Professor Meera Agar is a palliative medicine physician, with a particular interest in the supportive care needs of people suffering from advanced illness on the brain.
Meera leads a clinical research portfolio at UTS, including clinical trials and health service evaluation. She led a world-first clinical trial of antipsychotics in delirium and is leading a NSW Government-funded trial of the use of medicinal cannabis for the terminally ill.
A Fellow of the Royal Australasian College of Physicians, Fellow of the Australasian Chapter of Palliative Medicine and clinician scientist, she holds a Master in Palliative Care. Her doctorate was awarded in the area of delirium in advanced illness.
Her research and teaching have won numerous awards, including an Australian Learning & Teaching Council Citation, an Australian Award for University teaching and the European Association for Palliative Care Early Career Researcher Award.
President, Australian and New Zealand Society of Palliative Medicine
Member, Australasian Chapter of Palliative Medicine Committee, Royal Australasian College of Physicians
Board Member, European Delirium Association
Member, Australasian Delirium Association Management Committee
Choosing Wisely Australia Advisory Board
Scientific committee - Psycho-oncology cooperative research group (PoCOG)
Scientific committee - cooperative trials group for neuro-oncology (COGNO)
South West Sydney Human Research Ethics Committee
Can supervise: YES
- Palliative care
- Supportive care for people with brain tumours
- Advanced dementia
- Clinical Trials
- Anorexia cachexia
- Sleep disturbance in advanced illness
- Quality use of medicines at the end of life
- Geriatric Oncology
Delirium is the most common and serious neuropsychiatric complication in palliative care settings. It is a source of significant morbidity in patients, and often distresses family members and staff. Delirium is often a harbinger of impending death and can significantly interfere with pain and symptom control. Unfortunately delirium is often under-recognized or misdiagnosed in the terminally ill, and even when recognized, it frequently goes untreated or is inappropriately treated. Clinicians who care for patients with advanced illness must be able to diagnose delirium accurately, undertake appropriate assessment of aetiologies, and understand the risks and benefits of the pharmacological and non-pharmacological interventions currently available for managing delirium. Symptomatic treatment with antipsychotics or sedative medications is often necessary for the delirious patient with advanced illness to minimize distress to patients, families, and staff.
Delirium is highly prevalent in people with advanced life limiting illness(es), and current evidence can inform how we provide best delirium care in this setting. Whilst strategies to prevent and reverse delirium are the cornerstones of optimal care, the care for delirious patients who are approaching the end of life and their families pose specific challenges particularly if delirium is refractory flagging a grave prognosis. These include addressing additional supportive care needs, clinical decision-making about the degree of investigation and intervention, minimising distress from the symptoms of delirium itself and considering other concurrent problems contributing to agitation. A fine balance is needed to address other symptoms such as pain whilst minimizing psychoactive medication load. There is need for regular and clear information and communication about prognosis and goals of care. Witnessing a delirium episode in a loved one in close proximity to death requires consideration of the needs of the family into bereavement care.
Palliative care is person and family-centred care provided for a person with an active, progressive, advanced disease; who has little or no prospect of cure and who is expected to die, and for whom the primary treatment goal is to optimise quality of life. It is an approach which can be provided regardless of setting and diagnosis, and by both specialist palliative care teams and other health professionals.
Amgarth-Duff, I, Hosie, A, Caplan, G & Agar, M 2020, 'A systematic review of the overlap of fluid biomarkers in delirium and advanced cancer-related syndromes', BMC PSYCHIATRY, vol. 20, no. 1.View/Download from: Publisher's site
Amgarth-Duff, I, Hosie, A, Caplan, G & Agar, M 2020, 'Toward best practice methods for delirium biomarker studies: An international modified Delphi study', INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY.View/Download from: Publisher's site
Purpose: Delirium is common with serious short- and long-term sequelae. However, there are no licensed treatments internationally and relatively little biomedical discovery with the target of finding a cure, with the invisibility or underestimation of the economic implications as a potential driver for this inertia. Methods: We conducted a narrative review of published literature in English quantitatively evaluating the financial and social costs of delirium to the health and care systems, patients and their carers. Results: Delirium increases the cost of the index hospitalisation as well as increasing the need for post-acute care and the demands on unpaid, often older, carers. Delirium may cause as much as 10% of all cases of dementia and the ongoing need for care of these people with dementia doubles the cost of delirium. Prevention of delirium not only reduces the cost of delirium but also may decrease subsequent rate of dementia. Conclusion: The high cost of delirium itself as well as the resultant dementia warrants greater efforts to prevent delirium and discover effective treatment.
Crotty, M, Gnanamanickam, ES, Cameron, I, Agar, M, Ratcliffe, J & Laver, K 2020, 'Are people in residential care entitled to receive rehabilitation services following hip fracture? Views of the public from a citizens' jury', BMC GERIATRICS, vol. 20, no. 1.View/Download from: Publisher's site
Currow, DC & Agar, MR 2020, 'Benzodiazepine Prescribing in People with Chronic Obstructive Pulmonary Disease: Clinical Considerations', DRUGS & AGING, vol. 37, no. 4, pp. 263-270.View/Download from: Publisher's site
Currow, DC, Agar, MR & Phillips, JL 2020, 'Role of Hospice Care at the End of Life for People With Cancer', JOURNAL OF CLINICAL ONCOLOGY, vol. 38, no. 9, pp. 937-+.View/Download from: Publisher's site
DiGiacomo, M, Chang, S, Luckett, T, Phillips, J, Agar, M & Lam, L 2020, 'Financial stress experienced by informal carers of adults with a chronic disease: results from an Australian population-based cross-sectional survey', Australasian Journal of Ageing.View/Download from: Publisher's site
To identify caregiving characteristics that are associated with financial stress in Australian carers of people with a chronic disease.
Data were collected via the South Australian Health Omnibus, an annual population-based, cross-sectional survey. Individuals who provided care to someone with prevalent chronic conditions were asked about financial stress and caregiving characteristics.
Of 32.4% (988/3047) who were carers, 13.4% (132/988) experienced financial stress. Adjusting for age and household income, providing more than 20 hours of care per week (AOR=2.39,95%CI=1.48-3.86), transport assistance (AOR=1.89,95%CI=1.15-3.09) and assistance with household tasks (AOR=1.92,95%CI=1.14-3.26) and caring for a person with a mental illness (AOR=2.01, 95%CI=1.24-3.28) were associated with a significant increase in odds of experiencing financial stress. Caring for a person with cancer (AOR=0.49, 95%CI=0.30-0.81) or dementia (AOR=0.40, 95%CI=0.21-0.76) was associated with a decrease in odds.
Financial stress was reported by more than 13% of carers and factors other than household income were implicated.
Ferreira, DH, Louw, S, McCloud, P, Fazekas, B, McDonald, CF, Agar, M, Clark, K, McCaffrey, N, Ekström, M, Currow, DC & Australian national Palliative Care Clinical Studies Collaborative (PaCCSC) 2020, 'Controlled-release oxycodone versus placebo in the treatment of chronic breathlessness - a multi-site randomised placebo controlled trial.', Journal of Pain and Symptom Management.View/Download from: Publisher's site
CONTEXT:Chronic breathlessness is a clinical syndrome that results in significant distress and disability. Morphine can reduce chronic breathlessness when the contributing aetiologies are optimally treated. OBJECTIVE:Does oxycodone reduce chronic breathlessness compared with placebo? METHODS:A multi-site, randomised, placebo-controlled, double-blind, parallel-arm, fixed-dose trial of oral controlled-release oxycodone 15mg (5 mg 8 hourly) or placebo (ACTRN12609000806268 at www.anzctr.org.au). 'As needed' immediate-release morphine (2.5mg per dose; ≤6 doses/day) was available for both arms as required by one ethics committee overseeing the trial.Recruitment occurred from 2010 to 2014 in 14 inpatient and outpatient respiratory, cardiology and palliative care services across Australia. Participants were adults, with chronic breathlessness (modified Medical Research Council Scale 3 or 4), who were opioid naïve. The primary endpoint was the proportion of people with >15% reduction from baseline in the intensity of breathlessness now (0-100 mm visual analogue scale) comparing arms days 5-7. Secondary endpoints were 'average' and 'worst' breathlessness; quality of life; function; and harms. RESULTS:Of 157 participants randomised, 155 were included (74 oxycodone, 81 placebo), but the study did not reach target recruitment. There was no difference between groups for the primary outcome (p=0.489) nor any of the pre-specified secondary outcomes. Placebo participants used more 'as needed' morphine (mean 7.0 versus 4.2 doses; p≤0.001). Oxycodone participants reported more nausea (p<0.001). CONCLUSIONS:There was no signal of benefit from oxycodone over placebo. Future research should focus on investigating the existence of an opioid class effect on the reduction of chronic breathlessness.
Hickman, L, Ferguson, C, Davidson, PM, Allida, S, Inglis, S, Parker, D & Agar, M 2020, 'Key elements of interventions for heart failure patients with mild cognitive impairment or dementia: A systematic review.', European journal of cardiovascular nursing : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology, pp. 1474515119865755-1474515119865755.View/Download from: Publisher's site
BACKGROUND:The purpose of this systematic review was to (a) examine the effects of interventions delivered by a heart failure professional for mild cognitive impairment and dementia on cognitive function, memory, working memory, instrumental activities of daily living, heart failure knowledge, self-care, quality of life and depression; and (b) identify the successful elements of these strategies for heart failure patients with mild cognitive impairment or dementia. METHODS AND RESULTS:During March 2018, an electronic search of databases including CINAHL, MEDLINE, EMBASE and PsycINFO was conducted. All randomised controlled trials, which examined an intervention strategy to help heart failure patients with mild cognitive impairment or dementia cope with self-care, were included. An initial search yielded 1622 citations, six studies were included (N= 595 participants, mean age 68 years). There were no significant improvements in cognitive function and depression. However, significant improvements were seen in memory (p=0.015), working memory (p=0.029) and instrumental activities of daily living (p=0.006). Nurse led interventions improved the patient's heart failure knowledge (p=0.001), self-care (p<0.05) and quality of life (p=0.029). Key elements of these interventions include brain exercises, for example, syllable stacks, individualised assessment and customised education, personalised self-care schedule development, interactive problem-solving training on scenarios and association techniques to prompt self-care activities. CONCLUSIONS:Modest evidence for nurse led interventions among heart failure patients with mild cognitive impairment or dementia was identified. These results must be interpreted with caution in light of the limited number of available included studies.
King, MT, Agar, M, Currow, DC, Hardy, J, Fazekas, B & McCaffrey, N 2020, 'Assessing quality of life in palliative care settings: head-to-head comparison of four patient-reported outcome measures (EORTC QLQ-C15-PAL, FACT-Pal, FACT-Pal-14, FACT-G7)', SUPPORTIVE CARE IN CANCER, vol. 28, no. 1, pp. 141-153.View/Download from: Publisher's site
Kochovska, S, Huang, C, Johnson, MJ, Agar, MR, Fallon, MT, Kaasa, S, Hussain, JA, Portenoy, RK, Higginson, IJ & Currow, DC 2020, 'Intention-to-Treat Analyses for Randomized Controlled Trials in Hospice/Palliative Care: The Case for Analyses to be of People Exposed to the Intervention.', Journal of Pain and Symptom Management.View/Download from: Publisher's site
CONTEXT:Minimizing bias in randomized controlled trials (RCTs) includes intention-to-treat analyses. Hospice/palliative care RCTs are constrained by high attrition unpredictable when consenting, including withdrawals between randomization and first exposure to the intervention. Such withdrawals may systematically bias findings away from the new intervention being evaluated if they are considered nonresponders. OBJECTIVES:This study aimed to quantify the impact within intention-to-treat principles. METHODS:A theoretical model was developed to assess the impact of withdrawals between randomization and first exposure on study power and effect sizes. Ten reported hospice/palliative care studies had power recalculated accounting for such withdrawal. RESULTS:In the theoretical model, when 5% of withdrawals occurred between randomization and first exposure to the intervention, change in power was demonstrated in binary outcomes (2.0%-2.2%), continuous outcomes (0.8%-2.0%), and time-to-event outcomes (1.6%-2.0%), and odds ratios were changed by 0.06-0.17. Greater power loss was observed with larger effect sizes. Withdrawal rates were 0.9%-10% in the 10 reported RCTs, corresponding to power losses of 0.1%-2.2%. For studies with binary outcomes, withdrawal rates were 0.3%-1.2% changing odds ratios by 0.01-0.22. CONCLUSION:If blinding is maintained and all interventions are available simultaneously, our model suggests that excluding data from withdrawals between randomization and first exposure to the intervention minimizes one bias. This is the safety population as defined by the International Committee on Harmonization. When planning for future trials, minimizing the time between randomization and first exposure to the intervention will minimize the problem. Power should be calculated on people who receive the intervention.
Lee, SY, Fisher, J, Wand, APF, Milisen, K, Detroyer, E, Sockalingam, S, Agar, M, Hosie, A & Teodorczuk, A 2020, 'Developing delirium best practice: a systematic review of education interventions for healthcare professionals working in inpatient settings', EUROPEAN GERIATRIC MEDICINE, vol. 11, no. 1, pp. 1-32.View/Download from: Publisher's site
Mott, C, Herbert, A, Malcolm, K, Sansone, H & Agar, M 2020, 'Emergencies in Pediatric Palliative Care: A Survey of Ambulance Officers to Understand the Interface between Families and Ambulance Services', JOURNAL OF PALLIATIVE MEDICINE.View/Download from: Publisher's site
Oh, ES, Akeju, O, Avidan, MS, Cunningham, C, Hayden, KM, Jones, RN, Khachaturian, AS, Khan, BA, Marcantonio, ER, Needham, DM, Neufeld, KJ, Rose, L, Spence, J, Tieges, Z, Vlisides, P & Inouye, SK 2020, 'A roadmap to advance delirium research: Recommendations from the NIDUS Scientific Think Tank', Alzheimer's & Dementia, vol. 16, no. 5, pp. 726-733.View/Download from: Publisher's site
Rose, L, Agar, M, Burry, L, Campbell, N, Clarke, M, Lee, J, Marshall, J, Siddiqi, N & Page, V 2020, 'Reporting of Outcomes and Outcome Measures in Studies of Interventions to Prevent and/or Treat Delirium in the Critically Ill: A Systematic Review', CRITICAL CARE MEDICINE, vol. 48, no. 4, pp. E316-E324.View/Download from: Publisher's site
Rose, L, Agar, M, Burry, L, Campbell, N, Clarke, M, Lee, J, Marshall, J, Siddiqi, N, Page, V & Development of Core Outcome Sets for Effectiveness Trials of Interventions to Prevent and/or Treat Delirium (Del-COrS) Group 2020, 'Reporting of Outcomes and Outcome Measures in Studies of Interventions to Prevent and/or Treat Delirium in the Critically Ill: A Systematic Review.', Critical care medicine, vol. 48, no. 4, pp. e316-e324.View/Download from: Publisher's site
OBJECTIVES:To inform development of a core outcome set, we evaluated the scope and variability of outcomes, definitions, measures, and measurement time-points in published clinical trials of pharmacologic or nonpharmacologic interventions, including quality improvement projects, to prevent and/or treat delirium in the critically ill. DATA SOURCES:We searched electronic databases, systematic review repositories, and trial registries (1980 to March 2019). STUDY SELECTION AND DATA EXTRACTION:We included randomized, quasi-randomized, and nonrandomized intervention studies of pharmacologic and nonpharmacologic interventions. We extracted data on study characteristics, verbatim descriptions of study outcomes, and measurement characteristics. We assessed quality of outcome reporting using the Management of Otitis Media with Effusion in Children with Cleft Palate study scoring system; risk of bias and study quality using the Cochrane tool and Scottish Intercollegiate Guidelines Network checklists. We categorized reported outcomes using Core Outcome Measures in Effectiveness Trials taxonomy. DATA SYNTHESIS:From 195 studies (1/195 pediatric) recruiting 74,632 participants and reporting a mean (SD) of 10 (6.2) outcome domains, we identified 12 delirium-specific outcome domains. Delirium incidence (147, 75% of studies), duration (67, 34%), and antipsychotic use (42, 22%) were most commonly reported. We identified a further 94 non-delirium-specific outcome domains within 19 Core Outcome Measures in Effectiveness Trials taxonomy categories. For both delirium-specific and nonspecific outcome domains, we found multiple outcomes in domains due to differing descriptions and time-points. The Confusion Assessment Method-ICU with Richmond Agitation-Sedation Scale to assess sedation was the most common measure used to ascertain delirium (51, 35%). Measurement generally began at randomization or ICU admission, and lasted from 1 to 30 days, ICU/hospital discharge. Frequency of measureme...
To, THM, Collier, A, Agar, MR, Rowett, D & Currow, DC 2020, 'Symptomatic Events in a Community Palliative Care Population: A Prospective Pilot Study', JOURNAL OF PALLIATIVE MEDICINE.View/Download from: Publisher's site
Disalvo, D, Luckett, T, Bennett, A, Davidson, PM & Agar, M 2020, 'Multidisciplinary perspectives on medication-related decision-making for people with advanced dementia living in long-term care: a critical incident analysis', EUROPEAN JOURNAL OF CLINICAL PHARMACOLOGY, vol. 76, no. 4, pp. 567-578.View/Download from: Publisher's site
Kochovska, S, Garcia, M, Bunn, F, Goodman, C, Luckett, T, Parker, D, Phillips, JL, Sampson, EL, van der Steen, JT & Agar, MR 2020, 'Components of palliative care interventions addressing the needs of people with dementia living in long-term care: A systematic review', PALLIATIVE MEDICINE, vol. 34, no. 4, pp. 454-492.View/Download from: Publisher's site
Luckett, T, Luscombe, G, Phillips, J, Beattie, E, Chenoweth, L, Davidson, PM, Goodall, S, Pond, D, Mitchell, G & Agar, M 2020, 'Australian long-term care personnel's knowledge and attitudes regarding palliative care for people with advanced dementia.', Dementia.View/Download from: Publisher's site
Johnson, MJ, Sbizzera, I, Fairhurst, C, Fazekas, B, Agar, M, Ekstrom, M & Currow, DC 2020, 'No excess harms from sustained-release morphine: a randomised placebo-controlled trial in chronic breathlessness.', BMJ Supportive and Palliative Care.View/Download from: Publisher's site
OBJECTIVES:We aimed to identify and evaluate: (1) treatment-emergent adverse events (TEAE (worse or new since baseline)) and the subgroup of severe TEAEs in a placebo-controlled 7-day randomised trial of regular, low-dose, sustained-release oral morphine for chronic breathlessness and (2) clinical characteristics associated with TEAE. METHODS:Safety analysis of trial data. Adults with chronic breathlessness (modified Medical Research Council breathlessness score ≥2) due to heart or lung disease, or cancer, not on regular opioids were eligible. Symptoms associated with opioids (TEAE of special interest) were systematically sought using Common Terminology Criteria for Adverse Events (CTCAE) grading. Other harms could be reported at any time. The relationship between characteristics and presence of ≥1 TEAE of special interest was explored using univariable logistic regression analyses. RESULTS:1449/5624 (26%) Adverse Events from 279 participants were TEAE of which 150/1449 (10%) were severe (CTCAE grades 3-5). 1086/5624 (75%) were events of special interest of which 41/1086 (4%) were severe. Compared with placebo, morphine was not associated with more TEAE or severe TEAE of special interest (TEAE: OR 0.53, 95% CI 0.21 to 1.38, p=0.20; severe TEAE: OR 0.96, 95% CI 0.27 to 3.41, p=0.95) nor with CTCAE severity grade (χ2=4.39, p=0.50). Among the 26/150 (17%) with severe TEAEs, study withdrawal was more common in the morphine arm (18/26 (69%) morphine arm; 8/26 (30%) placebo arm). None of the severe TEAEs was a respiratory harm. CONCLUSIONS:Severe morphine-associated toxicity was uncommon and not associated with study arm. Clinical consequences were minor and self-limiting. TRIAL REGISTRATION NUMBER:ACTRN126000806268.
