13th INTERNATIONAL CONGRESS ON CARE OF THE TERMINALLY ILL

PAGE 1: MEDICAL AND CLINICAL PRESENTATIONS
PAGE 2: ALTERNATIVE, HOLISTIC, SPIRITUAL AND MUSIC THERAPY PRESENTATIONS

This information is scanned directly from the conference program booklet,  we apologize for any typos from the scanner and are correcting as time allows.
 

13th INTERNATIONAL CONGRESS ON CARE OF THE TERMINALLY ILL
ABSTRACTS RESEARCH PAPERS, WORKSHOPS,
SEPTEMBER 25-29,2000
PALAIS DES CONGRESS, MONTREAL, CANADA
PRESENTED BY
PALLIATIVE CARE DIVISION, DEPARTMENT OF ONCOLOGY, McGiLL UNIVERSITY

RESEARCH PAPERS
~ SESSION A01  Impact on Families of a Children's
Hospice Program: Evaluation
BETTY DAVIES. JOHN COLLINS, ROSE STEELE, INGRID
PIPKE, and KAREN COOK. University of British Colombia, Van-
couver, British Columbia, Canada
Canuck Place, established in 1995, is the first free-standing
children's hospice in North America. It was deemed impor-
tant, therefore, to evaluate the impact of the care program on
the children and families served. Based on the principles of
Participator)' Action Research, several data collection strate-
gies were used to gather both qualitative and quantitative
data. Analysis of interview data with an initial group of 18
families (n=50 family members) formed the basis for a mailed
questionnaire subsequently sent to all families (n=250). Re-
sponses were subjected to descriptive analysis. As well, focus
groups were held with non-user families, staff, and commu-
nity-based professionals. Overall, families were strongly posi-
tive in their interview comments, and highly satisfied in their
questionnaire ratings of the impact of the program on their
lives. Specific findings pertained to categories of staff (e.g.,
nurses, volunteers, physicians) and to the three components of
the program (respite, palliative care, and bereavement). The
extent to which staff implemented a pediatric hospice care
philosophy, rather than a hospital care philosophy, had a pro-
found impact on families in three major areas: family-centred
care, interdisdplinary and collaborative teamwork, and joint
decision-making between families and hospital staff. Recom-
mendations to promote and solidify the CP program are iden-
tified and have relevance for other hospice/palliative care
programs.

~ SESSION A01  Home-base: Focus Groups with
Family Caregivers
MAPJORIE Coristine, Ottawa Regional Cancer Centre,
DAUNA CROOKS, Hamilton Regional Cancer Centre, CAROLE
STONEBRIDGE, ANNE CHRISTIE, and EVA GRUNFELD, Ot-
tawa Regional Cancer Centre, Ottawa. Ontario, Canada
Background: Canadian women with advanced breast cancer
and their family caregivers are affected by the devolution
services to home-based health services. The study employs a
longitudinal cohort design with two years of follow-up. One
hundred and thirty women with advanced breast cancer and
their family caregivers were recruited from the Ottawa and
Hamilton Regional Cancer Centres. The goal was to examine
and describe the quality of care delivery. Methods: After the
patient's death, consenting family caregivers participated in a
focus group which explored the patient's need for home-
based services, barriers to receipt of care, as well as the burden
of care for family caregivers. Qualitative researchers per-
formed content analyses of the groups. Results; Reported bar-
riers to receipt of care included lack of knowledge of services,
and reluctance of patients and caregivers to seek services.
Reasons for not seeking services included concerns about 'in-
vasion of privacy', and that patients wanted family members
to provide their care. Usually someone outside the family ini-
tiated the process of accessing services. Caregivers had multi-
ple stressors including employment, child care, patient care,
and coping with their own reactions to the illness. Recogniz-
ing certain difficulties, home-based services were experienced
as necessary and helpful. Summary: Although home-based
health services were experienced as beneficial, services were
frequently accessed only after the families had surpassed their
ability to cope.

~ SESSION A01  Predictors of the Health, Family
Functioning and Care Satisfaction of Family Mem-
bers of Advanced Cancer Patients
S. ff. COHEN. McGill University, Montreal, Quebec, cambia, L.
KRISTJANSON, Edith Cowan University, Perth, Western Aus-
tralia, Australia. K.C. CARRIERE, University ol Alberta, Edmon-
ton. Alberta, A. LEIS. University of Saskatchewan, Saskatoon,
Saskatchewan, P.M. KOOP, University of Alberta, Edmonton,
Alberta, H.M. CHOCHINOV, University ot Manitoba, Winnipeg.
Manitoba, A.M. LAIZNER, University Oe Montreal, Montreal, Que-
bec, BM. MOUNT. McGill University, Montreal, Quebec, Canada
The purpose of this study was to determine the extent to
which variables concerning the process and outcomes of care,
and patient and family member characteristics predict the
health, satisfaction with care, and family functioning of family
members of patients with advanced cancer. Family members
from three care settings in four Canadian provinces completed
instruments measuring their care needs, expectations, percep-
tions, and satisfaction, as well as health, family functioning,
and demographic variables. Patients completed quality of life
and symptom distress questionnaires when possible. Data is
being analyzed using a multiple linear model to assess the
extent to which family care satisfaction, family members'
health, and family function are predicted by fulfillment of
needs theory, and the discrepancy between expectations and
perceptions of care. Preliminary analysis indicates that the
discrepancy score (p<.0001), delay in making the diagnosis
(p<0.01), and the extent to which needs are met (p<0.001)
may be significant predictors of family members' satisfaction
with care.
 

~ SESSION B01  Constellation of Symptoms for
Patients with Malignant Wounds
Valerie SCHULZ and OLIVE H. TRISKA, University of Alberta.
Edmonton, Alberta, Canada
Introduction: The life expectancy of patients with malignant
wounds has increased over the past few years, prompting an
investigation into this issue. The research question posed in
this study is: what constellation of symptoms is common to
patients with malignant wounds? Method: One hundred and
thirty-six health care workers enrolled in malignant wound
workshops completed surveys from September to December
1999 in Edmonton, Alberta; Winnipeg, Manitoba; and To-
ronto, London, and Windsor, Ontario. The survey was de-
signed to elicit responses using short-answer format, focusing
on the caregiver's perspective. Open-ended question re-
sponses were grouped into themes, coded according to recur-
ring symptoms, and analyzed using frequency of occurrence.
The frequency of replies was tabulated and descriptive statis-
tics were used to analyze the data. Results:  A total of 814
symptoms were reported from the 136 participants of the
workshops. The mean number of symptoms recorded for each
patient was six (Cl 95% 5.6-6.37). Descriptive statistics re-
vealed that II symptoms were prevalent within this cohort of
patients. The symptoms listed were pain (21%). psychological
stress (18%), odour (16%), exudate (11%), bleeding (10%.), and
six other symptoms (24"/o). The open-ended responses high-
lighted the severity and duration of pain, and quality of life of
the patients. Conclusions: A constellation of symptoms was
identified common to patients with malignant wounds, with
the commonest being pain, followed by psychological stress,
odour, exudate, and bleeding. The results of the pilot study
provide a framework for developing a systematic approach to
assessment and management of patients with malignant
wounds.

~ SESSION B01  Developing a Computerized Data-
base for Music Therapy in Palliative Medicine and
Hospice
Lisa GALLAGHER. KRISTINE NELSON. DECLAN WALSH, and
LOUISE STEELE, Harry R. Horvitz Center lor Palliative Medicine,
The Clinic Foundation and The Cleveland Music School Settle-
ment, Cleveland, Ohio. USA
The purpose of this presentation is to introduce findings
from a research study into the effects of music therapy on
an inpatient palliative medicine unit and hospice. For the
first time, a computerized database has been designed to
track music therapy intervention effectiveness, making it
possible to analyze a variety of data collected from serv-
ices provided to the terminally ill. Drawing from a pool of
160 inpatients and hospice patients, comparisons have
been made of the primary diagnosis, reason for referral to
music therapy, preferred music, goals selected, music
therapy interventions implemented, and goals met and
not met. Measurement of intervention effectiveness used
visual analog scales and behavioural observation. Com-
parison between the two patient groups included the per-
ception of pain, anxiety, and mood, as well as
vocalizations and body movement, before and after music
therapy. Also analyzed were the number, styles, and titles
of songs chosen by patients, as well as the level of patient
and family participation. An example of the database will
be shown and implications for future research will be dis-
cussed.

