Tuesday, November 29, 2005
As a palliative medicine physician involved in terminal extubations in the intensive care unit, I always encourage a team approach. During my residency I learned very quickly to include the respiratory therapist (RT) in making the plan to terminally extubate someone. I always ask the RT and the bedside nurse before we terminally extubate a patient two questions: Are you OK with this course of action? Do you have any suggestions to improve the care around the extubation? In addition I review the orders and the planned way we will extubate. I also stay with the patient before during and after the extubation to ensure quick access for symptom control measures.
After talking to a RT colleague of mine, I did a lit search on their involvement in the process and ran across this survey of RT attitudes and concerns regarding terminal extubation in the journal of Respiratory Care (free full text here). Since the RT and not the nurse or the physician is the person who actually extubates and enacts the order there may be issues of stress that are not always openly addressed. A one-page questionnaire was given to 183 RT's at 6 facilities in San Diego. Some of the more interesting findings were:
On average, respondents had been involved in terminal extubation on 2.2 occasions (range 0-12) within the last year, and 33 times in their entire career.The RT's were rarely included in the discussion with family or patient at the time of the decision. The estimates of physician presence averaged 18.6% (range 5.5-66%), and only 29% of RT's felt the attending physician should be present at time of terminal extubation. But they did find a correlation between the RT's perception of need for attending presence and how often the RT's estimated they were present. At the facility with 66% estimate of MD presence, more RT's felt their presence was important. This fact demonstrates how much the difference in ICU cultures can influence EOL care.
There are many more places this survey could go, particularly surveying hospitals with a strong or weak palliative medicine presence.
Tuesday, November 29, 2005 by Christian Sinclair ·
A couple things:
The current J of Clinical Oncology has a study on the incidence of jaw osteonecrosis in cancer patients receiving bisphosphonates. This is a prospective cohort study of 252 patients with heterogeneous cancers who received long-term bisphosphonates (median of 15 infusions over 20 months). Zoledronic acid & pamidronate were mostly used. Amount of exposure (median of 35 vs 15 treatments in those who did vs did not develop osteonecrosis) and time of exposure (median of 39 vs 19 months in those who did vs did not develop osteonecrosis) were strongly correlated with risk of osteonecrosis. The authors conclude with this:
The American Society of Clinical Oncology guidelines for [multiple myeloma] and breast cancer suggest that bisphosphonates should be administered "until there is evidence of a substantial decline in the patient's general performance status." Taking into consideration the natural history of these diseases, this could result in administration of bisphosphonates to some patients for several years. Nevertheless, the studies on which current guidelines were based usually administered bisphosphonates for a maximum of 2 years. In view of the data reported by us as well as by others, caution is required for use of pamidronate and zoledronic acid beyond 2 years.
This article is part of a larger focus of the issue of cancer treatment complications, including an interesting paper on regression of radiation fibrosis with pentoxifylline.
Also, the latest PC-FACS are out--excellent as always--but it seems the AAHPM is going to restrict them to members only (other than a free trial for non-members) & there are hints they may become subscription only. Perhaps this is part of a larger effort to improve the offerings to AAHPM members & thereby boost membership but there must be better ways. Mostly I'm afraid that this is going to have the inevitable effect of limiting the scope and influence of this valuable resource. Should people sign-up and pay for these? Hell yes. But I've been noticing what has happened at the NY Times ever since it hid its Op-Ed columnists behind a pay-only scheme ("NY Times Select"). Previously, 2-3 of the "top emailed articles" on NYtimes.com were always the latest from Krugman, Friedman, Dowd, and company. Now you rarely see any of them on the list. Sigh. Anyway, maybe there's some master plan that we aren't privvy to.
