Monday, August 15, 2005

The current Archives of Internal Medicine: four end of life articles!

The current Archives of IM has four end-of-life themed articles.  One article examines regional variations in early DNR orders in hospitalized patients in California and finds that people in smaller, non-profit, and non-academic hospitals were more likely to have early DNR orders than people in larger, for-profit, and academic hospitals. 
Another article looks at factors underlying the provision or denial of euthanasia requests in the Netherlands.  What I'll point out, and what went totally without comment in the article, was that the physicians surveyed for this article reported that 88% of the patients who 'received' euthanasia has no other treatment option including palliative.  This also means that for 12% of patients who recieved euthanasia their docs thought they did have palliative options....  Now the authors don't define what this means, maybe it was explicit like palliative chemo or radiation therapy, but I doubt it.  Of course I'm coming at this from the perspective that everyone can be palliated, and I acknowledge that most of the people seeking euthanasia do it not for physical suffering but out of existential suffering & fear of loss of control, & that perhaps terminal sedation is not the best treatment for existential suffering.  But is lethal injection a better alternative?
A third article presents a palliative clinical pathway for people dying in the hospital.  Publications examining the successes palliative clinical pathways are pretty common in the palliative journals, but this is the first I've seen in memory in a major non-palliative journal, so horray.
And finally there's a piece about foregoing artificial nutrition & hydration in severely demented Dutch nursing home patients.  It is an observational study which relies on the assessment of suffering by the NH physician & for most of the patients the decision to stop/not start artificial nutrition & hydration occurred around the time of an acute event (infection, stroke, etc).  All of this is to say that most people died pretty quickly and that their suffering decreased the closer they got to death probably b/c they were becoming unresponsive and were regressing to the mean after their acute event.  Thus, this article continues the long tradition of messy, observational surveys indicating that people don't seem to suffer much from foregoing artificial nutrition and hydration at the end of life, but one can't say that it has elevated the field much.

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