voice in palliative care: exploring the possibility of using consumer impact statements', Health Expectations, vol. 18, no. 5, pp. 653-660.
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Wysham, N.G., Miriovsky, B.J., Currow, D.C., Herndon, J.E., Samsa, G.P., Wilcock, A. & Abernethy, A.P. 2015, 'Practical Dyspnea Assessment: Relationship Between the 0-10 Numerical Rating Scale and the Four-Level Categorical Verbal Descriptor Scale of Dyspnea Intensity.', J Pain Symptom Manage, vol. 50, no. 4, pp. 480-487.
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CONTEXT: Measurement of dyspnea is important for clinical care and research. OBJECTIVES: To characterize the relationship between the 0-10 Numerical Rating Scale (NRS) and four-level categorical Verbal Descriptor Scale (VDS) for dyspnea assessment. METHODS: This was a substudy of a double-blind randomized controlled trial comparing palliative oxygen to room air for relief of refractory breathlessness in patients with life-limiting illness. Dyspnea was assessed with both a 0-10 NRS and a four-level categorical VDS over the one-week trial. NRS and VDS responses were analyzed in cross section and longitudinally. Relationships between NRS and VDS responses were portrayed using descriptive statistics and visual representations. RESULTS: Two hundred twenty-six participants contributed responses. At baseline, mild and moderate levels of breathlessness were reported by 41.9% and 44.6% of participants, respectively. NRS scores demonstrated increasing mean and median levels for increasing VDS intensity, from a mean (SD) of 0.6 (&plusmn;1.04) for VDS none category to 8.2 (1.4) for VDS severe category. The Spearman correlation coefficient was strong at 0.78 (P&nbsp;<&nbsp;0.0001). Based on the distribution of NRS scores within VDS categories, we calculated test characteristics of two different cutpoint models. Both models yielded 75% correct translations from NRS to VDS; however, Model A was more sensitive for moderate or greater dyspnea, with fewer misses downcoded. CONCLUSION: There is strong correlation between VDS and NRS measures for dyspnea. Proposed practical cutpoints for the relationship between the dyspnea VDS and NRS are 0 for none, 1-4 for mild, 5-8 for moderate, and 9-10 for severe.
Taylor, A., Morris, G., Tieman, J., Currow, D., Kidd, M. & Carati, C. 2015, 'Building an Architectural Component Model for a Telehealth Service', E-Health Telecommunication Systems and Networks, vol. 04, no. 03, pp. 35-44.
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Li, Y., Jackson, K.A., Slon, B., Hardy, J.R., Franco, M., William, L., Poon, P., Coller, J.K., Hutchinson, M.R., Currow, D.C. & Somogyi, A.A. 2015, 'CYP2B6 * 6 allele and age substantially reduce steady-state ketamine clearance in chronic pain patients: impact on adverse effects', British Journal of Clinical Pharmacology, vol. 80, no. 2, pp. 276-284.
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Currow, D.C. & Aranda, S. 2015, 'Cancer control is not beyond us… but  could be if we don't invest wisely: There must be a balanced investment portfolio in cancer control', Medical Journal of Australia, vol. 202, no. 2, pp. 63-64.
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Burns, E.J., Quinn, S.J., Abernethy, A.P. & Currow, D.C. 2015, 'Caregiver Expectations: Predictors of a Worse Than Expected Caregiving Experience at the End of Life.', J Pain Symptom Manage, vol. 50, no. 4, pp. 453-461.
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CONTEXT: The gap between informal caregivers' expectations of caregiving at the end of life and their actual caregiving experience has important affective and behavioral consequences. OBJECTIVES: This study analyzes for the first time the characteristics of those caregivers who report a worse or much worse than expected caregiving experience, providing a potential for future targeted intervention into the caregiving experience. METHODS: The South Australian Health Omnibus is an annual, random, face-to-face, and cross-sectional survey. From 2000 to 2007, respondents were asked a range of questions about end-of-life care, including in several years a question about how the caregiving experience compared with caregivers' expectation(s). Family members and friends who reported a worse or much worse than expected caregiving experience were the focus of this analysis. Univariable and multivariable logistic regression models were created to better define this group. RESULTS: Of the 1628 active caregivers for people at the end of life, almost half (48.3%) reported a worse or much worse than expected caregiving experience. A worse or much worse than expected caregiving experience was significantly associated with gender and with level of care provided. Women who provided daily hands-on care were significantly more likely to have a worse than expected experience compared with women who provided intermittent care (odds ratio [OR] 0.65; 95% CI 0.48-0.88; P&nbsp;=&nbsp;0.005) or rare care (OR 0.39; 95% CI 0.27-0.56; P&nbsp;<&nbsp;0.001). Of all those providing rare care, women were significantly less likely than men to report a worse than expected caregiving experience (OR 0.61; 95% CI 0.41-0.93; P&nbsp;=&nbsp;0.020). CONCLUSION: Caregiver expectations represent a novel and important focus for investigation into the caregiver experience. Explicitly eliciting expectations may in future lead to ways of better supporting caregivers.
Currow, D.C. 2015, 'Caregivers' three-cornered hats: Their tricornes.', Palliat Med, vol. 29, no. 6, pp. 485-486.
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Johnson, M.J. & Currow, D.C. 2015, 'Chronic refractory breathlessness is a distinct clinical syndrome.', Curr Opin Support Palliat Care, vol. 9, no. 3, pp. 203-205.
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Currow, D.C. & Higginson, I.J. 2015, 'Cochrane Reviews: Four Proposals for Improvement.', J Palliat Med, vol. 18, no. 11, pp. 906-907.
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Ekström, M., Nilsson, F., Abernethy, A.A. & Currow, D.C. 2015, 'Effects of opioids on breathlessness and exercise capacity in chronic obstructive pulmonary disease. A systematic review.', Ann Am Thorac Soc, vol. 12, no. 7, pp. 1079-1092.
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RATIONALE: Patients with chronic obstructive pulmonary disease (COPD) commonly suffer from breathlessness, deconditioning, and reduced health-related quality of life (HRQL) despite best medical management. Opioids may relieve breathlessness at rest and on exertion in COPD. OBJECTIVES: We aimed to estimate the efficacy and safety of opioids on refractory breathlessness, exercise capacity, and HRQL in COPD. METHODS: This was a systematic review and metaanalysis using Cochrane methodology. We searched Cochrane Central Register of Controlled Trials, MEDLINE, and Embase up to 8 September, 2014 for randomized, double-blind, placebo-controlled trials of any opioid for breathlessness, exercise capacity, or HRQL that included at least one participant with COPD. Effects were analyzed as standardized mean differences (SMDs) with 95% confidence intervals (CIs) using random effect models. MEASUREMENTS AND MAIN RESULTS: A total of 16 studies (15 crossover trials and 1 parallel-group study, 271 participants, 95% with severe COPD) were included. There were no serious adverse effects. Breathlessness was reduced by opioids overall: SMD, -0.35 (95% CI, -0.53 to -0.17; I(2), 48.9%), by systemic opioids (eight studies, 118 participants): SMD, -0.34 (95% CI, -0.58 to -0.10; I(2), 0%), and less consistently by nebulized opioids (four studies, 82 participants): SMD, -0.39 (95% CI, -0.71 to -0.07; I(2), 78.9%). The quality of evidence was moderate for systemic opioids and low for nebulized opioids on breathlessness. Opioids did not affect exercise capacity (13 studies, 149 participants): SMD, 0.06 (95% CI, -0.15 to 0.28; I(2), 70.7%). HRQL could not be analyzed. Findings were robust in sensitivity analyses. Risk of study bias was low or unclear. CONCLUSIONS: Opioids improved breathlessness but not exercise capacity in severe COPD.
Ahmadi, Z., Lundström, S., Janson, C., Strang, P., Emtner, M., Currow, D.C. & Ekström, M. 2015, 'End-of-life care in oxygen-dependent COPD and cancer: a national population-based study.', Eur Respir J, vol. 46, no. 4, pp. 1190-1193.
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Morgan, D.D., Cerdor, P.A., Brown, A. & Currow, D.C. 2015, 'Falls in Palliative Care.', J Palliat Med, vol. 18, no. 10, pp. 827-828.
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Ekström, M., Currow, D.C. & Johnson, M.J. 2015, 'Outcome measurement of refractory breathlessness: endpoints and important differences.', Curr Opin Support Palliat Care, vol. 9, no. 3, pp. 238-243.
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PURPOSE OF REVIEW: Standardized measurement of self-rated breathlessness using appropriate tools is essential for research and clinical care. The purpose was to review recent advances in the measurement of breathlessness and the minimal clinically important differences (MCIDs) in intensity of chronic breathlessness. RECENT FINDINGS: Two tools have been validated in people with chronic obstructive pulmonary disease (COPD) to measure daily symptoms and breathlessness related to daily activities. Two multidimensional tools have been developed for different settings and aetiologies, which measure both the perceived intensity, unpleasantness, quality of breathlessness, and the person's emotional response to it. MCIDs have been reported for the intensity of chronic refractory breathlessness, the daily symptom diary, and breathlessness related to daily activities in COPD. SUMMARY: There have been substantial developments in instruments able to provide reliable and valid unidimensional and multidimensional measurement of self-reported breathlessness and in the understanding of the MCID for chronic breathlessness. Routine use of agreed outcome measures in clinical practice and research are crucial steps to improve our understanding of the science of breathlessness and its impact on patients' outcomes.
Currow, D.C., Vergo, M.T. & Ekstrom, M. 2015, 'Sudden Death in Palliative Care.', J Pain Symptom Manage, vol. 50, no. 3, pp. e1-e2.
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LeBlanc, T.W., Smith, J.M. & Currow, D.C. 2015, 'Symptom burden of haematological malignancies as death approaches in a community palliative care service: a retrospective cohort study of a consecutive case series', The Lancet Haematology, vol. 2, no. 8, pp. e334-e338.
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Ekström, M.P., Abernethy, A.P. & Currow, D.C. 2015, 'The management of chronic breathlessness in patients with advanced and terminal illness.', BMJ, vol. 349, p. g7617.
Currow, D.C. & Aranda, S. 2015, 'There is another gap to narrow.', Aust J Rural Health, vol. 23, no. 1, pp. 2-3.
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Soeberg, M.J., Rogers, K., Currow, D.C. & Young, J.M. 2015, 'Trends in incidence and survival for anal cancer in New South Wales, Australia, 1972–2009', Cancer Epidemiology, vol. 39, no. 6, pp. 842-847.
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Burns, C.M., Dal Grande, E., Tieman, J., Abernethy, A.P. & Currow, D.C. 2015, 'Who provides care for people dying of cancer? A comparison of a rural and metropolitan cohort in a South Australian bereaved population study.', Aust J Rural Health, vol. 23, no. 1, pp. 24-31.
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OBJECTIVE: To examine and compare urban and rural palliative care service availability and patterns of care from randomised, population-based surveys of caregivers of people at the end of life. DESIGN, SETTING & PARTICIPANTS: Survey responses on the death of 'someone close' from 23,588 interviews of South Australians conducted between 2001 and 2007 are analysed. INTERVENTIONS: A randomised population survey. MAIN OUTCOME MEASURES: Explored palliative care service availability, caregiving provided, and characteristics of the deceased and their caregivers. RESULTS: There was no difference in reported rates of accessing specialist palliative care services between rural and urban respondents (in unadjusted and adjusted analyses) nor did the proportion of people for whom cancer was their life-limiting illness. There was greater reliance on friends than first degree relatives in hands-on care provided at the end of life in rural settings. The rates of reported need for more support did not differ between urban and rural respondents for caregivers of people at the end of life. CONCLUSION: Use of palliative care services was similar for rural and urban caregivers for someone close at the end of life with similar levels of met and unmet needs.
Dobbins, T.A., Creighton, N., Currow, D.C. & Young, J.M. 2015, 'Look back for the Charlson Index did not improve risk adjustment of cancer surgical outcomes.', J Clin Epidemiol, vol. 68, no. 4, pp. 379-386.
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OBJECTIVES: The Charlson score is a commonly used measure of comorbidity; however, there is little empirical research into the optimal implementation when studying cancer surgery outcomes using administrative data. We compared four alternative Charlson score implementations, including and excluding metastatic cancer and varying the look-back periods. STUDY DESIGN AND SETTING: Nine years of linked administrative data were used to identify patients undergoing surgery for cancer of the colon, rectum, or lung in New South Wales, Australia. Four binary outcomes of 30- and 365-day mortality, length of stay greater than 21 days, and emergency readmission within 28 days were compared between groups of similar hospitals. Hospital risk adjustment models were compared for alternative Charlson score implementations. RESULTS: Excluding metastatic cancer from the Charlson score improved model performance for short-term outcomes, but there was no implementation that was consistently optimal. Incorporating a look-back period reduced the number of patients for analysis but did not improve hospital risk adjustment. CONCLUSION: Charlson scores for hospital risk adjustment of short-term outcomes of cancer surgery should be calculated excluding metastatic cancer as a separate comorbidity. We found no clear best performing implementation and found no benefit in incorporating any look-back period.
Johnson, M.J., Simpson, M.I., Currow, D.C., Millman, R.E., Hart, S.P. & Green, G. 2015, 'Magnetoencephalography to investigate central perception of exercise-induced breathlessness in people with chronic lung disease: a feasibility pilot.', BMJ Open, vol. 5, no. 6, p. e007535.
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OBJECTIVES: Neuroimaging in chronic breathlessness is challenging. The study objective was to test the feasibility of magnetoencephalography (MEG) for functional neuroimaging of people with chronic breathlessness. DESIGN: Feasibility pilot study. SETTING: Respiratory clinic out-patients. PARTICIPANTS: 8 patients (mean age=62; (range 47-83); 4 men) with chronic non-malignant lung disease; modified MRC breathlessness score (median mMRC=4), intensity of exercise-induced breathlessness >3/10; no contraindication to MRI scanning. METHODS AND MEASURES: 4 MEG scans were conducted for each participant: (1) at rest (5 mins), (2) postseated leg exercise-induced breathlessness during recovery (10 mins). Recovery scans (2) were conducted with/without facial airflow in random order; both scans were repeated 1 h later. Participants rated breathlessness intensity (0-10 Numerical Rating Scale (NRS)) at baseline, maximal exertion and every minute during recovery, and rated acceptability of study procedures at the end of the study (0-10 NRS). A structural MRI scan was conducted for MEG coregistration and source-space analyses. Rest data were compared with data from healthy volunteers (N=6; 5 men; mean age=30.7 years &plusmn; 3.9 years). RESULTS: Exercises and MEG scanning were acceptable to all participants; 7/8 completed the MRI scans. Maximum breathlessness intensity was induced by 5 min' exercise. The same level was induced for repeat scans (median=8; IQR=7-8). All recovered to baseline by 10 min. Time-frequency profiles of data from the first and last 3 min were analysed in MEG source space based on breathlessness location estimates. Source localisation was performed, but anatomical source inference was limited to the level of the lobe. Differences in areas of activity were seen: during recovery scans; with and without airflow; and between participants/normal volunteers at rest. CONCLUSIONS: MEG is a feasible method to investigate exercise-induced breathlessness in people breathles...
Girgis, A., Abernethy, A.P. & Currow, D.C. 2015, 'Caring at the end of life: do cancer caregivers differ from other caregivers?', BMJ Supportive & Palliative Care, vol. 5, no. 5, pp. 513-517.
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Collier, A., Rowett, D., Allcroft, P., Greene, A. & Currow, D.C. 2015, 'Academic detailing of general practitioners by a respiratory physician for diagnosis and management of refractory breathlessness: A randomised pilot study Organization, structure and delivery of healthcare', BMC Health Services Research, vol. 15, no. 1.
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Currow, D.C., Hutchinson, A. & Johnson, M.J. 2015, 'Re: Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study: Rationale, design and analysis', Emergency Medicine Australasia, vol. 27, no. 5, pp. 498-499.
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Mitchell, G.K., Hardy, J.R., Nikles, C.J., Carmont, S.-.A.S., Senior, H.E., Schluter, P.J., Good, P. & Currow, D.C. 2015, 'The Effect of Methylphenidate on Fatigue in Advanced Cancer: An Aggregated N-of-1 Trial.', J Pain Symptom Manage, vol. 50, no. 3, pp. 289-296.
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CONTEXT: Fatigue is common in life-limiting cancer. Methylphenidate (MPH), a psychostimulant, may be a useful therapy. Gathering evidence in patients with advanced cancer can be challenging. OBJECTIVES: To determine if MPH improves cancer-related fatigue in people with advanced cancer. METHODS: N-of-1 trials are multicycle, double-blind, randomized, controlled crossover trials using standardized measures of effect in individuals. They are normally used to assess treatment effects in individuals. Aggregated N-of-1 trials from participants with end-stage cancer suffering fatigue were used to assess the group effect of MPH, producing an estimate of equivalent power to a parallel-group randomized controlled trial (RCT) but requiring less than half of the sample size. Up to three cycles of MPH 5&nbsp;mg twice daily (three days) vs. identical placebo (three days) capsules were offered to participants. Primary outcome was improvement in fatigue as measured by the Functional Assessment of Chronic Illness Therapy-Fatigue Scale and the Wu Cancer Fatigue Scale. Analysis used Bayesian statistical methods using intention-to-treat principles. RESULTS: Forty-three participants completed 84 cycles of MPH and placebo in random order, exceeding sample size estimates. Overall, MPH did not improve fatigue (mean difference 3.2; 95% credible interval -2.0, 9.0; posterior probability of favorable effect 0.890). Eight participants showed important improvement, and one participant showed important worsening of fatigue on MPH. There were no features that distinguished participants whose fatigue responded to MPH compared with those who did not. CONCLUSION: MPH does not improve fatigue in the population of patients with end-stage cancer. Aggregated N-of-1 trial methodology is feasible and produces population-based sample estimates with less than half the sample size required for the equivalent parallel-group RCT. It also identified individuals who did and did not respond to MPH, which is a featu...
Clark, K., Collier, A. & Currow, D.C. 2015, 'Dying in Australian hospitals: will a separate national clinical standard improve the delivery of quality care?', Aust Health Rev, vol. 39, no. 2, pp. 202-204.
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While it is commonly stated that for most people the preferred place of death is their own homes, the actual reality is that most people will die in hospitals. This is both by choice and necessity. However, for many, the care that they receive would not necessarily align with their expectations. The need to improve the quality of health care at the end of life has been acknowledged by the Australian Commission for Safety and Quality in Healthcare with the release of a recent discussion paper. It is presumed this is a prelude to the release of another quality standard specifically for end of life care. The aim of this paper is to question whether such a standard is likely to result in the hoped for improvements in care.
LeBlanc, T.W., McNeil, M.J., Kamal, A.H., Currow, D.C. & Abernethy, A.P. 2015, 'Polypharmacy in patients with advanced cancer and the role of medication discontinuation.', Lancet Oncol, vol. 16, no. 7, pp. e333-e341.
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Polypharmacy is a well known problem in elderly patients in general, but its prevalence and effects in patients with cancer are less clear, particularly in end-of-life settings. This Review examines the existing literature on polypharmacy in advanced cancer and end-of-life settings by reviewing evidence-based approaches to reduce polypharmacy, and outlining the potential benefits of decreasing the number of drugs that patients with cancer can take, with emphasis on the need for thoughtful discontinuation initiatives in the context of life-limiting malignant disease. In view of the apparent burden of polypharmacy in patients with advanced cancer, we expect that greater attention to polypharmacy could lead to improvements in adverse drug events, cost, and possibly quality of life. However, few data for specific interventions in the advanced cancer population are available, and thus more research is warranted.
Kutner, J.S., Blatchford, P.J., Taylor, D.H., Ritchie, C.S., Bull, J.H., Fairclough, D.L., Hanson, L.C., LeBlanc, T.W., Samsa, G.P., Wolf, S., Aziz, N.M., Currow, D.C., Ferrell, B., Wagner-Johnston, N., Zafar, S.Y., Cleary, J.F., Dev, S., Goode, P.S., Kamal, A.H., Kassner, C., Kvale, E.A., McCallum, J.G., Ogunseitan, A.B., Pantilat, S.Z., Portenoy, R.K., Prince-Paul, M., Sloan, J.A., Swetz, K.M., Von Gunten, C.F. & Abernethy, A.P. 2015, 'Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial.', JAMA Intern Med, vol. 175, no. 5, pp. 691-700.
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IMPORTANCE: For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy. OBJECTIVE: To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting. DESIGN, SETTING, AND PARTICIPANTS: This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach. INTERVENTIONS: Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins. MAIN OUTCOMES AND MEASURES: Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings. RESULTS: A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, -3.5% to 10.5%; P=.36) and did not meet the noninferiority end point. Total QOL was better for the g...
McCaffrey, N. & Currow, D.C. 2015, 'Separated at birth?', BMJ Support Palliat Care, vol. 5, no. 1, pp. 2-3.
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Chin, C.A., Butcher, H.H., Spathis, A., Ryan, R., Johnson, M., Pattinson, K., Currow, D., Banzett, R., Yorke, J., Clayson, H., Macnaughton, J., Penfold, C., Farquhar, M. & Booth, S. 2015, 'What's trending in breathlessness research? Proceedings from the 8th Annual Meeting of the Breathlessness Research Interest Group', Progress in Palliative Care, vol. 23, no. 6, pp. 326-330.
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Currow, D.C. & Johnson, M.J. 2015, 'Distilling the essence of breathlessness: the first vital symptom.', Eur Respir J, vol. 45, no. 6, pp. 1526-1528.
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Uronis, H.E., Ekström, M.P., Currow, D.C., McCrory, D.C., Samsa, G.P. & Abernethy, A.P. 2015, 'Oxygen for relief of dyspnoea in people with chronic obstructive pulmonary disease who would not qualify for home oxygen: a systematic review and meta-analysis.', Thorax, vol. 70, no. 5, pp. 492-494.
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We searched MEDLINE, EMBASE and the Cochrane Controlled Trials Register to determine whether oxygen relieves dyspnoea in mildly or non-hypoxemic COPD and included 18 randomised controlled trials (431 participants) in the meta-analysis using Cochrane methodology. Oxygen therapy reduced dyspnoea when compared with medical air; standardised mean difference -0.37 (95% CI -0.50 to -0.24; I(2)=14%). In a priori subgroup and sensitivity analyses, dyspnoea was reduced by continuous oxygen during exertion but not short-burst oxygen therapy. Continuous exertional oxygen can relieve dyspnoea in mildly or non-hypoxemic COPD, but evidence from larger clinical trials is needed.
Currow, D.C., Allingham, S., Yates, P., Johnson, C., Clark, K. & Eagar, K. 2015, 'Improving national hospice/palliative care service symptom outcomes systematically through point-of-care data collection, structured feedback and benchmarking', Supportive Care in Cancer, vol. 23, no. 2, pp. 307-315.
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Disler, R.T., Green, A.R., Luckett, T., Newton, P.J., Inglis, S., Currow, D. & Davidson, P.M. 2014, 'Experience of advanced chronic obstructive pulmonary disease: Metasynthesis of qualitative data.', Journal of Pain and Symptom Management, vol. 48, no. 6, pp. 1182-1199.
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Context. Chronic obstructive pulmonary disease (COPD) is a life-limiting illness. Despite best available treatments, individuals continue to experience symptom burden and have high health-care utilization. Objectives. To increase understanding of the experience and ongoing needs of individuals living with COPD.
Phillips, J.L., Chan, R. & Currow, D.C. 2014, 'Do palliative care health professionals settle for low level evidence?', Palliative Medicine, vol. 28, no. 1.
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Invited editorial
Lewis, J., DiGiacomo, M., Currow, D.C. & Davidson, P.M. 2014, 'Social capital in a lower socioeconomic palliative care population: a qualitative investigation of individual, community and civic networks and relations', BMC Palliative Care, vol. 13, no. 30.
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The article reports findings from a qualitative investigation of the needs and experiences of palliative care patients and caregivers who are experiencing financial hardship or disadvantage. This article highlights the individual, community and civic networks and relations relevant to these experiences.
Phillips, J.L., Lam, L., Luckett, T., Agar, M. & Currow, D. 2014, 'Is the Life Space Assessment applicable to a palliative care population? : A brief methodological report on its relationship to measures of performance and quality of life. Brief Methodological Report.', Journal of Pain and Symptom Management, vol. 47, no. 6, pp. 1121-1127.
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The spatial environments that palliative care patients frequent for business and leisure constrict as their disease progresses and their physical functioning deteriorates. Measuring a persons movement within his or her own environment is a clinically relevant and patient-centered outcome because it measures function in a way that reflects actual and not theoretical participation.
Johnson, M.J., Bland, J.M., Davidson, P.M., Newton, P.J., Oxberry, S.G., Abernethy, A.P. & Currow, D.C. 2014, 'The Relationship Between Two Performance Scales: New York Heart Association Classification and Karnofsky Performance Status Scale', Journal of Pain and Symptom Management, vol. 47, no. 3, pp. 652-658.
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To, T.H.M., Agar, M., Yates, P. & Currow, D.C. 2014, 'Prescribing for Nausea in Palliative Care: A Cross-Sectional National Survey of Australian Palliative Medicine Doctors', JOURNAL OF PALLIATIVE MEDICINE, vol. 17, no. 9, pp. 1032-1036.
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Bush, S.H., Leonard, M.M., Agar, M., Spiller, J.A., Hosie, A., Wright, D.K., Meagher, D.J., Currow, D.C., Bruera, E. & Lawlor, P.G. 2014, 'End-of-Life Delirium: Issues Regarding Recognition, Optimal Management, and the Role of Sedation in the Dying Phase', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 48, no. 2, pp. 215-230.
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Bush, S.H., Bruera, E., Lawlor, P.G., Kanji, S., Davis, D.H.J., Agar, M., Wright, D.K., Hartwick, M., Currow, D.C., Gagnon, B., Simon, J. & Pereira, J.L. 2014, 'Clinical Practice Guidelines for Delirium Management: Potential Application in Palliative Care', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 48, no. 2, pp. 249-258.
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Lawlor, P.G., Davis, D.H.J., Ansari, M., Hosie, A., Kanji, S., Momoli, F., Bush, S.H., Watanabe, S., Currow, D.C., Gagnon, B., Agar, M., Bruera, E., Meagher, D.J., de Rooij, S.E.J.A., Adamis, D., Caraceni, A., Marchington, K. & Stewart, D.J. 2014, 'An Analytical Framework for Delirium Research in Palliative Care Settings: Integrated Epidemiologic, Clinician-Researcher, and Knowledge User Perspectives', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 48, no. 2, pp. 159-175.
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Clark, K., Lam, L., Currow, D.C. & Agar, M. 2014, 'A Prospective Study to Investigate Contributory Factors That Lead to Constipation in Palliative Care Patients', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 47, no. 6, pp. E1-E4.
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Bush, S.H., Kanji, S., Pereira, J.L., Davis, D.H.J., Currow, D.C., Meagher, D.J., Rabheru, K., Wright, D.K., Bruera, E., Agar, M., Hartwick, M., Gagnon, P.R., Gagnon, B., Breitbart, W., Regnier, L. & Lawlor, P.G. 2014, 'Treating an Established Episode of Delirium in Palliative Care: Expert Opinion and Review of the Current Evidence Base With Recommendations for Future Development', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 48, no. 2, pp. 231-248.
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Hegarty, M., Breaden, K., Agar, M., Devery, K., Goh, C., Shaw, R., Swetenham, K. & Currow, D.C. 2014, 'Asia Pacific Palliative Care Development Through Education', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 47, no. 2, pp. E7-E9.
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Sweet, L., Adamis, D., Meagher, D.J., Davis, D., Currow, D.C., Bush, S.H., Barnes, C., Hartwick, M., Agar, M., Simon, J., Breitbart, W., MacDonald, N. & Lawlor, P.G. 2014, 'Ethical Challenges and Solutions Regarding Delirium Studies in Palliative Care', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 48, no. 2, pp. 259-271.
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Swetenham, K., Tieman, J. & Currow, D. 2014, 'Do patients and carers find separate palliative care clinic consultations acceptable? A pilot study.', International journal of palliative nursing, vol. 20, no. 6, pp. 301-305.
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BACKGROUND: As differing patient and carer information needs have been reported, and in light of changing health-system priorities and issues identified in a self-assessment study, a specialist palliative care service established an interdisciplinary psychosocial assessment clinic to separately assess patient and carer needs. AIM: To determine the acceptability of the separate assessment to patients and carers. METHOD: Patients with a high functional score and who were deemed well enough to manage an appointment were invited to attend the clinic. Consent to follow-up was obtained. Patient and carer satisfaction surveys were developed based on existing tools. Questionnaires were posted out with a pre-paid reply envelope to patients and carers. Data from completed surveys was entered into a data management system and frequency analysis completed. A secondary analysis of the comments was undertaken. FINDINGS: The clinic was attended by 41 patients and 37 carers between September 2011 and the end of February 2012. There was a 46% response rate, with 24 questionnaires returned from both the patient and their carer, 6 from patients only, and 6 from carers only (2 of whom were bereaved). The opportunity for privacy to discuss their own fears and concerns related to the illness was appreciated by 94% of the patients and 83% of the carers. CONCLUSION: This initial pilot data shows patient and carer satisfaction with this clinic model. Further qualitative data would provide more information on the patient and carer experiences of the clinic.
Scott, N., Donato-Hunt, C., Crane, M., Lafontaine, M., Varlow, M., Seale, H. & Currow, D. 2014, 'Knowledge, attitudes and beliefs about lung cancer in three culturally and linguistically diverse communities living in Australia: a qualitative study', HEALTH PROMOTION JOURNAL OF AUSTRALIA, vol. 25, no. 1, pp. 46-51.
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McCaffrey, N., Skuza, P., Breaden, K., Eckermann, S., Hardy, J., Oaten, S., Briffa, M. & Currow, D. 2014, 'Preliminary Development and Validation of a New End-of-Life Patient-Reported Outcome Measure Assessing the Ability of Patients to Finalise Their Affairs at the End of Life', PLOS ONE, vol. 9, no. 4.
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Young, J.M., Currow, D. & Dunlop, S. 2014, 'The association between tobacco plain packaging and Quitline calls REPLY', MEDICAL JOURNAL OF AUSTRALIA, vol. 200, no. 6, pp. 315-315.
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Tracey, E., Watt, H., Currow, D., Young, J. & Armstrong, B. 2014, 'Investigation of poorer bladder cancer survival in women in NSW, Australia: a data linkage study', BJU INTERNATIONAL, vol. 113, no. 3, pp. 437-448.
Hardy, J.R., Spruyt, O., Quinn, S.J., Devilee, L.R. & Currow, D.C. 2014, 'Implementing practice change in chronic cancer pain management: clinician response to a phase III study of ketamine', INTERNAL MEDICINE JOURNAL, vol. 44, no. 6, pp. 586-591.
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Russell, B.J., Rowett, D., Abernethy, A.P. & Currow, D.C. 2014, 'Prescribing for comorbid disease in a palliative population: focus on the use of lipid-lowering medications', INTERNAL MEDICINE JOURNAL, vol. 44, no. 2, pp. 177-184.
Johnson, C., Rushton, S., Tieman, J., Currow, D. & Aranda, S. 2014, 'Reclaiming the midnight hours: up-to-date evidence in just one click', EUROPEAN JOURNAL OF CANCER CARE, vol. 23, no. 6, pp. 760-761.
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Young, J.M., Stacey, I., Dobbins, T.A., Dunlop, S., Dessaix, A.L. & Currow, D.C. 2014, 'Association between tobacco plain packaging and Quitline calls: a population-based, interrupted time-series analysis.', The Medical journal of Australia, vol. 200, no. 1, pp. 29-32.
OBJECTIVES: To investigate whether the introduction of tobacco plain packaging in Australia from 1&nbsp;October 2012&nbsp;was associated with a change in the number of calls to the smoking cessation helpline, Quitline, and to compare this with the impact of the introduction of graphic health warnings from 1&nbsp;March 2006. DESIGN AND SETTING: Whole-of-population interrupted time-series analysis in New South Wales and the Australian Capital Territory between 1&nbsp;March 2005&nbsp;and October 2006&nbsp;for the comparator, graphic health warnings, and October 2011&nbsp;and April 2013&nbsp;for the intervention of interest, tobacco plain packaging. MAIN OUTCOME MEASURE: Weekly number of calls to the Quitline, after adjusting for seasonal trends, anti-tobacco advertising, cigarette costliness and the number of smokers in the community. RESULTS: There was a 78% increase in the number of calls to the Quitline associated with the introduction of plain packaging (baseline, 363/week; peak, 651/week [95% CI, 523-780/week; P <&nbsp;0.001]). This peak occurred 4&nbsp;weeks after the initial appearance of plain packaging and has been prolonged. The 2006&nbsp;introduction of graphic health warnings had the same relative increase in calls (84%; baseline, 910/week; peak, 1673/week [95% CI, 1383-1963/week; P <&nbsp;0.001]) but the impact of plain packaging has continued for longer. CONCLUSIONS: There has been a sustained increase in calls to the Quitline after the introduction of tobacco plain packaging. This increase is not attributable to anti-tobacco advertising activity, cigarette price increases nor other identifiable causes. This is an important incremental step in comprehensive tobacco control.
Dunlop, S., Dobbins, T., Young, J., Perez, D. & Currow, D. 2014, 'SHORT-TERM IMPACT OF AUSTRALIA'S NEW TOBACCO PLAIN PACKS ON ADULT SMOKERS' PACK-RELATED PERCEPTIONS AND RESPONSES: RESULTS FROM A CONTINUOUS TRACKING SURVEY', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, vol. 10, pp. 6-6.
Yee, J., Davis, G.M., Beith, J.M., Wilcken, N., Currow, D., Emery, J., Phillips, J., Martin, A., Hui, R., Harrison, M., Segelov, E. & Kilbreath, S.L. 2014, 'Physical activity and fitness in women with metastatic breast cancer', JOURNAL OF CANCER SURVIVORSHIP, vol. 8, no. 4, pp. 647-656.
