Background: End-of-life discussions are associated with improved quality of care for patients. In the UK, the General Medical Council outlines a requirement for medical graduates to involve patients and their families in discussions on their care at the end-of-life. However medical students feel ill-equipped to conduct these discussions. Methods: In 2018, Sheffield Medical School introduced a small group role-play session on

Opioid-induced constipation (OIC) is common and can significantly affect quality of life. Naloxegol and methylnaltrexone are peripherally acting µ-opioid receptor antagonists (PAMORAs) which are effective for the management of OIC. We report on a case in the palliative care setting where a patient with established OIC had an inadequate response to naloxegol but an effective and immediate response to methylnaltrexone at the dose recommended for her weight. This is the first reported case of two PAMORAs used concomitantly.

25 patients received VTE prophylaxis within the last 72 hours of life. Of these, 12 had VTE prophylaxis stopped in the coming days. 6 patients who were recognised as dying received VTE prophylaxis in their last 24 hours of life. Conclusions The results suggest that guidance regarding pharmacological thromboprophylaxis in the last days of life is not consistently followed even when the dying process has been recognised. They also highlight that improvement is needed in recognising the dying patient in the acute setting and that locally there is inadequate uptake of our 'last days of life' care plan.

BackgroundPecFent®is a powerful fast-acting fentanyl nasal spray which is used for breakthrough cancer pain. When it is not administered correctly or titrated quickly enough, we suspect aspects of patient care may suffer, with sub-optimal pain control, loss of confidence in the medication, and unnecessary cost to the health service.AimsTo assess hospital nurses' confidence and competence in administering PecFent®. To identify specific needs for further training.MethodsWe used a convenience sample of 5 nurses (who had previously administered PecFent®) per ward or hospice unit in Sheffield where PecFent®is commonly prescribed. A guided questionnaire-based interview, involving a standardised scenario using placebo PecFent®, was piloted on 4 specialist nurses. The scenario required the nurse to titrate the dose from 100 to 200 mcg and administer it to an actor, followed by questions on confidence, previous experience, training, and understanding of PecFent®.ResultsA total of 35 nurses were interviewed from 7 wards/units. 29% (10/35) chose the correct dose of 200mcg. Commonest reasons for reluctance to titrate the dose up were: “long interval since previous dose” (n=16); and “only had 100mcg doses previously” (n=8). Only 40% enquired about effectiveness of the previous dose. 34% gave a spray effectively (primed device, aiming at nasal septum, no deep inhalation, one nostril/spray). 6% gave the correct dose effectively. 69% of nurses had given PecFent®>10 times previously. 54% rated their confidence as ≤7/10. Only one nurse had received formal training; 80% of nurses had learnt through observing a colleague. 77% wanted further training.ConclusionWe have demonstrated lack of confidence and competence in administering and titrating PecFent®effectively. We are making a training video to cover priming, direction of spay, instructions for breathing, and dispelling the myths about titration.

Background Opioid-induced constipation is common in palliative care. The evidence base for most laxatives and rectal interventions is poor, but for sc methylnaltrexone is good. Patient choice is important for individualising treatment. Aims To identify if patients want to choose their laxative treatment from current options. To identify acceptability of different routes of administration and what factors are important to patients when making a decision. Method Patients were recruited who were on regular opioid and laxative medications, could give informed consent and had sufficient English. Bowel obstruction or stoma were exclusion factors. A piloted structured interview elicited views and experiences. Patients were asked to rank treatment options, with reasons, in a clinical scenario where they had not opened their bowels for 7 days. They were given written information about the three options of oral, rectal and sc injection (methylnaltrexone) with opportunity to ask questions. Results 30 patients (20 male) took part, mean age 61 years (range 29-88). 50% had previously been ≥7 days without a motion. 17/30 (57%) had experience of rectal measures, none of injection. Awareness of treatments was: oral 100%, rectal 70%; injection 7%. 87% of patients would prefer to be offered a choice, but in only 3/67 treatments previously received was choice offered. 4/17 (24%) receiving a rectal intervention had a bad experience and would not consider this again. First choice was injection for 40%, oral 30% and rectal 30%. Rectal route was ranked last choice by 53%, a common reason being embarrassment. Conclusion Palliative care patients are not being offered choice in OIC management. In the absence of evidence-base for oral and rectal measures, patients should have information about methylnaltrexone and be allowed to choose.