~ SESSION C01  Is Low-dose Ketamine Effective in
the Treatment of Cancer Pain?
MARY CHISHOLM, RAYMOND VIOLA, and SUSAN CHATER.
Universe ol Ottawa Institute of Palliative Care, Ottawa. Ontario,
Canada
While ketamine has been used for many years in
anesthesia and for treating acute pain, there has been in-
creasing interest in its role in palliative care. This paper
will review ketamine's characteristics, how it is reportedly
used lo treat cancer pain, and how it might best serve the
palliative care cancer population. A review of the litera-
ture regarding ketamine for treating cancer pain was per-
formed using MEDLINE. Ten articles published between
1990 and 1999 were identified where low-dose ketamine
was used in cancer patients. These articles included case
reports, case series, and retrospective reviews. The sample
size ranged from one to 18. Pain scenarios included intrac-
table neuropathic pain resistant to increasing opioids and
co-analgesics, central pain secondary to primary brain
tumors, and opioid toxicity and/or escalating pain in the
last hours of life. Ketamine doses and routes of adminis-
tration varied widely. Side effects attributed to ketamine
were reported in seven articles and included site inflam-
mation, sedation, confusion, and vivid dreams. Patient
outcomes reported included significantly improved pain
control, improved sleep, and improved family relations.
Low-dose ketamine appears to have potential as a co-an-
algesic in the treatment of cancer pain. However, the cur-
rent evidence relies heavily on anecdotal experience and
further research, including randomized controlled trials,
is  needed  to  clarify  ketamine's  roles,  appropriate doses,
and toxicity.
 
 

~ Session C01 — Methylphenldate Chlorhydrate Improves Cognitive Function ol Advanced Cancer Patients with Hypoactive Delirium

BRUNO GAGNON.GIL SCHREIER, and KRISTA LAWLOR. Monireal General Hospital. Montreal, Quebec. Canada

Introduction: Most patients with advanced cancer will suffer from delirium before death. This devastating syndrome is a source of suffering for patients and their families. Hypoactive delirium is characterized by sleepiness, decreased physical activities, sleep-awake pattern disruption, and decreased cognitive function. Purpose of the study: To evaluate the response of patients suffering from a hypoactive delirium to methylphenidate chlorhydrate. Methods: Advanced cancer patients referred to the palliative care service of the Montreal General Hospital are screened for decreased cognitive function using the Folstein's Mini-Mental State Questionnaire (MMSQ). Cognitively impaired patients were evaluated by a palliative care specialist to find the etiology. Patients with a diagnosis of hypoactive delirium received methylphenidate, 10 rng orally, in an open-label fashion, and clinical response was evaluated one hour after the first dose. If a positive response was documented, a twice daily dose was given, and the patient was followed up. Results: Preliminary results are available in eight patients. Their mean initial MMSQ was 21.3 (SD ± 5.0). One to four hours after methylphenidate chlorhydrate 10 mg orally, 25.4 (SD ± 5.0) I hr. post , and to 27.8 (SD ± 1.7) after 4-7 days of treatment. Complete results of this open-label trial will be presented. This finding is significant since it may improve the quality of life of advanced cancer patients suffering from hypoactive delirium.

~ SESSION D01 — Evaluating the Emotional Impact of a Palliative Care Education Program at the University of Arkansas for Medical Sciences

MILDRED A. SAVIDGE. and A. REED THOMPSON, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

The purpose of this study is to examine the emotional impact that a four-week program in palliative care has on third-year medical students. The palliative care education program at the University of Arkansas for Medical Sciences (UAMS) is part of a mandatory student rotation in the department of geriatrics, begun in 1998. Students receive 16 hours of palliative care instruction, delivered in four-hour blocks, one in each of the four weeks of the geriatric clerkship. Course objectives focus on development of the students' understanding of the physician's role in end-of-life issues. Curriculum includes lectures by physicians on symptom management, lectures by members of an interdi.sciplinary team on their role in palliative care, and weekly home hospice visits on an assigned patient. Students make their first visit with staff (a physician or nurse), and go alone on subsequent visits. After their home visits, students present their patients to faculty attendings. Program evaluation takes place in monthly focus group interviews conducted by an evaluation specialist. Initial interview results were disappointing, showing little emotional impact from this experience. One possible explanation for this was student discomfort in verbalizing their feelings. A written exercise was added to the focus group, with responses used to promote further discussion. This change has revealed responses showing greater emotional impact, more congruent with the expected outcome. Comparison of data from the two group processes, and information about students' responses, will be presented.

~ Session D01 — An Undergraduate Medical Survey on Academic Exposure to Palliative Care in Two Canadian Universities

DOREEN ONESCHUK. Division ol Palliative Care Medicine. University of Alberta, Edmonton. SEAN BAGSHAW, University of Calgary. Calgary. Alberta, and NEIL MACDONALD. Department of Oncology, McGill University. Montreal, Quebec, Canada

An anonymous survey of the 1999 graduating medical school classes from McGill University and University of Alberta was conducted to determine the students' perceived educational experience in palliative care topics (i.e. cancer pain management, and communication with dying patients and families), as compared to other topics in their medical curriculum (i.e. the management of hypertension, breast cancer, and AIDS). A Likert scale ranging from I (excellent) to 5 (very poor) was used to rate the students' educational experiences. An estimate of the total number of hours spent within operating theaters, in home visits to terminally ill patients, and in interprofessional activities was asked. Students were also asked whether they favoured increased palliative care teaching, and what courses they would have liked being shortened or replaced to permit increased exposure to palliative care education. Sixty of 114 (53%) of McGill University and 53/110 (48%) of University of Alberta medical students completed the survey. The mean ratings of educational experience for both universities combined were as follows: hypertension, 2.03; breast cancer, 2.33; cancer pain, 3.42; communicating with dying patients, 3.32; and AIDS, 4.15. The average number of hours spent in the operating theatres, home visits to terminally ill patients, and inter-professional teaching for both universities combined were 155 hours, 4.2 hours, and 16.0 hours, respectively. Eighty-three percent of responding students, from both universities, favored increased teaching in palliative care. Basic science courses and psychiatry were the two most favoured courses to be shortened. Medical students from two Canadian universities perceived their educational exposure to palliative care to be mediocre. Ongoing efforts are necessary to improve undergraduate palliative care education across Canada.

~ Session D01 — End of Life in Intensive Care and Palliative Care, and Sociological Concepts on Death

RUDDY VERBINNEN, Free University of Brussels, Brussels, Belgium

Objective: In a qualitative study, we examined the organization of the end of life in intensive care and palliative care, and compared these to the findings of a study of sociological literature. In the literature on death and dying, it is argued that death has lost its place in Western society (e.g. Glaser 1965, Blauner 1966, Thauberger 1974, Aries 1975, Berger 1978, Illich 1975, Mulkay 1991, Nuland 1994). Concepts used are the forbidden death (Aries 1975), and the mechanical technical medicalized professionalized death (Illich 1975) to point out the problematic relation between society and death. Societal phenomena that confirm this thesis are, among others, demographic changes that lead to the death free generation(Fulton 1Li76). the evolution from uncontrolled to controlled mortality (Goldscheider 1971), the improvement of living conditions, Mulkay (1991) observed a difference between biological and social death. Methods: Observations, in-depth interviews, and group discussions took place in intensive care wards, with palliative home care teams, and on palliative care hospital units. We observed and questioned nurses and doctors about the organization of end of life, and about their encounters with and attitudes towards death. The sociological concepts will be compared to our observations. Results: Methods will be discussed and results will be presented. This research is carried out as part of the Program of Forward Social and Economic Research of the Belgian Federal Office for Scientific, Technical and Cultural Affairs (DWTC), and is cofunded by the Free University of Brussels.

~ SESSION E01 — Psychometric Properties of "the Braden Scale for Predicting Pressure Sore Risk" in a Palliative Population

JULIE ALLSTON. RAYMOND VIOLA, JEAN KOZAK, EDWARD FITZGIBBON, PATRICIA ELLIOT-MILLER, JANE STEWART-GRAY, PATRICIA HAMILTON, and DIANE HUPE, University of Ottawa Institute of Palliative Care, Ottawa, Ontario. Canada

The Braden Scale was created to identify patients at risk of developing pressure ulcers. It consists of six subscales and its summary score ranges from 6-23. A score of >18 indicates increased risk. It has not previously been validated in palliative care. Its psychometric properties in a palliative care population are described here. The Braden scale was administered to 141 patients within 24 hours of admission to two palliative care unite. Patients were followed until death or discharge. Their average age was 70 yrs., 49% were female, and 95% had cancer. Pressure ulcer prevalence (stage I or greater) was 52% at admission. The mean Braden score al admission was 15.5, with 72.5% of patients scoring >18. Of those without ulcers at admission (n=53), 74.2"/ii developed at least a stage I ulcer if their initial Braden score was >18. while 25.8% did so otherwise. Internal consistency of the Braden scale was 0.84 (Cronbach's alpha). Three items (activity, mobility, friction/ shear) were highly correlated with each other and with the total score, indicating that they accounted for most of the variance (70% to 74%). The Braden scale is appropriate for use in an inpatient palliative care population, although the baseline risk for pressure ulcers is high. Some redundancy exists between certain items in the scale when it is used in this setting. Although the Braden scale is useful as a means of describing a palliative care population, its usefulness as a prediction tool in a high risk group remains to be established.

