Long-term home-based invasive ventilation in patients with motor neurone disease/amyotrophic lateral sclerosis (MND/ALS) remains rare in the UK. We describe a case of an MND/ALS patient who was treated with long-term invasive ventilation at home but subsequently requested its withdrawal despite a seemingly stable period of his illness. We also discuss the impact of the delivery of this treatment and its withdrawal on his carers, primary healthcare team, community trust managers and specialist palliative care team.

The discovery of peripheral opioid receptors has become the scientific basis for topical use of opioids in malignant and nonmalignant ulcers and oropharyngeal mucositis. This systematic review aimed to assess the quality of published literature and to examine whether topical opioids are effective in controlling pain in palliative care settings. After a systematic literature review, 19 studies (six randomized controlled trials [RCTs] and 13 case reports) met the inclusion criteria for the review. Eighteen studies favored topical opioids in pain relief, as evidenced by reductions in post-treatment pain scores, but time to onset and duration of analgesia varied widely. Because of the heterogeneity of the studies, meta-analysis was not possible. Despite clear clinical benefits described in small RCTs, there is a deficiency of higher-quality evidence on the role of topical opioids, and more robust primary studies are required to inform practice recommendations. N-of-1 trials should be encouraged for specific clinical circumstances.

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Background The review of the LCP included concerns that opiates and sedatives had been used inappropriately at end of life. Although studies of prescribing for hospice inpatients concluded safe practice and lack of evidence that their use shortens survival, there is a lack of studies examining similar aspects of prescribing in hospital inpatients. Aims The aims of the audit were to:

referral Triggers Tool would have proactively identified most or all patients who died during their non-elective hospital admission. The inclusion of disease and symptom-related parameters in a PC referral Trigger tool appears feasible as these are often documented in oncology records, whereas oncologists may not routinely identify psychosocial factors. 143 CREATION OF GUIDELINES FOR MANAGEMENT OF PATIENTS UNDERGOING ABDOMINAL PARACENTESIS FOR MALIGNANT ASCITES AT JOHN EASTWOOD HOSPICEStephanie Hill, Jillian Wall. John Eastwood Hospice 10. 1136 /bmjspcare-2018 Background The inpatient unit at John Eastwood Hospice (JEH) is increasingly providing care for patients with malignant ascites, allowing the relief of symptoms via paracentesis. With no established local or national guidelines to follow for peri procedural care, we felt there were varying approaches used for our patients. We set out to create a local protocol for patients undergoing paracentesis, and audit practice against this. Methods A thorough literature search alongside review of guidelines uploaded to palliativedrugs.com, and those publicly available on the internet, identified eleven established UK guidelines for management of malignant ascites.These were used to construct a protocol for use at JEH. Audit standards were then established alongside this, allowing for retrospective analysis of the management of patients who had undergone paracentesis at JEH. Results 8 patients had undergone this procedure in the preceding 12 months at JEH, giving a total of 10 completed procedures. Peri procedure management in several areas was variable.A set of baseline observations was documented prior to the procedure in only 10%. Documentation of observations post procedure varied significantly, ranging from half hourly to none at all. 60% had documentation of drain clamping at some point but in none of the cases was there any further detail of the clamping (e.g. length of time). For the 7 drains which were temporary, the length of time they remained in situ ranged from 31 hours to 195 hours. Conclusions This retrospective audit demonstrates significant variability in the management of patients undergoing paracentesis at JEH, which strayed from that suggested by the newly created guidelines. These guidelines will now be rolled out in the hospice, alongside education to staff, and re-audit completed to ascertain whether there is more uniform practice. Background Macmillan Specialist Care at Home seeks to enhance patient-centred care through community and homebased palliative and end of life care services. This article reports a qualitative study that formed part of a larger evaluation of a multi-site implementation of the specialist palliative care community service. Aim To examine caregiver, patient and carer experiences of service implementation and identify how its key features: early referral; clinical interventions at home; avoiding hospital admissions; and facilitating patients to die in their preferred place of death, worked in practice. Methods Qualitative ...