Hosie, A, Phillips, J, Lam, L, Kochovska, S, Noble, B, Brassil, M, Kurrle, S, Cumming, A, Caplan, GA, Chye, R, Ely, EW, Lawlor, PG, Bush, SH, Davis, JM, Lovell, M, Parr, C, Williams, S, Hauser, K, McArdle, S, Jacquier, K, Phillipson, C, Kuwahata, L, Kerfoot, J, Brown, L, Fazekas, B, Cheah, SL, Edwards, L, Green, A, Hunt, J, Attwood, R, Assen, T, Garcia, M, Wilcock, J & Agar, M 2020, 'A Multicomponent Nonpharmacological Intervention to Prevent Delirium for Hospitalized People with Advanced Cancer: A Phase II Cluster Randomized Waitlist Controlled Trial (The PRESERVE Pilot Study)', JOURNAL OF PALLIATIVE MEDICINE.View/Download from: Publisher's site
Currow, DC, Ekström, M, Louw, S, Hill, J, Fazekas, B, Clark, K, Davidson, PM, McDonald, C, Sajkov, D, McCaffrey, N, Doogue, M, Abernethy, AP & Agar, M 2019, 'Sertraline in symptomatic chronic breathlessness: a double blind, randomised trial.', European Respiratory Journal, vol. 53, no. 1.View/Download from: Publisher's site
Does sertraline provide symptomatic relief for chronic breathlessness in people with advanced disease whose underlying cause(s) are optimally treated?223 participants with chronic breathlessness (modified Medical Research Council breathlessness scale ≥2) who had optimal treatment of underlying cause(s) were randomised 1:1 to sertraline 25-100 mg (titrated upwards over 9 days) or placebo for 4 weeks. The primary outcome was the proportion who had an improvement in intensity of current breathlessness >15% from baseline on a 100-mm visual analogue scale.The proportion of people responding to sertraline was similar to placebo for current breathlessness on days 26-28 (OR 1.00, 95% CI 0.71-1.40) and for other measures of breathlessness. Quality of life in the sertraline arm had a higher likelihood of improving than in the placebo arm over the 4 weeks (OR 0.21, 95% CI 0.01-0.41; p=0.044). No differences in performance status, anxiety and depression, or survival were observed. Adverse event rates were similar between arms.Sertraline does not appear to provide any benefit over placebo in the symptomatic relief of chronic breathlessness in this patient population.
Assareh, H, Stubbs, JM, Trinh, LTT, Greenaway, S, Agar, M & Achat, HM 2019, 'Variations in hospital inpatient palliative care service use: a retrospective cohort study.', BMJ supportive & palliative care.View/Download from: Publisher's site
OBJECTIVE:Use of palliative care in hospitals for people at end of life varies. We examined rate and time of in-hospital palliative care use and associated interhospital variations. METHODS:We used admissions from all hospitals in New South Wales, Australia, within a 12-month period, for a cohort of adults who died in 73 public acute care hospitals between July 2010 and June 2014. Receiving palliative care and its timing were based on recorded use. RESULTS:Among 90 696 adults who died, 27% received palliative care, and the care was initiated 7.6 days (mean; SD: 3.3 days) before death. Over the 5-year period, the palliative care rate rose by 58%, varying extent across chronic conditions. The duration of palliative care before death declined by 7%. Patient (demographics, morbidities and service use) and hospital factors (size, location and availability of palliative care unit) explained half of the interhospital variation in outcomes: adjusted IQR in rate and duration of palliative care among hospitals were 23%-39% and 5.2-8.7 days, respectively. Hospitals with higher rates often initiated palliative care earlier (correlation: 0.39; p<0.01). CONCLUSION:Despite an increase over time in the palliative care rate, its initiation was late and of brief duration. Palliative care use was associated with patient and hospital characteristics; however, half of the between hospital variation remained unexplained. The observed suboptimal practices and variability indicate the need for expanded and standardised use of palliative care supported by assessment tools, service enhancement and protocols.
Boland, JW, Kabir, M, Bush, SH, Spiller, JA, Johnson, MJ, Agar, M & Lawlor, P 2019, 'Delirium management by palliative medicine specialists: A survey from the association for palliative medicine of Great Britain and Ireland', BMJ Supportive and Palliative Care.View/Download from: Publisher's site
© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ. Objectives: Delirium is common in palliative care settings. Management includes detection, treatment of cause(s), non-pharmacological interventions and family support; strategies which are supported with varying levels of evidence. Emerging evidence suggests that antipsychotic use should be minimised in managing mild to moderate severity delirium, but the integration of this evidence into clinical practice is unknown. Methods: A 21-question online anonymous survey was emailed to Association for Palliative Medicine members in current clinical practice (n=859), asking about delirium assessment, management and research priorities. Results: Response rate was 39%: 70% of respondents were palliative medicine consultants. Delirium guidelines were used by some: 42% used local guidelines but 38% used none. On inpatient admission, 59% never use a delirium screening tool. Respondents would use non-pharmacological interventions to manage delirium, either alone (39%) or with an antipsychotic (58%). Most respondents (91%) would prescribe an antipsychotic and 6% a benzodiazepine, for distressing hallucinations unresponsive to non-pharmacological measures. Inpatient (57%) and community teams (60%) do not formally support family carers. Research priorities were delirium prevention, management and prediction of reversibility. Conclusion: This survey of UK and Irish Palliative Medicine specialists shows that delirium screening at inpatient admission is suboptimal. Most specialists continue to use antipsychotics in combination with non-pharmacological interventions to manage delirium. More support for family carers should be routinely provided by clinical teams. Further rigorously designed clinical trials are urgently needed in view of management variability, emerging evidence and perceived priorities for research.
Jeon, MS, Dhillon, HM, Descallar, J, Lam, L, Allingham, S, Koh, ES, Currow, DC & Agar, MR 2019, 'Prevalence and severity of sleep difficulty in patients with a CNS cancer receiving palliative care in Australia', Neuro-Oncology Practice, vol. 6, no. 6, pp. 499-507.View/Download from: Publisher's site
© The Author(s) 2019. Background. The literature describing the incidence of sleep difficulty in CNS cancers is very limited, with exploration of a sleep difficulty symptom trajectory particularly sparse in people with advanced disease. We aimed to establish the prevalence and longitudinal trajectory of sleep difficulty in populations with CNS cancers receiving palliative care nationally, and to identify clinically modifiable predictors of sleep difficulty. Methods. A consecutive cohort of 2406 patients with CNS cancers receiving palliative care from sites participating in the Australian national Palliative Care Outcomes Collaboration were evaluated longitudinally on patientreported sleep difficulty from point-of-care data collection, comorbid symptoms, and clinician-rated problems. Multilevel models were used to analyze patient-reported sleep difficulty. Results. Reporting of mild to severe sleep difficulties ranged from 10% to 43%. Sleep scores fluctuated greatly over the course of palliative care. While improvement in patients' clinical status was associated with less sleep difficulty, the relationship was not clear when patients deteriorated. Worsening of sleep difficulty was associated with higher psychological distress (P < .0001), greater breathing problems (P < .05) and pain (P < .05), and higher functional status (P < .001) at the beginning of care. Conclusions. Sleep difficulty is prevalent but fluctuates widely in patients with CNS cancers receiving palliative care. A better-tailored sleep symptom assessment may be needed for this patient population. Early interventions targeting psychological distress, breathing symptoms, and pain for more functional patients should be explored to see whether it reduces sleep difficulties late in life.
Lee, JT, Sanderson, CR, Xuan, W & Agar, M 2019, 'Lidocaine for Cancer Pain in Adults: A Systematic Review and Meta-Analysis.', Journal of palliative medicine, vol. 22, no. 3, pp. 326-334.View/Download from: Publisher's site
BACKGROUND:Internationally, use of lidocaine infusions to treat cancer pain varies by center. Existing systematic reviews do not adequately inform use of lidocaine in cancer pain. OBJECTIVE:To assess the effects of systemic sodium channel blockers on cancer pain in adults, review the dose protocols for administration, and assess toxicity. DESIGN:Databases CENTRAL, MEDLINE, Embase, LILACS, CareSearch, and OpenGrey were searched from inception to 2016. Conference abstracts and reference lists were handsearched, and the lead investigators of included trials and Australian manufacturers were contacted. Included studies were randomized controlled trials evaluating one or more of lidocaine via intravenous or subcutaneous route, or mexiletine, flecainide, or tocainide via oral route; delivered at a site distant to the pain locus. The methodological quality of studies was assessed using the "risk of bias" domain-based evaluation by Jadad. Protocol is available on PROSPERO:CRD42016047092. RESULTS:One positive (n = 50) and three negative (n = 10 each) crossover trials evaluated lidocaine versus placebo, and one trial (n = 16) compared lidocaine with dexmedetomidine. Meta-analysis of pooled data in 60 patients demonstrated a significant benefit of lidocaine infusion of 4-5 mg/kg over 30-80 minutes compared with placebo for >50% reduction in cancer pain. Secondary outcomes did not show a significant difference. DISCUSSION:Based on the current available evidence, lidocaine infusion could be considered in refractory cancer pain where agents with level 1 evidence are ineffective. Further research is necessary to understand the protocol and population in which lidocaine may improve cancer pain and capitalize on the promising opportunities identified.
Pezzullo, L, Streatfeild, J, Hickson, J, Teodorczuk, A, Agar, MR & Caplan, GA 2019, 'Economic impact of delirium in Australia: a cost of illness study.', BMJ open, vol. 9, no. 9.View/Download from: Publisher's site
OBJECTIVES:To estimate the economic impact of delirium in the Australian population in 2016-2017, including financial costs, and its burden on health. DESIGN, SETTING AND PARTICIPANTS:A cost of illness study was conducted for the Australian population in the 2016-2017 financial year. The prevalence of delirium in 2016-2017 was calculated to inform cost estimations. The costs estimated in this study also include dementia attributable to delirium. MAIN OUTCOME MEASURES:The total and per capita costs were analysed for three categories: health systems costs, other financial costs including productivity losses and informal care and cost associated with loss of well-being (burden of disease). Costs were expressed in 2016-2017 pound sterling (£) and Australian dollars ($A). RESULTS:There were an estimated 132 595 occurrences of delirium in 2016-2017, and more than 900 deaths were attributed to delirium in 2016-2017. Delirium causes an estimated 10.6% of dementia in Australia. The total costs of delirium in Australia were estimated to be £4.3 billion ($A8.8 billion) in 2016-2017, ranging between £2.6 billion ($A5.3 billion) and £5.9 billion ($A12.1 billion). The total estimated costs comprised financial costs of £1.7 billion and the value of healthy life lost of £2.5 billion. Dementia attributable to delirium accounted for £2.2 billion of the total cost of delirium. CONCLUSIONS:These findings highlight the substantial burden that delirium imposes on Australian society-both in terms of financial costs associated with health system expenditure and the increased need for residential aged care due to the functional and cognitive decline associated with delirium and dementia. To reduce the substantial well-being costs of delirium, further research should seek to better understand the potential pathways from an episode of delirium to subsequent mortality and reduced cognitive functioning outcomes.
Sinclair, C, Bajic-Smith, J, Gresham, M, Blake, M, Bucks, RS, Field, S, Clayton, JM, Radoslovich, H, Agar, M & Kurrle, S 2019, 'Professionals' views and experiences in supporting decision-making involvement for people living with dementia', Dementia.View/Download from: Publisher's site
© The Author(s) 2019. Background: The provision of supported decision-making for people living with disabilities is an emerging area of practice and rights-based law reform, and is required under international law. Objectives: This qualitative study aimed to understand how Australian health and legal professionals conceptualised their professional roles in the practice of providing decision-making support for people living with dementia. Methods: The methods were informed by grounded theory principles. In-depth, semi-structured interviews were conducted with 28 health and legal professionals involved in providing care or services for people with dementia. Interviews explored how professionals described their practice of providing support for decision-making and how they conceptualised their roles. The analysis was underpinned by the theoretical perspective of symbolic interactionism. Results: Participants described providing support across a range of decision domains, some of which were specific to their professional role. Four key themes were identified: 'establishing a basis for decision-making', 'the supportive toolbox', 'managing professional boundaries' and 'individualist advocacy versus relational practice'. Participants identified a range of generic and specialised techniques they used to provide support for people with dementia. These techniques were applied subject to resource limitations and perceived professional obligations and boundaries. A continuum of professional practice, ranging from 'individualist advocacy' to 'relational practice' describes the approaches adopted by different professionals. Discussion: Professionals conceptualised their role in providing support for decision-making through the lens of their own profession. Differences in positioning on the continuum of 'individualist advocacy' through to 'relational practice' had practical implications for capacity assessment, engaging with persons with impaired decision-making capacity, and t...
Sinclair, C, Gersbach, K, Hogan, M, Blake, M, Bucks, R, Auret, K, Clayton, J, Stewart, C, Field, S, Radoslovich, H, Agar, M, Martini, A, Gresham, M, Williams, K & Kurrle, S 2019, '"A Real Bucket of Worms": Views of People Living with Dementia and Family Members on Supported Decision-Making.', Journal of bioethical inquiry, vol. 16, no. 4, pp. 587-608.View/Download from: Publisher's site
Supported decision-making has been promoted at a policy level and within international human rights treaties as a way of ensuring that people with disabilities enjoy the right to legal capacity on an equal basis with others. However, little is known about the practical issues associated with implementing supported decision-making, particularly in the context of dementia. This study aimed to understand the experiences of people with dementia and their family members with respect to decision-making and their views on supported decision-making. Thirty-six interviews (twenty-one dyadic and fifteen individual) were undertaken with fifty-seven participants (twenty-five people living with dementia and thirty-two family members) across three states in Australia. Interpretative Phenomenological Analysis (IPA) was used as the methodological approach, with relational autonomy as a theoretical perspective. We identified two overarching themes relating to participants' experiences with decision-making: "the person in relationship over time" and "maintaining involvement." Participant views on the practical issues associated with supported decision-making are addressed under the themes of "facilitating decision-making," "supported decision-making arrangements," "constraints on decision-making," and "safeguarding decision-making." While participants endorsed the principles of supported decision-making as part of their overarching strategy of "maintaining involvement" in decision-making, they recognized that progressive cognitive impairment meant that there was an inevitable transition toward greater involvement of, and reliance upon, others in decision-making. Social and contextual "constraints on decision-making" also impacted on the ability of people with dementia to maintain involvement. These themes inform our proposal for a "spectrum approach" to decision-making involvement among people living with dementia, along with recommendations for policy and practice to assist in th...
White, KM, Agar, MR & Currow, DC 2019, 'Assessing the exertion required to induce breathlessness in a population with advanced cancer: matching measures to the level of physical function.', BMC palliative care, vol. 18, no. 1.View/Download from: Publisher's site
BACKGROUND:The aim of the study was to assess four evidence-based assessments utilising exercise challenges that induce breathlessness, each with progressively less demanding levels of exertion, which can be tailored to people with a range of functional capabilities in the setting of advanced cancer for research studies. Functional cut off points for these assessments have not previously been defined. METHODS:A cross sectional study of four exercise tests attempted by all participants: 6 min walk test (6MWT); (derived) 2 min walk test (2MWT); arm exercises; and reading numbers aloud. Performance status (Australia-modified Karnofsky Performance Status (AKPS)), baseline breathlessness using the modified Medical Research Council (mMRC) breathlessness scale, and a visual analogue scale of intensity and unpleasantness of breathlessness were measured. Co-morbidity was codified using the Charlson Co-morbidity Index. Percentage of people completing each test by AKPS level of function and baseline mMRC breathlessness scores were quantified. RESULTS:In the 68 participants, poorer function decreased the proportion of people able to complete the exercise tests. For completion rates ≥80%, of 6MWT and 2MWT, only people with an AKPS 70-90 had completion. For arm exercises, this included people with an AKPS as low as ≥50; and for reading numbers, it included people with an AKPS of 40 but not below. CONCLUSIONS:Walking tests have poor utility in people with high levels of functional impairment. For people with high levels of dependence, reading numbers should be used in evaluating exercise-induced breathlessness in research studies. These data also suggest that people's exertional limitations have been under-estimated as cancer progresses.
Disalvo, D, Luckett, T, Bennett, A, Davidson, P & Agar, M 2019, 'Pharmacists' perspectives on medication reviews for long-term care residents with advanced dementia: a qualitative study.', International journal of clinical pharmacy, vol. 41, no. 4, pp. 950-962.View/Download from: Publisher's site
Background Medication reviews by pharmacists have been shown to identify and reduce drug-related problems in long-term care residents. Objective To explore pharmacist perspectives of the Australian Government funded pharmacist-conducted residential medication management review and its role improving the quality and safety of prescribing in long-term care, in particular for those living with advanced dementia. Setting Australian Long-term care pharmacists. Method A qualitative research methodology approach using semi-structured interviews was used, with participants pharmacists with Residential Medication Management Review experience. Interviews were recorded, transcribed and coded utilising a meta-model of Physician-Community Pharmacy Collaboration in medication review. Main outcome measure Pharmacists' perspectives on the Residential Medication Management Review and how to improve the quality of reviews for residents with advanced dementia. Results Fifteen accredited pharmacists participated. The majority believed that the Residential Medication Management Review had the potential to improve the quality and safety of medicines but highlighted systemic issues that worked against collaborative practice. Participants emphasised the importance of three-way collaboration between general practitioners, pharmacists and nursing staff and highlighted key strategies for its optimisation. Conclusion Incorporating avenues for greater communication between team members can improve collaboration between health professionals and ultimately the quality of medication reviews.
Fischer, T, Hosie, A, Luckett, T, Agar, M & Phillips, J 2019, 'Strategies for Pain Assessment in Adult Patients With Delirium: A Scoping Review.', Journal of pain and symptom management, vol. 58, no. 3, pp. 487-502.e11.View/Download from: Publisher's site
CONTEXT:Pain and delirium are highly prevalent in the same patient groups. Disturbances in attention, awareness, and cognition are characteristics for delirium and can compromise pain assessment. OBJECTIVES:The aim of this review was to examine and map models and understandings of pain and delirium as well as pain assessment instruments and strategies for adult patients with delirium. METHODS:A scoping review of all publications that reported on pain assessment in adult patients with delirium was conducted with no time and language constraints, searching Medline, CINAHL, Scopus, Embase, and PsycINFO and systematically assessing for inclusion. Standardized data extraction and a narrative synthesis followed. RESULTS:A total of 90 publications were included in the final analysis. Despite being recommended for practice, no evidence for the use of self-report or behavioral pain assessment instruments in patients with delirium was identified, with the exception of limited evidence for the validity of the Critical Care Pain Observation Tool and Behavioral Pain Scale in delirious intensive care patients. Proxy ratings of pain and comprehensive pain assessment hierarchies were also recommended, but not supported by evidence. Current models and/or understandings of pain and delirium were not applied in most publications. CONCLUSION:The current literature is insufficient to guide clinical practice in pain assessment in patients with delirium. Future research will be needed to address the validity of existing pain assessment instruments, apply theoretical and conceptual understandings of pain and delirium, and build on prior studies to close evidence gaps.