~ SESSION E01 — Compatibility and Stability of Morphine and Five Other Drugs Mixed Together in Sy ringes Under Different Experimental Conditions

SAMIR NASSR, Royal Victoria Hospital, and PAULINE LAVOIE.
   Henna-Quebec, Montreal, Qu6bec, Canada

The objectives of the study are to evaluate the compatibility and the stability of morphine when mixed with different drugs, and to provide recommendations for appropriate conservation conditions. Five drug mixtures used in a palliative care setting were stored in polypropylene syringes at different temperatures (4°C, 25°C) for up to 96 hours. The mixtures were: (a) morphine, dexamethasone, somatostatine, (b) morphine,  dexamethasone,  haloperidol,  (c)  morphine, somatostatine, haloperidol, midazolam, famotidine, (d) morphine, haloperidol, famotidine, metoclopramide, (e) morphine, somatostatine, haloperidol, famotidine, metoclopramide, dimenhydrinate. Drug mixtures were prepared in NaCI 0.9%, in order to obtain a 100 ml final solution containing the maximum daily dose of each component. Drugs were separated using a high performance liquid chromatography-diode array detector under elution gradient. The physical appearance of each solution was observed and drug concentrations were controlled just after preparing the drug mixtures, and 4, 8, 12, 24, 48, 72, and 96 hours thereafter. Drugs included in a tested mixture wew considered compatible if there was absence of haze, gas production, colour change, and precipitate formation. They were judged stable at a specific temperature and after a specific time if more than 90%" of the initial drug concentration was still present. Mixture 5 was not compatible. Mixing haloperidol and dexamethasone gave rise to the formation of a while precipitate. Mixture 3 was stable and compatible at 25"C but not compatible at 4C due to crystallization of haloperidol. All other drug mixtures were stable and compatible at both 4"C and 25"C for 96 hours.

~ Session E01 — Palatability of Liquid Medications Used in Palliative Care

PAUL WALKER and CATHY NEUMMAN, Division ol Palliative Care Medicine, University ol Alberta, Edmonton, Alberta, CATHY TURNBULL. Pharmacy Department, Grey Nuns Community Hospital & Health Centre, Edmonton, Alberta, Canada, EDUARDO BRUERA. Department of Symptom Control & Palliative Care, MD Anderson Cancer Center, Houston, Texas, USA

Terminally ill patients frequently have difficulty swallowing capsules and tablets as their clinical condition deteriorates. This leads to the use of liquid medications. The palatability of these medications have been reported anecdotally to be less than ideal. We undertook a taste test of various liquid medications used in palliative medicine. A total of 30 healthy volunteers sampled 22 medications in an unblinded fashion. Opioids, laxatives, antibiotics, prokinetics, and others were considered. They rated each drug on a numerical rating scale on the following domains: appearance, smell, texture, taste, aftertaste, and overall assessment. They were also asked on a five-point Likert scale, from I (strongly disagreed) to 5 (strongly agree), whether the medication would be acceptable for long term treatment (> than one week). A further direct comparison between two medications that could be used for the same purpose was undertaken on a seven-point scale (not significant to great importance). Figures will be presented comparing the medications on the five domains of appearance, smell, texture, taste, and aftertaste, as well as overall palatabitity, and acceptability of the medications for long term treatment. Of the five domains, taste correlated most highly with overall palatability (Spearman's rho: 0.904, p=0.0l). Overall palatability correlated most highly with acceptability of the medications for long term treatment (Spearman's rho: 0.881. p=0.01). To our knowledge, this type of study has not previously been performed in the field of palliative medicine

WORKSHOPS

~ SESSION B26 — Prognosis for the Terminally III

MAfilSSA SLAVEN, Both Israel Deaconess Medical Center, Boston, Massachusetts, USA This workshop will explore how to determine prognosis at the end of life, how to communicate prognosis, and why prognosis is a valuable piece of information for patients, families, and healthcare providers. Topics addressed will be appropriate for  people in all disciplines. Throughout their medical training  physicians are taught that they cannot know a patient's prognosis, nor should they reveal it if they do. This workshop will include a series of exercises, cases, and role-plays designed to refute these concepts. In this interactive session we will attempt to improve assessment of prognosis, particularly in patients with days or weeks to live. Particular attention will be paid to the use of functional assessments and slope of patient decline in determining prognosis. We will also examine barriers to effective communication of prognosis. We will encourage personal reflection on the meaning of prognosis for patients, their families, and ourselves. We will also explore how prognostic information has a dimension beyond simply time, which is related to quality of life. These exercises, as well as the relevant factual information provided during this session, will enable participants to teach their colleagues about progn

~ SESSION B26 — Prognosis in Terminal Cancer: an Evidence-based Approach

ANTONIO VIGAN0. Palliative Care Program and MARLENE DORGAN, J.W. Scott Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada

Traditionally, the determination of prognosis in terminal can cer patients has relied mostly on the prognostic judgement of health professionals. To date, this judgement appears to be only one criterion among others to determine life expectancy in this population. The other criteria are represented by prognostic factors for survival. Evidence-based medicine has provided methods for searching, critically appraising, and incorporating scientific evidence in the daily decision-making proc ess. Outcomes from a recent systematic review of the litera ture "in press" will be provided. The workshop is designed to help participants use key information sources (i.e. MEDLINE, EMBASE, CANCERLIT, and selected WWW sites). Practical indications for applying an evidence-based approach to prognosis in terminal cancer will be drawn from clinical scenarios. Topics offered for discussion will include: (a) definition of clear inception criteria to identify patients who are either at the beginning or at an advanced stage of their terminal phase, (b) identification of patients' characteristics deemed indispensable to ascertain the validity and applicability of prognostic studies, (c) challenges of multicentre studies, (d) definition of a "standard core" of prognostic variables that should always be examined, along with a new prognostic factor to facilitate comparisons of different study results.

~ SESSION B27 — Helping Grieving Children

MEG KERR, Children's Bereavement Coordinator, Seacoast Hospice, Exeter, New Hampshire, USA

Children are affected when a parent or sibling is ill and therefore need to be considered in our care plans. This workshop is based on work done at Bridges, a program for grieving children and teens now in its 10th year. We will outline the needs of children anticipating or grieving a death, and will present practical, creative tools, and activities used to help children integrate their experience of the death into their lives. Case studies will further illustrate the benefits of supporting children whose loved one is receiving hospice and/or palliative care. Children who receive support when anticipating and grieving a death develop skills that help them integrate the loss into their lives leaving them with increased resilience to handle future losses and challenges.

~ SESSION B27 — Grief Education for the Elderly: a Primary Prevention Program

SUSAN J. BENDOR, Yeshiva University School of Social Work.
 New York, New York, USA

Fifty percent of all cancer in the US is diagnosed after age 65 (National Center for Health Statistics 1990). Four million Americans have Aizheimer's disease, the fourth leading cause of death among adults. Nineteen million Americans have a family member with AD. Fourteen million Americans will have AD by 2050 unless a cure or prevention is found. These numbers suggest that elderly patients, relatives, and peers affected by these diseases will need preparation and support for confronting death, grief, and bereavement. To address these needs, the author developed a grief education program to be delivered in senior centres, hospitals, mental health clinics, and religious organizations. The four major strategies of primary prevention — stressor management, stressor avoidance, stress resistance building, stress reaction management — are incorporated into an eight-session program which builds on the writings of bereavement experts, synthesized with the author's extensive teaching and clinical experience in working with community based and institutionalized elderly. The following topics covered in the grief education program have elicited intense, constructive discussion from participants. Core Curriculum-, (a) physical, psychological, social and economic challenges of aging, (b) coping with multiple losses, attending to unresolved or disenfranchized grief, (c) anticipatory grief, (d) when death strikes, can we be prepared? (e) phases and tasks for mouirn ing — who is responsible for the work? (f) common reactions to loss, (g) cultural differences in reactions to loss, (h) what we know about normal versus pathological grieving, (i) skills adults need to develop for coping with loss, ((j) building a network of social support.

