Friday, December 29, 2006

Patients' "understanding" of CPR; some reviews; NY Times

A little New Year's clean out of my back-log of 'to-blog' articles, plus some news articles...

1)
Chest recently had an article about patients' & families' understanding of CPR. The study involved interviewing ~400 hospitalized patients (and some of their families) with advanced cancer or medical illness (CHF, COPD, cirrhosis). It was a multicenter study in several Canadian teaching hospitals; just under half of the patients had a pre-existing DNR order, and in follow-up over half the patients were dead at 6 months. Some of the results were pretty shocking, most notably that almost half (44%) of the subjects couldn't identify a single element of CPR (artificial breathing/intubation, chest compressions, shocks, drugs). Less surprising is that <5% of patients could accurately state their own prognosis for survival of CPR (most stated they didn't know or were wrong). A good third of the subjects said they didn't want to talk with their doctors about resuscitation (although this is difficult to interpret since most didn't really know what it meant anyway). Most patients endorsed some sort of shared decision making (with doc & family) about performing CPR or not, although a fifth said they thought the decision was theirs alone. Patients generally ranked prognostic outcomes as the most important information they need to know about CPR. There are lots more findings and it's a recommended read. I've long thought the problem with CPR discussions with patients etc. have been due to misconceptions about it, but this research suggests it's more that patients have no conceptions about it. I'm trying to decide whether this will change the way I speak with my patients about it and I'm not sure if it will. However, I'll likely incorporate it into how I teach housestaff/medical students how to have these discussion: assume the patient knows nothing, what they do know is wrong, and what they want to know is the expected outcome (not the gory details of the intervention).

2)
Geriatrics this summer had a review article on feeding tubes in advanced dementia, reviewing the evidence, ethics, and communication challenges surrounding them. It doesn't add much to the debate, but it is a good, comprehensive review of the issues involved and it's a good addition to one's teaching file (it's actually quite plainly written and would be easily understandable to non-medical colleagues--chaplains, social workers, etc.).

3)
Seminars in Oncology recently had two reviews of note: one on the management of spinal cord compression, the other on neoplastic meningitis.

4)
It's been a busy week in the NY Times. First is an op-ed about the "most-avoided conversation in medicine " (that would be the one about how the patient is dying). It's written by a surgeon, strongly advocates not avoiding the conversation, and liberally references the SUPPORT trial. Thanks to Dr. Lynn Bunch for alerting me to this. I'll also recommend the recent article about Dr. Michael DeBakey's aortic dissection repair at the age of 97--it's a fascinating story involving pseudonyms and late night emergency ethics meetings and discusses among other things the ethics of extraordinary care for the oldest old (and VIP's).

Friday, December 29, 2006 by Drew Rosielle MD ·

Wednesday, December 20, 2006

Another word on the Abigail decision

This is from my brother, a lawyer, on the Abigail decision. Probably a little more reasoned than my tantrum last week about this.

"[T]hat ruling was really, well, weird.

i googled it and came upon this summary which was pretty good:

juvanshealthlawupdate.typepad.com

so whats going on is that DC circuit is "finding" (quite literally discovering) a "new" right that is protected by the 14th A Due Process Clause (DPC).

Realize that these "discoveries" are very important - see e.g. protecting the rights of homosexuals to engage in sodomy (Lawrence v. Texas), right to privacy (and thus, right to abortion) (Roe).

So, as the blog points out, the DC Cir applied the "Glucksberg Test" to determine whether the right asserted is protected by the DPC. They obviously did, and, as Groopman points out, the really "weird" part is the use of Cruzan as precedent.

It doesn't seem to follow that a right to be free of battery, which is required for liberty/democracy/etc, also requires "the right to access potentially life-sustaining medication where there are no alternative government-approved treatment options."

(At this point he reads the ruling)...

"[H]ere is the holding:

"Terminally ill, mentally competent adult patients had a due process right to informed access to potentially life-saving investigational new drugs determined by the Food and Drug Administration (FDA) to be sufficiently safe for expanded human trials, where there were no alternative government-approved treatment options."

i think this means:

a) you are going to die
b) you are sane
c) thus you get access to drugs past phase I trial (which means drugs are in, or suitable for, phase II human trials - thus humans are getting the drugs anyway)
d) if there are no FDA approved drugs on the market

this seems distinct from what you say on your blog entry (sort of a anyone gets anything approach) but i just read your entry once so perhaps not.

i've skimmed the opinion and all i can say is that it is a pretty damn compelling read. i think Groopman suggested that it's ripe for reversal but i'm not entirely sure. Certainly an expansive view of the right to unregulated drugs is unlikely to be adopted, but, in my ignorance, i think points A) - D) above seem reasonable and potentially a constitutionally protected right."

Stated that way, it does seem more reasonable than my initial reaction, and I hope he's right. Thanks Julian Rosielle, Esq. And so, for real this time, Happy Holidays.

Wednesday, December 20, 2006 by Drew Rosielle MD ·

Oxygen for dyspnea; l-carnitine; opioids & hastened death (or not)

A few interesting articles from December's Journal of Pain and Symptom Management.

I'm going to be travelling for the next few days and likely won't post again until next week. For those of you who celebrate a winter holiday...Happy Holidays.

1)
First is a randomized trial of oxygen for dyspnea in advanced cancer patients. It looked at 50 advanced cancer patients in an Australian cancer center (both in- and outpatients); all had dysnpea due to their cancer (although this was determined quite subjectively). Median age 65; most had ECOG performance statuses of 3. 17 were hypoxic. They received either oxygen or room air delivered at 4L/minute by nasal canula in a randomized, double-blinded fashion. They received this for 15 minutes, had a 30 minute wash-out, then crossed over to the other treatment. Basically both groups' dyspnea improved equally. The hypoxic patients (14 of whom became normoxic with oxygen) also improved equally with air or oxygen. The authors conclude that supplemental oxygen does not per se improve dyspnea in these patients. While I'm sympathetic to these findings, and appreciate all reminders of the complicated, pleomorphic nature of dyspnea, this conclusion needs to be taken with a grain of salt. This is not a mandate to rip off nasal prongs, as patients receiving air through them improved (just no less than with oxygen). In addition, while the study was powered adequately to determine a difference between oxygen and air for the entire 50, it was not powered adequately to determine a difference in just the hypoxic patients, so we can't conclude oxygen and air are equivalent in these patients, and giving patients a trial of normoxia seems very justified! This study however highlights how much more is going on with dyspnea than simply a lack of supplemental oxygen....

2)
Next is a preliminary study of l-carnitine for cancer fatigue . This was a preliminary study that I'm not going to spend much time on other than to note it: cancer-related fatigue is widespread, poorly understood, and poorly-treated (insofar as we don't know how to treat it). This study looked at 27 advanced cancer patients with low serum l-carnitine levels and moderate to severe fatigue. L-carnitine supplementation wasn't toxic, some patients seemed to improve on it. One assumes we'll be seeing larger, placebo-controlled trials.

3)
Finally is a another study on opioid use and mortality in hospice patients. It is a retrospective study looking at ~700 hospice patients, opioid use and dose changes, and death. Essentially, the authors looked at the amount of opioid use and the amount and timing of opioid dose changes, divided the subjects into different groups based on these factors, and tried to find any differences among them regarding time to death. Overall, they didn't. In their multivariate analysis, final opioid dose was associated with time to death (higher opioid dose = shorter time to death), but timing of final dose change and the percent amount of the final dose change were not. In addition the magnitude of the final opioid dose explained only 6% of the variance in survival (meaning that it didn't strongly predict shortened death). In their sample, the median time to death from the last opioid dose change was ~12 days, again suggesting that--in this population as a whole--opioid dose changes didn't lead to death (12 days is long enough that the effect of the last opioid dose change likely had little to do with the timing of death).

It should be noted that there was a lot of missing data in this study (the data wasn't initially collected for the study), limiting its conclusions. That being said, this adds to the slowly accumulating empiric evidence that opioid use near death just isn't a big factor in hastening death (all the studies have been poor quality, but all have had similar conclusions, meaning that if opioids are hastening death it is not on a magnitude large enough to be picked up by these studies). Because of this I officially call for a moratorium on the use of "morphine in the dying patient" as an example of the principle of double effect in the medical education literature. While I'm fine with the PoDE, using this as an example subtly promotes the idea that we are killing people (hastening death) by providing comfort for them. On the other hand, it must always be held clear that these are population based studies, and individually, there probably are some patients whose deaths are hastened directly due to the use of opioids, but these are rare enough not to be picked up. When I have family members ask me about this I usually reassure them that if opioids do hasten death it's likely on the order of hours or a day or two, but no longer.

by Drew Rosielle MD ·

Tuesday, December 19, 2006

More on the Italian Right to Die Case

(My Standard Disclaimer: Dr. Sinclair, Pallimed and his current and former employers do not endorse or practice euthanasia or physician-assisted suicide, but do encourage the open, non-judgmental discussion of these topics for educational and ethical discourse about this controversial area of medicine.)

