118 Journal of Pain and Symptom Management Vol. 50 No.

1 July 2015

Brief Report

Quality of Life, Pain Perception, and Distress Correlated

to Ultrasound-Guided Peripherally Inserted Central Venous Catheters
in Palliative Care Patients in a Home or Hospice Setting
Roberto Bortolussi, MD, Paola Zotti, PhD, Maria Conte, MD, Rita Marson, RN, Jerry Polesel, ScD,
Annamaria Colussi, RN, Donatella Piazza, RN, Gianna Tabaro, BSc, and Simon Spazzapan, MD
Palliative Care and Pain Therapy Unit (R.B.), Psycho-Oncology Unit (P.Z.), Epidemiology and Biostatistics Department (J.P.), and Clinical
Trials Office (A.C., G.T., S.S.), CRO Aviano National Cancer Institute, Aviano; Hospice ‘‘Il Gabbiano’’ (M.C., D.P.), San Vito al
Tagliamento; and Hospice Via di Natale ‘‘Franco Gallini’’ (R.M., S.S.), Aviano, Italy

Abstract
Context. Intravenous fluid administration with peripherally inserted central venous catheters (PICCs) and midline
catheters in palliative care.
Objectives. To evaluate distress and pain perceived by patients during the positioning of a PICC or midline catheter, both
in the home and hospice settings.
Methods. This was a prospective observational study performed by the Palliative Care Network of Pordenone. In addition
to evaluating distress and pain, we monitored patient quality of life and the devices used. Quality of life was measured with the
European Organization for Research and Treatment of Cancer-Core 15-Palliative scale.
Results. From May 2012 to July 2013, 48 patients were enrolled in the study. The level of distress during the procedure was
null or very low in 95.8% of the patients and completely absent after one week. Pain during insertion was null or very little in
93.8% of the patients and zero after one week in 98% of the patients. Quality of life was significantly improved after one week
for certain specific parameters and also globally. The number of catheter days monitored was 3097. The weekly monitoring of
the devices revealed a series of minor complications. Only two catheters were removed for serious complications.
Conclusion. Our results showed a low impact on pain and distress, a low level of local and systemic complications and a
favorable impact on patients’ quality of life. However, other studies are necessary to evaluate the cost-effectiveness of the use of
these devices and their role in palliative care. J Pain Symptom Manage 2015;50:118e123. Ó 2015 American Academy of Hospice
and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Key Words
Central venous catheters, PICC, palliative care, quality of life

Introduction cancer, as well as myoclonus, hallucinations, fatigue,

and sedation.3 The method of choice for parenteral
The role of artificial nutrition and hydration (ANH)
administration of liquids and drugs in palliative care
in palliative care patients has not clearly been proven.
treatment is often the subcutaneous route because it
Recent revisions of the literature suggest that, even in
is simple to administer, does not cause trauma, and
the absence of strong evidence of benefit for the ma-
has few contraindications; limits include the composi-
jority of patients, in selected cases benefit can be ob-
tion and the volume to be infused. However, there are
tained.1,2 Moreover, a moderate level of hydration
data that indicate that both patients and caregivers
may prevent delirium in patients with advanced
consider intravenous hydration to be more

Address correspondence to: Roberto Bortolussi, MD, Division of Accepted for publication: February 14, 2015.
Anesthesiology, National Cancer Institute, Centro di
Riferimento Oncologico, Via Franco Gallini 2, 33081 Aviano,
Italy. E-mail: rbortolussi@cro.it