Kelly, AJ, Luckett, T, Clayton, JM, Gabb, L, Kochovska, S & Agar, M 2019, 'Advance care planning in different settings for people with dementia: A systematic review and narrative synthesis.', Palliative and Supportive Care, vol. 17, no. 6, pp. 707-719.View/Download from: Publisher's site
BACKGROUND:Advance care planning (ACP) is identified as being an important process for people with dementia. However, its efficacy for improving outcomes relevant for the individual, carers and the health system has yet to be established.AimWe conducted a systematic review with the aims of testing the efficacy of ACP for people with dementia and describing the settings and population in which it has been evaluated. METHODS:A search was completed of electronic databases in August 2016. Articles were included if they described interventions aimed at increasing planning for future care of people with dementia, delivered to the person with dementia, their carers and/or health professionals. RESULTS:Of 4,772 articles returned by searches, 30 met the inclusion criteria, testing interventions in nursing home (n= 16) community (n = 10) and acute care (n = 4) settings. Only 18 interventions directly involved the person with dementia, with the remainder focusing on surrogate decision-makers. In all settings, interventions were found effective in increasing ACP practice. In nursing homes, ACP was found to influence care and increase the concordance between end of life wishes and care provided. Interventions in the community were found to improve patient quality of life but were not shown to influence concordance. CONCLUSION:Future research should focus on ways to involve people with dementia in decision-making through supported means.
Luckett, T, Agar, M, DiGiacomo, M, Ferguson, C, Lam, L & Phillips, J 2019, 'Health status of people who have provided informal care or support to an adult with chronic disease in the last 5 years: results from a population-based cross-sectional survey in South Australia.', Australian Health Review, vol. 43, no. 4, pp. 408-414.View/Download from: Publisher's site
Support for Australian carers is warranted to ensure their continuing contributions to society and return to productivity after their caring role is completed.
Luckett, T, Agar, M, DiGiacomo, M, Lam, L & Phillips, J 2019, 'Health status in South Australians caring for people with cancer: A population-based study', PSYCHO-ONCOLOGY, vol. 28, no. 11, pp. 2149-2156.View/Download from: Publisher's site
Luckett, T, Phillips, J, Currow, DC, Agar, M & Molassiotis, A 2019, 'Cough in lung cancer: A survey of current practice among Australian health professionals', Collegian, vol. 26, no. 6, pp. 629-633.View/Download from: Publisher's site
© 2019 Australian College of Nursing Ltd Background: Systematic reviews and guidelines are available to guide management of cough in lung cancer, but evidence for intervention efficacy is limited, and little research has yet described current practice. Aim: To canvass the experiences and perspectives of Australian health professionals with regard to the clinical importance and current management of cough in people with lung cancer. Methods: An open, online, cross-sectional survey was conducted in 2018. Health professionals of all disciplines were eligible, and recruitment was by direct approach to lung cancer multidisciplinary teams, professional listservs and conferences. Findings: Fifty-eight people completed the survey, of whom 26 (45%) were medical practitioners, 21 (36%) registered nurses, and 10 (17%) allied health practitioners. Nearly all (>90%) considered cough to be of clinical concern and welcomed efforts to improve management. In most services, ≤25% of patients with clinically concerning cough receive management. Opiates were perceived to be the most consistently effective pharmacological strategy, with ≥50% participants indicating minimal or variable effectiveness for all others. The few participants who had experience of non-pharmacological strategies perceived these to be only somewhat or variably effective. Discussion: Results from this study identified variability in the management of cough associated with lung cancer, and suggest this problem may be under-treated in most services. Unmet needs identified by this study are likely under-estimated due to the volunteer effect associated with open surveys. Conclusion: Further efforts are needed to raise awareness about the importance of managing cough and provide evidence-based strategies for this population.
Sanderson, C, Sheahan, L, Kochovska, S, Luckett, T, Parker, D, Butow, P & Agar, M 2019, 'Re-defining moral distress: A systematic review and critical re-appraisal of the argument-based bioethics literature', Clinical Ethics, vol. 14, no. 4, pp. 195-210.View/Download from: Publisher's site
© The Author(s) 2019. The concept of moral distress comes from nursing ethics, and was initially defined as '...when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action'. There is a large body of literature associated with moral distress, yet multiple definitions now exist, significantly limiting its usefulness. We undertook a systematic review of the argument-based bioethics literature on this topic as the basis for a critical appraisal, identifying 55 papers for analysis. We found that moral distress is most frequently framed around individual experiences of distress in relation to local practices and constraints, and understood in terms of power relations and workplace hierarchies. This understanding is directly derived from, and often still seen as specific to, nursing. Frequently the perspective of the morally distressed individual is privileged. Understandings of moral distress have evolved towards an 'occupational health approach', with the assumption that moral distress should be measured and prevented. Counter-perspectives were identified, highlighting conceptual problems. Based on our review, we propose a redefinition of moral distress: 'Ethical unease or disquiet resulting from a situation where a clinician believes they have contributed to avoidable patient or community harm through their involvement in an action, inaction or decision that conflicts with their own values'. This definition is specific enough for research use, anchored in clinicians' professional responsibilities and concerns about harms to patients, framed relationally rather than hierarchically, and amenable to multiple perspectives on any given morally distressing situation.
Sopina, E, Chenoweth, L, Luckett, T, Agar, M, Luscombe, GM, Davidson, PM, Pond, CD, Phillips, J & Goodall, S 2019, 'Health-related quality of life in people with advanced dementia: a comparison of EQ-5D-5L and QUALID instruments.', Quality of Life Research, vol. 28, no. 1, pp. 121-129.View/Download from: Publisher's site
Assessing health-related quality of life (HRQOL) in people with advanced dementia is challenging but important for informed decision-making. Proxy measurement of this construct is difficult and is often rated lower than self-report. Accurate proxy rating of quality of life in dementia is related to identification of concepts important to the person themselves, as well as the sensitivity of the measures used. The main aim of this study was to compare the performance of two instruments-QUALID and EQ-5D-5L-on measuring HRQOL in people with advanced dementia.In a sub-study nested within a cluster-RCT we collected proxy(nurse)-completed EQ-5D-5L and QUALID measures at baseline, 3, 6, 9 and 12 months' follow-up for people with advanced dementia, residing in 20 nursing homes across Australia. Spearman's rank correlations, partial correlations and linear regressions were used to assess the relationship between the HRQOL instrument scores and their changes over time.The mean weight from 284 people for the EQ-5D-5L and QUALID at baseline were 0.004 (95% CI - 0.026, 0.033) and 24.98 (95% CI 24.13, 25.82), respectively. At 12 months' follow-up, 115 participants remained alive. EQ-5D-5L weights and QUALID scores at baseline and at follow-up were moderately correlated (r = - 0.437; p < 0.001 at 12 months). Changes within QUALID and EQ-5D-5L across the same follow-up periods were also correlated (r = - 0.266; p = 0.005). The regression analyses support these findings.Whilst these quality of life instruments demonstrated moderate correlation, the EQ-5D-5L does not appear to capture all aspects of quality of life that are relevant to people with advanced dementia and we cannot recommend the use of this instrument for use within this population. The QUALID appears to be a more suitable instrument for measuring HRQOL in people with severe dementia, but is not preference-based, which limits its application in economic evaluations of dementia care.
Hosie, A, Siddiqi, N, Featherstone, I, Johnson, M, Lawlor, PG, Bush, SH, Amgarth-Duff, I, Edwards, L, Cheah, SL, Phillips, J & Agar, M 2019, 'Inclusion, characteristics and outcomes of people requiring palliative care in studies of non-pharmacological interventions for delirium: A systematic review.', Palliative medicine, vol. 33, no. 8, pp. 878-899.View/Download from: Publisher's site
BACKGROUND:Delirium is common, distressing, serious and under-researched in specialist palliative care settings. OBJECTIVES:To examine whether people requiring palliative care were included in non-pharmacological delirium intervention studies in inpatient settings, how they were characterised and what their outcomes were. DESIGN:Systematic review (PROSPERO 2017 CRD42017062178). DATA SOURCES:Systematic search in March 2017 for non-pharmacological delirium intervention studies in adult inpatients. Database search terms were 'delirium', 'hospitalisation', 'inpatient', 'palliative care', 'hospice', 'critical care' and 'geriatrics'. Scottish Intercollegiate Guidelines Network methodological checklists guided risk of bias assessment. RESULTS:The 29 included studies were conducted between 1994 and 2015 in diverse settings in 15 countries (9136 participants, mean age = 76.5 years (SD = 8.1), 56% women). Most studies tested multicomponent interventions (n = 26) to prevent delirium (n = 19). Three-quarters of the 29 included studies (n = 22) excluded various groups of people requiring palliative care; however, inclusion criteria, participant diagnoses, illness severity and mortality indicated their presence in almost all studies (n = 26). Of these, 21 studies did not characterise participants requiring palliative care or report their specific outcomes (72%), four reported outcomes for older people with frailty, dementia, cancer and comorbidities, and one was explicitly focused on people receiving palliative care. Study heterogeneity and limitations precluded definitive determination of intervention effectiveness and only allowed interpretations of feasibility for people requiring palliative care. Acceptability outcomes (intervention adverse events and patients' subjective experience) were rarely reported overall. CONCLUSION:Non-pharmacological delirium interventions have frequently excluded and under-characterised people requiring palliative care and infrequently reported ...
Currow, DC, Agar, M & Ekstroem, M 2019, 'Sertraline or placebo in chronic breathlessness? Lessons from placebo research', EUROPEAN RESPIRATORY JOURNAL, vol. 53, no. 1.View/Download from: Publisher's site
Currow, DC, Ekstrom, M, Louw, S, Hill, J, Fazekas, B, Clark, K, Davidson, P, McDonald, C, Sajkov, D, McCaffrey, N, Doogue, M, Abernethy, AP & Agar, M 2019, 'Sertraline in symptomatic chronic breathlessness: a double blind, randomised trial', European Respiratory Journal, vol. 53, no. 1.View/Download from: Publisher's site
Hosie, A, Phillips, J, Lam, L, Kochovska, S, Noble, B, Brassil, M, Kurrle, SE, Cumming, A, Caplan, GA, Chye, R, Le, B, Ely, EW, Lawlor, PG, Bush, SH, Davis, JM, Lovell, M, Brown, L, Fazekas, B, Cheah, SL, Edwards, L & Agar, M 2019, 'Multicomponent non-pharmacological intervention to prevent delirium for hospitalised people with advanced cancer: study protocol for a phase II cluster randomised controlled trial.', BMJ open, vol. 9, no. 1, pp. e026177-e026177.View/Download from: Publisher's site
INTRODUCTION:Delirium is a significant medical complication for hospitalised patients. Up to one-third of delirium episodes are preventable in older inpatients through non-pharmacological strategies that support essential human needs, such as physical and cognitive activity, sleep, hydration, vision and hearing. We hypothesised that a multicomponent intervention similarly may decrease delirium incidence, and/or its duration and severity, in inpatients with advanced cancer. Prior to a phase III trial, we aimed to determine if a multicomponent non-pharmacological delirium prevention intervention is feasible and acceptable for this specific inpatient group. METHODS AND ANALYSIS:The study is a phase II cluster randomised wait-listed controlled trial involving inpatients with advanced cancer at four Australian palliative care inpatient units. Intervention sites will introduce delirium screening, diagnostic assessment and a multicomponent delirium prevention intervention with six domains of care: preserving natural sleep; maintaining optimal vision and hearing; optimising hydration; promoting communication, orientation and cognition; optimising mobility; and promoting family partnership. Interdisciplinary teams will tailor intervention delivery to each site and to patient need. Control sites will first introduce only delirium screening and diagnosis, later implementing the intervention, modified according to initial results. The primary outcome is adherence to the intervention during the first seven days of admission, measured for 40 consecutively admitted eligible patients. Secondary outcomes relate to fidelity and feasibility, acceptability and sustainability of the study intervention, processes and measures in this patient population, using quantitative and qualitative measures. Delirium incidence and severity will be measured to inform power calculations for a future phase III trial. ETHICS AND DISSEMINATION:Ethical approval was obtained for all four sites. Trial r...
Matsuoka, H, Agar, M, Vandersman, Z, Good, P, Fazekas, B, Brown, L, Hardy, J, Weil, J & Currow, DC 2019, 'Harms From Haloperidol for Symptom Management in Palliative Care-a Post Hoc Pooled Analysis of Three Randomized Controlled Studies and Two Consecutive Cohort Studies.', Journal of Pain and Symptom Management, vol. 58, no. 3, pp. e6-e8.View/Download from: Publisher's site
Matsuoka, H, Allingham, S, Fazekas, B, Brown, L, Vandersman, Z, Clark, K, Agar, MR & Currow, DC 2019, 'Comparability of the Australian National Cancer Symptom Trials (CST) Group's Study Populations to National Referrals to Non-CST Specialist Palliative Care Services Participating in the Palliative Care Outcomes Collaboration.', Journal of Pain and Symptom Management, vol. 57, no. 1, pp. e9-e14.View/Download from: Publisher's site
McCaffrey, N, Flint, T, Kaambwa, B, Fazekas, B, Rowett, D, Currow, DC, Hardy, J, Agar, MR, Quinn, S & Eckermann, S 2019, 'Economic evaluation of the randomised, double-blind, placebo-controlled study of subcutaneous ketamine in the management of chronic cancer pain.', Palliative medicine, vol. 33, no. 1, pp. 74-81.View/Download from: Publisher's site
Lovell, M, Birch, M-R, Luckett, T, Phillips, J, Davidson, PM, Agar, M & Boyle, F 2019, 'Screening and Audit as Service-Level Strategies to Support Implementation of Australian Guidelines for Cancer Pain Management in Adults: A Feasibility Study.', Pain Management Nursing, vol. 20, no. 2, pp. 113-117.View/Download from: Publisher's site
BACKGROUND:Pain in people with cancer is common but often under-recognized and under-treated. Guidelines can improve the quality of pain care, but need targeted strategies to support implementation. AIM:To test the feasibility of two service-level strategies for supporting guideline implementation: a screening system and medical record audit. DESIGN:Multimethods. SETTING:One oncology outpatient service, and one palliative care outpatient and inpatient service. PARTICIPANTS:Patients with advanced cancer. METHODS:Patients were screened in the waiting room with a modified version of the Edmonton Symptom Assessment System-revised either electronically or in paper-based format. Feasibility indicated the percentage of patients successfully screened from the total number attending the services. An audit assessed adherence to key indicators of pain assessment and management. Feasibility thresholds were set at 75% incidence for screening and a median of 30 minutes per patient for audit. RESULTS:Of 452 patient visits, 95% (n = 429) were successfully screened, 34% (n = 155) electronically and 61% (n = 274) paper-based. Electronic pain screening was technically challenging and time-intensive for nurses. Thirty-one patients consented to have their records audited. The median audit time was 37.5 minutes (range 10-120 minutes). Variability arose from the number and type of record (outpatient or inpatient). Adherence to indicators varied from 63% (pain assessment at first presentation) to 94% (regular pain assessment and medication prescribed at regular intervals). CONCLUSIONS:This study confirmed the need to implement evidence-based guidelines for cancer pain and generated useful insights into the feasibility of pain screening and audit.
Luckett, T, Davidson, PM, Green, A, Marie, N, Birch, M-R, Stubbs, J, Phillips, J, Agar, M, Boyle, F & Lovell, M 2019, 'Development of a cancer pain self-management resource to address patient, provider, and health system barriers to care', PALLIATIVE & SUPPORTIVE CARE, vol. 17, no. 4, pp. 472-478.View/Download from: Publisher's site
Best, M, Tang, E, Buhagiar, M & Agar, M 2018, 'Lower-limb oedema at the end of life: How common is it?', Journal of Lymphoedema, vol. 13, no. 1, pp. 20-23.
© 2018, OmniaMed Communications Ltd. All rights reserved. Objectives: Oedema at the end of life is an undertreated and burdensome problem in palliative care patients, but its prevalence and association with risk factors is unknown. The authors aimed to investigate the prevalence of lower-limb oedema at the end of life in a palliative care population and measure the associated risk factors. Methods: A cross-sectional cohort study was carried out in two palliative care units of pitting lower-limb oedema at the end of life and associated risk factorsThis was the first stage of a larger interventional study for treatment of oedema at the end of life in palliative care patients. Results: Fifty-nine participants were admitted during the 1-month study period. Of these, 50.8% had pitting oedema in one or both legs on clinical assessment. The mean age was 67.4 years and 64% were male. All patients had at least one risk factor for oedema at the end of life (mean 3.4). Conclusion: Lower-limb oedema at the end of life is a common problem in the palliative care population. Early recognition and further research on risk factors may enable the introduction of preventative strategies to reduce the incidence of this burdensome problem.
Digges, M, Hussein, A, Wilcock, A, Crawford, GB, Boland, JW, Agar, MR, Sinnarajah, A, Currow, DC & Johnson, MJ 2018, 'Pharmacovigilance in Hospice/Palliative Care: Net Effect of Haloperidol for Nausea or Vomiting.', Journal of Palliative Medicine, vol. 21, no. 1, pp. 37-43.View/Download from: Publisher's site
Haloperidol is widely prescribed as an antiemetic in patients receiving palliative care, but there is limited evidence to support and refine its use.To explore the immediate and short-term net clinical effects of haloperidol when treating nausea and/or vomiting in palliative care patients.A prospective, multicenter, consecutive case series.Twenty-two sites, five countries: consultative, ambulatory, and inpatient services.When haloperidol was started in routine care as an antiemetic, data were collected at three time points: baseline; 48 hours (benefits); day seven (harms). Clinical effects were assessed using the National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI CTCAE).Data were collected (May 2014-March 2016) from 150 patients: 61% male; 86% with cancer; mean age 72 (standard deviation 11) years and median Australian-modified Karnofsky Performance Scale 50 (range 10-90). At baseline, nausea was moderate (88; 62%) or severe (11; 8%); 145 patients reported vomiting, with a baseline NCI CTCAE vomiting score of 1.0. The median (range) dose of haloperidol was 1.5 mg/24 hours (0.5-5 mg/24 hours) given orally or parenterally. Five patients (3%) died before further data collection. At 48 hours, 114 patients (79%) had complete resolution of their nausea and vomiting, with greater benefit seen in the resolution of nausea than vomiting. At day seven, 37 (26%) patients had a total of 62 mild/moderate harms including constipation 25 (40%); dry mouth 13 (21%); and somnolence 12 (19%).Haloperidol as an antiemetic provided rapid net clinical benefit with low-grade, short-term harms.
Meagher, D, Agar, MR & Teodorczuk, A 2018, 'Debate article: Antipsychotic medications are clinically useful for the treatment of delirium', International Journal of Geriatric Psychiatry, vol. 33, no. 11, pp. 1420-1427.View/Download from: Publisher's site
© 2017 John Wiley & Sons, Ltd. Prescribing of antipsychotic medications for patients with delirium remains controversial. Concerns exist that these vulnerable and frail patients may be prescribed antipsychotics inappropriately as a substitute for non-pharmacological approaches when identifiable causes are not found or they challenge ward processes. Moreover, recent evidence suggests that antipsychotics may cause more harm than good in the palliative care patient group with delirium. On the other hand, guidelines in the United Kingdom and the Netherlands support prescribing of antipsychotics in certain circumstances, and a large European survey has revealed that antipsychotics tend to be prescribed first line for hyperactive delirium. Never before, therefore, is there a greater need to examine whether indeed these medications are clinically useful for the treatment of delirium. With this in mind, evidence-based arguments for and against prescribing antipsychotics for the treatment of delirium are presented in this debate article. The paper concludes with a moderation piece to help guide clinical practice.
