Death rattle: reassuring harbinger of imminent death or a perfect example of inadequacies in evidence-based practice Purpose of review Death is the inevitable consequence of life. Although clinicians are unlikely to accurately pinpoint when death is likely to occur in the people they care for, the death in a person with a diagnosis of malignant and nonmalignant tends to involve a period of predictable progressive clinical and functional deterioration. During this time, it is common for death rattle to occur. Due to its presentation, death rattle can cause stress and distress to caregivers. This often prompts clinicians to consider medical interventions that are not only ineffective in treating the problem but may also do harm. Recent findings There is a dearth of research related to the management of death rattle. Summary The article discusses the existing evidence in the management of death rattle, considerations for clinicians in the absence of reliable evidence and suggests areas for future research. Correspondence to Prof Bridget Johnston, School of Medicine, Dentistry & Nursing, and NHS Greater Glasgow and Clyde, College of Medical, Veterinary & Life Sciences, University of Glasgow, 57-61 Oakfield Avenue, Glasgow G12 8LL, UK. Tel: +44 0 141 330 3691; e-mail: Bridget.Johnston@glasgow.ac.uk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Endocrinopathies and cancer cachexia Purpose of review Cancer cachexia cannot be easily reversed by standard nutritional support and interventions directed at underlying metabolic derangements may be needed to prevent or reverse cachexia and maintain healthy body composition. The following review will highlight the contribution and potential therapeutic interventions for insulin resistance, alterations in ghrelin signaling, and hypogonadism in cancer patients. Recent findings In addition to decreased caloric intake, chronic inflammation, and altered metabolism of glucose, proteins and lipids, endocrine abnormalities can propagate weight loss or changes in body composition in cancer patients. Summary Cancer cachexia, loss of muscle mass with or without the loss of fat mass, is a multifactorial syndrome, which is associated with increased morbidity and mortality. Currently, limited therapeutic options for the treatment of weight loss in cancer patients exist, which lead to clinically meaningful improvements in weight gain and performance status. Treatment directed at underlying insulin resistance, low testosterone, and altered ghrelin sensitivity, in the future, may lead to potential therapeutic options for loss of lean body mass and cancer cachexia. Correspondence to Rony Dev, Symptom Control & Palliative Medicine, University of Texas MD Anderson Cancer Center, Texas, 77030, USA. Tel: +1 713 792 1173; fax: +1 713 792 6092; e-mail: rdev@mdanderson.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Measuring the success of interventions for caregivers: a focussed systematic review Purpose of review The selection and application of outcome measures are fundamental steps in the research process because they inform decisions around intervention efficacy. We aimed to describe the outcomes used in trials of supportive interventions for adult caregivers of people with three exemplar life-limiting conditions: heart failure, dementia or stroke. Recent findings We performed a focussed review of 134 published trials that included interventions designed to improve caregivers’ health and wellbeing and/or ability to function in their caring role. We extracted and categorized all caregiver outcomes described in the studies. We identified inconsistency in the outcomes measured; frequent use of bespoke and adapted tools (29% of outcomes were bespoke), and a lack of clarity in outcome priorities (the mean number of outcomes per trial was four [range: 1–11]). Outcome scales that purport to measure the psychological impact of the caring role were the most popular tools in all three caregiver groups. Summary Outcomes used in trials related to adult caregivers are characterized by inconsistencies in outcome measure selection and assessment. This heterogeneity complicates comparisons of treatments and attempts to pool data. Correspondence to Maria Drummond, School of Medicine, Dentistry & Nursing, University of Glasgow, 57-61 Oakfield Avenue, Glasgow G12 8LL, Scotland, UK. Tel: +44 791 298 1031; e-mail: m.drummond.1@research.gla.ac.uk Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.supportiveandpalliativecare.com). