Controlling cancer pain in primary care: the prescribing habits and knowledge base of general practitioners

Cancer-related post-treatment pain and its impact on treatment satisfaction with medication in women with breast cancer: a cross-sectional study from Palestine

BACKGROUND

Pain after therapy is an important clinical problem in patients with breast cancer. Unfortunately, cancer patients have a lower quality of life due to inadequate treatment of posttreatment pain; therefore, improving medication management plans and palliative care has become one of the most important targets of cancer therapy. Therefore, the current study aimed to examine the impact of posttreatment pain on medication satisfaction in patients with various stages of breast cancer in Palestine.

METHODS

A cross-sectional analytical study was conducted et al.-Watani Hospital and An-Najah National University Hospital in the Nablus area. Using the Brief Pain Inventory (BPI), the intensity and interference of pain were evaluated. In addition, patients' satisfaction with cancer management medications was measured using the Treatment Satisfaction Questionnaire for Medication (TSQM).

RESULTS

Two hundred fifty-four patients were included in this study. All were women, with a mean ± SD age of 53.1 ± 10.7 years. The median score for pain severity was 7.0. Pain in the lower extremities was the most reported location. There was a negative association between the global satisfaction domain and the presence of posttreatment pain (p < 0.001). Furthermore, significant differences and negative correlations were found between global satisfaction and posttreatment pain on the day of the interview (p = 0.001), pain medication (p < 0.001), paracetamol use (p < 0.001), and the presence of side effects (p = 0.003). There were significant negative correlations (p < 0.05) between pain severity and interference with effectiveness (r = -0.258, -0.319, respectively), side effects (r = -0.414, -0.514, respectively), convenience (r = -0.274, -0.307, respectively), and global satisfaction domain scores (r = -0.293, -0.287, respectively). Exposure to chemotherapy was the only significant positive correlation with global satisfaction (p = 0.007). The regression analysis results indicated an independent association between chemotherapy use and a higher global satisfaction score (p = 0.011).

CONCLUSIONS

Patients with posttreatment pain, side effects, and greater interference of pain with their functioning had lower satisfaction scores. Therefore, better management of their treatment medications, side effects, and pain medications is recommended to enhance their satisfaction and quality of life. Several aspects of palliative care should be organized to improve the patient's satisfaction and quality of life in addition to conducting longitudinal studies to evaluate the pain and satisfaction of different types of cancers.

Finding their place - general practitioners' experiences with palliative care-a Norwegian qualitative study

BACKGROUND

Modern palliative care focuses on enabling patients to spend their remaining time at home, and dying comfortably at home, for those patients who want it. Compared to many European countries, few die at home in Norway. General practitioners' (GPs') involvement in palliative care may increase patients' time at home and achievements of home death. Norwegian GPs are perceived as missing in this work. The aim of this study is to explore GPs' experiences in palliative care regarding their involvement in this work, how they define their role, and what they think they realistically can contribute towards palliative patients.

METHODS

We performed focus group interviews with GPs, following a semi-structured interview guide. We included four focus groups with a total of 25 GPs. Interviews were recorded and transcribed verbatim. We performed qualitative analysis on these interviews, inspired by interpretative phenomenological analysis.

RESULTS

Strengths of the GP in the provision of palliative care consisted of characteristics of general practice and skills they relied on, such as general medical knowledge, being coordinator of care, and having a personal and longitudinal knowledge of the patient and a family perspective. They generally had positive attitudes but differing views about their formal role, which was described along three positions towards palliative care: the highly involved, the weakly involved, and the uninvolved GP.

CONCLUSION

GPs have evident strengths that could be important in the provision of palliative care. They rely on general medical knowledge and need specialist support. They had no consensus about their role in palliative care. Multiple factors interact in complex ways to determine how the GPs perceive their role and how involved they are in palliative care. GPs may possess skills and knowledge complementary to the specialized skills of palliative care team physicians. Specialized teams with extensive outreach activities should be aware of the potential they have for both enabling and deskilling GPs.

Systematic review of general practice end-of-life symptom control

Background

End of life care (EoLC) is a fundamental role of general practice, which will become more important as the population ages. It is essential that general practice’s role and performance of at the end of life is understood in order to maximise the skills of the entire workforce.

