Sharing Current Scottish Practice

Poster Abstracts of the Month: April

The SPPC Annual Conference in 2018 featured 48 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on six of these:

• Evaluating the Safer Prescription of Opioids Tool (SPOT) in clinical practice
• Foundations in Palliative Care: A Programme of Facilitated Learning for Care Home Staff and Home Carers
• Hospital Doctor's Experience of Caring for Dying Patients: Report of themes from free text responses
• Impact of population ageing on end-of-life care in Scotland: Population based projections of place of death and recommendations for future service provision
• Improving identification of people who could benefit from a palliative care approach
• Improving Palliative Care for People who are Homeless in Scotland - Possible Solutions

Evaluating the Safer Prescription of Opioids Tool (SPOT) in clinical practice

Author(s)

S Botros; Dr D Buchanan; Sir A Cuschieri; Dr R Flint; J Forbes; Professor J George; Dr S Jamieson

Introduction and Aims:

The study evaluated The Safer Prescription of Opioids Tool (SPOT), an app-based equianalgesic opioid conversion tool as a clinician decision support (CDS) platform in opioid dose conversion using clinical data across primary, secondary and tertiary care in a palliative care setting at a Scottish Health Board.

Methods:

This prospective clinical utility single-centre pilot study followed a mixed methods design. Prescribers were asked to complete an initial survey to explore their current opioid prescribing practice in palliative and end-of-life care. Thereafter, prescribers were asked to use SPOT for opioid dosage conversions in parallel to usual clinical practice. Lastly, prescribers were asked to evaluate SPOT through a survey and follow up focus group.

Results:

62% of conversions were for cancer pain and 72% for 24 hour-daily dose conversions. SPOT correctly matched the Gold Standard result in 258 of 268 (96.3%) calculations performed during the study period. Users had a statistically significant increase in confidence in prescribing opioids after using the tool.

Conclusions:

The data from the study highlights the role of CDS when users prescribe high risk medicines. Almost all of those participating in the study would double-check their equianalgesic opioid conversion calculations if there was a simple, quick and safe option to do so, reflecting a pressing clinical need in a high-risk prescribing environment.

Foundations in Palliative Care: A Programme of Facilitated Learning for Care Home Staff and Home Carers

Author(s)

Ali Humphries; Suzanne Nimmo; Shannon Rendall; Karen Stewart

High quality palliative and end of life care delivery across Scotland should be the gold standard, but to achieve this there must be robust education and training in place to support all health and social care staff to achieve this goal.

The Strategic Framework for Action on Palliative and End of Life Care (2015) highlights that everyone should have access to palliative and end of life care but acknowledges that there are challenges for staff to be released for training. Similarly, Macmillan Cancer Support in Scotland have also outlined in their priorities that people with palliative and end of life care requirements should have their experience improved, but to do this, we must develop and integrate the wider cancer workforce.

In order to improve the palliative and end of life care experience of people throughout Scotland, Macmillan Cancer Support commenced an educational programme in November 2017. The Macmillan Foundations in Palliative Care resource pack (FIPC) underpins the delivery of this training to Care Home and Care at Home staff.

To date we have provided 15 courses throughout Scotland and have trained 209 people.

This poster outlines the rationale for the above project and provides evidence of the preliminary qualitative and quantitative results.

Hospital Doctor's Experience of Caring for Dying Patients: Report of themes from free text responses

Author(s)

D Gray; G Haworth; H Hood; G Linklater; C Smyth

The aim of this study was to examine, by means of a postal questionnaire, the experience of all grades of doctors caring for patients dying in an acute hospital in Scotland. There was an overall 42% response rate (127/306). Of responding doctors 55% had cared for 10 or more patients in the previous year. A quarter of respondents had personal experience of bereavement out with clinical practice within the previous year. 65% of responding doctors agreed that their most memorable patient death had had a strong emotional impact upon them. Responding doctors reported benefit from peer support. There was no association between length of time as a doctor and difficulty rating for talking to patients about death (p-value 0.203). There was no association between difficulty rating and length of time working as a doctor when talking to relatives about death and dying (p value 0.205). The questionnaire enabled respondents to provide further information in relation to their own experience and the response have been grouped into themes and reported in this poster.