And finally--I'm trying to be brief--the current New England Journal of Medicine has a piece by GJ Annas about the Supreme Court's California medical marijuana ruling and the commerce clause and what it may all mean for medicine. The upcoming decision on the Oregon physician assisted suicide challenge is mentioned.
by Drew Rosielle MD ·
Monday, November 28, 2005
Chest has published an open-label trial of epidural methadone to relieve dyspnea from COPD. The idea behind the study was that the authors had noticed a marked reduction in dyspnea in COPD patients after lung-volume reduction surgery who received epidural analgesia for post-operative pain. The authors enrolled 9 patients with advanced COPD (FEV1 <35% of predicted), placed a T4-5 epidural catheter in each (these were external devices...not implanted pumps), and infused methadone at 6mg/day. They were followed for one month. After a month 3 had dropped out--one for a catheter infection and two due to catheter migration. Essentially, all the findings were positive: at 1 week and 1 month dyspnea & quality of life had improved compared to baseline; the 6 minute walk test (a standard test of exercise capacity in lung disease) had improved; and there was no evidence of CO2 retention (in fact pCO2 decreased a touch in the group). Given that the major putative benefits of epidural vs. systemic opioids are fewer side effects I was disappointed that they appeared to not collect ANY data on the typical & limiting opioid side effects (nausea, somnolence, dysphoria, constipation, etc). In addition, the authors noted that, after completion of the month, most of the remaining patients eventually discontinued the pump due to migration or infection--problems partially due to the use of external pumps. To me, this study has provided "proof of principle" that epidural methadone can palliate dyspnea--that it offers some benefits. What is clearly needed now is a comparison study with systemic opioids to see if the risks & costs involved outweigh those benefits.
Monday, November 28, 2005 by Drew Rosielle MD ·
Monday, November 21, 2005
Monday, November 21, 2005 by Drew Rosielle MD ·
Saturday, November 19, 2005
BMJ has just published a metaanalysis evaluating the risks-benefits of sedatives for treating insomnia in the elderly. Sedatives here means benzodiazepines and benzo receptor agonists (zolpidem/Ambien, zaleplon/Sonata, etc). It aggregates data from 24 (total n=2400) randomized trials of sedative agents in people >60 years old. Most of the studies were for 2 weeks or less, although a couple were longer. They found that the number-needed-to-treat for any measurable sleep "improvement" (which was measured heterogeneously across the studies) was 13, & the number-needed-to-harm was 6 (this number catches any measurable side effect...from benign--GI upset--to severe--falls, etc). The average increase in sleep length was 25 minutes vs. placebo. The head-to-head studies of benzo's vs benzodiazepine receptor agonists essentially found no difference in effectiveness or adverse effects, including cognitive ones. Morning or daytime fatigue was significantly worse with active treatment vs. placebo, with quite a strong odds ratio (3.8, 1.88 to 7.8, p<.001). They did not mention that they were able to compare benzos to non-benzos specifically for this outcome.
All of this has me asking why do I prescribe these drugs at all and why do patients like them so much? What's the point if you feel worse the next day? This is naive of course, and insomnia is an unpleasant symptom that may have nothing to do with actual sleep/daytime energy/etc. for many patients, and these agents are effective (somewhat) for this symptom. What disappoints me is how relatively high the NNT is: 13 is great when you're saving lives through cardiovascular drugs but not to treat an unpleasant symptom. In addition, the NNH is not helpful in deciding, for a given patient, if the benefits outweigh the risks. GI upset or headache are qualitatively different from falls/severe psychomotor side effects and aggregating a global NNH is clinically meaningless.
And, I must add that in the middle of the article sits this sentence:
A significant improvement in sleep quality improved significantly[.] It actually makes sense in context but there must be a better way to say this...
Saturday, November 19, 2005 by Drew Rosielle MD ·
Friday, November 18, 2005
My wife is a pediatric emergency physician (done with fellowship in 2006!) and so I get the pleasure of perusing her Pediatrics journal when it is delivered to our mailbox monthly. Well the October 2005 Issue was particularly exciting because my wife was the lead author on the first paper. (Not a palliative med article)
But since anyone reading this blog is unlikely to be primarily concerned about the correlation between HSV and the signs of pediatric abuse, I will get to the 2 palliative medicine minded articles that were in this issue. I will focus here on one of them.