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Chan, R.J., Webster, J., Phillips, J. & Currow, D.C. 2014, 'The withdrawal of the Liverpool Care Pathway in the United Kingdom: what are the implications for Australia?', The Medical journal of Australia, vol. 200, no. 10, p. 573.
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Ekstrom, M.P., Bornefalk-Hermansson, A., Abernethy, A. & Currow, D.C. 2014, 'Safety Of Benzodiazepines And Opioids In Very Severe COPD: A National Prospective Study', AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, vol. 189.
Currow, D.C. & Abernethy, A.P. 2014, 'Anamorelin hydrochloride in the treatment of cancer anorexia-cachexia syndrome.', Future Oncol, vol. 10, no. 5, pp. 789-802.
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Anamorelin hydrochloride is an orally active ghrelin receptor agonist in development by Helsinn, for the treatment of non-small-cell lung cancer (NSCLC) cachexia. In preclinical and clinical studies, the potent affinity of anamorelin for the ghrelin receptor is associated with significant appetite-enhancing activity and resultant improvements in body weight, lean body mass, and handgrip strength compared with placebo. The accompanying stimulatory effects on growth hormone and IGF-1 are not associated with tumor growth, and overall survival in patients with cancer is not compromised. Anamorelin is well tolerated with no dose-limiting toxicities identified to date. The findings of ongoing Phase III studies are needed to confirm the significant potential of anamorelin to treat NSCLC cachexia.
Tieman, J.J., Morgan, D.D., Swetenham, K., To, T.H.M. & Currow, D.C. 2014, 'Designing clinically valuable telehealth resources: Processes to develop a community-based palliative care prototype', Journal of Medical Internet Research, vol. 16, no. 9.
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McConigley, R., Kristjanson, L.J., Aoun, S.M., Oldham, L., Currow, D.C., O'Connor, M. & Holloway, K. 2014, 'Staying just one step ahead: providing care for patients with motor neurone disease.', BMJ Support Palliat Care, vol. 4, no. 1, pp. 38-42.
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INTRODUCTION: There is limited information about the experiences and educational needs of health professionals who may be required to provide care for people with Motor Neurone Disease (MND) especially in the later stages of the disease. The aim of this study was to determine the experiences of, and need for, education of these health professionals. METHODS: Interviews and focus groups were conducted with 31 health professionals with some experience in providing palliative care for people with MND. Thematic content analysis was used to identify common themes. RESULTS: A key theme, Just One Step Ahead, emerged, that describes the central capability health professionals identified as necessary to help individuals plan and prepare for disease and lifestyle changes just before they arise. Two subthemes also emerged: Expertise in MND and Bespoke Communication. Expertise in MND described the required understanding of the disease and the particular individual's version of the disease to allow the health professional to plan, advise, support and anticipate the needs of the person living with MND. Bespoke Communication was the facility to tailor care messages sensitively and effectively to the range of people involved in care (patients, family, healthcare team members). CONCLUSIONS: Care of people with MND requires up-to-date expertise about the disease and skilled communication abilities to manage complexity and change. Timely and focused education and specialist MND support for care providers are essential to tailored and responsive care and a widely available education programme has been developed to address these needs.
Currow, D.C., You, H., Aranda, S., McCaughan, B.C., Morrell, S., Baker, D.F., Walton, R. & Roder, D.M. 2014, 'What factors are predictive of surgical resection and survival from localised non-small cell lung cancer?', Med J Aust, vol. 201, no. 8, pp. 475-480.
OBJECTIVE: To investigate opportunities to reduce lung cancer mortality after diagnosis of localised non-small cell lung cancer (NSCLC) in New South Wales through surgical resection. DESIGN, PATIENTS AND SETTING: In this cohort study, resection rates and lung cancer mortality risk were explored using multivariate logistic regression and competing risk regression, respectively. Data for 3040 patients were extracted from the NSW Central Cancer Registry for the diagnostic period 1 January 2003 to 31 December 2007. Subset analyses for patients at low surgical risk indicated resection rates and outcomes under ideal circumstances. MAIN OUTCOME MEASURES: Resection rates and lung cancer mortality. RESULTS: The resection rate in NSW was estimated to be between 38% and 43%, peaking at 59% by local health district (LHD) of residence. Not having a resection was associated with older age, lower socioeconomic status, lack of private health insurance, and residence by LHD. Adjusted 5-year cumulated probabilities of death were 76% in absence of resection, 30% for wedge resection, 18% for segmental resection, 22% for lobectomy and 45% for pneumonectomy. Of 255 "low surgical risk" patients, 71% had a resection. Those not receiving a resection had a higher probability of death (adjusted subhazard ratio, 14.1; 95% CI, 7.2-27.5). If the low overall resection rate of 38%-43% in NSW were increased to 59% (the highest LHD resection rate), the proportion of all patients with localised NSCLC dying of NSCLC in the 5 years from diagnosis would decrease by about 10%, based on differences in probabilities of death by resection estimated in this study. CONCLUSIONS: Potential exists to reduce deaths from NSCLC in NSW through increased resection.
Currow, D.C. & Sansom, L.N. 2014, 'Uptake of medicines and prescribing patterns in the palliative care schedule of the Pharmaceutical Benefits Scheme.', Med J Aust, vol. 200, no. 10, pp. 560-561.
Currow, D.C. & Abernethy, A.P. 2014, 'The science of breathlessness: '… as we come onto the home straight, Science is catching Clinical Practice. Just two lengths between them'.', Curr Opin Support Palliat Care, vol. 8, no. 3, pp. 189-190.
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Currow, D.C., Abernethy, A.P. & Ko, D.N. 2014, 'The active identification and management of chronic refractory breathlessness is a human right.', Thorax, vol. 69, no. 4, pp. 393-394.
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Chronic refractory breathlessness is defined as breathlessness at rest or on minimal exertion that will persist chronically despite optimal treatment of the underlying cause(s). At any time, 1% of the population report a modified Medical Research Council dyspnoea score of 3 chronically. Despite the prevalence, severity and chronicity of this symptom and an evidence base of affordable and safe interventions, chronic refractory breathlessness remains grossly undertreated. Many patients and clinicians accept the presence of the chronic refractory breathlessness as an inevitable part of an illness, with no thought of treating the symptom despite an evidence base for its safe treatment. Consensus statements from major respiratory clinician organisations now endorse such a clinical course. Failure to inquire about, assess and properly treat chronic refractory breathlessness with opioids as outlined in specialist clinical guidelines is now an unacceptable level of care ethically and is, arguably, a breach of people's human rights. Adequate pain control through access to pain relief is now accepted as a human right and, given its burden across the world, the symptomatic treatment of chronic refractory breathlessness should be seen in exactly the same way.
Ekström, M.P., Bornefalk-Hermansson, A., Abernethy, A.P. & Currow, D.C. 2014, 'Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study.', BMJ, vol. 348, p. g445.
OBJECTIVE: To evaluate the safety of benzodiazepines and opioids in patients with very severe chronic obstructive pulmonary disease (COPD). DESIGN: Population based longitudinal consecutive cohort study. SETTING: Centres prescribing long term oxygen therapy in Sweden. PATIENTS: 2249 patients starting long term oxygen therapy for COPD in Sweden between 2005 and 2009 in the national Swedevox Register. MAIN OUTCOME MEASURES: Effects of benzodiazepines and opioids on rates of admission to hospital and mortality, adjusted for age, sex, arterial blood gases, body mass index (BMI), performance status, previous admissions, comorbidities, and concurrent drugs. RESULTS: 1681 (76%) patients were admitted to hospital, and 1129 (50%) died under observation. No patient was lost to follow-up. Benzodiazepines and opioids were not associated with increased admission: hazard ratio 0.98 (95% confidence interval, 0.87 to 1.10) and 0.98 (0.86 to 1.10), respectively. Benzodiazepines were associated with increased mortality (1.21, 1.05 to 1.39) with a dose response trend. Opioids also had a dose response relation with mortality: lower dose opioids ( 30 mg oral morphine equivalents a day) were not associated with increased mortality (1.03, 0.84 to 1.26) in contrast with higher dose opioids (1.21, 1.02 to 1.44). Concurrent benzodiazepines and opioids in lower doses were not associated with increased admissions (0.86, 0.53 to 1.42) or mortality (1.25, 0.78 to 1.99). Associations were not modified by being naive to the drugs or by hypercapnia. CONCLUSIONS: Lower dose opioids are not associated with increased admissions or deaths in patients with COPD and might be safe for symptom reduction in severe respiratory disease.
Russell, B.J., Rowett, D. & Currow, D.C. 2014, 'Pro re nata prescribing in a population receiving palliative care: a prospective consecutive case note review.', J Am Geriatr Soc, vol. 62, no. 9, pp. 1736-1740.
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OBJECTIVES: To document pro re nata (PRN) prescribing practices and to identify patterns with respect to clinical characteristics and the medications prescribed. DESIGN: Prospective consecutive case note review. SETTING: Two interrelated consultative hospice and palliative care services in regional Victoria, Australia. PARTICIPANTS: Terminally ill inpatients and community-based individuals (N&nbsp;=&nbsp;203) at the time of referral to a hospice or palliative care service. MEASUREMENTS: Number of medications that the referring physician prescribed on a PRN basis and on a regular basis for symptom control; comorbid disease, performance status, comorbidity burden, disease phase, and survival. RESULTS: Mean number of PRN medications prescribed was 3.0, with significantly higher rates in the last week of life (rate ratio (RR)&nbsp;=&nbsp;1.30, 95% confidence interval (CI)&nbsp;=&nbsp;1.07-1.59) and during the terminal phase of disease (RR&nbsp;=&nbsp;1.36, 95% CI&nbsp;=&nbsp;1.09-1.68). One-quarter of prescriptions were for medications that met the Beers consensus criteria for potentially inappropriate medication use in elderly persons. CONCLUSION: These descriptive baseline data are new. A mean of three different medications allows responsiveness to a variety of fluctuating symptoms, but there was a large range within the sample, indicating that some individuals and their caregivers have a high burden of administration-related decision-making.
Currow, D.C. & Abernethy, A.P. 2014, 'Lessons from the Liverpool Care Pathway--evidence is key.', Lancet, vol. 383, no. 9913, pp. 192-193.
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Dunlop, S.M., Dobbins, T., Young, J.M., Perez, D. & Currow, D.C. 2014, 'Impact of Australia's introduction of tobacco plain packs on adult smokers' pack-related perceptions and responses: results from a continuous tracking survey.', BMJ Open, vol. 4, no. 12, p. e005836.
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OBJECTIVES: To investigate the impact of Australia's plain tobacco packaging policy on two stated purposes of the legislation--increasing the impact of health warnings and decreasing the promotional appeal of packaging--among adult smokers. DESIGN: Serial cross-sectional study with weekly telephone surveys (April 2006-May 2013). Interrupted time-series analyses using ARIMA modelling and linear regression models were used to investigate intervention effects. PARTICIPANTS: 15,745 adult smokers (aged 18years and above) in New South Wales (NSW), Australia. Random selection of participants involved recruiting households using random digit dialling and selecting the nth oldest smoker for interview. INTERVENTION: The introduction of the legislation on 1 October 2012. OUTCOMES: Salience of tobacco pack health warnings, cognitive and emotional responses to warnings, avoidance of warnings, perceptions regarding one's cigarette pack. RESULTS: Adjusting for background trends, seasonality, antismoking advertising activity and cigarette costliness, results from ARIMA modelling showed that, 2-3months after the introduction of the new packs, there was a significant increase in the absolute proportion of smokers having strong cognitive (9.8% increase, p=0.005), emotional (8.6% increase, p=0.01) and avoidant (9.8% increase, p=0.0005) responses to on-pack health warnings. Similarly, there was a significant increase in the proportion of smokers strongly disagreeing that the look of their cigarette pack is attractive (57.5% increase, p<0.0001), says something good about them (54.5% increase, p<0.0001), influences the brand they buy (40.6% increase, p<0.0001), makes their pack stand out (55.6% increase, p<0.0001), is fashionable (44.7% increase, p<0.0001) and matches their style (48.1% increase, p<0.0001). Changes in these outcomes were maintained 6months postintervention. CONCLUSIONS: The introductory effects of the plain packaging legislation among adult smokers are consistent wi...
Currow, D.C. & Morgan, D.D. 2014, 'Gallifreyan transformation of our patients.', J Palliat Med, vol. 17, no. 10, pp. 1082-1083.
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Smith, R.C., Creighton, N., Lord, R.V., Merrett, N.D., Keogh, G.W., Liauw, W.S. & Currow, D.C. 2014, 'Survival, mortality and morbidity outcomes after oesophagogastric cancer surgery in New South Wales, 2001-2008.', Med J Aust, vol. 200, no. 7, pp. 408-413.
OBJECTIVES: To examine the relationship between hospital volume and patient outcomes for New South Wales hospitals performing oesophagectomy and gastrectomy for oesophagogastric cancer. DESIGN, SETTING AND PATIENTS: A retrospective, population-based cohort study of NSW residents diagnosed with a new case of invasive oesophageal or gastric cancer who underwent oesophagectomy or gastrectomy between 2001 and 2008 in NSW hospitals using linked de-identified data from the NSW Central Cancer Registry, the National Death Index and the NSW Admitted Patient Data Collection. A higher-volume hospital was defined as one performing > 6 relevant procedures per year. MAIN OUTCOME MEASURES: Odds ratios for > 21-day length of stay, 28-day unplanned readmission, 30-day mortality and 90-day mortality, and hazard ratios (HRs) for 5-year absolute and conditional survival. RESULTS: Oesophagectomy (908 patients) and gastrectomy (1621 patients) were undertaken in 42 and 84 hospitals, respectively, between 2001 and 2008. Median annual hospital volume ranged from 2 to 4 for oesophagectomies and ranged from 2 to 3 for gastrectomies. Controlling for known confounders, no associations between hospital volume and > 21-day length of stay and 28-day unplanned readmission were found. Overall 30-day mortality was 4.1% and 4.4% for oesophagectomy and gastrectomy, respectively. Five-year absolute survival was significantly better for patients who underwent oesophagectomy in higher-volume hospitals (adjusted HR for lower-volume hospitals, 1.28 [95% CI, 1.10-1.49]; P = 0.002) and for those with localised gastric cancer who underwent gastrectomy in higher-volume hospitals (adjusted HR for lower-volume hospitals, 1.83 [95% CI, 1.28-2.61]; P = 0.001). CONCLUSIONS: These data support initial surgery for oesophagogastric cancer in higher-volume hospitals.
Currow, D.C., Ekstrom, M. & Abernethy, A.P. 2014, 'Opioids for chronic refractory breathlessness: right patient, right route?', Drugs, vol. 74, no. 1, pp. 1-6.
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Chronic breathlessness at rest or on minimal exertion despite optimal treatment of the underlying chronic cause(s) is termed chronic refractory breathlessness. This is prevalent across the community and is an independent indicator of poor prognosis. This narrative review focuses on the palliation of chronic refractory breathlessness in people predominantly with non-cancer diagnoses. Breathlessness is a complex sensation with at least three dimensions--intensity, distress/unpleasantness and its impact on function. It is the conscious representation of a mismatch between central ventilatory drive (the demand to breathe) and the responding respiratory output (the ability to breathe). Measurement relies on subjective reports by patients using a choice of uni- and multi-variable tools; the minimal clinically important difference is the smallest change conceived as clinically meaningful by the patients. Exogenous and endogenous opioids work centrally to reduce the sensation of breathlessness, with morphine as a mu opioid receptor agonist the most widely studied. Regular, low doses of sustained-release morphine have been shown to safely reduce breathlessness in this setting without evidence of respiratory depression nor obtundation. Patients should be initiated at a dosage of 10 mg/24 h and titrated by 10 mg if there is no benefit once in steady state. The highest dosage in the only dose-ranging study published to date was only 30 mg/24 h. Predictors of response to opioids for chronic refractory breathlessness include younger people with more severe breathlessness at baseline. Future research should address whether upward titration delivers further clinical benefit and whether all underlying aetiologies respond as predictably to opioids.
Clark, K. & Currow, D.C. 2014, 'Methylnaltrexone in Palliative Care: Further Research Is Needed', Journal of Pain and Symptom Management.
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Johnson, M.J., Currow, D.C. & Booth, S. 2014, 'Prevalence and assessment of breathlessness in the clinical setting.', Expert Rev Respir Med, vol. 8, no. 2, pp. 151-161.
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Breathlessness is a common symptom in the general population and a frequent reason for presentation in all healthcare settings. It causes serious functional limitations, distress for both patient and carer, and predicts poor clinical outcomes. Traditionally, clinical care focuses on investigation, diagnosis and treatment of the conditions causing breathlessness. Breathlessness itself is often not seen as a target for therapeutic interventions by either clinician or patient, and so breathlessness which persists despite optimum treatment of the condition is self-managed by the patient without medical help. There are evidence based interventions which benefit breathlessness, irrespective of its cause; systematic assessment should lead to individually tailored management plans. A simple measure of severity (intensity) and assessment of bother or distress caused by breathlessness in addition to the impact on quality of life should be routinely sought in a proactive manner so that appropriate management plans can be put in place.
LeBlanc, T.W., Currow, D.C. & Abernethy, A.P. 2014, 'On Goldilocks, care coordination, and palliative care: making it 'just right'.', Prim Care Respir J, vol. 23, no. 1, pp. 8-10.
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Johnson, M.J., Bland, J.M., Oxberry, S.G., Abernethy, A.P. & Currow, D.C. 2014, 'Measuring improvement in dyspnoea: should absolute or relative values be used?', Eur Respir J, vol. 44, no. 6, pp. 1700-1703.
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Rowett, D. & Currow, D. 2014, 'Pharmacovigilance in palliative care', Australian Prescriber, vol. 37, no. 6, pp. 204-208.
Bischoff, K., Currow, D.C., Corvera, C. & Pantilat, S.Z. 2014, 'Unanswered questions in malignant bowel obstruction.', J Palliat Care, vol. 30, no. 4, pp. 265-270.
Lewis, J., DiGiacomo, M., Luckett, T., Davidson, P.M. & Currow, D. 2013, 'A Social Capital Framework for Palliative Care: Supporting Health and Well-Being for People With Life-Limiting Illness and Their Carers Through Social Relations and Networks', Journal of Pain and Symptom Management, vol. 45, no. 1, pp. 92-103.
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This paper summarizes the literature on social capital, well-being, and quality of life for key outcomes to inform a model of social capital in palliative care.
Waller, A., Girgis, A., Davidson, P.M., Newton, P.J., Lecathelinais, C., Macdonald, P., Hayward, C. & Currow, D. 2013, 'Facilitating needs-based support and palliative care for people with chronic heart failure: preliminary evidence for the acceptability, inter-rater reliability and validity of a needs assessment tool', Journal of Pain and Symptom Management, vol. 45, no. 5, pp. 912-925.
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Context. Understanding the types and extent of need is critical to informing needs-based care for people with chronic heart failure (CHF). Objectives. To explore the psychometric quality of a newly developed rapid screening measure to assess the supportive and palliative care needs of people with CHF.
Luckett, T., Davidson, P.M., Lam, L., Phillips, J.L., Currow, D. & Agar, M. 2013, 'Do Community Specialist Palliative Care Services That Provide Home Nursing Increase Rates of Home Death for People with Life-Limiting Illnesses? A Systematic Review and Meta-Analysis of Comparative Studies', Journal of Pain and Symptom Management, vol. 45, no. 2, pp. 279-297.
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Context. Systematic reviews and meta-analyses suggest that community specialist palliative care services (SPCSs) can avoid hospitalizations and enable home deaths. But more information is needed regarding the relative efficacies of different models. Family caregivers highlight home nursing as the most important service, but it is also likely the most costly.
Crawford, G., Agar, M., Quinn, S., Phillips, J.L., Litster, C., Michael, N., Doogue, M., Rowett, D. & Currow, D. 2013, 'Pharmacovigilance in hospice/palliative care. Net effect of haloperidol for delirium', Journal Of Palliative Medicine, vol. 16, no. 11, pp. 1335-1341.
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Prescribing practice in hospice/palliative care is largely extrapolated from other areas of clinical practice, with few studies of net medication effects (benefits and harms) in hospice/palliative care to guide prescribing decisions. Hospice/palliative care patients differ in multiple ways from better studied participant groups, hence the applicability of studies in other participant groups is uncertain. Haloperidol, a butyrophenone derivative and dopamine antagonist, is commonly prescribed for nausea, vomiting, and delirium in hospice/palliative care. Its frequent use in delirium occurs despite little evidence of the effect of antipsychotics on the untreated course of delirium. The aim of this study was to examine the immediate and short-term clinical benefits and harms of haloperidol for delirium in hospice/palliative care patients. METHOD: A consecutive cohort of participants from 14 centers across four countries who had haloperidol commenced for delirium were recruited. Data were collected at three time points: baseline, 48 hours (clinical benefits), and day 10 (clinical harms). Investigators were also able to report clinical harms at any time up to 14 days after it was commenced. RESULTS: Of the 119 participants included, the average dose was 2.1?mg per 24 hours; 42 of 106 (35.2%) reported benefit at 48 hours. Harm was reported in 14 of 119 (12%) at 10 days, the most frequent being somnolence (n=11) and urinary retention (n=6). Seven participants had their medication ceased due to harms (2 for somnolence and 2 for rigidity). Approximately half (55/119) were still being treated with haloperidol after 10 days. CONCLUSION: Overall, 1 in 3 participants gained net clinical benefit at 10 days.
Currow, D. & Phillips, J.L. 2013, 'Evolution of palliative care in Australia 1973-2013', Cancer Forum, vol. 37, no. 1, pp. 38-42.
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In parallel with the rapid development of oncology in Australia, palliative and supportive care has evolved rapidly. The sponsorship for such development was largely generated by oncology services in response to unmet needs that were encountered daily. Development of state, territory and national strategies has mirrored the professional development in service delivery, education (of existing practitioners and tomorrows clinicians) and research. More recently, national programs are delivering better outcomes for palliative care patients and their families, world-leading clinical research, improved access to essential medications in the community and the ability to access quality evidence to inform practice and policy. These initiatives provide a valuable foundation for continuing to improve access to high quality clinical care wherever people live.
Breaden, K., Phillips, J.L., Agar, M., Grbich, C., Abernethy, A. & Currow, D. 2013, 'The clinical and social dimension of prescribing home oxygen for the relief of refractory dyspnea', Journal Of Palliative Medicine, vol. 16, no. 3, pp. 268-273.
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Background: Chronic breathlessness is a significant problem in palliative care and oxygen is often prescribed in an attempt to ameliorate it. Often, this prescription falls outside the current funding guidelines for long-term home oxygen use. The aim of this qualitative study was to understand the factors that most influence Australian specialist palliative care nurses' initiation of home oxygen for their patients. Methods: A series of focus groups were held across three states in Australia in 2011 involving specialist palliative care nurses. The invitation to the nurses was sent by e-mail through their national association. Recorded and transcribed data were coded for themes and subthemes. A summary, which included quotes, was provided to participants to confirm. Results: Fifty-one experienced palliative care nurses participated in seven focus groups held in three capital cities. Two major themes were identified: 1) logistic/health service issues (not reported in this paper as specific to the Australian context) involving the local context of prescribing and, 2) clinical care issues that involved assessing the patient's need for home oxygen and ongoing monitoring concerns. Palliative care nurses involved in initiating or prescribing oxygen often reported using oxygen as a second-line treatment after other interventions had been trialed and these had not provided sufficient symptomatic benefit. Safety issues were a universal concern and a person living alone did not emerge as a specific issue among the nurses interviewed. Conclusion: The role of oxygen is currently seen as a second-line therapy in refractory dyspnea by specialist palliative care nurses.
Davidson, P.M., Abernethy, A.P., Newton, P.J., Clark, K. & Currow, D.C. 2013, 'The caregiving perspective in heart failure: a population based study', BMC Health Services Research, vol. 13, no. 342.
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McCaffrey, N., Agar, M., Harlum, J., Karnon, J., Currow, D. & Eckermann, S. 2013, 'Is home-based palliative care cost-effective? An economic evaluation of the Palliative Care Extended Packages at Home (PEACH) pilot.', BMJ supportive & palliative care, vol. 3, no. 4, pp. 431-435.
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OBJECTIVE: The aim of this study was to evaluate the cost-effectiveness of a home-based palliative care model relative to usual care in expediting discharge or enabling patients to remain at home. DESIGN: Economic evaluation of a pilot randomised controlled trial with 28 days follow-up. METHODS: Mean costs and effectiveness were calculated for the Palliative Care Extended Packages at Home (PEACH) and usual care arms including: days at home; place of death; PEACH intervention costs; specialist palliative care service use; acute hospital and palliative care unit inpatient stays; and outpatient visits. RESULTS: PEACH mean intervention costs per patient ($3489) were largely offset by lower mean inpatient care costs ($2450) and in this arm, participants were at home for one additional day on average. Consequently, PEACH is cost-effective relative to usual care when the threshold value for one extra day at home exceeds $1068, or $2547 if only within-study days of hospital admission are costed. All estimates are high uncertainty. CONCLUSIONS: The results of this small pilot study point to the potential of PEACH as a cost-effective end-of-life care model relative to usual care. Findings support the feasibility of conducting a definitive, fully powered study with longer follow-up and comprehensive economic evaluation.
Nikles, J., Mitchell, G.K., Hardy, J., Agar, M., Senior, H., Carmont, S.-.A., Schluter, P.J., Good, P., Vora, R. & Currow, D. 2013, 'Do pilocarpine drops help dry mouth in palliative care patients: a protocol for an aggregated series of n-of-1 trials', BMC PALLIATIVE CARE, vol. 12.
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Hardy, J., Quinn, S., Fazekas, B., Agar, M. & Currow, D. 2013, 'Can the LANSS scale be used to classify pain in chronic cancer pain trials?', SUPPORTIVE CARE IN CANCER, vol. 21, no. 12, pp. 3387-3391.
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Agar, M., Ko, D.N., Sheehan, C., Chapman, M. & Currow, D.C. 2013, 'Informed Consent in Palliative Care Clinical Trials: Challenging but Possible', JOURNAL OF PALLIATIVE MEDICINE, vol. 16, no. 5, pp. 485-491.
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Sr, H.E.J., Mitchell, G.K., Nikles, J., Carmont, S.-.A., Schluter, P.J., Currow, D.C., Vora, R., Yelland, M.J., Agar, M., Good, P.D. & Hardy, J.R. 2013, 'Using aggregated single patient (N-of-1) trials to determine the effectiveness of psychostimulants to reduce fatigue in advanced cancer patients: a rationale and protocol', BMC PALLIATIVE CARE, vol. 12.
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To, T.H.M., Agar, M. & Currow, D.C. 2013, 'Rapid death after hospitalisation', INTERNAL MEDICINE JOURNAL, vol. 43, no. 4, pp. 471-471.
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Currow, D.C., Agar, M. & Abernethy, A.P. 2013, 'Hospital Can Be the Actively Chosen Place for Death', JOURNAL OF CLINICAL ONCOLOGY, vol. 31, no. 5, pp. 651-652.
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To, T.H.M., Agar, M., Shelby-James, T., Abernethy, A.P., Doogue, M., Rowett, D., Ko, D. & Currow, D.C. 2013, 'Off-label prescribing in palliative care - a cross-sectional national survey of Palliative Medicine doctors', PALLIATIVE MEDICINE, vol. 27, no. 4, pp. 320-328.
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van Zandwijk, N., Clarke, C., Henderson, D., Musk, A.W., Fong, K., Nowak, A., Loneragan, R., McCaughan, B., Boyer, M., Feigen, M., Currow, D., Schofield, P., Ivimey, B., Pavlakis, N., McLean, J., Marshall, H., Leong, S., Keena, V. & Penman, A. 2013, 'Guidelines for the diagnosis and treatment of malignant pleural mesothelioma', JOURNAL OF THORACIC DISEASE, vol. 5, no. 6, pp. E254-E307.
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Currow, D., Johnson, M., White, P. & Abernethy, A. 2013, 'Evidence-based intervention for chronic refractory breathlessness: practical therapies that make a difference', BRITISH JOURNAL OF GENERAL PRACTICE, vol. 63, no. 616, pp. 609-610.
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Cranston, J.M., Crockett, A., Currow, D. & Ekstrom, M. 2013, 'Oxygen therapy for dyspnoea in adults (vol 16, CD004769, 2008)', COCHRANE DATABASE OF SYSTEMATIC REVIEWS, no. 11.
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Yates, P., Schofield, P., Zhao, I. & Currow, D. 2013, 'Supportive and palliative care for lung cancer patients', JOURNAL OF THORACIC DISEASE, vol. 5, pp. S623-S628.
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Girgis, A., Lambert, S., Johnson, C., Waller, A. & Currow, D. 2013, 'Physical, psychosocial, relationship, and economic burden of caring for people with cancer: a review.', Journal of oncology practice, vol. 9, no. 4, pp. 197-202.
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The aim of this article is to provide an overview of the issues faced by caregivers of people diagnosed with cancer, with a particular emphasis on the physical, psychosocial, and economic impact of caring. A review of the literature identified cancer as one of the most common health conditions in receipt of informal caregiving, with the majority of caregivers reporting taking on the role of caring because of family responsibility and there being little choice or no one else to provide the care. For some, caregiving can extend for several years and become equivalent to a full-time job, with significant consequent health, psychosocial, and financial burdens. Having a better understanding of the critical and broad roles that caregivers play in the oncology setting and the impact of these on their health and well-being may assist health care professionals in supporting caregivers with these tasks and targeting services and interventions toward those most in need.
Hardy, J., Quinn, S., Fazekas, B., Eckermann, S., Agar, M.R., Spruyt, O., Rowett, D. & Currow, D. 2013, 'Ketamine in the Management of Cancer Pain Reply', JOURNAL OF CLINICAL ONCOLOGY, vol. 31, no. 10, pp. 1375-1376.
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Allcroft, P., Currow, D., Margitinovic, V., Greene, A., Agar, M., Clark, K. & Abernethy, A. 2013, 'THE ROLE OF BENZODIAZEPINES IN BREATHLESSNESS: A SINGLE-SITE, OPEN-LABEL, PILOT OF OPIOID SPARING ABILITY', RESPIROLOGY, vol. 18, pp. 57-57.
Soeberg, M., You, H., Allemani, C., Bannon, F., Carreira, H., Harewood, R., Wang, X.-.S., Ahn, J., Currow, D., Coleman, M. & Grp, C.O.N.C.O.R.D.W. 2013, 'AUSTRALIAN DATA IN GLOBAL SURVEILLANCE OF POPULATION-BASED CANCER SURVIVAL (THE CONCORD PROGRAMME)', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, vol. 9, pp. 134-134.
Crane, M., Aranda, S., Stacey, I., Lafontaine, M., Scott, N., O'Hara, B. & Currow, D. 2013, 'AWARENESS ABOUT THE SIGNS AND SYMPTOMS OF LUNG CANCER IN AUSTRALIA, A MIXED METHODS STUDY', JOURNAL OF THORACIC ONCOLOGY, vol. 8, pp. S250-S251.
Wiseman, R., Rowett, D., Allcroft, P., Abernethy, A. & Currow, D. 2013, 'Chronic refractory dyspnoea Evidence based management', AUSTRALIAN FAMILY PHYSICIAN, vol. 42, no. 3, pp. 137-139.
LeBlanc, T.W., Abernethy, A.P., Currow, D.C. & Kutner, J.S. 2013, 'Considerations in reporting palliative care clinical trials: standardizing information reported and authorship practices (vol 6, pg 494, 2012)', CURRENT OPINION IN SUPPORTIVE AND PALLIATIVE CARE, vol. 7, no. 1, pp. 129-129.
Clark, K., Sheehan, C. & Currow, D.C. 2013, 'Letter to the editor re "Four essential drugs needed for quality care of the dying: a Delphi-study based international expert consensus opinion".', Journal of palliative medicine, vol. 16, no. 7, pp. 721-722.
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Allcroft, P., Margitanovic, V., Greene, A., Agar, M.R., Clark, K., Abernethy, A.P. & Currow, D.C. 2013, 'The role of benzodiazepines in breathlessness: a single site, open label pilot of sustained release morphine together with clonazepam.', Journal of palliative medicine, vol. 16, no. 7, pp. 741-744.
BACKGROUND: Breathlessness at rest or on minimal exertion despite optimal treatment of underlying cause(s) is distressing and prevalent. Opioids can reduce the intensity of chronic refractory breathlessness and an anxiolytic may be of benefit. This pilot aimed to determine the safety and feasibility of conducting a phase III study on the intensity of breathlessness by adding regular benzodiazepine to low-dose opioid. METHODS: This is a single site, open label phase II study of the addition of regular clonazepam 0.5 mg nocte orally to Kapanol(R) 10 mg (sustained release morphine sulphate) orally mane together with docusate/sennosides in people with modified Medical Research Council Scale 2. Breathlessness intensity on day four was the efficacy outcome. Participants could extend for another 10 days if they achieved >15% reduction over their own baseline breathlessness intensity. RESULTS: Eleven people had trial medication (eight males, median age 78 years (68 to 89); all had COPD; median Karnofsky 70 (50 to 80); six were on long-term home oxygen. Ten people completed day four. One person withdrew because of unsteadiness on day four. Five participants reached the 15% reduction, but only three went on to the extension study, all completing without toxicity. CONCLUSION: This study was safe, feasible and there appears to be a group who derive benefits comparable to titrated opioids. Given the widespread use of benzodiazepines for the symptomatic treatment of chronic refractory breathlessness and its poor evidence base, there is justification for a definitive phase III study.
Currow, D.C., Higginson, I.J. & Johnson, M.J. 2013, 'Breathlessness--current and emerging mechanisms, measurement and management: a discussion from an European Association of Palliative Care workshop.', Palliat Med, vol. 27, no. 10, pp. 932-938.