Impact of population ageing on end-of-life care in Scotland: Population based projections of place of death and recommendations for future service provision

Author(s)

Anna Bone; Catherine Evans; Anne Finucane; Barbara Gomes; Irene Higginson; Richard Meade; Scott Murray; Tim Warren

Background:

Due to global population ageing, we are expecting a rise in the number of deaths, with implications for service provision in care settings.

Aims:

To project where people will die from 2017 to 2040 across all care settings in Scotland, and identify expert recommendations in response to projected trends.

Methods:

Population-based trend analysis of place of death and a consensus group meeting.

Results:

Annual deaths in Scotland are projected to increase by 15.9% from 2016 to 2040. Between 2004 and 2016, proportions of home and care home deaths increased, while the proportion of hospital deaths declined. If current trends continue, the numbers of deaths at home and in care homes will increase and two-thirds of patients will die outside of hospital by 2040. To sustain current trends, recommendations included: 1) increase, equip and sustain the health and social care workforce 2) to build community capacity and resilience and 3) to hold a realistic national debate on funding of palliative care.

Conclusion:

End-of-life care provision in community settings needs to increase by over 60% by 2040, otherwise hospital deaths will increase. Investing in a community-based health and social care workforce; and identifying and supporting informal carers are crucial.

Improving identification of people who could benefit from a palliative care approach

Author(s)

Paul Baughan; Michelle Church; Laura Dobie

The current situation is that many people across Scotland are not being identified and not receiving palliative care. There are lots of different tools that support earlier identification. So, one of the things that we have done in Healthcare Improvement Scotland is to try and make sense of which tool to use in which situation. We've produced the Palliative Care Identification tools comparator, which explains what tools are available, how they work and provides a decision tree that can help services decide what tool would best suit their aims.

Improving Palliative Care for People who are Homeless in Scotland - Possible Solutions

Author(s)

Joy Rafferty

There is need to consider how palliative care services can be more accessible and responsive to the needs of people who are homeless in Scotland. Review of published and grey literature, online searches and networking identified ongoing projects/services providing palliative care for homeless people in developed countries worldwide. These were examined, looking for examples of good practice and consideration made of transferability to the Scottish context. Eleven types of projects were identified aiming to improve palliative care for people who are homeless. One solution is unlikely to meet all the needs of this complex varied group with combinations of different services ideal. There is scope in Scotland to engage with specialist GP practices for people who are homeless and provision of support and education to staff working with this group. Consideration should be given to developing respite/intermediate care beds in culturally appropriate settings (e.g. homeless hostels), which can be utilised for those with palliative care needs. With many homeless people affected by profound and complex loss, specialist bereavement support can be helpful. Homeless people are unlikely to proactively access services so effective outreach involving relationship building and partnership working with other services is vital.

Poster Abstracts of the Month: November

The SPPC Annual Conference in 2017 featured 46 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on five of these:

• Rosebery End of Life Care and Choices
• Socioeconomic status is associated with place of death in patients known to hospice services
• Testing a WISeR approach to community palliative care and accompanying pamphlet
• The barriers and facilitators to implementing the Carer Support Needs Assessment Tool (CSNAT) in a community palliative care setting
• The decision to undergo palliative chemotherapy: how do patients feel about the decision making process at the Edinburgh Cancer Centre?

Rosebery End of Life Care and Choices

Author(s)

Marilyn Higham

“I have a Right to End of Life Care That Respects my Wishes”

Standards of care for Dementia in Scotland (2011)

This poster will present the development of Roseberry End of Life Care and Choices: A person-centred end of life care plan for people with dementia, their carers and their nurses.

A pilot study was conducted within an NHS in-patient mental health specialist unit for women experiencing stress and distress from advanced dementia, including in the last stages of their illness.

Quality improvement with co-production methodology was used to develop and test the approach and documentation. Quantitative data and qualitative feedback including focus groups and questionnaires captured the experience and impact on people with dementia, carers and staff.

A two-part document was devised, a care plan where carers share information with staff regarding the person and Information for You to support staff sharing information about the dying process with carers. A three-stage process of care and support has been tested and adopted, an initial meeting, use of the care plan at end-of-life and a follow-up phone call to the carer 3–4 weeks after a death.

