Tuesday, August 30, 2005

Topical morphine for esophagitis?

The current J of Pain & Symptom Management publishes a letter about a novel therapy for esophagitis in 3 individuals receiving chemoradiotherapy for lung CA who were having severe esophagitis pain not responding to systemic analgesics.  They were given 2-10mL of a 0.1% morphine gel (morphine solution in a carboxymethylcellulose gel) about an hour before meals.  All 3 of the patients had marked improvement in analgesia with swallowing, which lasted 2-4 hours.  Clearly further stuides with more people & some form of control are needed but this will be quite nice if it proves effective--especially if it provides several hours of relief.

Tuesday, August 30, 2005 by Drew Rosielle MD ·

Sunday, August 28, 2005

Two articles about radiotherapy.

The April Radiotherapy and Oncology has two articles that seem pretty interesting, but unfortunately I can't get these in full text.  One proposes using single fraction (8 Gy) radiotherapy for metastatic spinal cord compression & claims to have good results (although, the appropriateness of XRT alone in spinal cord compression is being challenged).  The other article presents evidence that pain flares do in fact occur after radiotherapy for painful bony mets, at the rate of "2-16%."
If anyone can send me .pdf's of these articles I'd greatly appreciate it.


Sunday, August 28, 2005 by Drew Rosielle MD ·

End-of-Life: the Islamic View

This week's Lancet has a viewpoint article--End-of-life: the Islamic View. Below is pretty much how it concludes, but having read the article a couple of times it's not clear to me how these conclusions are based in Islamic law. This suggests to me that besides a prohibition against suicide & euthanasia Islamic end of life ethics/law are not surprisingly just as plural, conflicted, and idiosyncratic as Jewish or Christian. Insofar as death is plural, conflicted, and idiosyncratic (& awfully hard to choreograph) this seems somehow right to me.

"Withdrawal of life-sustaining treatments in such instances is seen as allowing death to take its natural course. Notwithstanding a fine line between having and not having an intention to cause death in such instances, Islamic law permits withdrawal of futile and disproportionate treatment on the basis of the consent of the immediate family members who act on the professional advice of the physician in charge of the case. Some Muslim jurists recognise as legal a competent patient's informed refusal of treatment or a living will, which allows a person to die under circumstances in which there are no medical reasons to continue treatment. However, even in such rare recognition of the patient's autonomy in Muslim culture, the law takes into consideration the patient's long-term treatment relationship with a physician whose opinion, in the final assessment, serves as the grounds for turning off the respirator, for example. In this instance, death is recorded as caused by the person's underlying disease rather than the intentional act of turning off the respirator; a fact recognised by the Shari'ah."

by Drew Rosielle MD ·

Review of states of prolonged impaired consciousness

August's Mayo Clinical Proceedings has a review, coauthored by Dr. Ron Cranford, of prolonged states of impaired consciousness in adults.   It covers the PVS, MCS, as well as akinetic mutism and brain death.  It is a somewhat casual & mostly descriptive piece & quite an interesting read.  What was most interesting to me was a lengthy description of the range of range of clinical findings in the PVS (varieties of eye & bodily movements, startle responses etc.)  Not surprisingly, it concludes with some words about the Schiavo case, including a jab at Dr. William Hammesfar (the Schindler's expert neurologist)--although not by name--& this nugget:

      Unprecedented in this case was a major focus on distinguishing a permanent vegetative state from an MCS. Far more surprising, being in an MCS was considered by some an opportunity for therapeutic intervention and the approach to take despite Schiavo's unchanged catastrophic neurologic state for 15 years.

by Drew Rosielle MD ·

Monday, August 22, 2005

Surgery better than radiation & steroids for metastatic spinal cord compression

Lancet has published a randomized controlled trial comparing immediate surgery + XRT with XRT & steroids alone in patients with spinal cord compression from metastatic CA.  50 patients were randomized to each arm and the results are impressive.  84% of the surgery group vs 57% in the XRT group were able to walk afterwards; the surgery patients retained the ability to walk for longer (122 days vs 13).  These findings applied as well to those patients who were ambulatory at the time of presentation (94% vs. 74% were walking at the time treatment ended & those in the surgery group walked for 150 days vs 50 days in the non-surgery group).  Ambulation was defined as the ability to walk 4 steps with or without an assistive device.  There was a modest mortality benefit in the surgery group as well (126 vs. 100 days).  To me the trial seemed well put together, the effects were large & consistent and clinically relevant & all of this adds up to a practice changing paper.  The authors' caveats are as follows:
 
"The patient population studied consisted of those patients for whom surgery would be regarded as a realistic treatment option. Patients with very radiosensitive tumours, multiple areas of spinal cord compression, or total paraplegia for longer than 48 h were excluded."

