2019; Volume 20, No 10, October
Lessons from the Literature
Under My Microscope
Dr. Tania Pastrana
IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.
Methotrimeprazine versus haloperidol in palliative care patients with cancer-related nausea: a randomized, double-blind controlled trial
Hardy, J. R., Skerman, H., Philip, J., Good, P., Currow, D. C., Mitchell, G., & Yates, P. Methotrimeprazine versus haloperidol in palliative care patients with cancer-related nausea: a randomized, double-blind controlled trial. BMJ Open 2019; 9(9), e029942.
DOI: 10.1136/bmjopen-2019-029942.
Nausea is a common and distressing symptom affecting patients with advanced cancer that has a negative impact in the quality of life. Although the “emetic pathway” and multiple etiology have been described, and the arsenal of antiemetic medication has grown in the last years, the evidence is still weak. In the everyday praxis, the management of nausea continues to be a challenge.
Yate and collaborators compared two frequently used medications: methotrimeprazine (also known as levomepromazine) (6.25 mg) versus haloperidol (1.5 mg) in a double-blind controlled trial by 116 cancer patients in 11 sites with nauseas that are not therapy-induced.
No difference in the response rate between methotrimeprazine and haloperidol was found for the control of nausea in this setting. Furthermore, it is suggested that “newer, and often more expensive agents unlicensed for this indication (such as ondansetron, olanzapine, and methotrimeprazine) should only be used as second-line” treatment.
Additionally, I want to highlight the multisite effectiveness for the recruitment of patients for randomized controlled studies in palliative care.
Objectives: Methotrimeprazine is commonly used for the management of nausea but never tested formally against other drugs used in this setting. The aim was to demonstrate superior antiemetic efficacy.
Design: Double-blind, randomized, controlled trial of methotrimeprazine versus haloperidol.
Setting: 11 palliative care sites in Australia.
Participants: Participants were >18 years and had cancer, an average nausea score of ≥3/10 and were able to tolerate oral medications. Ineligible patients had acute nausea related to treatment, nausea for which a specific antiemetic was indicated, were about to undergo a procedure or had received either of the study drugs or a change in glucocorticoid dose within the previous 48 hours.
Interventions: Based on previous studies, haloperidol was used as the control. Participants were randomised to encapsulated methotrimeprazine 6.25mg or haloperidol 1.5mg one time or two times per day and were assessed every 24 hours for 72 hours. Main outcome measures: A ≥two-point reduction in nausea score at 72 hours from baseline. Secondary outcome measures: Complete response at 72 hours (end nausea score less than 3), response at 24 and 48 hours, vomiting episodes, use of rescue antiemetics, harms and global impression of change.
Results: Response to treatment at 72 hours was 75% (44/59) in the haloperidol (H) arm and 63% (36/57) in the methotrimeprazine (M) arm with no difference between groups (intention-to-treat analysis). Complete response rates were 56% (H) and 51% (M). In the per protocol analysis, there was no difference in response rates: 85% (44/52) (H) and 74% (36/49) (M). Complete per protocol response rates were 64% (H) and 59% (M). Toxicity worse than baseline was minimal with a trend toward greater sedation in the methotrimeprazine arm.
Conclusion: This study did not demonstrate any difference in response rate between methotrimeprazine and haloperidol in the control of nausea.
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Media Watch: Long-Term Care
Older persons living in long-term care facilities have palliative care needs, but it is only in recent years that the quality of end-of-life care in these settings has gained what might be termed “serious” attention. These articles on long-term care were selected from Barry R. Ashpole’s weekly report, Media Watch.
End of life care for long-term care residents with dementia, chronic illness and cancer: Prospective staff survey
BMC Geriatrics | Online – 22 May 2019 – This study found that New Zealand ranks highly in overall long-term care (LTC) and end-of-life care (EoLC) in comparison to other countries. The authors also found that symptom management needs in the last week of life do not vary by diagnosis overall, although sub-group analysis found that residents with dementia and chronic illness experience higher physical distress over a longer period of time before death than residents with cancer. Residents with advanced physical and cognitive frailty often require LTC for complex geriatric issues, which need to be integrated with palliative care (PC) principles in the months and possibly years before they die. It is essential that those working in LTC facilities recognize PC philosophy and practice as an integral part of their work, and that the model of care acknowledges the demands associated with LTC and EoLC. It is also crucial that specialist PC providers work collaboratively with, and become more skilled in, gerontology and complex geriatric syndromes.
An instrument to assess the education needs of nursing assistants within a palliative approach in residential aged care facilities
BMC Palliative care | Online – 23 July 2019 – Providing quality palliative care (PC) in residential aged care facilities is a high priority for ageing populations worldwide. Nursing assistants (NAs) – however termed – are the least qualified staff and provide most of the direct care. They have an important role at the frontline of care, spending more time with residents than any other care provider, but have been found to lack the necessary knowledge and skills to provide PC. The level of competence of this workforce to provide PC requires evaluation using a valid and reliable instrument designed for their level of education and the responsibilities and practices of their role. This study provides preliminary evidence for the validity and reliability of three new questionnaires that demonstrate sensitivity for NAs’ level of education and required knowledge, skills, and attitudes for providing a palliative approach. Implications for practice include the development of PC competencies through structured education and training across this workforce, and ongoing professional development opportunities for NAs, especially for those with the longest tenure.
Integrated palliative care for nursing home residents: Exploring the challenges in the collaboration between nursing homes, home care and hospitals
International Journal of Integrated Care | Online – 3 April 2019 – In several countries and health domains, governments aim to integrate the provision of care by creating care networks. Based on this study, the following policy recommendations can be made. First of all, the implementation of a care network does not guarantee successful collaboration between care organizations. In this mixed-method study, the coordinators of palliative care (PC) networks identify the need to formalize the interaction between various health care organizations with regard to PC, the establishment of formal channels of communication and information exchange, as well as the development of shared leadership. Secondly, when designing care networks, leadership positions should be taken into consideration. Given the difficulties network coordinators encounter with shared leadership, interpersonal skills training could be of benefit to their professional development. Also, incentives could be put forward to motivate key persons to attend meetings. Research needs to contribute more to the current understanding of how leadership is “made to happen.”
Media Watch, published by Barry R. Ashpole, a Canadian communications consultant and educator, monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.