Results indicate person-centred and relationship-centred care have improved with nurses enabled to provide timely highly-personalised end-of-life care that considers personal preferences and choices, dignity and control, whilst carers feel treated as partners in care.

Socioeconomic status is associated with place of death in patients known to hospice services

Author(s)

Sarah Bowers; Maire O'Riordan; Mike MacFarlane; Emma Carduff

Background: Place of death is a priority to patients and relatives at the end of life with most choosing home, yet 58% of Scottish deaths occur in hospital. Studies suggest that those living in deprivation are less likely to die at home.

Aim: To describe the relationship between place of death and socioeconomic status for patients known to a hospice over a 5-year period.

Method: Scottish Index of Multiple Deprivation (SIMD, 2016) was used to group. Place of death was examined for each deprivation quintile (DQ). Deaths where location was unknown or in a nursing home were excluded.

Results: Of 4585 patient deaths 41% died at home, 40% in the hospice and 19% in hospital. Deaths at home were lower in the most affluent group. There was a highly significant direct relationship between DQ and the proportion of patients dying in the hospice. There was an inverse correlation between DQ and the proportion dying in hospital.

Conclusion: Overall, this study demonstrates that patients from more deprived areas, known to the hospice, are still more likely to die in hospital than their more affluent counterparts. This is potentially inequitable, does not necessarily reflect need and has resource implications.

Testing a WISeR approach to community palliative care

Author(s)

Susanne Gray; Jackie Mearns; Cathy Quinn; Katie Clark; Alison McGill

Many people in Scotland who could benefit from palliative and end of life care (PEOLC) do not receive it. The Strategic Framework for Action on PEOLC aims to ensure that by 2021 everyone who needs palliative care will have access to it.

We sought to reduce variability in community palliative care (all settings and conditions), testing ways to develop a consistent response, that gives people and their families the opportunity to identify and discuss their concerns and plan ahead if they wish.

Aiming to promote equal opportunities for holistic person centred assessment via the introduction of a model that identifies and streams people with palliative care needs offering a proactive, coordinated, integrated model for palliative or any complex care that is fit for the future. We worked with GPs and health and social care services using a 'Plan-Do-Study-Act' (PDSA) approach to test and refine a new weekly multi-disciplinary team resource and allocation meeting (Weekly Integrated Standard Response - WISeR palliative care). We used focus groups and observation to collect qualitative data for evaluation.

Outcomes included:

ž improved integrated working

ž improved access to assessment and services

ž crisis prevention

ž improved communication.

Further testing is required to confirm results and evaluate the impact on patients and carers as well as staff.

The barriers and facilitators to implementing the Carer Support Needs Assessment Tool (CSNAT) in a community palliative care setting

Author(s)

Zoe Horseman (University of Edinburgh); Dr Anne Finucane (Marie Curie Hospice); Libby Milton (Marie Curie Hospice)

Family carers play a central role in community-based palliative care. However, caring for a terminally ill person puts the carer at increased risk of physical and mental morbidity. The validated Carer Support Needs Assessment Tool (CSNAT) provides a comprehensive measure of carer support needs and is intended for use in community palliative care. The CSNAT creates an opportunity for carers to discuss their needs with healthcare professionals, facilitating the provision of appropriate support. A recent audit demonstrated poor use of the CSNAT in a Scottish community specialist palliative care service despite training and support.

Research Aim: To identify barriers and facilitators to implementation of the CSNAT in a community specialist palliative care service.

A qualitative study was undertaken, involving interviews with 12 palliative care nurse specialists from two community nursing teams in Lothian, Scotland.

Data analysis is ongoing. The poster will present the results, identifying factors which enable and prevent the use of the CSNAT in a community palliative care setting. Recommendations for improving the acceptability of the CSNAT will be developed.

Findings from this study have the potential to enhance engagement with the CSNAT, make it more congruent with current nursing practice, and improve the experience of carers of people approaching the end-of-life.

The decision to undergo palliative chemotherapy: how do patients feel about the decision making process at the Edinburgh Cancer Centre?

Author(s)

Bethany Gwyther; Dr Morven Shearer; Professor Allan Price; Dr Joanna Bowden

The aim of this service evaluation conducted at the Edinburgh Cancer Centre (ECC) was to assess how people felt, with hindsight, about the decision to have palliative or curative chemotherapy for lung or gynaecological cancers. The SURE test, comprising four questions, was adapted for retrospective use with patients who had completed their treatment and had returned to the oncology clinic. A fifth question relating to regret was added. Questionnaires were completed in conversation with a medical student.