The first article highlighted 6 controversies in Pediatric EOL care and the knowledge of these issues from residents, attendings and nurses. Now in reading this I thought these are just as relevant in adult EOL care and I thought there could probably be more pediatric oriented EOL care issues than these. Here are the 6 issues.
1. Withholding versus withdrawing life support.I would think a more pediatric oriented EOL dilemma is the issue of autonomy and surrogate decision-making in the pediatric patient; especially for the tween to teenager ages.
An assessment, from the child's perspective, of the burdens and benefits of offering or continuing treatment is what should count ethically, not whether a treatment has begun or not.
2. Medically supplied food and fluids.
Medically supplied nutrition and hydration are not ethically and legally required in all circumstances. They can be stopped or foregone, like all other medical interventions, when their burdens outweigh their benefits.
3. Use of opioids.
However, recent research suggests that, if the dosage has been titrated properly, then respiratory depression is rare even when opioids are used at very high levels.
4. Use of paralytic agents.
Their use should never be initiated during the withdrawal of life-sustaining treatments.
5. Brain death.
In all 50 states, death can be defined on the basis of neurologic criteria (complete cessation of brain function) as well as cardiac criteria, and permission of the family is not necessary for withdrawal of ventilatory support when either type of criteria is met.
6. The dead-donor rule.
Permanently unconscious patients are not allowed, by current ethical standards, to serve as organ donors.
They took these 6 issues and asked nurses, attendings and residents about them and found that many had concerns of conscience. Statements such as:
At times, I have acted against my conscience in
providing treatment to children in my care.
Sometimes I feel we are saving children who should
not be saved.
demonstrated that pediatric Hem/Onc attendings felt this less than critical care attendings (p=.0051). And over 50% of house officers and nurses agreed with these statements. But attendings agreed with these statements around 30% of the time. There are some more nuggets in this article, and it is a good read for contrasting what people say they know, and what they show they know.
Friday, November 18, 2005 by Christian Sinclair ·
Wednesday, November 16, 2005
Anaesthesia has an interesting and somewhat unusual article about end of life decision making in the ICU and Myers-Briggs personality typing. It looks at several years of a single ICU's practice of limiting/withdrawing life sustaining care prior to death, and analyzes the frequency of those decisions by attending physician, and by the attending physician's Myers-Briggs personality type (yes, I am embracing Christian's use of Wikipedia). The study is unfortunately limited by a whole series of assumptions that the authors made to determine, given how often the attendings worked, what percent of the treatment limiting decisions they should have each made (assuming there was no variation between attendings). Much of what they found is not surprising: ~80% of ICU deaths were made after a decision to limit life-sustaining care in some way & there was a wide variation amongst physicians regarding the frequency of being involved with treatment limiting decisions. What they then did was to administer the MB to the docs & they found that those who were disproportionately involved with treatment limiting decisions clustered towards the 'judging' end of the judging/perceiving domain.
Wikipedia on judging types:
J[udging]-types tend to prefer a step-by-step (left brain: parts to whole) approach to life, relying on external rules and procedures, and prefering quick closure...
& the authors of the article:
These individuals prefer a clear idea of what is expected, communication that is clear and concise, and decisions to be made quickely, clearly and finally.
What all this means is entirely unclear. However, it is refreshing to consider that the wide inter-personal variability amongst physicians regarding a willingness to broach the withdrawing of life-sustaining care in dying patients has a measure of predictability. On the other hand it's very possible that this clustering on the MB is catching a completely different phenomena not measured by the authors (place of origin, social class, type of medical training [pulmonary vs. anesthesia], age/experience, religiousity, who knows...). I'm just glad the authors asked.