Ó 2015 American Academy of Hospice and Palliative Medicine. 0885-3924/$ - see front matter
Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpainsymman.2015.02.027
Vol. 50 No. 1 July 2015 PICC Insertion for Palliative Care in the Home Setting
efficacious.4 A disadvantage of this method is the diffi-
culty in finding venous access, especially in patients
with an advanced stage of disease. However, in the
last few years, peripherally inserted central venous
catheter devices (PICCs) have become available.
Other, shorter midline catheters, which have their
apex in the axillary vein, are even easier to position
and are compatible with isotonic solutions. In prelim-
inary studies, PICCs were considered safe, useful, and
comfortable for terminal cancer patients, with a low
percentage of complications both during placement
and thereafter.5 The gold standard for PICC place-
ment is through an ultrasound-guided technique.
The goal of this study was to evaluate distress and pain
perceived by patients during the positioning of a PICC or
midline catheter, both in the home and hospice settings.
Methods
After approval by the Ethics Committee of the Avia-
no National Cancer Institute, Aviano, Italy, a prospec-
tive, observational study was performed within the
Palliative Care Network of Pordenone between May
2012 and July 2013. This corresponds to a geograph-
ical area with a population of 315,000 and includes a
home care service and two hospices. Each patient
was evaluated for diagnosis, performance status, the
presence or absence of a permanent vascular access,
and the indications for a program of hydration, paren-
teral nutrition, or drug administration via the intrave-
nous route. Informed consent was then obtained, and
patients were assessed for feasibility by a palliative care
physician expert in the methodology of the proce-
dure. For patients who needed a PICC, chest radiog-
raphy or an intracavitary electrocardiogram control
was subsequently performed to confirm the correct
positioning of the catheter tip.
The primary objectives of the study were 1) to eval-
uate the level of distress and pain correlated to the
placement of the catheter via an ultrasound-guided
method and 2) to evaluate the impact of the device
placement on the level of distress and pain and on the
quality of life of the patients one week after placement.
The secondary objectives were 1) to record the time
needed to perform the procedure and 2) to monitor
any complications correlated to the use of PICC.
Patients who satisfied the following eligibility
criteria were consecutively enrolled in the study: 1)
diagnosis of oncologic disease or degenerative non-
oncologic disease who were cared for by the Palliative
Care team; 2) life expectancy of two weeks or more;
3) necessity of a PICC or midline catheter either in
the hospice or home setting; 4) age 18 years or older;
5) adequate cognitive function to be able to
119
understand the procedure and to complete the ques-
tionnaires; and 6) written informed consent.
The day before the procedure, a baseline assessment
of the patient’s quality of life was performed using the
European Organization for Research and Treatment
of Cancer Quality of Life Questionnaire Core-
15-Palliative (EORTC QLQ-C15-PAL),6 and a week later,
the same questionnaire was readministered to the pa-
tient. Within one hour after the procedure, the patient
was asked to rate the level of distress and pain perceived
using a four-point Likert scale (rated as: not at all, a little,
quite a lot, very much). The patient interviews were con-
ducted by one of the clinical nurses of the multidisci-
plinary team, all of whom, in the preliminary phase
before study initiation, received specific training on
how to conduct the interviews by the physician and
the psychologist responsible for the study. All the data
of each case were collected by the same clinical nurse.
The physician who positioned the device completed a
form with the details of the cannulated vein, the type
of device used, and the time spent on performing the
procedure. After seven days, the patient was asked to
self-evaluate, through separate interviews, the level of
distress and pain and quality of life correlated to the pro-
cedure. Each week, the team nurse who changed the ad-
hesive dressing and flushed the catheter, monitored the
state of the skin, the functionality of the venous access,
and any eventual local or systemic complications.
Assessment Tools
Distress and Pain Interviews. To measure the percep-
tion of distress and pain correlated to the application
and use of the intravenous device, two structured
interviews with specific questions were conducted by
a trained clinical nurse, which the patient answered
using a four-point Likert scale.
Quality of Life. The validated Italian version of the
EORTC QLQ-C15-PAL questionnaire was used.6
Answers were given on a four-point Likert scale.
PICC Monitoring Form. This was completed weekly by
a team nurse. It graded the state of the dressing and of
the skin, the catheter position related to the venipunc-
ture site and signaled any consequent systemic infec-
tion correlated to PICC, defined as the presence of
body temperature $39
C during the use of the cath-
eter or of persistent body temperature $38
C in the
absence of other evident sources of infection.
Statistical Analysis
Sample size was estimated using the optimal two-
stage design by the Simon method.7 With an expec-
tancy p1-p0 ¼ 15% between the percentage of
patients who express distress as null or very little in
120 Bortolussi et al. Vol. 50 No. 1 July 2015