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BACKGROUND: A pre-conference workshop at the 2012 European Association of Palliative Care meeting discussed the current scientific and clinical aspects of breathlessness. AIM: To describe a current overview of clinically relevant science in breathlessness. DESIGN: A collation of workshop presentations and discussions. DATA SOURCES: Narrative review. RESULTS: The mismatch between the drive to breathe and the ability to breathe underlies the major theories of breathlessness unifying central processing of peripheral inputs including more recent recognition of the importance of peripheral muscles in mediating efferent inputs, supporting reduction of breathlessness with muscle conditioning. Key questions are whether there is a 'final common pathway' for breathlessness? Are the central nervous system targets for reducing breathlessness identical irrespective of underlying aetiology? Central nervous system functional imaging confirms an ability to differentiate severity (intensity) from affective components (unpleasantness). Breathlessness generates suffering across the community for patients and their caregivers often for long periods. The exertional nature of breathlessness means that reduction rather than elimination of the symptom is the therapeutic goal. No single intervention is likely to relieve chronic refractory breathlessness, but interventions made up of several components may provide incremental relief. Having optimally treated any underlying reversible components, the resultant chronic refractory breathlessness can be treated with pharmacological, psychological and physical therapies to reduce the sensation and its impacts. CONCLUSION: Ensuring optimal delivery of interventions for breathlessness, whose design is underpinned by improving the understanding in the aetiology and maintenance of breathlessness, is the subject of ongoing controlled clinical trials.
Abernethy, A.P., Currow, D.C., Shelby-James, T., Rowett, D., May, F., Samsa, G.P., Hunt, R., Williams, H., Esterman, A. & Phillips, P.A. 2013, 'Delivery strategies to optimize resource utilization and performance status for patients with advanced life-limiting illness: results from the "palliative care trial" [ISRCTN 81117481].', J Pain Symptom Manage, vol. 45, no. 3, pp. 488-505.
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CONTEXT: Evidence-based approaches are needed to improve the delivery of specialized palliative care. OBJECTIVES: The aim of this trial was to improve on current models of service provision. METHODS: This 222 factorial cluster randomized controlled trial was conducted at an Australian community-based palliative care service, allowing three simultaneous comparative effectiveness studies. Participating patients were newly referred adults, experiencing pain, and who were expected to live >48 hours. Patients enrolled with their general practitioners (GPs) and were randomized three times: 1) individualized interdisciplinary case conference including their GP vs. control, 2) educational outreach visiting for GPs about pain management vs. control, and 3) structured educational visiting for patients/caregivers about pain management vs. control. The control condition was current palliative care. Outcomes included Australia-modified Karnofsky Performance Status (AKPS) and pain from 60 days after randomization and hospitalizations. RESULTS: There were 461 participants: mean age 71 years, 50% male, 91% with cancer, median survival 179 days, and median baseline AKPS 60. Only 47% of individuals randomized to the case conferencing intervention received it; based on a priori-defined analyses, 32% of participants were included in final analyses. Case conferencing reduced hospitalizations by 26% (least squares means hospitalizations per patient: case conference 1.26 [SE 0.10] vs. control 1.70 [SE 0.13], P=0.0069) and better maintained performance status (AKPS case conferences 57.3 [SE 1.5] vs. control 51.7 [SE 2.3], P=0.0368). Among patients with declining function (AKPS <70), case conferencing and patient/caregiver education better maintained performance status (AKPS case conferences 55.0 [SE 2.1] vs. control 46.5 [SE 2.9], P=0.0143; patient/caregiver education 54.7 [SE 2.8] vs. control 46.8 [SE 2.1], P=0.0206). Pain was unchanged. GP education did not change outcomes. CONCLUSI...
Currow, D.C. & Abernethy, A.P. 2013, 'Five years' time and the next five things for the list of choosing wisely.', J Palliat Med, vol. 16, no. 6, pp. 594-595.
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Ritchie, C.S., Currow, D.C., Abernethy, A.P. & Kutner, J.S. 2013, 'Multisite studies offer a solution to recruitment challenges in palliative care studies.', J Palliat Med, vol. 16, no. 3, p. 225.
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LeBlanc, T.W., Lodato, J.E., Currow, D.C. & Abernethy, A.P. 2013, 'Overcoming recruitment challenges in palliative care clinical trials.', J Oncol Pract, vol. 9, no. 6, pp. 277-282.
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PURPOSE: Palliative care is increasingly viewed as a necessary component of cancer care, especially for patients with advanced disease. Rigorous clinical trials are thus needed to build the palliative care evidence base, but clinical research-especially participant recruitment-is difficult. Major barriers include (1) patient factors, (2) "gatekeeping," and (3) ethical concerns. Here we discuss an approach to overcoming these barriers, using the Palliative Care Trial (PCT) as a case study. PATIENTS AND METHODS: The PCT was a 2 2 2 factorial randomized controlled trial (RCT) of different service delivery models to improve pain control in the palliative setting. It used a recruitment protocol that fused evidence-based strategies with principles of "social marketing," an approach involving the systematic application of marketing techniques. Main components included (1) an inclusive triage algorithm, (2) information booklets targeting particular stakeholders, (3) a specialized recruitment nurse, and (4) standardization of wording across all study communications. RESULTS: From an eligible pool of 607 patients, the PCT enrolled 461 patients over 26 months. Twenty percent of patients referred to the palliative care service were enrolled (76% of those eligible after screening). Several common barriers were minimized; among those who declined participation, family disinterest was uncommon (5%), as was the perception of burden imposed (4%). CONCLUSION: Challenges to clinical trial recruitment in palliative care are significant but not insurmountable. A carefully crafted recruitment and retention protocol can be effective. Our experience with designing and deploying a social-marketing-based protocol shows the benefits of such an approach.
McNamara, B.A., Rosenwax, L.K., Murray, K. & Currow, D.C. 2013, 'Early admission to community-based palliative care reduces use of emergency departments in the ninety days before death.', J Palliat Med, vol. 16, no. 7, pp. 774-779.
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BACKGROUND: Overcrowded emergency departments (EDs) and the staff within them are often not able to address the complex physical and psychosocial needs of people at the end of life. While some studies have suggested that the ED environment should be adapted and staff trained to address this issue, there are no previous studies which have investigated whether the provision of timely palliative care services could prevent people with palliative care needs from attending EDs. OBJECTIVE: This study investigates whether early admission to community-based palliative care reduces ED admissions in the last 90 days of life for patients with cancer. METHODS: The study was a retrospective, cross-sectional study using death registrations and hospital morbidity data for 746 Western Australian adults who died of cancer and where palliative care may have been a viable and appropriate option for care. RESULTS: In their final 90 days before death, 31.3% of decedents who had early access to palliative care and 52.0% of those who did not have early access to palliative care visited an ED (OR=2.86; 95% CI, 1.91, 4.30). Early admission to community-based palliative care reduces the use of EDs by cancer patients in the 90 days before death. CONCLUSIONS: Proactive care in the form of timely community-based palliative care assists in preventing vulnerable people at the end of life from being exposed to the stressful ED environment and decreases the pressure on EDs.
Clark, K. & Currow, D.C. 2013, 'Constipation in palliative care: what do we use as definitions and outcome measures?', J Pain Symptom Manage, vol. 45, no. 4, pp. 753-762.
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CONTEXT: Advances in the management of constipation in palliative care remain hindered by the lack of agreed-upon diagnostic criteria. OBJECTIVES: The objective of this work was to emphasize this issue by systematically examining the eligibility and primary outcome measures in studies of constipation in the hospice and palliative care population. METHODS: A palliative care-specific electronic literature search was undertaken using the validated domain filter "palliative care" and topic filter "constipation" in CareSearch (www.caresearch.com.au), which interrogates PubMed in real time (1965-2011). Studies were included if they were primary reports of the treatment of constipation in a palliative care setting. Articles could be prospective or retrospective; randomized controlled trials, cohort studies, or case series. RESULTS: Twenty articles on the palliative care population were included in which there were six different definitions of constipation. Only 12 of 20 articles used their cited definitions of constipation as the studies' primary outcome measures and four of four blinded, randomized, controlled trials. Articles that used the time between bowel actions or the use of laxatives as the definition of constipation were most likely to report outcomes based on these criteria. CONCLUSION: Constipation is a significant problem in palliative care; however, not having an agreed-upon definition limits research initiatives and the ability to apply these results clinically to people with constipation. Four domains are suggested as pivotal to the diagnosis: any life-long history of constipation (using the Rome Criteria), evaluation of physical changes that may cause or worsen constipation, the subjective sensation (such as feelings of incomplete defecation or bloating or fullness), and objective changes (such as frequency or consistency of stools).
Johnson, M.J., Abernethy, A.P. & Currow, D.C. 2013, 'The evidence base for oxygen for chronic refractory breathlessness: issues, gaps, and a future work plan.', J Pain Symptom Manage, vol. 45, no. 4, pp. 763-775.
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Breathlessness or "shortness of breath," medically termed dyspnea, is a common and distressing symptom featuring strongly in advanced lung, cardiac, and neuromuscular diseases; its prevalence and intensity increase as death approaches. However, despite the increasing understanding in the genesis of breathlessness, as well as an increasing portfolio of treatment options, breathlessness is still difficult to manage and engenders helplessness in caregivers and health care professionals and fear for patients. Although hypoxemia does not appear to be the dominant driver for breathlessness in advanced disease, the belief that oxygen is important for the relief of acute, chronic, and acute-on-chronic shortness of breath is firmly embedded in the minds of patients, caregivers, and health care professionals. This article presents current understanding of the use of oxygen for treating refractory breathlessness in advanced disease. The objective is to highlight what is still unknown, set a research agenda to resolve these questions, and highlight methodological issues for consideration in planned studies.
Currow, D.C., Quinn, S., Greene, A., Bull, J., Johnson, M.J. & Abernethy, A.P. 2013, 'The longitudinal pattern of response when morphine is used to treat chronic refractory dyspnea.', J Palliat Med, vol. 16, no. 8, pp. 881-886.
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BACKGROUND: While evidence supports using sustained release morphine for chronic refractory breathlessness, little is known about the longitudinal pattern of breathlessness intensity as people achieve symptomatic benefit. The aim of this study is to describe this pattern. METHODS: This secondary analysis used breathlessness intensity scores (100mm visual analogue scale (VAS)) from a prospective, dose increment study of once daily (morning) sustained release morphine for chronic refractory breathlessness. Participants who achieved <10% improvement over their own baseline at one week (10mg) were titrated to 20mg and if no response, another week later to 30mg for one week. Time was standardized at the first day of the week in which participants responded generating twice daily data one week either side of symptomatic benefit. Analysis used random effect mixed modeling. RESULTS: Of the 83 participants, 17/52 responders required >10mg: 13 participants (20mg) and 4 (30mg), contributing 634 VAS observations. In the week leading to a response, average VAS scores worsened by 0.3mm/day (p=0.16); the average improvement in the first 24 hours of response was 10.9mm (7.0 to 14.7; p<0.0001), with continued improvement of 2.2mm/day (p<0.001) for six more days. CONCLUSION: When treating chronic refractory breathlessness with once daily sustained release morphine, titrate to effect, since inadequate dose may generate no response; and following an initial response, further dose increases should not occur for at least one week. Whether further benefit would be derived beyond day six on the dose to which people respond, and what net effect a further dose increase would have are questions yet to be answered.
Kamal, A.H., Currow, D.C., Ritchie, C.S., Bull, J. & Abernethy, A.P. 2013, 'Community-based palliative care: the natural evolution for palliative care delivery in the U.S.', Journal of Pain and Symptom Management, vol. 46, no. 2, pp. 254-264.
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Tait, P.A., Gray, J., Hakendorf, P., Morris, B., Currow, D.C. & Rowett, D.S. 2013, 'Community pharmacists: A forgotten resource for palliative care', BMJ Supportive and Palliative Care, vol. 3, no. 4, pp. 436-443.
Clark, K. & Currow, D.C. 2013, 'A pilot study to assess the feasibility of measuring the prevalence of slow colon transit or evacuation disorder in palliative care.', J Palliat Med, vol. 16, no. 5, pp. 542-545.
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CONTEXT: Constipation is prevalent in palliative care. Whilst numerous factors contribute to this problem, opioid analgesia remains the most quoted aetiology. However, in gastroenterology, constipation is classified as a problem of prolonged transit times of colonic contents, impaired function of the structures of defecation or both. Little work in palliative care has used these assessments. AIMS: The report aims to describe the feasibility of assessing the colon transit times and pelvic floor structures of constipated palliative care patients and to report the results of a pilot study of 10 people who underwent these investigations. METHODS: Colon transit times were measured with a combination of orally administered radio-opaque markers and a single plain radiograph of the abdomen at day 5. Anal manometry plus rectal balloon expulsion was used to assess the pelvic floor. The results of the investigations were used to allocate people to one of four constipation subcategories: 1). slow colonic transit; 2) evacuation disorders; 3) mixed disorder or 4) normal transit. RESULTS: Two people had slow transit only, 2 people had evacuation disorders only and 5 had both. Only person had neither problem. The investigations were well tolerated and took a small amount of people's time. CONCLUSION: These pilot data strongly support the feasibility of undertaking comprehensive assessments of the colon and pelvic floor in palliative care patients with the results, although preliminary, highlighting the complexity of the problem of constipation. The results of this work underpin the need to progress to a much larger study.
Sanderson, C., Hardy, J., Spruyt, O. & Currow, D.C. 2013, 'Placebo and nocebo effects in randomized controlled trials: the implications for research and practice.', J Pain Symptom Manage, vol. 46, no. 5, pp. 722-730.
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Placebo and nocebo effects are known to contribute significantly to the response to symptom control, including analgesia. Clinical trial methodologies using placebo controls are designed to identify the magnitude of these effects in the research context. An adequately powered, randomized, double-blind, placebo-controlled trial of ketamine in cancer pain has recently been reported, which demonstrated no net clinical benefit for ketamine over and above that of placebo. Rates of placebo and nocebo responses were high. The setting of a clinical trial provides an opportunity to quantify the nonpharmacologic aspects of patient responses to analgesia, raising important clinical and ethical issues for practice. The findings of the ketamine study are analyzed in the context of a methodological discussion of placebo and nocebo effects, what is known about the biological and psychological bases for each of these, and their implications for a clinical trial design in the palliative care setting. Along with reviewing the use of ketamine after this negative trial, clinicians need to remain aware of the strength and significance of both placebo and nocebo responses in their own practices and the biopsychosocial complexity of why and how patients actually respond to pain management strategies. The results of this study strongly reinforce the importance of the therapeutic relationship and the context of care.
Johnson, M.J., Bland, J.M., Oxberry, S.G., Abernethy, A.P. & Currow, D.C. 2013, 'Opioids for chronic refractory breathlessness: patient predictors of beneficial response.', Eur Respir J, vol. 42, no. 3, pp. 758-766.
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Chronic refractory breathlessness is common and distressing in advanced disease. Despite level I evidence to support the use of opioids for this symptom, not all patients benefit. This study aimed to discover which patient characteristics predict those most likely to gain improvement in breathlessness. This is an international, multicentre, retrospective analysis of 213 individual pooled datasets from four clinical trials of an opioid for chronic refractory breathlessness. "Response to opioid" was defined as 1) an absolute value of 10 mm improvement on the visual analogue scale (VAS) and 2) a relative value of 10% improvement from baseline VAS. We investigated baseline predictors using logistic regression. In the final model, higher baseline breathlessness intensity scores strongly predicted absolute and relative response (p<0.001). Younger age also predicted relative response (p = 0.025); functional status and dominant cause of breathlessness did not. Some evidence supported the descriptor "not enough air", but was not statistically significant (p = 0.052). A therapeutic trial of opioids is appropriate, irrespective of the cause of the breathlessness or functional status. Younger people or those with worse breathlessness are more likely to benefit. Opioids have a role in the management of chronic refractory breathlessness, but net benefit for individuals must be optimised.
Currow, D.C., Clark, K., Mitchell, G.K., Johnson, M.J. & Abernethy, A.P. 2013, 'Prospectively collected characteristics of adult patients, their consultations and outcomes as they report breathlessness when presenting to general practice in Australia.', PLoS One, vol. 8, no. 9, p. e74814.
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INTRODUCTION: Breathlessness is a subjective sensation, so understanding its impacts requires patients' reports, including prospective patient-defined breathlessness as a reason for presenting to general practitioners (GP).The aim of this study was to define the prevalence of breathlessness as a reason for GP consultations while defining the clinico-demographic factors of these patients and the characteristics and outcomes of those consultations. METHODS: Using nine years of the Family Medicine Research Centre database of 100 consecutive encounters from 1,000 practices annually, the patient-defined reason for encounter 'breathlessness' was explored using prospectively collected data in people 18 years with clinical data coded using the International Classification for Primary Care V2. Dichotomous variables were analysed using chi square and 95% confidence intervals calculated using Kish's formula for a single stage clustered design. RESULTS: Of all the 755,729 consultations collected over a nine year period from 1 April, 2000, 7255 included breathlessness as a reason for encounter (0.96%; 95% CI 0.93 to 0.99) most frequently attributed to chronic obstructive pulmonary disease. Only 48.3% of GPs saw someone reporting breathlessness. The proportion of consultations with breathlessness increased with age. Breathlessness trebled the likelihood that the consultation occurred in the community rather than the consulting room (p<0.0001) and increased 2.5 fold the likelihood of urgent referral to hospital (p<0.0001). Of those with breathlessness, 12% had undiagnosed breathlessness at the end of the consultation (873/7255) with higher likelihood of being younger females. DISCUSSION: Breathlessness is a prevalent symptom in general practitioner. Such prevalence enables future research focused on understanding the temporal pattern of breathlessness and the longitudinal care offered to, and outcomes for these patients, including those who leave the consultation without a di...
Magnusson, R.S. & Currow, D.C. 2013, 'Could a scheme for licensing smokers work in Australia?', Med J Aust, vol. 199, no. 11, p. 742.
Nekolaichuk, C.L., Fainsinger, R.L., Aass, N., Hjermstad, M.J., Knudsen, A.K., Klepstad, P., Currow, D.C., Kaasa, S. & European Palliative Care Research Collaborative (EPCRC) 2013, 'The Edmonton Classification System for Cancer Pain: comparison of pain classification features and pain intensity across diverse palliative care settings in eight countries.', J Palliat Med, vol. 16, no. 5, pp. 516-523.
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BACKGROUND: Standardized approaches for assessing and classifying cancer pain are required to improve treatment of patients with complex pain profiles. The Edmonton Classification System for Cancer Pain (ECS-CP) offers a starting point for the evolution of a standardized international classification system for cancer pain and was introduced into multisite research initiatives of the European Palliative Care Research Collaborative (EPCRC). OBJECTIVES: The primary purpose of this study was to describe the prevalence of the five ECS-CP pain classification features: pain mechanism, incident pain, psychological distress, addictive behavior, and cognition--in a diverse international sample of patients with advanced cancer. METHODS: A total of 1070 adult patients with advanced cancer were recruited from 17 sites in Norway, the United Kingdom, Austria, Germany, Switzerland, Italy, Canada, and Australia; 1051 of 1070 patients were evaluable. A clinician completed the ECS-CP for each enrolled patient. Additional information, including pain intensity, were also collected through patient self-reports, using touch-sensitive computers. RESULTS: Of 1051 evaluable patients, 670 (64%) were assessed by a clinician as having cancer pain: nociceptive pain (n=534; 79.7%); neuropathic pain (n=113; 16.9%); incident pain (n=408; 60.9%); psychological distress (n=212; 31.6%); addictive behavior (n=30; 4.5%); normal cognition (n=616; 91.9%). The prevalence of ECS-CP features and pain intensity scores (11-item scale; 0=none, 10=worst; rated as now) varied substantially across sites and locations of care. CONCLUSION: The ECS-CP is a clinically relevant systematic framework, which is able to detect differences in salient pain classification features across diverse settings and countries. Further validation studies need to be conducted in varied advanced cancer and palliative care settings to advance the development of the ECS-CP toward an internationally recognized pain classification system...
Clark, K., Rowett, D., Robinson, M. & Currow, D.C. 2013, 'Uptake of methylnaltrexone in Australian patients with opioid-induced constipation: a review of the number of prescriptions presented in the first 12 months of subsidisation.', BMJ Support Palliat Care, vol. 3, no. 1, pp. 98-102.
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BACKGROUND: Disturbed bowel habits are very common in palliative care patients, most commonly thought to be due to opioid use. The peripheral opioid-antagonist methylnaltrexone has been subsidised in Australia to ensure that palliative care patients have timely and equitable access to this medication. The aim of this paper is to describe the use of methylnaltrexone in the first year after it was subsidised for palliative care, in particular focusing on the actual use of this medication compared with predicted need. METHODS: The predicted need for methylnaltrexone was calculated using an epidemiological approach based on data collected by the Australian Institute of Health and Welfare to determine the number of Australian deaths annually. A single source of data was used to determine the number of patients who die while under the care of palliative services in Australia (National Census of Palliative Care Services, 1999). These figures allowed the number of people likely to be receiving opioids to be estimated and therefore the number who could potentially benefit from methylnaltrexone. RESULTS: The number of patients who might benefit was calculated to be 5000, which contrasts with the 261 actual prescriptions written for methylnaltrexone. Even more striking was the disparity between initial prescriptions and the 93 requests for ongoing use. CONCLUSIONS: These data highlight much lower use of methylnaltrexone than predicted and raise a number of questions including the fact that the palliative care literature emphasises opioids as the dominant cause of constipation in palliative care patients given little ongoing use of methylnaltrexone.
Burns, C.M., Abernethy, A.P., Dal Grande, E. & Currow, D.C. 2013, 'Uncovering an invisible network of direct caregivers at the end of life: a population study.', Palliat Med, vol. 27, no. 7, pp. 608-615.
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BACKGROUND: Most palliative care research about caregivers relies on reports from spouses or adult children. Some recent clinical reports have noted the assistance provided by other family members and friends. AIM: This population study aims to define the people who actually provide care at the end of life. SETTING/PARTICIPANTS: A South Australian study conducted an annual randomized health population survey (n=23,706) over a 7 year period. A sample was obtained of self-identifying people who had someone close to them die and 'expected' death in the last 5 years (n=7915). Data were standardised to population norms for gender, 10-year age group, socioeconomic status, and region of residence. RESULTS: People of all ages indicated they provided 'hands on' care at the end of life. Extended family members (not first degree relatives) and friends accounted for more than half (n=1133/2028; 55.9%) of identified hands-on caregivers. These people came from the entire age range of the adult community. The period of time for which care was provided was shorter for this group of caregivers. People with extended family or friends providing care, were much more likely to be supported to die at home compared to having a spousal carer. CONCLUSION: This substantial network of caregivers who are mainly invisible to the health team provide the majority of care. Hospice and palliative care services need to create specific ways of identifying and engaging this cohort in order to ensure they are receiving adequate support in the role. Relying on 'next-of-kin' status in research will not identify them.
Magnusson, R.S. & Currow, D.C. 2013, 'Could a scheme for licensing smokers work in Australia?', Med J Aust, vol. 199, no. 3, pp. 181-184.
In this article, we evaluate the possible advantages and disadvantages of a licensing scheme that would require adult smokers to verify their right to purchase tobacco products at point of sale using a smart-card licence. A survey of Australian secondary school students conducted in 2011 found that half of 17-2013-old smokers and one-fifth of 12-2013-old smokers believed it was "easy" or "very easy" to purchase cigarettes themselves. Reducing tobacco use by adolescents now is central to the future course of the current epidemic of tobacco-caused disease, since most current adult smokers began to smoke as adolescents--at a time when they were unable to purchase tobacco lawfully. The requirement for cigarette retailers to reconcile all stock purchased from wholesalers against a digital record of retail sales to licensed smokers would create a robust incentive for retailers to comply with laws that prohibit tobacco sales to children. Foreseeable objections to introducing a smokers licence need to be taken into account, but once we move beyond the "shock of the new", it is difficult to identify anything about a smokers licence that is particularly offensive or demeaning. A smoker licensing scheme deserves serious consideration for its potential to dramatically curtail retailers' violation of the law against selling tobacco to minors, to impose stricter accountability for sale of a uniquely harmful drug and to allow intelligent use of information about smokers' purchases to help smokers quit.
Johnson, M.J., Bland, J.M., Oxberry, S.G., Abernethy, A.P. & Currow, D.C. 2013, 'Clinically important differences in the intensity of chronic refractory breathlessness.', J Pain Symptom Manage, vol. 46, no. 6, pp. 957-963.
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CONTEXT: Clinically important differences in chronic refractory breathlessness are ill defined but important in clinical practice and trial design. OBJECTIVES: To estimate the clinical relevance of differences in breathlessness intensity using distribution and patient anchor methods. METHODS: This was a retrospective data analysis from 213 datasets from four clinical trials for refractory breathlessness. Linear regression was used to explore the relationship between study effect size and change in breathlessness score (0-100mm visual analogue scale) and to estimate the change in score equivalent to small, moderate, and large effect sizes. Pooled individual blinded patient preference data from three randomized controlled trials were analyzed. The difference between the mean change in Day 4 minus baseline scores between preferred and non-preferred arms was calculated. RESULTS: There was a strong relationship between change in score and effect size (P&nbsp;=&nbsp;0.001; R(2)&nbsp;=&nbsp;0.98). Values for small, moderate, and large effects were -5.5, -11.3, and -18.2mm. The participant preference change in score was -9mm (95% CI, -15.8, -2.1) (P&nbsp;=&nbsp;0.008). CONCLUSION: This larger dataset supports a clinically important difference of 10mm. Studies should be powered to detect this difference.
Disler, R.T., Inglis, S., Currow, D. & Davidson, P.M. 2012, 'Palliative and supportive care in COPD: research priorities to decrease suffering.', Journal of Pulmonary and Respiratory Medicine, vol. 1, no. 6, pp. 1-3.
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Chronic obstructive pulmonary disease (COPD) affects 80 million people worldwide, is the fourth most prevalent cause of death globally and accounts for 3.5% of total years lost due to disability. Despite the similarities with malignant disease, many individuals suffer unnecessarily and continue to have limited access to palliative and endof-life care.
Disler, R.T., Currow, D., Phillips, J.L. & Davidson, P.M. 2012, 'Interventions to support a palliative care approach in patients with chronic obstructive pulmonary disease: An integrative review.', International Journal of Nursing Studies, vol. 49, no. 11, pp. 1443-1458.
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End-stage chronic obstructive pulmonary disease (COPD) is a debilitating, life-limiting condition. A palliative approach is appropriate for individuals with end-stage COPD, yet currently few interventions embrace this holistic, multidisciplinary and inclusive perspective.
Waller, A., Girgis, A., Johnson, C., Lecathelinais, C., Sibbritt, D., Forstner, D. & Currow, D. 2012, 'Improving outcomes for people with progressive cancer: interrupted time series trial of a needs assessment intervention', Journal of Pain and Symptom Management, vol. 43, no. 3, pp. 569-581.
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Improving the effectiveness of cancer care delivery has become a major focus of research. This study assessed the uptake and impact of the Palliative Care Needs Assessment Guidelines and Needs Assessment Tool: Progressive DiseasedCancer (NAT: PD-C) on the outcomes of people with advanced cancer.
Disler, R.T., Green, A.R., Luckett, T., Newton, P.J., Inglis, S., Currow, D. & Davidson, P.M. 2012, 'Unmet needs in chronic obstructive pulmonary disease: a metasynthesis protocol', International Journal of Research in Nursing, vol. 3, no. 1, pp. 15-20.
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Abstract: Problem statement: Chronic obstructive pulmonary disease is a chronic progressive illness. Despite the high burden experienced by individuals in the advanced stages of illness, individuals with advanced COPD continue to have unmet needs and limited access to palliative care. This Metasynthesis seeks to describe: the barriers and facilitators care access and provision; the unmet needs of individuals with advanced COPD, their families and carers; and the experiences of health professionals. Data sources: Medline, PsychINFO, AMED, CINAHL and Sociological Abstracts were searched for articles published between 1990 and December 31st 2011. Medical Subject Headings (MeSH) and key words will be used to guide the search. The strategy will be reviewed by the CareSearch palliative knowledge network and a health informatics expert. Approach: Metasyntheses are increasingly used to gain new insights and understandings of complex research questions through the amalgamation of data from individual qualitative studies. The principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and thematic synthesis will be used to achieve consistent reporting and transparency of methods. Results: Inclusion of studies, quality assessment and allocation of free codes into EPPI-Reviewer 4 software will be carried out by two independent investigators. Auditing of random cases will be undertaken and disagreements resolved through group discussion of an expert panel. Descriptive and analytical themes will be developed through thematic synthesis and expert panel discussion. Conclusion: Qualitative data provide useful information in understanding the individual's unique experience. Combining discrete qualitative studies provides an important opportunity to provide a voice to patients, their families and professional careers in managing advanced COPD.
Waller, A., Girgis, A., Johnson, C., Lecathelinais, C., Sibbritt, D., Seldon, N., Bonaventura, A. & Currow, D. 2012, 'Implications of a needs assessment intervention for people with progressive cancer: Impact on clinical assessment, response and service utlisation.', Psycho-oncology, vol. 21, no. 5, pp. 550-557.
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To assess the impact of the systematic use of the Palliative Care Needs Assessment Guidelines and Needs Assessment Tool: Progressive Disease - Cancer (NAT: PD-C) on clinical assessment, response and service utilisation.
Currow, D., Allingham, S., Bird, S., Yates, P., Lewis, J., Dawber, J. & Eagar, K. 2012, 'Referral patterns and proximity to palliative care inpatient services by level of socio-economic disadvantage. A national study using spatial analysis', BMC Health Services Research, vol. 12, no. 424, pp. 1-14.
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A range of health outcomes at a population level are related to differences in levels of social disadvantage. Understanding the impact of any such differences in palliative care is important. The aim of this study was to assess, by level of socio-economic disadvantage, referral patterns to specialist palliative care and proximity to inpatient services. This study examined all inpatient and community palliative care services nationally were geocoded (using postcode) to one nationally standardised measure of socio-economic deprivation Socio-Economic Index for Areas (SEIFA; 2006 census data). Referral to palliative care services and characteristics of referrals were described through data collected routinely at clinical encounters. Inpatient location was measured from each person's home postcode, and stratified by socio-economic disadvantage. This study covered July-December 2009 with data from 10,064 patients. People from the highest SEIFA group (least disadvantaged) were significantly less likely to be referred to a specialist palliative care service, likely to be referred closer to death and to have more episodes of inpatient care for longer time. Physical proximity of a persons home to inpatient care showed a gradient with increasing distance by decreasing levels of socio-economic advantage. These data suggest that a simple relationship of low socioeconomic status and poor access to a referral-based specialty such as palliative care does not exist. Different patterns of referral and hence different patterns of care emerge.
Agar, M., Draper, B., Phillips, P., Phillips, J., Collier, A., Harlum, J. & Currow, D. 2012, 'Making Decisions About Delirium: A Qualitative Comparison Of Decision Making Between Nurses Working In Palliative Care, Aged Care, Aged Care Psychiatry, And Oncology', Palliative Medicine, vol. 26, no. 7, pp. 887-896.
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Background: Delirium has a significant impact on nursing practice from diagnosis and management, with under-detection and variable management of delirium being international problems. This study aimed to explore nurses' assessment and management of delir
Agar, M., Draper, B., Phillips, J.L., Collier, A., Harlum, J. & Currow, D. 2012, 'Making decisions about delirium: a qualitative comparison of decision making between nurses working in palliative care, aged care, aged care psychiatry, and oncology.', Palliative Medicine, vol. 26, no. 7, pp. 887-896.
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Background: Delirium has a significant impact on nursing practice from diagnosis and management, with under-detection and variable management of delirium being international problems. This study aimed to explore nurses' assessment and management of delirium when caring for people with cancer, the elderly or older people requiring psychiatric care in the inpatient setting. Methods: Participants in this qualitative study were nurses working in Australian public hospital inpatient dedicated units in palliative care, aged care (geriatrics), aged care (geriatric) psychiatry and oncology. Semi-structured interviews were used to explore nurses' views about specific areas of delirium assessment and management. Purposive sampling was used and interviews conducted until thematic saturation reached. A thematic content analysis was performed from a grounded theory perspective. Results: A total of 40 participants were included in the study. The analysis revealed four broad analytical themes: (1) superficial recognition and understanding of the operational definition of delirium or recognition of delirium as a syndrome; (2) nursing assessment: investigative versus a problem solving approach; (3) management: maintaining dignity and minimizing chaos; and (4) distress and the effect on others. Discussion: Nurses have limited knowledge of the features of delirium regardless of their specialty discipline. Delirium was uniformly identified as a highly distressing experience for patients, families and staff alike. The majority of nurses had a superficial understanding of delirium management, and adopted a task-orientated approach aimed at addressing the more noticeable problems. These findings have implications for both education and knowledge translation. Innovative approaches are needed to align health professional behaviours with best evidence delirium care.
Hardy, J., Quinn, S., Fazekas, B., Plummer, J., Eckermann, S., Agar, M., Spruyt, O., Rowett, D. & Currow, D.C. 2012, 'Randomized, Double-Blind, Placebo-Controlled Study to Assess the Efficacy and Toxicity of Subcutaneous Ketamine in the Management of Cancer Pain', JOURNAL OF CLINICAL ONCOLOGY, vol. 30, no. 29, pp. 3611-3617.
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Sheehan, C., Agar, M. & Currow, D.C. 2012, 'End-of-Life Research: Do We Need To Build Proxy Consent into All Clinical Trial Protocols Studying the Terminal Phase?', JOURNAL OF PALLIATIVE MEDICINE, vol. 15, no. 9, pp. 962-962.