Wednesday, November 16, 2005 by Drew Rosielle MD ·
Pallimed: A Palliative Medicine Blog has now been linked to the Wikipedia.
(Pallimed, Blog, and Wikipedia: What are 3 words that my grandparents might confuse for curse words? What are three words I never would have said 12 months ago?)
For those of you not familiar with the editable by anyone internet sensation, Wikipedia, you should check it out. For those already familiar with the Wikipedia, you may have found the Pallimed blog by clicking on the link on the bottom of the palliative care page.
by Christian Sinclair ·
Tuesday, November 15, 2005
I had the pleasure of hearing Mary Labyak, MSSW, LCSW of The Hospice of the Florida Suncoast speak at the Missouri Hospice and Palliative Care Association meeting this week. She spoke about her experiences as President of the hospice agency that was charged with caring for Mrs. Schiavo. Ms. Labyak's talk fit very well with a recent article in the Annals of Internal Medicine reviewing Mrs. Schiavo's case from three different perspectives. A firm knowledge of the legal, ethical, and medical perspectives of this case from fellow professionals and not the media is essential for anyone willing to call themselves a palliative medicine professional.
Regardless of your discipline in end-of-life care, the issues surrounding the case of Mrs. Schiavo are frequently recalled by patients, families and health care staff. One of my main functions is to overcome misconceptions about end-of-life care that are pervasive. By having a clear handle on the facts of this important case, we do a better service.
A quick review of the American Academy of Neurology’s requirements for persistent vegetative state is followed by a few important facts that discount the likelihood of improved functional status of a prolonged vegetative state:
Of the patients in the persistent vegetative state for more than 3 months after nontraumatic injuries, the probability of moderate disability or good recovery was 1% (99% CI, 0% to 4%), but for patients still in the persistent vegetative state at 6 months, this probability was 0%. No patient, even those with traumatic brain injury, has been reported to recover after a full year of being in the persistent vegetative state.The authors are a lawyer, an ethicist, and a neurologist from Nashville. (Which reminds me of a good joke...) They do a concise and competent job reviewing this case for the health care professionals interested in end-of-life, palliative medicine and ethics.
Tuesday, November 15, 2005 by Christian Sinclair ·
Thank you for the kind introduction Drew.
I am glad to be a contributor to the Palllimed Blog. Together, Drew and I may be able to cover more area to help you, the Pallimed Blog reader, become more informed about the advances in Palliative Medicine. We appreciate any comments on our posts and any feedback about the site. I look forward to collaborating with Drew and the Pallimed readers!
by Christian Sinclair ·
Sunday, November 13, 2005
The current J of Clinical Oncology is devoted to prostate cancer, & along those lines has a review on bisphosphonates for the prevention and treatment of bone metastases in prostate cancer. It opens with a succinct summary of the pathophysiology of bony mets in prostate cancer, as well as the pharmacodynamics of bisphosphonates. Next, it critically summarizes the data for bisphosphonates in prostate cancer, which is not much: the only drug/situation that has demonstrated benefit is zoledronic acid for the treatment of asymptomatic mets in androgen-independent prostate cancer. It showed a modest reduction in skeletal events (pathologic fracture, spinal cord compression, surgery or radiation therapy to bone, or change in antineoplastic treatment to treat bone pain) with a number needed to treat of ~10 to prevent one complication for 15 months of treatment. I'm not suggesting a NNT of 10 is high, especially given the potentially devastating complications--cord compression, etc.--it's just that I was surprised by how little evidence there was.
The other article I'll note from this issue is a review of therapy for advanced & refractory prostate cancer. I'll give kudos to the authors for noting that palliation, pain, and supportive therapy are of primary importance in this setting & talking about that first thing in the article, before talking about chemo, etc. It seems usually in review articles of this sort, supportive care is relegated to a paragraph at the end, if it all. Newer chemotherapeutic agents and other treatments are briefly reviewed in the rest of the article.
