oxford handook of palliative care 2nd ed

OXFORD MEDICAL PUBLICATIONS
Oxford Handbook of
Palliative Care
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Oxford Handbook of
Palliative Care
SECOND EDITION
Max Watson
Consultant in Palliative Medicine, Northern Ireland
Hospice, Belfast; Lecturer in Palliative Care,
University of Ulster, Belfast; Special Adviser,
Hospice Friendly Hospitals Programme, Dublin;
Honorary Consultant in Palliative Medicine,
The Princess Alice Hospice, Esher
Caroline Lucas
Deputy Medical Director, The Princess Alice Hospice, Esher;
Consultant in Palliative Medicine, Surrey Primary Care

Trust; Honorary Consultant in Palliative Medicine, Ashford
and St. Peter’s Hospital NHS Trust
Andrew Hoy
Medical Director, The Princess Alice Hospice, Esher;
Consultant in Palliative Medicine, Epsom and St Helier
NHS Trust
Jo Wells
Support Service Coordinator, The Leukaemia Foundation,
South Australia; Formerly Nurse Consultant in Palliative Care,
The Princess Alice Hospice, Esher
1
1
Great Clarendon Street, Oxford OX2 6DP
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First edition published 2005
Second edition published 2009
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ISBN 978–0–19–923435–6
10 9 8 7 6 5 4 3 2 1
Oxford University Press makes no representation, express or implied, that the drug
dosages in this book are correct. Readers must therefore always check the product
information and clinical procedures with the most up to date published product
information and data sheets provided by the manufacturers and the most recent
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plication of material in this work. Except where otherwise stated, drug dosage and
recommendations are for the non-pregnant adult who is not breast-feeding.

v
Foreword
When a book rapidly goes to a second edition, it is a mark of esteem
of the fi rst edition. And this book is no exception—it is a handbook for
anyone providing care for those approaching the end-of-life.
It covers, concisely, all aspects of palliative care, tackling diffi cult subjects
such as ethical issues, communication and breaking bad news, up front at
the beginning of the book. The section on the principles of drug use in pal-
liative care specifi cally addresses the problems of drugs prescribed beyond
licence and drug interactions, making this book one of those essential
handbooks that will be taken off the shelf time and time again.
Many books are being replaced by internet publications; not this one.
This book will be on the desk or in the pocket of many doctors and nurses
around the globe. It is equally applicable in countries which are resource-
rich and those that are resource-poor.
While providing the theoretical background and evidence base, the
book remains eminently practical, for example in its step by step guide on
the use of intravenous analgesics in pain emergencies and how to deal with
cancer pain that appears to be resistant to opioids. It also elegantly gives
the indications for referring across to others such as radiotherapy and
outlines different types of chemotherapy that a patient might be having.
Few reference books are quite this packed with information.
Paediatric palliative care has recently emerged as a specialty in its own
right in the UK is also included in this book; the needs of dying children
have been neglected for far too long; here again, the book is up to date,
practical and helpful.
This book does not shy away from controversy; it has a balanced cri-
tique of complementary therapies, their benefi ts and their place in the
delivery of care overall.
The authors provide objective evidence and their enormous experience

shines through the text. The specifi c resources and further reading given
at the end of every chapter complements the ‘no nonsense’ layout of each
chapter throughout the book.
As a guide to modern palliative care, this book will serve patients well.
Professor Ilora Finlay FRCP FRCGP
(Baroness Finlay of Llandaff)
This page intentionally left blank
vii
Preface to the second
edition
I am always willing to learn, however I do not always like to be taught.
Winston Churchill
The fi rst edition of the Oxford Handbook of Palliative Care has been
warmly received. We have been encouraged by colleagues to make the
material presented here more relevant to non-medical readers. We there-
fore welcome to our team, Jo Wells, who is a nurse consultant in pallia-
tive care. We have added new sections on antibiotics, increased emphasis
on non-malignant disease, learning disabilities, palliative care in developing
countries and communication. All the chapters of the fi rst edition have
been reviewed and many have been completely rewritten.
We hope that the result will be a Handbook which is useful to the
whole of the multiprofessional team and will achieve a better balance than
its predecessor. Although the Handbook is somewhat larger than the fi rst
edition, we feel that this is a refl ection of the rapid changes and progress
of this fi eld of clinical practice in a relatively short period.
The aim of the Handbook remains as originally stated. We would like
to provide a readily accessible source of help to all those who care for
people who cannot be cured. This will include generalists and those
whose specialty is not palliative care. We hope that the Handbook may
also be a useful ready reference for those engaged in full-time palliative,

