Background: Little research has explored the detail of practice when using sedative medications at the end of life. One work package of the I-CAN-CARE research programme investigates this in UK palliative care. Aims: To investigate current practices when using sedative medication at the end of life in London, UK, by (1) qualitatively exploring the understandings of palliative care clinicians, (2) examining documented sedative use in patient records and (3) comparing findings from both investigations. Design: We conducted focus groups with experienced palliative care physicians and nurses, and simultaneously reviewed deceased patient records. Setting/participants: In total, 10 physicians and 17 senior nurses in London hospice or hospital/community palliative care took part in eight focus groups. Simultaneously, 50 patient records for people who received continuous sedation at end of life in the hospice and hospital were retrieved and reviewed. Results: Focus group participants all said that they used sedative medication chiefly for managing agitation or distress; selecting drugs and dosages as appropriate for patients’ individual needs; and aiming to use the lowest possible dosages for patients to be ‘comfortable’, ‘calm’ or ‘relaxed’. None used structured observational tools to assess sedative effects, strongly preferring clinical observation and judgement. The patient records’ review corroborated these qualitative findings, with the median continuous dose of midazolam administered being 10 mg/24 h (range: 0.4–69.5 mg/24 h). Conclusion: Clinical practice in these London settings broadly aligns with the European Association for Palliative Care framework for using sedation at the end of life, but lacks any objective monitoring of depth of sedation. Our follow-on study explores the utility and feasibility of objectively monitoring sedation in practice.

The correct use of opioids is the mainstay of effective management of pain in palliative care. This article describes the available analgesic options, reviews recent evidence and guidelines, and explores patients' and doctors' common concerns about opioid use.

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of training for those who are going to lead the programme in their home, including training for the managers to ensure it is well-led throughout the home, and then there are inhouse sessions for the individual homes to inform the whole team. Results Currently there have been 16 homes recruited and trained to implement the Namaste Care Programme. All homes are at varying degrees of the implementation phase due to individual circumstances of that home. There are some homes that have very early results that are showing both qualitative and quantitative improvements in individuals' quality of life within their homes. Conclusion We plan to review progress and publish results in March 2019.

ObjectivesPalliative care research suffers from underfunding and a workforce spread across multiple settings leading to a lack of large-scale studies. To facilitate multisite research and audit we set up the UK Palliative trainees Research Collaborative (UKPRC), the first national trainee-led audit and research collaborative in palliative care. Here, we critically review the progress and potential of the UKPRC since its inception in 2016, identifying key challenges and facilitators. Members of the UKPRC steering committee collaborated to write this reflection, reviewing existing evidence regarding trainee-led research collaboratives.FindingsThe UKPRC has representation from 16/19 UK training regions. Projects are run by a core team; local collaborators collect data at each site. The collaborative is supported by academic leads and newly qualified consultants to develop a culture of continuous improvement in practice. We have conducted four national projects to date, including an audit covering 119 sites. Facilitators for our work include a focus on inclusivity and national representation; support from recently qualified consultants to ensure continuity; and taking a pragmatic approach, focusing initially on straightforward projects to build momentum. Challenges include the step from national audit to multisite, patient-facing research and maintaining continuity in a membership with high turnover.ConclusionsThere is potential to change practice through large scale data collection via the trainee-led collaborative model. Collaboration is especially important in a small specialty with limited resources. The UKPRC has demonstrated ‘proof of concept’ and has the potential to support and sustain a culture where research can flourish within palliative care.