Objective

To provide a comprehensive description of the role and performance of general practitioners (GPs) and general practice nurses (GPNs) in EoLC symptom control.

Method

Systematic literature review of papers from 2000 to 2017 were sought from Medline, PsycINFO, Embase, Joanna Briggs Institute and Cochrane databases.

Results

From 6209 journal articles, 46 papers reported GP performance in symptom management. There was no reference to the performance of GPNs in any paper identified. Most GPs expressed confidence in identifying EoLC symptoms. However, they reported lack of confidence in providing EoLC at the beginning of their careers, and improvements with time in practice. They perceived emotional support as being the most important aspect of EoLC that they provide, but there were barriers to its provision. GPs felt most comfortable treating pain, and least confident with dyspnoea and depression. Observed pain management was sometimes not optimal. More formal training, particularly in the use of opioids was considered important to improve management of both pain and dyspnoea.

Conclusions

It is essential that GPs receive regular education and training, and exposure to EoLC from an early stage in their careers to ensure skill and confidence. Research into the role of GPNs in symptom control needs to occur.

Research Note — Prescribing Diamorphine for Medical Conditions: A Very British Practice

Diamorphine, with a 129-year history, is one of the longest established medications. In British medicine, diamorphine is sometimes used as a maintenance treatment for opiate addiction but is also routinely used in clinical practice to treat a number of general medical conditions. These ways of using diamorphine are very different but are often confused by observers of the British system. Although the routine clinical use of diamorphine in medicine is unique to the United Kingdom (UK), in other countries there is little awareness of this very British practice. Diamorphine is used in hospitals, primary care settings, and hospices. It may be administered by different routes, including oral, intramuscular, intravenous, subcutaneous, inhaled, epidural, and intrathecal routes. Among its most important medicinal uses is the treatment of severe and/or intractable pain. Discussion of the medical uses of diamorphine is often confused by entanglement of medical practice and illicit drug abuse problems. This article summarizes the history, regulation, and uses of diamorphine in the UK.

Descriptions by general practitioners and nurses of their collaboration in continuous sedation until death at home: in-depth qualitative interviews in three European countries

CONTEXT

One palliative care approach that is increasingly being used at home for relieving intolerable suffering in terminally ill patients is continuous sedation until death. Its provision requires a multidisciplinary team approach, with adequate collaboration and communication. However, it is unknown how general practitioners (GPs) and home care nurses experience being involved in the use of sedation at home.

OBJECTIVES

To present case-based GP and nurse descriptions of their collaboration, roles, and responsibilities during the process of continuous sedation until death at home in Belgium, The Netherlands, and the U.K.

METHODS

We held in-depth qualitative interviews with 25 GPs and 26 nurses closely involved in the care of 29 adult cancer patients who received continuous sedation until death at home.

RESULTS

We found that, in Belgium and The Netherlands, it was the GP who typically made the final decision to use sedation, whereas in the U.K., it was predominantly the nurse who both encouraged the GP to prescribe anticipatory medication and decided when to use the prescription. Nurses in the three countries reported that they commonly perform and monitor sedation in the absence of the GP, which they reported to experience as "emotionally burdensome."

CONCLUSION

We found variety among the countries studied regarding the decision making and provision of continuous sedation until death at home. These differences, among others, may be the result of different organizational contexts in the three countries such as the use of anticipatory medication in the U.K.

IASP global year against pain in older persons: highlighting the current status and future perspectives in geriatric pain

This year represents the international year against pain in older persons and it is opportune, therefore, to reflect upon the current status and possible future directions in pain-management practice for this large and growing segment of the population. Epidemiologic studies show a very high prevalence of persistent pain, often exceeding 50% of community-dwelling older persons and up to 80% of nursing home residents. Recently, there has been a major push to develop age-appropriate pain assessment tools, including several observer-rated scales of behavioral pain indicators for use in those with dementia. There has also been the release of several comprehensive guidelines for the assessment and management of pain in older persons, although the current evidence-base used to guide clinical practice is extremely limited. Unfortunately, despite these advances, pain remains grossly under treated in older persons, regardless of the healthcare setting. With the demographic imperative of a rapidly aging society, much greater attention is now being devoted to the problem of geriatric pain, with new initiatives in healthcare planning, calls for better professional education in geriatrics and pain management as well as new directions and funding resources for research into this important problem. Of course, this increased awareness must still be translated into action, not just because better pain relief for older adults is an ethically desirable outcome, but out of the sheer necessity of dealing with the millions of older persons who will suffer from persistent and bothersome pain in the years to come.