Just an update on Piergiorgio Welby, the 60 year old man in Italy with muscular dystrophy who is requesting to be sedated and have his ventilator to be removed. The NY Times has probably the most in-depth and human article I have read on the issue so far.

A couple of key points that complicate the matter:

Most media outlets are confusing the terms euthanasia, suicide, and withdrawal of unwanted medical support.

Some clarification of the terms for serious ethical discussions about this topic:
  • Euthanasia: the act of ending of life via intentional administration by a health care professional of medications at doses considered supertherapeutic with the goal of ending life. The cause of death becomes the medication and not the disease process. Euthanasia can be termed voluntary or involuntary.
  • Suicide (Physician-assisted): the act of ending of life via intentional self-administration of medications at doses considered supertherapeutic with the goal of ending life.
  • Withdrawal/Withholding of Medical Treatment: the act of withdrawing/withholding any medical therapy (ventilator, hemodialysis, chemotherapy, medications, artificial nutrition, artificial hydration), when the therapy A) no longer meets the goals of the patient (or surrogate decision maker when the patient lacks capacity), or B) the burdens/risks greatly outweigh the benefits.
  • Aggressive Symptom Management/Palliative Care: the process of assessing, treating and reassessing symptoms and adjusting medical treatment in a measured and gradual manner with the goal of controlling symptoms, with the cause of death being from the progression of disease.
Some clarifications of legalities:
  • In the United States, euthanasia is illegal and not supported by any major medical societies.
  • In the United States, (physician-assisted) suicide is illegal except in the state of Oregon, where it was approved by voters in 1994 and again in 1997. It has been allowable by law since 1997, and has been heard by the Supreme Court of the US.
  • In the United States, withdrawal or withholding of medical treatment is considered legal in all 50 states, and ethical by most major medical societies.
Apparently in Italy this last point is not legal, and apparently physicians are required to continue medical treatments to prolong life no matter the burden to the patient, effectiveness of the treatment, or the requests of the patient.

The matter is also complicated in that the patient has long been an advocate of euthanasia (which is legal in the Netherlands, Belgium and Switzerland) in Italy. Also the Catholic Church is involved with many hospitals and physician groups as well as Italian politics so that brings in the theological aspects of this discussion as well as the medical, ethical, legal and cultural norms.

Here are a few other links on the matter which may be of interest:

Italian article (in English) from Dec 13 highlighting the political situation

Video reading of letter (below) in English (first video post on Pallimed...woo-hoo!)



Piergiorgio Welby's letter to the Italian President (quite long, but he is a skilled writer, except again he fails to clarify the difference between euthanasia as I described above, and withdrawing unwanted medical treatment)
Open letter to the President of the Republic, Giorgio Napolitano

From Piergiorgio Welby, Co-President of the Luca Coscioni Association
September 21, 2006

Mr President,

I am writing to you, and through you I am addressing also those citizens that will have the opportunity to listen to these words, to this cry of mine, which is not one of desperation, but one full of human and civil hope for our country.

Until two and a half months ago, my life may have been marked by rather serious difficulties, but I was able, at any time of the day, to use my computer and write, read, do research and chat with my friends on the Internet. Today, I seem to have fallen into an abyss from which there is no exit.

The day starts with the alarm of the lung ventilator device, while humidifying filter and the mouth catheter is changed, the day continues with the radio in the background, between frequent aspirations of tracheal secretions, the monitoring of oximetric parameters, personal cleaning, medication, and Pulmocare beverages. I used to get up at ten at the latest, and start writing on my PC. Today, my pathology, muscular dystrophy, is in such advanced state, that I cannot make any movements, and my physical balance has become extremely precarious. I get up at noon with the help of my wife and an assistant, but more and more frequently I find myself sitting without opening my computer, because I feel dead tired. I force myself on the chair to assume, for at least an hour, a position other than lying in bed. When I go back to bed, at times I fall asleep, but wake up in a fright, perspiring and more tired than before. I turn on the radio, but listen to it without paying attention. I cannot concentrate because I am constantly thinking on how to put an end to this life. Around six, I make another effort to sit, with the help of my wife Mina and my nephew Simone. Every day I get worse, weaker and more tired. After about an hour they take me back to bed. I watch TV waiting for the Tavor tablet so that I can fall asleep and not feel anything, hoping that I will not wake in the morning.

I love life, Mr President. Life is the woman who loves you, the wind through your hair, the sun on your face, an evening stroll with a friend. Life is also a woman who leaves you, a rainy day, a friend who deceives you. I am neither melancholic nor manic depressive. I find the idea of dying horrible, but what is left to me is no longer a life… it is only a stubborn and senseless obstinacy of keeping active the biological functions. My body is no longer mine… it is there, spread before doctors, assistants, and relatives. Montanelli would understand me. If I were Swiss, Belgian or Dutch, I could escape from this utter outrage, but I am Italian and there is no pity in Italy.

You are probably thinking, Mr President, that I am appealing for a “dignified death” for myself. But no. That is not it. And I am not talking only about my death.

Death cannot be “dignified;” it is life that should be dignified or decent, especially when it is growing weak because of old age or incurable illness. Death is something else. To define death by “dignified” euthanasia is to deny the tragic dimension of dying. It is tantamount to continuing to conceal and to distort death that, driven from home, hidden by a screen in hospitals, neglected in the loneliness of the homes for the aged, seems to be something that it is not. For what is death? Death is an indispensable condition for life. Aeschylus has written. “It’s hard to struggle. Decay is setting in, like a swelling flood. A blind ocean, a cesspool of pain surrounds me without even a glimmer of hope. There is no landing place. There is no landfall.”

And yet there is a landfall, but euthanasia is not a “dignified death” but an appropriate death, in the words of a man of faith, Jacques Pohier. Appropriate is that which “carries to the port;” for Plutarch, the death of young people is a shipwreck, that of old people a landing at a port, and Leopardi defines it as the only “place” where rest, not bound but secure, is possible.

In Italy, euthanasia is a crime, but this does not mean it does not “exist:” there are calls for euthanasia which are not heeded to because the doctors are afraid of being criminally prosecuted, and conversely, acts of euthanasia may be practiced without the informed consent of patients who are conscious. To grant a request for euthanasia, certain European countries, such as the Netherlands and Belgium, have introduced procedures that enable a “terminally ill” patient to plan with the doctor, the course for “landing” at an appropriate death.

A law on euthanasia is not the incomprehensible request of a few eccentrics either. Even in Italy, there were four or five bills already introduced in the last legislature. The association of anaesthetists, with great circumspection, has asked for a clearer law; the recent decision of the lapsed (and not yet renewed) national bioethics committee on the advance directives for healthcare revealed that it was impossible to exclude any eventuality of euthanasia in the event that the doctor adheres to the advance provisions drawn up by the patients. Even in the Church’s strict position there are certain openings, albeit within the confines of tradition, that allow for a heavy intervention with palliative cures and do not allow for intervention with disproportionate treatments that do not entail concrete benefits for the patient. Public opinion is always more aware of the inherent risks of leaving every decision about treatment up to the doctor. Many have helped a family member, a friend or a relative during an incurable or highly debilitating illness and have come to the decision, that if they were faced with the same predicament, they would not follow the same path. Others have witnessed the tragedy of a person in a persistent vegetative state.

When we face issues connected to the end of life, we are not dealing with a dispute as to who is in favour of life and who of death: all patients want to be cured, not to die. Those who share, with love, the course imposed by the illness on the loved one, want that person to recover. Between wishes and hopes, time passes relentlessly, and with the passage of times, hopes grow weaker and the desire to be cured becomes a desire to shorten the course of desperation before reaching that natural end that the reanimation technicians and machines that support or stimulate the vital function risk posting ever forward in time. As to our technical possibilities of keeping people alive, there will come a day when swarms of living dead will come out of reanimation centres, who will wind up vegetating for years. We will probably all have to learn that death is also a learning process, and merely a matter of falling into a state of unconsciousness.