29 patients completed the questionnaire (13 males, 16 females.) Patients generally reported high levels of certainty that treatment had been the right choice, both at the time of the decision, and upon treatment completion. Most also reported feeling that they were supported well with the decision. The lowest scoring areas related to understanding of treatment risks and benefits.

It is reassuring that most patients felt confident in the decision making around treatment. Others' work locally has revealed that regret often comes late, and it is possible that findings would have been different if patients had been surveyed later. Poor understanding of risks of treatment could reflect a number of scenarios, and warrants exploration with future work.

Poster Abstracts of the Month: October

The SPPC Annual Conference in 2017 featured 46 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on five of these:

• Patients, carers and healthcare professionals’ perceptions and experiences of managing metastatic spinal cord compression: a qualitative multiple case study
• Person-centred care – at the heart of what we do
• Proactive Discharge - a person-centred approach to wellbeing within a hospice day service
• 'Putting Activity Back into Life: The Inception of a Wellbeing Group'
• Relational elements of end of life anticipatory care planning (ACP): implementation in Dumfries and Galloway

Patients, carers and healthcare professionals’ perceptions and experiences of managing metastatic spinal cord compression: a qualitative multiple case study

Siew Hwa Lee; Lynn Kilbride; Robin Gran; Catriona Kennedy

Background: Metastatic spinal cord compression (MSCC) is an oncology emergency with a poor prognosis if treated late. Guidelines exist to improve patient outcomes, however the outcome for many remains poor.

Aim: To report the findings of patients, carers and healthcare professionals’ perceptions and experiences of managing MSCC.

Methods: A qualitative multiple case study design. Participants were recruited from an acute cancer centre and primary care in Scotland. Three focus groups (n=25) and interviews with healthcare professionals (n=7) were carried out in phase one. Phase two semi-structured interviews include patients (n=8), carers (n=6) and healthcare professionals (n=42). Patients and carers were interviewed at two time points. Data were analysed thematically.

Results: In phase one, healthcare professionals were ‘negotiating the care-pathway’ as existing guidelines lack a strong evidence base. Phase two revealed a constant movement between uncertainty and enduring inconsistencies (of information, treatment and advice), which results in a struggle to find a balance.

Conclusions: Patient’s preferences are central to managing symptoms where life expectancy is limited. A theory of collaborative decision-making is proposed to reduce uncertainty and facilitate decision-making. The key constructs are: awareness of signs and symptoms of MSCC, collaborative decision-making, prioritising and maximising life and end of life care.

Person-centred care – at the heart of what we do

Katy Simpson

Background: Meeting the holistic, social, spiritual, psychological and physical needs of our inpatients, community patients, their families and carers. Through the use of creative activities, we can provide a robust emotional support service. All of our therapeutic services are provided within The Margaret Kerr Unit. A study carried out by The Canadian Counselling and Psychotherapy Association found that art therapy encourages the development of healthy coping strategies¹. This supports our ongoing ‘Public Health Palliative Care’ campaign by raising awareness and engaging with members of the community outwith The Margaret Kerr Unit and palliative care service.

How? By providing services to inpatient and community based patients, it provides social stimulation through enabling them to meet new people and for those out with the unit, it helps break down the barriers and stigma about the Unit and the service we provide. Our events are held weekly and bi-annually to coincide with Dying Awareness Week.

Findings: Patients and families feel many of their needs are well supported alongside the clinical care they are receiving. The uptake of these activities continues to grow each week due to discussions being generated on social media around death and dying awareness.

¹ https://www.ccpa-accp.ca/psychological-benefits-of-art-therapy/

Proactive Discharge - a person-centred approach to wellbeing within a hospice day service

Lynsay Bain; Janice Allan; Ann-Majella McFadden

Previous feedback demonstrated patients felt unprepared for discharge from a palliative care day service, Kilbryde Hospice (KH) staff sought a more effective method to support patients through the discharge process. A new Wellbeing Group (WG) was created.