Managing pain in advanced cancer: a survey of United kingdom general practitioners and community nurses

CONTEXT

General practitioners (GPs) and community nurses (CNs) have a central role in palliative care. With health policy focusing more and more on enabling patients to die at home, primary health care professionals are increasingly responsible for symptom management of patients near the end of life.

OBJECTIVES

1) To investigate GPs' and CNs' training and knowledge in palliative care and 2) to identify the characteristics of GPs and CNs with lower levels of palliative care knowledge.

METHODS

A postal questionnaire was sent to all GPs and CNs in two areas of the U.K. A panel of doctors and nurses with palliative care expertise rated the response categories with regard to correctness and questions with regard to importance for their professional group. These weightings were combined and applied to answers to assess knowledge levels.

RESULTS

Response rates were 54% and 35% for GPs and CNs, respectively. Respondents reported receiving training in most areas of palliative care throughout their careers, with the exceptions of syringe driver use and bereavement care. High levels of knowledge concerning pain management and syringe driver use were found, with no significant differences in the overall knowledge between the professions. Some important gaps were identified for future educational focus. Regression analyses did not identify characteristics that explained the variation in knowledge scores.

CONCLUSION

Both groups had a high level of knowledge concerning key issues in pain management and syringe driver use that should equip them well for their central role in palliative care. Recommendations for the focus of future education sessions are made.

Clinical effectiveness of online training in palliative care of primary care physicians

BACKGROUND

Primary care physicians (PCPs) have a major responsibility in the management of palliative patients. Online palliative care (PC) education has not been shown to have a clinical impact on patients that is equal or different to traditional training.

OBJECTIVE

This study tested the clinical effectiveness of online PC education of physicians through impact on symptom control, quality of life (QOL), caregiver satisfaction, and knowledge-attitude of physicians at 18 months of the intervention.

METHODS

We conducted a randomized clinical trial. Subjects were 169 physicians randomly assigned to receive the online model or traditional training. Consecutive patients with advanced cancer requiring PC were included. Physicians and patients completed the Palliative Care Outcome Scale (POS), and patients the Brief Pain Inventory (BPI) and the Rotterdam Symptom Checklist (RSCL) twice, 7 to 10 days apart. Caregivers completed the SERVQUAL. Physicians' level of knowledge-attitude was measured at 18 months.

RESULTS

Sixty-seven physicians enrolled 117 patients. The intervention group had reduced scores for pain, symptoms, and family anxiety. The global RSCL scale showed a difference between groups. There was no significant difference in the questionnaires used. Caregiver satisfaction was comparable between groups. Physicians in the intervention group significantly increased their knowledge without any differences in attitude. Online training was completed by 86.6% in the intervention group, whereas 13.4% in the control group accessed traditional training.

CONCLUSIONS

Participation in an online PC education program by PCPs improved patient scores for some symptoms and family anxiety on the POS and also showed improved global QOL. Significant differences were found in physicians' knowledge at short and long term.

Opioid Prescribing for Cancer Pain During the Last 3 Months of Life: Associated Factors and 9-Year Trends in a Nationwide United Kingdom Cohort Study

Purpose

To determine time trends and characteristics associated with opioid analgesic prescribing to patients with cancer who are approaching the end of life.

Patients and Methods

This population-based cohort study used data on 29,825 patients diagnosed with five common cancers—lung (34.2%), colorectal (19.9%), female breast (21.6%), prostate (19.1%), and head and neck (5.2%)—in the United Kingdom General Practice Research Database (GPRD) who died between 2000 and 2008. Opioid prescription rates in the last 3 months of life were described. Characteristics associated with opioid prescribing were investigated by using generalized estimation equation models.