His Holiness, Pope Benedict XVI, has said that “to the claim often put forward that it is necessary to resort to euthanasia in order to eliminate suffering, we must corroborate the inviolable dignity of human life, from conception to its natural end.” But what is “natural” in a reanimation room? What is natural in a hole in the belly and a pump that fills it with fats and proteins? What is natural about a hole in the windpipe and a pump that blows air into the lungs? What is natural about a body kept biologically functional with the help of artificial respirators, artificial feed, artificial hydration, artificial intestinal emptying, of death artificially postponed? I believe that it is possible to play with words for reasons of power or faith, but I do not believe that it is possible to “play” with the life and pain of someone else for the same reasons.

When a terminally ill patient decides to forego emotions, memories, friendships, and life, and asks to put an end to a survival that is cruelly “biological,” … I believe that his will should be respected and heeded with the compassion represented by the force and consistency of secular thinking.

I am aware, Mr President, that I have spoken to you, through my sick body, also of politics, and of objectives necessarily to be debated freely in Parliament, that do not call for your intervention or decision as to their merits. What I do take the liberty of recommending to you, however, is the defence of the right of each and every citizen to be apprised of the proposals, reasons, stories, wills and lives which, like mine are faced with this conundrum.

Luca Coscioni’s dream was to free research and to give a voice – in every sense of the term – to those who are ill. His dream was interrupted and it became known only after it was interrupted. So it is now up to us to dream for him too.

My dream, also in my capacity as co-president of the association that bears Luca’s name, my will, my request, that I wish to bring before all authorities, starting with the political and judicial bodies, is today clearer and more precise in my mind than ever before: to be able to obtain euthanasia. So that Italian citizens can have the same opportunity that is granted to Swiss, Belgian and Dutch citizens.

Piergiorgio Welby


Did you really read all the way to the end? I am so impressed! Leave some comments please, this is a contentious issue, surely this is something you want to say something about. Or leave some comments about the letter and some of the very interesting phrases he uses.

Tuesday, December 19, 2006 by Christian Sinclair ·

Monday, December 18, 2006

Some musings on the Sunday Paper: Cancer & Prognosis; Right to die in Italy

I have a keen interest in the way medicine is portrayed in the media (TV, print, etc.). I think most good docs should have a good understanding of how most of their patients may collect information about disease, treatments, and outcomes. There has been a big push for health care to be more openly measured on performance and cost, but even with a lot of metrics out there, I think most of our patients and their families will go on information passed on by friends, and by a report of a great breakthrough in "(insert name of disease here)" on the evening news or in the paper.

So I was relatively pleased to see a large second page article in my Sunday paper about prognostication in cancer. The push for more information to get to the consumer with the benefit of multiple new therapeutic options (of varying toxicity and benefit) has made most people realize that making these decisions can be very difficult.

When a patient in the article was offered a host of choices by her doctor she replied:

"I'm having a little trouble following you," Rastelli, a single mom, said doubtfully.

"I know. This is a lot to take in," said her doctor, Kathy Albain.

They then turned to something called Adjuvant Online. It is a pretty slick JAVA Web based prognostic modeler for Breast Cancer, Lung Cancer, and Colorectal Cancer. It basically will tell you based on a number of disease specific factors, and patient related characteristics, what the difference in mortality is from cancer, therapy, or other disease at five years. It is intended to be used by health care professionals in counseling patients. Of note it is sponsored by a Breast Cancer foundation and AstraZeneca (maker of ARIMIDEX® (anastrozole)).

It is a well put together program with lots of extra information and slides/pictures for shared decision making with your patients. If you are an oncologist you should surely take a look at this site. For palliative med providers, we could consider making programs like this for approximating many other interventions and their values closer to the end of life. For more on evidence based formulation of prognosis you should come to the Annual Assembly at the AAHPM in Feb 2007 and see my 4 hour pre-conference on the topic. (Shameless plug!)

The article also mentioned a Mayo Clinic program called Numeracy, which does a similar thing, but even with my Google skills, I could not find it.

Dateline Rome, Italy
The other article that caught my interest was one that described a case in Italy where a judge rejected a request for withdrawal of a ventilator from a 60 year old man, Piergiorgio Welby, diagnosed with muscular dystrophy as a teenager. He receives artificial nutrition and communicates with a voice synthesizer which reads his eye movements. Apparently he has a constitutional right to refuse treatment and even stop treatment once started, but the Italian medical code (not a law) requires maintenance of life (apparently without a clause about patient choice or at what cost.) Italian physicians stated they could not carry out 'treatments aimed at causing death.' They also mislabeled this as a potential suicide or euthanasia if carried through. First of all it cannot be suicide because the main actor in a suicide is the patient himself. And euthanasia involves the introduction of a new means other than disease progression as the cause. This is more accurately described as withdrawal of medical therapy which then should be argued on its own merits, as opposed to using such polarizing and misunderstood terms as suicide and euthanasia. There was a slight nod in the article to the influence of the Roman Catholic Church with the courts in Italy.

For more article you can use Google News.

A last quote for reflection.

He has even written to Italy's president asking to be taken off the machine that keeps him alive so he can, in his words, "find peace for my tortured and shattered body"

Monday, December 18, 2006 by Christian Sinclair ·

Saturday, December 16, 2006

Site feed problems

I've realized that since I upgraded the blog that there's problems with the site feed. The former feed doesn't seem to be updating & Feedblitz appears to have stopped updating as well. I can't say that I've figured it all out yet.

It appears that the new feed may be: http://pallimed.blogspot.com/feeds/posts/default

That is now what's in Feedblitz. If you subscribe to Pallimed's feed another way you may need to update it. Sorry for any inconvenience...although I suspect the problems aren't over yet.

--Drew

Saturday, December 16, 2006 by Drew Rosielle MD ·

Friday, December 15, 2006

Captain Drew's Real Doctor Hoary Plantain Solution

Well it's media week (or month, frankly, looking back over recent posts) here at Pallimed...

The current New Yorker has a feature article by Jerome Groopman about the movement here in the US to expand dying patients' access to experiment drugs. This includes proposed rules by the FDA to--essentially--expand, simplify, and make more economically viable 'compassionate use' of drugs that are in phase III trials (or are looking good late into phase II trials). That, such as it is, seems pretty reasonable and a good thing.

On the other hand, the article also describes a movement, centered around the group "Abigail Alliance ," which is promoting a position that dying patients have a right to receive experimental drugs in sort of a de-regulated 'compassionate use for everyone no matter what the drug is' fashion. There is related legislation floating around which tries to enact this--and my understanding of this legislation is that it would include drugs which have passed only phase I testing (someone in the article points out you could easily get shark cartilage past phase I). In addition, a D.C. District Court of Appeals recently upheld a decision that access to experimental drugs is a "constitutional right." This, to me, is the real story here. The consensus of the legal experts quoted in the article is that this decision is bunk. It's sort of discussed as a reverse-Cruzan decision (Cruzan: patients can refuse medical treatments even if life-prolonging vs. This one: patients have a right to medical treatments even if bunk[=not life prolonging=no even preliminary human evidence that likely to be beneficial]). Cruzan & similar decisions however have their basis in well established common law (informed consent rulings, right of the individual to determine what is done to their body, unwanted touching is battery, Schloendoff case, etc.), whereas this ruling is based in, well, nothing per the legal experts in the article. (It's being appealed.)

Contemplating what this ruling could lead to if upheld is fun in a sick way. If dying patients have a constitutional right to new drugs which have no evidence to support their use in such patients, then why don't they have a right to any treatment? Why not the right to die with a tube down their throat, hemorrhaging, hooked up to CVVH, with a 24 year old anesthesia prelim cracking their ribs, getting bilateral femoral central lines placed simultaneously, receiving purified sea-cucumber extract which didn't kill anyone, after all, in phase I testing. Because, after all, if the result is death anyway, shouldn't people have the right to demand any treatment they want (and, given that it's a constitutional right-n-all, I guess us doctors, nurses, anesthesia prelims, pharmacists, etc. will have to provide it). This seems so far from established professional and legal norms that one assumes it will not come to pass.

One more thing before I change track here. A quote:
"The judges in Abigail Alliance reasoned that the same right of self-determination that allows someone to refuse treatment allows him to "choose to use potentially life-saving investigational new drugs." They pointed out that for "over half of our Nation's history"—until the passage, in 1906, of the Pure Food and Drug Act, which made it a crime to sell mislabelled or adulterated medicines—"a person could obtain access to any new drug without any government interference whatsoever.""