Sinclair, C, Gersbach, K, Hogan, M, Bucks, RS, Auret, KA, Clayton, JM, Agar, M & Kurrle, S 2018, 'How couples with dementia experience healthcare, lifestyle, and everyday decision-making', INTERNATIONAL PSYCHOGERIATRICS, vol. 30, no. 11, pp. 1639-1647.View/Download from: Publisher's site
Smith, AB, Agar, M, Delaney, G, Descallar, J, Dobell-Brown, K, Grand, M, Aung, J, Patel, P, Kaadan, N & Girgis, A 2018, 'Lower trial participation by culturally and linguistically diverse (CALD) cancer patients is largely due to language barriers.', Asia-Pacific Journal of Clinical Oncology, vol. 14, no. 1, pp. 52-60.View/Download from: Publisher's site
Clinical trials play a critical role in advancing cancer care, but international research shows that few cancer patients, particularly culturally and linguistically diverse (CALD) patients, participate in trials. This limits generalizability of trial results and increases health disparities. This study aimed to establish rates and correlates of trial participation among CALD patients in South Western Sydney Local Health District (SWSLHD), a highly culturally diverse area.Data from all cancer patients diagnosed and/or treated in SWSLHD from January 2006 to July 2016 were analyzed retrospectively. The primary outcome was trial enrolment among patients born in non-English speaking countries (CALD) versus English speaking countries (non-CALD). Multivariable logistic regression evaluated CALD status as a predictor of trial participation. Moderators of trial participation by the different CALD groups, namely those whose preferred language was English (CALD-PLE) or was not English (CALD-PLNE), were examined by testing interactions between CALD status and other demographic and clinical variables.A total of 19 453 patients were analyzed (54.9% non-CALD, 16.5% CALD-PLE, 18.5% CALD-PLNE). Overall, 7.4% of patients were enrolled in a trial. Trial participation was significantly lower in CALD patients than non-CALD patients (5.7% vs 8.4%; odds ratio [OR] = 0.80; 95% confidence interval [CI], 0.69-0.91; P = 0.001). CALD-PLNE patients were less likely to participate in trials than non-CALD (OR = 0.45; 95% CI, 0.36-0.56; P < 0.0001) and CALD-PLE patients (OR = 0.53; 95% CI, 0.67-0.41; P < 0.0001).Limited English proficiency seems particularly unfavorable to trial participation. Development and evaluation of strategies to overcome language barriers (e.g. simplified and translated multimedia participant information materials) is needed.
Smith, TA, Agar, M, Jenkins, CR, Ingham, JM & Davidson, PM 2018, 'Experience of acute noninvasive ventilation-insights from 'Behind the Mask': a qualitative study.', BMJ Supportive and Palliative Care, vol. 9.View/Download from: Publisher's site
Non-invasive ventilation (NIV) is widely used in the management of acute and acute-on-chronic respiratory failure. Understanding the experiences of patients treated with NIV is critical to person-centred care. We describe the subjective experiences of individuals treated with NIV for acute hypercapnic respiratory failure.Qualitative face-to-face interviews analysed using thematic analysis.Australian tertiary teaching hospital.Individuals with acute hypercapnic respiratory failure treated with NIV outside the intensive care unit. Individuals who did not speak English or were unable or unwilling to consent were excluded.13 participants were interviewed. Thematic saturation was achieved. Participants described NIV providing substantial relief from symptoms and causing discomfort. They described enduring NIV to facilitate another chance at life. Although participants sometimes appeared passive, others expressed a strong conviction that they knew which behaviours and treatments relieved their distress. Most participants described gaps in their recollection of acute hospitalisation and placed a great amount of trust in healthcare providers. All participants indicated that they would accept NIV in the future, if clinically indicated, and often expressed a sense of compulsion to accept NIV. Participants' description of their experience of NIV was intertwined with their experience of chronic disease.Participants described balancing the benefits and burdens of NIV, with the goal of achieving another chance at life. Gaps in recall of their treatment with NIV were frequent, potentially suggesting underlying delirium. The findings of this study inform patient-centred care, have implications for the care of patients requiring NIV and for advance care planning discussions.
Disalvo, D, Luckett, T, Luscombe, G, Bennett, A, Davidson, P, Chenoweth, L, Mitchell, G, Pond, D, Phillips, J, Beattie, E, Goodall, S & Agar, M 2018, 'Potentially inappropriate prescribing in Australian nursing home residents with advanced dementia: a sub-study of the IDEAL Study', Journal of Palliative Medicine, vol. 21, no. 10, pp. 1472-1479.
Kochovska, S, Luckett, T, Agar, M & Phillips, JL 2018, 'Impacts on employment, finances, and lifestyle for working age people facing an expected premature death: A systematic review.', Palliative and Supportive Care, vol. 16, no. 3, pp. 347-364.View/Download from: Publisher's site
The working ages (25-65 years) are a period when most people have significant work, financial, and family responsibilities. A small proportion of working age people will face an expected premature death from cancer or other life-limiting illness. Understanding the impact an expected premature death has on this population is important for informing support. The current study set out to summarize research describing the effects that facing an expected premature death has on employment, financial, and lifestyle of working age people and their families.A systematic review using narrative synthesis approach. Four electronic databases were searched in July 2016 for peer-reviewed, English language studies focusing on the financial, employment, and lifestyle concerns of working age adults living with an advanced life-limiting illness and/or their carers and/or children.Fifteen quantitative and 12 qualitative studies were included. Two-thirds (n = 18) were focused on cancer. All studies identified adverse effects on workforce participation, finances, and lifestyle. Many patients were forced to work less or give up work/retire early because of symptoms and reduced functioning. In addition to treatment costs, patients and families were also faced with child care, travel, and home/car modification costs. Being younger was associated with greater employment and financial burden, whereas having children was associated with lower functional well-being. Changes in family roles were identified as challenging regardless of diagnosis, whereas maintaining normalcy and creating stability was seen as a priority by parents with advanced cancer. This review is limited by the smaller number of studies focussing on the needs of working age people with nonmalignant disease. Significance of results Working age people facing an expected premature death and their families have significant unmet financial, employment, and lifestyle needs. Comparing and contrasting their severity, timing, and p...
Campbell, R, McCaffrey, N, Brown, L, Agar, MR, Clark, K & Currow, DC 2018, 'Clinician-reported changes in octreotide prescribing for malignant bowel obstruction as a result of an adequately powered phase III study: A transnational, online survey', PALLIATIVE MEDICINE, vol. 32, no. 8, pp. 1363-1368.View/Download from: Publisher's site
Luckett, T, Phillips, J, Agar, M, Lam, L, Davidson, PM, McCaffrey, N, Boyle, F, Shaw, T, Currow, DC, Read, A, Hosie, A & Lovell, M 2018, 'Protocol for a phase III pragmatic stepped wedge cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of screening and guidelines with, versus without, implementation strategies for improving pain in adults with cancer attending outpatient oncology and palliative care services: the Stop Cancer PAIN trial', BMC HEALTH SERVICES RESEARCH, vol. 18.View/Download from: Publisher's site
Agar, MR, Lawlor, PG & Quinn, S 2017, 'Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial (vol 177, pg 34, 2017)', JAMA INTERNAL MEDICINE, vol. 177, no. 2, pp. 293-293.View/Download from: Publisher's site
Boland, JW, Allgar, V, Boland, EG, Oviasu, O, Agar, M, Currow, DC & Johnson, MJ 2017, 'Effect of Opioids and Benzodiazepines on Clinical Outcomes in Patients Receiving Palliative Care: An Exploratory Analysis.', Journal of Palliative Medicine.View/Download from: Publisher's site
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.
Boland, JW, Allgar, V, Boland, EG, Oviasu, O, Agar, M, Currow, DC & Johnson, MJ 2017, 'O-3 Opioids, benzodiazepines, anti-cholinergic load and clinical outcomes in patients with advanced cancer', BMJ Supportive & Palliative Care, vol. 7, no. Suppl 1, pp. A1.3-A2.View/Download from: Publisher's site
Bush, SH, Marchington, KL, Agar, M, Davis, DHJ, Sikora, L & Tsang, TWY 2017, 'Quality of clinical practice guidelines in delirium: a systematic appraisal', BMJ OPEN, vol. 7, no. 3.View/Download from: Publisher's site
Collier, A, Breaden, K, Phillips, JL, Agar, M, Litster, C & Currow, DC 2017, 'Caregivers' Perspectives on the Use of Long-Term Oxygen Therapy for the Treatment of Refractory Breathlessness: A Qualitative Study.', Journal of Pain and Symptom Management, vol. 53, no. 1, pp. 33-39.View/Download from: Publisher's site
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.
Currow, DC, Phillips, J & Agar, M 2017, 'Population-based models of planning for palliative care in older people.', Current Opinion in Supportive and Palliative Care, vol. 11, no. 4, pp. 310-314.View/Download from: Publisher's site
Health service planning requires demographic, clinical, and health systems data and is unique to each health system. Planning for palliative care in older people must include patients and their carers. This review explores literature from the last 24 months.The proportion of people living in skilled nursing facilities is increasing and many residents require quality palliative care. Simultaneously, the complexity of care for older people is also increasing. Systematic approaches to improving palliative care in these facilities have shown benefits that are cost-effective.Although advance care planning is widely promoted, a randomized controlled trial failed to show the benefits seen in nonrandomized trials. This requires a reconceptualization of current programs that seek to increase uptake.Caregivers take on complex decision-making which can be stressful. By contrast, patients are often very confident that the people who are close to them will make good decisions on their behalf.Specific subgroups considered in this review include carers (and the challenges they face), the 'oldest old' and people with dementia.Excellent research is being done to improve the care of older people with palliative care needs. Ultimately, how can key findings be incorporated into clinical care?
Hosie, A, Agar, M, Lobb, E, Davidson, PM & Phillips, J 2017, 'Improving delirium recognition and assessment for people receiving inpatient palliative care: a mixed methods meta-synthesis', INTERNATIONAL JOURNAL OF NURSING STUDIES, vol. 75, pp. 123-129.View/Download from: Publisher's site
Jeon, MS, Dhillon, HM & Agar, MR 2017, 'Sleep disturbance of adults with a brain tumor and their family caregivers: A systematic review', Neuro-Oncology, vol. 19, no. 8, pp. 1035-1046.View/Download from: Publisher's site
© The Author(s) 2017. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. The high incidence and psychophysiological morbidities of sleep disturbance in cancer have been increasingly recognized. Yet, more detailed understanding of sleep disturbance and options for management have been neglected areas in both clinical care and research. Brain tumor patients have been particularly overlooked. A systematic search of the literature from 1990 to 2015 was performed to review sleep disturbance in adults with primary or secondary brain tumor and their family caregivers. Fifty eligible studies were identified, of which 12 focused on sleep, 37 reported sleep items within a health-related quality of life measure and 1 reported caregivers' sleep. No sleep intervention has been developed or tested for brain tumor patients. Sleep disturbance and somnolence were frequently reported as the most severely rated symptoms within health-related quality of life across the disease course or treatments, along with fatigue. However, sleep-focused studies yielded inconsistent results in small samples of mostly benign brain tumors in long-term remission from total tumor resection. The research using standardized, multifaceted sleep assessments, particularly in patients with malignant brain tumor and caregivers who are undergoing treatment, is seriously lacking. A more systematic examination of sleep disturbance is warranted to inform the development of better symptom management programs in this population.
Laver, K, Cumming, R, Dyer, S, Agar, M, Anstey, KJ, Beattie, E, Brodaty, H, Broe, T, Clemson, L, Crotty, M, Dietz, M, Draper, B, Flicker, L, Friel, M, Heuzenroeder, L, Koch, S, Kurrle, S, Nay, R, Pond, D, Thompson, J, Santalucia, Y, Whitehead, C & Yates, M 2017, 'Evidence-based occupational therapy for people with dementia and their families: What clinical practice guidelines tell us and implications for practice.', Australian Occupational Therapy Journal, vol. 64, no. 1, pp. 3-10.View/Download from: Publisher's site
The first evidence-based Clinical Practice Guidelines and Principles of Care for People with Dementia in Australia have been released. The Guidelines detail a number of important evidence-based recommendations for occupational therapists. The aim of this paper is (1) to provide an overview of Guideline development, and (2) to describe the evidence supporting a recommendation for occupational therapy. Common characteristics of effective occupational therapy programmes for people with dementia are described.Guideline development involved adaptation of existing high-quality guidelines developed overseas and 17 systematic reviews to ensure that the most recent high-quality evidence was included. One of the systematic reviews involved examining the evidence for interventions to promote independence in people with dementia. Specifically, we looked at the evidence for occupational therapy and its effect on activities of daily living, quality of life and carer impact.A total of 109 recommendations are included in the Guidelines. Occupational therapy was found to significantly increase independence in activities of daily living and improve quality of life. Effective occupational therapy programmes involve: environmental assessment, problem solving strategies, carer education and interactive carer skills training.Occupational therapists working with people with dementia in community settings should ensure that their time is spent on those aspects of intervention that are shown to be effective.
Nguyen, K-H, Sellars, M, Agar, M, Kurrle, S, Kelly, A & Comans, T 2017, 'An economic model of advance care planning in Australia: a cost-effective way to respect patient choice', BMC HEALTH SERVICES RESEARCH, vol. 17.View/Download from: Publisher's site
Rose, L, Agar, M, Burry, LD, Campbell, N, Clarke, M, Lee, J, Siddiqi, N & Page, VJ 2017, 'Development of core outcome sets for effectiveness trials of interventions to prevent and/or treat delirium (Del-COrS): study protocol', BMJ OPEN, vol. 7, no. 9.View/Download from: Publisher's site
To, THM, LeBlanc, TW, Eastman, P, Neoh, K, Agar, MR, To, LB, Rowett, D, Vandersman, Z & Currow, DC 2017, 'The Prospective Evaluation of the Net Effect of Red Blood Cell Transfusions in Routine Provision of Palliative Care.', Journal of Palliative Medicine, vol. 20, no. 10, pp. 1152-1157.View/Download from: Publisher's site
Red Blood Cell (RBC) transfusions are commonly used in palliative care. RBCs are a finite resource, transfusions carry risks, and the net effect (benefits and harms) is poorly defined for people with life-limiting illnesses.To examine the indications and effects of RBC transfusion in palliative care patients.This international, multisite, prospective consecutive cohort study.Palliative care patients undergoing RBC transfusion.Target symptoms (fatigue, breathlessness, generalized weakness, or dizziness) were assessed before transfusion and at day 7 by treating clinicians, using National Cancer Center Institute Common Terminology Criteria for Adverse Events. Assessment of harms was made at day 2.One hundred and one transfusions with day 7 follow-up were collected. Median age was 72.0 (interquartile range 61.5-83.0) years, 58% men, and mean Australia-modified Karnofsky Performance Status (AKPS) of 48 (standard deviation [SD] 17). A mean 2.1 (SD 0.6) unit was tranfused. The target symptoms were fatigue (61%), breathlessness (16%), generalized weakness (12%), dizziness (6%), or other (5%). Forty-nine percent of transfusions improved the primary target symptom, and 78% of transfusions improved at least one of the target symptoms. Harms were infrequent and mild. An AKPS of 40%-50% was associated with higher chances of symptomatic benefit in the target symptom; however, no other predictors of response were identified.In the largest prospective consecutive case series to date, clinicians generally reported benefit, with minimal harms. Ongoing work is required to define the optimal patient- and clinician-reported hematological and functional outcome measures to optimize the use of donor blood and to minimize transfusion-associated risk.
Yamaguchi, T, Kuriya, M, Morita, T, Agar, M, Choi, YS, Goh, C, Lingegowda, KB, Lim, R, Liu, RKY, MacLeod, R, Ocampo, R, Cheng, S-Y, Phungrassami, T, Nguyen, Y-P & Tsuneto, S 2017, 'Palliative care development in the Asia-Pacific region: an international survey from the Asia Pacific Hospice Palliative Care Network (APHN).', BMJ Supportive and Palliative Care, vol. 7, pp. 23-31.View/Download from: Publisher's site
Although palliative care is an important public healthcare issue worldwide, the current situation in the Asia-Pacific region has not been systematically evaluated.This survey aimed to clarify the current status of palliative care in the Asia-Pacific region.Questionnaires were sent to a representative physician of each member country/region of the Asia Pacific Hospice Palliative Care Network (APHN). The questionnaire examined palliative care service provision, information regarding physician certification in palliative care, the availability of essential drugs for palliative care listed by the International Association for Hospice and Palliative Care (IAHPC) and the regulation of opioid-prescribing practice.Of the 14 member countries/regions of the APHN, 12 (86%) responded. Some form of specialist palliative care services had developed in all the responding countries/regions. Eight member countries/regions had physician certifications for palliative care. Most essential drugs for palliative care listed by the IAHPC were available, whereas hydromorphone, oxycodone and transmucosal fentanyl were unavailable in most countries/regions. Six member countries/regions required permission to prescribe and receive opioids.The development of palliative care is in different stages across the surveyed countries/regions in the Asia-Pacific region. Data from this survey can be used as baseline data for monitoring the development of palliative care in this region.
Agar, M, Luckett, T, Luscombe, G, Phillips, J, Beattie, E, Pond, D, Mitchell, G, Davidson, P, Cook, J, Brooks, D, Houltram, J, Goodall, S & Chenoweth, L 2017, 'Effects of facilitated family case conferencing for advanced dementia: A cluster randomised clinical trial', PLoS ONE, vol. 12, no. 8, pp. e0181020-e0181020.
Luckett, T, Chenoweth, L, Phillips, J, Brooks, D, Cook, J, Mitchell, G, Pond, D, Davidson, P, Beattie, E, Luscombe, G, Goodall, S, Fischer, T & Agar, M 2017, 'A facilitated approach to family case conferencing for people with advanced dementia living in nursing homes: Perceptions of Palliative Care Planning Coordinators and other health professionals in the IDEAL Study', International Psychogeriatrics, vol. 29, pp. 1713-1722.
Luckett, T, Phillips, J, Johnson, M, Garcia, M, Bhattarai, P, Carrieri-Kohlman, V, Hutchinson, A, Disler, RT, Currow, D, Agar, M, Ivynian, S, Chye, R, Newton, PJ & Davidson, PM 2017, 'Insights from Australians with respiratory disease living in the community with experience of self-managing through an emergency department 'near miss' for breathlessness: a strengths-based qualitative study.', BMJ Open, vol. 7, no. 12, pp. 1-11.View/Download from: Publisher's site
Breathlessness 'crises' in people with chronic respiratory conditions are a common precipitant for emergency department (ED) presentations, many of which might be avoided through improved self-management and support. This study sought insights from people with experience of ED 'near misses' where they considered going to the ED but successfully self-managed instead.A qualitative approach was used with a phenomenological orientation. Participants were eligible if they reported breathlessness on most days from a diagnosed respiratory condition and experience of ≥1 ED near miss. Recruitment was through respiratory support groups and pulmonary rehabilitation clinics. Semistructured interviews were conducted with each participant via telephone or face-to-face. Questions focused on ED-related decision-making, information finding, breathlessness management and support. This analysis used an integrative approach and independent coding by two researchers. Lazarus and Cohen's Transactional Model of Stress and Coping informed interpretive themes.Interviews were conducted with 20 participants, 15 of whom had chronic obstructive pulmonary disease. Nineteen interviews were conducted via telephone. Analysis identified important factors in avoiding ED presentation to include perceived control over breathlessness, self-efficacy in coping with a crisis and desire not to be hospitalised. Effective coping strategies included: taking a project management approach that involved goal setting, monitoring and risk management; managing the affective dimension of breathlessness separately from the sensory perceptual and building three-way partnerships with primary care and respiratory services.In addition to teaching non-pharmacological and pharmacological management of breathlessness, interventions should aim to develop patients' generic self-management skills. Interventions to improve self-efficacy should ensure this is substantiated by transfer of skills and support, including knowledge...
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.View/Download from: Publisher's site
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...