Results

In the last 3 months of life, 43.6% (95% CI, 43.0% to 44.2%) of patients received at least one prescription of opioids: morphine (33.4%; 95% CI, 32.8% to 33.9%), diamorphine (11.6%; 95% CI, 11.2% to 11.9%), and fentanyl family (10.2%; 95% CI, 9.8% to 10.5%). Over time, prescription rates increased for opioids predominant during specific time periods, especially oxycodone. Older patients (age > 60 years) had significantly lower chances of receiving opioids than their younger (age < 50 years) peers (prevalence ratio [PR] range, 0.14 to 0.78), even adjusted for comorbidity. Women were slightly more likely than men to receive any type of opioid (PR,1.07; 95% CI, 1.04 to 1.11). Morphine and diamorphine (PR range, 1.14 to 1.56) were more commonly prescribed for lung and colorectal cancers and fentanyl family for head and neck cancers (PR, 1.39; 95% CI, 1.19 to 1.62) compared with for prostate cancers.

Conclusion

Morphine and diamorphine remain the stronghold for treating cancer pain in the United Kingdom. Opioid prescription rates are increasing over time. Prescription rates are lower for older people for all opioids, suggesting that this group needs attention.

Effects of online palliative care training on knowledge, attitude and satisfaction of primary care physicians

Background

The Spanish Palliative Care Strategy recommends an intermediate level of training for primary care physicians in order to provide them with knowledge and skills. Most of the training involves face-to-face courses but increasing pressures on physicians have resulted in fewer opportunities for provision of and attendance to this type of training. The effectiveness of on-line continuing medical education in terms of its impact on clinical practice has been scarcely studied. Its effect in relation to palliative care for primary care physicians is currently unknown, in terms of improvement in patient's quality of life and main caregiver's satisfaction. There is uncertainty too in terms of any potential benefits of asynchronous communication and interaction among on-line education participants, as well as of the effect of the learning process.

The authors have developed an on-line educational model for palliative care which has been applied to primary care physicians in order to measure its effectiveness regarding knowledge, attitude towards palliative care, and physician's satisfaction in comparison with a control group.

The effectiveness evaluation at 18 months and the impact on the quality of life of patients managed by the physicians, and the main caregiver's satisfaction will be addressed in a different paper.

Methods

Randomized controlled educational trial to compared, on a first stage, the knowledge and attitude of primary care physicians regarding palliative care for advanced cancer patients, as well as satisfaction in those who followed an on-line palliative care training program with tutorship, using a Moodle Platform vs. traditional education.

Results

169 physicians were included, 85 in the intervention group and 84 in the control group, of which five were excluded. Finally 82 participants per group were analyzed. There were significant differences in favor of the intervention group, in terms of knowledge (mean 4.6; CI 95%: 2.8 to 6.5 (p = 0.0001), scale range 0-33), confidence in symptom management (p = 0.02) and confidence in terms of communication (p = 0.038). Useful aspects were pointed out, as well as others to be improved in future applications. The satisfaction of the intervention group was high.

Conclusions

The results of this study show that there was a significant increase of knowledge of 14%-20% and a significant increase in the perception of confidence in symptom management and communication in the intervention group in comparison with the control group that received traditional methods of education in palliative care or no educational activity at all. The overall satisfaction with the intervention was good-very good for most participants.

This on-line educational model seems a useful tool for palliative care training in primary care physicians who have a high opinion about the integration of palliative care within primary care. The results of this study support the suggestion that learning effectiveness should be currently investigated comparing different Internet interventions, instead of Internet vs. no intervention.

Trial Registration

German Clinical Trials Register DRKS00000694

Issues in rural palliative care: views from the countryside

CONTEXT

Growing concern exists among health professionals over the dilemma of providing necessary health care for Canada's aging population. Hospice palliative services are an essential need in both urban and rural settings. Rural communities, in particular, are vulnerable to receiving inadequate services due to their geographic isolation.

PURPOSE

To better understand experiences and issues related to rural palliative care.

METHODS

Focus groups were held for health professionals, family members and volunteers in 3 rural British Columbia communities. A coding schema was developed and the data were then thematically analyzed using a constant comparison technique.

FINDINGS

Three themes in rural palliative care were established: nature of palliative health care services, nature of rural relationships, and competencies required for rural palliative care. Findings indicated that the diversity in rural communities requires tailored approaches to palliative care that consider the geographic, cultural and health aspects of residents in order to optimize care.