Monday, August 22, 2005 by Drew Rosielle MD ·

Saturday, August 20, 2005

Briefly, a couple of prognosis articles in the major journals

There have been a couple of articles relevant to prognostication in the last week. First, Annals of Internal Medicine has an article validating the International Prognostic Index (which uses age, disease stage, serum lactate dehydrogenase, ECOG performance status, and extent of extranodal disease to evaluate prognosis in AIDS related lymphoma) in the era of HAART & finds that it, along with the CD4 count, is valid. Those with the worst score had a 1 year survival of ~15%.
JAMA has an article looking at the epidemiology of acute renal failure in critically ill patients, finding that hospital mortality was 60%.

Saturday, August 20, 2005 by Drew Rosielle MD ·

Wednesday, August 17, 2005

Predicting prognosis in COPD

I've been digging around the literature on predicting prognosis in COPD & came across a very tidy & up to date summary in Current Opinion in Pulmonary Medicine. What has become clear, & what the COPM article corroborates, is that there are no clear ways of predicting who is 'hospice appropriate' by the 6 month criteria. All the published prediction criteria are helpful to differentiate prognosis on the order of years, not months (that is--who are most likely to die in 1-2 years as opposed to many years). Even the BODE grading system which was published in the NEJM last year (which uses BMI, FEV1, dyspnea, and exercise capacity to stratify mortality in COPD patients) differentiates people on the order of years--about half of those in the 4th quartile (worst quartile) of BODE scores were alive at 36 months. All of this makes me curious as to how physicians make decisions to enter COPD patients into hospice. Thinking about my own patients I guess it's been a gestalt of 1) severe COPD/low FEV1/hypoxia at rest/etc, 2) falling off the curve-ness (weight loss, loss of ADL's, increased frequency of hospitalizations), & 3) the patient's goals of care are hospice-congenial. All of this is very loose, but I'm not sure if the science is up to improving things currently. The natural history of COPD, though, just may make it a disease that's impossible to fit nicely into this 6 month business imposed by the Medicare hospice benefit that works well with cancer & ALS & there may never be a good way to predict mortality in COPD on the order of months. Perhaps what is needed is a more reliable way of identifying people with end stage COPD as they begin to fall off that curve...

Addendum--EPERC has recently published a Fast Fact on this very topic.

Wednesday, August 17, 2005 by Drew Rosielle MD ·

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.

Monday, August 15, 2005 by Drew Rosielle MD ·

Tuesday, August 9, 2005

Oral transmucosal fentanyl & how to dose it

A more mundane posting...the current Pain Medicine a nice long article about dosing strategies for oral transmucosal fentanyl. I'll freely admit that I checked Epocrates to make sure transmucosal fentanyl was available in the US--which it is--but I've yet to see it used, let alone use it myself. However, cost aside, I can imagine scenarios where it would be useful & this article is probably what I'll reach for on that day.

Addendum 8/18/05: of course the day after writing this slightly snarky post I found myself reaching for this article to troubleshoot converting Actiq to morphine in a patient who had to stop Actiq for financial/insurance reasons.

Tuesday, August 9, 2005 by Drew Rosielle MD ·

"Dying is awfully hard to choreograph"

This Sunday's NY Times magazine's cover story is about the changing face of hospice and palliative care in the US & asks, among other things, if hospice is losing its soul. It begins along these lines...