I practially choked on my dinner reading this. If the court really thinks we need less 'government interference' in taxpayers' access to drugs then 1) I'll start synthesizing LSD in my basement tonight (call me in about a week), and 2) if you suffer from aches, pains, rheumatism, dropsy, chilblains, hysteria, canker sores, onanism, sugar diabetes, female complaints, or geriatric profanity disorder, I highly recommend the patented Captain Drew's Real Doctor Hoary Plantain Solution--it's all-natural, cheaper than a trip to the doctor's, & comes with a 100%-satisfaction-guarantee.

Enough of that.

Groopman, who you can tell is not a fan of the court ruling, does however frame the article in his own experience in treating AIDS patients around the time protease inhibitors were being developed--including losing patients who likely would have lived much longer if they had access to on-trial antiretrovirals--and very skillfully and compassionately talks in the article about the balance between safety and access to potentially life-prolonging therapies.

Thanks to Dr. Marcin Chwistek for alerting me to this.

(Related NPR story here.)

(And in a story with some consonance with the above discussion, the woman in a PVS in the UK effectively treated her state of being awake instead of curing her of her state of being in a whose family's petition for withdrawal of life-prolonging medical treatments was denied by a judge because they hadn't given her zolpidem [yes, Ambien, I kid you not--there are a handful of case reports suggesting people temporarily responded to it] tried zolpidem. It made her sleep. And because zolpidem effectively treated her state of being awake, as opposed to effectively treating her state of being in a PVS, the judge has ruled that the family's petition for ceasing life-prolonging treatment can be honored. The family had argued that it would be cruel to even try the treatment as even temporary awareness of her state would have been needlessly cruel to the poor woman.)

Friday, December 15, 2006 by Drew Rosielle MD ·

Thursday, December 14, 2006

Rationing care at the end of life

Canada's Globe & Mail recently published a provocative editorial about health-care rationing at the end of life. The article is a call to debate, as opposed to making recommendations per se. Its context seems to assume a future crunch in health care dollars in Canada and asks how will decisions be made about what constitutes worthwhile treatments for dying patients. The article throws out questions cutting both ways--why pay for costly treatment at the end of life unlikely to extend life--but also asks by what metric does a society choose to pay for palliative-only interventions?

"What amount of benefit should be considered worthwhile? What is it worth to extend life by a few days? What if this extension in life is accompanied by a decrease in quality of life, because of the toxicity associated with treatment? What is the value of interventions that are not associated with improved survival?"

It mentions the UK's NHS's policy of not approving new treatments that cost more than ~$60,000 per quality adjust year of life gained. How does this fit with costly interventions that do not prolong life at all (intrathecal pumps)?

In the States, palliative care is frequently 'sold' to hospitals and health systems as a money saver, which is probably true currently. The problem with this is that it ties our existence to proving ongoing cost-savings which makes us vulnerable if something changes ( e.g. culture of medicine as a whole--unlikely--or our practice, or payment structures, etc.) and we are no longer so cost-attractive. This requires us to prove our worth in other ways, since policy makers won't be convinced by values-driven messages.

Thanks to Dr. Paul McIntyre for letting me know about this.

Thursday, December 14, 2006 by Drew Rosielle MD ·

Monday, December 11, 2006

Advanced directives and LMWH in cancer

Two from the latest American Journal of Medicine.

1)
First is a look at ambulatory patients' knowledge of advanced directives. It comes from a survey of ~500 medicine outpatients in Buffalo, NY in 2004. A lot of data is presented that is probably of little interest to the average reader (including me). What was notable was 86% of the subjects said they didn't know what an 'advanced directive' was (although 86% of those subjects knew what a 'living will' was suggesting at least for this population 'advanced directive' is just not a familiar term, although the concept probably is). (This was also pre-Schiavo and one wonders if that made any difference.) The other notable finding was that over a third of patients did not want to discuss AD's with their provider, the vast majority of whom "didn't want to think about it." That says a lot, although it needs to be stressed that the survey included younger patients.

2)
And from the supportive cancer front, there's a prospective, randomized, open-label trial comparing LMWH (tinzaparin) with coumadin for long-term anti-coagulation for cancer patients with venous thromboembolic (VTE) disease. This was a Canadian, multicenter study which looked at 200 patients with a DVT or PE--the primary outcome was the incidence of recurrent VTE disease. Most had solid tumors, and there was a relatively equal mix between metastatic and limited-stage disease (this was not a study of advanced cancer patients only). Patients received 3 months of LMWH or coumadin (coumadin patients initially received unfractionated heparin). After 3 months patients were taken off protocol (& it's unclear to me how many stayed on any anti-coagulation and if they did if they stayed on coumadin or LMWH or switched etc.)--patients were followed though for 12 months. They had data for 99% of patients randomized. Almost half the patients in each group had died by 12 months (no significant differences or even trends towards differences between the groups). Major bleeding and other complications were pretty equal between the groups. However--at both 6 and 12 months the LMWH group had less recurrent VTE (7% vs. 16% at 12 months, p=.044). This is further evidence that low molecular weight heparins might actually be more efficacious than coumadin for VTE in cancer patients. One can tell that the authors were disappointed that they didn't demonstrate a mortality benefit, although when 50% of your population dies during the study anyway you'd likely need a lot more than 200 patients in order to show a mortality benefit if it existed. That said, this was a missed opportunity for the researchers to look at health-related quality of life to see if it differed between the patients--and for me this is quite frustrating. How can you do such a solid, well-organized intervention study of a population in which 42% of the subjects have metastatic solid tumors and not look at quality of life as an outcome?

Monday, December 11, 2006 by Drew Rosielle MD ·

Saturday, December 9, 2006

Pallimed layout update

As promised, I have upgraded Pallimed to the new Blogger/Blogspot software version. You will notice some layout changes--I tried to keep these as inoffensive as possible. I did widen the blog a little so it will display better on higher-resolution screens, although this meant I had to sacrifice the nicely rounded corners on most of the blog's text frames. If Pallimed no longer displays well on your computer let me know--I write Pallimed with a Mac, using Firefox, and I realize it likely displays differently with PCs & IE. I also had to destroy my previous blogger profile and merge another one I had with the blog. Blah blah blah.

The biggest change for readers is the addition of labels/tags: they should be clearly visible at the bottom of this post. These are tags related to the blog post topic--you can now browse Pallimed by topic by clicking on the label tags at the bottom of each post. (For instance, I labeled this post as 'meta' since it's about the blog itself.) There's also a section with all the labels in the sidebar on the right (since moved to the left). When I'm feeling really idle I may go back to previous posts and start labeling them but I'm not going to promise that. I did label some recent ones to give readers unfamiliar with tags an idea of how they work.

Saturday, December 9, 2006 by Drew Rosielle MD ·

Friday, December 8, 2006

Tube feeding in dementia

BMJ has an opinion piece about tube feeding in advanced dementia which addresses the issue from a novel perspective. The author, a physician, essentially makes the following argument.... Weight loss in advanced dementia is normal and OK. The muscle wasting associated with progressive physical disability causes a concomitant slowing of the metabolic rate and many patients will lose a lot of weight but eventually settle out, taking in very little nutrition, but enough to supply their meager energy requirements. This is ok, and tube feeding then becomes a non-issue--it's just not indicated. The author provides little evidence to support this, and I can't say that the article will likely change the debate much, particularly as proponents of tube feeding can provide a lot of evidence that weight loss in dementia is associated with increased mortality--that is the only thing in this entire debate about which we can be sure.

Friday, December 8, 2006 by Drew Rosielle MD ·

Thursday, December 7, 2006

Get Palliative Care (.org)

CAPC has announced their new website promoting palliative care "getpalliativecare.org." It is mostly informational material aimed at the public (patients and families) about palliative care, where you can get it, etc. It looks like it will be a valuable resource to refer people to. I may try to see if I can get it printed on my business cards with the next lot.

Somewhat controversially (ok, to be honest, I'm the one saying it's controversial), the website distinctly de-emphasizes death & dying. In fact 'death,' 'dying,' 'end of life,' etc. are absent from the main page--replaced (not inaccurately of course) with 'serious illness.' On the page ' What is palliative care?' death and dying aren't really mentioned except to distinguish palliative care from hospice, although I'd wager terminal care is a large component of what most of us in palliative care do. On the other hand the "For clinicians" page lists patient criteria that clinicians should use to trigger palliative care involvement: these criteria (mostly) describe patients likely to die soon. I find this distinction between the two pages interesting but understandable, at least from a promotional standpoint (making 'palliative care' more palatable to patients-- it's about how you live, after all), although the naive fool in me just wishes it didn't have to be this way.

