A survey of smoking in WELSH palliaTIve care units Nicotine addiction in palliative care inpatients A survey of smoking in WELSH palliaTIve care units Dr Rhian Davies Dr Fiona Rawlinson Y Bwthyn Newydd, Bridgend

Introduction Background on smoking law Results of a survey on smoking Exploring issues related to palliative care

Background - smoking 21% of the population aged over 16 in GB are smokers Only 66% of smokers want to give up – so 33% wish to continue smoking 17% of smokers light up within 5 minutes of waking http://www.statistics.gov.uk/cci/nugget.asp?id=313 http://students.umf.maine.edu/~swandm/smokingEPA_468x316.jpg Source: Office for national statistics. Smoking. Pub 11 March 09. <http://www.statistics.gov.uk/cci/nugget.asp?id=313>

“The smoking ban” Smoke-free legislation came into force in Wales on 2nd April 2007, ending smoking in enclosed and substantially enclosed public places On July 1st 2007, England also introduced a new law.

Smoke-free legislation “In certain types of accommodation, a balance is needed between allowing people to smoke in their own residential spaces, and protecting others - including other residents and staff - from exposure to second-hand smoke” ‘Designated rooms’ will be permitted in the following premises in Wales: Care homes A hospice for adults A mental health unit

Provision for smoking No legal obligation for care homes, hospices or mental health units to offer designated smoking rooms if they do not wish to do so. Smoking room: Designated in writing by the person in charge of the establishment as a room in which smoking is permitted Clearly marked as a smoking room. Other guidance also on room specifications

Survey Aim To assess the provisions made for smoking in patients with terminal illness in the last stages of life. Method A telephone-based survey Conducted in September 2009 15 adult inpatient palliative care units in Wales.

Questions asked Are there formal provisions for smoking? Any informal provisions? Where do patients go to smoke? (incl. informally) Has smoking been an issue?

Results 15 units surveyed: 6 had formal provisions for smoking 7 had no formal provisions 2 gave no response

Results: Where patients smoke Units with formal provisions: 1 had a sheltered outside area for smoking 5 had a smoking room Units without formal provisions: In 6 units, patients ‘unofficially’ smoked on site 1 gave no response

Results: Is smoking an issue? Yes: 4 No: 8 Of which: 6 had formal provision 1 had an unofficial arrangement which worked well 1 said nicotine replacement meant it wasn’t an issue No answer: 3

Results: Is smoking an issue? Issues: Relatives smoking on the ward Staff having to “turn a blind eye” Immobile patients that can’t go outside unaided Patients who can’t make it to smoke outside smoking on the ward

Discussion Questions that need to be addressed: Is it fair expecting staff to ‘turn a blind eye’? If at discretion of trust why varying provision within trusts? Nicotine replacement; but is this really the issue? The ‘act of smoking’ - a distraction at time of distress?

Nicotine withdrawal symptoms An intense craving for nicotine Aim is symptom control in terminal illness Not secondary prevention of other diseases DSM IV criteria: Nicotine withdrawal Dysphoric/depressed mood Insomnia Irritability, frustration or anger Anxiety Difficulty concentrating Restlessness Decreased heart rate Increased appetite or weight gain Source: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM)

How the WHO defines our role

“freedom to determine one’s own actions and behaviour” Autonomy “freedom to determine one’s own actions and behaviour”

Conclusion Attempts should be made to minimise distress and discomfort in last stages of life Take smoking into account Issues that need addressing Consider the need for uniformity Consider the need for formal provisions