hospice or end-of-life care. We remain proud to be associated with the
Oxford University Press Handbook series, and are well aware of the heavy
responsibility which this confers.
We regard the Oxford Textbook of Palliative Medicine as the parent text
for much of the material in this Handbook. There are various references
throughout to the current, third edition. However, readers may need to be
aware that a new fourth edition is in preparation, and should be available
later in 2009.
MW
CL
AH
JW
This page intentionally left blank
ix
Most clinical professionals have been affected by caring for patients with
palliative care needs. Such patients may challenge us at both a professional
and at a personal level in areas where we feel our confi dence or compe-
tence is challenged.
I wanted to help her, but I just didn’t know what to do or say
As in every other branch of medicine, knowledge and training can help us
extend our comfort zone, so that we can better respond to such patients
in a caring and professional manner. However, in picking up this Handbook
and reading thus far you have already demonstrated a motivation that is
just as important as a thirst for knowledge, the central desire to improve
the care of your patients.
It was out of just such a motivation that the modern hospice move-
ment began 40 years ago, and it is that same motivation that has fuelled
the spread of the principles of palliative care—in fact the principles of
ALL good care—across the globe: respect for the person, attention to
detail, scrupulous honesty and integrity, holistic care, team caring and con-

summate communications (often more about listening than telling and
talking).
I knew we couldn’t cure him, but didn’t know when or how to start
palliative care
Increasingly it is being recognized that every person has the right to
receive high-quality palliative care whatever the illness, whatever its stage,
regardless of whether potentially curable or not. The artifi cial distinction
between curative and palliative treatments has rightly been recognized as
an unnecessary divide, with a consequent loss of the border crossings that
previously signifi ed a complete change in clinical emphasis and tempo.
Medical knowledge is developing rapidly, with ever more opportunities
for and emphasis on curative treatment, to the point when any talk of pal-
liative care can sometimes be interpreted as ‘defeatist’.
Today the principles of palliative care interventions may be employed
from the fi rst when a patient’s illness is diagnosed. Conversely, a patient
with predominantly palliative care needs, late in their disease journey, may
benefi t from energetic treatments more usually regarded as ‘curative’.
I just felt so helpless watching him die. Surely it could have been better?
Governments and professional bodies now recognize that every nurse and
doctor has a duty to provide palliative care and, increasingly, the public and
the media have come to expect—as of right—high-quality palliative care
from their healthcare professionals irrespective of the clinical setting.
Many of these palliative care demands can best be met, as in the past,
by the healthcare professionals who already know their patients and fami-
lies well. This Handbook is aimed at such hospital- or community-based
Preface to the fi rst
edition
x
professionals, and recognizes that the great majority of patients with pal-
liative needs are looked after by doctors and nurses who have not been

trained in specialist palliative care but who are often specialist in the
knowledge of their patients.
Even though I knew she had had every treatment possible, still, when
she died I really felt that we had failed her and let her family down.
Junior healthcare staff members throughout the world have used the
Oxford Handbook series as their own specialist pocket companion
through the lonely hours of on-call life. The format, concise (topic-a-page),
complete and sensible, teaches not just clinical facts but a way of thinking.
Yet for all the preoccupation with cure, no healthcare professional
will ever experience greater satisfaction or confi rmation of their choice
of profession, than by bringing comfort and dignity to someone at the
end-of-life.
I had never seen anyone with that type of pain before and just wished I
could get advice from someone who knew what to do.
The demands on inexperienced and hard-pressed doctors or nurses in
looking after patients with palliative care needs can be particularly stressful.
It is our hope that this text, ideally complemented by the support and
teaching of specialist palliative care teams, will reduce the often expressed
sense of helplessness, a sense of helplessness made all the more poignant
by the disproportionate gratitude expressed by patients and families for
any attempts at trying to listen, understand and care.
It was strange, but I felt he was helping me much more than I was helping
him
While it is our hope that the Handbook will help the reader access impor-
tant information quickly and succinctly, we hope it will not replace the
main source of palliative care knowledge: the bedside contact with the
patient.
It is easier to learn from books than patients, yet what our patients teach
us is often of more abiding signifi cance: empathy, listening, caring, existen-
tial questions of our own belief systems and the limitations of medicine. It