~ SESSION B28 — Existential Sedation ~ the Challenge for the Interdisciplinary Team (IDT) — What about Euthanasia or Physician-assisted Suicide?

M. BERCOVITCH. A. WALLER. A. ADUNSKY, Te! HaShomer Hospice, The Chaim Sheba Medical Center. Tel HaShomer, The Sackler School of Medicine, School of Continuing Medical Education. Tel Aviv University, Israel Cancer Association, Israel

In the old and the recent studies, the rate of need of sedation for refractory symptom control was 70% and 25%, respectively. In particular, sedation for existential anguish was stressed by the Spanish researcher ( J.M. Nunez-Olarte) in a Montreal workshop on sedation in September 1998, and represents a heavy challenge for every interdisciplinary team (IDT). In this workshop we will describe our approach to the request for sedation. In the case presentation of one of our patients with existential anguish, first reversibly sedated and then discharged, we will illustrate all the complexities and ethical issues connected with this form of treatment. We will indicate the importance of repeated assessment by the IDT, especially the clinical psychologist, the trial for routine treatment for anxiety, depression, and existential distress, and the importance of conscious sedation, both reversible and temporary. The workshop will use role-playing to teach the appropriated skills and attitudes. We hope that this experience will clearly demarcate the line between conscious sedation for refractory symptom control and/or existential distress, and euthanasia or physician-assisted suicide. Finally, if despite all the best supportive care, the patient still chooses suicide, should it be heard by the palliative care team as a cry for help in providing the option of euthanasia?

~ SESSION B28 — Recognizing and Managing Global Suffering and Somatization

PAUL WALKER, Division of Palliative Care Medicine. ZINIA PRITCHARD. BETTE EMERY, and WENDY LEVEE, Palliative Care Program. Edmonton, Alberta, Canada

  Global or total suffering has lung been recognized as a corn\  plicated problem in terminal care. Patients may or may not have some degree of insight into the psychological, social, and spiritual aspects of their suffering. Pain management can be complicated, as pain is a complex construct and its multidimensional nature is often influenced by these factors. In psychiatry, this concept is termed somatization, reflecting the expression of psychological suffering via somatic complaints. Little is known about the actual psychological processes involved in somatization, however, palliative care practitioners are required to respond to these individuals to address their symptom management or expression of suffering. Often this may be difficult, because the process of somatization may be difficult to recognize and few guidelines are proposed for management. This workshop will aim to present a framework from which to recognize this concern when it is not obvious based on past history and current observations of behaviour. A framework for management will be reviewed based on a multidisciplinary approach. The use of drug and non-drug therapies will be discussed.

PAULA L. BRINDLEY. and CARLEEN BRENNEIS, Regional Palliative Care Program, Edmonton, Alberta. Canada

The development a regional palliative care program which provides multilevel care and support for patients and families in the home, hospice, and hospital environments, presents a variety of challenges for the management of palliative care volunteers. The protection of the vulnerability of the patients and families touched by cancer, as well as of the prospective volunteers, is a primary consideration. The maintenance and retention of a highly trained and motivated volunteer workforce is an equally a crucial component in the provision of high standards of patient and family care. This workshop will discuss the merits of standardized policies and procedures for a regional palliative care volunteer program, and will present the screening, training, and support components specifically designed to meet some of the challenges. Findings from a recent study regarding the motivating factors of palliative care program volunteers will be used as a framework for discussion regarding the development of future initiatives for maintaining recruitment and retention of palliative care volunteers.

~ SESSION B45 — Mini-Mental Status Examination — a Structural Analysis

CATHERINE A. JENKINS. Division of Palhalive Medicine, University of Alberta, Edmonton. Alberta, Canada

The Folstein Mini-Mental Status Examination has been widely adopted as a cognitive impairment screening tool in palliative care. The test has many advantages: it is easy to administer, the numerical score allows comparisons over time and between patients, and the test had been widely validated in a variety of populations. However, the test provides an incomplete mental status assessment. It is heavily weighted towards language-based tasks. Although these tests provide a good assessment of dominant temporal and parietal lobe function, frontal lobe and non-dominant hemisphere functions are less well tested. The Folstcin was also not designed to diagnose delirium, and this is the most common cognitive disturbance in palliative patients. This workshop will review the structure of the Mini-Mental Status Examination to show which cognitive domains are adequately tested. Supplemental tests for the under-represented cognitive domains will also be reviewed. Emphasis will be on those tests that can be effectively administered at the bedside in patients with limited energy or patience for extensive cognitive testing. The workshop will also examine the extent to which the Mini-Mental Status Examination, particularly the way the patient responds to the test, can be used as a starting point in determining the specific cause of the patient's cognitive impairment.

~ SESSION B45 — Assessing Delirium in the Palliative Care Setting: the Importance of Practical Strategies and Phenomenology Recognition

PETEH G. LAWLOR and ROBIN L. FAINSINGER. Division ot Palliative Care Medicine. University of Alberta,  Edmonton, Alberta, Canada

Delirium is a frequent complication in the advanced cancer population. The presence of delirium binders communication and has profound management implications, particularly in relation to patient distress, family distress, symptom assessment, and counselling. Many studies have demonstrated the failure to recognize delirium and its frequent misdiagnosis. Delirium is frequently a terminal event in this population, yet it  is  also  eminently  reversible  in  a  significant  proportion  of patients. This often creates dilemmas in relation to the appropriate intensity of assessment strategies. Selected instruments in the screening, diagnosis, and assessment of delirium will be reviewed in terms of clinical utility and some psychometric properties. Diagnostic criteria will be clarified and special emphasis will be placed on discussing nursing observational instruments, which impose a low burden for the palliative care patient. The findings of six recent prospective studies by our group will be summarized with a view to promoting some practical evidence-based guidelines in the clinical assessment of delirium reversibility. The main objectives of this workshop are to enhance the participant's knowledge of both delirium assessment instruments and the clinical strategies in assessing delirium reversibility. An interactive case-based approach will be employed in relation to the clinical guidelines presented.

~ SESSION B46 — Subcutaneous Site Initiation and Maintenance

DONNA DEMOSSIAC, Regional Palliative Care Program, KAREN MACMILLAN, SANDRA MCKINNON. Palliative Care Program, Edmonton, Alberta, Canada

Following an extensive review of the literature on subcutaneous (SC) medication administration and hypoderrnoclysis, our interdisciplinary multisite committee developed a policy and procedure for site initiation and maintenance. This policy and procedure has since been adopted as the standard within our regional health authority. Our group has more than 16 years of experience using the SC route for patients no longer able to take oral fluids or medication. We have found that most published research, including our own, pertains to the safety and efficacy of medications given via this route, and little research is  related  to the initiation and maintenance of SC sites.  Be-cause of the paucity of information in this area, the policy and procedure developed is based on anecdotal articles that describe clinical practice, in addition lo our own clinical experience. Participants in this workshop will: (a) hear about existing research related to the SC route, (b) observe the initiation of a SC site, with rationale for the principles used, (c) practice the proposed techniques (on inanimate objects), (d) be encouraged to ask question? and share comments related to the SC route, (e) explore best methods for hypodermoclysis: bolus versus continuous infusions, hyalLironidase dose, choice of solutions, (f) explore j  areas for potential research related to the SC route, (g) receive guidelines for care and maintenance of the SC site, '   (h) receive a handout listing common palliative care medii  cations approved for SC administration.