Thursday, December 7, 2006 by Drew Rosielle MD ·

Wednesday, December 6, 2006

End of life care on NPR

NPR's Fresh Air yesterday included an interview with Stephen Kiernan about his book Last Rights: Rescuing the End of Life from the Medical System . (This book appears to be getting a lot of press lately, as it was one of the NY Times articles I mentioned last week.) The interview is quite interesting, and worth its fifteen minutes. In fact, it's the sort of sane, overall accurate coverage that end of life care, palliative care, etc. so desperately needs. My favorite moment was when Terry Gross asked about DNR orders and Mr. Kiernan's immediate response was to talk about how DNR orders are not end of life care plans or advanced directives etc., but, well, just that--DNR orders--and what is desperately needed is real & realistic end of life care planning, etc.

You can listen to the interview online, for free, at the link above.

In keeping with recent tradition, I'll thank my wife, Sarah--who I just discovered is lurking on online knitting bulletin boards under the name ' benjamom'--for alerting me to this.

Wednesday, December 6, 2006 by Drew Rosielle MD ·

Monday, December 4, 2006

Alternative therapies in cancer in JCO: pediatric ethics & lack of evidence

Two from the latest Journal of Clinical Oncology

1)
First is an opinion piece about parents refusing standard cancer treatments for children with favorable-prognosis cancer. They describe a case in which a 7 year old with ALL who was undergoing curative chemotherapy (expected 85% chance of a long-term cure), and whose parents stopped the chemotherapy and put the boy under the care of a MD who was also a licensed 'holistic' practitioner. Child protection was notified and declined to intervene, as was the state medical board (regarding the 'holistic' MD) who also declined to intervene. The boy's leukemia relapsed.

The article is mostly a gloss of the pertinent medical-ethical-legal issues. Some interesting points were made: 6 cases like this that have been reported in the legal and ethical literature & of those six, when a licensed physician is responsible for the 'alternative' therapies, the courts have sided with the parents, refusing to judge the relative merits of different medical interventions recommended by different licensed medical practitioners. They also noted that the public reaction to the above case was very supportive of the parents' right to choose therapy for their children. What is interesting here is that apparently the calculus used by the courts is based on the mere fact of there being a licensed physician willing to give the 'alternative' therapies. Medical evidence--the fact that as a scientific and professional community we can say, with broad consensus, that intervention X (chemotherapy and supportive care) is very likely to lead to outcome Y (not dying from cancer when you're 7 years old), and that we can say with equal consensus that there exists no evidence that certain interventions (so called 'holistic ones') will lead to that outcome--apparently doesn't particularly enter into the court's decisions. It's as if there being some guy with an MD and a DEA saying "I'll do this" creates sufficient doubt to warrant parents making a decision that is objectively inferior. The problem of course is where does one draw the line, and clearly a 16 year old requesting 'holistic' treatment is different than a very vulnerable 7 year old's parents doing the requesting, and as medical uncertainty increases, medicine's imperative to treat against parents' wishes decreases, but this case, personally, gives me the willies.

2)
Second is a "systematic review" of complementary & alternative therapies in cancer pain. Following a theme from a post from last week, one could predict the findings prior to even reading the abstract ("there is a paucity of data"). Just to give you an idea of the 'quality' factor that these reviewers were dealing with, I'll highlight one sentence from the Results section: "Two trials were listed as RCTs but did not present any data about comparison with a control group." Ouch. I'll repeat that for emphasis...Ouch. One's not sure how to even to begin to comprehend how such a trial could be published in an ostensibly peer-reviewed venue. The major message, besides the lack of evidence, is that what little there is is suggestive that some mind-body modalities hold some promise (hypnosis, relaxation, etc.). There are general exhortations that there needs to be more, better research into CAM at the end. That is certainly true, but one also has to ask the "Public Health" question. That is--given that there are limited research dollars into cancer symptom management--from a public health standpoint where is the best place to be putting those dollars? Standard medical research? CAM? Research and public programming focused on systems change--changing systems of delivery of care etc in order to improve the management of cancer systems? If I was a betting man I'd say that the 3rd would give you the biggest bang for your buck, but that is clearly my bias--that the epidemic of poorly treated cancer pain is not primarily due to a problem of lack of research into analgesic therapies. As a society we are not obliged to throw our money at research which is likely not to show any benefit.

Monday, December 4, 2006 by Drew Rosielle MD ·

Thursday, November 30, 2006

Hospice: The Movie!

The portrayal of hospice in the movies or mainstream entertainment has been relatively obscure. There are obviously many movies, TV shows, books, and songs that deal with death and dying. Hey death and dying makes for instant drama, just add water. But any mention of hospice is usually an aside, or indirectly related to the rest of the storyline.

Well now we have a movie called Two Weeks (web site - trailer - NY Times Review) opening this weekend that seems to focus a little more on the end of life and even involves hospice as part of the storyline. I am not sure why Pallimed did not get sent and advanced review (ahem!), but luckily Hospice Guy over at Hospice Blog did. He gives a very well written two part review. First from just a movie critic/general public point of view, and then from a hospice workers point of view. Even watching the trailer, you can get the general gist of the movie, and see some moments that are pretty commonly experienced by people in hospice and palliative medicine. (Such as the ever present - "Can we have medicines for the family too" wise crack.) You really should go read his review as he discusses many important points, without giving too much away of the plot.

The movie is quite an accomplishment to complete, and I appreciate what writer/director Steve Stockman has done, since I too would eventually like to write a screenplay and direct a movie (A boy can dream...). The movie web site has a blog with stories about how this movie came to be and the writer/director's own experiences with his dying mother. They also have a cross-over site with Yahoo! Health and there we have Dr. Ira Byock from Dartmouth blogging as well.

Now one thing I would like to point out in the trailer is that they focus in on a book that is entitled "How to Die." This book does not exist. The author printed on the cover is Mark Ragland (only Google reference is to a Art Director for the movie Ernest Goes to Jail, but he is also listed as the Locations Manager for the movie Two Weeks...Interesting!). A quick search of Amazon and Google do not bring up any books entitled "How to Die." But it does make for an interesting search. And here is what I turned up...

Learning How to Die - A book about Wilco frontman Jeff Tweedy and his clash with the record industry. Unknown why it refers to death and dying as that does not appear to be a central topic of the book.

How to Die in the Outdoors: 100 Interesting Ways - Not exactly a palliative medicine book by the sounds of the title, although I have had two patients request to be outdoors at the time of their death, I don't think this book would actually be helpful. Sounds more like a 'survival guide.'

Learn How to Die the Easy Way
- This appears to be a art and photography book.

How to Die Without a Lawyer
- A ebook designed to help you stay away from probate and lawyers gobbling up fees while settling your estate after you die.

To Die Well: A Holistic Approach for the Dying and Their Caregivers - Finally a book that most likely is probably what the movie was aiming for.

So the book "How to Die" does not exist, I guess it was probably more of a prop to move the plot along in the movie. It may have been a disguised reference to Final Exit the book that spawned much controversy in the early 90's about instructing people on how to end their lives. But since I have not seen the movie, I am not sure what role this fake book plays. I just thought it was interesting that they refer to a book that could be so controversial as too what lies inside, but in reality does not exist. After the movie comes out Pallimed may have to review it like the rest of the world.

(PS I just posted the most web links ever in a Pallimed post. Top that Drew!)

Thursday, November 30, 2006 by Christian Sinclair ·

Wednesday, November 29, 2006

Advanced directives in the NY Times; Depression treatment in cancer; Pediatric palliative care education

Some light reading...

1)
A few from this week's Science Times in the NY Times .

First is a discussion of advanced directives and how inadequate they so frequently are. Yet, it seems to perpetuate the myth that having a DNR order means "do not treat". See this: "The admitting physician reading your living will may interpret it as a "do not resuscitate," or D.N.R., statement, meaning you want no treatment for your life-threatening infection, in which case you would probably die. Yet a course of antibiotics and a week or so with assisted breathing could restore you to your previously active state." When this was written I thought to myself, "Oh this is a straw-man which the journalist is going to beat on," but no, she perpetuates this idea. Health care personnel interpreting a DNR order as meaning do-not-treat is the problem, and not the DNR order in and of itself. The article also describes some recent proposals for making advanced directives more effective. All of this is fine but, to me, the problems with advanced directives is not that people don't do them right, it's that there's no good way to do it, to predict what's going to happen, to spell out what you'd want in circumstances X, Y, or Z. Because, frankly, the only good way of knowing what you'd want in circumstance Y is to live it, and to sit down with your loved ones, physicians, and other care providers and talking over the best course of action. AD's have to be vague, and by design, don't work like people expect them to. Additionally there's a decent amount of evidence that, at least as far as AD's have been currently implemented, they haven't really improved medical care at the end of life and are frequently ignored. (I'm not trying to suggest at all that they have no value--they do--particularly in that they can give emotional "permission" to family members to limit certain types of medical care, as well as of course if people have absolute limits to what they'd accept, but they don't really 'direct' much care, such as it is.)

