This study aimed to clarify corticosteroid prescribing during final hospice care, realizing the clinical and ethical dilemmas that may be associated with this therapy. A retrospective review was performed of deaths occurring at our unit during a 6-month period. Corticosteroid use was recorded from drug charts and cross-referenced by case note review. Fifty-one percent of 178 patients received corticosteroids, which were continued until death in 53%. Only 2% were switched from oral to parenteral corticosteroids. The reason for using corticosteroids was documented in 67% of patients. The main indications included treatment for raised intracranial pressure and to give a "boost." The foremost reason for withdrawing corticosteroids was loss of the oral route. These data confirm the high prevalence of corticosteroid use in the terminal phase, even until death. This contrasted with the near absolute withdrawal of corticosteroids once the oral route was lost. The study suggests a need for greater vigilance in corticosteroid prescribing, and identified issues to be addressed in the prescribing of these drugs.

Up to 40% of patients with mild haemophilia A have a discrepancy whereby factor VIII (FVIII) measurements by a two-stage chromogenic assay (FVIII:C(CH)) are disproportionately reduced compared with the FVIII one-stage clotting value (FVIII:C). Which assay best reflects the coagulation potential and clinical phenotype in this patient group is of clinical significance, yet remains unclear. We have assessed the global coagulant ability of haemophilia patients with FVIII assay discrepancy using calibrated automated thrombography (CAT). A total of 18 patients with mutations Arg531His/Cys or Arg698Trp causing FVIII discrepancy were investigated, together with 12 haemophilia patients with concordant FVIII values and 15 normal controls. Factor VIII levels in all patients and controls were measured using both one-stage clotting assay and two-stage chromogenic assay. Thrombin generation was assessed in platelet-poor plasma by CAT using a low tissue factor concentration (1 pm). FVIII:C(CH) values were below normal in all patients, and in the discrepant group were between 1.5- and 8-fold lower than FVIII:C values. CAT parameters were affected in all haemophilia patients. The endogenous thrombin potential (ETP) was reduced to 58-67% of the mean normal value (1301 nm min(-1)), whereas peak thrombin was further reduced to 27-30% of the mean normal value (178 nm) in both discrepant and concordant patient groups. Analysis of the discrepant patient group showed the most significant correlation between the one-stage FVIII:C assay and ETP (r(2) = 0.44) and peak thrombin parameters (r(2) = 0.27).

To develop, implement and evaluate a collaborative intervention in care homes seeking to increase the confidence and competence of staff in end of life care and enable more people to receive end of life care in their usual place of residence.\ud Aim To develop, implement and evaluate a collaborative intervention in care homes seeking to increase the confidence and competence of staff in end of life care and enable more people to receive end of life care in their usual place of residence.\ud \ud Method A two-phase exploratory mixed methods design was used, evaluating the effect of an end of life care toolkit and associated training in care homes, facilitated by a specialist palliative care team. Six care homes in England were recruited to the intervention; 24 staff participated in discussion groups; 54 staff attended at least one training session; and pre- and post-intervention questionnaires were completed by 78 and 103 staff respectively.\ud \ud Results Staff confidence in receiving emotional and clinical support and managing end of life care symptoms increased post-intervention, but confidence in discussing death and dying with residents and relatives decreased. Audit data indicate greater reduction in the number of residents from participating care homes dying in hospital than those from comparison homes.\ud \ud Conclusion Collaborative end of life care interventions support care home staff to manage end of life and may enable residents to have choice about their place of death

While the additional value from adding the option of virtual visits is not in question, numerous issues are raised around how to decide between face-to-face and virtual visits in individual cases and how best to set up such provision within an organisation. With only limited palliative care-specific literature and no time to set up and evaluate pilots, we had to get on and set up a prototype ‘virtual visits’ model, retro-fitting guidance and a supporting ethical framework. We looked at the issues spanning clinical, ethical and logistics domains; identifying areas of benefit as well as drawbacks, some specific to the rushed implementation because of COVID-19’s infective risks and the ‘rules’ of lockdown, but many are generic areas to help guide longer term service design. Unsurprisingly, it appears clear that a ‘one-size-fits-all’ mentality is a poor fit for the individualised needs of the heterogeneous palliative care population. Virtual visits have great potential even if they are not a panacea.

Schwartz Centre Rounds® aim to explore the human and emotional impact of everyday work by giving healthcare staff the opportunity to come together in a safe but open environment. We evaluated the experience of introducing Schwartz Centre Rounds in a UK hospice over 1-year using a mixed method approach. These rounds were reported as providing staff with a greater appreciation of the interprofessional approach. Individuals were more actively acknowledged by other colleagues as a result of contributions at rounds with an appreciation of a wider team, spanning the whole organisation. This appeared to relieve feelings of isolation and enhance a sense of shared purpose. Some staff chose not to attend but valued their contribution to the organisation without witnessing the emotional impact of hospice work. Our findings indicate that Schwartz Rounds offer staff the environment to explore the human element of their work and appear to improve interprofessional working.