Changes: I am excited to announce that in the next week or so I'll be joined by a co-blogger on Pallimed! More info to come....
Sunday, November 13, 2005 by Drew Rosielle MD ·
Friday, November 11, 2005
September's Archives of Surgery has a paper examining surgeon's training experiences in palliative care and attitudes towards what they describe as "palliation in cancer." The study was based on a survey of a heterogeneous group of surgeons in the Sacramento area. Like most of the rest of the world, the surgeons evaluated had zero to little palliative care training (almost none in residency and fellowship--altho most had been practicing for over a decade--and about half had had a few hours of palliative care CME). What an opportunity....
Friday, November 11, 2005 by Drew Rosielle MD ·
Update Nov 13, 2005: well the reason I couldn't find any other news stories on this is because the warnings came out in July, which I completely missed, and for some reason Medscape decided to write a news story about it on the 9th. I'm laughing at myself.
by Drew Rosielle MD ·
Wednesday, November 9, 2005
Pain has a couple of very interesting piece amidst the murine model papers I've never been able to appreciate. First, an editorial about current research that buprenorphine not only has analgesic effects but also anti-hyperalgesic effects (as in opioid-induced hyperalgesia), via kappa-opioid receptor antagonism. The editorial of course refers to an actual article in Pain, but for the average reader (like me) I'd suggest sticking with the editorial. "Today, opioids cannot only be considered for their potency to reduce nociceptive symptoms but also for their ability to oppose active processes leading to pain hypersensitivity. This might be a new and beneficial approach for preemptive analgesia and improving the treatment of some forms of chronic pain dominated by central sensitization."
And then, the article which explains several life-long habits of mine: chewing gum relieves pain. I'm not going to bother to critique this one--it's actually really interesting with a lengthy discussion about serotonin in nociception, speculation about the the necessity of rhythmic chewing to achieve the nociception, and a brief review of the chewing & analgesia literature. I do want to highlight my appreciation of the authors' quietly funny prose however:
"The NFR recording and stimulating electrodes were attached to the subject. All recording and stimulation electrode sites were cleaned and gently abraded. The reflex was induced by transcutaneous electrical stimulation of the sural nerve at the right ankle while the subject reclined in a comfortable armchair with the lower legs bent to an angle of less than 150 degrees so as to achieve a state of muscular relaxation."
A subject was asked to chew gum voluntarily and rhythmically for 20 min at a comfortable speed (task experiment). To ensure the intensity and rhythm of mastication, we monitored EMG of masseter muscle throughout gum chewing. The composition of gum (Xylish sugarless, Meiji Co., Tokyo, Japan) was gumbase, maltitol, xylitol and so on. The flavor was mint. The quantity of gum was up to the subject. The mean quantity was 4.3±1.4 g."
Finally, there's a review on neuropathic pain from the non-surgical treatment of breast cancer (chemo and radiation therapy).
Wednesday, November 9, 2005 by Drew Rosielle MD ·
Tuesday, November 8, 2005
Annals of Internal Medicine has an article from the San Diego Hospice about " The Academic Hospice." It is a brief introduction of the relatively new (& according to the authors, exclusive field as there are only 6 in the US) phenomenon. It is written with the confidence of a specialty/field which is about to come into its own in the mainstream of US medicine. What, however, is most interesting about the piece are its several opening paragraphs weaving together the history of hospice with the history of medicine. A sample:
The link between medicine and religion was inextricable until the Renaissance. Religious societies ran the earliest institutions called hospices that cared for the ill, primarily people who became ill while traveling. People either recovered and continued traveling, or died. The words hospitality, hotel, hospice, hostel, and hospital are all derived from the same Latin root word hospes, meaning "guest". Hospitals as identifiable institutions evolved from these early efforts. For example, St. Bartholomew's Hospital in London was founded in 1123. At the time, there was no practical difference between the meaning of hospital and hospice. Hospitals as institutions for teaching evolved from the observation that the care and study of patients are more convenient for physicians if the patients are assembled in one place. The need for hospitals to "market" themselves also evolved. Records from 1544 from St. Bartholomew's Hospital indicate that patients were not to be admitted if they had incurable diseases or conditions. The hospital apparently wanted a reputation for caring for people who could be cured. Subsequently, the term hospice was reserved for dedicated places for the care of patients who were incurably ill (and poor). These hospices were mostly administered and staffed by Christian religious orders in France, Ireland, Scotland, and England. In the United States, early examples of hospice care were the Dominican Sisters of Hawthorne and Calvary Hospital, both located in New York City.