Currow, D, Watts, GJ, Johnson, M, McDonald, CF, Miners, JO, Somogyi, AA, Denehy, L, McCaffrey, N, Eckert, DJ, McCloud, P, Louw, S, Lam, L, Greene, A, Fazekas, B, Clark, KC, Fong, K, Agar, MR, Joshi, R, Kilbreath, S, Ferreira, D, Ekström, M & Australian national Palliative Care Clinical Studies Collaborative (PaCCSC) 2017, 'A pragmatic, phase III, multisite, double-blind, placebo-controlled, parallel-arm, dose increment randomised trial of regular, low-dose extended-release morphine for chronic breathlessness: Breathlessness, Exertion And Morphine Sulfate (BEAMS) study protocol.', BMJ Open, vol. 7, no. 7, pp. 1-19.View/Download from: Publisher's site
INTRODUCTION: Chronic breathlessness is highly prevalent and distressing to patients and families. No medication is registered for its symptomatic reduction. The strongest evidence is for regular, low-dose, extended- release (ER) oral morphine. A recent large phase III study suggests the subgroup most likely to benefit have chronic obstructive pulmonary disease (COPD) and modified Medical Research Council breathlessness scores of 3 or 4. This protocol is for an adequately powered, parallel-arm, placebo-controlled, multisite, factorial, block-randomised study evaluating regular ER morphine for chronic breathlessness in people with COPD. METHODS AND ANALYSIS: The primary question is what effect regular ER morphine has on worst breathlessness, measured daily on a 0-10 numerical rating scale. Uniquely, the coprimary outcome will use a FitBit to measure habitual physical activity. Secondary questions include safety and, whether upward titration after initial benefit delivers greater net symptom reduction. Substudies include longitudinal driving simulation, sleep, caregiver, health economic and pharmacogenetic studies. Seventeen centres will recruit 171 participants from respiratory and palliative care. The study has five phases including three randomisation phases to increasing doses of ER morphine. All participants will receive placebo or active laxatives as appropriate. Appropriate statistical analysis of primary and secondary outcomes will be used. ETHICS AND DISSEMINATION: Ethics approval has been obtained. Results of the study will be submitted for publication in peer-reviewed journals, findings presented at relevant conferences and potentially used to inform registration of ER morphine for chronic breathlessness. TRIAL REGISTRATION NUMBER: NCT02720822; Pre-results.
Agar, MR, Quinn, SJ, Crawford, GB, Ritchie, CS, Phillips, JL, Collier, A & Currow, DC 2016, 'Predictors of Mortality for Delirium in Palliative Care', JOURNAL OF PALLIATIVE MEDICINE, vol. 19, no. 11, pp. 1205-1209.View/Download from: Publisher's site
Burmeister, EA, Jordan, SJ, O'Connell, DL, Beesley, VL, Goldstein, D, Gooden, HM, Janda, M, Merrett, ND, Wyld, D, Neale, RE, Cosman, PH, Bullen, A, Burge, M, Eastgate, M, Powell, J, Deuble, M, Pryor, D, Whelan, J, Algie, L, Gupta, S, Lynch, SV, Burmeister, BH, Slater, K, Fletcher, D, Van Hazel, G, Raftopoulos, S, Spry, N, Agar, M, Brecciaroli, F, Caird, S, Cameron, D, Chan, P, Chantrill, L, Christie, D, Chua, YJ, Croese, J, Cronk, M, Gani, J, Grimison, P, Hruby, G, Jefford, M, Samra, JS & Wysocki, AP 2016, 'Using a Delphi process to determine optimal care for patients with pancreatic cancer', Asia-Pacific Journal of Clinical Oncology, vol. 12, no. 2, pp. 105-114.View/Download from: Publisher's site
© 2016 John Wiley & Sons Australia, Ltd Aim: Overall 5-year survival for pancreatic cancer is ∼5%. Optimizing the care that pancreatic cancer patients receive may be one way of improving outcomes. The objective of this study was to establish components of care which Australian health professionals believe important to optimally manage patients with pancreatic cancer. Methods: Using a Delphi process, a multidisciplinary panel of 250 health professionals were invited to provide a list of factors they considered important for optimal care of pancreatic cancer patients. They were then asked to score and then rescore (from one [no importance/disagree] to 10 [very important/agree]) the factors. The mean and coefficient of variation scores were calculated and categorized into three levels of importance. Results: Overall, 63 (66% of those sent the final questionnaire; 25% of those initially invited) health professionals from nine disciplines completed the final scoring of 55 statements/factors encompassing themes of presentation/staging, surgery and biliary obstruction, multidisciplinary team details and oncology. Mean scores ranged from 3.7 to 9.7 with the highest related to communication and patient assessment. There was substantial intra- and interdisciplinary variation in views about MDT membership and roles. Conclusion: Overall, the opinions of Australian health professionals reflect international guideline recommended care; however, they identified a number of additional factors focusing on where patients should be treated, the importance of clear communication and the need for multidisciplinary care which were not included in current clinical practice guidelines. Differences in priorities between specialty groups were also identified.
Bush, SH, Lacaze-Masmonteil, N, McNamara-Kilian, MT, MacDonald, AR, Tierney, S, Momoli, F, Agar, M, Currow, DC & Lawlor, PG 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.View/Download from: Publisher's site
Cumming, R, Agar, M, Anstey, K, Beattie, E, Brodaty, H, Broe, T, Clemson, L, Crotty, M, Dietz, M, Draper, B, Flicker, L, Friel, M, Heuzenroeder, L, Koch, S, Kurrle, S, Nay, R, Pond, D, Thompson, J, Santalucia, Y, Whitehead, C, Yates, M, Laver, K & Dyer, S 2016, 'Clinical Practice Guidelines for Dementia in Australia: A step towards improving uptake of research findings in health- and aged-care settings', AUSTRALASIAN JOURNAL ON AGEING, vol. 35, no. 2, pp. 86-89.View/Download from: Publisher's site
Hatano, Y, Moroni, M, Wilcock, A, Quinn, S, Csikos, A, Allan, SG, Agar, M, Clark, K, Clayton, JM & Currow, DC 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.View/Download from: Publisher's site
Hosie, A, Agar, M & Phillips, J 2016, 'Re-thinking our approach to care of the dying person with delirium: Time for a new care paradigm', International Journal of Palliative Nursing, vol. 22, no. 10, pp. 472-473.View/Download from: Publisher's site
Hosie, A, Lobb, E, Agar, M, Davidson, P, Chye, R, Lam, L & Phillips, J 2016, 'Measuring delirium point-prevalence in two Australian palliative care inpatient units', INTERNATIONAL JOURNAL OF PALLIATIVE NURSING, vol. 22, no. 1, pp. 13-21.
Laver, K, Cumming, RG, Dyer, SM, Agar, MR, Anstey, KJ, Beattie, E, Brodaty, H, Broe, T, Clemson, L, Crotty, M, Dietz, M, Draper, BM, Flicker, L, Friel, M, Heuzenroeder, LMA, Koch, S, Kurrle, S, Nay, R, Pond, CD, Thompson, J, Santalucia, Y, Whitehead, C & Yates, MW 2016, 'Clinical practice guidelines for dementia in Australia', The Medical journal of Australia, vol. 204, no. 5, pp. 191-193.
About 9% of Australians aged 65 years and over have a diagnosis of dementia. Clinical practice guidelines aim to enhance research translation by synthesising recent evidence for health and aged care professionals. New clinical practice guidelines and principles of care for people with dementia detail the optimal diagnosis and management in community, residential and hospital settings. The guidelines have been approved by the National Health and Medical Research Council. The guidelines emphasise timely diagnosis; living well with dementia and delaying functional decline; managing symptoms through training staff in how to provide person-centred care and using non-pharmacological approaches in the first instance; and training and supporting families and carers to provide care.
Watts, GJ, Clark, K, Agar, M, Davidson, PM, McDonald, C, Lam, LT, Sajkov, D, McCaffrey, N, Doogue, M, Abernethy, AP & Currow, DC 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.View/Download from: Publisher's site
Disalvo, D, Luckett, T, Agar, M, Bennett, A & Davidson, PM 2016, 'Systems to identify potentially inappropriate prescribing in people with advanced dementia: a systematic review', BMC GERIATRICS, vol. 16.View/Download from: Publisher's site
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.View/Download from: Publisher's site
Agar, M, Koh, E-S, Gibbs, E, Barnes, EH, Hovey, E, Livingstone, A, Sawkins, K, Chye, R, Lovell, MR, Clark, K, Vardy, J & King, M 2016, 'Validating self-report and proxy reports of the Dexamethasone Symptom Questionnaire -Chronic for the evaluation of longer-term corticosteroid toxicity', SUPPORTIVE CARE IN CANCER, vol. 24, no. 3, pp. 1209-1218.View/Download from: Publisher's site
Dong, ST, Butow, PN, Agar, M, Lovell, MR, Boyle, F, Stockler, M, Forster, BC & Tong, A 2016, 'Clinicians' Perspectives on Managing Symptom Clusters in Advanced Cancer: A Semi-Structured Interview Study.', Journal of Pain and Symptom Management, vol. 51, no. 4, pp. 706-717.View/Download from: Publisher's site
Managing "symptom clusters," or multiple concurrent symptoms in patients with advanced cancer remains a clinical challenge. The optimal processes constituting effective management of symptoms clusters remain uncertain.To describe the attitudes and strategies of clinicians in managing multiple co-occurring symptoms in patients with advanced cancer.Semi-structured interviews were conducted with 48 clinicians (palliative care physicians [n=10], oncologists [n=6], general practitioners [n=6], nurses [n=12], and allied health providers [n=14]), purposively recruited from two acute hospitals, two palliative care centers, and four community general practices in Sydney, Australia. Transcripts were analyzed using thematic analysis and adapted grounded theory.Six themes were identified: uncertainty in decision making (inadequacy of scientific evidence, relying on experiential knowledge, pressure to optimize care); attunement to patient and family (sensitivity to multiple cues, prioritizing individual preferences, addressing psychosocial and physical interactions, opening "Pandora's Box"); deciphering cause to guide intervention (disaggregating symptoms and interactions, flexibility in assessment, curtailing investigative intrusiveness); balancing complexities in medical management (trading off side effects, minimizing mismatched goals, urgency in resolving severe symptoms); fostering hope and empowerment (allaying fear of the unknown, encouraging meaning making, championing patient empowerment, truth telling); and depending on multidisciplinary expertise (maximizing knowledge exchange, sharing management responsibility, contending with hierarchical tensions, isolation and discontinuity of care).Management of symptom clusters, as both an art and a science, is currently fraught with uncertainty in decision making. Strengthening multidisciplinary collaboration; continuity of care; more pragmatic planning of clinical trials to address more than one symptom; and training in sym...
Dong, ST, Butow, PN, Tong, A, Agar, M, Boyle, F, Forster, BC, Stockler, M & Lovell, MR 2016, 'Patients' experiences and perspectives of multiple concurrent symptoms in advanced cancer: a semi-structured interview study', SUPPORTIVE CARE IN CANCER, vol. 24, no. 3, pp. 1373-1386.View/Download from: Publisher's site
Dong, ST, Costa, DSJ, Butow, PN, Lovell, MR, Agar, M, Velikova, G, Teckle, P, Tong, A, Tebbutt, NC, Clarke, SJ, van der Hoek, K, King, MT & Fayers, PM 2016, 'Symptom Clusters in Advanced Cancer Patients: An Empirical Comparison of Statistical Methods and the Impact on Quality of Life', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 51, no. 1, pp. 88-98.View/Download from: Publisher's site
Luckett, TR, 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.View/Download from: Publisher's site
Sanderson, C, Quinn, SJ, Agar, M, Chye, R, Clark, K, Doogue, M, Fazekas, B, Lee, J, Lovell, MR, Rowett, D, Spruyt, O & Currow, DC 2016, 'Pharmacovigilance in hospice/palliative care: net effect of pregabalin for neuropathic pain.', BMJ Supportive and Palliative Care, vol. 6, pp. 323-330.View/Download from: Publisher's site
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 ≤21 days; and day 21 (short-term benefits).Median dose for 155 patients at day 21 was 150 mg/24 h. 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 7 days, 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 21 days. 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 21 days. 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.
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 speciﬁc symptoms however this approach has notbeen evaluated in randomised trials. To compare the efﬁcacyof risperidone relative to placebo in the control of speciﬁcdelirium 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
Currow, DC, Quinn, S, Agar, M, Fazekas, B, Hardy, J, McCaffrey, N, Eckermann, S, Abernethy, AP & 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.View/Download from: Publisher's site
Halkett, GKB, Lobb, EA, Miller, L, Phillips, JL, Shaw, T, Moorin, R, Long, A, King, A, Clarke, J, Fewster, S, Hudson, P, Agar, M & Nowak, AK 2015, 'Protocol for the Care-IS Trial: a randomised controlled trial of a supportive educational intervention for carers of patients with high-grade glioma (HGG)', BMJ OPEN, vol. 5, no. 10.View/Download from: Publisher's site
Hosie, A, Lobb, E, Agar, M, Davidson, PM, Chye, R & Phillips, J 2015, 'Nurse perceptions of the Nursing Delirium Screening Scale in two palliative care inpatient units: a focus group study', JOURNAL OF CLINICAL NURSING, vol. 24, no. 21-22, pp. 3276-3285.View/Download from: Publisher's site
Marston, C, Agar, M & Brown, T 2015, 'Patients' and caregivers' perceptions of occupational therapy and adapting to discharge home from an inpatient palliative care setting', BRITISH JOURNAL OF OCCUPATIONAL THERAPY, vol. 78, no. 11, pp. 688-696.View/Download from: Publisher's site
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.View/Download from: Publisher's site
Mowll, J, Lobb, EA, Lane, L, Lacey, J, Chochinov, HM, Kelly, B, Agar, M, Links, M & Kearsley, JH 2015, 'A preliminary study to develop an intervention to facilitate communication between couples in advanced cancer', PALLIATIVE & SUPPORTIVE CARE, vol. 13, no. 5, pp. 1381-1390.View/Download from: Publisher's site
Nikles, J, Mitchell, GK, Hardy, J, Agar, M, Senior, H, Carmont, S-A, Schluter, PJ, 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.View/Download from: Publisher's site
Agar, M, Beattie, E, Luckett, T, Phillips, J, Luscombe, G, Goodall, S, Mitchell, G, Pond, D, Davidson, PM & Chenoweth, L 2015, 'Pragmatic cluster randomised controlled trial of facilitated family case conferencing compared with usual care for improving end of life care and outcomes in nursing home residents with advanced dementia and their families: the IDEAL study protocol', BMC Palliative Care, vol. 14, no. 63.View/Download from: Publisher's site
Virdun, C, Brown, N, Phillips, JL, Luckett, T, Agar, M, Green, AR & Davidson, PM 2015, 'Elements of optimal paediatric palliative care for children and young people: An integrative review using a systematic approach', Collegian, vol. 22, no. 4, pp. 421-431.View/Download from: Publisher's site
Background: Models of palliative care need to address the unmet needs of children, youngpeople and families.Objective: To undertake an integrative review to identify the key elements of optimal paediatric palliative care from the perspectives of children and young people with palliative care needs and their parents.
Luckett, T, Bhattarai, P, Phillips, J, Agar, M, Currow, D, Krastev, Y & Davidson, PM 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.View/Download from: Publisher's site
Currow, DC, Clark, K, Kamal, A, Collier, A, Agar, MR, Lovell, MR, Phillips, JL & 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.View/Download from: Publisher's site
Lovell, M, Luckett, T, Boyle, F, Stubbs, J, Phillips, J, Davidson, PM, Olver, I, von Dincklage, J & Agar, M 2015, 'Adaptation of international guidelines on assessment and management of cancer pain for the Australian context', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, vol. 11, no. 2, pp. 170-177.View/Download from: Publisher's site
Phillips, JL, Lovell, M, Luckett, T, Agar, M, Green, AR & Davidson, PM 2015, 'Australian survey of current practice and guideline use in adult cancer pain assessment and management: The community nurse perspective', Collegian, vol. 22, no. 1, pp. 33-41.View/Download from: Publisher's site
Cancer pain remains a major public health concern. Despite effective treatmentsbeing available to manage the majority of cancer pain, this debilitating symptom is frequentlyunder treated. As cancer has becomes a chronic disease a range of health professionals, includ-ing community nurses in Australia are increasingly caring for people living with cancer relatedpain. Yet, little is known about community nurses capacity to assess and manage cancer painin accordance with best available evidence.
Sanderson, C, Quinn, SJ, Agar, M, Chye, R, Clark, K, Doogue, M, Fazekas, B, Lee, J, Lovell, MR, Rowett, D, Spruyt, O & Currow, DC 2015, 'Pharmacovigilance in hospice/palliative care: net effect of gabapentin for neuropathic pain', BMJ SUPPORTIVE & PALLIATIVE CARE, vol. 5, no. 3, pp. 273-280.View/Download from: Publisher's site
Boustani, M, Rudolph, J, Shaughnessy, M, Gruber-Baldini, A, Alici, Y, Arora, RC, Campbell, N, Flaherty, J, Gordon, S, Kamholz, B, Maldonado, JR, Pandharipande, P, Parks, J, Waszynski, C, Khan, B, Neufeld, K, Olofsson, B, Thomas, C, Young, J, Davis, D, Laurila, J, Page, V, Teodorczuk, A, Agar, M, Meagher, D, Spiller, J, Schieveld, J, Milisen, K, de Rooij, S, van Munster, B, Kreisel, S, Cerejeira, J, Hasemann, W, Wilson, D, Cunningham, C, Morandi, A, Slooter, A, Detroyer, E, Caraceni, A & MacLullich, A 2014, 'The DSM-5 criteria, level of arousal and delirium diagnosis: Inclusiveness is safer', BMC Medicine, vol. 12, no. 1, pp. 1-4.View/Download from: Publisher's site
© 2014 European Delirium Association et al.; licensee BioMed Central Ltd. Background: Delirium is a common and serious problem among acutely unwell persons. Alhough linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity.Discussion: Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises 'consciousness' as 'changes in attention'. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested.Summary: Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation.
Bush, SH, Bruera, E, Lawlor, PG, Kanji, S, Davis, DHJ, Agar, M, Wright, DK, Hartwick, M, Currow, DC, Gagnon, B, Simon, J & Pereira, JL 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.View/Download from: Publisher's site
CONTEXT: Delirium occurs in patients across a wide array of health care settings. The extent to which formal management guidelines exist or are adaptable to palliative care is unclear. OBJECTIVES: This review aims to 1) source published delirium management guidelines with potential relevance to palliative care settings, 2) discuss the process of guideline development, 3) appraise their clinical utility, and 4) outline the processes of their implementation and evaluation and make recommendations for future guideline development. METHODS: We searched PubMed (1990-2013), Scopus, U.S. National Guideline Clearinghouse, Google, and relevant reference lists to identify published guidelines for the management of delirium. This was supplemented with multidisciplinary input from delirium researchers and other relevant stakeholders at an international delirium study planning meeting. RESULTS: There is a paucity of high-level evidence for pharmacological and non-pharmacological interventions in the management of delirium in palliative care. However, multiple delirium guidelines for clinical practice have been developed, with recommendations derived from "expert opinion" for areas where research evidence is lacking. In addition to their potential benefits, limitations of clinical guidelines warrant consideration. Guidelines should be appraised and then adapted for use in a particular setting before implementation. Further research is needed on the evaluation of guidelines, as disseminated and implemented in a clinical setting, focusing on measurable outcomes in addition to their impact on quality of care. CONCLUSION: Delirium clinical guidelines are available but the level of evidence is limited. More robust evidence is required for future guideline development.