CONCLUSION

Tailored approaches to palliative care developed in conjunction with rural communities are needed in order to optimize care.

Cancer pain management in ambulatory care: can we link assessment and action to outcomes?

PURPOSE

Good cancer pain control requires appropriate assessment and treatment. The purpose of this study was to examine the relationships among physician, nurse practitioner, and nurse knowledge, documentation of assessment, treatment, and pain reduction in cancer patients seen in ambulatory settings.

METHOD

The study method included an assessment of pain knowledge of providers (physicians, nurse practitioners, and nurses) who worked in cancer clinics and a retrospective review of patients' records treated for cancer-related pain in their clinics. Fifty-eight providers from eight cancer clinics completed the knowledge questionnaire; 56 patient records were reviewed for assessment, treatment, and outcome data. Pain relief, the outcome, was obtained from documentation at the next clinic visit.

RESULTS

Of the 54 patient records that documented pain relief at the next clinic visit, 61.9% reported no relief. Chi square analysis revealed clinics with a higher level of pain knowledge documented a greater number of elements of an ideal pain assessment (p = 0.03) but was unrelated to treatment and pain relief reported. Assessment and treatment were unrelated to reported pain relief at the next clinic visit.

CONCLUSION

These data suggest that providers' pain knowledge is related to pain assessment but not treatment or outcome. In addition, these data showed no relationship between assessment, treatment prescribed, and pain relief in these ambulatory settings.

Rural Palliative Care: A Comprehensive Review

Abstract Background: Access to integrated, palliative care regardless of location of residence is a palliative care standard yet we know such access is limited for those living in rural and remote settings. As a beginning step in the development of research aimed at informing policy and program development, a comprehensive review of the state of knowledge regarding palliative care in rural contexts is required. Purpose: To identify, evaluate and synthesize the published literature on rural palliative care. Design: Comprehensive review. Methods: Computer searches were conducted on PubBMed, ISI Web of Science, PsycInfo, CINAHL, and Ageline using the search terms palliative care, hospice, terminal care, end-of-life care, end-of-life, and rural or remote. Results: One hundred fifty-eight studies were retrieved. After screening using relevance and quality criteria, 79 studies were included in the review. Studies were grouped by subject matter into one of three categories: patient and caregiver perspectives; professional attitudes, knowledge and practice issues; and health care services. Conclusion: The body of research literature is small and eclectic, which means there is little strong evidence to inform palliative policy and service development in rural settings. Coordinated programs of research are clearly required to develop a body of knowledge that is adequate to support effective service and policy development.

Implementation and impact of the Gold Standards Framework in community palliative care: a qualitative study of three primary care trusts

The Gold Standards Framework (GSF) has been widely adopted within UK general practices, yet there is little understanding of its impact on the provision of community palliative care services. This study presents data on the anticipation and adoption of the GSF within three Primary Care Trusts in North West England. Forty-seven interviews were conducted with generalist and specialist palliative and primary care professionals. Important aspects of the GSF identified were the patient register, communication and out-of-hours protocols. Positive benefits to professionals included improved communication between professionals and appropriate anticipatory prescribing. Negative aspects included increased nursing workload and the possibility of fewer or later visits for patients. Many respondents believed that the GSF needed local champions to be sustainable. Slow or incomplete adoption was reported. The GSF was recognised as important because it facilitated changes to previously difficult aspects of work between professionals, but few respondents reported direct benefits to patient care.

Systematic review of educational interventions in palliative care for primary care physicians

BACKGROUND

A literature review of educational interventions in palliative care (PC) for primary care physicians (PCP) was performed, to evaluate its impact in changing professional practice.

METHODS

Studies undertaking any educational intervention in PC by PCP, published between 1966 and February 2005, identified through Medline, EMBASE, Cochrane Database of Systematic Reviews and Clinical Trials, Educational Resources Information Centre, Research and Development Resource Base in Continuing Medical Education, Spanish Medical Index, using a combined text word and MESH heading search strategy.

RESULTS

Eighteen articles were included with 1653 physicians. Educative methods were: role model training, small group discussions, and distribution of guidelines. Quality of the studies was low. Opioids prescription improved in two studies. Discrepancies were shown between the perception of PCP in symptom management, determined through questionnaires, and the data concerning opioids prescription. Knowledge improved in all studies. Some benefit of multifaceted approach was stated. Carers were satisfied, in general, with the PCP care, but dissatisfied with patients' pain control.