the standard positioning (p0 ¼ 75%) and that of the Table 1

ultrasound-guided positioning (p1 ¼ 90%), while Baseline Characteristics of 48 Patients Undergoing
Catheter Positioning
fixing the probability error a ¼ 0.05 and b ¼ 0.20,
the number of patients needed in the first stage was Characteristics n (%)
13. The study would have terminated if, at the first Gender
stage less than 10 patients reported their distress level Men 30 (62.5)
Women 18 (37.5)
as null or very little. None of these patients reported Age (yrs)
pain or distress. The study then proceeded until 48 pa- <65 9 (18.8)
tients were enrolled. To evaluate the impact of PICC 65e74 21 (43.8)
$75 18 (37.5)
positioning on quality of life after one week using Disease
the EORTC QLQ-C15-PAL, the different scales of Pancreatic cancer 8 (16.7)
the questionnaire were analyzed using the procedure Stomach cancer 8 (16.7)
Other miscellaneous cancer 30 (62.5)
recommended by EORTC. The rough score was trans- Non-neoplastic diseases 2 (4.2)
formed to a linear scale from 0 to 100. For each scale, Performance status (Karnofsky)
the impact of PICC positioning was evaluated in terms 30 5 (10.4)
40 17 (35.4)
of the difference in the scores before and after the 50 12 (25.0)
positioning of the device via the t-test for coupled sam- 60 14 (30.2)
ples (two-tailed). Type of device
PICC 13 (27.1)
Midline catheter 35 (72.9)
Palliative care setting
Home 33 (68.8)
Results Hospice 15 (31.3)

Between May 2012 and July 2013, 371 new consecu- PICC ¼ peripherally inserted central venous catheter.

tive patients were assessed for enrollment in the study.

Of these, 48 (12.9%) fulfilled the eligibility criteria days) for a total of 3097 catheter days. On the date
and gave their informed consent to participate in of study closure (September 30, 2013), seven patients
the study. Fifty other patients who underwent were still alive (two PICCs and five midline catheters).
ultrasound-guided PICC or midline catheter place- Complications observed during the weekly follow-
ment were excluded because they did not meet all up after device placement were
the inclusion criteria. Among the 48 enrolled patients,
the success rate of the procedure was 100%. Among 1) Secretion of blood serum from the catheter inser-
the patients who were not enrolled, seven PICCs and tion point: one PICC at Day 7; one PICC-midline
42 midline catheters were successfully positioned. In at Day 10;
only one patient did the procedure fail and was not
repeated (99.01% success rate). 2) Inflammation (reddening without secretion of
The indications for positioning the PICCs were serum or pus) at the catheter insertion point:
hydration and/or parenteral nutrition in 37 cases, two midline catheters at Day 8 and at 6.5 months;
drug infusion in 38 cases, and blood sampling in 13
cases. The characteristics of the 48 patients who were 3) Skin reaction to the stat-lock adhesive dressing:
enrolled in the study are described in Table 1. Fifteen one PICC-midline at 71 days;
catheters (31.3%) were inserted in a hospice, and the
remaining 33 (68.8%) in the home setting. The posi- 4) Catheter displacement: one PICC-midline at
tion of the atriocaval junction of the apex of PICC three months.
was controlled in one case via an intracavitary electro-
cardiogram, whereas in all the other cases, a chest Table 2
X-ray was performed. The time needed to insert Characteristics of Positioning According to Device
PICC, measured from the preparation of the sterilized PICC Midline Catheter All
operative area until the application of the stat-lock Characteristics n (%) n (%) n (%)
dressing, was between 13 and 22 minutes (median
Duration (min)
time 16 minutes). Less time was needed to position Median (min-max) 16 (13e22) 11 (8e33) 12 (8e33)
the midline catheters (range 8e33 minutes; median Vein
11 minutes). No differences in time were seen in rela- Basilic 12 (92.3) 30 (85.7) 42 (87.5)
Brachial 1 (7.7) 5 (14.3) 6 (12.5)
tion to hospice vs. home setting (Table 2). The num- Cephalic 0 (0.0) 0 (0.0) 0 (0.0)
ber of days of catheter permanence for PICCs was Side
13e462 days (median 102 days), whereas that of the Right 10 (76.9) 18 (51.4) 28 (58.3)
Left 3 (23.1) 17 (48.6) 20 (41.7)
midline catheters was 8e231 days (median 50.5
Vol. 50 No. 1 July 2015 PICC Insertion for Palliative Care in the Home Setting 121