  ~ SESSION B46 ~- A Classification System for Cancer Pain

I      ROBiN L. FAINSINGER, Division of Palliative Care Medicine, I    ANTONIO VIGANO, Palliative Care Program. PETER G. LAWLOR. Division of Palliative Care Medicine, University ot Alberta, Edmonton. Alberta, Canada

A review of the cancer pain literature reveals the difficulty in comparing results of both outcome surveys and clinical trials in cancer management. Classifications of cancer pain emphasize the various physical syndromes, while review articles on cancer pain management emphasize the pharmacological approach. The many other characteristics that may influence the outcome or success of pain management are seldom mentioned. A comprehensive assessment of cancer pain has to include more than pathophysiology. The development of a clinical staging system for many cancers (TNM System) has been a major advance in cancer research and treatment. A clinical staging system for cancer pain, including all of the recognized prognostic factors for treatment response, has been reported. This Edmonton Staging System included seven features: mechanism of pain, incidental pain, previous opioid use, cognitive function, psychological distress, tolerance, and past history of addiction to alcohol or drugs. The results of the initial two validation studies and subsequent reports by other groups will be reviewed. The I  lessons learned from a number of prospective and retrospective research reports that have used lhe staging sv~temm to define the study population have also provided a useful experience. The problems of interpretation of the seven original prognostic factors will be discussed, along with proposed solutions. A proposal for refining the staging system, and for proceeding with further validation and research will provide the focus for discussion with workshop participants. Results of preliminary work in using a refined system will be presented. The half century of discussion to build consensus for the TNM System for cancer diagnosis is a vivid demonstration of the magnitude of the task ahead for a similar j  system for cancer pain.

~ SESSION C26 — Palliative Care Day Hospital — an Innovation in Care

CLEMENCE RHEAUME, BRUNO GAGNON, and LOUISE PILON. McGill University Hospital Centre, Montreat, Quebec. Canada

The palliative care day hospital's role is, in collaboration with community health care services, to evaluate, intervene, and coordinate care for patients with a limited prognosis. Our goal is to help patients stay at home as long as possible or desired.
 The palliative care day hospital opened in December 1998. it  is  a  consultation  service offered  by  the  McGill  University I  Hospital Centre as part of the pilot project "Ven> l'etablis-sement d'un continuum de soins et de services a l'intention des usilgers adultes en phrase terminale". The pilot project promotes links between the MUHC (McGill University Hospital Centre) and five CLSCs (local community health centres in the Montreal region). The purpose of the presentation is four fold: (a) to share the experiences and challenges of the palliative care team of the day hospital and how its role has evolved, (b) to emphasize the importance of a team approach in making clinical and psychosocial evaluations, (c) to describe our patient population, the nature of the team intervention, and outcomes, (d) a case study will also be presented lo promote discussion of the day-to-day functioning and further j  understanding of the day hospital's role.

~ SESSION C26 — Promoting a Continuum of Palliative Care for the Patient

FERNAND MUCCI. CLSC NDG/Montreal West. Montreal, Quebec, Canada

Five West-End CLSCs, in partnership with the McGill University Health Centre, are working together on a research/action project which will develop, test, and propose a model of integrated palliative care and services for adult patients. The model proposes a betier integration of hospital services (palliative care unit, clay hospital, and other hospital departments), home care services (CLSC), community services, respite care, temporary or long term housing, as well as pastoral/spiritual care. The goal is a wamless passage between types of care and resources for the patient with terminal illness. The workshop will present one case study which illustrates the variety of services available to the patient and his/her family. The project has developed additional services for this clientele, and the presentation will !  show how these additional services are now integrated into the regular range of CLSC home care services. Professional staff will describe their role within the team and how their professional duties have been transformed in order to deliver quality palliative care in the community

~ SESSION E16—A Palliative Care Database: Meeting the Constructional Challenges and Exploring Utility

PETEP G. LAWLOR. Division of Palliative Care Medicine, University of Alberta, HUE QUAN and CARLEEN BRENNEIS. Edmonton Regional Palliative Care Program, A. VIGANO. Palliative Care Program, Edmonton. Alberta, Canada

The frenetic pace of advances in information technology is expected to continue unabated into the next millennium. This coincides with growing demand for healthcare quality and other outcome assessments. The combination of the~ee factors has created an impetus to establish reliable patient information databases. Computerized databases are already established in manv palliative care programs and serve as structured electronic filing systems for patient information, albeit this information is often relatively rudimentary. A relational database contains tables of information recurds that are connected by explicit key identifiers. The information stored in such databases can be retrieved in a report format for both administrative and research purposes. The Edmonton Palliative Care Program database began in 1993. This database captures data on basic demographics, cognitive assessment through Mini Mental State Examination scores, symptom visual analog scores through the Edmonton Symptom Assessment System, pain control prognostic indicators through the Edmonton Staging System, functional status through the Edmonton Functional Assessment Tool, and opioid use by means of the morphine equivalent daily dose. In this workshop the Edmonton Palliative Care Program database will be reviewed, and serve as a template for database development, integration, and expansion. Research uses and administrative audit functions, such as quality Assurance and utilization management, will be summarized. The role of emerging technologies, such as hand-held computer devices, will also be addressed. The objective of this workf»hop is to provide a framework for participants wishing to either develop a database de novo, or those wishing to expand on an existing database.

~ SESSION El 6 — Instructional Technologies (IT) in Palliative Care Education: Lessons Learned

JOSE PEREIRA, Division of Palliative Care Medicine, University of Alberta, Etirronlon, Canada, DAVID E. WEISSMANN, Palliative Care Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA

The goal of improving end-of-life care, rather than the novelty of the media, should drive the adoption of new instructional technologies (IT). In embracing IT, an early commitment to evaluation and the use of a multilevel evaluation plan is essential. as is utilization based on an understanding of the technologies, their weaknesses and their strengths, the pedagogy, the users, and instructional design. Creative partnerships involving content experts, programmers, and instructional designers arc crucial, while an appreciation of new learning paradigms, such as lile-long learning, self-directed learning, and distributed learning, serves as goal posts. This workshop will explore the above within the context of ongoing work at two separate centres. Participants will be provided with a framework for adopting IT. The Edmonton Palliative Program has been piloting online courses for students, residents, and health care professionals practicing in rural, urban, and international locales. Collaborative learning environments and access to online materials are at their core. The End of Lite Physician Education Resource Center (EPERC) has been established at the Medical College of Wisconsin. Users will be able to locate the most recent information related to end-of-life care, while educators can disseminate their work, thus encouraging the sharing of resources and increasing opportunities to network.

~ SESSION El 7 — Information Technologies for Palliative Care I

JAY LYNCH. University of Ottawa Institute of Palliative Care. SCO Hospital. Ottawa. LES MORGAN. Growth House Inc., San Francisco. California, USA. PIPPA HALL, LYNDA WEAVER. CORI SCHRODER and MARYSE BOUVETTE. University of Ottawa Institute of Palliative Care. SCO Hospital. Ottawa, Ontario, Canada

Palliative medicine highlights both the strengths imd potential pitfalls of modern tecimoiogy in modern practice. Hainan needs, fears. hopes ami strengths are never more openly displayed than at the bedside of the dying. The issue is not whether, tout how to apply modern technology in paltiative care. Seely JF, Mount BM. CMAJ 1999; 161 (9). Although clearly not a panacea, new information technologies can empower health care professionals lo develop and deliver palliative care services in their own comnnunities. They can also facilitate learner-centered pedagogies for palliative care education. The challfiige is how to harness information technologies for palliative care while simultaneously keeping the standards for content high and not allowing the demands of working in this medium to overwhelm you or your organization's resources. In this interactive workshop, the following issues will be discussed: (a) evidence of information technologies supporting and empowering palliative care. Is there any? What is it? (b) small group development work between palliative care clinicians and a technical solutions provider: a model, (c) potential and unexpected challenges and strategies for dealing with them, (d) status of current projects, (e) guidelines fur beginners. This is a hands-on workshop. Following an initial presentation, learners will be asked to work in small groups. A live Internet link will provide workshop participants with the opportunity to experience the medium firsthand. Emphasis will be on the role of health care professionals as content, rather than technical, experts.

~ SESSION El 7 — Information Technologies for Palliative Care II

JAY LYNCH. LYNDA WEAVER, STEPHANIE LANGLOIS, MARNIE STUNT. PIPPA HALL. CORI SCHRODER, and MARYSE BOUVETTE, University of Ottawa institute of Palliative Care, SCO Hospital, Ottawa. Ontario, Canada

Telehealth is a general term that refers to the use of information technology to deliver health care services, education, and information over distance electronically. In June 1999, the University of Ottawa Institute of Palliative Care launched a pilot project providing education to rural palliative care providers through telehealth. The project was undertaken to support the Institute's stated goal of empowering health care professionals in rural communities to develop and deliver palliative care expertise and services locally. During the project, teaching faculty of the Institute developed and delivered an interdisciplinary palliative care education series using telehealth technology. In the pilot, teaching faculty and their partners in the community explored and developed new teaching approaches to maximize the benefits of this experience for learners. A systematic review of the literature and survey of the participant learning needs were also conducted. The project was evaluated formatively, through the use of questionnaires administered to learners, and discussion with the educators and a telehealth planning committee. In this interactive workshop, faculty of the Institute and their partners from the community will summarize the results of this pilot proiect. and then conduct a demonstration of telehealth for palliative care education. A live video-conferencing link to other locations will provide workshop participants with the opportunity to experience the medium firsthand.