CONCLUSION

PC education for PCP is poorly studied. Adequate research designs are necessary in future studies with objective outcomes and patient opinion.

A UK-wide postal survey to evaluate palliative care education amongst General Practice Registrars

OBJECTIVES

To evaluate the content of General Practice Registrars' (GPRs) palliative care education in the U.K.

METHODS

Postal questionnaires were sent to 492 eligible GPRs across six purposively sampled U.K. postgraduate deaneries.

RESULTS

GPRs were satisfied with their course coverage on control of pain, other symptoms and communication skills, and were also moderately confident in applying the knowledge gained in these areas. They showed a high level of knowledge in the management of cancer-related pain. There was less satisfaction with the coverage given to syringe driver use (38%) and bereavement care (36%), with fewer expressing confidence in applying their knowledge to these areas.

CONCLUSIONS

GPRs have mixed perceptions about their palliative care education. Future educational packages should ensure that GPRs receive planned systematic training in bereavement care and some practical experience in the use of syringe drivers. Both Postgraduate General Practice Education departments and specialist palliative care providers should explore ways of working more closely together to provide GPRs with more expertize in palliative care.

A cognitive behavioral intervention for symptom management in patients with advanced cancer

PURPOSE/OBJECTIVES

To evaluate the effectiveness of a cognitive behavioral intervention in decreasing symptom severity in patients with advanced cancer undergoing chemotherapy.

DESIGN

Prospective, randomized clinical trial based on cognitive behavioral theory.

SETTING

Six urban cancer centers in the midwestern United States.

SAMPLE

124 patients 21 years of age or older were recruited and randomized to receive conventional care or conventional care and an intervention. Participants were newly diagnosed with stage III, stage IV, or recurrent cancer (solid tumor or non-Hodgkin lymphoma), undergoing chemotherapy, cognitively intact, and able to read and speak English.

METHODS

Data were gathered via telephone interviews at baseline and 10 and 20 weeks after randomization. Nurses with experience in oncology delivered a five-contact, eight-week intervention aimed at teaching patients problem-solving techniques to affect symptom severity.

MAIN RESEARCH VARIABLES

Gender, site of cancer, age, symptom severity and depressive symptoms at baseline, group (i.e., experimental versus control), and total symptom severity.

FINDINGS

Patients in the experimental group and those with lower symptom severity at baseline had significantly lower symptom severity at 10 and 20 weeks; the experimental difference at 20 weeks occurred primarily in those 60 years of age and younger. Depressive symptoms at baseline predicted symptom severity at 20 weeks; however, age, gender, and site of cancer did not affect symptom severity at either time point.

CONCLUSIONS

A cognitive behavioral intervention to teach problem-solving skills can be effective for patient symptom self-management during and following an intervention.

IMPLICATIONS FOR NURSING

Problem-solving strategies should be included in educational programs for patients with advanced cancer, particularly those 60 years of age and younger.

General practitioners (GPs) and palliative care: perceived tasks and barriers in daily practice

BACKGROUND

General practitioners (GPs) play a crucial part in palliative care. The quality of care can be improved by investigating and addressing barriers perceived by GPs in daily practice. The aim of this study was to investigate GPs' task perception and barriers involved in palliative care.

METHODS

Qualitative focus group study. We gathered together a group of GPs representing a broad range of experience in palliative care. Content analysis was performed to derive a comprehensive view of tasks and barriers in daily palliative care.

RESULTS

GPs described their palliative care tasks as satisfactory and varied, but burdensome. Palliative care tasks included somatic and psychosocial care. Opinions differed with respect to whether the coordination of care belonged to the primary GP tasks. Barriers were classified according to three levels: (1) personal: barriers related to knowledge, skills, emotions; (2) relational: barriers concerning communication and collaboration; (3) organizational: barriers related to the organization of care and compartmentalization in healthcare.

CONCLUSIONS

This study revealed a complex web of tasks and barriers. It may be possible to trace back a problem (lack of knowledge, for example) on the personal level to an isolated knowledge gap, but the problem may well have originated from communication or compartmentalization problems. To maintain GPs' feeling of being at ease with palliative care requires helping them acquire the appropriate balance between technical and organizational interventions and a compassionate orientation to their terminally ill patients.

