title: Triggers in advanced neurological conditions: prediction and management of the terminal phase.
abstract: BACKGROUND
  The challenge to provide a palliative care service for individuals with advanced neurological conditions is compounded by variability in disease trajectories and symptom profiles. The National End of Life Care Programme (2010) recommended seven 'triggers' for a palliative approach to care for patients with advanced neurological conditions.
  
  
  OBJECTIVE
  To establish the frequency of triggers in the palliative phase, and if they could be reduced to fewer components. Management of the terminal phase also was evaluated.
  
  
  METHODS
  Retrospective study of 62 consecutive patients under the care of a specialist palliative neurology service, who had died. Principle component analysis (PCA) was performed to establish the interrelationship between triggers.
  
  
  RESULTS
  Frequency of triggers increased as each patient approached death. PCA found that four symptom components explained 76.8% of the variance. These represented: rapid physical decline; significant complex symptoms, including pain; infection in combination with cognitive impairment; and risk of aspiration. Median follow-up under the palliative care service was 336 days. In 56.5% of patients, the cause of death was pneumonia. The terminal phase was recognised in 72.6%. The duration of the terminal phase was 8.8 days on average, and the Liverpool Care of the dying Pathway was commenced in 33.9%. All carers were offered bereavement support.
  
  
  CONCLUSIONS
  Referral criteria based on the triggers can facilitate appropriate and timely patient access to palliative care. The components deduced through PCA have face validity; however larger studies prospectively validating the triggers are required. Closer scrutiny of the terminal phase is necessary to optimise management.
authors.affiliation: Department of Palliative Care, St. Catherine's Hospice, Scarborough, UK.
authors.forename: Jamilla
authors.initials: J
authors.lastname: Hussain
authors.forename: Debi
authors.initials: D
authors.lastname: Adams
authors.forename: Victoria
authors.initials: V
authors.lastname: Allgar
authors.forename: Colin
authors.initials: C
authors.lastname: Campbell
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000453:epidemiology*; D059408:Pain Management / Q000379:methods*; D010166:Palliative Care / Q000379:methods*; D015985:Precipitating Factors; D025341:Principal Component Analysis; D012189:Retrospective Studies; D012307:Risk Factors; D013727:Terminal Care / Q000379:methods*; D006113:United Kingdom / Q000453:epidemiology; D055815:Young Adult
keywords: End-of-life; Neurological conditions; Prognosis; Terminal care