Table 3 The patients’ levels of distress and pain during the

Perception of Distress and Pain During PICC Positioning procedure and at follow-up after one week are
and at Follow-Up
described in Table 3. Most patients (95.8%) reported
Questionnaire Items n % (95% CI) no or very little distress during the procedure, whereas
Was the PICC positioning a distressing experience? after one week the level of distress was none or very lit-
No 40 83.3 (72.8e93.9) tle in 100% of the patients. Pain perceived during the
A little 6 12.5 (3.1e21.9)
Quite a lot 1 2.1 (0.0e6.1) procedure was zero or very little in 93.8% of the
Very much 1 2.1 (0.0e6.1) patients and zero or very little in 98% of the patients
Did you experience pain during PICC positioning? at the one-week follow-up.
No 37 77.1 (65.2e89.0)
A little 8 16.7 (6.1e27.2) The results of the EORTC QLQ-C15-PAL functional
Quite a lot 3 6.3 (0.0e13.1) and symptom scales are described in Table 4. A signif-
Very much 0 0.0 (d) icant improvement of the global quality of life was
Distress at follow-up
No 41 85.4 (75.4e95.4) reported. The functional scales showed an improve-
A little 7 14.6 (4.6e24.6) ment in physical functioning but a worsening of the
Quite a lot 0 0.0 (d) emotional state of the patients, but without any statis-
Very much 0 0.0 (d)
Pain at follow-up tical significance. An improvement in all the physical
No 45 93.8 (86.9e100) symptoms was seen but was statistically significant
A little 2 4.2 (0.0e9.8) only for nausea. No significant results were revealed
Quite a lot 1 2.1 (0.0e6.1)
Very much 0 0.0 (d) in global quality of life, symptoms, and function in cor-
relation to sex, age, home or hospice setting, and type
of device used (Table 5).

All the above complications were resolved and

allowed the subsequent normal use of the catheter.
5) Correlated systemic infections: a suspected infec-
tion of one PICC at Day 19, treated systemically
and resolved; the same patient presented signs
of another suspected infection at Day 188, and
blood cultures revealed a contamination by Serra-
tia marcencens and Candida parapsilosis. PICC was
subsequently removed and not replaced;
6) Catheter obstruction of one midline catheter at
102 days, which was resolved and then
re-occurred on Day 139 in the same patient; the
catheter was removed and subsequently replaced.
Discussion
To our knowledge, this is the only study that has
investigated the impact of PICCs in a palliative care pa-
tient population since the study of Yamada.5 The deci-
sion to initiate a program of ANH within a palliative
care program is one that needs to be carefully dis-
cussed by the multidisciplinary team, especially
because of the lack of clear evidence on the efficacy
of this type of treatment. Over the years, a series of
guidelines have been produced that may be of help
to the team when deciding what is best for the
patient.8,9 A recent review on the attitudes toward
ANH at the end of life reported that one-third of pub-
lic opinion considers that this increases the patients’

Table 4
EORTC QLQ-C15-PAL Functional and Symptom Scales at PICC Positioning (T0) and After One Week (T1)
Mean Scale Value
Difference
Scales (range) n T0 T1 T1eT0 Pa