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Shelby-James, T.M., Hardy, J., Agar, M., Yates, P., Mitchell, G., Sanderson, C., Luckett, T., Abernethy, A.P. & Currow, D.C. 2012, 'Designing and conducting randomized controlled trials in palliative care: A summary of discussions from the 2010 clinical research forum of the Australian Palliative Care Clinical Studies Collaborative', PALLIATIVE MEDICINE, vol. 26, no. 8, pp. 1042-1047.
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Clark, K., Smith, J., Lovell, M. & Currow, D.C. 2012, 'Longitudinal Pain Reports in a Palliative Care Population', JOURNAL OF PALLIATIVE MEDICINE, vol. 15, no. 12, pp. 1335-1341.
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Harrington, A., Mitchell, P., Jones, J., Swetenham, K. & Currow, D. 2012, 'Transition to an in-patient palliative care unit: carers share their experiences.', International journal of palliative nursing, vol. 18, no. 11, pp. 548-552.
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BACKGROUND: For a carer, transitioning the care of a person who is dying to others may be a challenging experience. At this time, more than any other, carers' experiences need to be understood. The emotional impact of care transitions may have clinical significance for both carers and those they care for. AIM: To explore carers experiences of the transition of the person they were caring for to in-patient care. METHOD: Carers reflected on their. experiences through an explorative/descriptive research methodology. RESULTS: Feelings of guilt and relief figured prominently in the participants' discourses. CONCLUSIONS: Prominent feelings of guilt and relief overshadowed the participants' experiences of transitioning care. This finding needs to be considered by care providers.
McConigley, R., Aoun, S., Kristjanson, L., Colyer, S., Deas, K., O'Connor, M., Harris, R., Currow, D. & Yates, P. 2012, 'Implementation and evaluation of an education program to guide palliative care for people with motor neurone disease', PALLIATIVE MEDICINE, vol. 26, no. 8, pp. 994-1000.
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Waller, A., Girgis, A., Johnson, C., Lecathelinais, C., Sibbritt, D., Forstner, D., Liauw, W. & Currow, D.C. 2012, 'Improving Outcomes for People With Progressive Cancer: Interrupted Time Series Trial of a Needs Assessment Intervention', Journal of Pain and Symptom Management, vol. 43, no. 3, pp. 569-581.
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To, T., Agar, M., Shelby-James, T., Abernethy, A., Doogue, M., Rowett, D. & Currow, D.C. 2012, 'Off-Label Prescribing in Palliative Care: A Cross-sectional National Survey of Australian Palliative Medicine Doctors', JOURNAL OF PALLIATIVE CARE, vol. 28, no. 3, pp. 189-190.
Hardy, J. & Currow, D.C. 2012, 'Sector-wide approach to phase III studies', PALLIATIVE MEDICINE, vol. 26, no. 6, pp. 864-864.
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Currow, D.C. & Abernethy, A.P. 2012, 'The ultimate personalised medicine', INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, vol. 66, no. 9, pp. 824-826.
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Clark, K., Byfieldt, N., Dawe, M. & Currow, D.C. 2012, 'Treating Constipation in Palliative Care: The Impact of Other Factors Aside From Opioids', AMERICAN JOURNAL OF HOSPICE & PALLIATIVE MEDICINE, vol. 29, no. 2, pp. 122-125.
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Dear, R.F., Barratt, A.L., Askie, L.M., Butow, P.N., McGeechan, K., Crossing, S., Currow, D.C. & Tattersall, M.H.N. 2012, 'Impact of a cancer clinical trials web site on discussions about trial participation: a cluster randomized trial', ANNALS OF ONCOLOGY, vol. 23, no. 7, pp. 1912-1918.
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Tracey, E.A., Roder, D.M. & Currow, D.C. 2012, 'What factors affect the odds of NSW cancer patients presenting with localised as opposed to more advanced cancer?', CANCER CAUSES & CONTROL, vol. 23, no. 2, pp. 255-262.
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Clark, K. & Currow, D.C. 2012, 'Response to "A cross-sectional study of constipation and laxative use in advanced cancer patients: insights for revision of current practise"', SUPPORTIVE CARE IN CANCER, vol. 20, no. 12, pp. 3027-3028.
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Toye, C., Abbey, J., Currow, D., Hegarty, M., Holloway, K. & Tieman, J. 2012, 'Community aged care: guidelines for a palliative approach', AUSTRALASIAN JOURNAL ON AGEING, vol. 31, pp. 67-67.
Currow, D.C. & Agar, M. 2012, 'Evidence-based practice - Where does the buck stop?', Journal of Pharmacy Practice and Research, vol. 42, no. 2, pp. 91-93.
Currow, D.C., Rowett, D., Doogue, M., To, T.H.M. & Abernethy, A.P. 2012, 'An international initiative to create a collaborative for pharmacovigilance in hospice and palliative care clinical practice.', J Palliat Med, vol. 15, no. 3, pp. 282-286.
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BACKGROUND: Medication registration currently requires evidence of safety and efficacy from adequately powered phase 3 studies. Pharmacovigilance (phase 4 studies, postmarketing data, adverse drug reaction reporting) provide data on more widespread and longer term use. Historically, voluntary reporting systems for pharmacovigilance have had low reporting rates, relying on ad hoc reporting and retrospective chart reviews, or prospective registries have often been limited to specific drugs or clinical conditions. Furthermore, these data are often irrelevant in hospice and palliative care due to the timeliness of which such data become available and the unique characteristics of our population and prescribing: compounding comorbidities, progressive organ failure, accumulation of symptom-specific medications, tendency to attribute toxicity to disease progression, use of old, off-patent medications, and incorporation of evolving evidence. There is a need for prospective, systematic pharmacovigilance in hospice and palliative care. METHOD: Here we describe an international, Web-based, 128-bit secure initiative to collect pharmacovigilance data documenting net clinical benefit and safety of common medications. The intention is for a diverse and large group of clinical units to record data prospectively on a small deidentified consecutive cohort of patients started on the medication of interest. A new medication would be studied every 3 months. Three key time points (different for each medication) will be assessed for each patient, collecting easily codefiable data at baseline, a point at which clinical benefit should be experienced, and a point at which short- to medium-term toxicities may occur. Toxicities can additionally be recorded at any time they occur. Data collection will take a maximum of 10 minutes per patient. CONCLUSION: The intention is to create an efficient, relevant system to improve hospice and palliative care with maximally generalizable results.
Hjermstad, M.J., Lie, H.C., Caraceni, A., Currow, D.C., Fainsinger, R.L., Gundersen, O.E., Haugen, D.F., Heitzer, E., Radbruch, L., Stone, P.C., Strasser, F., Kaasa, S., Loge, J.H. & European Palliative Care Research Collaborative (EPCRC) 2012, 'Computer-based symptom assessment is feasible in patients with advanced cancer: results from an international multicenter study, the EPCRC-CSA.', J Pain Symptom Manage, vol. 44, no. 5, pp. 639-654.
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CONTEXT: Symptom assessment by computers is only effective if it provides valid results and is perceived as useful for clinical use by the end users: patients and health care providers. OBJECTIVES: To identify factors associated with discontinuation, time expenditure, and patient preferences of the computerized symptom assessment used in an international multicenter data collection project: the European Palliative Care Research Collaborative-Computerized Symptom Assessment. METHODS: Cancer patients with incurable metastatic or locally advanced disease were recruited from 17 centers in eight countries, providing 1017 records for analyses. Observer-based registrations and patient-reported measures on pain, depression, and physical function were entered on touch screen laptop computers. RESULTS: The entire assessment was completed by 94.9% (n = 965), with median age 63 years (range 18-91 years) and median Karnofsky Performance Status (KPS) score of 70 (range 20-100). Predictive factors for noncompletion were higher age, lower KPS, and more pain (P 0.012). Time expenditure among completers increased with higher age, male gender, Norwegian nationality, number of comorbidities, and lower physical functioning (P 0.007) but was inversely related to pain levels and tiredness (P 0.03). Need for assistance was predicted by higher age, nationality other than Norwegian, lower KPS, and lower educational level (P < 0.001). More than 50% of patients preferred computerized assessment to a paper and pencil version. CONCLUSION: The high completion rate shows that symptom assessment by computers is feasible in patients with advanced cancer. However, reduced performance status reduces compliance and increases the need for assistance. Future work should aim at identifying the minimum set of valid screening questions and refine the software to optimize symptom assessment and reduce respondent burden in frail patients.
LeBlanc, T.W., Abernethy, A.P., Currow, D.C. & Kutner, J.S. 2012, 'Considerations in reporting palliative care clinical trials: standardizing information reported and authorship practices.', Curr Opin Support Palliat Care, vol. 6, no. 4, pp. 494-499.
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PURPOSE OF REVIEW: The nature of palliative care practice, especially the reliance on referrals and differing models of service delivery, poses unique challenges for the creation and interpretation of an evidence base, frequently limiting the applicability of data to patient care. Here we discuss two core aspects of clinical trials reporting in palliative medicine: proposed standards governing the collection and reporting of data, and rules governing authorship and publication. RECENT FINDINGS: Existing literature often inadequately describes the characteristics of patients, caregivers, clinicians, systems, and interventions included in studies, thereby limiting the utility of results. SUMMARY: A generalizability framework is needed to ensure a robust evidence base that advances practice. Lessons learned through the development of research cooperative groups in palliative care reinforce the importance of an authorship protocol for large trials and working groups.
Kamal, A.H., Maguire, J.M., Wheeler, J.L., Currow, D.C. & Abernethy, A.P. 2012, 'Dyspnea review for the palliative care professional: treatment goals and therapeutic options.', J Palliat Med, vol. 15, no. 1, pp. 106-114.
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Although dyspnea is frequently encountered in the palliative care setting, its optimal management remains uncertain. Clinical approaches begin with accurate assessment, as delineated in part one of this two-part series. Comprehensive dyspnea assessment, which encompasses the physical, emotional, social, and spiritual aspects of this complex symptom, guide the clinician in choosing therapeutic approaches herein presented as part two. Global management of dyspnea is appropriate both as complementary to disease-targeted treatments that target the underlying etiology, and as the sole focus when the symptom has become intractable, disease is maximally treated, and goals of care shift to comfort and quality of life. In this setting, current evidence supports the use of oral or parenteral opioids as the mainstay of dyspnea management, and of inhaled furosemide and anxiolytics as adjuncts. Nonpharmacologic interventions such as acupuncture and pulmonary rehabilitation have potential effectiveness, although further research is needed, and use of a simple fan warrants consideration given its potential benefit and minimal burden and cost.
Currow, D.C., Samsa, G.P. & Abernethy, A.P. 2012, 'Understanding the impact of withdrawing from phase III studies in palliative care: Reply to Johnson et al.', Journal of Pain and Symptom Management, vol. 44, no. 6.
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Currow, D.C., Plummer, J.L., Kutner, J.S., Samsa, G.P. & Abernethy, A.P. 2012, 'Analyzing phase III studies in hospice/palliative care. a solution that sits between intention-to-treat and per protocol analyses: the palliative-modified ITT analysis.', J Pain Symptom Manage, vol. 44, no. 4, pp. 595-603.
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Intention-to-treat (ITT) analyses are the standard way to evaluate randomized controlled trials (RCTs) to minimize Type I errors related to differential rates of noncompletion from one study arm. People in palliative care often die sooner than predicted as a direct result of disease progression, some of whom will be participating in RCTs and who will, therefore, withdraw or die after randomization for reasons unrelated to the intervention. This proportion of withdrawals is statistically negligible in other clinical disciplines, but commonplace in hospice/palliative care, creating a systematic bias away from the true effect. ITT analyses in hospice/palliative care that deem all withdrawals to be treatment failures or that impute data from deteriorating participants systematically underestimate the benefits of interventions, reducing the power of these studies. Equally unacceptable would be a per protocol analysis that excludes all withdrawals after randomization as this will underestimate toxicity. A modified analytic approach is needed on a continuum between ITT and per protocol analyses. To address data after randomization where there is a high rate of withdrawals because of death or deterioration, criteria need to include being: 1) prespecified in the original protocol; 2) clinically absolutely the result of disease progression; 3) identified by the blinded Independent Data Monitoring Committee as being unrelated to the intervention(s); and 4) accounted for in the study's CONSORT diagram. Such data should not be included in the analysis of the primary outcome. This article aims to define a better way of balancing Type I and Type II errors in hospice/palliative care RCT analyses using the palliative-modified ITT analysis. Arguably, the palliative-modified ITT analysis should be the primary evaluation of hospice/palliative care Phase III studies but, as a minimum, should routinely be the key sensitivity analysis.
Uronis, H.E., Shelby, R.A., Currow, D.C., Ahmedzai, S.H., Bosworth, H.B., Coan, A. & Abernethy, A.P. 2012, 'Assessment of the psychometric properties of an English version of the cancer dyspnea scale in people with advanced lung cancer.', J Pain Symptom Manage, vol. 44, no. 5, pp. 741-749.
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CONTEXT: Dyspnea is a poorly understood subjective sensation. Existing dyspnea measures fail to adequately address its multidimensionality. A Japanese group developed and validated the Cancer Dyspnea Scale (CDS) for assessing dyspnea in patients with advanced lung cancer. OBJECTIVES: We evaluated the validity and reliability of the English version of the CDS (CDS-E) that has 12 items and takes, on average, 140 seconds for individuals to complete. METHODS: Eligible patients had advanced lung cancer, consented, and were fluent in English. Participants completed a 100 mm visual analogue scale (VAS), the modified Borg scale, the CDS-E, the Hospital Anxiety and Depression Scale, and the Functional Assessment of Cancer Therapy--Lung quality-of-life scale. Demographic, radiographic, and treatment information were obtained from patients' medical records. RESULTS: One hundred twelve participants were enrolled at three sites in the U.S., Australia, and the U.K. Mean age was 64.5 years (SD 11.5); 90% were Caucasian, 68% had Eastern Cooperative Oncology Group performance status 0-1, and 50% had non-small cell carcinoma. All completed the CDS-E independently, without difficulty. The CDS-E had reasonable internal consistency overall (Cronbach's = 0.71) and for each of the three factors (effort, anxiety, discomfort Cronbach's = 0.80-0.84). CDS-E scores were significantly correlated with the 100mm VAS (r = 0.82; P < 0.001) and the modified Borg (r = 0.87; P < 0.001). After factor analysis, the CDS-E was revised by removing three items (r-CDS-E). CONCLUSION: The CDS-E and r-CDS-E are reliable and valid measures of the sensation and the psychological components of dyspnea, with the shorter version having similar psychometric properties.
Currow, D.C. & Abernethy, A.P. 2012, 'Breathlessness in an age of noncommunicable diseases.', Curr Opin Support Palliat Care, vol. 6, no. 2, pp. 127-128.
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Zafar, S.Y., Currow, D.C., Cherny, N., Strasser, F., Fowler, R. & Abernethy, A.P. 2012, 'Consensus-based standards for best supportive care in clinical trials in advanced cancer.', Lancet Oncol, vol. 13, no. 2, pp. e77-e82.
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Best supportive care is poorly defined in clinical trials, and a standard framework for delivery of such care is needed, using best available evidence and allowing replication of studies. We convened a panel of 36 experts to develop consensus statements via the Delphi method. The first round included open-ended questions; subsequent rounds sought to develop consensus-based standards. Consensus was assessed by use of a 5-point Likert agreement scale; more than 70% of panellists had to give a score of 5 to meet a-priori levels of consensus. The panel identified four key domains of best supportive care in clinical trials: multidisciplinary care; supportive care documentation; symptom assessment; and symptom management. Consensus was reached on 11 statements within these four domains. For example, 24 (96%) panellists recommended that the intervals between symptom assessments should be identical for control and experimental groups. Availability of resources was cited as a challenge to implementation of best supportive care standards.
Currow, D.C., Bruner, D.W. & Abernethy, A.P. 2012, 'Editorial: death to the fiefdoms.', Curr Opin Support Palliat Care, vol. 6, no. 4, pp. 457-458.
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Toye, C. 2012, 'Guidelines for a palliative approach for aged care in the community setting: A suite of resources', australasian medical journal, vol. 5, no. 10, pp. 569-574.
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Kamal, A.H., Miriovsky, B.J., Currow, D.C. & Abernethy, A.P. 2012, 'Improving the management of dyspnea in the community using rapid learning approaches.', Chron Respir Dis, vol. 9, no. 1, pp. 51-61.
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Patients with chronic pulmonary disease often suffer from breathlessness or dyspnea. Traditional evidence generation techniques to expand upon current treatment paradigms are limited by the significant delay between study initiation and clinical implementation of findings. Rapid learning health care is a novel approach to health care delivery that relies on intelligent and continuous integration of clinical and research data sets to deliver personalized medicine using the most current evidence available. Results of important studies in the management of chronic respiratory disease are presented in brief; however, the focus of this review is on evidence supporting the implementation of a rapid learning model for symptom management. Recent findings suggest that a rapid learning system is feasible and acceptable to patients with advanced illness, helps monitor symptoms overtime, facilitates study of the impact of novel interventions, and can identify unrecognized needs and concerns. A rapid learning model improves comprehensive assessment, timeliness of intervention, and accrual of contemporaneous data to support best practice that tailors care specific to the needs of patients as their disease and lifestyle change overtime. Using the rapid learning health care model, data collected in the process of routine care can simultaneously function both as clinical information and as a resource for research on patient-centered experiences and outcomes.
Clark, K. & Currow, D.C. 2012, 'Re: oral docusate in the management of constipation in hospice patients.', J Pain Symptom Manage, vol. 44, no. 6, pp. e6-e7.
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Currow, D.C., Vella-Brincat, J., Fazekas, B., Clark, K., Doogue, M. & Rowett, D. 2012, 'Pharmacovigilance in hospice/palliative care: rapid report of net clinical effect of metoclopramide.', J Palliat Med, vol. 15, no. 10, pp. 1071-1075.
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BACKGROUND: Understanding the performance of prescribed medications in day-to-day practice is important to minimize harm, maximize clinical benefits, and, eventually, better target the people who are most likely to benefit, especially in hospice/palliative care where there may be limited time to optimize prescribing. Metoclopramide, a benzamide prokinetic antiemetic, is widely used for a number of indications including nausea, vomiting, hiccups, and reflux. It has recently had a new "black box" warning issued by the Food and Drug Administration in relation to tardive dyskinesia to limit use to 12 weeks. METHODS: A consecutive cohort of patients from 12 participating centers in two countries who were having metoclopramide initiated had data collected at three time points--baseline, 2 days (clinical benefit), and day 7 (clinical harm). Additionally, harms could be recorded at any time. RESULTS: Of the 53 people included in the cohort, 23 (43%) reported benefit at 48 hours, but only 18 (34%) of these people were still using it one week after commencing it. For the other 5, the medication was ceased due to harms. The most frequent harms were akathisia (n=4), headache (n=4), and abdominal pain (n=4). Nine people (17%) had no clinical benefit and experienced harms. CONCLUSION: Overall, one in three people gained net clinical benefit at one week. Limiting effects include side-effects that need to be sought actively in clinical care.
Rowett, D.S., Clark, K., Robinson, M.K. & Currow, D.C. 2012, 'Subsidised use of methylnaltrexone in Australia for palliative care.', Med J Aust, vol. 197, no. 9, p. 492.
Currow, D.C. 2012, 'We need champions, passionate champions.', J Palliat Med, vol. 15, no. 8, pp. 842-843.
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Currow, D.C., Abernethy, A.P. & Johnson, M.J. 2012, 'Activity as a measure of symptom control.', J Pain Symptom Manage, vol. 44, no. 5, pp. e1-e2.
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Clark, K. & Currow, D.C. 2012, 'Assessing constipation in palliative care within a gastroenterology framework.', Palliat Med, vol. 26, no. 6, pp. 834-841.
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BACKGROUND: Constipation is common and distressing in palliative care. Despite this, approaches to assessment and subsequent treatment are most remarkable for the numbers who fail adequate palliation. AIM: The primary aim of this paper is to summarise the current approaches to assessing constipation in palliative care, contrasting these approaches with those recommended by gastroenterologists in the assessment of resistant constipation in non-palliative care. The secondary aim is to suggest ways that the approaches used by gastroenterologist could be modified to be tolerable to palliative care. DESIGN: A non-systematic review of the literature was undertaken. DATA SOURCES: The electronic databases (MEDLINE, CINHAL) were searched for English language articles that explored assessment of constipation in palliative care and evidence-based gastroenterology guidelines that summarised assessment and management of constipation. RESULTS: Currently, the assessment of constipation in palliative care is predominantly based on people's reports, physical examination and if further imaging is deemed necessary, a plain abdominal radiograph. However, data in non-palliative care patients refutes the usefulness of self-reported symptoms to localise whether problems are due to colon dysfunction or structures of defaecation. Plain radiographs are most useful to exclude a bowel obstruction only. In cases of resistant constipation, gastroenterology guidelines recommend an assessment approach that includes measuring colon transit time and an assessment of the structures that facilitate defaecation. CONCLUSIONS: Current approaches to assessing constipation in palliative care are very different to those recommended by gastroenterology guidelines. However, modified approaches may be tolerable to palliative care patients and offer the chance of developing targeted palliation.
Greene, A., Aranda, S., Tieman, J.J., Fazekas, B. & Currow, D.C. 2012, 'Can assessing caregiver needs and activating community networks improve caregiver-defined outcomes? A single-blind, quasi-experimental pilot study: community facilitator pilot.', Palliat Med, vol. 26, no. 7, pp. 917-923.
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BACKGROUND: Although the unit of care in palliative care is defined as the patient and their family, there are few rigorous studies on how to improve support for family and friends as they take on the role of caregiver for someone at the end of life. AIM: Separate to patient evaluation and care, this pilot study aimed to define the feasibility and possible outcome measures to evaluate routine assessments and supports specifically for caregivers. DESIGN: In a quasi-experimental design, two communities were included: one received standard specialist palliative care support and one additionally was allocated to a community network facilitator who assessed caregivers' needs and helped mobilize the caregiver's own support network or initiated contact with other community supports in three planned visits. Data were collected at baseline, 4 and 8 weeks using three caregiver assessment tools. Within group comparisons were made using Wilcoxon signed rank test and between group using the Mann-Whitney U-test. PARTICIPANTS: Sixty-six caregivers participated. RESULTS: At 8 weeks, participants in the intervention arm showed significant within-group improvement in caregiver fatigue, sufficient support from others, decreased resentment in the role, greater confidence in asking for assistance and were better able to find resources and support. No between-group changes were seen in this pilot study. CONCLUSIONS: There were objective measures of improved support within the intervention group over time for caregivers through the active engagement of the community network facilitator. This pilot supports the case for an adequately powered study.
Johnson, M.J., Abernethy, A.P. & Currow, D.C. 2012, 'Gaps in the evidence base of opioids for refractory breathlessness. A future work plan?', J Pain Symptom Manage, vol. 43, no. 3, pp. 614-624.
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Breathlessness or "shortness of breath," medically termed dyspnea, remains a devastating problem for many people and those who care for them. As a treatment intervention, administration of opioids to relieve breathlessness is an area where progress has been made with the development of an evidence base. As evidence in support of opioids has accumulated, so has our collective understanding about trial methodology, research collaboration, and infrastructure that is crucial to generate reliable research results for palliative care clinical settings. Analysis of achievements to date and what it takes to accomplish these studies provides important insights into knowledge gaps needing further research and practical insight into design of pharmacological and nonpharmacological intervention trials in breathlessness and palliative care. This article presents the current understanding of opioids for treating breathlessness, what is still unknown as priorities for future research, and highlights methodological issues for consideration in planned studies.
Johnson, M.J., Bowden, J.A., Abernethy, A.P. & Currow, D.C. 2012, 'To what causes do people attribute their chronic breathlessness? A population survey.', J Palliat Med, vol. 15, no. 7, pp. 744-750.
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OBJECTIVE: Chronic breathlessness is a daily experience for millions of people, despite current therapies. The objective of this study was to find out to what people attributed their breathlessness irrespective of health service utilization, and to understand the demographic characteristics in each diagnostic group. METHODS: A face-to-face, population-based survey (n=4432) asked community-dwelling South Australians the modified Medical Research Council (breathlessness) Scale (mMRC), and, if they were breathless was it chronic (daily for at least 3 of the last 6 months), total duration of this breathlessness and to what body system they attributed their breathlessness. Categorical and continuous variables were analyzed appropriately. RESULTS: With a participation rate of 63.7%, 8.9% of respondents had an mMRC score 1. Breathless people were older (54.3 years SD 19.5, versus 44.9 years SD 18.7; p<0.001), most often attributed their chronic breathlessness to lung disease (65%) and, if breathlessness was the result of lung disease, experienced chronic breathlessness for significantly longer periods of time (13.8 years, SD 15.8) compared with other attributed causes (5.7 years; SD 9.1; p<0.001). CONCLUSION: Breathlessness is widely encountered. The burden in prevalence and duration generated by lung disease greatly surpasses other causes. This underlines the need to intensify efforts to minimize the causes of chronic lung disease, and to more actively palliate the subjective symptom of chronic breathlessness.
Abernethy, A.P. & Currow, D.C. 2012, 'Time-limited trials.', JAMA, vol. 307, no. 1, pp. 33-34.
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To, T.H.M., Clark, K., Lam, L., Shelby-James, T. & Currow, D.C. 2012, 'The role of ondansetron in the management of cholestatic or uremic pruritus--a systematic review.', J Pain Symptom Manage, vol. 44, no. 5, pp. 725-730.
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CONTEXT: Pruritus associated with hepatic or renal failure can be a troublesome symptom, refractory to treatment and associated with significant physical and emotional distress and a reduction in quality of life for patients already burdened with chronic disease. Serotonin has been implicated as a possible pathological mediator, and, therefore, 5HT(3) antagonists have been suggested as a possible therapeutic intervention. OBJECTIVES: This review of the literature systematically explores the role of ondansetron in the management of cholestatic or uremic pruritus. METHODS: Electronic databases were systematically searched for randomized controlled trials examining the role of ondansetron in cholestatic or uremic pruritus between 1966 and 2008. RESULTS: Five randomized controlled trials were included in this systematic review: three for cholestatic pruritus and two for uremic pruritus. All trials examined ondansetron vs. placebo, with differing treatment protocols. Overall, three studies showed no benefit to ondansetron over placebo; however, two studies in cholestatic pruritus showed small reductions in pruritus with questionable clinical significance. CONCLUSION: Ondansetron was demonstrated to have negligible effect on cholestatic or uremic pruritus on the basis of a limited number of studies.
To, T.H.M., Ong, W.Y., Rawlings, D., Greene, A. & Currow, D.C. 2012, 'The disparity between patient and nurse symptom rating in a hospice population.', J Palliat Med, vol. 15, no. 5, pp. 542-547.
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BACKGROUND: Meticulous assessment, monitoring, and treatment of symptoms are key components of palliative care. The Symptom Assessment Scale (SAS) is a 0-10 numerical rating scale (NRS) used for self-report of sleep, appetite, nausea, bowels, breathing, fatigue, and pain. Ideally, symptom rating should be by self-report; however, the ratings are often completed by nurses. The aim of this study was to examine the relationship between simultaneous symptom ratings of patients and nurses in an Australian inpatient palliative care unit. METHODS: All inpatients and their treating nurse (blinded to the patient's report) scored the SAS weekly. Nurse symptom rating was considered accurate if the score for an individual symptom differed by 1. The relationship for each dyad was examined by comparing absolute values, mean differences, and Pearson correlations. RESULTS: Sixty-four pairs of symptom ratings were obtained from 29 patients (mean 65 years, male 55%, malignancy 90%, mean Karnofsky 50). The absolute differences were closest for nausea, bowels, and breathing domains, and worst for appetite. Mean differences and Pearson correlations did not adequately reflect the disparity between patient and nurse symptom rating, and nurses systematically underreported symptoms. The total difference for the seven items ranged from nurses overreporting the patients' symptoms by 39 points to underreporting by 31 out of a possible 70 points. DISCUSSION: Proxy symptom assessment only modestly correlates with patient symptom rating, can significantly misrepresent the patient's actual symptom burden, and should only be used when the patient is absolutely unable to contribute his or her own view.
Currow, D.C., Tieman, J.J., Greene, A., Zafar, S.Y., Wheeler, J.L. & Abernethy, A.P. 2012, 'Refining a checklist for reporting patient populations and service characteristics in hospice and palliative care research.', J Pain Symptom Manage, vol. 43, no. 5, pp. 902-910.
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CONTEXT: In specialist hospice and palliative care services, variations occur in diagnoses and prognoses of subpopulations referred, service configuration, and the health systems delivering care. These three levels of variation limit the ability to generalize study findings. OBJECTIVES: This article reports on coding one year of palliative care research using a previously developed checklist. The aims were to 1) quantify current reporting of factors related to generalizability in specialist palliative care research; 2) review and potentially refine the checklist in light of the first aim; 3) demonstrate the feasibility of collecting these data; and 4) set out simple processes to aid researchers in reporting, and clinicians in applying, new research evidence in hospice and palliative care. METHODS: A previously published checklist (five domains, 14 core subdomains, and 24 noncore subdomains) was used to code all research articles (n=189) published in 2007 in the three leading palliative care research journals. RESULTS: The most frequently reported subdomains were patient age, gender, and diagnosis; model of service delivery; and patient performance status. Data in subdomains, including time from referral to death, socioeconomic indices, and ethnicity, were rarely reported; none reported whole-of-service or whole-of-population data. In total, 2646 (18914) core subdomains could have been reported. Data were provided in 28% (746/2646). CONCLUSION: Checklists such as the Consolidated Standards of Reporting Trials evaluate study design, focusing mainly on internal validity. The proposed checklist deals with specific content of hospice and palliative care, focusing on external validity.
Wheeler, J.L., Greene, A., Tieman, J.J., Abernethy, A.P. & Currow, D.C. 2012, 'Key characteristics of palliative care studies reported in the specialized literature.', J Pain Symptom Manage, vol. 43, no. 6, pp. 987-992.
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CONTEXT: Although research activity in palliative care is rapidly increasing, the composition of published studies--in terms of significant research characteristics--has not yet been well described. OBJECTIVES: To describe the topics of and funding for palliative care studies reported in the three hospice and palliative care journals with the highest impact factors (Journal of Pain and Symptom Management, Palliative Medicine, and Journal of Palliative Medicine). METHODS: This was a substudy of a larger bibliographic study. The targeted journals were searched for 2007 using a previously validated Ovid MEDLINE filter for palliative care. All empirical palliative care studies were included. Articles were classified according to topics (palliative care patient, caregiver/family, health professional, service provision, tool development, healthy volunteer, medication compatibility, community), study type (intervention, nonintervention), country of origin, and funding source (pharmaceutical company, other funder, unfunded). RESULTS: Of 409 citations identified, the search yielded 189 eligible articles. Most articles were descriptive/observational. Approximately half were unfunded. Caregivers, healthy volunteers, and health service research were the least frequent topics for research. Only five randomized controlled trials were reported. CONCLUSION: Although there is a broad range of research undertaken in palliative care, few studies generate high-level evidence, with data showing a relative lack of funding for hospice and palliative care studies.
Clark, K., Smith, J.M. & Currow, D.C. 2012, 'The prevalence of bowel problems reported in a palliative care population.', J Pain Symptom Manage, vol. 43, no. 6, pp. 993-1000.
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CONTEXT: Constipation and other disturbances of bowel function are distressing problems for people with specialist palliative care needs. Recent observations suggest that such problems may worsen as people become more unwell, but the changes in intensity over time are not well documented. OBJECTIVES: The objectives of this work were to understand the prevalence, intensity, and progression of self-reported bowel disturbances across a community palliative care population, which included people with cancer and noncancer diagnoses. METHODS: All people referred to a community-based palliative care service over a period of 6.3 years had their bowel problem scores reported, using a numerical rating score at every clinical encounter until their death, at four discrete time points, namely, 90, 60, 30, and seven days before death. This allowed change over three time periods to be considered. At the same time, other symptom scores were collected including nausea, fatigue, pain, appetite problems, and breathing problems. Patients were categorized according to the underlying disease that accounted for their referral to palliative care, namely, cancer diagnoses (upper gastrointestinal cancers, lower gastrointestinal cancers, cancers of the associated digestive organs, and other cancers) and nonmalignant diagnoses. Group differences over the time periods were assessed using analysis of variance. Bivariate analysis was used to explore the relationship between bowel disturbances and other symptoms using Spearman's Rho correlation. RESULTS: For 7772 patients, data were collected an average of 22.5 times, generating 174,783 data collection points over an average of 98.6 days on the service. At the time of referral to the service, 3248 (42.4%) people had disturbed bowel scores, 548 (7.2%) of whom described these as severe. Only 1020 (13.1%) people never described disturbed bowel function over their time in palliative care. At each time point, approximately one-third were experiencin...
Currow, D.C., Spruyt, O. & Hardy, J. 2012, 'Defining refractory pain in cancer for clinicians and researchers.', J Palliat Med, vol. 15, no. 1, pp. 5-6.
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Shelby-James, T.M., Butow, P., Davison, G. & Currow, D.C. 2012, 'Case conferences in palliative care - a substudy of a cluster randomised controlled trial.', Aust Fam Physician, vol. 41, no. 8, pp. 608-612.
BACKGROUND: In palliative care, case conferences have demonstrated improved maintenance of function and a significant reduction in hospitalisations. This study aimed to define the content and themes of palliative care case conferences. METHODS: This was a substudy of a cluster randomised controlled trial. Case conferences meeting the requirements for Medicare Benefits Schedule reimbursement were organised by the research officer in conjunction with the general practitioner and the participating palliative care service. All were audiotaped, coded and analysed for content and themes, using qualitative methods and interaction analysis. RESULTS: Seventeen case conferences were transcribed and coded. Physical issues were the dominant topic. Management of psychosocial concerns were rarely discussed. Lack of information was a common theme and time was spent during each conference ensuring all people were familiar with the issues and patient history. Healthcare professionals tended to respond to the content of patient concerns, but not the emotion. DISCUSSION: The discussions were complex and health professional participants rarely summarised information or checked that patients and carers had understood the information provided.