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The value of the ethnographic approach to research issues in palliative care Purpose of review Qualitative research in the field of palliative care allows for a crucial study of the final stage of life from a social point of view and cultural perspective. This review evaluates the advantages and challenges of applying an ethnographic approach to palliative care research. Recent findings Thirteen ethnographic articles on the subject of organization or quality of care, decision-making, delirium, death, and the process of dying, were reviewed. Most studies use interviews, participant observation, and field notes as their primary data collection techniques. In ethnographic research, cultural issues, relationships and interactions of a group, the meanings and perceptions of the participants, the communication process, and the use of language in a particular and natural context were analyzed. Data collection and information analysis took an average of 14 months in the included studies. Summary The ethnographic method, applied with rigor, is valuable in the analysis of a real phenomenon if the particular context in which the study developed is well defined. With an ethnographic approach, researchers can uncover cultural nuances that evidence different realities. Correspondence to Carla Reigada, PhD, Universidad de Navarra, Instituto Cultura y Sociedad, ATLANTES, Campus Universitario, Pamplona 31009, España. E-mail: creigada@unav.es Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Dealing with prognostic uncertainty: the role of prognostic models and websites for patients with advanced cancer Purpose of review To provide an updated overview of prognostic models in advanced cancer and highlight the role of prognostic calculators. Recent findings In the advanced cancer setting, many important healthcare decisions are driven by a patient's prognosis. However, there is much uncertainty in formulating prognosis, particularly in the era of novel cancer therapeutics. Multiple prognostic models have been validated for patients seen by palliative care and have a life expectancy of a few months or less, such as the Palliative Performance Scale, Palliative Prognostic Score, Palliative Prognostic Index, Objective Prognostic Score, and Prognosis in Palliative Care Study Predictor. However, these models are seldom used in clinical practice because of challenges related to limited accuracy when applied individually and difficulties with model selection, computation, and interpretation. Online prognostic calculators emerge as tools to facilitate knowledge translation by overcoming the above challenges. For example, www.predictsurvival.com provides the output for seven prognostic indexes simultaneously based on 11 variables. Summary Prognostic models and prognostic websites are currently available to augment prognostication in the advanced cancer setting. Further studies are needed to examine their impact on prognostic accuracy, confidence, and clinical outcomes. Correspondence to David Hui, MD, MSc, Department of Palliative Care, Rehabilitation and Integrative Medicine, Unit 1414, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA. Tel: +1 713 792 6258; fax: +1 713 792 6092; e-mail: dhui@mdanderson.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

What information and resources do carers require pre and post bereavement in the acute hospital setting? A rapid review Purpose of review: This mixed-method, rapid review of published research from 2014 to 2019 aims to explore the experiences of pre and postbereaved carers, and the information that they receive in the acute hospital setting. The quality of articles was evaluated using a standardized quality matrix. The techniques of conceptual analysis and idea mapping were used to create a structured synthesis of the findings. Recent findings: From the initial search of 432 articles, ten studies met the inclusion criteria for this review. These studies generated data from 42 patients, 1968 family/carers and 139 healthcare staff. Themes that were generated from a synthesis of the included articles were clear and timely communication, workforce provision and environment. Summary: This review has highlighted the need for improvements in information provision for carers as part of end of life care. Furthermore, the need for specific staff education and training to enable staff to confidently communicate with dying patients and their relatives in the acute setting is also warranted. Understanding and addressing gaps in knowledge and practice are essential to develop strategies in this complex area. Simple strategies can be implemented to improve the care of carers both pre and post bereavement in acute care. Correspondence to Professor Bridget Johnston, School of Medicine, Dentistry & Nursing, and NHS Greater Glasgow and Clyde College of Medical, Veterinary & Life Sciences, University of Glasgow, 57-61 Oakfield Avenue, Glasgow G12 8LL, Scotland, UK. E-mail: Bridget.Johnston@glasgow.ac.uk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Evaluating the effects of the pharmacological and nonpharmacological interventions to manage delirium symptoms in palliative care patients: systematic review Purpose of review There is a high prevalence of delirium in palliative care patients. This review aims to evaluate the effects of the pharmacological and nonpharmacological interventions used to manage delirium symptoms in this patient group. Recent findings A recent study has suggested there is no role for antipsychotic medication in the management of delirium in palliative care patients, which is a move away from