Bush, SH, Kanji, S, Pereira, JL, Davis, DHJ, Currow, DC, Meagher, DJ, Rabheru, K, Wright, DK, Bruera, E, Agar, M, Hartwick, M, Gagnon, PR, Gagnon, B, Breitbart, W, Regnier, L & Lawlor, PG 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.View/Download from: Publisher's site
CONTEXT: Delirium is a highly prevalent complication in patients in palliative care settings, especially in the end-of-life context. OBJECTIVES: To review the current evidence base for treating episodes of delirium in palliative care settings and propose a framework for future development. METHODS: We combined multidisciplinary input from delirium researchers and other purposely selected stakeholders at an international delirium study planning meeting. This was supplemented by a literature search of multiple databases and relevant reference lists to identify studies regarding therapeutic interventions for delirium. RESULTS: The context of delirium management in palliative care is highly variable. The standard management of a delirium episode includes the investigation of precipitating and aggravating factors followed by symptomatic treatment with drug therapy. However, the intensity of this management depends on illness trajectory and goals of care in addition to the local availability of both investigative modalities and therapeutic interventions. Pharmacologically, haloperidol remains the practice standard by consensus for symptomatic control. Dosing schedules are derived from expert opinion and various clinical practice guidelines as evidence-based data from palliative care settings are limited. The commonly used pharmacologic interventions for delirium in this population warrant evaluation in clinical trials to examine dosing and titration regimens, different routes of administration, and safety and efficacy compared with placebo. CONCLUSION: Delirium treatment is multidimensional and includes the identification of precipitating and aggravating factors. For symptomatic management, haloperidol remains the practice standard. Further high-quality collaborative research investigating the appropriate treatment of this complex syndrome is needed.
Bush, SH, Leonard, MM, Agar, M, Spiller, JA, Hosie, A, Wright, DK, Meagher, DJ, Currow, DC, Bruera, E & Lawlor, PG 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.View/Download from: Publisher's site
CONTEXT: In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase. OBJECTIVES: To review delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium. METHODS: We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO, and CINAHL) to inform this narrative review. RESULTS: The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high-level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health-care staff, clear communication, education, and emotional support are vital components to assist with decision making and direct the treatment care plan. CONCLUSION: Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement is needed in this patient population.
Clark, K, Lam, L, Currow, DC & 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.View/Download from: Publisher's site
Hegarty, M, Breaden, K, Agar, M, Devery, K, Goh, C, Shaw, R, Swetenham, K & Currow, DC 2014, 'Asia Pacific Palliative Care Development Through Education', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 47, no. 2, pp. E7-E9.View/Download from: Publisher's site
Hosie, A, Agar, M, Lobb, E, Davidson, PM & Phillips, JL 2014, 'Palliative care nurses' recognition and assessment of delirium symptoms: a qualitative study using Critical Incident Technique.', International Journal of Nursing Studies, vol. 51, no. 10, pp. 1353-1365.View/Download from: Publisher's site
Delirium is prevalent in palliative care inpatient settings and management is often challenging. Despite nurses integral patient care role, little is known about palliative care nurses capacity to recognise, assess and respond to patients delirium symptoms.
Hosie, A, Lobb, E, Agar, M, Davidson, PM & Phillips, J 2014, 'Identifying the barriers and enablers to palliative care nurses' recognition and assessment of delirium symptoms: a qualitative study.', Journal of pain and symptom management, vol. 48, no. 5, pp. 815-830.View/Download from: Publisher's site
CONTEXT: Delirium is underrecognized by nurses, including those working in palliative care settings where the syndrome occurs frequently. Identifying contextual factors that support and/or hinder palliative care nurses' delirium recognition and assessment capabilities is crucial, to inform development of clinical practice and systems aimed at improving patients' delirium outcomes. OBJECTIVES: The aim of the study was to identify nurses' perceptions of the barriers and enablers to recognizing and assessing delirium symptoms in palliative care inpatient settings. METHODS: A series of semistructured interviews, guided by critical incident technique, were conducted with nurses working in Australian palliative care inpatient settings. A hypoactive delirium vignette prompted participants' recall of delirium and identification of the perceived factors (barriers and enablers) that impacted on their delirium recognition and assessment capabilities. Thematic content analysis was used to analyze the qualitative data. RESULTS: Thirty participants from nine palliative care services provided insights into the barriers and enablers of delirium recognition and assessment in the inpatient setting that were categorized as patient and family, health professional, and system level factors. Analysis revealed five themes, each reflecting both identified barriers and current and/or potential enablers: 1) value in listening to patients and engaging families, 2) assessment is integrated with care delivery, 3) respecting and integrating nurses' observations, 4) addressing nurses' delirium knowledge needs, and 5) integrating delirium recognition and assessment processes. CONCLUSION: Supporting the development of palliative care nursing delirium recognition and assessment practice requires attending to a range of barriers and enablers at the patient and family, health professional, and system levels.
Lawlor, PG, Davis, DHJ, Ansari, M, Hosie, A, Kanji, S, Momoli, F, Bush, SH, Watanabe, S, Currow, DC, Gagnon, B, Agar, M, Bruera, E, Meagher, DJ, de Rooij, SEJA, Adamis, D, Caraceni, A, Marchington, K & Stewart, DJ 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.View/Download from: Publisher's site
CONTEXT: Delirium often presents difficult management challenges in the context of goals of care in palliative care settings. OBJECTIVES: The aim was to formulate an analytical framework for further research on delirium in palliative care settings, prioritize the associated research questions, discuss the inherent methodological challenges associated with relevant studies, and outline the next steps in a program of delirium research. METHODS: We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting, relevant literature searches, focused input of epidemiologic expertise, and a meeting participant and coauthor survey to formulate a conceptual research framework and prioritize research questions. RESULTS: Our proposed framework incorporates three main groups of research questions: the first was predominantly epidemiologic, such as delirium occurrence rates, risk factor evaluation, screening, and diagnosis; the second covers pragmatic management questions; and the third relates to the development of predictive models for delirium outcomes. Based on aggregated survey responses to each research question or domain, the combined modal ratings of "very" or "extremely" important confirmed their priority. CONCLUSION: Using an analytical framework to represent the full clinical care pathway of delirium in palliative care settings, we identified multiple knowledge gaps in relation to the occurrence rates, assessment, management, and outcome prediction of delirium in this population. The knowledge synthesis generated from adequately powered, multicenter studies to answer the framework's research questions will inform decision making and policy development regarding delirium detection and management and thus help to achieve better outcomes for patients in palliative care settings.
Leonard, MM, Agar, M, Spiller, JA, Davis, B, Mohamad, MM, Meagher, DJ & Lawlor, PG 2014, 'Delirium diagnostic and classification challenges in palliative care: subsyndromal delirium, comorbid delirium-dementia, and psychomotor subtypes.', Journal of Pain and Symptom Management, vol. 48, no. 2, pp. 199-214.View/Download from: Publisher's site
CONTEXT: Delirium often presents difficult diagnostic and classification challenges in palliative care settings. OBJECTIVES: To review three major areas that create diagnostic and classification challenges in relation to delirium in palliative care: subsyndromal delirium (SSD), delirium in the context of comorbid dementia, and classification of psychomotor subtypes, and to identify knowledge gaps and research priorities in relation to these three areas of focus. METHODS: We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant PubMed literature searches as the knowledge synthesis strategy in this review. RESULTS: We identified six (SSD), 33 (dementia), and 44 (psychomotor subtypes) articles of relevance in relation to the focus of our review. Recent literature data highlight the frequency and impact of SSD, the relevance of comorbid dementia, and the propensity for a hypoactive presentation of delirium in the palliative population. The differential diagnoses to consider are wide and include pain, fatigue, mood disturbance, psychoactive medication effects, and other causes for altered consciousness. CONCLUSION: Challenges in the diagnosis and classification of delirium in people with advanced disease are compounded by the generalized disturbance of central nervous system function that occurs in the seriously ill, often with comorbid illness, including dementia. Further research is needed to delineate the pathophysiological and clinical associations of these presentations and thus inform therapeutic strategies. The expanding aged population and growing focus on dementia care in palliative care highlight the need to conduct this research.
Leonard, MM, Nekolaichuk, C, Meagher, DJ, Barnes, C, Gaudreau, J-D, Watanabe, S, Agar, M, Bush, SH & Lawlor, PG 2014, 'Practical assessment of delirium in palliative care.', Journal of Pain and Symptom Management, vol. 48, no. 2, pp. 176-190.View/Download from: Publisher's site
CONTEXT: Delirium is a common, distressing neuropsychiatric complication for patients in palliative care settings, where the need to minimize burden yet accurately assess delirium is hugely challenging. OBJECTIVES: This review focused on the optimal clinical and research application of delirium assessment tools and methods in palliative care settings. METHODS: In addition to multidisciplinary input from delirium researchers and other relevant stakeholders at an international meeting, we searched PubMed (1990-2012) and relevant reference lists to identify delirium assessment tools used either exclusively or partly in the context of palliative care. RESULTS: Of the 26 delirium scales identified, we selected six for in-depth review: three screening tools, two severity measures, and one research tool for neuropsychological assessment of delirium. These tools differed regarding intended use, ease of use, training requirements, psychometric properties, and validation in or suitability for palliative care populations. The Nursing Delirium Screening Scale, Single Question in Delirium, or Confusion Assessment Method, ideally with a brief attention test, can effectively screen for delirium. Favoring inclusivity, use of Diagnostic and Statistical Manual of Mental Disorders-IV criteria gives the best results for delirium diagnosis. The Revised Delirium Rating Scale and the Memorial Delirium Assessment Scale are the best available options for monitoring severity, and the Cognitive Test for Delirium provides detailed neuropsychological assessment for research purposes. CONCLUSION: Given the unique characteristics of patients in palliative care settings, further contextually sensitive studies of delirium assessment are required in this population.
Smith, T, Agar, M, Davidson, P, Jenkins, C & Ingham, J 2014, 'Noninvasive Ventilation: Better Than You Think; Insights From Behind the Mask.', Chest, vol. 146, no. 4, Supplement 2, pp. 26A-26A.View/Download from: Publisher's site
SESSION TITLE: COPD Diagnosis and Evaluation Posters ISESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: Non-invasive ventilation (NIV) is increasingly used in the management of acute respiratory failure due to decompensated chronic cardiorespiratory disease. The increasing burden of chronic disease and focus on person-centred care, necessitates frank discussions of the benefits and burdens of treatment and an understanding of the patients' perspective. We aimed to describe the subjective experience of individuals undergoing NIV for acute hypercapnic respiratory failure.METHODS: Face-to-face interviews, analysed using qualitative thematic analysisRESULTS: Thirteen participants were interviewed. Six interrelated themes emerged: A passenger on a journey dominated by chronic illness; Balancing benefits and burdens of NIV; Looking to another chance; Knowing what alleviates my distress; Struggling and suffering; Feeling vulnerable and trusting staff. Participants viewed NIV as a two-edged sword; providing substantial relief from symptoms, but engendering discomfort and burden. No participant would forgo this treatment in the future. While participants sometimes appeared passive, they often had significant insight into what relieved their subjective distress. Participants expressed both a sense of compulsion to accept NIV and gratitude for NIV as it facilitated another chance at life. Many participants described minimal recollection of their acute hospitalisation, and placed a great amount of trust in health care providers.CONCLUSIONS: Participants described balancing benefits and burdens of NIV, with the goal of achieving 'another chance' at life. This goal was highly valued despite their description of their life as one of struggle and suffering. While many knew what might alleviate their distress they often appeared passive, like passengers on a journey dominated by their chronic illness.CLINICAL IMPLI...
Sweet, L, Adamis, D, Meagher, DJ, Davis, D, Currow, DC, Bush, SH, Barnes, C, Hartwick, M, Agar, M, Simon, J, Breitbart, W, MacDonald, N & Lawlor, PG 2014, 'Ethical challenges and solutions regarding delirium studies in palliative care.', Journal of Pain and Symptom Management, vol. 48, no. 2, pp. 259-271.View/Download from: Publisher's site
CONTEXT: Delirium occurs commonly in settings of palliative care (PC), in which patient vulnerability in the unique context of end-of-life care and delirium-associated impairment of decision-making capacity may together present many ethical challenges. OBJECTIVES: Based on deliberations at the Studies to Understand Delirium in Palliative Care Settings (SUNDIPS) meeting and an associated literature review, this article discusses ethical issues central to the conduct of research on delirious PC patients. METHODS: Together with an analysis of the ethical deliberations at the SUNDIPS meeting, we conducted a narrative literature review by key words searching of relevant databases and a subsequent hand search of initially identified articles. We also reviewed statements of relevance to delirium research in major national and international ethics guidelines. RESULTS: Key issues identified include the inclusion of PC patients in delirium research, capacity determination, and the mandate to respect patient autonomy and ensure maintenance of patient dignity. Proposed solutions include designing informed consent statements that are clear, concise, and free of complex phraseology; use of concise, yet accurate, capacity assessment instruments with a minimally burdensome schedule; and use of PC friendly consent models, such as facilitated, deferred, experienced, advance, and proxy models. CONCLUSION: Delirium research in PC patients must meet the common standards for such research in any setting. Certain features unique to PC establish a need for extra diligence in meeting these standards and the employment of assessments, consent procedures, and patient-family interactions that are clearly grounded on the tenets of PC.
To, THM, Agar, M, Yates, P & Currow, DC 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.View/Download from: Publisher's site
BACKGROUND: Nausea can be a debilitating symptom for patients with a life-limiting illness. While addressing reversible components, nonpharmacological strategies and antiemetics are the main therapeutic option. The choice of medication, dose, and route of administration remain highly variable. OBJECTIVE: The aim of this study was to codify the current clinical approaches and quantify any variation found nationally. METHODS: A cross-sectional study utilizing a survey of palliative medicine clinicians examined prescribing preferences for nausea using a clinical vignette. Respondent characteristics, the use of nonpharmacological interventions, first- and second-line antiemetic choices, commencing and maximal dose, and time to review were collected. RESULTS: Responding clinicians were predominantly working in palliative medicine across a range of settings with a 49% response rate (105/213). The main nonpharmacological recommendation was "small, frequent snacks." Metoclopramide was the predominant first-line agent (69%), followed by haloperidol (26%), while second-line haloperidol was the predominant agent (47%), with wide variation in other nominated agents. Respondents favoring metoclopramide as first-line tended to use haloperidol second-line (65%), but not vice versa. Maximal doses for an individual antiemetic varied up to tenfold. CONCLUSION: For nausea, a commonly encountered symptom in palliative care, clinicians' favored metoclopramide and haloperidol; however, after these choices, there was large variation in antiemetic selection. While most clinicians recommended modifying meal size and frequency, use of other nonpharmacological therapies was limited.
The WHO analgesic ladder for the treatment of cancer pain provides a three-step sequential approach for analgesic administration based on pain severity that has global applicability. Nonopioids were recommended for mild pain, with the addition of mild opioids for moderate pain and strong opioids for severe pain. Here, we review the evidence for the use of nonopioid analgesic agents in patients with cancer and describe the mode of action of the main drug classes. Evidence supports the use of anti-inflammatory drugs such as acetaminophen/paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) for mild cancer pain. Adding an NSAID to an opioid for stronger cancer pain is efficacious, but the risk of long-term adverse effects has not been quantified. There is limited evidence to support using acetaminophen with stronger opioids. Corticosteroids have a specific role in spinal cord compression and brain metastases, where improved analgesia is a secondary benefit. There is limited evidence for adding corticosteroids to stronger opioids when pain control is the primary objective. Systematic reviews suggest a role for antidepressant and anticonvulsant medications for neuropathic pain, but there are methodologic issues with the available studies. Bisphosphonates improve pain in patients with bony metastases in some tumor types. Denosumab may delay worsening of pain compared with bisphosphonates. Larger studies of longer duration are required to address outstanding questions concerning the use of nonopioid analgesia for stronger cancer pain.
Luckett, T, Phillips, JL, Agar, M, Virdun, C, Green, AR & Davidson, PM 2014, 'Elements of effective palliative care models: a rapid review', BMC Health Services Research, vol. 14, pp. 1-22.View/Download from: Publisher's site
Background: Population ageing, changes to the profiles of life-limiting illnesses and evolving societal attitudes prompt a critical evaluation of models of palliative care. We set out to identify evidence-based models of palliative care to inform policy reform in Australia.
Phillips, JL, 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.View/Download from: Publisher's site
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.
Dong, S, Butow, P, Tong, A, Lovell, M & Agar, M 2014, '"Finding the Balance Between Art and Science": Healthcare Providers' Perspectives on Multiple Symptoms in Advanced Cancer', PSYCHO-ONCOLOGY, vol. 23, pp. 223-224.
Dong, S, Butow, P, Tong, A, Lovell, M & Agar, M 2014, '"Longing for an End to the Emotional Rollercoaster": A Qualitative Study on Patients' Attitudes and Experiences of Multiple Symptoms in Advanced Cancer', PSYCHO-ONCOLOGY, vol. 23, pp. 221-222.
Dong, ST, Butow, PN, Costa, DSJ, Lovell, MR & Agar, M 2014, 'Symptom clusters in patients with advanced cancer: a systematic review of observational studies.', Journal of Pain and Symptom Management, vol. 48, no. 3, pp. 411-450.View/Download from: Publisher's site
CONTEXT: Advanced cancer patients typically experience multiple symptoms, which may influence patient outcomes synergistically. The composition of these symptom clusters (SCs) differs depending on various clinical variables and the timing and method of their assessment. OBJECTIVES: The objective of this systematic review was to examine the composition, longitudinal stability, and consistency across methodologies of common SCs, as well as their common predictors and outcomes. METHODS: A search of MEDLINE, CINAHL, Embase, Web of Science, and PsycINFO was conducted using variants of symptom clusters, cancer, and palliative care. RESULTS: Thirty-three articles were identified and reviewed. Many SCs were identified, with four common groupings being anxiety-depression, nausea-vomiting, nausea-appetite loss, and fatigue-dyspnea-drowsiness-pain. SCs in most cases were not stable longitudinally. The various statistical methods used (most commonly principal component analysis, exploratory factor analysis, and hierarchical cluster analysis) tended to reveal different SCs. Different measurement tools were used in different studies, each containing a different array of symptoms. The predictors and outcomes of SCs were also inconsistent across studies. No studies of patient experiences of SCs were identified. CONCLUSION: Although the articles reviewed revealed four groups of symptoms that tended to cluster, there is limited consistency in the way in which SCs and variables associated with them are identified. This is largely due to a lack of agreement about a robust, clinically relevant definition of SCs. Future research should focus on patients' subjective experience of SCs to inform a clinically relevant definition of SCs and how they are managed over time.
Lovell, MR, Luckett, T, Boyle, FM, Phillips, J, Agar, M & Davidson, PM 2014, 'Patient Education, Coaching, and Self-Management for Cancer Pain', JOURNAL OF CLINICAL ONCOLOGY, vol. 32, no. 16, pp. 1712-+.View/Download from: Publisher's site
Luckett, T, Davidson, PM, Boyle, F, Liauw, W, Agar, M, Green, A & Lovell, M 2014, 'Australian survey of current practice and guideline use in adult cancer pain assessment and management: Perspectives of oncologists', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, vol. 10, no. 2, pp. E99-E107.View/Download from: Publisher's site
Agar, M 2013, 'CARE FOR PEOPLE LIVING WITH CANCER IN RESIDENTIAL AGED CARE', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, vol. 9, pp. 69-69.
Agar, M 2013, 'EAPC early researcher award 2013 - Reflections on winning', European Journal of Palliative Care, vol. 20, no. 5, p. 248.
Agar, M 2013, 'RECENT DEVELOPMENTS IN THERAPEUTICS AND INTERVENTIONS IN PALLIATIVE CARE', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, vol. 9, pp. 94-95.