Toye, C., Blackwell, S., Maher, S., Currow, D.C., Holloway, K., Tieman, J. & Hegarty, M. 2012, 'Guidelines for a palliative approach for aged care in the community setting: A suite of resources', Australasian Medical Journal, vol. 5, no. 11, pp. 569-574.
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Currow, D.C., Kutner, J.S. & Abernethy, A.P. 2012, 'Management of polypharmacy: Can we safely discontinue medications?', Australian Prescriber, vol. 35, no. 3, pp. 75-76.
Currow, D.C. & Abernethy, A.P. 2012, 'The importance of publishing studies with negative results in palliative care', European Journal of Palliative Care, vol. 19, no. 4, pp. 186-190.
Johnson, C., Girgis, A., Paul, C., Currow, D., Adams, J. & Aranda, S. 2011, 'Australian Palliative Care Providers Perceptions And Experiences Of The Barriers And Facilitators To Palliative Care Provision', Supportive Care in Cancer, vol. 19, no. 3, pp. 343-351.
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People with advanced cancer who may benefit from specialised palliative care (SPC) do not necessarily access such services. To obtain a deeper understanding of issues affecting access to SPC, five focus groups were undertaken with nurses (35), physicians
Du, H., Newton, P.J., Zecchin, R., Denniss, A.R., Salamonson, Y., Everett, B., Currow, D., Macdonald, P. & Davidson, P.M. 2011, 'An intervention to promote physical activity and self-management in people with stable chronic heart failure The Home-Heart-Walk study: study protocol for a randomized controlled trial', Trials, vol. 12, no. 63.
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Background: Chronic heart failure (CHF) is a chronic debilitating condition with economic consequences, mostly because of frequent hospitalisations. Physical activity and adequate self-management capacity are important risk reduction strategies in the management of CHF. The Home-Heart-Walk is a self-monitoring intervention. This model of intervention has adapted the 6-minute walk test as a home-based activity that is self-administered and can be used for monitoring physical functional capacity in people with CHF. The aim of the Home-Heart-Walk program is to promote adherence to physical activity recommendations and improving self-management in people with CHF. Methods/Design: A randomised controlled trial is being conducted in English speaking people with CHF in four hospitals in Sydney, Australia. Individuals diagnosed with CHF, in New York Heart Association Functional Class II or III, with a previous admission to hospital for CHF are eligible to participate. Based on a previous CHF study and a loss to follow-up of 10%, 166 participants are required to be able to detect a 12-point difference in the study primary endpoint (SF-36 physical function domain). All enrolled participant receive an information session with a cardiovascular nurse. This information session covers key self-management components of CHF: daily weight; diet (salt reduction); medication adherence; and physical activity. Participants are randomised to either intervention or control group through the study randomisation centre after baseline questionnaires and assessment are completed. For people in the intervention group, the research nurse also explains the weekly Home-Heart-Walk protocol. All participants receive monthly phone calls from a research coordinator for six months, and outcome measures are conducted at one, three and six months.
Davidson, P.M., Jiwa, M., Goldsmith, A.J., McGrath, S., DiGiacomo, M., Phillips, J.L., Agar, M., Newton, P.J. & Currow, D. 2011, 'Decisions for lung cancer chemotherapy: the influence of physician and patient factors', Supportive Care in Cancer, vol. 19, no. 8, pp. 1261-1266.
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Purpose The purpose of this study is to review the literature examining how the beliefs and behaviours of physicians and patients influence clinical communication, doctor-patient interaction and treatment decisions for lung cancer treatment. Methods Literature was obtained via electronic database searches and hand searching of journals from 1990 to 2011. Results Wide variability in perceptions of the value of chemotherapy in lung cancer is present among both physicians and patients. There is a mismatch in the degree patients and physicians weigh survival, such that patients value survival benefits highly whilst physicians strongly emphasize toxicity and associated symptoms. This lack of congruence between patients and clinicians is influenced by a range of factors and has implications for treatment decisions, long-term survival and quality of life in people affected by lung cancer. Conclusion The divergence of treatment priorities indicates a need for improved communication strategies addressing the needs and concerns of both patients and clinicians. Patients should understand the benefits and risks of treatment options, while clinicians can gain a greater awareness of factors influencing patients' decisions on treatments. Reflecting these perspectives and patient preferences for lung cancer treatment in clinical guidelines may improve clinician awareness.
Johnson, C., Paul, C., Girgis, A., Adams, J. & Currow, D. 2011, 'Australian General Practitioners And Oncology Specialists Perceptions Of Barriers And Facilitators Of Access To Specialist Palliative Care Services', Journal Of Palliative Medicine, vol. 14, no. 4, pp. 429-435.
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Purpose: Doctors in Australia play an important role in facilitating access to specialist palliative care (SPC) services for people with advanced cancer. This study aimed to describe doctors perceptions of barriers to referring patients for SPC, and to i
Lewis, J., DiGiacomo, M., Currow, D. & Davidson, P.M. 2011, 'Dying in the margins: understanding palliative care and socioeconomic deprivation in the developed world', Journal of Pain and Symptom Management, vol. 42, no. 1, pp. 105-118.
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Individuals from low socioeconomic (SE) groups have less resources and poorer health outcomes. Understanding the nature of access to appropriate end-of-life care services for this group is important. This article evaluated the literature in the developed world for barriers to access for low SE groups. Electronic databases searched in the review included MEDLINE (1996&acirc;2010), CINAHL (1996&acirc;2010), PsychINFO (2000&acirc;2010), Cochrane Library (2010), and EMBASE (1996&acirc;2010). Publications were searched for key terms &acirc;socioeconomic disadvantage,&acirc; &acirc;socioeconomic,&acirc; &acirc;poverty,&acirc; &acirc;poor&acirc; paired with &acirc;end-of-life care,&acirc; &acirc;palliative care,&acirc; &acirc;dying,&acirc; and &acirc;terminal Illness.&acirc; Articles were analyzed using existing descriptions for dimensions of access to health services, which include availability, affordability, acceptability, and geographical access. A total of 67 articles were identified for the literature review. Literature describing end-of-life care and low SE status was limited. Findings from the review were summarized under the headings for dimensions of access. Low SE groups experience barriers to access in palliative care services. Identification and evaluation of interventions aimed at reducing this disparity is required.
Currow, D., Burns, C., Agar, M., Phillips, J.L., McCaffrey, N. & Abernethy, A. 2011, 'Palliative caregivers who would not take on the role again', Journal of Pain and Symptom Management, vol. 41, no. 4, pp. 661-672.
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Abstract Context Health and social services rely heavily on family and friends for caregiving at the end of life. Objectives This study sought to determine the prevalence and factors associated with an unwillingness to take on the caregiving role again by interviewing former caregivers of palliative care patients. Methods The setting for this study was South Australia, with a population of 1.6 million people (7% of the Australian population) and used the South Australian Health Omnibus, an annual, face-to-face, cross-sectional, whole-of-population, multistage, systematic area sampling survey, which seeks a minimum of 3000 respondents each year statewide. One interview was conducted per household with the person over the age of 15 who most recently had a birthday. Using two years of data (n = 8377; 65.4% participation rate), comparisons between those who definitely would care again and those who would not was undertaken.
Lobb, E.A., Swetenham, K., Agar, M. & Currow, D.C. 2011, 'A Collateral Benefit of Research in Palliative Care', JOURNAL OF PALLIATIVE MEDICINE, vol. 14, no. 9, pp. 986-987.
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Uronis, H., McCrory, D.C., Samsa, G., Currow, D. & Abernethy, A. 2011, 'Symptomatic oxygen for non-hypoxaemic chronic obstructive pulmonary disease', Cochrane Database of Systematic Reviews, no. 6.
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Abstract BACKGROUND: Dyspnoea is a common symptom in chronic obstructive pulmonary disease (COPD). People who are hypoxaemic may be given long-term oxygen relief therapy (LTOT) to improve their life expectancy and quality of life. However, the symptomatic benefit of home oxygen therapy in mildly or non-hypoxaemic people with COPD with dyspnoea who do not meet international funding criteria for LTOT (PaO(2)< 55 mmHg or other special cases) is unknown. OBJECTIVES: To determine the efficacy of oxygen versus medical air for relief of subjective dyspnoea in mildly or non-hypoxaemic people with COPD who would not otherwise qualify for home oxygen therapy. The main outcome was patient-reported dyspnoea and secondary outcome was exercise tolerance. SEARCH STRATEGY: We searched the Cochrane Airways Group Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, to November 2009, to identify randomised controlled trials. We handsearched reference lists of included articles. SELECTION CRITERIA: We only included randomised controlled trials of oxygen versus medical air in mildly or non-hypoxaemic people with COPD. Two review authors independently assessed articles for inclusion. DATA COLLECTION AND ANALYSIS: One review author completed data extraction and methodological quality assessment. A second review author then over-read evidence tables to assess for accuracy. MAIN RESULTS: Twenty-eight trials on 702 patients met the criteria for inclusion; 18 trials (431 participants) were included in the meta-analysis. Oxygen reduced dyspnoea with a standardised mean difference (SMD) of -0.37 (95% confidence interval (CI) -0.50 to -0.24, P < 0.00001). We observed significant heterogeneity. AUTHORS' CONCLUSIONS: Oxygen can relieve dyspnoea in mildly and non-hypoxaemic people with COPD who would not otherwise qualify for home oxygen therapy. Given the significant heterogeneity among the included studies, clinicians should continue to evaluate patients on a...
Dear, R., Barratt, A., Askie, L., McGeechan, K., Arora, S., Crossing, S., Currow, D. & Tattersall, M. 2011, 'Adding value to clinical trial registries: insights from Australian Cancer Trials Online, a website for consumers', CLINICAL TRIALS, vol. 8, no. 1, pp. 70-76.
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Clark, K., Lam, L. & Currow, D. 2011, 'Exploring the Relationship Between the Frequency of Documented Bowel Movements and Prescribed Laxatives in Hospitalized Palliative Care Patients', AMERICAN JOURNAL OF HOSPICE & PALLIATIVE MEDICINE, vol. 28, no. 4, pp. 258-263.
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Nikles, J., Mitchell, G.K., Schluter, P., Good, P., Hardy, J., Rowett, D., Shelby-James, T., Vohra, S. & Currow, D. 2011, 'Aggregating single patient (n-of-1) trials in populations where recruitment and retention was difficult: The case of palliative care', JOURNAL OF CLINICAL EPIDEMIOLOGY, vol. 64, no. 5, pp. 471-480.
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To, T.H.M., Greene, A.G., Agar, M.R. & Currow, D.C. 2011, 'A point prevalence survey of hospital inpatients to define the proportion with palliation as the primary goal of care and the need for specialist palliative care', INTERNAL MEDICINE JOURNAL, vol. 41, no. 5, pp. 430-433.
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Currow, D.C., Foley, K., Zafar, S.Y., Wheeler, J.L. & Abernethy, A.P. 2011, 'The need for a re-evaluation of best supportive care studies reported to date', BRITISH JOURNAL OF CANCER, vol. 104, no. 3, pp. 390-391.
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Hardy, J., Agar, M.R. & Currow, D.C. 2011, 'Progressing an evidence-base beyond case series.', Journal of palliative medicine, vol. 14, no. 12, p. 1283.
Currow, D.C., Agar, M.R., To, T.H., Rowett, D., Greene, A. & Abernethy, A.P. 2011, 'Adverse events in hospice and palliative care: a pilot study to determine feasibility of collection and baseline rates.', Journal of palliative medicine, vol. 14, no. 3, pp. 309-314.
BACKGROUND: Continuous quality improvement is fundamental in all health care, including hospice and palliative care. Identifying and systematically reducing symptomatic adverse events is limited in hospice and palliative care because these events are mostly attributed to disease progression. OBJECTIVES: The aim of this study was to assess the feasibility of symptomatic adverse events in hospice and palliative care and assessing their incidence. METHODS: A retrospective, consecutive cohort of notes from a specialist palliative care inpatient service was surveyed by a clinical nurse consultant for symptomatic adverse events: falls, confusion, decreased consciousness, hypo- and hyperglycaemia, urinary retention, and hypotension. Demographic and clinical factors were explored for people at higher risk. RESULTS: Data were available on the most recent admissions of 65 people, generating >900 inpatient days. Fifty people (78%) had events precipitating admission, of whom 31 (62%) had at least one further event during admission. Eleven of 15 people who were admitted without an event experienced at least one during their admissions. Only 4 did not have an adverse event. During their stay, there were 0.13 (standard deviation [SD]=0.19) events per patient per day. No drug-drug or drug-host events were noted. No clinical or demographic factors predicted groups at higher risk. CONCLUSIONS: This pilot highlights the feasibility of collecting, and ubiquity of, symptomatic adverse events, and forms a baseline against which future interventions to decrease the frequency or intensity can be measured. Given the frailty of hospice and palliative patients, any adverse event is likely to accelerate irreversibly their systemic decline.
Currow, D.C., Agar, M.R. & Abernethy, A.P. 2011, 'Tackling the Challenges of Clinical Trials in Palliative Care', Pharmaceutical Medicine, vol. 25, no. 1, pp. 7-15.
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Currow, D.C., Agar, M.R. & Abernethy, A.P. 2011, 'Tackling the challenges of clinical trials in palliative care', Pharmaceutical Medicine, vol. 25, no. 1, pp. 7-15.
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Currow, D.C., Farquhar, M., Ward, A.M., Crawford, G.B. & Abernethy, A.P. 2011, 'Caregivers' perceived adequacy of support in end-stage lung disease: results of a population survey.', BMC Pulm Med, vol. 11, p. 55.
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BACKGROUND: End-stage lung disease (ESLD) is a frequent cause of death. What are the differences in the supports needed by caregivers of individuals with ESLD at end of life versus other life-limiting diagnoses? METHODS: The South Australian Health Omnibus is an annual, random, face-to-face, cross-sectional survey. In 2002, 2003 and 2005-2007, respondents were asked a range of questions about end-of-life care; there were approximately 3000 survey participants annually (participation rate 77.9%). Responses were standardised for the whole population. The families and friends who cared for someone with ESLD were the focus of this analysis. In addition to describing caring, respondents reported additional support that would have been helpful. RESULTS: Of 1504 deaths reported, 145 (9.6%) were due to ESLD. The ESLD cohort were older than those with other 'expected' causes of death (> 65 years of age; 92.6% versus 70.6%; p < 0.0001) and were less likely to access specialised palliative care services (38.4% versus 61.9%; p < 0.0001). For those with ESLD, the mean caring period was significantly longer at 25 months (standard deviation (SD) 24) than for 'other diagnoses' (15 months; SD 18; p < 0.0001). Domains where additional support would have been useful included physical care, information provision, and emotional and spiritual support. CONCLUSIONS: Caregiver needs were similar regardless of the underlying diagnosis although access to palliative care specialist services occurred less often for ESLD patients. This was despite significantly longer periods of time for which care was provided.
Currow, D.C. 2011, 'Evidence-based policy', Journal of Palliative Medicine, vol. 14, no. 7, p. 803.
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Hegarty, M.M., Abernethy, A.P., Olver, I. & Currow, D.C. 2011, 'Former palliative caregivers who identify that additional spiritual support would have been helpful in a population survey.', Palliat Med, vol. 25, no. 3, pp. 266-277.
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BACKGROUND: Palliative care encompasses physical, psychosocial and spiritual care for patients and caregivers. No population data are available on bereaved people who subsequently report that additional spiritual support would have been helpful. METHODS: In a population survey, a respondent-defined question was asked regarding 'additional spiritual support' that would have been helpful if someone 'close to them had died' an expected death in the previous five years. Data (socio-demographic [respondent]); clinical [deceased]) directly standardized to the whole population were analysed. RESULTS: There were 14,902 participants in this study (71.6% participation rate), of whom 31% (4665) experienced such a death and 1084 (23.2%) provided active hands-on (day-to-day or intermittent) care. Fifty-one of the 1084 (4.7%) active caregivers identified that additional spiritual support would have been helpful. The predictors in a regression analysis were: other domains where additional support would have been helpful (OR 1.69; 95% CI 1.46-1.94; p<0.001); and being female (OR 3.23; 95% CI 1.23 to 8.33; p=0.017). 'Additional spiritual support being helpful' was strongly associated with higher rates where additional support in other domains would also have been helpful in: all bereaved people (2.7 vs 0.6; p<0.0001); and in active caregivers (3.7 vs 0.8; p<0.0001). CONCLUSION: People who identify that additional spiritual support would have been helpful have specific demographic characteristics. There is also a strong association with the likelihood of identifying that a number of other additional supports would have been helpful. Clinically, the need for additional spiritual support should open a conversation about other areas where the need for further support may be identified.
Currow, D.C., McDonald, C., Oaten, S., Kenny, B., Allcroft, P., Frith, P., Briffa, M., Johnson, M.J. & Abernethy, A.P. 2011, 'Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study.', J Pain Symptom Manage, vol. 42, no. 3, pp. 388-399.
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CONTEXT: Randomized controlled trials can answer questions of efficacy, but long-term pharmacovigilance studies generate complementary safety data. OBJECTIVES: Level I evidence supports short-term efficacy of opioids in reducing chronic refractory dyspnea. This study aimed to determine the minimum effective once-daily dose of sustained-release morphine, and whether net clinical benefits are sustained safely. METHODS: In a Phase II dose increment study, 10mg daily of sustained-release morphine was administered, and increased in nonresponders by 10mg daily each week to a maximum of 30 mg daily. The participant was withdrawn if there were unacceptable side effects or no response to maximum dose. If participants had a 10% improvement in dyspnea over their own baseline, they joined a long-term Phase IV effectiveness/safety study at that dose. Complying with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, response and side effects are described, with demographic and clinical characteristics of responders. RESULTS: Eighty-three participants (53 males, mean age 75 years, 54% with chronic obstructive pulmonary disease) provided more than 30 patient-years of data. Fifty-two participants derived 10% benefit (on average 35% improvement over baseline), giving a response rate of 62% (number needed to treat of 1.6: number needed to harm 4.6); for 70%, this dose was 10mg/24h. Benefit was maintained at three months for 28 (33%) people. Ranking of breathlessness was reduced significantly (P<0.001), but constipation increased (P<0.001) despite laxatives. There were no episodes of respiratory depression or hospitalizations as a result of the sustained-release morphine. Overall, one in three people continued to derive benefit at three months. CONCLUSION: Ten milligrams of sustained-release oral morphine once daily is safe and effective for most people who respond.
Currow, D.C., Abernethy, A.P., Bausewein, C., Johnson, M., Harding, R. & Higginson, I. 2011, 'Measuring the net benefits of hospice and palliative care: a composite measure for multiple audiences-palliative net benefit.', J Palliat Med, vol. 14, no. 3, pp. 264-265.
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Nadimi, F. & Currow, D.C. 2011, 'As death approaches: a retrospective survey of the care of adults dying in Alice Springs Hospital.', Aust J Rural Health, vol. 19, no. 1, pp. 4-8.
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OBJECTIVE: Australians are more likely to die in a hospital than anywhere else, and most of these deaths are 'expected'. The aims of this survey were to identify if specific end-of-life issues were documented in clinical records of a regional hospital serving remote Australia. DESIGN: A retrospective consecutive case-note audit covering 18 months from 1 January 2006. SETTING: Alice Springs Hospital. PARTICIPANTS: Adult deaths in Alice Springs Hospital. During this period there were 128 deaths. OUTCOME MEASURES: Demographic, process (diagnosis of dying documented, 'not for resuscitation' documentation, intensive care unit (ICU) admission, social worker referral and specialised palliative care service referral) and outcome data ('comfort at end of life') were surveyed. RESULTS: Of the 128 admissions, 55 cases were excluded: 10 were children under 18, 33 died in < 48 hours, nine were coroner's cases and three files could no't be found. Of the 73 deaths surveyed (33 men), 47 (64%) were Aboriginal. A diagnosis of dying was made in 84%, 88% had an 'not for resuscitation' order, 48% were admitted to ICU during their last admission, 66% were referred to social workers, 68% were referred to palliative care and 85% of people were documented to be 'comfortable' during the dying process with no differential outcomes for Aboriginal and non-Aboriginal decedents except age (P < 0.0001). CONCLUSION: This survey highlights the continuing need to diagnose dying, understand optimal use of intensive care and improve comfort care at the end of life.
Coleman, M.P., Forman, D., Bryant, H., Butler, J., Rachet, B., Maringe, C., Nur, U., Tracey, E., Coory, M., Hatcher, J., McGahan, C.E., Turner, D., Marrett, L., Gjerstorff, M.L., Johannesen, T.B., Adolfsson, J., Lambe, M., Lawrence, G., Meechan, D., Morris, E.J., Middleton, R., Steward, J., Richards, M.A. & ICBP Module 1 Working Group 2011, 'Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995-2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data.', Lancet, vol. 377, no. 9760, pp. 127-138.
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BACKGROUND: Cancer survival is a key measure of the effectiveness of health-care systems. Persistent regional and international differences in survival represent many avoidable deaths. Differences in survival have prompted or guided cancer control strategies. This is the first study in a programme to investigate international survival disparities, with the aim of informing health policy to raise standards and reduce inequalities in survival. METHODS: Data from population-based cancer registries in 12 jurisdictions in six countries were provided for 24 million adults diagnosed with primary colorectal, lung, breast (women), or ovarian cancer during 1995-2007, with follow-up to Dec 31, 2007. Data quality control and analyses were done centrally with a common protocol, overseen by external experts. We estimated 1-year and 5-year relative survival, constructing 252 complete life tables to control for background mortality by age, sex, and calendar year. We report age-specific and age-standardised relative survival at 1 and 5 years, and 5-year survival conditional on survival to the first anniversary of diagnosis. We also examined incidence and mortality trends during 1985-2005. FINDINGS: Relative survival improved during 1995-2007 for all four cancers in all jurisdictions. Survival was persistently higher in Australia, Canada, and Sweden, intermediate in Norway, and lower in Denmark, England, Northern Ireland, and Wales, particularly in the first year after diagnosis and for patients aged 65 years and older. International differences narrowed at all ages for breast cancer, from about 9% to 5% at 1 year and from about 14% to 8% at 5 years, but less or not at all for the other cancers. For colorectal cancer, the international range narrowed only for patients aged 65 years and older, by 2-6% at 1 year and by 2-3% at 5 years. INTERPRETATION: Up-to-date survival trends show increases but persistent differences between countries. Trends in cancer incidence and mortality are...
Currow, D.C., Wheeler, J.L. & Abernethy, A.P. 2011, 'International perspective: outcomes of palliative oncology.', Semin Oncol, vol. 38, no. 3, pp. 343-350.
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Accompanying the ascendance of cancer as a leading cause of death worldwide is a new set of global health priorities focused on palliative care--the relief of symptoms and suffering, optimization of functional status, and quality of life for those with advanced, potentially life-limiting illnesses. In high-income countries, palliative care improves outcomes for patients, caregivers, provider organizations, and health systems. Data are not yet available to demonstrate similar benefits in low- and middle-income countries, where access to even the most basic palliative interventions (eg, opioids for pain management) is inadequate and unevenly distributed. This article describes current global disparities in the availability of palliative care. We make the case for international prioritization of palliative care as a critical strategy for improving outcomes for people with cancer and their caregivers worldwide.
Kamal, A.H., Maguire, J.M., Wheeler, J.L., Currow, D.C. & Abernethy, A.P. 2011, 'Dyspnea review for the palliative care professional: assessment, burdens, and etiologies.', J Palliat Med, vol. 14, no. 10, pp. 1167-1172.
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BACKGROUND: Dyspnea is a common symptom experienced by many patients with chronic, life-threatening, and/or life-limiting illnesses. Although it can be defined and measured in several ways, dyspnea is best described directly by patients through regular assessment, as its burdens exert a strong influence on the patient's experience throughout the trajectory of serious illness. Its significance is amplified due to its impact on family and caregivers. DISCUSSION: Anatomic and physiologic changes associated with dyspnea, and cognitive perceptions related to patients and the underlying disease, provide insights into how to shape interventions targeting this oppressive symptom. Additionally, as described in the concept of "total dyspnea," the complex etiology and manifestation of this symptom require multidisciplinary treatment plans that focus on psychological, social, and spiritual distress as well as physical components. Several validated assessment tools are available for clinical and research use, and choice of method should be tailored to the individual patient, disease, and care setting in the context of patient-centered care. CONCLUSION: This article, the first in a two-part series, reviews the identification and assessment of dyspnea, the burden it entails, and the underlying respiratory and nonrespiratory etiologies that may cause or exacerbate it.
Kamal, A.H., Currow, D.C., Ritchie, C., Bull, J., Wheeler, J.L. & Abernethy, A.P. 2011, 'The value of data collection within a palliative care program.', Curr Oncol Rep, vol. 13, no. 4, pp. 308-315.
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Collecting reliable and valid data is an increasing expectation within palliative care. Data remain the crux for demonstrating value and quality of care, which are the critical steps to program sustainability. Parallel goals of conducting research and performing quality assessment and improvement can also ensure program growth, financial health, and viability in an increasingly competitive environment. Mounting expectations by patients, hospitals, and payers and inevitable pay-for-performance paradigms have transitioned data collection procedures from novel projects to expected standard operation within usual palliative care delivery. We present types of data to collect, published guides for data collection, and how data can inform quality, value, and research within a palliative care organization. Our experiences with the Quality Data Collection Tool (QDACT) in the Carolinas Palliative Care Consortium to collect data on quality have led to valuable lessons learned in creating a data collection system. Suggested steps in forming data-sharing collaborations and building data collection procedures are shared.
Abernethy, A.P. & Currow, D.C. 2011, 'Time for better integration of oncology and palliative care', Journal of Oncology Practice, vol. 7, no. 6, pp. 346-348.
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Currow, D.C. & Abernethy, A.P. 2011, 'Therapeutic nihilism: the next hurdle in improving the treatment of breathlessness.', Curr Opin Support Palliat Care, vol. 5, no. 2, pp. 69-70.
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Currow, D.C. 2011, 'The PRISMA Symposium 3: lessons from beyond Europe. why invest in research and service development in palliative care? An Australian perspective.', J Pain Symptom Manage, vol. 42, no. 4, pp. 505-510.
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Hospice and palliative care services need to be able to compete with finite health care resources. To compete for such funding, the sector needs to continuously improve the evidence base that demonstrates improved outcomes, or else funding will continue to be at the level of a "social good" rather than as services that deliver improved health outcomes. Three questions need to be answered for policy makers and health funders: 1) Why invest health care spending in hospice and palliative care?, 2) Why invest research monies in hospice and palliative care clinical research and health service development?, and 3) How can emerging evidence be more effectively implemented to improve patient outcomes? No single measure captures the net benefit of hospice and palliative care services. By patient-defined parameters, hospice and palliative care services have demonstrated benefits, including physical symptom control. To meet patients' concerns, greater emphasis needs to be placed on maintaining physical independence for a longer period of time. Targeted investment of research funding can deliver further improvements in patient outcomes and models of service delivery. Rigorous studies are feasible and necessary if each patient is going to receive the best possible support. Benchmarking and service development strategies can deliver improved patient outcomes. With routine point-of-care data collection and feedback loops to individual services, patient-valued outcomes and resourcing can be improved in hospice and palliative care. Public-good investments in hospice and palliative care research are vital to building the evidence base for improving the quality of care offered.
Bowden, J.A., To, T.H.M., Abernethy, A.P. & Currow, D.C. 2011, 'Predictors of chronic breathlessness: a large population study.', BMC Public Health, vol. 11, p. 33.
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BACKGROUND: Breathlessness causes significant burden in our community but the underlying socio-demographic and lifestyle factors that may influence it are not well quantified. This study aims to define these predictors of chronic breathlessness at a population level. METHODS: Data were collected from adult South Australians in 2007 and 2008 (n = 5331) as part of a face-to-face, cross-sectional, whole-of-population, multi-stage, systematic area sampling population health survey. The main outcome variable was breathlessness in logistic regression models. Lifestyle factors examined included smoking history, smoke-free housing, level of physical activity and body mass index (obesity). RESULTS: The participation rate was 64.1%, and 11.1% of individuals (15.0% if aged 50 years) chronically had breathlessness that limited exertion. Significant bivariate associations with chronic breathlessness for the whole population and only those 50 included: increasing age; female gender; being separated/divorced/widowed; social disadvantage; smoking status; those without a smoke-free home; low levels of physical activity; and obesity. In multi-variate analyses adjusted for age, marital status (p < 0.001), physical activity (p < 0.001), obesity (p < 0.001), gender (p < 0.05) and social disadvantage (p < 0.05) remained significant factors. Smoking history was not a significant contributor to the model. CONCLUSIONS: There is potential benefit in addressing reversible lifestyle causes of breathlessness including high body mass index (obesity) and low levels of physical activity in order to decrease the prevalence of chronic breathlessness. Clinical intervention studies for chronic breathlessness should consider stratification by body mass index.
Currow, D.C. & Dessaix, A. 2011, 'Plain packaging for tobacco products.', BMJ, vol. 343, p. d5693.
Abernethy, A.P. & Currow, D.C. 2011, 'Patient self-reporting in palliative care using information technology: Yes, there is hope!', Palliat Med, vol. 25, no. 7, pp. 673-674.
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Burns, C.M., Abernethy, A.P., Leblanc, T.W. & Currow, D.C. 2011, 'What is the role of friends when contributing care at the end of life? Findings from an Australian population study.', Psychooncology, vol. 20, no. 2, pp. 203-212.
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PURPOSE: To examine the role of friends as caregivers of people with terminal illness. METHOD: Piloted questions were included in the 2001-2007 random face-to-face annual health surveys of 23588 South Australians on the death of a loved one, caregiving provided, and characteristics of the caregiver and deceased individual. The survey was representative of the population by age, gender, and region of residence. Analyses focused on friends of the deceased loved one, providing daily or intermittent 'hands on' care. Logistic regression assessed predictors of home death. RESULTS: Daily 'hands on' carers were much more likely to be female and aged between 55 and 64; there was also a younger (<age 45) cohort of intermittent 'hands on' caregivers. When friends were carers, the deceased was more frequently younger (<age 65) and had cancer (p0.001). Almost a third of caregiving friends were actively involved in care for >12 months. Home deaths were more frequent (32%, p=0.014) when friends were carers, and the rate of palliative care use was higher than when family/others provided care (70 vs 61%). Regression analyses confirmed friends as caregivers as a predictor of home death (OR 1.73: 95%, CI 1.15-2.87). CONCLUSION: Friends contribute their caregiving: A cohort of younger caregivers may reflect changing social mores as the extended family shrinks and people turn to friendship networks for care and support at the end of life.
Johnson, C.E., Girgis, A., Paul, C.L. & Currow, D.C. 2011, 'Palliative care referral practices and perceptions: the divide between metropolitan and non-metropolitan general practitioners.', Palliat Support Care, vol. 9, no. 2, pp. 181-189.
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OBJECTIVE: Late or non-referral of patients to specialist palliative care (SPC) services may affect patients' and their carers' quality of care. General practitioners (GPs) are key professionals in linking people with SPC. The aim of this article is to assess GPs' perceptions and SPC referrals for their patients with advanced cancer and differences between metropolitan (M GPs) and non-metropolitan GPs (NM GPs). METHOD: Self-report survey mailed to a stratified random sample of 1,680 Australian GPs was used. RESULTS: Thirty-one percent (469) of eligible GPs returned surveys. More M GPs than NM GPs reported referring >60% of their patients for SPC (p = 0.014); and that a more comprehensive range of SPC services was available. The most frequently reported referral prompts were: presence of terminal illness (M GPs, 71%, NM GPs, 66%, ns (not significant)); future need for symptom control (69% vs. 59%, ns) and uncontrolled physical symptoms (63% vs. 54%, ns). Reasons for not referring were: doctor's ability to manage symptoms (62% vs. 68%, ns) and the absence of symptoms (29% vs. 18%, p = 0.025). Higher referral was associated with: having a palliative care physician or consultative service available; agreeing that all patients with advanced cancer should be referred, and agreeing that with SPC, the needs of the family are better met. SIGNIFICANCE OF RESULTS: Referrals for SPC were primarily disease-related rather than for psychological and emotional concerns. Measures are needed to encourage referrals based upon psychosocial needs as well as for physical concerns, and to support GPs caring for people with advanced cancer in areas with fewer comprehensive SPC services.
Rosenwax, L.K., McNamara, B.A., Murray, K., McCabe, R.J., Aoun, S.M. & Currow, D.C. 2011, 'Hospital and emergency department use in the last year of life: a baseline for future modifications to end-of-life care.', Med J Aust, vol. 194, no. 11, pp. 570-573.
OBJECTIVES: To describe hospital and emergency department use in the last year of life by people for whom death from cancer or one of another nine conditions was an expected outcome. DESIGN, PARTICIPANTS AND SETTING: Retrospective cross-sectional study based on death registrations and morbidity data for 1071 Western Australians who died between 1 August 2005 and 30 June 2006. Decedents had an informal primary carer, did not live in residential aged care and died of a condition amenable to palliative care. MAIN OUTCOME MEASURES: Total number of hospital admissions; emergency presentations (with and without hospital admission); days spent in hospital by age group at death, sex, metropolitan or rural place of residence and cancer versus non-cancer diagnosis; proportion in hospital on any day in the last 365 days of life; time points of change in the last 365 days of life at which there was an increasing proportion of hospital admissions for those with cancer and non-cancer conditions. RESULTS: All but 4% of the decedents spent time in hospital with a marked increase in hospitalisations in the last 108 days of life for people who died of cancer and the last 83 days of life for people who died of non-cancer conditions. Those with cancer spent less time in hospital than those with other diagnoses. Seventy per cent of the cohort had at least one emergency presentation. On the last day of life, 61.5% of people were in hospital and 4.0% had been seen in emergency departments. CONCLUSIONS: Western Australian hospitals currently provide extensive and progressively greater care at the end of life. Identifying patterns of emergency and inpatient use for various disease trajectories will assist in the planning of appropriate services for people where death is an expected outcome.