~ SESSION El 8 — Informational Needs of the Next of Kin in the Transition from Curative to Palliative Care

MARIA FRIEDRICHSEN, PETER STRANG. and MARIA CARLSSON. Palliative Research Unit. NoirkOping, Sweden

In the transition from curative to palliative care knowledge about the family's informational needs are spare. The aim of this study was to explore next-of-kin's perceptions about given information in the transition from curative to palliative care, focusing on their informational needs. Materials and method: Twenty next-of-kin to cancer patients admitted to a hospitalbased home care unit participated in this study. Qualitative interviews were conducted, transcribed verbatim, and analyzed using a qualitative method. Rrsuits: As this study is in the analyzing phase, results are preliminary. The following categories were found to be of central importance: being aware of the prognosis, meaning, getting knowledge of what can be expected to happen with their severely ill relative (e.g., necessary observations to make, time left, and possible causes of death). They also wanted to receive this information in private, without the presence of the patient and without his/her knowledge of it. This  privacy aimed  to  protect  the patient and  to  allow  the next-of-kin to ask delicate questions of an emotional character. The relatives needed this information to be practically and p.77  mentally prepared as the cancer progressed. Condusion: It i I  an ethical question whether or not to provide next-of-kin in I  formation without the patient's consent. The carer wants th knowledge in order to be prepared, but this interferes with th patient's autonomy.

~ SESSION E18 — Anger: Identifying and Acknowledging Anger in the Patient-Family-Team System and Using it Therapeutically

MARY ANNE HUGGINS and LAURA BROOKS, Princess Margaret Hospital, SHARON ROGERS, University Health Nei work. Toronto, Ontario, Canada

Anger in oncology and end-of-life care, especially when diff' cult decisions are being made, seems inevitable. Anger and it aftermath can affect the patient-family-team system in a wa I   that can divert energy from providing good care for the patier and family, and deflect the focus from the real issues that need  to be discussed. Time and energy can be used up with difficu' interactions between the team, and the patient and family which do not further working toward the goals of care. Thi j  anger is an emotional response that, if not acknowledged and  dealt with, can escalate to destructive proportions. If the emotions and behaviours of the patient, family, and team can b identified as the response to a distressing situation, then coir munication and conflict resolution strategies can diffuse the   tensions. This will help clarify expectations and goals of care and improve satisfaction with care and quality of life. This  workshop will be interactive and will be a case'based discus sion, with cases being brought by the participants. Some of the  issues and analyses from the literature will be presented, followed by discussion of cases that illustrate the points and demonstrate approaches that have been helpful, and those that have  been less than ideal.

~ SESSION C27— Palliative Care in Aboriginal Populations: a Needs Assessment to Improve the Care of the Terminally Ill in Chisasibi, James Bay, Quebec

JUAN-DiEGO HARRlS-GIRALDO, ROBERT HARRIS-GIRALDO. MARIE -ODILE GILBERT, and ROSE ISSERHOFF. Chisasibi Hospital, Chisasibi, Quebec, Canada

A needs assessment to improve the care of terminally ill among the Eeyou population of the Cree nation of Chisasibi, James Bay, Quebec, was conducted from May to August, 1998. The main purpose of this community-based research was to improve the delivery of palliative care services. The lack of studies on this topic has prevented the development of any guidelines to help provide culturally appropriate palliative care lo Aboriginal populations. Qualitative research methods were used to gather information in two overlapping areas: traditional Eeyou knowledge, attitudes, and beliefs regarding death; and attitudes towards the care provided to the terminally ill in the community. Some of the results include: the desire of families to play 3 major role in the direct care of the patient; the need to respect the traditional way in which families relate to their terminally ill relative (the preference not to discuss the terminal illness openly with the dying relative, the importance of not showing sadness in front of him/her, all with belief that doing otherwise would accelerate their death); the significance of dreams and spirituality in the grieving process; the preference to die at home or in the bush. These findings represent a step towards meting the palliative care needs of Aboriginal populations in Canada. It is hoped that the information of this study will be used by other health care professionals working with Aboriginal populations, in order to better satisfy their needs.

~ Session D41 — Model of a Volunteer Bereavement Program in an Oncology Setting

LESLEY LEVY, Hope & Cope. Jewish General Hospital, and ROSANNA MAGNONE, Hope & Cope, Montreal. Quebec. Canada

Our workshop will describe how a team of 12 volunteers follow individuals and families for up to a year following a death through cancer. The program is coordinated by a social worker one day a week, and has three modalities: (a) oulreach, (b) companions, (c) self-help support group. The death of someone close can be a devastating experience, and many people do not receive the understanding and resources required to get through this difficult life event. The support received during the illness may dwindle, leaving the bereaved isolated and at risk. Because our volunteers have experienced a loss through cancer themselves, they can offer valuable peer support, understanding, and resources that can help people through their first year, and ultimately link them with other community support. Our referral base comes from the oncology department, palliative care, and the community at large. The workshop is suitable for professionals and volunteers who would like to offer bereavement support in their own setting.

~ SESSION 044 — International Variation in Medications Used in Palliative Care Programs in the Last Week of Life

ROBIN L. FAINSINGER . Division ol Palliative Care Medicine. University of Alberta, Edmonton, Canada, ALEXANDER WALLER, and MICHAELA BERCOVITCH, Tel Hashomer Hospice. Tel Haviv, Israel. KELVIN BENGTSON. Highway Hospice, Durban, South Africa, JUAN M. NUNEZ-OLARTE. Madrid, Spain. WALTER LANDMAN, and MICHAEL HOSKING. St. Luke Hospice. Cape Town, South Africa

The evidence for pharmacological management of symptoms in palliative care patients is often more empirical and anecdotal than driven by definitive research. This often leads to a wide diversity of international practice. A multicentre study involving four countries (Canada, Israel, Spain, and South Africa) investigated medications used for patients in the last week of life to highlight similarities and differences. Data was collected from inpatients on six hospice/palliative care units in Canada, Israel, Spain and South Africa, and an acute care hospital in Canada. Medications were recorded at seven days prior to death, and then daily records of further changes were noted. The medications used show a wide diversity of practice. Morphine is the moat common analgesic used in alt countries. However, the alternative analgesics used vary widely in all countries. There is some consistency with metoclopramide, the most commonly prescribed antiemetic, and haloperidol, the most commonly prescribed antipsychotic. A wide variety of benzodiazepines are prescribed, with lorazepam and midazolam being the most common choices. Steroids, and dexamethasone in particular, are widely used. The diversity of antibiotics shows very little consistency of practice. There are some individual medications that have a particularly high profile in individual countries: indomethacin, diclofenac, hyoscine butylbromide,  and  glycopyrrolate in  Durban; midazolam, clonazepam. dipyrone, ranitidine, hyoscine butylbromide, and scopolamine in Madrid; papaverine, furosemide, and spironolactone in Israel. The international panel involved in this project will describe the local circumstances resulting in their particular pharmacological prescribing profile. The panel and workshop participants will discuss areas of consensus, controversy, and potential for further research.

~ SESSION D44 — The Enigma and Challenge of Breakthrough Pain in Cancer Patients

YOKO TARUMI, JOSE PEREIRA, and SHARON WATANABE. Division of Palliative Care Medicine. University ol Alberta, Edmonton, Alberta, Canada
The term "breakthrough pain" is applied to discrete transitory flares of pain which interrupt a tolerable background pain. Breakthrough pain is recognized as a prevalent, heterogeneous, and clinically important phenomenon in cancer patients. However, empirical information about this phenomenon is limited. We have reviewed the existing literature, and are currently undertaking a prospective study to further describe this entity and its response to treatment. The purpose of this workshop will be to provide a forum to discuss key clinical and research issues pertaining to breakthrough pain, including definition, characteristics, assessment, impact, and management. Specific attention will be given to the use of rescue opioid (optimal type, route, and timing of administration, and dose), as well as the role ofpharmacological and non-pharmacological adjuvant approaches.