The unique role of diamorphine in British medical practice: a survey of general practitioners and hospital doctors

AIMS

Diamorphine (heroin) is one of the longest established medications with a 130-year history. In British medicine diamorphine is sometimes used as a maintenance treatment for opiate addiction but is also routinely used in clinical practice to treat a number of general medical conditions. These uses are very different but are often confused by observers of the British system. The routine clinical use of diamorphine in medicine is unique to the UK, but this is not well known outside the UK. The present study investigates the use of diamorphine to treat medical conditions by general practitioners and by hospital doctors.

METHOD

In a survey of 141 medical practitioners who had prescribed diamorphine for the treatment of a medical condition, data were collected on conditions prescribed for, numbers of patients, dosage, routes of administration, duration of treatment, worries about prescribing diamorphine and observed adverse effects.

FINDINGS

Many doctors had prescribed diamorphine to a large number of patients. The four main conditions for which diamorphine had been prescribed in the previous year were myocardial infarction, palliative care, pulmonary oedema, and post-operative pain. More than half of the sample (57%) reported no reservations about prescribing diamorphine. Of the doctors (n = 60, 43%) who expressed worries, this was most often about possible problems of respiratory depression or respiratory arrest. Respiratory arrest/failure was also the most frequent observed adverse effect. Relatively few doctors reported worries about addiction.

CONCLUSIONS

Although diamorphine was widely used and most doctors regarded it as a useful medication, there remains insufficient research information about current clinical practice. At a time when diamorphine may be coming under increased scrutiny, more detailed information is required of its uses and applications.

Personal and professional pain experiences and pain management knowledge among Greek nurses

The purpose of this exploratory study was to describe Greek registered nurses' personal and professional pain experiences and to examine the relationship with their pain management knowledge. Forty-six Greek nurses provided written responses to open-ended questions about their personal and professional experiences with pain and beliefs about suffering. Reporting a personal pain experience was associated with describing a positive professional pain experience, Phi=0.44, p < 0.03. The nurses vividly described their personal and professional pain experiences. One nurse wrote " em leader I begged to lose consciousness, in order not to feel". These compelling accounts might motivate nurses to strengthen their understanding of pain management.

Is there a need for an interactive teaching tool on pain management in cancer?

The management of pain remains one of the most problematic areas in the care of the cancer patient, with evidence suggesting that one half of terminally ill patients needlessly experience pain (Hanks, 1995). Although significant advances in pain management have been made, there are several factors that prevent the provision of the best palliative care. These include misconceptions and myths about opiates and the reluctance of patients to comply with treatment and report their pain (Redmond, 1998; Drayer et al, 1999).

General practice vocational training in the UK: what teaching is given in palliative care?

BACKGROUND

Palliative care is an integral part of the general practitioner's role and palliative care teaching and training should be available for GP registrars during vocational training.

AIM

This study was carried out to evaluate the content, amount and nature of generic palliative care teaching during vocational training in the UK.

METHOD

A postal questionnaire survey of all course organizers enquired as to whether palliative care teaching was included in the core training sessions; professional background of the teachers; teaching methods used; whether the local hospice was used as a resource and whether GP registrars were able to choose a post in a hospice within their training scheme.

RESULTS

Three hundred and seventy-seven questionnaires were distributed and 240 were returned completed--a 64% response rate. A total of nine one-year schemes replied that they did not include any teaching in palliative care--the median amount of teaching given for one-year schemes was 4.75 hours and nine hours for the three-year schemes. Statistically significant differences were found in teaching on psychosocial issues and bereavement between one- and three-year schemes. Less than half of all schemes included teaching on financial issues related to palliative care. Several schemes cited difficulties in accessing hospice placements and in accessing hospice medical staff to provide teaching.

CONCLUSION

There is wide disparity in both the amount and content of teaching about palliative care within UK vocational training schemes. Difficulty in accessing placements within hospices and in accessing staff from such units to undertake teaching may be a barrier to effective and comprehensive palliative care teaching for doctors working in primary care. We suggest that a national generic curriculum of palliative care within primary care be implemented.