Clark, K., Girgis, A. & Currow, D.C. 2011, 'Palliative care of people with oesophageal cancer', Cancer Forum, vol. 35, no. 3, pp. 175-179.
Davidson, P.M., Macdonald, P., Newton, P.J. & Currow, D. 2010, 'End stage heart failure patients: Palliative care in general practice', Australian family physician, vol. 39, no. 12, pp. 2-6.
Background: Chronic heart failure is common, particularly in older individuals, and comorbidities are frequent. Patients with end stage heart failure can be highly symptomatic and require careful monitoring and treatment adjustment to improve symptoms.
Davidson, P.M. & Currow, D. 2010, 'Management of refractory dyspnoea:evidence-based interventions', Cancer Forum, vol. 34, no. 2, pp. 86-90.
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Breathlessness is a common and distressing symptom in both malignant and non-malignant conditions. Both pharmacological and non-pharmacological strategies are necessary to minimise symptom burden and distress. Assessing the individual&acirc;s needs and clarifying the goals of treatment is an important first step in determining an effective treatment plan. Although the evidence supporting the use of some of these therapies is variable, there is an increasing evidence base to inform clinical decision making and treatment plans. Pharmacotherapy with opioids is a common and effective strategy for managing breathlessness, yet requires judicious titration and management. The adverse effects of opioid therapy, including constipation and drowsiness, can be anticipated and managed with adjunctive therapies. The use of oxygen in people who are hypoxaemic is supported, but is of limited value in people who are not hypoxaemic. Individualised strategies and advance care planning is important to avoid unnecessary hospitalisations and futile treatments at the end of life. There is a clear mismatch between the prevalence and burden of this problem and data to inform evidence-based guidelines. Refractory breathlessness is a fertile area for ongoing research and requires increased attention to address the burden of this highly prevalent symptom.
Currow, D., Smith, J., Davidson, P.M., Newton, P.J., Agar, M., Care, M.P. & Abernethy, A. 2010, 'Do the Trajectories of Dyspnea Differ in Prevalence and Intensity By Diagnosis at the End of Life? A Consecutive Cohort Study', Journal of Pain and Symptom Management, vol. 39, no. 4, pp. 680-690.
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Context. Breathlessness reportedly worsens as death approaches for many people, but the differences in intensity and time course between underlying causes are not well described. Objectives. To determine differences in the intensity of breathlessness by diagnosis over time as death approaches in a consecutive cohort seen by a specialist palliative care service. Methods. Patients referred to Silver Chain Hospice Care Service over a period of four years (January 2004 to December 2007) had dyspnea evaluated at every clinical encounter until death. A numeric rating scale (NRS) was used to measure the intensity. Patients were categorized into five clusters (lung cancer, secondary cancer to lung, heart failure, end-stage pulmonary disease, and no identifiable cardiorespiratory cause) at three time points (60e53 [T3], 30e23 [T2], and 7e0 [T1] days before death [T0]). Group differences were assessed using analysis of variance. Joinpoint regression models defined significant changes in mean breathlessness intensity.
Waller, A., Girgis, A., Lecathelinais, C., Scott, W., Foot, L., Sibbritt, D. & Currow, D. 2010, 'Validity, reliability and clinical feasibility of a Needs Assessment Tool for people with progressive cancer', Psycho-oncology, vol. 19, pp. 726-733.
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Background: Needs assessment is a valuable approach for determining the way health and social services allocate resources to people with cancer and their caregivers. Aim: To assess the reliability, validity and acceptability of a Needs Assessment Tool (NAT) in a palliative care clinical setting.
Waller, A., Girgis, A., Johnson, C., Mitchell, G., Yates, P., Kristjanson, L., Tattersall, M., Lecathelinais, C., Sibbritt, D., Kelly, B., Gorton, E. & Currow, D. 2010, 'Facilitating needs based cancer care for people with a chronic disease: Evaluation of an intervention using a multi-centre interrupted timeseries design', BMC Palliative Care, vol. 9, no. 2, pp. 1-6.
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Background: Palliative care should be provided according to the individual needs of the patient, caregiver and family, so that the type and level of care provided, as well as the setting in which it is delivered, are dependent on the complexity and severity of individual needs, rather than prognosis or diagnosis [1]. This paper presents a study designed to assess the feasibility and efficacy of an intervention to assist in the allocation of palliative care resources according to need, within the context of a population of people with advanced cancer.
Phillips, J.L. & Currow, D. 2010, 'Cancer as a chronic disease', Collegian, vol. 17, no. 2, pp. 47-50.
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Background Over the past two decades the number of people living with cancer has increased. Many cancer survivors end up with long term disabilities requiring ongoing care and support. For many people, cancer survival now means living with a chronic and complex condition. Aim The purpose of this paper is to provide an overview of the long term management issues for cancer survivors and strategies to enhance their care. Discussion Cancer survivors require ongoing support in four key areas: prevention; surveillance; intervention for consequences of cancer and its treatment; and coordination between specialist and generalist providers. Conclusion Cancer survivors experience significant physical and psychological morbidity which makes minimising their burden of disability and distress an important priority. Survivors require ongoing care that is well co-ordinated, focuses on prevention, provides going surveillance whilst minimising and managing the long term effects of treatment and other co-morbidities.
Currow, D. & Agar, M. 2010, 'The Necessary Work Program for Safe Delivery of Combinations of Injectable Medications', JOURNAL OF PALLIATIVE MEDICINE, vol. 13, no. 9, pp. 1052-1052.
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Currow, D.C., Agar, M., Plummer, J.L., Blyth, F.M. & Abernethy, A.P. 2010, 'Chronic pain in South Australia - population levels that interfere extremely with activities of daily living', AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH, vol. 34, no. 3, pp. 232-239.
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Agar, M., To, T., Plummer, J., Abernethy, A. & Currow, D. 2010, 'Anti-Cholinergic Load, Health Care Utilization, and Survival in People with Advanced Cancer: A Pilot Study', JOURNAL OF PALLIATIVE MEDICINE, vol. 13, no. 6, pp. 745-752.
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Clark, K., Lam, L.T., Agar, M., Chye, R. & Currow, D.C. 2010, 'The impact of opioids, anticholinergic medications and disease progression on the prescription of laxatives in hospitalized palliative care patients: a retrospective analysis', PALLIATIVE MEDICINE, vol. 24, no. 4, pp. 410-418.
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Currow, D.C., Shelby-James, T.M., Agar, M., Plummer, J., Rowett, D., Glare, P., Spruyt, O. & Hardy, J. 2010, 'Planning phase III multi-site clinical trials in palliative care: the role of consecutive cohort audits to identify potential participant populations', SUPPORTIVE CARE IN CANCER, vol. 18, no. 12, pp. 1571-1579.
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Burns, C.M., LeBlanc, T.W., Abernethy, A. & Currow, D. 2010, 'Young Caregivers in the End-of-Life Setting: A Population-Based Profile of an Emerging Group', JOURNAL OF PALLIATIVE MEDICINE, vol. 13, no. 10, pp. 1225-1235.
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Aoun, S., Bird, S., Kristjanson, L.J. & Currow, D. 2010, 'Reliability testing of the FAMCARE-2 scale: measuring family carer satisfaction with palliative care', PALLIATIVE MEDICINE, vol. 24, no. 7, pp. 674-681.
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Horton, R., Rocker, G. & Currow, D. 2010, 'The dyspnea target: can we zero in on opioid responsiveness in advanced chronic obstructive pulmonary disease?', Current opinion in supportive and palliative care, vol. 4, no. 2, pp. 92-96.
PURPOSE OF REVIEW: Despite recognition that opioids alleviate dyspnea in chronic obstructive pulmonary disease, many clinicians remain reluctant to use them outside of the final days of life. This article defines the term 'opioid responsiveness' as it pertains to dyspnea, and poses that it may be possible to predict more accurately the patients with chronic obstructive pulmonary disease and refractory dyspnea who might benefit from opioid treatment for either short-term use during episodes of dyspnea crisis or for long-term use for chronic dyspnea on minimal exertion. RECENT FINDINGS: This article highlights recent evidence of known dimensions contributing to the sensation of dyspnea in chronic obstructive pulmonary disease and builds on clinical observational experience to generate a conceptual model of opioid responsiveness. The 'dyspnea target' and 'opioid responsiveness score' are proposed as a means of defining more clearly the sensations encountered by a given patient and the likelihood of symptomatic improvement in response to opioids. SUMMARY: The 'dyspnea target' or similar conceptual models that attempt to predict how specific aspects of dyspnea may affect response to treatments offer clinicians the potential to more effectively target interventions. The model is presented in its theoretical stage in order to stimulate further discussion and research in an area of current interest.
Waller, A., Girgis, A., Johnson, C., Mitchell, G., Yates, P., Kristjanson, L., Tattersall, M., Lecathelinais, C., Sibbritt, D., Kelly, B., Gorton, E. & Currow, D. 2010, 'Facilitating needs based cancer care for people with a chronic disease: Evaluation of an intervention using a multi-centre interrupted time series design.', BMC palliative care, vol. 9, p. 2.
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BACKGROUND: Palliative care should be provided according to the individual needs of the patient, caregiver and family, so that the type and level of care provided, as well as the setting in which it is delivered, are dependent on the complexity and severity of individual needs, rather than prognosis or diagnosis [1]. This paper presents a study designed to assess the feasibility and efficacy of an intervention to assist in the allocation of palliative care resources according to need, within the context of a population of people with advanced cancer. METHODS/DESIGN: People with advanced cancer and their caregivers completed bi-monthly telephone interviews over a period of up to 18 months to assess unmet needs, anxiety and depression, quality of life, satisfaction with care and service utilisation. The intervention, introduced after at least two baseline phone interviews, involved a) training medical, nursing and allied health professionals at each recruitment site on the use of the Palliative Care Needs Assessment Guidelines and the Needs Assessment Tool: Progressive Disease - Cancer (NAT: PD-C); b) health professionals completing the NAT: PD-C with participating patients approximately monthly for the rest of the study period. Changes in outcomes will be compared pre-and post-intervention. DISCUSSION: The study will determine whether the routine, systematic and regular use of the Guidelines and NAT: PD-C in a range of clinical settings is a feasible and effective strategy for facilitating the timely provision of needs based care. TRIALS REGISTRATION: ISRCTN21699701.
Sladek, R.M., Tieman, J. & Currow, D.C. 2010, 'Searchers be aware: limiting PubMed searches to 'humans' loses more than you think', INTERNAL MEDICINE JOURNAL, vol. 40, no. 1, pp. 88-89.
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Hardy, J., Shelby-James, T. & Currow, D.C. 2010, 'Research in palliative care: is death always an adverse event?', INTERNAL MEDICINE JOURNAL, vol. 40, no. 1, pp. 89-90.
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Davidson, P.M., Macdonald, P.S., Newton, P.J. & Currow, D.C. 2010, 'End stage heart failure patients - palliative care in general practice.', Australian Family Physician, vol. 39, no. 12, pp. 916-920.
BACKGROUND: Chronic heart failure is common, particularly in older individuals, and comorbidities are frequent. Patients with end stage heart failure can be highly symptomatic and require careful monitoring and treatment adjustment to improve symptoms. OBJECTIVE: This article summarises the fundamentals of implementing palliative care in general practice and provides guidelines on caring for chronic heart failure patients at the end of life. DISCUSSION: The high mortality in chronic heart failure underscores the importance of effective communication, symptom management and advanced care planning. The unpredictability and uncertainty around the timing of death mean that individuals, and their families, may be less likely to have an understanding of their prognosis or have access to supportive and palliative care. Ideally, patients with symptomatic chronic heart failure should be managed in collaboration with a multidisciplinary heart failure program. Symptom management can be achieved by additive therapies and access to specialist palliative care services should be considered when the symptom burden is high.
Shelby-James, T., Agar, M.R. & Currow, D.C. 2010, 'A case study evaluation of ethics review systems for multicentre clinical trials.', The Medical journal of Australia, vol. 192, no. 5, p. 292.
Abernethy, A.P., Aziz, N.M., Basch, E., Bull, J., Cleeland, C.S., Currow, D.C., Fairclough, D., Hanson, L., Hauser, J., Ko, D., Lloyd, L., Morrison, R.S., Otis-Green, S., Pantilat, S., Portenoy, R.K., Ritchie, C., Rocker, G., Wheeler, J.L., Zafar, S.Y. & Kutner, J.S. 2010, 'A strategy to advance the evidence base in palliative medicine: formation of a palliative care research cooperative group.', J Palliat Med, vol. 13, no. 12, pp. 1407-1413.
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BACKGROUND: Palliative medicine has made rapid progress in establishing its scientific and clinical legitimacy, yet the evidence base to support clinical practice remains deficient in both the quantity and quality of published studies. Historically, the conduct of research in palliative care populations has been impeded by multiple barriers including health care system fragmentation, small number and size of potential sites for recruitment, vulnerability of the population, perceptions of inappropriateness, ethical concerns, and gate-keeping. METHODS: A group of experienced investigators with backgrounds in palliative care research convened to consider developing a research cooperative group as a mechanism for generating high-quality evidence on prioritized, clinically relevant topics in palliative care. RESULTS: The resulting Palliative Care Research Cooperative (PCRC) agreed on a set of core principles: active, interdisciplinary membership; commitment to shared research purposes; heterogeneity of participating sites; development of research capacity in participating sites; standardization of methodologies, such as consenting and data collection/management; agile response to research requests from government, industry, and investigators; focus on translation; education and training of future palliative care researchers; actionable results that can inform clinical practice and policy. Consensus was achieved on a first collaborative study, a randomized clinical trial of statin discontinuation versus continuation in patients with a prognosis of less than 6 months who are taking statins for primary or secondary prevention. This article describes the formation of the PCRC, highlighting processes and decisions taken to optimize the cooperative group's success.
Clark, K., Currow, D.C. & Talley, N.J. 2010, 'The use of digital rectal examinations in palliative care inpatients.', J Palliat Med, vol. 13, no. 7, p. 797.
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Eagar, K., Watters, P., Currow, D.C., Aoun, S.M. & Yates, P. 2010, 'The Australian Palliative Care Outcomes Collaboration (PCOC)--measuring the quality and outcomes of palliative care on a routine basis.', Aust Health Rev, vol. 34, no. 2, pp. 186-192.
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Australia is leading the way in establishing a national system (the Palliative Care Outcomes Collaboration - PCOC) to measure the outcomes and quality of specialist palliative care services and to benchmark services across the country. This article reports on analysis of data collected routinely at point-of-care on 5939 patients treated by the first fifty one services that voluntarily joined PCOC. By March 2009, 111 services have agreed to join PCOC, representing more than 70% of services and more than 80% of specialist palliative care patients nationally. All states and territories are involved in this unique process that has involved extensive consultation and infrastructure and close collaboration between health services and researchers. The challenges of dealing with wide variation in outcomes and practice and the progress achieved to date are described. PCOC is aiming to improve understanding of the reasons for variations in clinical outcomes between specialist palliative care patients and differences in service outcomes as a critical step in an ongoing process to improve both service quality and patient outcomes.
Zafar, S.Y., Currow, D.C., Daugherty, C.K. & Abernethy, A.P. 2010, 'Standards for palliative care delivery in oncology settings.', Cancer J, vol. 16, no. 5, pp. 436-443.
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This review aims to describe available standards for delivery of palliative and supportive care for cancer patients and discuss to what extent these guidelines have been evaluated and disseminated into standard care. Ovid searches were conducted to identify relevant guidelines, randomized studies comparing guideline-based care to usual care, and articles describing the use of guidelines in the usual care setting. Published guidelines address specific issues related to symptom management. Broader consensus statements have presented a framework for the delivery of palliative care for cancer patients. Dissemination of guidelines into standard care has been limited. Limited data suggest that implementation of palliative and supportive care guidelines can improve patient outcomes. Clinical trial publications rarely address supportive care in detail. Guideline efficacy has not been evaluated, and their dissemination into standard care has been poor. A conceptual framework for better implementation of existing guidelines might improve usage and outcomes.
Currow, D.C. & Abernethy, A.P. 2010, 'Potential opioid-sparing effect of regular benzodiazepines in dyspnea: longer duration of studies needed.', J Pain Symptom Manage, vol. 40, no. 5, pp. e1-e2.
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Abernethy, A.P. & Currow, D.C. 2010, 'Need for mechanistically focused research of global systemic interventions in palliative care.', J Pain Symptom Manage, vol. 40, no. 3, pp. e5-e8.
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Abernethy, A.P., Wheeler, J.L. & Currow, D.C. 2010, 'Common approaches to dyspnoea management in advanced life-limiting illness.', Curr Opin Support Palliat Care, vol. 4, no. 2, pp. 53-55.
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Abernethy, A.P., McDonald, C.F., Frith, P.A., Clark, K., Herndon, J.E., Marcello, J., Young, I.H., Bull, J., Wilcock, A., Booth, S., Wheeler, J.L., Tulsky, J.A., Crockett, A.J. & Currow, D.C. 2010, 'Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial.', Lancet, vol. 376, no. 9743, pp. 784-793.
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BACKGROUND: Palliative oxygen therapy is widely used for treatment of dyspnoea in individuals with life-limiting illness who are ineligible for long-term oxygen therapy. We assessed the effectiveness of oxygen compared with room air delivered by nasal cannula for relief of breathlessness in this population of patients. METHODS: Adults from outpatient clinics at nine sites in Australia, the USA, and the UK were eligible for enrolment in this double-blind, randomised controlled trial if they had life-limiting illness, refractory dyspnoea, and partial pressure of oxygen in arterial blood (PaO(2)) more than 7.3 kPa. Participants were randomly assigned in a 1:1 ratio by a central computer-generated system to receive oxygen or room air via a concentrator through a nasal cannula at 2 L per min for 7 days. Participants were instructed to use the concentrator for at least 15 h per day. The randomisation sequence was stratified by baseline PaO(2) with balanced blocks of four patients. The primary outcome measure was breathlessness (0-10 numerical rating scale [NRS]), measured twice a day (morning and evening). All randomised patients who completed an assessment were included in the primary analysis for that data point (no data were imputed). This study is registered, numbers NCT00327873 and ISRCTN67448752. FINDINGS: 239 participants were randomly assigned to treatment (oxygen, n=120; room air, n=119). 112 (93%) patients assigned to receive oxygen and 99 (83%) assigned to receive room air completed all 7 days of assessments. From baseline to day 6, mean morning breathlessness changed by -0.9 points (95% CI -1.3 to -0.5) in patients assigned to receive oxygen and by -0.7 points (-1.2 to -0.2) in patients assigned to receive room air (p=0.504). Mean evening breathlessness changed by -0.3 points (-0.7 to 0.1) in the oxygen group and by -0.5 (-0.9 to -0.1) in the room air group (p=0.554). The frequency of side-effects did not differ between groups. Extreme drowsiness was report...
Abernethy, A.P., Wheeler, J.L. & Currow, D.C. 2010, 'Utility and use of palliative care screening tools in routine oncology practice.', Cancer J, vol. 16, no. 5, pp. 444-460.
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Palliative care, which seeks to alleviate suffering and optimize quality of life, is an increasingly recognized and valued medical subspecialty. With its focus on identifying and managing symptoms and problems encountered in expected functional decline, the domain of palliative care overlaps significantly with that of oncology, where patients typically experience a host of disease- and treatment-related effects. Assessment instruments have been developed and validated in the context of both disciplines, but oncology may benefit from the inclusion of palliative care screening instruments specifically developed for patients with advanced, life-limiting illnesses. New methods of screening, particularly technology-based ones such as electronic data capture, allow greater flexibility across care settings and longitudinal data capture for ongoing evaluation. This article reviews frequently used and available screening instruments for common palliative needs in cancer patients and provides an example of a novel technology-based screening approach to quickly identify and address a critical patient concern.
Abernethy, A.P., Clark, K. & Currow, D.C. 2010, 'How should we conduct and interpret phase III clinical trials in palliative care?', J Pain Symptom Manage, vol. 39, no. 1, pp. e6-e8.
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Currow, D.C. 2010, 'Why don't we do more rigorous clinical research so that we can stop experimenting on patients?', J Palliat Med, vol. 13, no. 6, pp. 636-637.
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Tieman, J.J., Abernethy, A. & Currow, D.C. 2010, 'Not published, not indexed: issues in generating and finding hospice and palliative care literature.', J Palliat Med, vol. 13, no. 6, pp. 669-675.
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INTRODUCTION: Accessing new knowledge as the evidence base for hospice and palliative care grows has specific challenges for the discipline. This study aimed to describe conversion rates of palliative and hospice care conference abstracts to journal articles and to highlight that some palliative care literature may not be retrievable because it is not indexed on bibliographic databases. METHODS: Substudy A tracked the journal publication of conference abstracts selected for inclusion in a gray literature database on www.caresearch.com.au . Abstracts were included in the gray literature database following handsearching of proceedings of over 100 Australian conferences likely to have some hospice or palliative care content that were held between 1980 and 1999. Substudy B looked at indexing from first publication until 2001 of three international hospice and palliative care journals in four widely available bibliographic databases through systematic tracing of all original papers in the journals. RESULTS: Substudy A showed that for the 1338 abstracts identified only 15.9% were published (compared to an average in health of 45%). Published abstracts were found in 78 different journals. Multiauthor abstracts and oral presentations had higher rates of conversion. Substudy B demonstrated lag time between first publication and bibliographic indexing. Even after listing, idiosyncratic noninclusions were identified. DISCUSSION: There are limitations to retrieval of all possible literature through electronic searching of bibliographic databases. Encouraging publication in indexed journals of studies presented at conferences, promoting selection of palliative care journals for database indexing, and searching more than one bibliographic database will improve the accessibility of existing and new knowledge in hospice and palliative care.
Clark, K., Urban, K. & Currow, D.C. 2010, 'Current approaches to diagnosing and managing constipation in advanced cancer and palliative care.', J Palliat Med, vol. 13, no. 4, pp. 473-476.
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Constipation is common in advanced cancer. Despite this, clinicians' understanding of the underlying changes affecting the colon and the rest of the gastrointestinal tract are limited. Two case histories are used to illustrate the problems encountered when the current approaches to diagnosing and managing altered bowel habits are unsuccessful. An alternative paradigm in which to consider the problems of constipation encountered by some people with advanced cancer is proposed.
Aoun, S., McConigley, R., Abernethy, A. & Currow, D.C. 2010, 'Caregivers of people with neurodegenerative diseases: profile and unmet needs from a population-based survey in South Australia.', J Palliat Med, vol. 13, no. 6, pp. 653-661.
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INTRODUCTION: Neurodegenerative diseases (NDD) are characterized by progressive decline and loss of function, requiring considerable third-party care. NDD carers report low quality of life and high caregiver burden. Despite this, little information is available about the unmet needs of NDD caregivers. METHODS: Data from a cross-sectional, whole of population study conducted in South Australia were analyzed to determine the profile and unmet care needs of people who identify as having provided care for a person who died an expected death from NDDs including motor neurone disease and multiple sclerosis. Bivariate analyses using chi(2) were complemented with a regression analysis. RESULTS: Two hundred and thirty respondents had a person close to them die from an NDD in the 5 years before responding. NDD caregivers were more likely to have provided care for more than 2 years and were more able to move on after the death than caregivers of people with other disorders such as cancer. The NDD caregivers accessed palliative care services at the same rate as other caregivers at the end of life, however people with an NDD were almost twice as likely to die in the community (odds ratio [OR] 1.97; 95% confidence interval [CI] 1.30 to 3.01) controlling for relevant caregiver factors. NDD caregivers reported significantly more unmet needs in emotional, spiritual, and bereavement support. CONCLUSION: This study is the first step in better understanding across the whole population the consequences of an expected death from an NDD. Assessments need to occur while in the role of caregiver and in the subsequent bereavement phase.
Abernethy, A.P., Currow, D.C., Wurzelmann, J., Janning, S.W., Bull, J., Norris, J.F., Baringtang, D.C., Pierce, A. & Snidow, J. 2010, 'Enhancing enrollment in palliative care trials: key insights from a randomized, placebo-controlled study.', J Support Oncol, vol. 8, no. 3, pp. 139-144.
Currow, D. & Davis, C. 2010, 'How quick are palliative care doctors to adopt new evidence?', European Journal of Palliative Care, vol. 17, no. 5, p. 213.
Gordon, R., Eagar, K., Currow, D. & Green, J. 2009, 'Current Funding and Financing Issues in the Australian Hospice and Palliative Care Sector', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 38, no. 1, pp. 68-74.
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Agar, M., Currow, D., Plummer, J., Seidel, R., Carnahan, R. & Abernethy, A.P. 2009, 'Changes in anticholinergic load from regular prescribed medications in palliative care as death approaches', PALLIATIVE MEDICINE, vol. 23, no. 3, pp. 257-265.
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Currow, D.C., Agar, M., Smith, J. & Abernethy, A.P. 2009, 'Does palliative home oxygen improve dyspnoea? A consecutive cohort study', PALLIATIVE MEDICINE, vol. 23, no. 4, pp. 309-316.
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Roder, D. & Currow, D. 2009, 'Cancer in Aboriginal and Torres Strait Islander People of Australia', ASIAN PACIFIC JOURNAL OF CANCER PREVENTION, vol. 10, no. 5, pp. 729-733.
Rocker, G., Horton, R., Currow, D., Goodridge, D., Young, J. & Booth, S. 2009, 'Palliation of dyspnoea in advanced COPD: revisiting a role for opioids', THORAX, vol. 64, no. 10, pp. 910-915.
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Nikles, J., Mitchell, G., Walters, J., Hardy, J., Good, P., Rowett, D., Shelby-James, T. & Currow, D. 2009, 'Prioritising drugs for single patient (n-of-1) trials in palliative care', PALLIATIVE MEDICINE, vol. 23, no. 7, pp. 623-634.
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Cherny, N.I., Abernethy, A.P., Strasser, F., Sapir, R., Currow, D. & Zafar, S.Y. 2009, 'Improving the Methodologic and Ethical Validity of Best Supportive Care Studies in Oncology: Lessons From a Systematic Review', JOURNAL OF CLINICAL ONCOLOGY, vol. 27, no. 32, pp. 5476-5486.
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Clark, K., Lam, L.T., Gibson, S. & Currow, D. 2009, 'The effect of ranitidine versus proton pump inhibitors on gastric secretions: a meta-analysis of randomised control trials', ANAESTHESIA, vol. 64, no. 6, pp. 652-657.
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Ferris, F.D., Bruera, E., Cherny, N., Cummings, C., Currow, D., Dudgeon, D., JanJan, N., Strasser, F., von Gunten, C.F. & Von Roenn, J.H. 2009, 'Palliative Cancer Care a Decade Later: Accomplishments, the Need, Next Steps-From the American Society of Clinical Oncology', JOURNAL OF CLINICAL ONCOLOGY, vol. 27, no. 18, pp. 3052-3058.
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Clark, K., Lam, L. & Currow, D. 2009, 'Reducing gastric secretions-a role for histamine 2 antagonists or proton pump inhibitors in malignant bowel obstruction?', SUPPORTIVE CARE IN CANCER, vol. 17, no. 12, pp. 1463-1468.
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Dorman, S., Jolley, C., Abernethy, A., Currow, D., Johnson, M., Farquhar, M., Griffiths, G., Peel, T., Moosavi, S., Byrne, A., Wilcock, A., Alloway, L., Bausewein, C., Higginson, I. & Booth, S. 2009, 'Researching breathlessness in palliative care: consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup', PALLIATIVE MEDICINE, vol. 23, no. 3, pp. 213-227.
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Abernethy, A., Burns, C., Wheeler, J. & Currow, D. 2009, 'Defining distinct caregiver subpopulations by intensity of end-of-life care provided', PALLIATIVE MEDICINE, vol. 23, no. 1, pp. 66-79.
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Agar, M., Currow, D., Plummer, J., Seidel, R., Carnahan, R. & Abernethy, A.P. 2009, 'Changes in Anticholinergic Load From Regular Prescribed Medications in Palliative Care as Death Approaches Editorial Comment', JOURNAL OF UROLOGY, vol. 182, no. 6, pp. 2840-2840.
Tieman, J.J., Sladek, R.M. & Currow, D.C. 2009, 'Multiple sources: mapping the literature of palliative care', PALLIATIVE MEDICINE, vol. 23, no. 5, pp. 425-431.
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Zafar, S.Y., Abernethy, A.P. & Currow, D. 2009, 'Other Problems With Phase III Best Supportive Care Studies IN REPLY', JOURNAL OF CLINICAL ONCOLOGY, vol. 27, no. 5, pp. 829-829.
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Rose, M. & Currow, D.C. 2009, 'The need for chemical compatibility studies of subcutaneous medication combinations used in palliative care.', Journal of pain & palliative care pharmacotherapy, vol. 23, no. 3, pp. 223-230.
When a person with a life-limiting illness is unable to swallow, the subcutaneous route of administration is a widely used way of administering many medications, either as repeated bolus injections or by continuous infusions to complement transdermal, sublingual, or rectal routes of administration. To optimize symptom control as changes are made from other routes of administration to subcutaneous delivery, basic principles for ensuring optimal net clinical benefit (therapeutic benefit and minimizing side effects) must be understood as fully as science will allow. Despite the widespread use of combinations of injectable medications in this clinical setting and the availability of the technology to do the studies, the limited work done suggests that there may be significant drug loss with some combinations of medications without any visual or physical changes apparent. Work needs to be done urgently to evaluate a wide range of medication combinations used extensively in hospice and palliative care for chemical compatibility, while ensuring the work that has been done in other areas (anesthetics, chronic pain) is adopted into practice as results become available. Almost all of these medications are off-patent and there is therefore no financial incentive for the pharmaceutical industry to do the studies on medications now produced generically. Other sources of funding need to be identified. At best, it is likely that optimal symptom control is at times compromised in palliative care without chemical compatibility data for combinations of injectable medications and, at worst, toxicity is generated unknowingly.
Currow, D.C., Ward, A.M. & Abernethy, A.P. 2009, 'Advances in the pharmacological management of breathlessness.', Curr Opin Support Palliat Care, vol. 3, no. 2, pp. 103-106.
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PURPOSE OF REVIEW: To explore advances in the pharmacological treatment of refractory breathlessness and the physiological evidence for treatments. RECENT FINDINGS: The evidence for the role of oral and parenteral opioids in the reduction of breathlessness continues to strengthen from individual studies and from systematic reviews. Importantly, more data are emerging about a lack of lowering in oxygenation or carbon dioxide retention with opioid therapy. In healthy volunteers and those with refractory dyspnoea, nebulized frusemide appears to be worthy of further investigation with adequately powered phase III studies. SUMMARY: Opioids prescribed regularly can help to predictably and safely reduce breathlessness for people with a range of end-stage illnesses.
McCaffrey, N., Currow, D.C. & Eckermann, S. 2009, 'Measuring impacts of value to patients is crucial when evaluating palliative care.', J Pain Symptom Manage, vol. 37, no. 6, pp. e7-e9.
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Currow, D.C. & Abernethy, A.P. 2009, 'Ideas whose times have come.', Curr Opin Support Palliat Care, vol. 3, no. 2, pp. 91-92.
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Rowett, D., Ravenscroft, P.J., Hardy, J. & Currow, D.C. 2009, 'Using national health policies to improve access to palliative care medications in the community.', J Pain Symptom Manage, vol. 37, no. 3, pp. 395-402.
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Access to affordable priority palliative care medicines needs to be informed by good clinical data from well-conducted clinical trials designed to address efficacy, cost-effectiveness, and safety. Availability of priority palliative care symptom control medicines improves the provision of palliation in the place of patient's choice including the community. Within Australia, a National Medicines Policy and a Palliative Care Strategy endorsed by Federal and State and Territory health ministers have facilitated a process to improve the evidence for palliative clinical practice and, through this, improve community availability of key medications for people at the end of life. The initiative, coordinated by a working party under government auspices, has brought together medicine regulators, the pharmaceutical industry, government, policy makers, and clinicians. The brief was to improve availability of key palliative care medications within the current national drug regulatory and funding frameworks. The results to date include: a palliative care section within the Pharmaceutical Benefits Scheme generating the first ever patient-defined section; medicines not previously listed now available; commitment of AU$9.46 M for a national multisite collaborative clinical study network to improve the evidence for clinical interventions in the palliative care setting through systematic investigation with rigorous Phase III and IV studies to inform registration and subsidy applications; and establishing a national Communication Network of the Palliative Care Medications Working Group for the health workforce and community to improve the quality use where improved access has been achieved.
Currow, D.C., To, T.H.M. & Abernethy, A.P. 2009, 'Prescribing at times of clinical transition in chronic or progressive diseases', International Journal of Gerontology, vol. 3, no. 1, pp. 1-8.
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Abernethy, A.P., Uronis, H.E., Wheeler, J.L. & Currow, D.C. 2009, 'Management of dyspnea in patients with chronic obstructive pulmonary disease.', Wien Med Wochenschr, vol. 159, no. 23-24, pp. 583-590.
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A progressive and debilitating illness, chronic obstructive pulmonary disease (COPD) has major worldwide impact. In addition to the care for underlying causes of disease, COPD treatment involves palliative intervention to address associated symptoms; in later stages of disease, when the underlying disease has been maximally treated, symptom management assumes primacy as the goal of care. Dyspnea is the most distressing symptom experienced by COPD patients. When dyspnea cannot be relieved by traditional COPD management strategies (i.e., "refractory dyspnea"), the goal of care shifts from prolonged survival to minimized symptoms, improved function, and enhanced quality of life. Numerous pharmacologic and non-pharmacologic interventions are available to achieve these goals, but supporting evidence is variable. This review summarizes options for managing refractory dyspnea in COPD patients, referring to the available evidence and highlighting areas for further investigation. Topics include oxygen, opioids, psychotropic drugs, inhaled frusemide, Heliox28, nutrition, psychosocial support, and breathing techniques.