The WG focused on enhancing knowledge and self-empowerment using a person centred approach. Using self-management techniques, enabling and empowering patients to make shared decisions and understand realistic medicine⁽¹⁾. Creating an inclusive and positive discharge process. This reflects the Scottish Governments vision of practising Realistic Medicine putting patients at the centre of decision making. Outcomes were evaluated through the use of evaluation, Patient Activation Measure (PAM)⁽²⁾ and Views on Care (VoC)⁽³⁾

⁽¹⁾ Scottish Government (2017) Realising Realistic Medicine, Chief Medical Officer Annual Report, https://beta.gov.scot/news/realising-realistic-medicine/ accessed on 31/08/17

⁽²⁾ Hibbard, J., Gilburt, H., (2014) Patient Activation Measure, Supporting people to manage their health, An introduction to patient activation, The Kings Fund Patient Activation Measure_, https://www.kingsfund.org.uk/publications/supporting-people-manage-their-health accessed on 31/08/17

⁽³⁾ Witt J, Murtagh FEM, de Wolf-Linder S et al (2013) Views on Care Introducing the Outcome Assessment and Complexity Collaborative (OACC) Suite of Measures A Brief Introduction Kings College London, https://www.kcl.ac.uk/lsm/research/divisions/cicelysaunders/attachments/Studies-OACC-Brief-Introduction-Booklet.pdf p15 accessed on 31/08/17

'Putting Activity Back into Life: The Inception of a Wellbeing Group'

Sarah Mitchell

The Day Hospice team at St Vincent's Hospice (SVH) has been developing an approach which integrates rehabilitation, enablement, self-management and self-care into the holistic model of palliative care. This has led to the team delivering a 'Wellbeing Group', which is the first of its kind in a hospice setting.

The group combines exercise, support and education, which reflects the well-established and effective format of cardiac and pulmonary rehabilitation. It aims to allow patients to maintain/increase functional fitness, become more active, less sedentary and improve their knowledge of their illness therefore encouraging self-management.

Six palliative care patients attended an 8 week, 2-hour outpatient programme at SVH. The exercise component consisted mainly of circuit-based exercise and the 8 educational components covered topics such as coping with pain, breathlessness and fatigue.

At the end of the programme, the outcome measures (5 functional fitness tests) showed that every patient had improved their functional fitness in at least one aspect. Feedback from the patients was positive and showed they were starting to be more active despite their condition.

The initial Wellbeing Group achieved its aims. The team acknowledge that future programmes should evaluate the impact of the educational component to assess the potential impact on self-management in palliative care patients.

Relational elements of end of life anticipatory care planning (ACP): implementation in Dumfries and Galloway

Jacqueline Kandsberger

This study explores how ACP is currently operationalised in Dumfries and Galloway.

GPs from various districts and levels of urban-rural classification have been recruited. ACP data are being extracted from the medical records of decedent patients and GPs are completing a survey soon after the death of each patient, detailing the different elements of ACP discussions in each case and the associated relational and structural barriers.

After the first 5 months of the study 64 surveys on expected deaths have been collected across 18 GPs. ACP is a coherent process to GPs, however, time is a barrier to implementation and there is insufficient feedback for reflexive monitoring of the process. In 36% of cases patients were open to and capable of discussing ACP and in 67% family members were involved. Specific treatment wishes and personal relationships that influence care are examples of elements most often discussed, while cultural and other values or spiritual beliefs were almost never part of ACP. In 47% of cases information from ACP discussions changed the GPs’ care plan and recommendations at least to a small degree. 72% of patients had a KIS with varying levels of completion and effects on dying in their preferred place of death.

Poster abstracts of the month: September

The SPPC Annual Conference in 2017 featured 46 poster displays, sharing work and research underway across Scotland. Each month, this blog focuses on the content of a few of these posters. This month, we focus on five of these:

• Palliative and end of life care in the community
• Palliative and end of life care research in Scotland 2006 – 2015: A scoping review
• Palliative care in the ICU setting
• Palliative care from diagnosis to death: developing a rationale
• Palliative intent treatment for head and neck cancer: an analysis of local practice and outcomes

Palliative and end of life care in the community

Author(s)

Robert Sanders; Michelle Church; Paul Baughan

How the Living Well in Communities team - part of Healthcare Improvement Scotland's Improvement Hub - will support six Health and Social Care Partnerships across Scotland to improve the identification and care coordination of people with palliative care needs, fulfilling commitment one of the Strategic Framework for Action for Palliative and End of Life Care.

