Footnotes
UMJ is an open access publication of the Ulster Medical Society (http://www.ums.ac.uk).
. 2024 Nov 26;93(3):132–134.
Ulster Med J. 2024 Nov 26;93(3):132–134.
Photo from Wikipedia (https://en.wikipedia.org/)
What is this and why is it famous?
How many people die per second worldwide?
Ulster Med J. 2024 Nov 26;93(3):132–134.
Photo by Ramsey Cardy for Sportsfile, The Times
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Prior to the Paris Olympics 2024, 300 water fountains were installed around the city in an effort to prevent spectator dehydration due to an anticipated heatwave throughout the competition.1
What is the most reliable and accurate clinical measure of dehydration from the following:
Thirst
Reduced skin turgor
Postural hypotension, >/= 20mmHg?
What percentage of patients in the terminal phase of advanced cancer are likely to receive clinically assisted hydration (CAH)? Are there specific evidence-based guidance to guide for its use in patients in their last days?
Ulster Med J. 2024 Nov 26;93(3):132–134.
Photo from Shutterstock.com 2156716329
Why might a hospice inpatient complain of pain while combing their hair?
What would you do to manage this?
Ulster Med J. 2024 Nov 26;93(3):132–134.
Photo: Ó ehopisce 2024
Who is the lady standing behind the late Queen Elizabeth II?
Why was 1990 a significant year for both her and the wider palliative care community?
CONSIDER CONTRIBUTING TO CURIOSITAS?
Please refer to ‘Curiositas: Guidelines for contributors’ http://www.ums.ac.uk/curiositas.html and email curiositas@ums.ac.uk with your ideas and submissions.
Ulster Med J. 2024 Nov 26;93(3):132–134.
a) Although it looks like a crowded city, according to the Guinness World Records, this is the largest burial ground is the world. It is an Islamic cemetery called Wadi al-Salam - translated as ‘Valley of Peace’ - and it is located in the city of Najaf, Iraq.1 Iraq estimates the graveyard to cover an area of 9.17 km2 (3.54 sq mi) – or more than 1,700 football fields and is thought to contain around 6 million sets of human remains.1 Burial at the Wadi al-Salam usually means being interred in one of the tens of thousands of communal crypts, mausoleums or catacombs, some of which can hold as many as 50 sets of remains.1 The cemetery is also considered one of the oldest in the world, as it has been in continuous use for more than 1400 years.2
b) In 2024, approximately 1.98 people die worldwide every second.3 Or about 119 people worldwide every minute.1 Or about 7,116 worldwide deaths an hour.3 Or 170,791 worldwide deaths a day.3 Based on 2022 annual data, an average of 47 people die in Northern Ireland every day. 4 This mortality rate is predicted to grow, and with it, the need for palliative care services. The inevitability of death often causes us to mentally look away – ‘staring at the sun’ or contemplating death can be an overwhelming task for our patients and for ourselves. There are many concepts looking at coping with death anxiety – including the idea of ‘middle knowledge’.5 ‘Middle knowledge’ suggests we can both simultaneously deny death, and at the same time make practical plans for death – perhaps allowing us a little breathing room to accommodate the inevitable at a manageable pace.5
References
- 1.Guinness World Records Largest Cemetery (Online) Available: https://www.guinnessworldrecords.com/world-records/69153-largest-cemetery. (Accessed 26/09/2024)
- 2.UNESCO World Heritage Centre Wadi Al-Salam (Online) Available https://whc.unesco.org/en/tentativelists/5578/ (Accessed 26/09/2024).
- 3.World Population Review. (Accessed 26/09/2024). https://worldpopulationreview.com/countries/deaths-per-day.
- 4.Registrar General Annual Report 2022 Deaths. Northern Ireland Statistics and Research Agency. 2023. https://www.nisra.gov.uk/publications/registrar-general-annual-report-2022-deaths (Accessed 26/09/2024)
- 5.Breitbart W. On the inevitability of death. Palliat Support Care. 2017 Jun;15(3):276–278. doi: 10.1017/S1478951517000372. [DOI] [PMC free article] [PubMed] [Google Scholar]
Ulster Med J. 2024 Nov 26;93(3):132–134.
a) iii: postural hypotension, >/= 20mmHg.
There are currently no universally accepted diagnostic criteria for dehydration in palliative medicine, although a number of laboratory investigations are deemed more accurate and reliable than most symptoms/clinical findings.2 Postural hypotension has a medium to high reliability and accuracy, with thirst having medium and reduced skin turgor low.2
b) Clinically assisted hydration (CAH) can be hugely emotive in a patient’s last days. The use of CAH in the terminal phase is extremely variable within clinical practice, with it suggested that anywhere between 12-88% of cancer patients in the last week of life may receive CAH.3 In some cases, the decision is relatively straightforward depending on the indication or contraindication (e.g. malignant hypercalcaemia or decompensated heart failure respectively), however in many cases the decision is much more subjective. With this variability in mind, there has been updated guidance published in March 2024 on the use of CAH in patients with advanced cancer by the Palliative Care Study Group of the Multinational Association of Supportive Care in Cancer (MASCC).4 Due to the paucity of evidence, they were unable to develop a specific guideline and so a collection of 12 “expert opinion statements” have been collated, plus a helpful algorithm to aid decision making (https://link.springer.com/article/10.1007/s00520-024-08421-6xs). They acknowledge that the provision of CAH in the terminal phase is one of the most contentious issues in medicine, but give a framework from which we can guide our decision-making in this often emotive situation.