Currow, D.C., Wheeler, J.L., Glare, P.A., Kaasa, S. & Abernethy, A.P. 2009, 'A framework for generalizability in palliative care.', J Pain Symptom Manage, vol. 37, no. 3, pp. 373-386.
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Palliative medicine has only recently joined the ranks of evidence-based medical subspecialties. Palliative medicine is a rapidly evolving field, which is quickly moving to redress its historical paucity of high-quality research evidence. This burgeoning evidence base can help support the application of evidence-based principles in palliative and hospice clinical care and service delivery. New knowledge is generally taken into practice relatively slowly by established practitioners. At present, the translation of evidence into palliative and hospice care clinical practice lags behind emerging research evidence in palliative care at even greater rates for three critical reasons: 1) the application of research results to specific clinical subpopulations is complicated by the heterogeneity of palliative care study subpopulations and by the lack of a recognized schema for describing populations or services; 2) definitional issues in service provision are, at best, confusing; and 3) fundamental research concepts (e.g., external validity, effect size, generalizability, applicability) are difficult to apply meaningfully in palliative care. This article provides a suggested framework for classifying palliative care research subpopulations and the clinical subpopulations to which the research findings are being applied to improve the ability of clinicians, health planners, and funders to interpret and apply palliative care research in real-world settings. The framework has five domains: patients and caregivers; health professionals; service issues; health and social policy; and research.
Currow, D.C., Plummer, J.L., Crockett, A. & Abernethy, A.P. 2009, 'A community population survey of prevalence and severity of dyspnea in adults.', J Pain Symptom Manage, vol. 38, no. 4, pp. 533-545.
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Given the progress in the symptomatic treatment of breathlessness, and the physical and psychological morbidity associated with chronic breathlessness, estimates of the size of the population that may benefit from better support become imperative. Prevalence estimates have varied widely (0.9% of clinical encounters to 32%) and have largely relied only on respondents who used clinical services. Whole-of-population approaches may be able to define better the "true" prevalence of chronic breathlessness and quantify exertion limited by breathlessness. The aim of this study was to estimate population levels of chronic breathlessness, severity of limits to exercise, and demographic predictors of the presence of breathlessness. A whole-of-population face-to-face survey method (n=8,396) in South Australia was used, directly standardized for age, gender, country of birth, and rurality. Respondents were asked about breathlessness and levels of exertion causing breathlessness for at least three of the last six months using a modified Medical Research Council dyspnea scale. Univariate and multivariate analyses identify the demographic characteristics of people more likely to experience chronic breathlessness. With a participation rate of 65.3%, 8.9% of respondents had breathlessness that chronically limited exertion. Significant associations with chronic breathlessness in multivariate analysis included female sex (P<0.001), not working full time (P<0.001), low income (P=0.007), and older age (P=0.031). There are significant levels of chronic breathlessness in the community. Given the prevalence, it is feasible to explore the onset of breathlessness, the underlying etiologies and subsequent health service utilization, and health consequences.
Currow, D.C. 2009, 'Even in death ...', J Palliat Med, vol. 12, no. 11, pp. 983-984.
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Currow, D.C. & Rowett, D.S. 2009, 'Cancer pain--progress and ongoing issues in Australia.', Pain Res Manag, vol. 14, no. 5, pp. 351-352.
Clark, K., Currow, D.C., Agar, M., Fazekas, B.S. & Abernethy, A.P. 2008, 'A pilot phase II randomized, cross-over, double-blinded, controlled efficacy study of octreotide versus hyoscine hydrobromide for control of noisy breathing at the end-of-life.', Journal of pain & palliative care pharmacotherapy, vol. 22, no. 2, pp. 131-138.
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Noisy breathing at the end of life (noisy breathing ("NB") occurs in up to 90% of people. Interventions have not been systematically evaluated. There has been clinical observation coupled with a proposed mechanism of effect that supports a role for octreotide in management of NB. The aim of this phase II study was to assess ten completed participants for the feasibility of an adequately powered phase III study. This randomized, double-blind, crossover pilot trial recruited participants from an inpatient palliative unit. Participants while well and their proxies simultaneously provided written informed consent. If NB were encountered, people were randomized to 200 mcg octreotide or 400 mcg hyoscine hydrobromide subcutaneously. If subsequent treatment was needed, the other medication was administered. A five point categorical scale documented the nurses' assessment of secretions over six hours. Eighty participants were consented of whom 10 (3 females, 7 males; median age 79, all with advanced cancer) received medication, five in each arm. There was no difference in the median time to administration of the second medication (3 hours). Two participants in each arm had a 2 category reduction of intensity after the second medication. Although feasible to consent and study this population in a way that respects autonomy and dignity even in the terminal hours of life, this pilot study suggests reconsideration of the pharmacological interventions (choice of agents, dosing, timing of dosing and pharmacokinetic profiles), standardizing of non-pharmacological care; and ways to measure directly family distress before further randomized studies for this symptom.
Jeyasingam, L., Agar, M., Soares, M., Plummer, J. & Currow, D. 2008, 'A prospective study of unmet activity of daily living needs in palliative care inpatients', AUSTRALIAN OCCUPATIONAL THERAPY JOURNAL, vol. 55, no. 4, pp. 266-272.
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Agar, M., Currow, D.C., Shelby-James, T.M., Plummer, J., Sanderson, C. & Abernethy, A.P. 2008, 'Preference for place of care and place of death in palliative care: are these different questions?', PALLIATIVE MEDICINE, vol. 22, no. 7, pp. 787-795.
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Agar, M., Currow, D.C., Plummer, J., Chye, R. & Draper, B. 2008, 'Differing management of people with advanced cancer and delirium by four sub-specialties', PALLIATIVE MEDICINE, vol. 22, no. 5, pp. 633-640.
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Currow, D.C., Agar, M., Tientan, J. & Abernethy, A.P. 2008, 'Multi-site research allows adequately powered palliative care trials; web-based data management makes it achievable today', PALLIATIVE MEDICINE, vol. 22, no. 1, pp. 91-92.
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Currow, D.C., Agar, M., Sanderson, C. & Abernethy, A.P. 2008, 'Populations who die without specialist palliative care: does lower uptake equate with unmet need?', PALLIATIVE MEDICINE, vol. 22, no. 1, pp. 43-50.
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Tieman, J., Sladek, R. & Currow, D. 2008, 'Changes in the Quantity and Level of Evidence of Palliative and Hospice Care Literature: The Last Century', JOURNAL OF CLINICAL ONCOLOGY, vol. 26, no. 35, pp. 5679-5683.
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Waller, A., Girgis, A., Currow, D. & Lecathelinais, C. 2008, 'Development of the Palliative Care Needs Assessment Tool (PC-NAT) for use by multi-disciplinary health professionals', PALLIATIVE MEDICINE, vol. 22, no. 8, pp. 956-964.
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Zafar, S.Y., Currow, D. & Abernethy, A.P. 2008, 'Defining Best Supportive Care', JOURNAL OF CLINICAL ONCOLOGY, vol. 26, no. 31, pp. 5139-5140.
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Boyle, P., Anderson, B.O., Andersson, L.C., Ariyaratne, Y., Auleley, G.-.R., Barbacid, M., Bartelink, H., Baselga, J., Behbehani, K., Belardelli, F., Berns, A., Bishop, J., Brawley, O., Burns, H., Clanton, M., Cox, B., Currow, D., Dangou, J.-.M., de Valeriola, D., Dinshaw, K., Eggermont, A., Fitzpatrick, J., Forstmane, M., Garaci, E., Gavin, A.T., Kakizoe, T., Kasler, M., Keita, N., Kerr, D., Khayat, D., Khleif, S., Khuhaprema, T., Knezevic, T., Kubinova, R., Mallath, M., Martin-Moreno, J., McCance, D., McVie, J.G., Merriman, A., Ngoma, T., Nowacki, M., Orgelbrand, J., Park, J.-.G., Pierotti, M., Ashton, L.P., Puska, P., Escobar, C.V.R., Rajan, B., Rajkumar, T., Ringborg, U., Robertson, C., Rodger, A., Roovali, L., Santini, L.A., Sarhan, M., Seffrin, J., Semiglazov, V., Shrestha, B.M., Soo, K.C., Stamenic, V., Tamblyn, C., Thomas, R., Tuncer, M., Tursz, T., Vaitkiene, R., Vallejos, C., Veronesi, U., Wojtyla, A., Yach, D., Yoo, K.-.Y., Zatonski, W., Zaridze, D., Zeng, Y.-.X., Zhao, P. & Zheng, T. 2008, 'Need for global action for cancer control', ANNALS OF ONCOLOGY, vol. 19, no. 9, pp. 1519-1521.
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Cranston, J.M., Crockett, A. & Currow, D. 2008, 'Oxygen therapy for dyspnoea in adults', COCHRANE DATABASE OF SYSTEMATIC REVIEWS, no. 3.
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Aoun, S., Kristjanson, L.J., Oldham, L. & Currow, D. 2008, 'A qualitative investigation of the palliative care needs of terminally ill people who live alone', COLLEGIAN, vol. 15, no. 1, pp. 3-9.
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Clayton, J.M., Hancock, K., Parker, S., Butow, P.N., Walder, S., Carrick, S., Currow, D., Ghersi, D., Glare, P., Hagerty, R., Olver, I.N. & Tattersall, M.H.N. 2008, 'Sustaining hope when communicating with terminally ill patients and their families: a systematic review', PSYCHO-ONCOLOGY, vol. 17, no. 7, pp. 641-659.
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Currow, D.C., Christou, T., Smith, J., Carmody, S., Lewin, G., Aoun, S. & Abernethy, A.P. 2008, 'Do Terminally Ill People Who Live Alone Miss Out on Home Oxygen Treatment? An Hypothesis Generating Study (vol 11, pg 1015, 2008)', JOURNAL OF PALLIATIVE MEDICINE, vol. 11, no. 9, pp. 1285-1285.
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Currow, D.C., Burns, C.M. & Abernethy, A.P. 2008, 'Financial burden of caring until the end of life', INTERNAL MEDICINE JOURNAL, vol. 38, no. 9, pp. 745-745.
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Dupont, A., Abernethy, A., Bums, C.M., Wheeler, J. & Currow, D. 2008, 'Defining distinct Caregiver sub-populations by intensity of end-of-life care provided', PSYCHO-ONCOLOGY, vol. 17, pp. S122-S122.
Uronis, H.E., Currow, D.C., McCrory, D.C., Samsa, G.P. & Abernethy, A.P. 2008, 'Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis', BRITISH JOURNAL OF CANCER, vol. 98, no. 2, pp. 294-299.
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Johnson, C.E., Girgis, A., Paul, C.L. & Currow, D.C. 2008, 'Cancer specialists' palliative care referral practices and perceptions: results of a national survey', PALLIATIVE MEDICINE, vol. 22, no. 1, pp. 51-57.
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Currow, D.C. 2008, 'Managing respiratory symptoms in everyday practice.', Curr Opin Support Palliat Care, vol. 2, no. 2, pp. 81-83.
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Currow, D.C., Allen, K., Plummer, J., Aoun, S., Hegarty, M. & Abernethy, A.P. 2008, 'Bereavement help-seeking following an 'expected' death: a cross-sectional randomised face-to-face population survey', BMC Palliative Care, vol. 7, no. 1.
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Currow, D.C., Ward, A.M., Plummer, J.L., Bruera, E. & Abernethy, A.P. 2008, 'Comfort in the last 2 weeks of life: relationship to accessing palliative care services.', Support Care Cancer, vol. 16, no. 11, pp. 1255-1263.
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INTRODUCTION: Specialised palliative care services (SPCS) aim to address the needs of patients and caregivers confronting life-limiting illnesses but only half of the potential cohort are referred. Randomised controlled trials of SPCS provision can no longer be ethically justified so there is a need to develop new methods to evaluate the net impact of SPCS for the whole community, not just for those who access SPCS. The aim of this study was to assess whether perceived comfort in the last 2 weeks of life was associated with accessing SPCS. METHODS: This study utilised a whole-of-population random survey (n = 4,366) in South Australia. A total of 802 respondents had someone close to them die within the last 5 years due to a terminal illness, and they had the complete data. A subsequent question was asked whether SPCS had been accessed. Perceived comfort levels for those who had used SPCS were compared with those who did not by using stereotype logistic regression, weighted to a standardised population. RESULTS: Higher levels of comfort of the deceased having been assessed 'very comfortable' was associated with the use of SPCS (p = 0.04; odds ratio, 1.78; 95% confidence interval, 1.02-3.08). For people who accessed SPCS, 13.3% were reported as 'very comfortable' compared with 8.0% without SPCS. Almost one half of respondents (48.4%) reported that the deceased was considered 'uncomfortable' or 'very uncomfortable', irrespective of SPCS access. DISCUSSION: While this study provides further incremental evidence of benefit from access to SPCS, there is much that still needs to be done to improve care for the whole community at the end of life.
Currow, D.C., Christou, T., Smith, J., Carmody, S., Lewin, G., Aoun, S. & Abernethy, A.P. 2008, 'Do terminally ill people who live alone miss out on home oxygen treatment? An hypothesis generating study.', J Palliat Med, vol. 11, no. 7, pp. 1015-1022.
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INTRODUCTION: Oxygen for refractory dyspnea at the end of life is commonly prescribed, even when the criteria for long-term home oxygen therapy are not met. Is palliative oxygen less likely to be prescribed when a person lives alone at the end of life? METHODS: Three years of consecutively collected clinical data from a regional community palliative care program in Western Australia were used in univariate analyses utilizing chi(2) and analysis of variance, as appropriate. Multivariable logistic regression was used to identify characteristics of people for who oxygen has been prescribed. RESULTS: Of the study population (n = 5203), 9.8% (n = 507) did not have a caregiver. Oxygen was less likely to be prescribed for patients living alone (11.8% versus caregiver 20.6%; p < 0.001), those with cancer (18.8% versus noncancer 26.5%; p < 0.001), and older people (oxygen 68.1 years versus no oxygen 69.6 years; p = 0.005), and more likely to be prescribed for those with worse dyspnea (mean score 7/10, oxygen 7.6 versus no oxygen 4.2; p < 0.001). With severe dyspnea (= 7/10), people who lived alone had twice as many clinician visits before oxygen was prescribed (4.2 versus caregiver 1.7; p = 0.03). In multifactor analyses lung disease, dyspnea severity, and female gender predicted oxygen prescription, while not having a caregiver reduced the likelihood significantly (odds ration [OR] 0.51, 95% confidence interval [CI] 0.35-0.74; p < 0.001). DISCUSSION: Presence of a caregiver in the home is associated with palliative oxygen prescription having controlled for time in hospital. This study raises questions about the reasons for oxygen prescription, and the role caregivers may play in initiating requests for therapy.
Currow, D.C., Eagar, K., Aoun, S., Fildes, D., Yates, P. & Kristjanson, L.J. 2008, 'Is it feasible and desirable to collect voluntarily quality and outcome data nationally in palliative oncology care?', J Clin Oncol, vol. 26, no. 23, pp. 3853-3859.
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Hospice/palliative care is a critical component of cancer care. In Australia, more than 85% of people referred to specialized hospice/palliative care services (SHPCS) have a primary diagnosis of cancer, and 60% of people who die from cancer will be referred to SHPCS. The Palliative Care Outcomes Collaboration (PCOC) is an Australian initiative that allows SHPCS to collect nationally agreed-upon measures to better understand quality, safety, and outcomes of care. This article describes data (October 2006 through September 2007) from the first 22 SHPCS, with more than 100 inpatient admissions annually. Data include phase of illness, place of discharge, and, at each transition in place of care, the person's functional status, dependency, and symptom scores. Data are available for 5,395 people for 6,379 admissions. After categorizing by phase of illness and dependency, there remain at the end of each admission 12-fold differences (mean, 26%; range, 4% to 52%) in the percentage of patients who became stable after an unstable phase; seven-fold differences (mean, 22%; range, 6% to 41%) in the percentage of patients with improved symptom scores, five-fold differences (mean, 25%; range, 12% to 64%) in discharge back to the community, four-fold differences (mean, 10%; range, 4% to 16%) in improved function, and three-fold differences in the length of stay (mean, 14 days; range, 6 to 19 days). PCOC shows it is feasible to collect quality national palliative care outcome data voluntarily. Variations in outcomes justify continued enrollment of services. Benchmarking should include all patients whose cancer will cause death and explore observed variations.
Abernethy, A.P., Currow, D.C., Fazekas, B.S., Luszcz, M.A., Wheeler, J.L. & Kuchibhatla, M. 2008, 'Specialized palliative care services are associated with improved short- and long-term caregiver outcomes.', Support Care Cancer, vol. 16, no. 6, pp. 585-597.
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GOALS OF WORK: The goal of this study was to evaluate, at a population level, the association between specialized palliative care services (SPCS) and short- and long-term caregiver outcomes. PATIENTS AND METHODS: The Health Omnibus Survey, a face-to-face survey conducted annually in South Australia since 1991, collects health-related data from a rigorously derived, representative sample of 4,400 households. This study included piloted questions in the 2001, 2002, and 2003 Health Omnibus Survey on the impact of SPCS. Sample size was 9,088 individuals. "Unmet needs," a short-term outcome relevant to the caregiving period during a life-limiting illness, were tallied. "Moving on," a long-term caregiver-defined outcome reflecting the caregiver's adaptation and return to a new equilibrium after the death, was assessed with and without SPCS. RESULTS: Thirty-seven percent (3,341) indicated that someone close to them had died of a terminal illness in the preceding 5 years, of whom 949 (29%) reported that they provided care. SPCS were involved in caring for 60% of deceased patients. Day-to-day caregivers indicated fewer unmet needs when SPCS were involved (p = 0.0028). More caregivers were able to "move on" with their lives when SPCS were involved than when SPCS were not involved (86 vs 77%, p = 0.0016); this effect was greatest in the first 2 years after the loved one's death. CONCLUSION: At a population level, SPCS were associated with meaningful improvements in short-term ("unmet needs") and long-term ("moving on") caregiver-defined outcomes.
Abernethy, A.P. & Currow, D.C. 2008, 'Culture and financing influence palliative care services, study populations, and generalizability of research findings.', J Palliat Med, vol. 11, no. 2, p. 146.
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Abernethy, A.P., Uronis, H.E., Wheeler, J.L. & Currow, D.C. 2008, 'Pharmacological management of breathlessness in advanced disease', Progress in Palliative Care, vol. 16, no. 1, pp. 15-20.
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Currow, D.C., Ward, A., Clark, K., Burns, C.M. & Abernethy, A.P. 2008, 'Caregivers for people with end-stage lung disease: characteristics and unmet needs in the whole population.', Int J Chron Obstruct Pulmon Dis, vol. 3, no. 4, pp. 753-762.
INTRODUCTION: End-stage lung disease (ESLD) (predominantly caused by chronic obstructive pulmonary disease and restrictive lung disease) is a significant cause of death. Little is known about community care for people with ESLD especially in the period leading to death. This paper describes demographic characteristics of caregivers, and key characteristics of the deceased irrespective of specialist service utilization. METHODS: The South Australian Health Omnibus is an annual, random, face-to-face, cross-sectional survey conducted statewide. For the last eight years questions about end of life have been asked of 3000 respondents annually (participation rate 77.9%). Directly standardized to the whole population, this study describes people who cared for someone with ESLD until death. RESULTS: One third (6370/18267) had someone die in the last five years from a terminal illness, 644 from ESLD (3.5% of respondents; 10.2% of deaths). One in five (20.8%) provided physical care: 43 respondents provided day-to-day and 63 provided intermittent hands-on care for an average of 40.1 months (SD 56.9). Caregivers were on average 51.2 years old (range 17-85; SD 16.5) and one in five was a spouse. Additional support to provide physical care was an unmet need by 17% of caregivers. The deceased were an average of 73.9 years old (range 47-92; SD 10.4). Only 31.1% were assessed as 'comfortable' or 'very comfortable' in the last fortnight of life. DISCUSSION: Given the health consequences of caregiving, caregivers of people with ESLD would benefit from prospectively defining their needs given the time for which intense caregiving is provided.
Grbich, C., Abernethy, A.P., Shelby-James, T., Fazekas, B. & Currow, D.C. 2008, 'Creating a research culture in a palliative care service environment: a qualitative study of the evolution of staff attitudes to research during a large longitudinal controlled trial (ISRCTN81117481).', J Palliat Care, vol. 24, no. 2, pp. 100-109.
This study investigated the impact of a three-year randomized control trial of different models of service provision on palliative care staff associated with the hospice where the trial was being conducted. Eleven open access de-identified qualitative focus groups were held over a period of three years: three months into the trial, one year after its inception, and at the end of the trial. Four staff groups were involved: inpatient hospice nurses, palliative care outreach nurses, medical palliative specialists, and administrative staff and social workers. Initially the impact of the trial produced high levels of staff stress which largely diminished over time, to be replaced by enthusiasm for the changes achieved and sadness that post trial the perceived benefits gained would be lost. When attempting to change a clinical culture to incorporate research, and in particular where increased staff workload is involved, highly interactive levels of communication and valuing of staff input are required to minimize the stress and burden of this imposition.
Greene, A.G., Kenny, B. & Currow, D.C. 2008, 'Reducing the paperwork for residential aged-care facility waiting lists.', Med J Aust, vol. 189, no. 1, p. 50.
Currow, D.C., Burns, C.M. & Abernethy, A.P. 2008, 'Place of death for people with noncancer and cancer illness in South Australia: a population-based survey.', J Palliat Care, vol. 24, no. 3, pp. 144-150.
A large representative population survey of 9,500 households reports the association between place of death, diagnosis (cancer vs. noncancer), and use of palliative care services of terminally ill South Australians. Thirty-one percent (1,920) indicated that someone close to them had died of a terminal illness in the preceding five years; 18% had died of noncancer illness and 82% of cancer. Sixty-two percent of deceased individuals accessed palliative care services. More patients with cancer than noncancer had had palliative care (65% vs. 48%; p < 0.0001). Compared with cancer patients, those with noncancer illness had died in hospices less frequently (9% vs. 15%; p = 0.0015) and in nursing homes more frequently (15% vs. 5%; p < 0.0001). Similar proportions had died in hospital (60%) and at home (16%-20%). Palliative care service involvement did not reduce institutional deaths, but shifted them from hospital to hospice.
Nadimi, F. & Currow, D.C. 2008, 'Transitions in parenting responsibilities for sole parents who are dying.', J Palliat Care, vol. 24, no. 3, pp. 167-172.
Hancock, K., Clayton, J.M., Parker, S.M., Wall der, S., Butow, P.N., Carrick, S., Currow, D., Ghersi, D., Glare, P., Hagerty, R. & Tattersall, M.H.N. 2007, 'Truth-telling in discussing prognosis in advanced life-limiting illnesses: a systematic review', PALLIATIVE MEDICINE, vol. 21, no. 6, pp. 507-517.
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Hancock, K., Clayton, J.M., Parker, S.M., Walder, S., Blttow, P.N., Carrick, S., Currow, D., Ghersi, D., Glare, P., Hagerty, R. & Tattersall, M.H.N. 2007, 'Discrepant perceptions about end-of-life communication: A systematic review', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 34, no. 2, pp. 190-200.
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Parker, S.M., Clayton, J.M., Hancock, K., Walder, S., Butow, P.N., Carrick, S., Currow, D., Ghersi, D., Glare, P., Hagerty, R. & Tattersall, M.H.N. 2007, 'A systematic review of prognostic/end-of-life communication with adults in the advanced stages of a life-limiting illness: patient/caregiver preferences for the content, style, and timing of information.', Journal of pain and symptom management, vol. 34, no. 1, pp. 81-93.
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Evidence-based recommendations concerning how to discuss dying, life expectancy, and likely future symptoms with patients with a limited life expectancy and their families are lacking. The aim of this systematic review was to review studies regarding prognostic/end-of-life communication with adult patients in the advanced stages of a life-limiting illness and their caregivers. Relevant studies meeting the inclusion criteria were identified by searching computerized databases up to November 2004. One hundred twenty-three studies met the criteria for the full review, and 46 articles reported on patient/caregiver preferences for content, style, and timing of information. The majority of the research was descriptive. Although there were individual differences, patients/caregivers in general had high levels of information need at all stages of the disease process regarding the illness itself, likely future symptoms and their management, and life expectancy and information about clinical treatment options. Patient and caregiver information needs showed a tendency to diverge as the illness progressed, with caregivers needing more and patients wanting less information. Patients and caregivers preferred a trusted health professional who showed empathy and honesty, encouraged questions, and clarified each individual's information needs and level of understanding. In general, most patients/caregivers wanted at least some discussion of these topics at the time of diagnosis of an advanced, progressive, life-limiting illness, or shortly after. However, they wanted to negotiate the content and extent of this information.
Aoun, S., Kristjanson, L.J., Currow, D., Skett, K., Oldham, L. & Yates, P. 2007, 'Terminally-ill people living alone without a caregiver: an Australian national scoping study of palliative care needs', PALLIATIVE MEDICINE, vol. 21, no. 1, pp. 29-34.
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Parker, S.M., Clayton, J.M., Hancock, K., Walder, S., Butow, P.N., Carrick, S., Currow, D., Ghersi, D., Glare, P., Eth, A., Hagerty, R. & Tattersall, M.H.N. 2007, 'A systematic review of Prognostic/End-of-Life communication with adults in the advanced stages of a life-limiting illness: Patient/caregiver preferences for the content, style, and timing of information', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 34, no. 1, pp. 81-93.
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Tieman, J., Mitchell, G., Shelby-James, T., Currow, D., Fazekas, B., O'Doherty, L., Hegarty, M., Eriksson, L., Brown, R. & Reid-Orr, D. 2007, 'Integration, coordination and multidisciplinary care: What can these approaches offer to Australian primary health care?', AUSTRALIAN JOURNAL OF PRIMARY HEALTH, vol. 13, no. 2, pp. 56-65.
Clayton, J.M., Hancock, K.M., Butow, P.N., Tattersall, M.H., Currow, D.C., Adler, J., Aranda, S., Auret, K., Boyle, F., Britton, A., Chye, R., Clark, K., Davidson, P., Davis, J.M., Girgis, A., Graham, S., Hardy, J., Introna, K., Kearsley, J., Kerridge, I., Kristjanson, L., Martin, P., McBride, A., Meller, A., Mitchell, G., Moore, A., Noble, B., Olver, I., Parker, S., Peters, M., Saul, P., Stewart, C., Swinburne, L., Tobin, B., Tuckwell, K. & Yates, P. 2007, 'Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers.', The Medical journal of Australia, vol. 186, no. 12 Suppl, pp. S77-108.
Currow, D.C., Stevenson, J.P., Abernethy, A.P., Plummer, J. & Shelby-James, T.M. 2007, 'Prescribing in palliative care as death approaches.', J Am Geriatr Soc, vol. 55, no. 4, pp. 590-595.
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OBJECTIVES: To determine how prescribing for comorbid illnesses and symptom control changes during the palliative phase of a terminal illness. DESIGN: This prospective cohort study explores the relative contribution to prescribing of symptom-specific medications (SSMs) and long-term medications for comorbid medical conditions. SETTING: Regional consultative palliative care program, Adelaide, South Australia. PARTICIPANTS: Two hundred sixty consecutive patients, 96% of whom had cancer, who enrolled and subsequently died in a larger randomized trial exploring palliative service delivery. MEASUREMENTS: Medication and performance data were collected monthly from referral until death (mean 107 days, median 93 days, standard deviation (SD) 103 days, range 11-752 days). Prespecified subgroup analyses of age, performance status, and the baseline use of medications for comorbid medical conditions were performed. RESULTS: At baseline, the mean total number of medications+/-SD was 4.9+/-2.8 (range 0-16), SSMs was 2.3+/-1.5 (range 0-7), and medications for comorbid medical conditions was 2.6+/-2.4 (range 0-13). As death approached, the total number of medications increased because of SSM prescribing (2.5 more medications, 95% confidence interval (CI)=2.2-2.9; P<.001) with a decrease in medications for comorbid medical conditions (1.1 fewer medications, 95% CI=0.8-1.3; P<.001). There was an increase in the number of medications meeting Beers' criteria for high-risk inappropriate medication use for SSMs (29% to 48%). More SSMs were prescribed in people with better performance status, and older participants took more medications for comorbid medical conditions. CONCLUSION: Prescribing changes as life-limiting illnesses progress, with older people taking more medications. Medications for comorbid medical conditions should be reviewed in the context of their original therapeutic goals.
Currow, D.C., Plummer, J., Frith, P. & Abernethy, A.P. 2007, 'Can we predict which patients with refractory dyspnea will respond to opioids?', J Palliat Med, vol. 10, no. 5, pp. 1031-1036.
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INTRODUCTION: Dyspnea is frequently encountered in end-stage diseases even when reversible issues are addressed. Which clinical factors best define patient subpopulations that will most predictably benefit from opioids in this clinical setting? METHODS: Thirty-eight patients with refractory dyspnea were randomized to an 8-day crossover trial of 4 days of 20 mg sustained release morphine or placebo, switching arms on day 5 (Clinical Trial Registry Number: ACTRN012607000075482). Dyspnea was measured on a 100-mm visual analogue scale (VAS). Day 4 and day 8 morning and evening VAS scores were the primary outcome. Correlation between baseline dyspnea and response to opioids was explored; potentially important clinical predictors tested with two-sided Student's t test. RESULTS: In this exploratory study, no relationship could be defined between baseline dyspnea and response to opioids (Spearman correlation 0.03, p = 0.88). The study was not powered to define other predictors, but younger age, better functional status, and significant cardiac findings on entry to the study deserve further prospective evaluation in a larger cohort. DISCUSSION: Phase 4 pharmaco-vigilance trials are needed in palliative care to define people who are most likely to experience a net benefit from treatment such as opioids for refractory dyspnea.
Shelby-James, T.M., Abernethy, A.P., McAlindon, A. & Currow, D.C. 2007, 'Handheld computers for data entry: High tech has its problems too', Trials, vol. 8.
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Currow, D.C., Fazekas, B. & Abernethy, A.P. 2007, 'Oxygen use--patients define symptomatic benefit discerningly.', J Pain Symptom Manage, vol. 34, no. 2, pp. 113-114.
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Currow, D.C. & Abernethy, A.P. 2007, 'Pharmacological management of dyspnoea.', Curr Opin Support Palliat Care, vol. 1, no. 2, pp. 96-101.
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PURPOSE OF REVIEW: This paper reviews the current evidence for the pharmacological treatment of refractory symptomatic breathlessness in people with advanced life-limiting illnesses. The paper does not explore changes in function. RECENT FINDINGS: Oral and parenteral opioids reduce dyspnoea, and data continue to add to this indication for these drugs. Optimal dosing of opioids is being refined. Interest in other medications continues to be explored - benzodiazepines, nebulised frusemide, and selective serotonin reuptake inhibitors - but their role in day-to-day clinical practice is not defined. SUMMARY: Low-dose regular opioids, especially sustained-release preparations, have a key role in the pharmacological management of dyspnoea when titrated for effect, and may be used regularly across a range of underlying pathophysiologies. Key research questions for all the current symptomatic pharmacological agents used in refractory dyspnoea remain.
Clayton, J.M., Butow, P.N., Tattersall, M.H.N., Devine, R.J., Simpson, J.M., Aggarwal, G., Clark, K.J., Currow, D.C., Elliott, L.M., Lacey, J., Lee, P.G. & Noel, M.A. 2007, 'Randomized controlled trial of a prompt list to help advanced cancer patients and their caregivers to ask questions about prognosis and end-of-life care.', J Clin Oncol, vol. 25, no. 6, pp. 715-723.
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PURPOSE: To determine whether provision of a question prompt list (QPL) influences advanced cancer patients'/caregivers' questions and discussion of topics relevant to end-of-life care during consultations with a palliative care (PC) physician. PATIENTS AND METHODS: This randomized controlled trial included patients randomly assigned to standard consultation or provision of QPL before consultation, with endorsement of the QPL by the physician during the consultation. Consecutive eligible patients with advanced cancer referred to 15 PC physicians from nine Australian PC services were invited to participate. Consultations were audiotaped, transcribed, and analyzed by blinded coders; patients completed questionnaires before, within 24 hours, and 3 weeks after the consultation. RESULTS: A total of 174 patients participated (92 QPL, 82 control). Compared with controls, QPL patients and caregivers asked twice as many questions (for patients, ratio, 2.3; 95% CI, 1.7 to 3.2; P < .0001), and patients discussed 23% more issues covered by the QPL (95% CI, 11% to 37%; P < .0001). QPL patients asked more prognostic questions (ratio, 2.3; 95% CI, 1.3 to 4.0; P = .004) and discussed more prognostic (ratio, 1.43; 95% CI, 1.1 to 1.8, P = .003) and end-of-life issues (30% v 10%; P = .001). Fewer QPL patients had unmet information needs about the future (21 = 4.14; P = .04), which was the area of greatest unmet information need. QPL consultations (average, 38 minutes) were longer (P = .002) than controls (average, 31 minutes). No differences between groups were observed in anxiety or patient/physician satisfaction. CONCLUSION: Providing a QPL and physician endorsement of its use assists terminally ill cancer patients and their caregivers to ask questions and promotes discussion about prognosis and end-of-life issues, without creating patient anxiety or impairing satisfaction.
Currow, D.C., Plummer, J.L., Cooney, N.J., Gorman, D. & Glare, P.A. 2007, 'A randomized, double-blind, multi-site, crossover, placebo-controlled equivalence study of morning versus evening once-daily sustained-release morphine sulfate in people with pain from advanced cancer.', J Pain Symptom Manage, vol. 34, no. 1, pp. 17-23.
