Objective: Collusion refers to a secret agreement made between clinicians and family members to hide the diagnosis of a serious or life-threatening illness from the patient. Our goal was to reduce the rate of collusion among the family members of patients referred to our institution's palliative care service such that 80% of patients would be aware of their diagnosis within four weeks of referral to the service. We aimed to achieve this target within six months of starting the project.Methods: We undertook a clinical practice improvement project using the methodology of Brent James et al of Intermountain Health to see how we could reduce collusion among clinicians and family members of patients with advanced-stage cancers. This strategy included creating awareness among patients, family, and clinicians of the problems with collusion from the standpoint of each group; adopting an empathetic and compassionate approach to communication; using pamphlets; seeking patients' views; empowering families to reveal the truth to patients; and supporting patients and families until the last moment of each patient's life.Results: Between December 2004 and June 2008, 655 patients with advanced-stage cancers were referred to us. We were able to maintain an average awareness rate of nearly 80% of patients starting in February 2005, when we implemented awareness measures. Conclusion:The deeply entrenched cultural practice of collusion can be changed with simple strategies based on the universal principles of medical ethics and best practices.

Introduction: While opioids are effective in carefully selected patients with chronic non-cancer pain (CNCP), they are associated with potential risks. Therefore, treatment recommendations for the safe and effective use of opioids in this patient population are needed. Materials and Methods: A multidisciplinary expert panel was convened by the Pain Association of Singapore to develop practical evidence-based recommendations on the use of opioids in the management of CNCP in the local population. This article discusses specific recommendations for various common CNCP conditions. Results: Available data demonstrate weak evidence for the long-term use of opioids. There is moderate evidence for the short-term benefit of opioids in certain CNCP conditions. Patients should be carefully screened and assessed prior to starting opioids. An opioid treatment agreement must be established, and urine drug testing may form part of this agreement. A trial duration of up to 2 months is necessary to determine efficacy, not only in terms of pain relief, but also to document improvement in function and quality of life. Regular reviews are essential with appropriate dose adjustments, if necessary, and routine assessment of analgesic efficacy, aberrant behaviour and adverse effects. The reasons for discontinuation of opioid therapy include side effects, lack of efficacy and aberrant drug behaviour. Conclusion: Due to insufficient evidence, the task force does not recommend the use of opioids as first-line treatment for various CNCP. They can be used as second- or third-line treatment, preferably as part of a multimodal approach. Additional studies conducted over extended periods are required. Key words: Chronic pain, Consensus statement, Guidelines, Non-cancer pain, Opioids

No abstract

No abstract