~ Session D45 — Palliative Care MAINPRO-C Clinical Traineeship: a Continuing Medical Education Initiative for Primary Care Physicians

ANNA W. TAUBE and DOREEN ONESCHUK. Division of Palliative Care Medicine,  DAVID MOORES, Department of Family Medicine, University of Alberta. Edmonton. Alberta, Canada, EDUARDO BRUERA, Department of Symptom Control & Palliative Care, University of Texas. Houston, Texas, USA

The vast majority of Canadian cancer patient palliative medicine is in the hands of primary care physicians, most of whom have received no formal training in palliative medicine. The Division of Palliative Medicine, in conjunction with the Department of Family Medicine, University of Alberta, developed this "hands-on" palliative care clinical traineeship for family physicians. The first of its kind in Canada, this program may become a model for other continuing medical education programs for this physician population. The traineeship is a two-month course in which trainees (primary care physicians) are mentored one-on-one with the Edmonton Regional Palliative Care Program palliative consultant physicians, with the opportunity to take on the care of new palliative patients in either the home or hospice setting. Due to its fulfilling the requirement of both pre- and post-trainee formal evaluation and active participant involvement in patient care, this course has been accredited by the College of Family Physicians of Canada for 24 MAINPRO-C credits. This workshop will review the details of this program and offer participants the opportunity to explore their resources to set up other primary care physician training opportunities. Topics to be covered will include: primary care physician needs assessment, core palliative medicine topics, bibliography selection, post-course trainee evaluation, course evaluation and the College of Family Physicians of Canada MAINPRO-C accreditation process. Future directions needed to reach national standardization for such training programs will be offered for discussion.

~ SESSION D45 — Review and Disseminatlon of Physician End-of-life Education Materials: the EPERC Project

DAVID WEISSMAN. DEBORAH SIMPSON, JUDY REHM, SANDRA MUCHKA, and KATHY BIERNAT, Medical College of Wisconsin. Milwaukee, Wisconsin. USA There is a shortage of high quality education resources for physician end-of-life (EOL) education. EPERC (End-of-Life Physician Education Resource Center) was established as a webbased community of EOL educators (www.fperc.mcw.edu). The purpose of EPERC 'is to provide: (a) a searchable database of peerreviewed physician education material (course syllabus, overheads/slide set, audio/videotape, OSCE, role play exercise, learner evaluation measure, etc.), (b) an Educator's Bookshelf containing key references, books, meetings, and training opportunities, and (c) a discussion forum for educators. This workshop will review elements of the EPERC database, and allow participants to understand the material submission and review process. Participants will review a compendium of international physician education resources: books, manuals, pocket guides, course syllabi, and educational policy documents. Participants will have the opportunity to review and practice elements of curriculum design: write educational objectives, learn to match objectives with the optimal teaching format, and design learner and program evaluation measures.

~ SESSION 046 — Conducting Clinical Trials in Palliative Care: Roles and Challenges

KATHRYN CALDER, BARBARA TOM. and ANTONIO VIGANO.
   Palliative Care Program. Edmonton. Alberta, Canada

Clinical trials in the palliative care setting not only offer tremendous potential for discovery, but also many unique challenges. While it is recognized that properly conducted research is the best way to improve the understanding and treatment of the palliative care patient, various issues still threaten to impede progress. Attitudes of patients, families, and healthcare providers can cast negative views on research involving individuals with advanced disease. Past experiences with experimental treatments can render patients suspicious of all new clinical trials. With the vast array of active treatment research initiatives available, competition for willing study patients is greater than ever. Throughout the years, a structured palliative care research program was consolidated in Edmonton under the guidance of Dr. Eduardo Bruera. The above issues, along with other challenges such as the accrual of consecutive and representative samples, and the changes in the structure of the health care system, were successfully managed within this research program. Throughout this interactive workshop, we will review the roles and responsibilities of the palliative care research team members, identify challenges and potential obstacles to conducting clinical trials with advanced cancer patients, and explore ways in which we can modify current procedures to maximize our effectiveness. Examples will be drawn from the experience of the Edmonton group in both quantitative and qualitative studies. Workshop participants will be encouraged to share their experiences in conducting research with palliative care patients in multiple settings, including acute care hospitals, hospices, and their homes.

~ SESSION D46 — The Information Age; the Challenge for Palliative Care

JOSE PEREIRA, Division of Palliative Care Medicine. University of Alberta, and GARY FRANK, Regional Palliative Care Program, Edmonton. Alberta. Canada

The birth of this millennium can be characterized by the unprecedented growth of information technologies. Millions of people around the world now have access lo amounts and types of information on a scale that previously was unimaginable. These technologies have, and will continue to influence society in ways that are often conspicuous, sometimes nonapparent, and occasionally unforeseen. The purpose of this workshop is to highlight some areas where this influence is already being felt in the care of the terminally ill, and to challenge the palliative care community to be vigilant for, and to respond appropriately to these influences. The first part of the presentation will illustrate, by way of case studies and ongoing research, the reasons patients and their families are going online, and the impact that technologies such as the Internet are having on their care and well-being. This will be followed by a discussion on educational and data management applications. The need for systematic and appropriate evaluations of these technologies to guide their appropriate integration into palliative care will be highlighted.

~ SESSION D47 — Is Palliative Care Education Needed in Your Long-term Care Facility?

PIPPA HALL. VALERIE FISET, MARYSE BOUVETTE, LYNDA WEAVER. AND DIANE HUPE, Institute of Palliative Care, Elizabeth Palmer. Extendicare Starwood. Ottawa, Ontario, Canada

With recent changes in the health care system, more terminally ill residents of long-term care (LTC) facilities are remaining at their facility to die. The goal of palliative care is to optimize quality of life of the dying person, as well as to support formal and informal caregivers through an interdisciplinary approach. Appropriate cultural sensitivity is also necessary. Staff at LTC facilities need knowledge, skills, and attitudes to give these residents the best palliative care. The importance of education in the development of this expertise is recognized, but developing appropriate and effective palliative care education programs is a challenge. Using the example of a palliative care educational needs assessment conducted in LTC facilities in eastern Ontario and the subsequent process of curriculum development as a basis for discussion, the participants at this workshop will be able to: (a) discuss the role of palliative care in LTC facilities, (b) understand and discuss the importance of a learning needs assessment when developing an educational program for their facility, (c) ex-plain how a learning needs assessment can be done in their own facility, (d) discuss the significance and relevance of the results presented in the context of their own facility, (e) participate in creative educational planning for a palliative care educational program relevant to LTC needs.
 
 
 

~ SESSION C45 — Conducting Research on Personal Costs in Palliative Care

ANTONIO VIGANO, Regional Palliative Care Program, PETER CALDER, Department ol Educational Psychology, PHIL JACOBS, Department of Public Health Sciences. University of Alberta, CARLEEN BRENNEIS, Regional Palliative Care Program, PENNY PARKER. Capital Health Authority Palliative Home Care Program, Edmonton, Alberta, Canada

While few studies have explored the impact of palliative care programs in terms of utilization of health services (i.e. number of cancer deaths and inpatient days in acute care facilities), very little has been done on the personal costs incurred by terminally ill patients and their care givers. Findings from a recent study on individuals with HIV have shown that many are faced with needs but do not have the financial resources to meet those needs. The largest personal costs appeared associated with loss of income, followed by costs related to their caregiving, and then transportation costs related to their care. The purpose of this workshop is to describe the steps that the team of authors (physician, psychologist, economist/accountant, and two nurse-administrators) has taken in collecting and analyzing appropriate personal costing data within the Regional Palliative Care Program and Palliative Home Care in Edmonton, Alberta. The workshop is designed to facilitate participants carrying out of costing studies in the area of palliative care. Some of the topics to be covered will be; (a) defining personal costs according to health economic standards, (b) methods and issues in collection of personal cost data, (c) defining legitimate personal costs, (d) classification of types of personal costs according to nature of costs, (e) classification of costs according to payer, (f) setting values for cost equivalents, (g) collection of actual value of personal costs, (h) areas in need of research.

~ SESSION C45 — Current Challenges and Future Directions in Psychosocial Assessment in Palliative Care

CHERYL L. NEKOLAICHUK. Division of Palliative Care Medicine. University of Alberta. Palliative Care Program, KAREN MACMILLAN. and BETTE EMERY, Palliative Care Program. PAULA L. BRINDLEY, Regional Palliative Care Program, Edmonton, Albena, Canada

Psychosocial assessment is an important component of palliative care, yet it continues to elude researchers and clinicians. The purpose of this workshop is to highlight several challenges in the development of psychosocial assessment techniques for the terminally ill. These challenges will be presented within a three-dimensional framework focusing on the elusive nature of the psychosocial concept (theory), the rigor of measurement and assessment techniques (methods), and the unique needs of the palliative population (clinical practice). Several assumptions underpinning this framework will also be presented: (a) the need to weave theory, methods, and practice within the development of assessment techniques, (b) the view of measurement as a subset of the assessment process, which is continuous and dynamic, and (c) the awareness of ethical issues revolving around the development and use of assessment techniques. To highlight some of these challenges, findings from a recent study focusing on the assessment of hope in palliative patients will be presented. Directions for future research will also be discussed.