Agar, M, Ko, DN, Sheehan, C, Chapman, M & Currow, DC 2013, 'Informed Consent in Palliative Care Clinical Trials: Challenging but Possible', JOURNAL OF PALLIATIVE MEDICINE, vol. 16, no. 5, pp. 485-491.View/Download from: Publisher's site
Agar, M, White, K & Currow, D 2013, 'FEASIBILITY OF MEASUREMENT OF FUNCTION IN ADVANCED CANCER: COMPARISON OF THE 6-MINUTE WALK TEST, 2-MINUTE WALK TEST, ISOMETRIC ARM EXERCISES AND READING NUMBERS ALOUD', JOURNAL OF THORACIC ONCOLOGY, vol. 8, pp. S423-S423.
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.
Allcroft, P, Margitanovic, V, Greene, A, Agar, MR, Clark, K, Abernethy, AP & Currow, DC 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.View/Download from: Publisher's site
Breaden, K, Phillips, JL, 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.View/Download from: Publisher's site
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.
Clark, K, Agar, MR & Currow, D 2013, 'Metoclopramide for chronic nausea in adult palliative care patients with advanced cancer', Cochrane Database of Systematic Reviews, vol. 2013, no. 11.View/Download from: Publisher's site
© 2013 The Cochrane Collaboration. This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the efficacy of metoclopramide administered by any route to control the chronic nausea of cancer which is advanced as defined by the fact the cancer is no longer amenable to cure. Additionally, if the data permit: to identify which adverse reactions to the medication were documented, the doses at which they occurred and the characteristics of the affected people; the frequency with which adverse events occur; the duration of therapeutic response that could be expected.
Connell, T, Fernandez, RS, Duong, T, Griffiths, R, Harlum, J & Agar, M 2013, 'Quality of life of community-based palliative care clients and their caregivers', PALLIATIVE & SUPPORTIVE CARE, vol. 11, no. 4, pp. 323-330.View/Download from: Publisher's site
Crawford, G, Agar, M, Quinn, S, Phillips, JL, 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.View/Download from: Publisher's site
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.
Hardy, J, Quinn, S, Fazekas, B, Eckermann, S, Agar, MR, 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.View/Download from: Publisher's site
Hosie, A, Davidson, PM, Agar, M, Sanderson, CR & Phillips, JL 2013, 'Delirium prevalence, incidence, and implications for screening in specialist palliative care inpatient settings: A systematic review', Palliative Medicine, vol. 27, no. 6, pp. 486-498.View/Download from: Publisher's site
Background: Delirium is a serious neuropsychiatric syndrome frequently experienced by palliative care inpatients. This syndrome is under-recognized by clinicians. While screening increases recognition, it is not a routine practice. Aim and design: This systematic review aims to examine methods, quality, and results of delirium prevalence and incidence studies in palliative care inpatient populations and discuss implications for delirium screening.
Lobb, E, Lane, L, Lacey, J, Chochinov, HM, Kelly, B, Agar, M, Mowll, J, Links, M, Kearsley, J, Liauw, W, Lynch, J & Brock, C 2013, 'A Pilot Study of an Intervention for Couples to Facilitate Communication Where One Member of the Couple has Advanced Cancer', PSYCHO-ONCOLOGY, vol. 22, pp. 1-2.View/Download from: Publisher's site
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.View/Download from: Publisher's site
Morandi, A, Davis, D, Taylor, JK, Bellelli, G, Olofsson, B, Kreisel, S, Teodorczuk, A, Kamholz, B, Hasemann, W, Young, J, Agar, M, de Rooij, SE, Meagher, D, Trabucchi, M & MacLullich, AM 2013, 'Consensus and variations in opinions on delirium care: a survey of European delirium specialists', INTERNATIONAL PSYCHOGERIATRICS, vol. 25, no. 12, pp. 2067-2075.View/Download from: Publisher's site
Nikles, J, Mitchell, GK, Hardy, J, Agar, M, Senior, H, Carmont, S-A, Schluter, PJ, 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.View/Download from: Publisher's site
Phillips, JL, West, P, Davidson, PM & Agar, M 2013, 'Does case conferencing for people with advanced dementia living in nursing homes improve care outcomes: Evidence from an integrative review?', International Journal of Nursing Studies, vol. 50, no. 8, pp. 1122-1135.View/Download from: Publisher's site
Objective: This integrative review aimed to appraise the evidence for case conferencing as an intervention to improve palliative care outcomes for older people living with advanced dementia in nursing homes.
Senior, HE, Mitchell, GK, Nikles, J, Carmont, S-A, Schluter, PJ, Currow, DC, Vora, R, Yelland, MJ, Agar, M, Good, PD & Hardy, JR 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, no. 1, pp. 17-17.View/Download from: Publisher's site
BACKGROUND: It is estimated that 29% of deaths in Australia are caused by malignant disease each year and can be expected to increase with population ageing. In advanced cancer, the prevalence of fatigue is high at 70-90%, and can be related to the disease and/or the treatment. The negative impact of fatigue on function (physical, mental, social and spiritual) and quality of life is substantial for many palliative patients as well as their families/carers. METHOD/DESIGN: This paper describes the design of single patient trials (n-of-1 s or SPTs) of a psychostimulant, methylphenidate hydrochloride (MPH) (5 mg bd), compared to placebo as a treatment for fatigue, with a population estimate of the benefit by the aggregation of multiple SPTs. Forty patients who have advanced cancer will be enrolled through specialist palliative care services in Australia. Patients will complete up to 3 cycles of treatment. Each cycle is 6 days long and has 3 days treatment and 3 days placebo. The order of treatment and placebo is randomly allocated for each cycle. The primary outcome is a reduction in fatigue severity as measured by the Functional Assessment of Cancer Therapy-fatigue subscale (FACIT-F). Secondary outcomes include adverse events, quality of life, additional fatigue assessments, depression and Australian Karnovsky Performance Scale. DISCUSSION: This study will provide high-level evidence using a novel methodological approach about the effectiveness of psychostimulants for cancer-related fatigue. If effective, the findings will guide clinical practice in reducing this prevalent condition to improve function and quality of life. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12609000794202.
To, THM, Agar, M, Shelby-James, T, Abernethy, AP, Doogue, M, Rowett, D, Ko, D & Currow, DC 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.View/Download from: Publisher's site
Luckett, T, Davidson, PM, Lam, L, Phillips, JL, 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.View/Download from: Publisher's site
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.
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.View/Download from: Publisher's site
Lovell, M, Agar, M, Luckett, T, Davidson, PM, Green, AR & Clayton, J 2013, 'Australian survey of current practice and guideline use in adult cancer pain assessment and management: Perspectives of palliative care physicians', Journal of Palliative Medicine, vol. 16, no. 11, pp. 1403-1409.View/Download from: Publisher's site
Background: Cancer pain continues to be undertreated, despite the availability of evidence-based guidelines. The Australian National Pain Strategy identified establishment of systems and guidelines to adequately manage cancer pain as a high priority.
Agar, M 2012, 'Pain and delirium', Cme Journal Geriatric Medicine, vol. 14, no. 1, pp. 9-15.
Pain and delirium are significant clinical issues in the older person, which both impact on outcomes. Pain and delirium overlap in several ways including interaction of pathophysiological processes; analgesics being predisposing or precipitating factors in delirium; and uncontrolled pain as a risk for delirium. Assessment requires careful review of clinical features and potential precipitants of both pain and delirium. Current strategies for clinical management to both maximise pain control and reduce delirium risk are discussed. © 2012 Rila Publications Ltd.
Agar, M, Draper, B, Phillips, JL, Collier, A, Harlum, J, Currow, D & Phillips, PA 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.View/Download from: Publisher's site
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.
Currow, DC, Clark, K, Cartmill, J, Pather, S, Plummer, J, Eckermann, S, Abernethy, AP, Agar, M & Quinn, S 2012, 'A multi-site, fixed dose, parallel arm, double-blind, placebo controlled, block randomised trial of the addition of infusional octreotide or placebo to regular ranitidine and dexamethasone for the evaluation of vomiting associated with bowel obstruction at the end of life.', Journal of Clinical Oncology, vol. 30, no. 15_suppl, pp. TPS9153-TPS9153.View/Download from: Publisher's site
TPS9153 Background: Bowel obstruction due to advanced cancer that is surgically inoperable is a major management problem. Studies to date have either been underpowered or have used comparators that may not draw on the best available evidence. Methods: This double-blind, block randomised, placebo controlled, set dose, parallel arm study was conducted across 12 sites in Australia. Eligibility included inoperable bowel obstruction secondary to cancer or its treatments. The intervention was the addition of infusional octreotide or placebo in addition to 200mg ranitidine per 24 hours parenterally and 4mg per 24 hours parenterally of dexamethasone. The primary outcome measure was the numbers of days free of vomiting up to 72 hours after all medications were administered the first time. Participants were also administered between 10-20mls per hour of subcutaneous isotonic fluid over the 72 hour period. Results: This study will close to recruitment in March 2012. To date 89 of 92 required participants have been randomised. Conclusions: This adequately powered study will define the additional net clinical benefit derived from octreotide over placebo in people who have an anti-secretary agent (ranitidine) and glucocorticoids (dexamethasone).
Currow, DC, 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, vol. 30, no. 15_suppl, pp. 2604-2604.View/Download from: Publisher's site
2604 Background: The dissociative anaesthetic ketamine is widely used for cancer related pain. A Cochrane review concluded that insufficient evidence was available to support its use in this setting. Methods: This phase III, multisite, double-blind, dose escalation, placebo, randomised controlled study aimed to determine whether ketamine, delivered subcutaneously over three to five days is more effective than placebo, when used in conjunction with adjuvant therapy in the management of chronic uncontrolled cancer pain. Ketamine would be considered to be of net benefit if it provided a reduction in average pain scores by ≥2/10 points from baseline, with limited breakthrough analgesia and acceptable toxicity. Results: For the 185 participants, there was no significant difference between the proportion of positive outcomes (0.04 (-0.10, 0.18) p=0.55) in the placebo and intervention arms (response rates 27% (25/92) and 31% (29/93)). Pain type (nociceptive versus neuropathic) was not a predictor of response. There was almost twice the incidence of adverse events worse than baseline in the ketamine group after day 1 (IRR = 1.95 (1.46, 2.61), p<0.001) and throughout the study. Those receiving ketamine were more likely to experience a more severe grade of adverse event/day (OR=1.09 (1.00, 1.18), p=0.039). The number needed to treat for one additional patient to get a positive outcome from ketamine was 25 (6, ∞). The number needed to harm, because of toxicity-related withdrawal was 6 (4, 13). Conclusions: Ketamine does not have net clinical benefit when used as an adjunct to opioids and standard co-analgesics in cancer pain.
Dimoska, A, Butow, PN, Lynch, J, Hovey, E, Agar, M, Beale, P & Tattersall, MHN 2012, 'Implementing patient question-prompt lists into routine cancer care', PATIENT EDUCATION AND COUNSELING, vol. 86, no. 2, pp. 252-258.View/Download from: Publisher's site
Hardy, J, Quinn, S, Fazekas, B, Plummer, J, Eckermann, S, Agar, M, Spruyt, O, Rowett, D & Currow, D 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 PALLIATIVE CARE, vol. 28, no. 3, pp. 202-202.
Hardy, J, Quinn, S, Fazekas, B, Plummer, J, Eckermann, S, Agar, M, Spruyt, O, Rowett, D & Currow, DC 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.View/Download from: Publisher's site
Sheehan, C, Agar, M & Currow, DC 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.View/Download from: Publisher's site
Thm, T, Agar, M, Shelby-James, T, Abernethy, A, Doogue, M, Rowett, D & Currow, DC 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.
Thongkhamcharoen, R, Breaden, K, Agar, M & Hamzah, E 2012, 'Dyspnea Management in Palliative Home care: A Case Series in Malaysia', INDIAN JOURNAL OF PALLIATIVE CARE, vol. 18, no. 2, pp. 128-133.View/Download from: Publisher's site
White, K, Agar, M & Currow, D 2012, 'FEASIBILITY OF MEASUREMENT OF FUNCTION IN ADVANCED CANCER: COMPARISON OF THE 6-MINUTE WALK TEST, 2-MINUTE WALK TEST, ISOMETRIC ARM EXERCISES AND READING NUMBERS ALOUD', JOURNAL OF THORACIC ONCOLOGY, vol. 7, no. 9, pp. S187-S188.
Purpose of review: The aim of this review is to summarize the current state of the science in physical symptoms and other end-of-life care domains and/or illness-specific outcomes in palliative care. The review includes progress in outcome measure development and interpretation, with specific reference to the clinical trial context. Recent findings: There are validated measures in a wide range of domains, which can measure outcomes specific to palliative care interventions; which are sufficiently validated to ensure the results of the trial are robust and measuring differences which are both clinically meaningful. In several areas, consensus is emerging which will allow consolidation of outcome measurement and the ability to extend measurement from the clinical trial setting into routine clinical practice. Potential exists for composite measures covering areas prioritized by patients to improve comparability and efficiency. Adverse events need to be measured with the same degree of rigor as efficacy outcomes. Summary: Clinical trials of palliative care interventions need to consider a range of outcomes, however, the choice and timing of measurement of the primary outcome need to be guided by the domain most likely to be influenced by the intervention.
Shelby-James, TM, Hardy, J, Agar, M, Yates, P, Mitchell, G, Sanderson, C, Luckett, T, Abernethy, AP & Currow, DC 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.View/Download from: Publisher's site
Connell, T, Griffiths, R, Fernandez, RS, Tran, D, Agar, M & Harlum, J 2011, 'Quality-of-life trajectory of clients and carers referred to a community palliative care service.', International Journal of Palliative Nursing, vol. 17, no. 2, pp. 80-85.View/Download from: Publisher's site
Palliative care clients often have a reduced quality of life (QOL). The purpose of this study was to explore the QOL trajectory of clients and carers newly referred to a community palliative care service. A total of 49 clients and 43 carers respectively completed the McGill QOL scale (MQOL) and the caregiver QOL cancer scale (CQOLC) questionnaires. Baseline data relating to demographics, health status, and QOL are presented for the 49 participants and their 43 carers, and these are compared with follow-up data from 22 clients and 13 carers (matched pairs). On average, there were no significant differences between baseline and follow-up QOL scores in any respects for either clients or carers, including measures of burden, disruptiveness, positive adaptation, and financial concerns. Whether this indicates that the care administered succeeded in cancelling out the worsening of the clients' conditions or whether it indicates a shortcoming of the care was not assessed.
Currow, D, Burns, C, Agar, M, Phillips, JL, 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.View/Download from: Publisher's site
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.
There is an ethical imperative to provide the best quality of care for all people, including people at the end of life. In order to provide such care, each intervention used in clinical practice must be tested objectively for net clinical benefit (response and toxicity). For pharmacological and non-pharmacological interventions, the gold standard of evidence remains a phase III randomized, controlled study. In palliative care, there is a gradually emerging evidence base for clinical practice derived from rigorously designed and conducted interventional studies. Such studies can effectively recruit, even in this clinical setting, to completion.There are design and implantation challenges in all controlled clinical trials. Some issues are highly likely in palliative care and will influence trial design and analysis including expected attrition unrelated to the intervention, wide variation in the diagnosis and timing of referral to individual palliative care services and responsible reporting of serious adverse events. Factors that are not unique to palliative care but are often magnified in such studies include concerns by referrers and participants about randomization and blinding, how and when to measure endpoints that are clinically relevant, how to minimize the burden of data collection, ensuring studies are adequately powered and how best to deal with primary outcomes that are subjective. Many studies in the palliative care population have successfully overcome these challenges by thoughtful study design. Factors associated with successful (palliative care) study completion include (i) a shared vision about what the research is designed to achieve; (ii) governance structures independent of the researchers; (iii) ways of defining standard practice for the control arm using best available evidence and consensus; (iv) face-to-face meetings especially for protocol development; (v) adequate funding given estimates that four to six palliative care patients will be s...
Currow, DC, Agar, MR, To, THM, Rowett, D, Greene, A & Abernethy, AP 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.View/Download from: Publisher's site
Davidson, PM, Jiwa, M, Goldsmith, AJ, McGrath, S, DiGiacomo, M, Phillips, JL, Agar, M, Newton, PJ & 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.View/Download from: Publisher's site
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.
Lobb, EA, Swetenham, K, Agar, M & Currow, DC 2011, 'A Collateral Benefit of Research in Palliative Care', JOURNAL OF PALLIATIVE MEDICINE, vol. 14, no. 9, pp. 986-987.View/Download from: Publisher's site
Meera, A 2011, 'Pain and opioid dependence: Is it a matter of concern', Indian Journal of Palliative Care, vol. 17, no. 4 SUPPL..View/Download from: Publisher's site
Opioids are extremely effective in managing cancer pain, and now are utilized for longer periods of time in cancer patients as the treatment for malignancies has become more successful.  The goals in cancer pain treatment includes maintaining function in patients with cancer pain (especially in earlier stage disease), and palliation in advanced disease.  The perception of the lay public and inexperienced clinicians that addiction is inevitable, often leads to an inappropriate fear to utilize opioids to appropriately manage pain; resulting in persistent under-treatment of cancer pain internationally. [2,3] There is much confusion about the phenomenon of physical dependence and how this can be differentiated from the maladaptive behaviors that constitute a diagnosis of substance abuse. The burden of cancer and associated cancer pain is projected to continue to rise, and is often at an advanced stage at diagnosis in less developed countries.  To be able to provide quality care for this patient population availability of opioids and skilled clinicians in pain management is paramount. In the majority of cases, the main concern is to abate concerns about risks of opioid addiction; to allow adequate pain relief. To understand the infrequent phenomenon of substance abuse in the setting of cancer pain management clear definitions are needed, and review of the epidemiology of occurrence in cancer populations is needed. It is also important to clearly separate the issues of substance abuse at the patient level and diversion of prescribed opioids. There are principles of managing cancer pain in the rare clinical scenario when the risk of substance abuse is high, which can still allow safe management of cancer pain with opioids.
To, THM, Greene, AG, Agar, MR & Currow, DC 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.View/Download from: Publisher's site
Agar, M 2010, 'Palliative care: Compassion, care and complexity', Cancer Forum, vol. 34, no. 2, pp. 73-74.
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.View/Download from: Publisher's site
Clark, K, Lam, LT, Agar, M, Chye, R & Currow, DC 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.View/Download from: Publisher's site
Connell, T, Fernandez, RS, Griffiths, R, Tran, D, Agar, M, Harlum, J & Langdon, R 2010, 'Perceptions of the impact of health-care services provided to palliative care clients and their carers', International Journal of Palliative Nursing, vol. 16, no. 6, pp. 274-284.View/Download from: Publisher's site
A wide range of services are provided to palliative care clients to alleviate pain and improve their quality of life. The purpose of this study was to explore the perceptions of clients and their carers regarding palliative care services in New South Wales, Austalia. Ten patients and their carers (n=7) were randomly selected from a sample of palliative care clients and were informed of the study and interviewed. Interview data were coded independently by three researchers and thematic analysis was undertaken. The themes identified were similar for both clients and carers and included: access to services; service provision; impact on way of life; usefulness of services; and staffing. An additional theme identified by clients was the burden of caregiving on carers. Knowledge of perceptions and concerns of client and carers is important to consider when planning palliative care services.
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.View/Download from: Publisher's site
Currow, D, Smith, J, Davidson, PM, Newton, PJ, Agar, M, Care, MP & 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.
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.
Currow, DC, Agar, M, Plummer, JL, Blyth, FM & Abernethy, AP 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.View/Download from: Publisher's site
Currow, DC, Shelby-James, TM, 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.View/Download from: Publisher's site
Sanderson, C & Agar, M 2010, 'Delirium in advanced cancer', Cancer Forum, vol. 34, no. 2, pp. 77-82.