previous expert opinion. In addition, recent findings suggest there may be a role for the use of antipsychotics in combination with benzodiazepines in the management of agitated delirium. Summary It is too early to abandon the use of antipsychotic medication entirely in the management of delirium, however there remains inadequate evidence to support the routine use of either pharmacological or nonpharmacological interventions for delirium treatment. Clinicians should determine the delirium subtype and severity, using this to inform the most appropriate pharmacological treatment if required. Further rigorously designed research is needed to seek clarity over whether the alleviation of symptoms is dose dependent, and to determine whether there is a severity threshold over which pharmacological interventions are most effective. Future research is required to evaluate nonpharmacological interventions in this population. Correspondence to Dr Luke Skelton, Psychiatry Registrar, John Dickson Ward, South London and the Maudsley NHS Trust, London, United Kingdom. E-mail: Luke.skelton@slam.nhs.uk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Cardiac cachexia: the mandate to increase clinician awareness Purpose of review Heart failure is a frequent problem in an ageing population, associated with high rates of morbidity and mortality. Today, it is important to not only treat heart failure itself but also the related comorbidities. Among them, cardiac cachexia is one of the major challenges. It is a complex multifactorial disease with a negative impact on quality of life and prognosis. Therefore, prevention, early recognition and treatment of cardiac cachexia is essential. Recent findings Cardiac cachexia frequently presents with skeletal as well as heart muscle depletion. Imaging-based diagnostic techniques can help to identify patients with cardiac cachexia and muscle wasting. Several blood biomarkers are available to detect metabolic changes in cardiac cachexia. Summary Several studies are currently ongoing to better comprehend the underlying pathophysiological mechanisms of cardiac cachexia and to find new treatments. It is essential to diagnose it as early as possible to initiate therapy. Correspondence to Markus S. Anker, MD, Department of Cardiology, Campus Benjamin Franklin (CBF), Charité University Medicine, Berlin, Germany. E-mail: markus.anker@charite.de Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

From cachexia to obesity: the role of host metabolism in cancer immunotherapy Purpose of review Currently, several clinical trials in cancer therapy have demonstrated the success of immunomodulatory therapies. However, only a variable fraction of patients actually benefit from these treatments. The understanding of key mechanisms behind this response heterogeneity is one of the major unmet need and intense research field in immuno-oncology. This review will discuss the host metabolic dysfunctions derived from cachexia or obesity that can affect the response to cancer immunotherapy. Recent findings Preclinical studies demonstrated that chronic inflammation, nutritional intake impairment and endocrine dysfunction may affect anticancer innate and adaptive immunity, both in cachexia and obesity. New emerging clinical findings have highlighted the impact of metabolic biomarkers in predicting response to immune checkpoint inhibitors in cancer patients. Summary Patient's weight and inflammatory status could be relevant in the clinical decision-making process before starting cancer immunotherapy and for an effective patient selection and stratification in future clinical trials employing this class of anticancer agents. Correspondence to Davide Brocco, Medical Oncology Unit, SS Annunziata Hospital, Chieti, Italy. Tel: +39 3291967107; e-mail: davide.brocco1@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Cancer cachexia and treatment toxicity Purpose of review Cancer cachexia is a metabolic disturbance resulting in a loss of skeletal muscle mass that is generally not reversed through traditional nutritional interventions. We review on both the impact of nutritional status on cancer treatment side effects, as well as cancer- specific outcomes. Recent findings Cancer-specific cachexia and sarcopenia are associated with increased treatment-associated toxicity, and overall worse cancer-specific outcomes across all cancer types in surgical, chemotherapeutic, and radiotherapeutic populations. Despite the fact that cancer cachexia is generally thought to be irreversible, there is some evidence that nutritional intervention can be helpful. Summary Nutritional status is an important factor to consider in determining cancer therapy. Patients with poor nutritional status should be identified prior to the initiation of therapy and be monitored judiciously. Correspondence to Varun Kumar Chowdhry, MD, Assistant Professor of Oncology, Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, USA. Tel: +1 716 845 3173; fax: +1 716 845 3549; e-mail: Varun.Chowdhry@RoswellPark.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.