There is also a follow-up article with advice from
Stephen P. Kiernan who wrote "Last Rights: Rescuing the End of Life From the Medical System" about advanced directives which is a little more reasonable.

The other is an article by a physician as to why doctors don't cry much in the hospital. I can't say it answered for me the question as to why doctors don't cry much in the hospital.

Thanks to my mother-in-law, Dr. Linda Thompson, for alerting me to these articles.
NYT articles are usually free online for a week.

2)
Supportive Care in Cancer has a systematic review of treatment of depression in cancer patients. One could almost guess, verbatim, their summary statement in their conclusions...

The evidence for the effectiveness of treatment for MD and other depressive disorders in cancer patients is limited and of modest quality.

3)
Pediatrics had a recent article reporting the results of a needs assessment on palliative care education for pediatric residents. To tie together two themes from earlier in today's blog post...

a) The summary results were dismal, and discouragingly predictable:
First, we found that pediatric residents report minimal training, experience, knowledge, competence, and comfort in virtually all areas of palliative care for children. The responses in no area achieved even a moderate level.

It goes on like this for a while. It reminded me of a phrase my palliative team uses sometimes when we encounter "the wide open gaping jaws of need" in our patients.

b) Thanks again to my mother-in-law for alerting me to this.

Wednesday, November 29, 2006 by Drew Rosielle MD ·

Monday, November 27, 2006

Morphine side effects

For those of you who celebrated it, I hope you had a fine Thanksgiving last week.

I'm trying to slowly dig through my backlog of un-blogged articles I had flagged and thought I'd mention an interesting article from the American Journal of Hospice & Palliative Medicine. It's a prospective study of morphine related side effects in (mostly advanced) cancer patients chronically on morphine, who were cared for by the Cleveland Clinic palliative medicine team (median age 64 years, half had ECOG's of 3 or 4 at the start of the study, median daily oral morphine dose was 144mg, most were also receiving non-morphine analgesics/adjuvants). The subjects answered a 32 item questionnaire about their symptoms once weekly for 4 weeks (42 patients answered at least one questionnaire; 30 answered all 4). The prevalence of symptoms at the time of the first interview had some surprises: 90% had dry mouth, 69% sedation, 64% myoclonus, 60% constipation, 48% flushing, 38% urinary hesitancy, 36% dysphoria, 26% nausea, 24% nausea, 21% nightmares. The symptoms that were present for an entire month in those who answered all 4 questionnaires were dry mouth (77%, although only 20% moderate to severe), 23% had constipation (3% mod-severe), 13% sedation (10% mod-severe), 43% myoclonus (0% mod-severe), 23% had urinary hesitancy (3% severe), 10% nausea (0% severe), 10% itching (0% severe).

A couple things about this. First, the authors noted this was the first prospective study of morphine related side effects in this patient population which was initially shocking to me, but on further reflection seemed congruent with the general poor state of symptom research in the cancer patient (outside of Epo/fatigue & 5HT3 inhibitors/chemo-nausea studies). The other point is that these are symptoms of advanced cancer patients who are chronically on morphine, not necessarily symptoms due to morphine (this was a straight-forward descriptive study without a control or comparison group, and clearly much of this symptom burden is from other drugs/processes). That aside, what surprised me (and the authors too) was that certain symtpoms such as dry mouth and myoclonus were pretty common (and 20% reported moderate to severe dry mouth for the entire month!), as were urinary retention symptoms--these were reported much more than I am noticing in my practice. On the other hand nausea was not very common and thankfully persistent moderate to severe nausea was absent from this group. This supports the idea that patients quickly become tolerant to morphine's nauseating effects. On the other hand sedation was quite common and 10% complained of persistent moderate to severe sedation for the entire month. Again, how much of this is due to morphine is unclear, but it is consistent with observations that a certain percentage of patients never get fully tolerant to the CNS toxicity associated with opioids. Personally, this study has raised for me the need to more aggressively look for these maybe-more-frequent-than-previously-suspected side effects such as myoclonus, xerostomia, and urinary hesitancy.

Monday, November 27, 2006 by Drew Rosielle MD ·

Friday, November 17, 2006

Endoscopic celiac plexus blocks; California law; antibiotics in the dying; breakthrough pain

I am traveling for the next week and may not post again until after Thanksgiving. I know a couple of weeks ago I promised/threatened a Pallimed format update--that is still forthcoming but I'm not sure when it will be (it has to do with Blogspot/Blogger's software update which is being rolled out in bits & pieces). However, when it does happen, it looks like we will have tags and labels, making searching/sorting the blog much easier (we now have 255 posts). It will also make the comment spammers that much happier; up until now I have been able to manually remove most of their ads for "Vico-profen" & requests to "come visit [their] website--I think you'll like it!" Hopefully I'll be able to keep this up.

I'm going to try to unload a few from my large back-log before the holiday...

1)
The Journal of Supportive Oncology has a case series on using endoscopic ultrasound to guide celiac plexus blocks. It's mostly just a general discussion of the technique & the actual case series is little more than a hand-waving 'this seemed to be helpful for most of our patients.' While I'm happy that this relatively new technique is out there, the best study ever of CPB was not a resounding endorsement of the practice. The same issue has an interesting review of hypovolemia in the cancer patient.

2)
The IAHPC website has a brief summary of the new California controlled substances act which appears to be very reasonable and supportive of using controlled substances for analgesia. This summary is all I know about this.

3)
A recent European Journal of Cancer Care has an article examining antibiotic use in dying cancer patients (free full-text here). It's a case series looking at antibiotic prescribing patterns in cancer patients admitted to a single hospital in South Korea for terminal care (mean duration of stay prior to death was 30 days). Not too much can be gleaned from the study other than antibiotic use was very common (84%--this number exceeded the percentage of patients for whom there was documented suspicion of infection). Similar to a previous study I blogged most patients didn't appear to have symptom relief (although, again, this wasn't a prospective study designed to look at symptom relief so who really knows). This area, along with the role of thromboembolism prophylaxis in similar patient populations (& I'm sure a few others), remains nearly a blank when it comes to quality research to guide us as to what, if anything, we should be doing on behalf of our patients. One can make arguments about what makes sense, of course, but what makes sense is often wrong when examined empirically.

4)
The Journal of Pain recently had an article on the prevalance and characteristics of breakthrough pain in chronic non-cancer pain patients. This was a motley group of 228 patients with a wide variety of pain syndromes who were all on opioids with relatively stable pain control. 3/4 of them however had 'severe' episodes of breakthrough pain, a median of two of them a day, and which lasted on average ~60 minutes.


Happy Thanksgiving

Friday, November 17, 2006 by Drew Rosielle MD ·

Wednesday, November 15, 2006

Katrina editorial; terminal sedation; palliative radiotherapy; quality measures

1)
NEJM has an editorial about the Katrina physician/nurse homicide charges. It's written by a physician who worked in New Orleans during the disaster, and makes the very reasonable suggestion that decisions on how to care for moribund patients in similar disasters should be made prior to the disaster, not haphazardly during one.

2)
Nathan Cherney has a review on terminal sedation in the current Nature Clinical Practice Oncology. I can't actually access the full text of the article but I appreciated his succinct summary of some people's ethical concerns with terminal sedation: Sedation is controversial in that it diminishes the capacity of the patient to interact, function, and, in some cases, live.

3)
2 on radiation therapy from Supportive Care in Cancer. First is a review on attitudes towards palliative radiotherapy (to treat painful bone metastases) regarding the 8 Gy in a single dose vs. 20-30 Gy in multiple fractions controversy (multiple studies have shown that they are more or less equally effective, although duration of analgesia is clearly longer with with fractionated therapy). They found a wide variation of preferences among different constituencies (radiation oncologists vs patients) and locations. The study clearly supports the idea that use of single fraction therapy is not widespread, despite evidence for its use, and (surprising to me) some studies have shown that patients would prefer multiple fractions over a single dose. Perhaps it feels more like they're receiving 'real' treatment?