Global health status (0e100) 44 29.92 41.29 þ11.36 0.02

Functional scales
Physical functioning (3e12) 46 8.39 8.85 þ0.46 0.24
Emotional functioning (2e8) 46 4.46 4.15 0.30 0.21
Symptom scales
Fatigue (2e8) 46 6.26 5.85 0.41 0.10
Nausea (1e4) 47 1.87 1.45 0.43 <0.01
Pain (2e8) 46 6.26 5.85 0.41 0.10
Dyspnea (1e4) 44 1.95 1.84 0.11 0.40
Insomnia (1e4) 46 2.37 2.09 0.28 0.12
Appetite loss (1e4) 45 2.67 2.29 0.38 0.06
Constipation (1e4) 46 2.52 2.20 0.33 0.06
EORTC QLQ-C15-PAL ¼ European Organization for Research and Treatment of Cancer-Core 15-Palliative scale.
a
t-Test for paired samples (two-tailed).
122 Bortolussi et al. Vol. 50 No. 1 July 2015

0.61

0.42
0.23

0.41
0.51
0.41
0.09
0.33
0.49
0.19
level of comfort; the majority also thought that

Pa
EORTC QLQ-C15-PAL Functional and Symptom Scales at PICC Positioning (T0) and After One Week (T1) According to Gender, Age, Device Type, Setting, and patients can derive physical and psychological benefits
Performance Status
from hydration therapy. These opinions are less prev-

þ9.33

þ0.73
0.04

0.24
0.35
0.24
þ0.08
0.12
0.25
0.12
alent among health care staff.10 The opportunity for
50þ ANH, however, narrows toward the final stages of
life. A multicenter study on this issue concluded that
hydrating patients in the last two weeks of life did
þ14.04

þ0.10
0.62

0.62
0.52
0.62
0.39
0.48
0.52
0.57
<50

not improve quality of life or symptoms correlated to

dehydration.11
Another important point, in our opinion, that
0.31

0.87
0.51

0.07
0.11
0.07
0.04
0.60
0.37
0.17
a
P

underlines the significance of the availability of these

new, low impact techniques, is the indication for intra-
venous drug infusion, requested for 38 patients,

EORTC QLQ-C15-PAL ¼ European Organization for Research and Treatment of Cancer-Core 15-Palliative scale; PICC ¼ peripherally inserted central venous catheter.
Hospice

þ17.78

þ0.36
0.53

1.07
0.73
1.07
þ0.29
0.43
0.64
0.67
Setting

79.1% of our cases. A daily dose of hundreds of milli-

grams of morphine chlorhydrate or an equivalent
opioid is often needed to obtain pain relief. The
opioid may be diluted in the same solution with other
Home

þ8.05

þ0.50
0.19

0.10
0.28
0.10
0.30
0.22
0.26
0.16

drugs. The stability of the solution is correlated to the

drug interactions and to the dilution volume.12 If a
large total volume is necessary for an adequate dilu-
0.15

0.57
0.54

0.61
0.37
0.61
0.89
0.86
0.18
0.04
a

tion, the hourly infusions may be elevated and may

P

not be compatible with a comfortable infusion via

the subcutaneous route. For 13 patients (27%), the
Midline

þ15.59

þ0.32
0.21

0.33
0.50
0.33
0.13
0.30
0.53
0.55
Device

request to position a PICC also was correlated to the

need to perform blood draws. This is a practice that
Performance Status

is usually not recommended when using these devices

because of the increased risk of catheter occlusion,
þ1.28

þ0.83
0.54

0.62
0.23
0.62
0.08
0.23
þ0.09
þ0.23
PICC
Table 5

but by taking suitable precautions such as repeated

catheter flushing after the blood draw, one can avoid
the stress and pain caused by venipuncture.
0.52

0.60
0.93

0.34
0.83
0.34
0.10
0.20
0.82
0.77
a
P

The positioning of a PICC or midline catheter is

undoubtedly more costly when compared with that of
Age (yrs)

þ13.33

þ0.59
0.29

0.58
0.41
0.58
0.26
0.44
0.41
0.29

placing a Teflon catheter in a peripheral vein. The esti-

$70

mated cost could be as high as 10e20 times more. How-

ever, one must remember that the duration of a Teflon
venous catheter is three to four days, whereas that of a
þ7.14

þ0.14
0.33

0.07
0.47
0.07
þ0.23
þ0.07
0.31
0.40
<70

PICC or midline catheter is a few months. In addition,

the procedures to medicate and maintain these cathe-
ters are easy and quick for the health care professional
0.99

0.06
0.47

1.00
0.11
1.00
0.45
0.59
0.49
0.23

and comfortable for the patient who does not have to

a
P

endure frequent venipunctures.

