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ObjectivesThe majority of people would prefer to die at home and the stated intentions of both statutory and voluntary healthcare providers aim to support this. This service evaluation compared the preferred and actual place of death of patients known to a specialist community palliative care service.DesignAll deaths of patients (n=2176) known to the specialist palliative care service over a 5-year period were examined through service evaluation to compare the actual place of death with the preferred place of death previously identified by the patient. Triggers for admission were established when the patients did not achieve this preference.ResultsBetween 2009 and 2013, 73% of patients who expressed a choice about their preferred place of death and 69.3% who wanted to die at home were able to achieve their preferences. During the course of their illness, 9.5% of patients changed their preference for place of death. 30% of patients either refused to discuss or no preference was elicited for place of death.ConclusionsDirect enquiry and identification of preferences for end-of-life care is associated with patients achieving their preference for place of death. Patients whose preferred place of death was unknown were more likely to be admitted to hospital for end-of-life care.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It provides recommendations on the assessments and interventions for this group of patients receiving palliative and supportive care.Recommendations• Palliative and supportive care must be multidisciplinary. (G)• All core team members should have training in advanced communication skills. (G)• Palliative surgery should be considered in selected cases. (R)• Hypofractionated or short course radiotherapy should be considered for local pain control and for painful bony metastases. (R)• All palliative patients should have a functional endoscopic evaluation of swallowing (FEES) assessment of swallow to assess for risk of aspiration. (G)• Pain relief should be based on the World Health Organization pain ladder. (R)• Specialist pain management service involvement should be considered early for those with refractory pain. (G)• Constipation should be avoided by the judicious use of prophylactic laxatives and the correction of systemic causes such as dehydration, hypercalcaemia and hypothyroidism. (G)• Organic causes of confusion should be identified and corrected where appropriate, failing this, treatment with benzodiazepines or antipsychotics should be considered. (G)• Patients with symptoms suggestive of spinal metastases or metastatic cord compression must be managed in accordance with the National Institute for Health and Care Excellence guidance. (R)• Cardiopulmonary resuscitation is inappropriate in the palliative dying patient. (R)• ‘Do not attempt cardiopulmonary resuscitation’ orders should be completed and discussed with the patient and/or the family unless good reasons exist not to do so where appropriate. This is absolutely necessary when a patient's care is to be managed at home. (G)

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Although the more recently introduced antipsychotic drugs are increasing in popularity, the pattern of symptomatology when taken in overdose is not well defined. We monitored all enquiries to the National Poisons Information Service, London (NPIS, London) concerning antipsychotic drugs over a 9-month period in 1997 and report our findings concerning four drugs (olanzapine, clozapine, risperidone and sulpiride). All overdoses involving a single agent were followed up by a letter to the enquirer requesting details and outcome of the case. Although a total of 574 enquiries involving the selected antipsychotic drugs were received, only 45 of these cases involved overdose with a single agent. There were no fatalities or cases of convulsions in the series. Cardiac arrhythmias were only noted with sulpiride. Symptoms were most marked with clozapine, with a majority of patients experiencing agitation, dystonia, central nervous system (CNS) depression and tachycardia. Olanzapine and sulpiride produced a range of different symptoms, while most patients who had taken risperidone were asymptomatic. Monitoring poisons centre enquiries is a useful way of comparing overdose toxicities. We conclude that at least two of the novel antipsychotic agents, olanzapine and risperidone, appear to have a favourable overdose profile, which suggests that they are safer in overdose than the phenothiazines and butyrophenones.