Along these same lines, the same issue has a prospective study looking at pain flares from palliative radiation therapy for painful bone mets. The data is from a randomized study comparing, guess what, 8 Gy single dose vs. 20 Gy fractionated therapy. Patients completed pain diaries during their treatment (this was a relatively small study of about 100 patients and only half of these agreed to do the pain diaries). Depending on how a 'pain flare' was defined it seemed to occur in 35-40% of patients overall (and a flare appeared to be more common in patients receiving single dose therapy). There was a trend toward prevention of a pain flair with concurrent dexamethasone use, although this was not statistically significant. They didn't actually talk about when the flares occurred, although presumably it was early on. This study brought to my attention the interesting research question of how does one define a 'pain flare.' They actually used a couple of definitions in this study, but basically it was at least a 2 point increase in pain score on a 0-5 Likert pain scale for at least 2 days in a row (in the absence of decreasing analgesic use) or a 50% increase in analgesic dose without an associated decrease in pain. The first criterion seems to be too conservative to me--assuming you can translate a 0-5 Likert scale to a 0-10 NRS (and yes, maybe I shouldn't be assuming this) their criterion would be at least a 4/10 increase on the NRS which seems like a lot, and one wonders if 'milder' pain flares are much more common.

4)
A recent Journal of Clinical Oncology has a review on quality measures for symptoms and advanced care planning in cancer patients. To make a long story short, there are many measures, most of them seem reasonable (that's my gloss), however there's little evidence (yet) that implementation of these quality measures improves quality of care. The article does provide a nice collation of the many articles trying to develop quality measures, and may be a useful starting point for quality improvement projects.

Wednesday, November 15, 2006 by Drew Rosielle MD ·

Tuesday, November 14, 2006

NPR first person account of being a caregiver for the dying and word puzzle answers

For those of you who listen to NPR on the way home, you are often treated to insights into end-of-life issues. I believe that NPR is one of the media outlets that typically focuses on death and dying more than most mainstream media outlets. Well yesterday (Monday 11/13) there was a great story I heard on the way home. It was the story of Adrian Leon LeBlanc (requires Windows Media Player) who died in 2003. The story was narrated by his daughter, writer Adrian Nicole LeBlanc, who had taped some of the conversations as he was dying. The audio story is only under 13 minutes, so find yourself some quiet time and listen to it.

I think you will recognize the role of patient and caregiver in his story. As I listened to the story I recalled some of the patients and families that have impacted me through this work. It is also a good reminder of the powerful relationship between caregiver and patient, and how talking can be an important part of the 'work' that people do as they approach death for themselves and their family members.

2. The answers for the wordgame I posted from last week are in the comments section of this post. That's for those of you who can't help but look immediately for the answers. In case you missed it here was the wordgame:

(More details than the original post)

WORD GAME

Palliate (PAL-ee-ate: To make less severe or intense; alleviate)

Average mark 28 words
Time Limit: 45 minutes

Can you find 42 or more words in PALLIATE?

Tuesday, November 14, 2006 by Christian Sinclair ·

Monday, November 13, 2006

Palliative Medicine Fellowship

Some shameless self-promotion (Christian, this constitutes a free-pass for one act of shameless self-promotion on Pallimed).

My institution, the Medical College of Wisconsin, has openings for our palliative medicine fellowship for the 2007-8 year and beyond. Our fellowship is an accredited, one-year clinical fellowship that gives a good mix of inpatient & outpatient palliative care, as well as hospice experience. We have an established palliative care service which is well-integrated into our major teaching hospital; a swell group of experienced palliative care physicians and nurses; a good mix of didactic and supervised clinical time; educational training; and research opportunities. I did my fellowship here and felt like I received great training. And, contrary to popular opinion, Milwaukee totally rocks.

If you're interested please contact me via email. Or you can skip the middle-man & contact our fellowship director directly, Dr. Lisa Marr, at (414)805-4607 or lmarr@mcw.edu.

Monday, November 13, 2006 by Drew Rosielle MD ·

Friday, November 10, 2006

DNR orders; palliative care for the frail elderly; antioxidants for everything

1)
The Journal of General Internal Medicine has a trial of changing a DNR order policy at a hospital in New York. For those of you not familiar with the NY situation--there is legislation there that most hospitals have interpreted to mean that a patient (or their proxy) has to sign a consent form in order for a physician to write a DNR order. These forms are notoriously long and complicated. (In contrast, at my hospital, while there is a special DNR physician order form, patients don't have to sign anything, and there is a policy in place allowing physicians to write a DNR order against a patient's wishes if resuscitation is felt not to be medically indicated.) In this article the hospital developed a new DNR order form and policy which greatly simplified the process, allowed for verbal 'consent**' only, and prompted physicians to consider multiple categories of treatment limitations as well as palliative priorities (pain, psychosocial & spiritual concerns, etc.). The authors compared what happened at their hospital with a similar 'control' institution which did not change their DNR policy. In short they found that the policy was well received and improved some markers of quality of care, as well as rates of DNR orders. Intriguingly, they looked at surrogate (patient family members, etc.) stress regarding DNR orders and found it decreased after the policy change. This is modest empiric evidence for a long-standing clinical observation--that particularly regarding what are viewed as 'life or death' decisions (such as DNR orders, terminal extubations, etc.) family members generally want physicians to make and be responsible for these decisions (so that the family member doesn't feel like s/he is responsible for someone's death--acknowledging of course that they almost certainly aren't responsible for the death, but they don't want to feel like they are being asked to 'choose'). That sentence was too long, I apologize.

**"Consenting" to a DNR order is somewhat of a weird concept. Consent, in medicine, usually refers to a patient understanding and agreeing to a medical intervention. In this case, however, it is about not using a medical intervention which is unlikely to benefit a patient in any material way. Surgeons 'consent' patients to operate; when surgeons choose not to operate because the risks outweigh the benefits of surgery they don't consent the patient to not operate--it's just considered good medical care.

2)
JAMA has a couple of articles this week. First is a ' coda' for the recent Clinician's Corner piece about spirituality & dying. Then there's a new Clinician's Corner/Perspectives on Care at the Close of Life piece about palliative care for frail elderly adults. It's discussion of hospice care for those with a functional decline but no 'clear' 'terminal' diagnosis is good, and good to see in a general journal.

3)
I stumbled across this press release touting antioxidants as analgesics (some researchers gave some mice a whole bunch of antioxidants and then injected formalin subcutaneously and found that the mice exhibited fewer pain behaviors). It's an interesting bit of research but will likely end up on the trash heap of novel human analgesics, although I hope not. The press release is peppered with a lot of "opioids=addictive=bad" language.

4)
On Monday I took the ABHPM's final board exam before it dissolves and is replaced by the new ABMS hospice & palliative medicine board. It's the end of palliative care's infancy (in the U.S.) which is exciting, but sad to see the ABHPM undergo its planned dissolution. It does mean--assuming I pass--that I can proudly tell my palliative medicine fellows ~30 years from now (some of whom may not be born yet) that I am so old that I was boarded by the ABHPM (I'll reassure them that was long before we discovered antioxidants were fantastic analgesics).

Friday, November 10, 2006 by Drew Rosielle MD ·

Monday, November 6, 2006

Palliative Care and Media Attention

A couple of things have crossed my path recently and each item is tied to the media exposure of hospice and palliative care. A colleague recently came up to me while I was attending our palliative medicine consult service and wanted to know why we were still calling ourselves 'palliative care.' Here is a little reenactment (you must provide your own voices):

Colleague: "You guys should really think about changing your name."
Me:
"You mean 'Palliative Care Team'? Why's that?"
Colleague: "Well, no one really knows what it means. Why don't you call it something that people already know the name of, like what's that the oncologists call their thing?"
Me: "Supportive Care?"
Colleague: "Yeah."
Me: "Well our team has been the palliative care team for seven years so we have a lot of time invested in that name and our number of consults have gone up quite a bit over that time. And palliative medicine was just approved as a medical specialty so there should be a lot more support for that name. Also I get a chance to define palliative care to others when they ask 'What is palliative care?' as more than just end of life care or help with cancer care."
Colleague: "Oh that's good news about the approval of the specialty. Just think about that name change thing. It might help you."

So what can we do as palliative care specialists, palliatist, palliativists, or whatever you want to call our field? Well James Hallenbeck, MD has a good recent post over at Growthhouse entitled "Got Palliative Care?" In it he summarizes how our field can take some points from advertising (the Got Milk? campaign) and applying it to demonstrate our principles. Now I don't know what kind of copyrights exist for this sort of thing, but I really like the ideas he presented in his blog. I would do a disservice by summarizing his blog. You should take the time to read it yourself. Besides he writes much better than I do!

