Introduction - Fiona Graham
Background
The subcutaneous route is the parenteral route of choice in symptom management in palliative care when oral medication is impossible. In UK practice, this means continuous subcutaneous infusion (CSCI) administered via a syringe driver, but internationally a range of devices and approaches is employed.
Aim
To investigate, via a pilot study, the use of the subcutaneous route in palliative care in contrasting international settings to gain insight into its most effective use from a variety of perspectives.
Method
Semi-structured recorded interviews with seven physicians practising palliative care in six countries (Argentina, Australia, India, Nigeria, Romania, Spain).
Analysis
Full transcriptions were subject to a constant comparative method analysis based on grounded theory approaches.
Results
The subcutaneous route was considered valuable in all settings. Various devices, including the syringe driver, were employed to deliver CSCI particularly with inpatients. Intermittent subcutaneous injections, however, were often cited as an effective, often preferable, alternative for both clinical and social reasons including cost, increased patient contact and family carer empowerment.
Conclusion
The subcutaneous route is useful in symptom management in palliative care. Many approaches are employed, with intermittent subcutaneous injections often considered preferable even in settings with the resources available to undertake CSCI. This challenges accepted practice in some settings, notably the UK, and raises more general questions about clinical ‘norms’ and the role of the evidence base. These issues will be explored in more detail in a doctoral research project comprising a systematic review of the literature and further interviews with practitioners internationally. Beyond this study, further investigation of the comparative effectiveness of intermittent subcutaneous injections compared to CSCI is essential to inform the debate on the most effective use of the subcutaneous route in palliative care.