Tuesday, November 8, 2005 by Drew Rosielle MD ·
Monday, November 7, 2005
November's Mayo Clinical Proceedings has several important articles ( table of contents for the entire issue).
First, is a lengthy summary and discussion of the, as they put it, Terri Schiavo "saga," that grew out of a grand rounds at Mayo. It is quite thorough and a good read, and one hopes--probably unrealistically--that certain public officials and prominent opinion makers will read this with an open mind. It ends with several pages of addressing the specific ethical questions the case raised, as well as asking "Is there a better way?" Which brings up something I meant to blog a while back: I attended a speech given by Michael Schiavo (at an end of life ethics conference) & he said a few interesting things. First, given that it is often mentioned as an unclear point in the Schiavo history (including this article), Michael Schiavo stated that it was, indeed a conflict over money/the settlement that caused the rift between him and the Schindlers. The second, and much more interesting point, is that Mr. Schiavo said it's his belief that there's nothing doctors/the medical community could have done to prevent the conflict, that it was a family/personal conflict, & not a failure of Terri Schiavo's docs or anyone else. As a doc, that sounds reassuring to me, and on reviewing the case in this article, it seems like he's right. Despite being touchstones for all of us, cases like Schiavo's going to the courts are rare; and while getting the courts involved is generally undesirable her case seems like a reasonable one for the courts (to establish what her wishes would be given there was intractable conflict within the family & no written evidence of her wishes). What went tragically wrong with the case was not this but the extra-judicial involvement, the political intervention--"Terri's Law," Jeb Bush, Bill Frist's speech, Tom Delay's intimations of violence against "activist judges," President Bush flying back from Crawford, Judge Greer getting death threats and booted out of his church, etc. That's the problem & promoting advanced directives isn't going to fix that....
I've already blogged too long tonight, but there's also a review of the medical and ethical aspects of long-term enteral tube feeding. Thorough, and despite being written by a bunch of MD's, seems to have a distinct speech-pathologist flavor to it. It presents much of the same material as the JAMA 2004 review of tube feeding, with more stuff on post-stroke & cancer patients.
And finally, there's a review of adult acute lymphoblastic leukemia for those of you interested.
Monday, November 7, 2005 by Drew Rosielle MD ·
Wednesday, November 2, 2005
Wednesday, November 2, 2005 by Drew Rosielle MD ·
Tuesday, November 1, 2005
The current NEJM has a review on the medical management of depression. It's solid. One sentence of it caught my attention however, in the section about discontinuing treatment: " The discontinuation syndrome is sometimes called the withdrawal syndrome, erroneously implying drug dependence." Am I wrong in thinking this is a weird and misleading statement, especially from a psychiatrist? I have been taught that (physical) drug dependence is in fact defined by the occurance of a withdrawal syndrome if the drug is discontinued (which usually prominently includes somatic symptoms and not necessarily "cravings"). I'm not sure if the author meant to write "erroneoulsy implying drug addiction" or if there's some custom of only using the term "dependence" in relation to drugs of (potential) abuse/addiction. If so, that seems wrong to me, and not based in physiology. Correct me, however, if there's something I'm missing.
Tuesday, November 1, 2005 by Drew Rosielle MD ·