Delirium is a distressing and under-diagnosed syndrome of acute alteration in mental state. It occurs frequently in patients with advanced cancer and is often associated with a worsening of prognosis and difficult challenges in symptom management. Given its associations with older age, recognition and management of delirious patients are likely to become an even more important aspect of oncological practice in the future. The potential for prevention of delirium is being studied, and protocols which involve modifications in hospital care, in addition to screening and rapid identification and treatment of precipitants, may reduce the burden of the condition. However, such approaches require further study and validation in an advanced cancer population. Routine use of appropriate and validated screening tools is a low burden strategy which is likely to improve diagnosis, care and understanding of delirium. The evidence to guide pharmacological management is not strong. Well designed clinical trials are urgently needed in order to improve supportive care outcomes for delirious patients and to clarify the role of antipsychotic and other medications in symptomatic management.
Shelby-James, T, Agar, MR & Currow, DC 2010, 'A case study evaluation of ethics review systems for multicentre clinical trials', MEDICAL JOURNAL OF AUSTRALIA, vol. 192, no. 5, pp. 292-292.View/Download from: Publisher's site
Agar, M, Currow, D, Plummer, J, Seidel, R, Carnahan, R & Abernethy, AP 2009, 'Changes in anticholinergic load from regular prescribed medications in palliative care as death approaches', PALLIATIVE MEDICINE, vol. 23, no. 3, pp. 257-265.View/Download from: Publisher's site
Agar, M, Currow, D, Plummer, J, Seidel, R, Carnahan, R & Abernethy, AP 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.
Currow, DC, Agar, M, Smith, J & Abernethy, AP 2009, 'Does palliative home oxygen improve dyspnoea? A consecutive cohort study', PALLIATIVE MEDICINE, vol. 23, no. 4, pp. 309-316.View/Download from: Publisher's site
Ward, AM, Agar, M & Koczwara, B 2009, 'Collaborating or co-existing: a survey of attitudes of medical oncologists toward specialist palliative care', PALLIATIVE MEDICINE, vol. 23, no. 8, pp. 698-707.View/Download from: Publisher's site
Agar, M, Currow, DC, 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.View/Download from: Publisher's site
Agar, M, Currow, DC, Shelby-James, TM, Plummer, J, Sanderson, C & Abernethy, AP 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.View/Download from: Publisher's site
Clark, K, Currow, DC, Agar, M, Fazekas, BS & Abernethy, AP 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 and Palliative Care Pharmacotherapy, vol. 22, no. 2, pp. 131-138.View/Download from: Publisher's site
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. © 2008 by Informa Healthcare USA, Inc. All rights reserved.
Currow, DC, Agar, M, Sanderson, C & Abernethy, AP 2008, 'Populations who die without specialist palliative care: does lower uptake equate with unmet need?', PALLIATIVE MEDICINE, vol. 22, no. 1, pp. 43-50.View/Download from: Publisher's site
Currow, DC, Agar, M, Tientan, J & Abernethy, AP 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.View/Download from: Publisher's site
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.View/Download from: Publisher's site
Objective: The objective of this study is to provide an expert review of delirium in the context of palliative care. Methods: Based on a primary selection criterion, firstly, studies were included for review if the population studied either had a diagnosis of advanced cancer or was receiving palliative care; alternatively, in the absence of data derived from these populations, studies conducted in other populations were included. Secondly, from the studies meeting the primary selection criterion, we selected those that examined specific standard outcome measures. Thirdly, we selected studies and literature reviews that identified delirium research issues. Results: Delirium occurs commonly in the context of palliative care where it is likely to cause heightened distress for patients, carers, and families alike, and make interpretation of pain and other symptoms extremely difficult. There is a profound dearth of rigorous studies on delirium in this setting. Ambiguous terminology, varying definitions in internationally recognized classification systems, and failure to use validated assessment tools lead to wide-ranging incidence and prevalence of delirium episodes in such populations. Episodes are usually multifactorial in origin and may portend poor prognosis by preceding death in many cases. Despite this, many are often at least partially reversible with relatively low-burden interventions. The patient's disease status, previous quality of life, and prior expressed wishes regarding goals of care should all be taken into account. Antipsychotics are the pharmacotherapeutic agents most commonly used to control symptoms despite limited evidence either supporting their efficacy or examining their adverse event profile. Often, symptomatic control alone is indicated. In cases with refractory symptoms, deeper or "palliative" sedation may be required. Conclusion: Further research is needed regarding delirium recognition, phenomenology, the development of low-burden instrum...
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.
Agar, M, Webster, R, Lacey, J, Donovan, B & Walker, A 2004, 'The use of subcutaneous omeprazole in the treatment of dyspepsia in palliative care patients', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 28, no. 6, pp. 529-531.View/Download from: Publisher's site
Agar, M, Broadbent, A & Chye, R 2004, 'The management of malignant psoas syndrome: Case reports and literature review', JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, vol. 28, no. 3, pp. 282-293.View/Download from: Publisher's site
Webster, R, Lacey, J, Agar, M, Walker, A & Donovan, B 2004, 'The use of subcutaneous omeprazole in the treatment of dyspepsia in palliative care patients: Case reports and literature review', JOURNAL OF PALLIATIVE CARE, vol. 20, no. 3, pp. 250-250.
KEREIAKES, D, FERGUSON, JJ, POPMA, JJ, SHAW, RE, TCHENG, JE, WEISMAN, H, LINCOFF, AM, BREZINA, K & AGUIRRE, F 1994, 'UNTITLED', JOURNAL OF INVASIVE CARDIOLOGY, vol. 6, pp. A43-A56.
This chapter outlines how health professionals may best prevent, recognise, assess, manage and support people with palliative diagnoses who are at risk of delirium, and their families, according to best-evidence and the circumstances, needs and wishes of the person. The chapter also presents evidence-practice gaps in delirium care in palliative contexts, and briefly outlines future directions for research and clinical practice development.
Agar, M & Phillips, JL 2015, 'Palliative medicine and care of the elderly' in The Oxford Textbook of Palliative Medicine, Oxford University Press.
Currow, D, Louw, S, McCloud, P, Fazekas, B, Plummer, J, Mcdonald, CF, Agar, M, Clark, K, McCaffrey, N & Ekstrom, MP 2020, 'Regular, sustained-release morphine for chronic breathlessness: a multicentre, double-blind, randomised, placebo-controlled trial', THORAX, BMJ PUBLISHING GROUP, pp. 50-56.View/Download from: Publisher's site
Morris, L, Turner, S, Thiruthaneeswaran, N, O'Donovan, A, Agar, M & Simcock, R 2019, 'Radiation Oncology for the Older Person: Defining international standards for trainee education', RADIOTHERAPY AND ONCOLOGY, 38th Annual Meeting of the European-Society-for-Radiotherapy-and-Oncology (ESTRO), ELSEVIER IRELAND LTD, Milan, ITALY, pp. S886-S887.View/Download from: Publisher's site
Sands, MB, Sharma, S, Lujic, S, Carpenter, LJ, Hartshawn, A, Lee, JT, Congdon, ME, Buchanan, AM, Agar, M & Vardy, JL 2019, 'SQiD: Can a single question help clinicians identify delirium in hospitalised cancer patients?', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY, pp. 94-94.
Sands, MB, Wee, IJY, Agar, M & Vardy, JL 2019, 'Detection of delirium in admitted oncology patients: A scoping review', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY, pp. 207-208.
Currow, D, Louw, S, Mccloud, P, Fazekas, B, Plummer, J, Mcdonald, C, Agar, M, Clark, K, Mccaffrey, N, Abernethy, A & Ekstrom, M 2018, 'Regular extended release morphine for chronic breathlessness: a multi-centre double-blind RCT', EUROPEAN RESPIRATORY JOURNAL, International Congress of the European-Respiratory-Society, EUROPEAN RESPIRATORY SOC JOURNALS LTD, Paris, France.View/Download from: Publisher's site
Currow, DC, Matsuoka, H, Allingham, S, Fazekas, B, Brown, L, Vandersman, Z, Clark, K & Agar, M 2018, 'Comparability of the Cancer Supportive Care Clinical Studies Collaborative (CSCCSC) study population to national referrals to other specialist palliative care services.', JOURNAL OF CLINICAL ONCOLOGY, Palliative and Supportive Care in Oncology Symposium, AMER SOC CLINICAL ONCOLOGY, San Diego, CA.View/Download from: Publisher's site
Mileshkin, LR, Yoong, J, Nowak, AK, Philip, J, Lee, BH, Agar, M, Phillips, J, Goodall, S, Schofield, P, Ugalde, A, Ball, D, Currow, D, Stubbin, I, Temel, JS, Clark, K, Lorgelly, PK, Brown, C, Tognela, A, Jurkovic, H, Mersiades, A & Stockler, MR 2018, 'PEARL: A randomised phase 3 trial of early referral to palliative care (PC) for patients with advanced thoracic malignancies', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY, pp. 200-200.
Shaw, J, Beatty, L, Kirsten, L, Kissane, D, Mitchell, G, Kelly, B, Sherman, K, Agar, M, Vaccaro, L & Turner, J 2018, 'Making Community-based Shared Care for Depression in Cancer a Reality: Addressing the Barriers and Facilitators to Support Sustainable Implementation', PSYCHO-ONCOLOGY, WILEY, pp. 216-216.
Shaw, J, Beatty, L, Kirsten, L, Vaccaro, L, Kissane, D, Mitchell, G, Kelly, B, Sherman, K, Agar, M & Turner, J 2018, 'Building bridges: addressing the barriers and facilitators to support sustainable implementation of community-based shared care for depression in cancer', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY, pp. 68-69.
Shaw, J, Kirsten, L, Beatty, L, Vacarro, L, Kissane, D, Mitchell, G, Kelly, B, Sherman, K, Agar, M & Turner, J 2018, 'Development of cancer-specific manualised depression treatment', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY, pp. 57-58.
Currow, D, Louw, S, Hill, J, Fazekas, B, Clark, K, Davidson, P, Mcdonald, C, Sajkov, D, Mccaffrey, N, Doogue, M, Abernethy, A & Agar, M 2018, 'Sertraline in symptomatic chronic breathlessness: a double blind, randomised trial', EUROPEAN RESPIRATORY JOURNAL, International Congress of the European-Respiratory-Society, EUROPEAN RESPIRATORY SOC JOURNALS LTD, Paris, France.View/Download from: Publisher's site
Currow, DC, Glare, PA, Watts, G, Louw, S, Martin, P & Clark, K 2018, 'Treating anorexia in people with advanced cancer. a randomised, double blind, controlled trial of megestrol acetate, dexamethasone or placebo', JOURNAL OF CLINICAL ONCOLOGY, AMER SOC CLINICAL ONCOLOGY.View/Download from: Publisher's site
Hosie, A, Phillips, J, Lam, L, Kochovska, S, Brassil, M, Noble, B, Kurrle, S, Cumming, A, Caplan, G, Chye, R, Le, B, Ely, EW, Lawlor, P, Bush, S, Davis, JM, Lovell, M, Brown, L, Fazekas, B, Cheah, SL, Edwards, L & Agar, M 2018, 'A phase II cluster randomised controlled trial of a multicomponent non-pharmacological intervention to prevent delirium for in-patients with advanced cancer (The PRESERVE pilot study)', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY, pp. 166-166.
Jeon, M, Dhillon, H, Koh, E-S, Nowak, A, Lam, L, Miller, L, Marshall, N & Agar, M 2017, 'SLEEP DISTURBANCE AMONG ADULT PATIENTS WITH PRIMARY AND SECONDARY BRAIN TUMORS AND THEIR CAREGIVERS: A CROSS-SECTIONAL STUDY', NEURO-ONCOLOGY, Joint Conference of 22nd Annual Scientific Meeting and Education Day of the Society-for-Neuro-Oncology / Conference of the Society-for-CNS-Interstitial-Delivery-of-the-Therapeutics (SCIDOT) on Therapeutic Delivery to the CNS, OXFORD UNIV PRESS INC, San Francisco, CA, pp. 206-207.
Sands, MB, Sharma, S, Carpenter, L, Lee, J, Congdon, M, Buchanan, A, Lujic, S, Agar, M & Vardy, J 2017, 'SQiD: Can a single question help clinicians identify delirium in people in hospital with cancer?', PSYCHO-ONCOLOGY, WILEY, pp. 133-134.
Smith, B, Agar, M, Delaney, G, Descallar, J, Dobell-Brown, K, Grand, M, Aung, JCC, Patel, P, Kaadan, N & Girgis, A 2017, 'Cancer Research Participation by Culturally and Linguistically Diverse (CALD) Patients in South Western Sydney from 2006 to 2016: A Retrospective Analysis', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY, pp. 96-96.
Disler, RT, 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 Cross-Sectional Survey Study', AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, International Conference of the American-Thoracic-Society (ATS), AMER THORACIC SOC, Washington, DC.
Disler, RT, Luckett, T, Phillips, JL, 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, PM 2017, 'Respiratory Patient Experiences In Self-Managing Emergency Department 'near-Miss' For Breathlessness: A Strengths-Based Qualitative Study', AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, International Conference of the American-Thoracic-Society (ATS), AMER THORACIC SOC, Washington, DC.
Luckett, T, Agar, M, DiGiacomo, M, Ferguson, C, Lam, L, Newton, P & Phillips, J 2017, 'Predictors of Health Status in South Australians Caring for People With Cancer: A Population-Based Study', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY, pp. 163-163.
Phillips, JL, Kochovska, S, Luckett, T & Agar, M 2017, 'Impacts on Employment, Finances and Lifestyle for Working Age People Facing an Expected Premature Death: A Systematic Review', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY, pp. 220-220.
Currow, D, Ekstrom, M, Fazekas, B, Plummer, J, Quinn, S, McDonald, C, Agar, M, Clark, K, Eckermann, S & Abernethy, A 2016, 'A phase III, multi-site, randomised, double blind, placebo controlled parallel arm study of daily extended release (ER) morphine for chronic breathlessness', EUROPEAN RESPIRATORY JOURNAL, EUROPEAN RESPIRATORY SOC JOURNALS LTD.View/Download from: Publisher's site
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.
White, K, Agar, M & Currow, D 2016, 'Breathlessness-inducing exercise in advanced cancer populations. Which measures to use as functional status declines?', EUROPEAN RESPIRATORY JOURNAL, EUROPEAN RESPIRATORY SOC JOURNALS LTD.View/Download from: Publisher's site
Agar, M, Luckett, T, Luscombe, G, Phillips, J, Beattie, E, Pond, D, Mitchell, G, Cook, J, Davidson, PM, Brooks, D, Houltram, J, Goodall, S & Chenoweth, L 2016, 'Pragmatic cluster randomised controlled trial of facilitated family case conferencing versus usual care for people with advanced dementia living in aged care: effects on end of life care', Palliative Care Nurses Australia Conference, Canberra.
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, Annual Scientific Meeting of the American-Geriatrics-Society (AGS), WILEY-BLACKWELL, National Harbor, MD, pp. S99-S99.
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.
Lovell, MR, Birch, M-R, Luckett, T, Davidson, PM, Phillips, J, Agar, M, Boyle, FM, Stubbs, J & Spruyt, O 2014, 'PILOT OF PAIN INDICATOR AUDIT TOOL AS PART OF A COMPLEX INTERVENTION TO IMPROVE CANCER PAIN OUTCOMES', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY-BLACKWELL, pp. 45-45.
Lovell, MR, Luckett, T, Phillips, J, Boyle, F, Davidson, PM, Stubbs, J, Birch, M-R, Spruyt, O & Agar, M 2014, 'CANCER PAIN: CLOSING THE EVIDENCE-PRACTICE GAP', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY-BLACKWELL, pp. 101-101.
Clark, K, Currow, D, Talley, N, Dinning, P, Lam, L, Agar, M, Davidson, P, Shelby-James, T & Phillips, J 2012, 'Exploring the Underlying Physical Changes That Contribute to Bowel Problems in Palliative Care: Preliminary Result', JOURNAL OF PALLIATIVE CARE, CENTRE RECHERCHE INSTITUT UNIV GERIATRIE MONTREAL, pp. 223-224.
Currow, DC, Clark, K, Cartmill, J, Pather, S, Plummer, J, Eckermann, S, Abernethy, AP, Agar, M & Quinn, S 2012, 'A multi-site, fixed dose, parallel arm, double-blind, placebo controlled, block randomised trial of the addition of infusional octreotide or placebo to regular ranitidine and dexamethasone for the evaluation of vomiting associated with bowel obstruction at the end of life', JOURNAL OF CLINICAL ONCOLOGY, 48th Annual Meeting of the American-Society-of-Clinical-Oncology (ASCO), AMER SOC CLINICAL ONCOLOGY, Chicago, IL.
Currow, DC, 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, 48th Annual Meeting of the American-Society-of-Clinical-Oncology (ASCO), AMER SOC CLINICAL ONCOLOGY, Chicago, IL.
Clayton, J, Davidson, PM, Phillips, J, Luckett, T, Green, A, Agar, M, Broadbent, A & Lovell, M 2012, 'STOP PAIN PROJECT: A COLLABORATIVE, INTERDISCIPLINARY PROJECT TO IMPROVE THE PERSON-CENTREDNESS OF ASSESSMENT AND MANAGEMENT OF CANCER PAIN', ASIA-PACIFIC JOURNAL OF CLINICAL ONCOLOGY, WILEY-BLACKWELL, pp. 267-267.
Currow, DC, 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, European Multidisciplinary Cancer Congress on Integrating Basic and Translational Science, Surgery, Radiotherapy, Medical oncology, Advocacy and Care, ELSEVIER SCI LTD, Stockholm, SWEDEN, pp. S152-S152.
Smith, T, Dunford, M, Agar, M, Davidson, P, Jenkins, C & Ingham, J 2014, 'Symptom Burden and Distress in Individuals Undergoing Noninvasive Ventilation for Acute Respiratory Failure.', Elsevier, pp. 39A-39A.
SESSION TITLE: COPD Diagnosis and Evaluation Posters IISESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: Patients with cardiorespiratory disease have a high symptom burden when assessed in inpatient or outpatient settings. Such patients may develop to acute exacerbations, complicated by respiratory failure. Non-invasive ventilation (NIV) is increasingly used to manage acute respiratory failure due to decompensated cardiorespiratory disease. Little is known about the distress experienced by patients undergoing NIV, including symptom burden and delirium point prevalence. To date, no studies have quantified either of these important clinical endpoints.METHODS: Consecutive consenting, English speaking, cognitively intact patients treated outside ICU with NIV for hypercapnic respiratory failure were recruited. Assessment occurred within 36 hours of starting NIV. Symptom burden over the previous 72 hours was assessed measured using the Condensed Memorial Symptom Assessment Scale (CMSAS). This scale assesses the peak bothersomeness of 11 physical symptoms (rated 0-4) and frequency of 3 psychological symptoms (rated 0-4). Delirium point prevalence was assessed using the Confusion Assessment Method for ICU (CAM-ICU).RESULTS: Fifty participants (64% female, mean age 71.9yrs, SD 13.1) were recruited. Prior to NIV, mean arterial pH was 7.30(SD 0.08) and a mean arterial pCO2 58.1mmHg(SD 11.9). Of these, 38% had obstructive lung disease, 14% had heart failure, 30% had both these conditions. The remainder had other causes of respiratory failure. The most prevalent symptoms were breathlessness(92%), dry mouth(88%) and lack of energy(86%). These were also the most bothersome symptoms. The most frequent psychological symptom was worry(64%). The mean total CMSAS score was 1.60(SD 0.66), with the mean physical symptom score of 1.62(SD 0.63) and the mean psychological score of 1.57(SD1.22). Four(8%) patients screened p...
Improving Palliative Care Through Clinical Trials (ImPaCCT)
Palliative Care Clinical Studies Collaborative (PaCCSC)
Ingham Institute of Applied Medical Research
NHMRC Cognitive Decline Partnership Centre