is at the bedside that we learn to be of practical help to people who are
struggling to come to terms with their own mortality and face our own
mortality in the process.
Readers may notice some repetition of topics in the Handbook. This
is not due to weariness or oversight on the part of the editors, but is an
attempt to keep relevant material grouped together—to make it easier
for those needing to look up information quickly.
It is inevitable that in a text of this size some will be disappointed at
the way we have left out, or skimped on, a favourite area of palliative care
interest. To these readers we offer our apologies and two routes of redress:
almost 200 blank pages to correct the imbalances; and the OUP website,
where your suggestions for how
the next edition could be improved would be gratefully received.
Preface to the fi rst edition
xi
We must acknowledge and thank many people, without whome this
edition of the Oxford University Handbook of Palliative Care would not
have been possible. Our colleagues in Ireland and Surrey have been end-
lessly tolerant of our absence both physical and psychological. They have
kept the patients care show on the road when we were chasing refer-
ences, new procedures, novel drugs or faulty syntax. They have also been
asked to provide new review materisl for inclusion or been required to
comment on our initial efforts. We hope that all these expert witness have
been included in the updated list of contributors. Particular mention and
thanks must go to the consultant staff at the North Ireland Hospice and
the Princess Alice, the eager specialist registrars, the ward staff and clinical
nurse specialists and the allied health care professiobals. All have given
time and expertise with unstinting generosity.
We would be lost without the invaluable backup of our secretaties, Liz
Huckle, and Susan Lockwood. Jan Brooman has unfailingly checked every

single reference. Gill Eyers and Margaret Gibbs have provided invaluable
pharmacy advice. The staff at OUP have been both expert and also infi -
nitely patient, especially Beth Womack and Kate Wilson.
We continues to be indebted to Dr. Ian Back for the excellence of his
o website as an invaluable palliative resource. We
are also grateful to Barness Finaly for her willingness to erite the forward
to this edition on top of her many commitments
Our greatest thanks, however, is reserved for the many contributors and
reviewers who so generously gave of their time to allow this edition to be
completed. We realise that this work was often carried out in the "small
hours", after the completion of clinical responsibilities. Without such col-
laboration this handbook would not have been possible.
Finally, we must acknowledge and thank our respective spouses who have
patiently kept us both fed and watered but also tried to supply a sence of
proportion and humour.
We are also indebted for permission to reproduce material within the
handbook from the following sources:
Bruera E., Higginson I. (1996) Cachexia–Anorexia in Cancer Patients. Oxford:
Oxford University Press.
Doyle D., et al (eds) (2004) Oxford Textbook of Palliative Medicine (3rd edn).
Oxford: Oxford University Press.
Ramsay J H. R. (1994) A King, a doctor and a convenient death. British
Medical Journal, 308: 1445.
The South West London and the Surrey, West Sussex and Hampshire,
Mount Vernon and Sussex Cancer Networks. M. Watson, C. Lucas, A. Hoy
(2006) Adult Palliative Care Guidance (2nd edn).
Acknowledgements
xii
Thomas K. (2003) Caring for the Dying at Home: Companions on the Journey.
Oxford: Radcliffe Medical Press.

Twycross R., Wilcock A. (2007) Palliative Care Formulary (3rd edn).
palliativedrugs.com
Winston’s Wish: supporting bereaved children and young people.
www.winstonswish.org.uk.
www.rch.org.au/rch_palliative
MW
CL
AH
JW
ACKNOWLEDGEMENTS
xiii
Contributors xvii
Abbreviations xxi
Introduction xxv
1 Ethical issues
1
2 Communication: Breaking bad news
17
3 Research
a Research in palliative care
39
b Quality of life
51
4 Principles of drug use in palliative care
61
a The use of drugs beyond licence
65
b Drug interactions in palliative care
67
c Syringe drivers

97
d Antibiotics in palliative care
109
e Non-medical prescribing
113
5 Oncology and palliative care
117
6 Symptom management
a The management of pain
215
b Gastrointestinal symptoms
299
c Cachexia, anorexia and fatigue
349
d Sweating and fever
359
e Respiratory symptoms
363
f Skin problems in palliative care
381
g Genitourinary problems
393
h Palliation of head and neck cancer
411
i Endocrine and metabolic complications of
advanced cancer
445
Contents
xiv
j Neurological problems in advanced cancer

