A recent Palliative Care digest,
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Study Type: Cross-sectional survey

Key Question: What is the current landscape of advance care planning (ACP) implementation across Asia Pacific hospice palliative care sectors?

Key Findings:

• National/organisational ACP programmes (Taiwan, New Zealand, Singapore) were associated with better perceived uptake and accessibility compared to ad hoc approaches
• Family-led decision-making predominates in 9 Asian sectors (Hong Kong, India, Indonesia, South Korea, Malaysia, Sri Lanka, Thailand, Vietnam) even when patients have capacity
• Top implementation barriers were lack of public awareness (9/15 sectors), healthcare professional disempowerment (13/15 sectors), and social taboos (11/15 sectors)

Clinical Relevance: This comparative analysis highlights cultural variations in ACP approaches that UK clinicians should consider when caring for patients from Asia Pacific backgrounds, particularly regarding family involvement in decision-making processes.

Limitations: The study relied on expert perceptions rather than objective implementation metrics, potentially introducing bias in assessing ACP uptake and effectiveness.

Study Type: Prospective observational study

Key Question: What is the prevalence and pattern of hormone changes in cancer patients receiving long-term opioid therapy?

Key Findings:

• In 175 cancer patients on ≥25mg daily morphine for ≥3 months, significant hormonal suppression occurred across multiple axes over 12 weeks (p<0.001)
• Testosterone decreased from 2.49 to 2.01 ng/mL, T4 from 1.30 to 1.05 pg/mL, and ACTH from 31.41 to 25.36 pg/mL
• Prolactin increased from 11.06 to 13.35 ng/mL while TSH rose from 2.12 to 2.57 µIU/mL

Clinical Relevance: This supports routine endocrine monitoring in UK cancer patients on chronic opioids, as hormonal dysfunction may contribute to fatigue, mood changes, and reduced quality of life—symptoms often attributed to cancer progression alone.

Limitations: Single-centre study from India may limit generalisability to UK populations, and lacks comparison with opioid-naive cancer patients to isolate opioid effects from cancer-related endocrine dysfunction.

Study Type: Multicentre cross-sectional questionnaire study

Key Question: Do patients meeting Asian Working Group for Cachexia (AWGC) diagnostic criteria experience greater eating-related distress than those meeting European Palliative Care Research Collaborative (EPCRC) criteria?

Key Findings:

• Among 192 advanced cancer patients, cachexia prevalence was 74% (AWGC) vs 64% (EPCRC criteria)
• After adjusting for covariates, only AWGC-defined cachexia remained significantly associated with higher eating-related distress scores (p=0.020 vs p=0.095 for EPCRC)
• Anorexia scores were significantly associated with AWGC-defined cachexia (p<0.001) but not EPCRC-defined cachexia (p=0.177)

Clinical Relevance: The AWGC criteria, which incorporate subjective symptoms like anorexia, may better identify patients experiencing eating-related distress and could inform more comprehensive cachexia assessment in UK palliative care services.

Limitations: Cross-sectional design prevents determination of causality between cachexia definitions and eating-related distress.

Study Type: Cross-sectional website content analysis

Key Question: Do UK hospice websites accurately communicate the meaning of palliative care according to WHO and IAHPC definitions?

Key Findings:

• Only 8 of 24 manually reviewed hospice websites included a definition of palliative care
• No websites clarified that palliative care does not hasten death; only 3 stated it can be provided alongside curative treatment
• All websites mentioned cancer as a diagnosis served, but fewer than half referenced non-malignant conditions

Clinical Relevance: UK hospices are missing opportunities to educate the public and correct widespread misconceptions about palliative care, potentially affecting patient referrals and access to appropriate care.

Limitations: Analysis limited to websites with sitemaps and manual review of only 24 sites may not represent all UK hospice communications.

Study Type: Secondary analysis of randomised controlled trial

Key Question: Do breakthrough medication requirements correlate with symptom severity in dying patients receiving dexmedetomidine versus midazolam background sedation?

Key Findings:

• In dexmedetomidine patients, pain scores correlated with opioid breakthrough use (r=0.46, p=0.001) and psychological symptoms with sedative use (r=0.49, p=0.003)
• Midazolam patients showed no significant correlations between symptom scores and breakthrough medication use (r=-0.24 to 0.068, all p>0.05)
• Both groups had similar mild symptom severity (median scores 0-1) and breakthrough medication frequency (2.5-3 doses daily)

Clinical Relevance: This suggests dexmedetomidine may provide more predictable symptom-medication relationships in terminal sedation, potentially enabling more responsive symptom management in UK hospice and hospital palliative care settings.

Limitations: Small sample size of 52 patients with predominantly mild symptoms limits generalisability to patients with more severe terminal distress.

Study Type: Cross-sectional descriptive study

Key Question: What factors influence quality of life among caregivers of cancer patients?

Key Findings:

• Mean caregiver quality of life score was 87.55±20.31 on the CQOLC scale among 300 caregiver-patient pairs
• Caregivers providing care alone had significantly lower quality of life than those sharing caregiving responsibilities (p<0.001)
• Caregiver quality of life decreased significantly as patient functional status deteriorated (ECOG 3-4 vs better performance status, p<0.001)

Clinical Relevance: This identifies modifiable risk factors for caregiver burden that UK palliative care teams can address through social support interventions and early identification of high-risk caregivers.

Limitations: Cross-sectional design prevents establishing causality between identified factors and caregiver quality of life outcomes.

Study Type: Retrospective cohort study

Key Question: How do social determinants of health influence specialist paediatric palliative care (SPPC) involvement and end-of-life circumstances in a quaternary children's hospital?

Key Findings:

• Among 679 paediatric deaths, SPPC was involved in 49.2% of cases, with lower involvement in infants (aOR 0.39, 95% CI 0.22-0.67) and patients with international/self-pay insurance (aOR 0.18, 95% CI 0.07-0.48)
• Interpreter involvement was associated with higher odds of peri-mortem CPR (aOR 2.27, 95% CI 1.22-4.24) and prolonged ICU stays (aOR 3.83, 95% CI 1.88-7.78)
• Race/ethnicity and neighbourhood opportunity indices were not associated with SPPC involvement

Clinical Relevance: This demonstrates that insurance status and language barriers—factors relevant to UK's diverse population including asylum seekers and non-English speakers—may create disparities in paediatric palliative care access and end-of-life quality.

Limitations: Single-centre study from a North American healthcare system limits generalisability to NHS settings.

Study Type: Prospective multicenter observational cohort study

Key Question: How do consciousness trajectories differ between sedated and non-sedated advanced cancer patients during their final days in hospice care?

Key Findings:

• 58.4% of 286 dying cancer patients received palliative sedation, with 43.1% requiring complex sedation (≥2 drugs)
• Consciousness declined similarly in both groups until the final hours, when sedated patients had lower Richmond Agitation-Sedation Scale scores (-5 vs -4, p=0.0002)
• Delirium was the primary indication for palliative sedation (65.9%), with complex sedation associated with higher clinical complexity

Clinical Relevance: This provides reassuring evidence that palliative sedation doesn't dramatically alter natural dying processes, supporting its appropriate use for refractory symptoms in UK hospice settings.

Limitations: Observational design cannot establish causality between sedation practices and consciousness trajectories.