~ SESSION C46 — The Opioid Menu: Considerations in Selecting and Switching

JOSE PEREIRA. SHARON WATANABE. PETER LAWLOR. and PAUL WALKER. Division of Palliative Care Medicine, Edmonton.
   Alberta, Canada

Opioid analgesics represent a mainstay of treatment for moderate to severe cancer pain. Although oral morphine has traditionally been the strong opioid of first choice for the treatment of cancer pain, an expanding variety of opioids and opioid formulations are making their appearances internationally. These include hydromorphone, oxycodone, methadone, and fentanyl in a variety of formulations. The purpose of this workshop is to review the literature related to these opioids, and to provide a framework to guide clinicians in selecting and switching between them. Reported advantages with respect to the efficacy and adverse-effect profiles of the different opioids and formulations will be analyzed. Indications, with case examples, for switching opioids will be discussed, as will methods of switching between them. New knowledge related to the use of equianalgesic dose tables will be introduced. The spectrum of opioid "toxicities" and strategies for prevention will be presented. Directions for future research will be discussed.

~ SESSION C46 — Methadone Workshop: Issues and Experiences

RAYMOND VIOLA. CORINNE SCHRODER. and ROBERTE LEGER. University of Ottawa Institute of Palliative Care, Ottawa, Ontario, Canada, JEREMY KEEN, St. Columba's Hospice, Edinburgh, Scotland

Methadone has received increasing attention during the past few years for the management of pain experienced by patients with terminal cancer. Its unique pharmacological properties make it both attractive and problematic. Controversies prevail regarding its role in palliative care and how it should be used. This workshop will provide an international forum for sharing knowledge about and experiences with methadone use in palliative care. Participants will acquire increased knowledge and understanding about methadone, its advantages, disadvantages, and possible roles in palliative care. They will also learn about different suggested methods for initiating methadone use with individual patients. The workshop will start with a presentation of background information regarding methadone's pharmacokinetics, activities, and purported unique advantages and uses. Experiences using methadone will then be described and participants will be invited to sum-marize their experiences. Specific case studies will be used to emphasize key issues. Protocols for initiating the use of this drug will be outlined, compared, contrasted, and debated. The workshop will close with a summary oi the main issues addressed and the current understanding about the use of methadone in palliative care. Gaps in knowledge requiring further research will be identified.

~ SESSION D26 — "The Sore Spot", Dealing with Pressure and Malignant Ulcers in Terminal Care

PAUL WALKER, Division of Palliative Care Medicine & Department of Public Health Sciences, University of Alberta, TREVA CUNNINGHAM. Palliative Care Program. VALERIE SCHULZ, Department of Public Health Sciences, University of Alberta, Edmonton. Alberta, Canada
Written records of the existence of pressure ulcers can be found dating back to biblical times. This ancient problem continues today in our terminally ill patients. This workshop will address the current knowledge regarding pressure ulcers with emphasis on the etiology and pathophysiology of the condition. Treatment approaches will be outlined, beginning with how to stage pressure ulcers. Ulcer care will be addressed, especially issues regarding debridement, wound dressings, and the multitude of adjuvant therapies that have been proposed. Recognizing and managing bacterial infection will be discussed. The option of surgical repair will also be reviewed. The issue of proper support surface (i.e. specialized beds and mattresses) will be presented. Nutritional issue", will be explored. The problem of how aggressive to become in managing these ulcers in the terminally ill will be discussed. Nonhealing wounds are a particular challenge in the palliative patient. The cutaneous spread of malignancy resulting in malignant wounds exemplifies this problem. Assessment and management of malignant wounds will be presented. Attention will be focused on the prevalent symptoms of pain, odor, exudate, bleeding, and psychological and social distress associated with these wounds. The perspective of honouring the patient's goals and preferences, and the awareness of the discomfort that may be caused from overaggressive management will be reviewed. Often it is a great challenge to manage terminally ill patients with severe pressure ulcers and malignant wounds. The dogma that all patients should have treatment directed at healing these lesions will be challenged. When these lesions do not heal, the question of the quality of care may arise in the palliative care setting and this will be discussed.

Session D26 - Is Rehabilitation  Missing? Challenges and Future Direction of Rehabilitation In Palliative Care
MARY ANNE SCHLEINICH. Palliative Care Program, TERRY KAASA, Cross Cancer Institute, GLENN WARREN. Palliative Care Program, Edmonton. Alberta, Canada

While rehabilitation is an important part of palliative care, it is often overlooked in the drive for improved pain and symptom control. There is a paucity of literature attesting to the contribution of rehabilitation in successful symptom management. Even conceptually, both academics and clinicians have difficulty viewing "rehabilitation" and '"palliative" in the same service context. Furthermore, in our experience, recipients of physical and occupational therapy services have difficulty recognizing treatment, even following tangible outcomes attained from rehab interventions. The purpose of this workshop is to address current challenges in the provision of rehab services. It will provide an interactive forum in which the multidisciplinary team can come away with strategies for enhancing rehabilitation and widening access for optimal service delivery. Communication and teamwork are essential for bridging the gap between current and future services. Therefore, the workshop is directed to both medical and paramedical professionals. Challenges will be portrayed within the context of existing clinical and university programs. To concretize the rehabilitation component of palliative care and highlight challenges. quantitative and qualitative outcome measures, and research initiatives at two Edmonton institutions will be presented. Particular attention will be paid to the challenge of delivering services across the continuum of cancer care, from the cancer treatment clinic to the hospice setting.

~ SESSION D27 — Dialysis in Advanced Cancer Patients: Technical and Ethical Considerations

CATHERINE A. JENKINS. Division of Palliative Medicine. University of Alberta Edmonton, Alberta, Canada

Intensive therapies such as dialysis are not usually considered part of the palliative model of care. However, a portion of patients with advanced cancer who develop renal failure will choose to be dialyzed. Dialysis is effective life-prolonging therapy, as well as a potential treatment for symptoms such as delirium, nausea, and fatigue. Undertaking an invasive procedure such as dialysis in advanced cancer patients has implications for other aspects of the patient's palliative management. The process of dialysis can cause patient discomfort and morbidity, particularly as complications of advanced cancer can make dialysis more technically difficult. Many of the medications used in palliative care are renally excreted and, therefore, medication regimens require alteration. Administering effective dialysis requires more intensive laboratory and hemodynamic monitoring than is usually offered by palliative care. Tile decision to offer dialysis changes the nature of the palliative intervention from solely supportive care to actively prolonging life. For those patients who eventually decide to stop dialysis, the emotional experience for both them and their families is that of choosing to die, rather than that of accepting the natural disease process. Whether the choice of dialysis should be given to all advanced cancer patients who develop renal failure, or only to a select group, also represents an ethical dilemma. Using case histories, this workshop will discuss some of the technical and ethical issues involved in combining dialysis with palliative care.

~ SESSION D27 — End Stage Renal Disease (ESRD) Withdrawal of Dialysis: the Interface with Palliative Care

SUSAN CHATER. Palliative Care Service, KEVIN BURNS. Division of Nephrology, Ottawa Hospital, Ottawa. Ontario, Canada

Patients with end stage renal disease (ESRD) who withdraw from hemodialysis are a unique population. Their "end-of-life issues" and "terminal care" arc compressed into a very short period of time. Symptoms may change rapidly from day to day and management, particularly drug dosing, needs to be very finely tailored. Over the next five to 10 years, there will be a significant increase in the number of patients on dialysis. particularly those >65 yrs., and also of those withdrawing from dialysis. We will review the literature on the subject of withdrawal of dialysis. A series of patients with ESRD referred to a palliative care service will be reviewed, looking at symptoms and psychosocial issues at the end of their life. We will look more closely at a number (-30) of patients who have withdrawn from hemodialysis. This workshop is designed to enable participants to have a good understanding of: (a) why patients may need to withdraw from hemodialysis, (b) symptoms experienced after withdrawal and the appropriate management of these symptoms and end-of-life care, (c) the unique medical and psychosocial issues for these patients, their families, and the staff caring for them. The participants will have an opportunity to work through two illustrative case histories.