461
k Sleep disorders
471
l Palliative haematological aspects
475
m Psychiatric symptoms in palliative care
507
7 Paediatric palliative care
529
8 Palliative care in non-malignant disease
653
a Palliative care in non-malignant
respiratory disease
655
b Heart failure
669
c Palliative care in non-malignant
neurological disease
675
d Renal failure
697
e AIDS in adults
707
f Palliation in the care of the elderly
725
9 Spiritual care
739
10 The contribution to palliative care of allied
health professions
755

a Rehabilitation
757
b Occupational therapy
761
c Dietetics and nutrition
765
d Physiotherapy
771
e Speech and language therapy
775
f Clinical and other applied psychology in
palliative care
781
g Social work
785
h Chaplaincy
791
i Pharmacy
801
CONTENTS
xv
j Art therapy
803
k Music therapy
805
11 Complementary and alternative medicine
in palliative care
807
12 Palliative care in the home
841

13 Hospital liaison palliative care
887
14 Palliative care for people with learning disabilities
905
15 Emergencies in palliative care
917
16 The terminal phase
929
17 Bereavement
947
18 Self-care for health professionals
965
19 Miscellaneous
a Legal and professional standards of care
969
b Death certifi cation and referral to the coroner
991
c Fitness to drive
997
d Dermatomes
1001
e Genograms
1003
f Peripheral nerve assessment
1005
g Travelling abroad
1007
h Tissue donation
1009
i Help and advice for patients

1011
j Laboratory reference values
1015
Index 1017
CONTENTS
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xvii
Owen Barr
Head of School,
School of Nursing,
University of Ulster,
N. Ireland
Pauline Beldon
Nurse Consultant in Tissue
Viability, Epsom and St Helier NHS
Trust, UK
Barbara Biggerstaff
Senior Occupational Therapist,
The Princess Alice Hospice, Esher,
UK
Kathy Birch
Physiotherapist, The Princess Alice
Hospice, Esher, UK
Maggie Breen
Macmillan Clinical Nurse Specialist,
Oncology Outreach and Symptom
Care Nurse Specialist Team, Royal
Marsden Hospital, Surrey, UK
Michael Burgess
H.M.Coroner for Surrey, Coroner

of The Queen’s Household, UK
David Cameron
Associate Professor in the
Department of Family Medicine,
University of Pretoria, South Africa
Robin Cole
Consultant Urological Surgeon,
Ashford and St Peter’s Hospital
NHS Trust, UK
Simon Coulter
Specialist Registrar in Palliative
Medicine, Marie Curie Hospice,
Belfast, UK
Melaine Coward
Deputy Head of Programmes,
Division of Health and Social Care,
Faculty of Health and Medical
Sciences, University of Surrey, UK
Kay de Vries
Research Fellow at Surrey
University, and Senior lecturer at
The Princess Alice Hospice, Esher,
UK
Judith Delaney
Haematology/Oncology Senior
Pharmacist, Great Ormond Street
Hospital for Children NHS Trust,
London, UK
Gill Eyers
Senior Principal Pharmacist,

Princess Alice Hospice, Esher,
Kingston Hospitals NHS Trust, UK
Craig Gannon
Consultant in Palliative Medicine,
Princess Alice Hospice, Esher, UK
Rebecca Goody
Specialty Registrar in Clinical
Oncology at the Northern Ireland
Cancer Centre, Belfast City
Hospital, Belfast, UK
Patricia Grocott
Reader in Palliative Wound Care
Technology Transfer, Division of
Health and Social Care Research,
King’s College London, UK
David Hill
Consultant in Pain Medicine,
Ulster Hospital, Belfast,UK
Jenny Hynson
Consultant Paediatrician,
Victorian Paediatric Palliative
Care Program, Royal Children’s
Hospital, Victoria, Australia
Contributors
xviii
Jean Kerr
Specialist Speech & Language
Therapist, The Princess Alice
Hospice, Esher, and Head of
Speech & Language Therapy,