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Diurnal variation in pain perception is recognized. The question of whether opioid prescribing should be adjusted to account for diurnal variation can be tested with the advent of once-daily sustained-release morphine. The study recruited 45 people with opioid-responsive pain on stable doses of analgesics and advanced cancer from five regional palliative care programs in Australia. Each participant took one placebo and a 24-hourly dose of sustained-release morphine daily, 12 hours apart-active dose in the morning for one week and in the evening for the other week. The order of the weeks was randomized in a double-blind manner. The primary outcome from the last two days (steady state) on both arms was averaged four-hourly pain scores while awake on a 100 mm visual analogue scale (VAS). Secondary outcomes included VAS and categorical scales for other pain parameters, quality of sleep, nausea, vomiting, constipation, confusion, and somnolence. Twenty-six of 42 participants completed the study and provided adequate power for analysis. Mean VAS was 16 mm for morning dosing and 14 mm for evening dosing (P=0.76, difference of adjusted means 2 mm, 95% confidence interval: -2, 6). No differences were found in pain control, pain during the day, pain disturbing sleep, or with breakthrough medication use. This study suggests that any difference between morning and evening dosing of once-daily sustained-release morphine in people with significant opioid-responsive pain and advanced cancer is small and unlikely to be clinically significant for most people.
Stevenson, J.P., Currow, D.C. & Abernethy, A.P. 2007, 'Frameworks for prescribing in comorbid illness.', J Pain Symptom Manage, vol. 34, no. 2, pp. 117-118.
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Hegarty, M. & Currow, D.C. 2007, 'Palliative aged care: Collaborative partnerships between gerontology, geriatrics and palliative care', International Journal of Gerontology, vol. 1, no. 3, pp. 112-117.
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Sladek, R.M., Tieman, J. & Currow, D.C. 2007, 'Improving search filter development: a study of palliative care literature.', BMC Med Inform Decis Mak, vol. 7, p. 18.
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BACKGROUND: It is difficult to systematically search for literature relevant to palliative care in general medical journals. A previously developed search filter for use on OVID Medline validated using a gold standard set of references identified through hand searching, achieved an unacceptably low sensitivity (45.4%). Retrieving relevant literature is integral to support evidence based practice, and understanding the nature of the incorrectly excluded citations (false negatives) using the filter may lead to improvement in the filter's performance. METHODS: The objectives were to describe the nature of subjects reflected in the false negative citations and to empirically improve the sensitivity of the search filter. A thematic analysis of MeSH terms by three independent reviewers was used to describe the subject coverage of the missed records. Using a frequency analysis of MeSH terms, those headings which could individually contribute at least 2.5% to sensitivity (occurring 19 or more times) were added to the search filter. All previously run searches were rerun at the same time as the revised filter, and results compared. RESULTS: Thematic analysis of MeSH terms identified thirteen themes reflected in the missing records, none of them intrinsically palliative. The addition of six MeSH terms to the existing search filter (physician-patient relations, prognosis, quality of life, survival rate, treatment outcome and attitude to health) led to an increase in sensitivity from 46.3% to 64.7%, offset by a decrease in precision from 72.6% to 21.9%. CONCLUSION: The filter's sensitivity was successfully increased using frequency analysis of MeSH terms, offset by a decrease in precision. A thematic analysis of MeSH terms for the false negative citations confirmed the absence of any intrinsically palliative theme or term, suggesting that future improvements to search filters for palliative care literature will first depend on better identifying how clinicians and researcher...
Clayer, M.T. 2007, 'Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers.', Med J Aust, vol. 187, no. 8, p. 478.
Sanderson, C.R., Koczwara, B. & Currow, D.C. 2007, 'In reply [4]', Medical Journal of Australia, vol. 186, no. 4, pp. 214-215.
Shelby-James, T.M., Currow, D.C., Phillips, P.A., Williams, H. & Abernethy, A.P. 2007, 'Promoting patient centred palliative care through case conferencing.', Aust Fam Physician, vol. 36, no. 11, pp. 961-964.
BACKGROUND: What are the characteristics of case conferences between general practitioners and specialised palliative care services (SPCS)? METHODS: Study participants were adults (N=461) with pain in the preceding 3 months who were referred to a SPCS and their GPs (N=230). Patients were randomised to case conferences or routine care by SPCS. RESULTS: One hundred and sixty-seven conferences were held; 46 patients withdrew and 142 died before the conference could be conducted. Medicare payment was requested for 72 (43%) conferences. Median time from randomisation to case conference was 52 days (SD: 55), and from case conference to death/end of study was 79 days (SD: 166). Twenty-five percent of conferences had over three health professionals participant; patients and/or their caregivers participated in 91%. Average conference duration was 39 minutes (SD: 13). Mean conference length did not increase when more health professionals were present (3 vs. >3, 39 [SD: 14] vs. 42 [SD 11] minutes, p=0.274), nor when patients/caregivers were present (present vs. absent, 39 [SD: 13] vs. 44 [SD: 14] minutes, p=0.159). DISCUSSION: Case conferencing involving SPCS, the GP, other health professionals and the patient can be an efficient part of routine care.
Clayton, J.C., Hancock, K.M., Butow, P.N., Tattersall, M.H.N. & Currow, D.C. 2007, 'Reply', Medical Journal of Australia, vol. 187, no. 8, p. 478.
Uronis, H.E., McCrory, D.C., Samsa, G.P., Currow, D.C. & Abernethy, A. 2007, 'Palliative oxygen for non-hypoxaemic chronic obstructive pulmonary disease', Cochrane Database of Systematic Reviews, no. 2.
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Stevenson, J.P., Currow, D.C. & Abernethy, A.P. 2007, 'The broader implications of managing statins at the end of life.', J Palliat Care, vol. 23, no. 3, pp. 188-189.
Currow, D. & Abernethy, A.P. 2006, 'A framework for managing comorbid conditions in palliative care', JOURNAL OF PALLIATIVE MEDICINE, vol. 9, no. 3, pp. 620-620.
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Agar, M., Chye, R., Currow, D. & Draper, B. 2006, 'Survey of current practice: Management of delirium by palliative care, psychogeriatric, geriatric, and oncology specialists in Australia and New Zealand', JOURNAL OF PALLIATIVE CARE, vol. 22, no. 3, pp. 209-210.
Currow, D., Hegarty, M., Allen, K., Swetenham, K. & Abernethy, A. 2006, 'Bereavement help-seeking following a palliative death', JOURNAL OF PALLIATIVE CARE, vol. 22, no. 3, pp. 192-192.
Allen, K., Swetenham, K., Currow, D., Hegarty, M. & Abernthy, A. 2006, 'Bereavement help-seeking following a palliative death-a cross-sectional randomised population survey', PSYCHO-ONCOLOGY, vol. 15, no. 2, pp. S425-S426.
Currow, D., Shelby-James, T., Plummer, J., Stevenson, J. & Abernethy, A. 2006, 'Polypharmacy worsens as death approaches', JOURNAL OF PALLIATIVE CARE, vol. 22, no. 3, pp. 214-214.
Currow, D.C., Abernethy, A.P., Shelby-James, T.M. & Phillips, P.A. 2006, 'The impact of conducting a regional palliative care clinical study.', Palliat Med, vol. 20, no. 8, pp. 735-743.
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End-of-life care must be informed by methodologically rigorous, high-quality research, but well-documented barriers make the conduct of palliative care clinical trials difficult. With careful consideration to study design and procedures, these barriers are surmountable. This paper discusses the approach used in a large scale, randomised, controlled trial of service-based interventions in a regional palliative care service in South Australia, and the impact of this trial on palliative care research more broadly, the changes to the service in which it was conducted, and on health policy beyond palliative care. The Palliative Care Trial evaluated three interventions in a 2 x 2 x 2 factorial cluster randomised design: case conferences, general practitioner education, and patient education. Main outcomes were performance status, pain intensity, and resource utilisation. A total of 461 patients were enrolled in the study. Pre-study planning and piloting is crucial, and accurately estimated withdrawal and death rates in the study. Other study design elements that facilitated this research included assessment of three interventions at one time, a dedicated recruitment role, a single clinical triage point, embedding data collection into routine clinical assessments, and meaningful outcome measures. Recruitment and retention of participants is possible if barriers are systematically identified and addressed. This study challenged and developed the research culture within our clinical team and subsequently translated into further research.
Abernethy, A.P., Currow, D.C., Hunt, R., Williams, H., Roder-Allen, G., Rowett, D., Shelby-James, T., Esterman, A., May, F. & Phillips, P.A. 2006, 'A pragmatic 2 x 2 x 2 factorial cluster randomized controlled trial of educational outreach visiting and case conferencing in palliative care-methodology of the Palliative Care Trial [ISRCTN 81117481].', Contemp Clin Trials, vol. 27, no. 1, pp. 83-100.
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The demand for palliative care is increasing, yet there are few data on the best models of care nor well-validated interventions that translate current evidence into clinical practice. Supporting multidisciplinary patient-centered palliative care while successfully conducting a large clinical trial is a challenge. The Palliative Care Trial (PCT) is a pragmatic 2 x 2 x 2 factorial cluster randomized controlled trial that tests the ability of educational outreach visiting and case conferencing to improve patient-based outcomes such as performance status and pain intensity. Four hundred sixty-one consenting patients and their general practitioners (GPs) were randomized to the following: (1) GP educational outreach visiting versus usual care, (2) Structured patient and caregiver educational outreach visiting versus usual care and (3) A coordinated palliative care model of case conferencing versus the standard model of palliative care in Adelaide, South Australia (3:1 randomization). Main outcome measures included patient functional status over time, pain intensity, and resource utilization. Participants were followed longitudinally until death or November 30, 2004. The interventions are aimed at translating current evidence into clinical practice and there was particular attention in the trial's design to addressing common pitfalls for clinical studies in palliative care. Given the need for evidence about optimal interventions and service delivery models that improve the care of people with life-limiting illness, the results of this rigorous, high quality clinical trial will inform practice. Initial results are expected in mid 2005.
Uronis, H.E., Currow, D.C. & Abernethy, A.P. 2006, 'Palliative management of refractory dyspnea in COPD.', Int J Chron Obstruct Pulmon Dis, vol. 1, no. 3, pp. 289-304.
COPD is a progressive illness with worldwide impact. Patients invariably reach a point at which they require palliative interventions. Dyspnea is the most distressing symptom experienced by these patients; when not relieved by traditional COPD management strategies it is termed "refractory dyspnea" and palliative approaches are required. The focus of care shifts from prolonging survival to reducing symptoms, increasing function, and improving quality of life. Numerous pharmacological and non-pharmacological interventions can achieve these goals, though evidence supporting their use is variable. This review provides a summary of the options for the management of refractory dyspnea in COPD, outlining currently available evidence and highlighting areas for further investigation. Topics include oxygen, opioids, psychotropic drugs, inhaled furosemide, Heliox, rehabilitation, nutrition, psychosocial support, breathing techniques, and breathlessness clinics.
Currow, D.C. & Abernethy, A.P. 2006, 'The broader implications of diabetes management at the end of life.', Palliat Med, vol. 20, no. 6, pp. 638-639.
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Currow, D. & Hegarty, M. 2006, 'Suffering - At the bedside of the dying', Journal of Religion, Spirituality and Aging, vol. 18, no. 2-3, pp. 123-136.
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Sanderson, C.R., Koczwara, B. & Currow, D.C. 2006, 'The "therapeutic footprint" of medical, complementary and alternative therapies and a doctor's duty of care.', Med J Aust, vol. 185, no. 7, pp. 373-376.
Complex societal factors unrelated to evidence of efficacy influence the increasing use of complementary and alternative therapies, which can be viewed as one form of health consumerism. The "therapeutic footprint" is a conceptual model that "plots" medical therapies and complementary and alternative therapies in relationship to one another and to their levels of risk and supporting evidence, acknowledging that medical therapies also entail risks. Philosophies about management of risk and adverse effects differ between complementary and alternative therapies and standard medical care, due to fundamental differences between professionalism within medicine and the demands of health consumerism. In standard medical care, patients' risks are mediated prior to treatment via the doctor-patient relationship and informed consent. With complementary and alternative therapies, protection mechanisms for consumers come into effect mainly after a problem has occurred. Understanding this difference helps doctors whose patients are using complementary or alternative therapies to define the boundaries between these therapies and professional medicine and provide appropriate disclosure of risks. Discussing complementary and alternative therapies and how they differ from standard medical care can provide opportunities to explore patients' concerns and improve the therapeutic relationship.
Currow, D.C. & Abernethy, A.P. 2006, 'Frameworks for approaching prescribing at the end of life.', Arch Intern Med, vol. 166, no. 21, p. 2404.
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Shelby-James, T., Abernethy, A.P. & Currow, D.C. 2006, 'Evidence in palliative care research: how should it be gathered?', Med J Aust, vol. 184, no. 4, pp. 196-197.
Currow, D.C. & Abernethy, A.P. 2006, 'Reader questions benefit of nebulized opioids.', Oncol Nurs Forum, vol. 33, no. 3, p. 513.
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Sladek, R., Tieman, J., Fazekas, B.S., Abernethy, A.P. & Currow, D.C. 2006, 'Development of a subject search filter to find information relevant to palliative care in the general medical literature.', J Med Libr Assoc, vol. 94, no. 4, pp. 394-401.
PURPOSE: The research developed and validated palliative care search filters for use in the general biomedical literature. METHODS: Four general medical journals were hand-searched to identify articles relevant to palliative care, forming a "gold standard" reference set. Searches comprising Medical Subject Headings (MeSH) and text-words were created for use in Ovid MEDLINE, and retrieved references were compared to the gold standard. Sensitivity, specificity, accuracy, and precision rates were calculated. RESULTS: By hand-searching 20,501 articles published in the 4 journals during the 3-year study period (1999-2001), reviewers identified 773 items relevant to palliative care (3.8%). A master search combining 9 MeSH descriptors with 3 text-words achieved 45.4% sensitivity, 99.3% specificity, 73% precision, and 97.3% accuracy. Efforts to increase the sensitivity by modifying 3 relevant published but unvalidated searches did not improve the yield, except in 1 case which resulted in an improved sensitivity of 56.9% but was offset by reduced specificity (92.1%), precision (22%), and accuracy (90.8%). CONCLUSIONS: The study confirmed that literature relevant to palliative care is difficult to identify in general medical journals. While the filter developed in this research represents the best trade-off between sensitivity, specificity, accuracy, and precision, the sensitivity is unacceptably low. Further research, such as frequency analysis of text-words and MeSH terms, is required to increase the sensitivity of searching in this subset of the literature.
Girgis, A., Johnson, C., Aoun, S. & Currow, D. 2006, 'Challenges experienced by informal caregivers in cancer', Cancer Forum, vol. 30, no. 1, pp. 21-25.
Currow, D.C. & Hegarty, M. 2006, 'Residential aged-care facility palliative care guidelines: improving care.', Int J Palliat Nurs, vol. 12, no. 5, pp. 231-233.
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The Guidelines for a Palliative Approach in Residential Aged Care (Australian Government Department of Health and Ageing, 2004) are the result of the synthesis of evidence from three disciplines: geriatrics, gerontology and palliative care. Each paradigm challenges and informs the others, together developing a balanced and enriched understanding of palliative aged care. The guidelines address the challenges of the clinical and service delivery contexts of palliative care in residential aged care facilities, including the impact of complex, co-morbid illnesses with unpredictable trajectories; shorter, more dependent inpatient stays; and an evolving accreditation process.
Tieman, J. & Currow, D.C. 2006, 'Evidence in palliative care research: how should it be gathered?', Med J Aust, vol. 184, no. 4, pp. 197-198.
Good, P.D., Cavenagh, J.D., Currow, D.C., Woods, D.A., Tuffin, P.H. & Ravenscroft, P.J. 2006, 'What are the essential medications in pallative care? - a survey of Australian palliative care doctors.', Aust Fam Physician, vol. 35, no. 4, pp. 261-264.
BACKGROUND: There is a disparity of availability and cost of drugs in the community for palliative care patients through the Pharmaceutical Benefits Scheme (PBS) compared to those available to inpatients in public hospitals. METHODS: The Joint Therapeutics Committee of the Australian and New Zealand Society of Palliative Medicine, Palliative Care Australia and the Clinical Oncological Society of Australia surveyed palliative care practitioners in Australia to compile a list of drugs they considered essential. RESULTS: Drugs nominated generally had good levels of evidence for use in palliative care, although many practitioners still used some without evidence of benefit. DISCUSSION: We are now working with the Commonwealth Department of Health and Ageing to agree on a list of drugs for specific palliative care indications. As a result, the first ever section in the PBS for a specific patient population has been created. There is a need for high quality studies in palliative care to determine the best drugs to add to the list.
Seidel, R., Sanderson, C., Mitchell, G. & Currow, D.C. 2006, 'Until the chemist opens - palliation from the doctor's bag.', Aust Fam Physician, vol. 35, no. 4, pp. 225-231.
BACKGROUND: People with a life limiting illness may have unpredictable exacerbations of their symptoms requiring after hours care by general practitioners using medications that are readily accessible. All doctors are provided with injectable 'doctor's bag' emergency drugs for use in such a crisis. OBJECTIVE: This article aims to: identify which medications from the doctor's bag can be used in the palliative care crises that are most frequently encountered, present the best possible evidence for these indications, and to provide GPs caring for palliative care patients after hours with management strategies so, whenever appropriate, they can continue to be managed at home. DISCUSSION: The clinical context, including disease trajectory and patient and caregivers' wishes, must be assessed in palliative care crises. Having excluded reversible problems, symptoms can be treated using doctor's bag medications. Attention must be given to route of administration, duration of effect, and appropriate doses for effective palliation.
Hall, W., Christie, M.J. & Currow, D. 2005, 'Cannabinoids and cancer: causation, remediation, and palliation', LANCET ONCOLOGY, vol. 6, no. 1, pp. 35-42.
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Aoun, S.M., Kristjanson, L.J., Currow, D.C. & Hudson, P.L. 2005, 'Caregiving for the terminally ill: at what cost?', Palliat Med, vol. 19, no. 7, pp. 551-555.
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This literature review exposes the nature and extent of physical and psychosocial morbidity and economic disadvantage, home palliative caregivers suffer as a direct result of their caregiving role. Research has demonstrated that caregivers providing support to individuals receiving palliative care report unmet needs for information, communication, service provision and support from health and community services. Three sets of challenges are highlighted in this literature review which help explain why the needs of home palliative caregivers are largely unmet: (i) barriers to seeking help; (ii) a dearth of research-based interventions focused on reducing the negative aspects of caregiving; and (iii) a number of impediments to effective policy and service development for family caregivers. Furthermore, invited submissions from caregivers echoed and confirmed the issues reported in the literature. Recommendations for enhancing caregiver support are outlined.
Currow, D.C., Easterbrook, S. & Mattes, R. 2005, 'Improving choices for community palliative care: A prospective 2-year pilot of a live-in support person', Progress in Palliative Care, vol. 13, no. 5, pp. 257-262.
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Currow, D. 2005, 'Editorial: Korean Declaration', Progress in Palliative Care, vol. 13, no. 1, p. 1.
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Tieman, J.J., Abernethy, A.P., Fazekas, B.S. & Currow, D.C. 2005, 'CareSearch: Finding and evaluating Australia's missing palliative care literature', BMC Palliative Care, vol. 4.
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Currow, D.C. & Abernethy, A.P. 2005, 'Quality palliative care: practitioners' needs for dynamic lifelong learning.', J Pain Symptom Manage, vol. 29, no. 4, pp. 332-334.
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Abernethy, A.P., Shelby-James, T., Fazekas, B.S., Woods, D. & Currow, D.C. 2005, 'The Australia-modified Karnofsky Performance Status (AKPS) scale: A revised scale for contemporary palliative care clinical practice [ISRCTN81117481]', BMC Palliative Care, vol. 4.
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Aoun, S.M., Kristjanson, L.J., Hudson, P.L., Currow, D.C. & Rosenberg, J.P. 2005, 'The experience of supporting a dying relative: Reflections of caregivers', Progress in Palliative Care, vol. 13, no. 6, pp. 319-325.
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Abernethy, A.P., Currow, D.C., Frith, P. & Fazekas, B. 2005, 'Prescribing palliative oxygen: a clinician survey of expected benefit and patterns of use.', Palliat Med, vol. 19, no. 2, pp. 168-170.
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Toye, C., Kristjanson, L., White, K., Sullivan, K., Currow, D., Cordingley, S., Oldham, L., Hearn, L., Leavesley, S., Cook, P., Taylor, A., Shiels, W., Harris, P., Schaper, F. & Walton, J. 2004, 'The Volunteering in Palliative Residential Aged Care Project', AUSTRALASIAN JOURNAL ON AGEING, vol. 23, pp. A3-A3.
Currow, D., Andrews, G. & Lawrence, J. 2004, 'Palliative care in aged care - a key initiative for the aged care sector', AUSTRALASIAN JOURNAL ON AGEING, vol. 23, pp. A51-A52.
Currow, D. 2004, 'Editorial', Progress in Palliative Care, vol. 12, no. 1, p. 1.
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Currow, D.C., Abernethy, A.P. & Fazekas, B.S. 2004, 'Specialist palliative care needs of whole populations: a feasibility study using a novel approach.', Palliat Med, vol. 18, no. 3, pp. 239-247.
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BACKGROUND: Defining whether people with life-limiting illnesses (PLLI) who do not access specialized palliative care services (SPCS) have unmet needs is crucial in planning and evaluating palliative care. This study seeks to establish the viability of a whole-of-population method to help characterize SPCS access through proxy report. METHODS: Questions were included in a piloted annual face-to-face health survey of 3027 randomly selected South Australians on the need for, uptake rate of, and satisfaction with SPCS in 2000. The survey was representative of the cross-section of South Australians by age, gender, socioeconomic status and region. RESULTS: One in three people surveyed (1069) indicated that someone 'close to them' had died of a terminal illness in the preceding five years. Of those who identified that a palliative service had not been used (38%, 403), reasons cited included family/friends provided the care (34%, 136) and the service was not wanted (21%, 86). Respondents with income > AU dollars 60000 per year were more likely to report that a SPCS had been used (P = 0.01). People who had cancer as their life-limiting illness were more likely to access SPCS (P < 0.001). The results generate a model comparing SPCS utilization with client benefit. The survey was acceptable to interviewees. DISCUSSION: Uptake rates of SPCS in this survey are consistent with other South Australian whole population estimates of SPCS utilization. Although there are limitations in this survey approach and the questions asked, this method can be developed to improve our understanding of the characteristics and needs of PLLI and their carers.
Stevenson, J., Abernethy, A.P., Miller, C. & Currow, D.C. 2004, 'Managing comorbidities in patients at the end of life.', BMJ, vol. 329, no. 7471, pp. 909-912.
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Currow, D. 2003, 'From Australia', PALLIATIVE MEDICINE, vol. 17, no. 2, pp. 158-159.
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Abernethy, A.P., Currow, D.C., Frith, P., Fazekas, B.S., McHugh, A. & Bui, C. 2003, 'Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea.', BMJ, vol. 327, no. 7414, pp. 523-528.
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OBJECTIVE: To determine the efficacy of oral morphine in relieving the sensation of breathlessness in patients in whom the underlying aetiology is maximally treated. DESIGN: Randomised, double blind, placebo controlled crossover study. SETTING: Four outpatient clinics at a hospital in South Australia. PARTICIPANTS: 48 participants who had not previously been treated with opioids (mean age 76, SD 5) with predominantly chronic obstructive pulmonary disease (42, 88%) were randomised to four days of 20 mg oral morphine with sustained release followed by four days of identically formulated placebo, or vice versa. Laxatives were provided as needed. MAIN OUTCOME MEASURES: Dyspnoea in the morning and evening as shown on a 100 mm visual analogue scale, quality of sleep, wellbeing, performance on physical exertion, and side effects as measured at the end of the four day treatment period. RESULTS: 38 participants completed the study; three withdrew because of definite and two because of possible side effects of morphine (nausea, vomiting, and sedation). Participants reported significantly different dyspnoea scores when treated with morphine: an improvement of 6.6 mm (95% confidence interval 1.6 mm to 11.6 mm) in the morning and of 9.5 mm (3.0 mm to 16.1 mm) in the evening (P = 0.011 and P = 0.006, respectively). During the period in which they were taking morphine participants also reported better sleep (P = 0.039). More participants reported distressing constipation while taking morphine (9 v 1, P = 0.021) in spite of using laxatives. All other side effects were not significantly worse with morphine, although the study was not powered to address side effects. CONCLUSIONS: Sustained release, oral morphine at low dosage provides significant symptomatic improvement in refractory dyspnoea in the community setting.
Currow, D. 2003, 'New directions for Progress in Palliative Care 2004', Progress in Palliative Care, vol. 11, no. 5, p. 247.
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Taylor, K. & Currow, D. 2003, 'A prospective study of patient identified unmet activity of daily living needs among cancer patients at a comprehensive cancer care centre', Australian Occupational Therapy Journal, vol. 50, no. 2, pp. 79-85.
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Currow, D.C. & Nightingale, E.M. 2003, '"A planning guide": Developing a consensus document for palliative care service provision.', Med J Aust, vol. 179, no. 6 Suppl, pp. S23-S25.
Over the past 30 years, palliative care services have developed in an ad-hoc way in Australia and around the world. Community expectations for palliative care have grown in recent years. As palliative care has evolved, the World Health Organization definition of palliative care has changed substantially. The changes challenge those who are involved in planning, funding and provision of services to meet new expectations. Many services have not attracted adequate nursing, medical and allied health resources to provide interdisciplinary palliative care. A national consensus document ("a planning guide") has been developed in consultation with key stakeholders and organisations. It outlines the minimum needs for service provision, independent of fundholders and models of service delivery.
Hordern, A.J. & Currow, D.C. 2003, 'A patient-centred approach to sexuality in the face of life-limiting illness.', Med J Aust, vol. 179, no. 6 Suppl, pp. S8-11.
Sexuality is intrinsic to a person's sense of self and can be an intimate form of communication that helps relieve suffering and lessens the threat to personhood in the face of life-limiting illness. Health professionals struggle to accept that people with life-limiting illness, especially older people, continue to be sexual beings. People facing life-limiting illness may appreciate the opportunity to discuss issues of sexuality and intimacy with a trusted health professional. Practical strategies to assist health professionals to communicate effectively about sexuality and intimacy include creating a conducive atmosphere, initiating the topic, using open-ended questions and a non-judgmental approach, and avoiding medical jargon.
Currow, D.C., Noel, M.A. & Sullivan, K.A. 2003, 'Place of death. What is the measure of success?', Ir Med J, vol. 96, no. 4, pp. 120-121.
Berrill, J.W. & Linnasne, S.J. 2003, 'Morphine for management of refractory dyspnoea: opiates should be used with caution.', BMJ, vol. 327, no. 7426, p. 1288.
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Currow, D. 2002, 'Australia: State of palliative service provision 2002', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 24, no. 2, pp. 170-172.
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Mitchell, G. & Currow, D. 2002, 'Chemotherapy and radiotherapy. When to call it quits.', Australian family physician, vol. 31, no. 2, pp. 129-133.
BACKGROUND: Patients diagnosed with cancer are often treated with chemotherapy and radiotherapy with curative intent. The transition from curative to palliative intent involves re-evaluation of treatment, and has to take into account the attitudes, beliefs and life aims of the patient. OBJECTIVE: To discuss the difficulties in determining when to cease chemotherapy and radiotherapy in patients with advanced cancer. DISCUSSION: The concept of treatment evaluation using a 'burden versus benefit' paradigm is discussed. Treatment aims must be in concordance with those of the patient, which are often couched in functional terms or linked to future significant life events. Chemotherapy and radiotherapy can offer patients in the palliative phase of cancer illness, benefits in terms of relief of symptoms and meaningful prolongation of life, and should be considered in appropriate circumstances.
Currow, D.C. 2002, 'Integrating cancer and supportive services: The progress and the challenges', Cancer Forum, vol. 26, no. 1, pp. 3-4.
Campbell, D.A. & Currow, D.C. 2002, 'Palliative medicine.', Med J Aust, vol. 176, no. 1, p. 33.
Currow, D.C. 2002, 'MEDicine or MADness.', Med J Aust, vol. 176, no. 4, p. 190.
Hall, W.D., Degenhardt, L.J. & Currow, D. 2001, 'Allowing the medical use of cannabis', MEDICAL JOURNAL OF AUSTRALIA, vol. 175, no. 1, pp. 39-40.
Barton, M.B., Dawson, R., Jacob, S., Currow, D., Stevens, G. & Morgan, G. 2001, 'Palliative radiotherapy of bone metastases: an evaluation of outcome measures', JOURNAL OF EVALUATION IN CLINICAL PRACTICE, vol. 7, no. 1, pp. 47-64.
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Abernethy, A., Phillips, P. & Currow, D. 2001, 'Applying the evidence to improve the quality of our system of cancer care: What do the words mean?', Cancer Forum, vol. 25, no. 2, pp. 109-111.
Currow, D.C. 2001, 'Palliative service provision in Australia.', Med J Aust, vol. 175, no. 10, pp. 534-536.
Palliative services in Australia have grown and evolved rapidly over the past 20 years. They now offer care to people facing life-limiting illness and to their families long before the stage of terminal care. A coordinated, interdisciplinary approach is most useful, but models of care vary greatly across the country. There is still unmet need, particularly among people with non-cancer illnesses and in particular regions. Choices about place of care (community or inpatient setting) may be limited by factors such as funding policies for medications.
Stuart-Harris, R., Joel, S.P., McDonald, P., Currow, D. & Slevin, M.L. 2000, 'The pharmacokinetics of morphine and morphine glucuronide metabolites after subcutaneous bolus injection and subcutaneous infusion of morphine', BRITISH JOURNAL OF CLINICAL PHARMACOLOGY, vol. 49, no. 3, pp. 207-214.
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Dawson, R., Currow, D., Stevens, G., Morgan, G. & Barton, M.B. 1999, 'Radiotherapy for bone metastases: A critical appraisal of outcome measures', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 17, no. 3, pp. 208-218.
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Bui, C.D.H., Martin, C.J. & Currow, D.C. 1999, 'Effective community palliation of intractable malignant ascites with a permanently implanted abdominal drain', Journal of Palliative Medicine, vol. 2, no. 3, pp. 319-321.
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Currow, D.C., Coughlan, M., Fardell, B. & Cooney, N.J. 1997, 'Use of ondansetron in palliative medicine.', J Pain Symptom Manage, vol. 13, no. 5, pp. 302-307.
Ondansetron was the first of several selective 5-hydroxytryptamine (5-HT3) antagonists to be available as an antiemetic. Its uses in the setting of highly and moderately emetogenic chemotherapy and radiotherapy are well established. Ondansetron has also been used to manage nausea and vomiting in other patients. We report a retrospective analysis of its use in all 16 patients who were commenced on ondansetron after admission to our institution for nausea and/or vomiting over a 4-year period. Nine patients had advanced human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and seven had malignancy. These patients were not undergoing disease-modifying treatment and had inadequate responses to therapeutic doses of standard antiemetics, used either singly or in combination. Responses were independently reviewed and graded by two investigators. Response was judged at 48 hr after commencing therapy. Potential causes of nausea were also reviewed. Overall, 13 of 16 [81%, 95% confidence interval (CI) 54%-96%] derived benefit. Twelve of 15 patients (80%) with nausea had a demonstrable improvement, and ten of 14 patients (71%) with vomiting also improved. Eight of ten patients (80%) admitted with nausea and/or vomiting as one of their presenting problems had the symptom controlled within 48 hr of ondansetron therapy. Treatment with ondansetron was well tolerated, onset of action was rapid, and response rates were high and sustained over time. Seven of the 16 patients continued ondansetron therapy for more than 10 days. With minimal reductions in inpatient bed stays, the total costs of ondansetron could be met while at the same time better supporting patients remaining in the community.
Currow, D.C., Noble, P.D. & Stuart-Harris, R.C. 1995, 'The clinical use of ondansetron. New South Wales Therapeutic Assessment Group.', Med J Aust, vol. 162, no. 3, pp. 145-149.
OBJECTIVE: To establish guidelines for use of ondansetron. DATA SOURCES: MEDLINE computer search (to July 1993) and information from the manufacturer. DATA EXTRACTION: We circulated a position paper based on our literature review for comment by clinicians and directors of pharmacy in major teaching hospitals in New South Wales who had an interest in ondansetron. DATA SYNTHESIS: Ondansetron is effective in the control of nausea and vomiting occurring 24-48 hours after highly emetogenic chemotherapy and after radiotherapy. There are no data to support its use in delayed emesis. Combination with dexamethasone may improve emetic control. The most commonly reported adverse effects are headache and constipation. Optimal dose, frequency of dosing and route of administration have not been established. The cost for each inpatient treated successfully is about 3% more than conventional antiemetic therapy. CONCLUSIONS: Ondansetron shows clinical benefit in the management of acute nausea and vomiting in patients receiving highly emetogenic chemotherapy, those who have responded poorly to other antiemetics after moderately emetogenic chemotherapy, those who have intolerable side effects with conventional antiemetic agents and those receiving radiotherapy to the upper abdomen. It is also marketed for the prevention and treatment of postoperative nausea and vomiting.
Currow, D. & Cooney, N. 1994, 'Comparison of metal versus Vialon subcutaneous catheters in a palliative care setting.', Palliative medicine, vol. 8, no. 4, pp. 333-336.
In 63 evaluable palliative care patients requiring intermittent bolus subcutaneous administration of medication, who were randomly assigned either a standard metal subcutaneous needle or a PTFE (Vialon) catheter, there was a significantly greater incidence of local reactions at the insertion site with the metal needles (9/30) compared with the PTFE catheters (2/33). Despite this, there was no significant difference between the two in functional survival. Volume of medication injected per day was the best predictor of total time that the subcutaneous lines remained in situ.
Currow, D.C. & Cooney, N.J. 1994, 'Octreotide in palliative medicine.', Palliat Med, vol. 8, no. 2, p. 168.
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