Each test site will consider ways to improve identification of people with a palliative need, develop anticipatory care planning and test community based models of care that increase opportunities for both generalist and specialist palliative care in the community.

The improvement programme will run for two years and learning from the tests of change will be shared during the lifetime of the programme in the form of learning assets and events.

Palliative and end of life care research in Scotland 2006 – 2015: A scoping review

Author(s)

Anne Finucane; Emma Carduff; Jean Lugton; Stephen Fenning; Bridget Johnston; Marie Fallon; David Clarke; Juliet Spiller; Scott A. Murray

Background: The Scottish Government set out its 5-year vision to improve palliative care in its Strategic Framework for Action 2016-2021. This includes a commitment to strengthening research and evidence based knowledge exchange across Scotland. A comprehensive scoping review of Scottish palliative care research was considered an important first step.

Method: Five databases were searched with relevant MeSH (Medical Subject Headings) terms and keywords; additional papers authored by members of the Scottish Palliative and End of Life Care Research Forum were added.

Results: In total, 1,919 papers were screened, 496 underwent full text review and 308 were retained in the final set. The top three areas were experiences and/or needs; services and settings; and physical symptoms. 58 papers were concerned with palliative care for people with conditions other than cancer – nearly one fifth of all papers published.

Conclusion: The findings reveal a considerable increase in palliative care research output over the last decade when compared with a similar Scottish review in 2006 and the 151 papers identified in a review of Irish palliative care research in 2013. The Scottish Research Forum in Palliative care will now disseminate key findings to clinicians, service managers and policy-makers to improve the reach and quality of palliative care.

Palliative care in the ICU setting

Author(s)

Dr Caroline Burke; Dr Niamh Feely; Dr Patricia Sheahan

A quality improvement project looking at the number of deaths in the ICU setting in a peripheral hospital in Kerry, Ireland in 2016 with regard to the prevalence of referrals to the Palliative Care Team and analysis of the cases where palliative care referral may have improved patient care. The problematic nature of providing expert palliation in critical and acute settings has been well recognised.

What is the definition of a "good death"? A significant number of seriously ill patients undergo overly aggressive management, inadequate pain control and suffer as a result of poor communication. There is huge variation in the withdrawal and withholding of therapy in European ICUs. This study was a retrospective chart review. The number of deaths in the ICU in UHK in 2016 was quantified at 40. Charts were analysed for data: Was the death expected or unexpected? If expected was the Palliative Care Team involved? If palliative care was not involved could they have improved care? Was there a missed opportunity for palliative input? 35 deaths were deemed to be expected. Of the 35 patients whose deaths were expected there were 9 incidences of Palliative Care Team involvement. There were 8 missed opportunities for Palliative Care Team involvement.

Palliative care from diagnosis to death: developing a rationale

Author(s)

Murray SA; Kendall M; Mitchell G; Moine S; Amblas-Novellas J; Boyd K

Early palliative care may prolong life as well as improve its quality, but it is frequently only started in the last weeks or days of life and largely for people with cancer. Its huge potential to minimise and prevent pain and distress across illnesses is not realised. This poster shows how early palliative care may be triggered for people living and dying from different conditions. It also points out the elements of palliative care that might often be relevant for people at different points in their illness. Palliative care might be triggered by non-physical needs which may alter greatly as the illness progresses.

Palliative intent treatment for head and neck cancer: an analysis of local practice and outcomes

Author(s)

Finn Begbie; Catriona Douglas; Fiona Finlay; Jenny Montgomery

Management of head and neck cancer is a complex area and there is often significant morbidity associated with treatment. Management options are divided into those given with curative intent and those given with palliative intent. Palliative treatment, sometimes described as best supportive care, can involve a wide variety of treatments. There is little consensus, and indeed a paucity of literature, on which palliative treatments should be provided for primary head and neck cancer and predicting outcome remains a grey area. The present study sought to delineate local practice and outcomes in patients treated with palliative intent in terms of survival, treatment received and associated morbidity in order to better inform treatment decisions in the palliative management of head and neck cancer.