Kingston Hospital NHS Trust, UK
Lulu Kreeger
Consultant in Palliative Medicine,
The Princess Alice Hospice, Esher,
Kingston Hospitals NHS Trust, UK
Victoria Lidstone
Consultant in Palliative Medicine,
Cwm Taff NHS Trust, Wales, UK
Mari Lloyd-Williams
Professor / Director of Academic
Palliative and Supportive Care,
School of Population, Community
and Behavioural Sciences,
University of Liverpool, UK
Stefan Lorenzl
Associate Professor of
Neurology and
Consultant in Palliative Medicine,
University Hospital Grosshadern,
Munich, Germany
Farida Malik
Clinical Research Training Fellow,
Cicely Saunders International,
London, UK
James McAleer
Senior Lecturer and Consultant
in Clinical Oncology, Queen’s
University, Belfast, UK
Joan McCarthy
Lecturer in Healthcare Ethics,

School of Nursing and Midwifery,
Brookfi eld Health Sciences
Complex, University College Cork,
Ireland
Dorry McLaughlin
Lecturer in Palliative Care,
Northern Ireland Hospice Care,
Belfast, UK
Caroline McLoughlin
Specialist Registrar in Palliative
Medicine, Northern Ireland
Deanery, UK
Alan McPhearson
Specialist Registrar in Palliative
Medicine, Northern Ireland
Hospice, Belfast, UK
Teresa Merino
Consultant in Palliative Medicine,
Royal Surrey County Hospital,
Guildford, UK
Caroline Moore
Specialist Registrar in Urology,
Frimley Park NHS Trust, UK
Barbara Munroe
Frimley Park Chief Executive,
St Christopher’s Hospice,
London, UK
Simon Noble
Clinical Senior Lecturer in
Palliative Medicine, Cardiff

University, Cardiff, Wales, UK
Steve Nolan
Chaplain, The Princess Alice
Hospice, Esher, UK
Ciaran O’Boyle
Professor of Psychology and
Chairman, International School
of Healthcare Management, Royal
College of Surgeons in Ireland,
Dublin, Ireland
Julian O’Kelly
Day Hospice Manager / Music
Therapist, The Princess Alice
Hospice, Esher, UK
David Oliviere
Director of Education and Training,
Education Centre, St Christopher’s
Hospice, London, UK
CONTRIBUTORS
xix
Victor Pace
Consultant in Palliative Medicine,
St Christopher’s Hospice, London,
UK
Malcolm Payne
Director, Psycho-social and
Spiritual Care, St Christopher’s
Hospice, London, UK
Sheila Payne
Help the Hospices Chair in

Hospice Studies, Institute for
Health Research, Lancaster
University, UK
Max Pittler
Senior Research Fellow in
Complementary Medicine,
Peninsula Medical School,
Universities of Exeter and
Plymouth, UK
Mandy Pratt
Art Psychotherapist, Creative
Response - Professional
Association of Art Therapists
in Palliative Care, AIDS, Cancer
& Loss Affi liated to St Helena
Hospice, Colchester, UK
Joan Regan
Consultant in Palliative Medicine,
Marie Curie Hospice & Belfast
NHS Trust, UK
Margaret Reith
Social Work Manager, The Princess
Alice Hospice, Esher, UK
Karen Ryan
Consultant in Palliative Medicine,
St Francis Hospice, Mater
Misericordiae University Hospital
and Connolly Hospital, Dublin,
Ireland
Nigel Sage

Consultant Clinical Psychologist,
The Beacon Community Cancer &
Palliative Care Centre, Guildford,
Surrey, UK
Libby Sallnow
Specialty Trainee in Medicine,
Brighton and Sussex University
Hospitals Trust, UK
Paula Scullin
Locum Consultant in Medical
Oncology, Cancer Centre,
Belfast City Hospital, Belfast, UK
Kathy Stephenson
Macmillan Palliative Care
Community Liaison Pharmacist,
Craigavon Area Hospital, Southern
Health and Social Care Trust,
N.Ireland, UK
Nigel Sykes
Medical Director and
Consultant in Palliative Medicine,
St Christopher’s Hospice,
London, UK
Keri Thomas
National Clinical Lead for the Gold
Standards Framework Centre,
Walsall PCT, UK, Hon Senior
Lecturer, University of Birmingham,
UK, and Chair Omega, the National
Association for End of Life Care

