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Evaluation of palliative care

EDrroR,-In response to the paper by Ian R McWhinney and colleagues' we wish to report our experience of recruitment into trials in the palliative care setting. The trials were not of a palliative care service but of palliative therapeutic interventions in a specialist cancer hospital. These included randomised studies of pharmacological and non-pharmacological strategies in the management of bowel obstruction, hypercalcaemia, nausea induced by opiates, anorexia, pain, and dyspnoea as well as non-randomised studies in patients in pain. In the 12 months to October 1994, 344 patients were referred to one of two research sisters in palliative care as being suitable for entry to one of the above studies. Both inpatients and outpatients were referred by medical and nursing staff throughout the hospital. Of the 344 patients, 109 were not approached as they did not fulfil the criteria for inclusion in the studies. Thus after full discussion regarding the implications of entering the trial 235 patients were asked if they would agree to participate in one of the studies. Only 142 patients gave informed consent. The remainder were not entered into the studies because they were too unwell or their condition had deteriorated (27), they were eligible but declined to consent (38), they lived too far away from the hospital (16), or for unknown reasons (12). Thus 41% of the patients initially referred and 60% of the patients who were approached were entered into studies. These figures are low but are likely to be higher than those achieved in other palliative care settings since the patients were recruited in a specialist cancer hospital with a high research profile, where the role of the research sister is well established. We agree with Henry McQuay and Andrew Moore that palliative care should not be excused from conducting randomised controlled trials simply because they are difficult to do,2 but our recruitment data show several of the inherent difficulties.