Purpose: Cancer-related fatigue in adults has been the subject of considerable recent research, confirming its importance as a common and debilitating symptom, and establishing a number of evidence-based interventions. There has, however, been limited focus on the fatigue suffered by teenagers and young adults with cancer, a group recognized as having unique experiences and developmental needs. We have undertaken a systematic review of the literature to provide a comprehensive overview of studies evaluating fatigue in this younger patient group in order to guide clinical practice and future research. Method: We searched MEDLINE, EMBASE, PsycINFO, and CINAHL databases for literature containing data relating to any aspect of fatigue in patients aged 13-24 at cancer diagnosis or treatment. Results: Sixty articles were identified, of which five described interventional clinical trials. Cancer-related fatigue was consistently one of the most prevalent, severe, and distressing symptoms, and it persisted long-term in survivors. It was associated with a number of factors, including poor sleep, depression, and chemotherapy. There was little evidence for the effectiveness of any intervention, although exercise appears to be the most promising. Importantly, fatigue was itself a significant barrier to physical and social activities. Conclusion: Cancer-related fatigue is a major and disabling problem in young cancer patients. Effective management strategies are needed to avoid compounding the dependence and social isolation of this vulnerable patient group. Future research should focus on providing evidence for the effectiveness of interventions, of which activity promotion and management of concurrent symptoms are the most promising.

Background Making Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and treatment escalation decisions facilitate a dignified death for patients in acute hospital settings, but not all doctors find it easy to have the necessary discussions with patients. 1 The GMC's "Tomorrow's Doctors" requires that medical schools adequately prepare trainees to "contribute to the care of patients and their families at the end of life". 2 We conducted a survey of the experience of junior doctors in UHBristol NHS Trust. Method An online questionnaire was sent to all junior doctors. Respondents were asked to rate their confidence when discussing DNACPR decisions with patients and their families, what training they had received and whether or not they felt their undergraduate training had adequately prepared them for these conversations. A comments space was provided. Results We received 84 responses. 68% of juniors felt confident when discussing DNACPR decisions with patients and families. However 15% did not. Only 5% felt they had been well prepared by undergraduate teaching. 40% felt they could have been better prepared and 22% felt very unprepared. 50% reported learning by observing senior colleagues in the clinical environment. There were mixed comments regarding which grade was the most appropriately placed doctor to have these discussions with patients; some believed only a consultant should, but others stated junior doctors were usually first to recognise the need for escalation decisions. Several commented that they had learnt by observing seniors conducting these consultations but noted they were not always done well. Some thought practicing in the clinical environment (trial and error) was the best way to improve their communication skills. Conclusion Acute hospitals cannot assume their junior doctors feel prepared to discuss DNACPR decisions with patients. Formal teaching opportunities should be provided to supplement the observation of seniors, the current mainstay of their learning.

Background NICE guidelines stress the importance of individualised anticipatory prescribing for people who are likely to need symptom control in the last days of life. A Community Palliative Care Drug Chart for the authorisation of individualised subcutaneous palliative care medication via injection or syringe pump was developed and introduced by a regional anticipatory prescribing working party. The chart does not use a proforma approach, which has been linked to over medication, but does incorporate guidance and is designed to cross settings. Aim . To evaluate whether the chart and guidance facilitates safe, appropriate and consistent anticipatory prescribing for patients 1 year after introduction. . To identify any required chart adaptations and areas for education.Methods The notes of 49 expected deaths from District Nurse caseloads were examined for the presence of a chart. 32 charts were reviewed to establish whether anticipatory prescribing complied with local guidelines and to record any themes from non-compliance. A survey of 20 local GPs was conducted.Results 47 of the 49 expected deaths had a chart in place. For as required medication the percentage meeting the standards for choice of drug, dose and route were as follows: opioid (84%), antiemetic (97%), antisecretory (94%) and anxiolytic (94%). In 7 cases the range for opioid or midazolam in a syringe pump was greater than advised in guidelines. All GPs surveyed agreed that the chart facilitates safe and appropriate anticipatory prescribing. Conclusion The chart and guidance facilitate safe, appropriate and consistent anticipatory prescribing for patients, resulting in improved compliance with standards when compared to a local audit from 2010. Changes to the chart and further education is needed in relation to syringe pump ranges and timing of authorisation. We have subsequently developed a new 'intelligent' protocol within the EMIS GP record to further enhance individualised anticipatory prescribing.

No abstract