Jo Venables
Consultant in Community Child
Health, Abertawe Bro Morgannwg
University Trust, Wales, UK
Barbara Wider
Research Fellow in
Complementary Medicine,
Peninsula Medical School,
Universities of Exeter and
Plymouth, Exeter, UK
Meg Williams
Specialist Registrar in Palliative
Medicine, All Wales Higher Training
Programme, Cardiff, UK
CONTRIBUTORS
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xxi
ADLs activities of daily living
AF atrial fi brillation
AIDS acquired immune defi ciency syndrome
Amp. ampoule
ARV anti-retroviral
b.d. twice daily
BNF British National Formulary
BP blood pressure
Caps capsules
CD controlled drug
CHF congestive heart failure
CMV cytomegalovirus
CNS central nervous system

CO
2
carbon dioxide
COPD chronic obstructive pulmonary disease
COX cyclo-oxygenase
CSCI continuous subcutaneous infusion
C/T chemotherapy
CT computed tomography
CTPA computed tomography pulmonary arteriogram
CTZ chemoreceptor trigger zone
CVA cerebrovascular accident
DIC disseminated intravascular coagulation
DN district nurse
DVT deep vein thrombosis
ECG electrocardiogram
ECOG Eastern Cooperative Oncology Group
EDDM equivalent daily dose of morphine
FBC full blood count
FEV
1
forced expiratory volume in one second
FNA fi ne needle aspiration
g gram
GERD gastro-oesophageal refl ux disease
GI gastrointestinal
GMC General Medical Council
GP general practitioner
Gy Gray(s): a measure of radiation
Abbreviations
xxii

h hour or hourly
HAART highly active anti-retroviral therapy
HIV human immunodefi ciency virus
HNSCC head and neck squamous-cell carcinoma
ICP intracranial pressure
IM intramuscular
Inj. injection
i/r immediate release
i/t intrathecal
IV intravenous
IVI intravenous infusion
IVU intravenous urogram
KS Kaposi’s sarcoma
kV kilovolt
L litre
L/A local anaesthetic
LFT liver function tests
LVF left ventricular failure
MAI Mycobacterium avium intracellulare
MAOI monoamine oxidase inhibitor(s)
max. maximum
MeV mega electronvolt
mcg microgram
MND motor neurone disease
m/r modifi ed release
MRI magnetic resonance imaging
MUPS multiple unit pellet system
MV megavolt
m/w mouthwash
NaSSA noradrenergic and specifi c serotoninergic antidepressant

neb nebulizer
NG nasogastric
NMDA N-methyl-
D-aspartate
nocte at night
NSAID non-steroidal anti-infl ammatory drug
NSCLC non small-cell lung carcinoma
NYHA New York Heart Association
o.d. once daily
o.m. in the morning
OTFC oral transmucosal fentanyl citrate
PCA Patient controlled analgesia
ABBREVIATIONS
xxiii
PCF Palliative Care Formulary
PCT palliative care team
PE pulmonary embolism
PEG percutaneous endoscopic gastrostomy
PET positron emission tomography
PHCT primary healthcare team
p.o. by mouth
PPI proton pump inhibitor
p.r./PR per rectum/progesterone receptor
p.r.n. when required
PSA prostate-specifi c antigen
PTH parathyroid hormone
p.v. per vaginam
PVS persistent vegetative state
q.d.s. four times daily
QoL quality of life

RBL renal bone liver (investigations)
RCT randomized controlled trial
RIG radiologically inserted gastrostomy
RT radiotherapy
SALT speech and language therapy
SC subcutaneous
SCLC small-cell lung carcinoma
S/D syringe driver (CSCI)
SE side-effects
SERMs selective oestrogen-receptor modulators
SL sublingual
soln solution
SPC specialist palliative care
SR slow or modifi ed release
SSRI selective serotonin-reuptake inhibitor
Stat immediately
Supps suppositories
Susp. suspension
SVC superior vena cava
SVCO superior vena cava obstruction
Tabs tablets
TB tuberculosis
TBM tubercular meningitis
t.d.s. three times daily
TENS transcutaneous electrical nerve stimulation
ABBREVIATIONS
TIA transient ischaemic attack
TSD therapeutic standard dose
U&E urea and electrolytes
UEA Ung Emulcifi cans Aqueosum

URTI upper respiratory tract infection
UTI urinary tract infection
V/Q ventilation/perfusion
VTE venous thromboembolism
WHO World Health Organization
ABBREVIATIONS