1 - All patients with advanced cancer should be regularly assessed regarding hydration/dehydration
2 - Patients should be practically supported to maintain oral intake
3 - Reversible causes of decreased fluid intake, or increased fluid loss, should be treated
4 - Decisions relating to clinically assisted hydration should be made by an appropriately constituted multidisciplinary healthcare team together with the patient and their family
5 - Clinically assisted hydration should be considered in patients at risk of dying from dehydration before dying from their cancer
6 - Protocols/processes should exist to deal with conflicts over the initiation (or withdrawal) of clinically assisted hydration
7 - Patients receiving clinically assisted hydration should have a hydration care plan which defines the agreed objectives of treatment and the agreed conditions for withdrawal of treatment
8 - Patients should be given fluids via the most appropriate route (for that patient)
9 - Patients who are dehydrated should be given sufficient fluids to reverse the dehydration
10 - Patients who are not dehydrated should be given sufficient fluids to maintain hydration/prevent dehydration
11 - Clinically assisted hydration should be available in all settings, including the home setting
12 - All patients receiving clinically assisted hydration should be regularly reassessed.
As with much of our decision-making in palliative medicine, this requires an individualised approach.
References
- 1.Rings of Fire II: report published by BASIS, Front Runners and Climate Central. (Accessed 27/09/2024) ( https://basis.org.uk/resource/rings-of-fire-2/)
- 2.Armstrong LE, Kavouras SA, Walsh NP, Roberts WO. Diagnosing dehydration? Blend evidence with clinical observations. Curr Opin Clin Nutr Metab Care. 2016;19:434–438. doi: 10.1097/MCO.0000000000000320. [DOI] [PubMed] [Google Scholar]
- 3.Raijmakers NJ, van Zuylen L, Costantini M, Caraceni A, Clark J. Lundquist G et al (2011) Artifcial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and efects. Ann Oncol. 22:1478–1486. doi: 10.1093/annonc/mdq620. [DOI] [PubMed] [Google Scholar]
- 4.Hayes J, Bruera E, Crawford G, Fleury M, Santos M, Thompson J, Davies A. Multinational Association of Supportive Care in Cancer (MASCC) expert opinion/guidance on the use of clinically assisted hydration in patients with advanced cancer. Supportive Care in Cancer. 2024;32:228. doi: 10.1007/s00520-024-08421-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
Ulster Med J. 2024 Nov 26;93(3):132–134.
a) If they are taking opioids, they may be suffering from opioid-induced hyperalgesia (OIH). OIH is an increased response to a painful stimulus, associated with exposure to opioids.1 It has been shown in both acute and chronic pain and appears to result from sustained sensitization of the nervous system, in which excitatory neurotransmitters and the NMDA-receptor–channel complex play important roles.2 Clinical features include increased sensitivity to pain stimulus (hyperalgesia), worsening pain despite increasing doses of opioids or pain which becomes more diffuse, extending beyond the distribution of the pre-existing pain. It can occur with any dose of any opioid, but particularly with high- dose morphine or hydromorphone, and in renal impairment. On examination you may elicit pain from ordinary non- painful stimuli, e.g. stroking skin with cotton or combing hair (allodynia). There may also be the presence of other manifestations of opioid-induced neural hyperexcitability, e.g. myoclonus, seizures, delirium.3 A diagnosis of OIH is generally made on the basis of a high level of clinical suspicion, probability, and pattern recognition.
b) Treatment options include reducing the opioid dose, switching opioid and using a multimodal approach to analgesia with adjuvants such as paracetamol, NSAIDs, pregabalin or ketamine, an NMDA-receptor–channel blocker. If these steps do not lead to a resolution of the OIH, consider spinal, regional or local analgesia, and tail off systemic opioids completely. Remember to check for hypomagnesaemia because this can aggravate OIH. 4, 5
References
- 1.Higgins C, et al. Evidence of opioid-induced hyperalgesia in clinical populations after chronic exposure: a systematic review and meta-analysis. British Journal of Anaesthesia. 2019;122:e114–e126. doi: 10.1016/j.bja.2018.09.019. [DOI] [PubMed] [Google Scholar]
- 2.Edwards DA, Chen L. The evidence for opioid- induced hyperalgesia today. Austin Journal of Anesthesia and Analgesia. 2014;2:12. [Google Scholar]
- 3.Zylicz Z, Twycross R. Opioid-induced hyperalgesia may be more frequent than previously thought. Journal of Clinical Oncology. 2008;26:1564. doi: 10.1200/JCO.2007.15.6919. [DOI] [PubMed] [Google Scholar]
- 4.Walker SM, Cousins MJ. Reduction in hyperalgesia and intrathecal morphine requirements by low-dose ketamine infusion. Journal of Pain and Symptom Management. 1997;14:129–133. doi: 10.1016/S0885-3924(97)00171-1. [DOI] [PubMed] [Google Scholar]
- 5.Charlesworth S, editor. 7th ed. Pharmaceutical Press; 2020. Palliative Care Formulary. [Google Scholar]
Ulster Med J. 2024 Nov 26;93(3):132–134.
a) Dame Cicely Saunders (1918-2005), considered the founder of the modern hospice movement, opening St Christopher’s Hospice in 1967.1 She originally trained as a nurse, then a social worker and, finally, a physician. While working in hospital, she was known to reject the concept of the term “nothing more can be done” and instead, adopted the approach of “there is so much more to be done”.1 This attitude is part of what drove her to establish the modern hospice movement and the concept of “holistic” care of patients with terminal illness, including their physical, practical, spiritual and emotional needs.1
b) 1990 was the year that Palliative Medicine as a specialty was born. Although practiced as a sub-specialty prior to this, the World Health Organisation recognised palliative medicine as a distinct specialty in its own right in 1990, dedicated to relieving suffering and improving quality of life for patients with life-limiting illnesses; still only a young thing!
References
- 1.St Christopher’s. (accessed 27/09/2024) https://www. stchristophers.org.uk/about/damecicelysaunders/