The low incidence of complications observed during
Women

þ11.46

0.47
0.53

0.41
0.71
0.41
0.25
0.41
0.56
0.06
Gender

the monitoring period suggest, to date, the validity of

these devices. Removal of the device was necessary in
Analysis of variance for repeated measures.

only two cases, after 188 and 139 days, respectively, and
were the only serious complications observed in 3097
þ11.31

þ1.00
0.17

0.41
0.27
0.41
0.04
0.21
0.28
0.48
Men

catheter days. The ultrasound-guided technique in our

study guaranteed a very high percentage of success
(99.01%). It also reduced the time needed to
Global health status

position the catheter, thereby guaranteeing a high level

Loss of appetite
Functional scales

of comfort for the patient. The feasibility of the proce-

Symptom scales

Constipation
Emotional

dure, even in the home setting, was confirmed by the

Insomnia
Dyspnea
Physical

Fatigue
Nausea

overlap of the median times of the procedure and the

Pain
Scales

low incidence of distress and pain seen in the hospice

setting. We did not perform post-mortem cultures of
a
Vol. 50 No. 1 July 2015 PICC Insertion for Palliative Care in the Home Setting
the catheter tips as in Yamada’s study because we felt that
enough safety data relative to the use of PICCs are avail-
able.13,14 The choice between PICC and midline cathe-
ters (Yamada’s group used only PICCs) fell mostly on
the latter (72.9%) in our cases. These devices are more
manageable, equally stable over time, more economical,
and quicker to place. All the catheters were positioned by
expert palliative care physicians, but it is known that the
procedure also can be performed by nurses who have un-
dergone adequate training. Once the indications for the
procedure have been identified, it is up to the profes-
sional to evaluate the feasibility conditions, which must
aim at the highest level of comfort for the patient. Last
but not least, we feel that the results of an improvement
in quality of life of the patient after one week need to be
interpreted cautiously; this could have been influenced
by the simultaneous start of palliative care treatment.
We also are aware of the small sample size (48 patients)
and the lack of comparators, which do not allow us to
draw any definitive conclusions in terms of change in
quality of life. The sample size was originally determined
to test the percentage of patients who express no or very
little distress during PICC positioning. Therefore, the
sample size may not be large enough for the secondary
endpoints, that is, to evaluate the changes over time in
quality of life subscales (EORTC QLQ-C15-PAL). Infor-
mation bias also may have occurred. However, inter-
viewers were centrally trained and the EORTC QLQ
C15-PAL questionnaire was previously validated. We
would like to emphasize that the central venous catheter
was positioned in the home setting in 33 patients. This is
the first study, to our knowledge, which has demon-
strated the safety of this procedure in the natural pallia-
tive care setting, that is, the patient’s home.
Conclusions
The encouraging results concerning the low level of
stress and pain at the time of placement and during
use of the PICCs and midline catheters, together
with a low incidence of complications both in the hos-
pice and the home settings, are, in our opinion, useful
indicators to consider these devices relevant for pallia-
tive care patients who need venous access. It is also
very important that, in relation to the unit costs of
PICC and midline catheters and of the apparatus
necessary for their placement, further research be
done to study the cost-effectiveness of these devices
and the best role they may have in different palliative
care settings.
Disclosures and Acknowledgments
This study was made possible thanks to the donation
of a dedicated ultrasound apparatus by the Association
123
‘‘Amici dell’Hospice’’ of S. Vito al Tagliamento and to
the participation of the medical and nursing
personnel of the Pordenonese Palliative Care
Network: Giorgio Simon, Tiziana Danielis, Graziella
Ricci, Cinzia Cozzi, Antonella Rovedo, Giuliana Tassan
Got, Marta Zanutel, and Marta Deforni.
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