      It's all part of the new trend in hospice toward ''open access,'' meaning that terminally ill patients can continue chemotherapy and other treatments and still get hospice benefits through Medicacre. The idea began in the 1980's, when AIDS patients started enrolling in hospices and weren't quite ready to give up all medical options. Today hospice workers are also aligning with doctors in a field known as palliative medicine -- an approach that emphasizes pain relief, symptom control and spiritual and emotional care for the dying and their families. With hospice becoming so inclusive, and with palliative care on its way to becoming a new medical subspecialty with its own licensing exam, the natural, machine-free deaths we say we want are starting to look a lot like the medicalized deaths they were meant to replace.
The trend reflects society's deep ambivalence about dying. During the long and public agony over the death of Terri Schiavo, debate centered on the right to make end-of-life decisions. But underlying the political posturing was a shared assumption that was barely acknowledged: the belief that dying is something over which we have some control. This death-denying culture has led to a system of care for the terminally ill that allows us to indulge the fantasy that dying is somehow optional.

After reading this part I thought the piece was going to be an ignorant diatribe about how hospice should be little more than nurses putting cold towels on dying patients' foreheads and dripping morphine under their tongue.  However the article is long, balanced, and quite a detailed look into the contradictions involved in caring for the dying, especially when the dying aren't quite ready to die.  There's an undercurrent
of surpise in the author's rhetoric that the success of the hospice/palliative movement in the US hasn't dramatically made Americans more at peace with death and dying but, as she says midway through the piece, "dying is awfully hard to coreograph."  This is my new motto. 

by Drew Rosielle MD ·

Sunday, August 7, 2005

Turning off a pacemaker to hasten death

The Journal of Vascular Surgery has piece labeled a "surgical ethics challenge" about what to do about a request by a competent & terminally ill patient to turn off a pacemaker to specifically hasten his death.  I'm not sure why this is in a vascular surgery journal but perhaps in some places vascular surgeons implant pacemakers?  This is one of my favorite topics and there's been very little written about it.  Quite a bit has been written about turning off defibrillator-cardioverters at the EOL which is "easier" ethically as getting cardioverted is certainly a "burdensome" medical intervention; whereas a pacemaker, once installed, is itself quite a low "burden" medical intervention.  Requests to turn off a pacemaker are made specifically to hasten death; the "burden" is the suffering involved with the underlying illness, not the pacing.  The article concludes pacing is a medical intervention like any other & thus can be stopped for whatever reason.  One hopes in the next few years there won't be a Papal allocution defining pacing as a basic act of human caring & not a medical therapy...

Sunday, August 7, 2005 by Drew Rosielle MD ·

Advanced care planning for those with serious mental illnesses

The May 2005 issue of Psychiatric Services has an article about advanced care planning interests & preferences of those with serious mental illnesses .  This is, the authors believe, the first article looking at the a.c.p. needs of this population.  What is interesting, although I suppose it shouldn't be that interesting, is how straight-forward and common this population's end of life concerns were:  pain & suffering, financial problems, effects on loved-ones, etc.  Compared with a non-seriously-mentally-ill population they were a little more concerned with a proxy making life & death decisions for them, as well as less likely to name a family member as a proxy. 

by Drew Rosielle MD ·

Tuesday, August 2, 2005

This month's JPSM: questioning whole brain irradiation for metastatic disease

This month's J of Pain and Symptom Management has an interesting article about symptoms after whole brain irradiation for brain metastases .  This was a prospective cohort study using the Edmonton symptom assessment scale; average baseline Karnofsky score was 60.  Essentially they found no significant change in symptoms with the exception of slight worsening in fatigue, drowsiness, and appetite after the WBI at 12 weeks.  Median survivial was 8 weeks however, and they raise the question of the benefits of WBI in people who are likely to die within a few months.  They conclude by recommending a trial of dexamethasone alone vs WBI in this population, which sounds like a good idea of course, but selecting out those who have "anticipated short survival" would be tricky.
 
A quote:
The benefits of whole brain radiotherapy in brain metastases patients with poor performance status, extensive active extracranial disease, and anticipated short survival have been questioned. The magnitude of benefit using whole brain radiotherapy above dexamethasone alone in this subset of patients remains uncertain. There has been a proposal of a trial of dexamethasone alone versus radiotherapy and dexamethasone in patients with poor performance status and anticipated short survival.

Tuesday, August 2, 2005 by Drew Rosielle MD ·

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