Also my Uncle recently sent me a magazine for the Denver Metro area called 5280 (mile high connection, I guess.) He sent it because it featured the top Denver doctors. Well I quickly thumbed through it and found no listing for Hospice or Palliative Medicine physicians. I also found a San Diego Magazine listing their top doctors. Again Hospice or Palliative Medicine doctors listed. Same with Ingram's top doctor's for Kansas City, although their list was much more exclusive. So I challenge all Pallimed readers to contact your city's newspaper or high-society magazine and ask them to include hospice and palliative medicine as a specialty to select physicians. Not that this particular recognition of an individual doctor means anything but if it gets the word out that palliative medicine is a recognized specialty we will start to see that it belongs as a standard part of medical care of the ill as Drew has mentioned in these posts many times before.

And for fun we have a word puzzle, since it is National Hospice and Palliative Care Month (President Bush did sign a proclamation by the way.)

How many words can you make from this word:

PALLIATE

The answers will be provided in one week, so go ahead and try at home.

(I found this puzzle in the newspaper last week. At least the puzzlers are spreading the word.)

Monday, November 6, 2006 by Christian Sinclair ·

Friday, November 3, 2006

Natural history of PHN; truth telling and cancer; a few more scraps of data on methadone; spirituality & HIV

Several things in brief before the weekend:

1)
Pain has a prospective study looking at the natural history of post-herpetic neuralgia. It followed 94 older patients who had shingles and were felt to be at high risk for PHN (defined as having acute pain over 2/10 for at least 48 hours). 30 patients had PHN at 6 months (defined as any residual pain); however only 2 patients had pain at least 3/10 at 6 months. A substantial number of patients had pain for much of the study period (although most had resolved by 6 months). An interesting finding of this study was a suggestion that pain decreased at the same rate for the subjects: the worse your pain was at baseline the longer it would take for your pain to go away, but it overall steadily decreased. Overall this study adds to the perception that PHN that is both severe and prolonged is rare.

2)
Lancet Oncology has a "personal view" piece about truth telling in oncology . It's pretty good.

3)
For you methadone junkies out there (poor choice of words I guess...):
Therapeutic Drug Monitoring has a study on methadone enantiomers in hospice patients. This is a small study of 13 hospice cancer patients who were switched to methadone from morphine. I am sure there are many elements to this study which will be of interest to the more pharmacologically minded, but I took note of it because there still remains such little data on switching to methadone that everything published is of interest. (The study hails from my familial homeland of beautiful Perth, Australia.) Overall the study lends support to the consensus on methadone: a) final morphine:methadone "equianalgesic" ratios varied widely (final mean ratio was 5.2:1, range 1.3-11) between patients; b) methadone's potency generally increased as baseline morphine dose increased; and c) methadone's half-life is very long (averaged in the 30-50 hour range). For what it's worth, about half the patients achieved "optimal pain control" with the switch but I can't say the study is a resounding endorsement of rotation to methadone. Analgesia seemed to have little relation to methadone serum level. One patient had super-high methadone serum levels but this was not apparently clinically evident. Despite these two findings the authors for some reason recommend following methadone levels in hospice patients, but their study seems to support the futility of doing this as far as I can tell.

4)
The Journal of General Internal Medicine has an entire supplement issue on spirituality and HIV/AIDS patients .

Happy weekend.

Friday, November 3, 2006 by Drew Rosielle MD ·

Tuesday, October 31, 2006

Palliative care in Newsweek

Newsweek recently published a report on 'fixing U.S. hospitals.' It covers many areas including electronic medical records, treatment guidelines, hospital acquired infections, etc., but also includes a section on hospital based palliative care (it focuses on the Mt. Sinai program in New York).

1) It's encouraging to see this as part of a prescription to 'fix' U.S. hospitals.
2) It's actually a decent--especially for a mainstream press article--introduction for non-medical people to what palliative care is--what we do, how palliative care is different from hospice, etc. There are no grossly misleading statements. It does, however, play up this image of massages for caregivers of people with advanced illnesses--and how that is emblematic of palliative care. While I'll agree that it's emblematic--caregiver support & care is integral to palliative care--I cringed a little at the attention given to this idea. It does imply that what we do is a balm, a band-aid, some sort of nice, let's all get together and smile type of approach and not what I personally view it as: the comprehensive, patient + caregiver focused, medical care of those with advanced and terminal illnesses. No more, no less, and to 'other-ize' palliative care (i refuse to respond to any comments complaining about that neologism)--to make it out to be something super-special, something more than, or distinct from (what should be) routine, excellent, state of the art medical care--is to do our field & specialty a disservice. There should be nothing, in particular, special about what we do.

Tuesday, October 31, 2006 by Drew Rosielle MD ·

Monday, October 30, 2006

Buccal fentanyl tablets (OraVescent technology!!); Long-acting hydromorphone as a breatkthrough analgesic?

2 from the Clinical Journal of Pain

1)
First is a randomized, placebo-controlled trial of a buccal fentanyl tablet** for breakthrough pain in cancer patients. It looked at ~80 cancer patients who had at least 4 breakthrough pain episodes daily. They went through an open label dose-finding titration phase where they used higher doses of the fentanyl tablet until they found a dose that was effective (up to 800mcg at a time). Those that found an effective dose then were blindly given either fentanyl or placebo for subsequent episodes of breakthrough pain (patients could use their prior rescue analgesia med if they didn't receive adequate analgesia with this). They found that the fentanyl tablet provided better analgesia than the placebo and was pretty well tolerated.

A couple things about this. The study seems like it was more or less done to generate data for FDA approval of the drug, and is not very helpful clinically. I'm not knocking this, these studies have to be done, and there are still some clinically relevant aspects to this article. The patients initially went through an open-label phase to see if they found the fentanyl tablet efficacious and tolerable. Those patients who didn't find the tablet efficacious or tolerable weren't included in the placebo controlled part of this trial (these patients constituted a quarter of the initial subject population), so it's no surprise that the placebo-controlled trial found the fentanyl tablet to be, well, efficacious and tolerable. FDA-wise this is helpful: the new drug seems to be safe and it certainly works for some patients. It doesn't however help us clinicians to have a good sense of: what to expect when we start our patients on this, who to start it on, what a reasonable adverse event rate is, etc. One would like to see head-to-head trials of this (or, for that matter, Actiq) with oral short-acting opioids for breakthrough pain (I'm being hopeful here and not suggesting that the authors should have done this in this particular study).

A secondary finding of the study is that, as with Actiq (the transbuccal fentanyl lollipop), the initial breakthrough dose of the fentanyl tablet (as defined through the open label dose-finding phase) seems to have no relationship with a patient's pre-existing opioid requirement. That is, the "your breakthrough dose should be approximately 10% of your total oral opioid dose" rule doesn't seem to apply with these drugs. This could be for two reasons: one is that there's something different about transbuccal fentanyl than oral opioids. The other is that appropriate breakthrough dosing of oral opioids has never really been studied (the ~10% rule is based on expert opinion) and maybe we should be going through a formal dose-finding on all our patients. (Of course, many of us do this, albeit not necessarily formally...I assume many of us out there have patients whose breakthrough dosing varies greatly from the dose the ~10% rule suggests).

**Per the article: "The fentanyl buccal tablet (FBT) incorporates a novel drug delivery platform, OraVescent technology, which employs an effervescence reaction to enhance fentanyl absorption through the buccal mucosa...." While I'm sure this is a swell new drug delivery method "OraVescent" sounds like it should describe some sort of new breath-freshener, mouthwash, or toothpaste and not an opioid delivery system. One wonders if the Freshtastic OraVescence of this product will preclude its blinded comparison with other opioids.

2)
Second is a prospective look at opioid rotation to long-acting hydromorphone in cancer patients. I've already blogged enough for one day so I'll keep this short.

i) They rotated ~50 patients at a morphine to hydromorphone ratio of 5:1 then decreased the dose by another 1/3 presumably for incomplete cross-tolerance.
ii) Speaking of breakthrough pain...they used long-acting hydromorphone for breakthrough pain (they didn't mention telling the patients to crush/chew it so one has to assume the patients were indeed taking an intact long-acting opioid for breakthrough).
iii) This seemed to be safe and well-tolerated overall, but across the group there weren't consistent improvements in pain or side effects (but clearly some patients did benefit).

Conclusion: if you're a student of the opioid-rotation literature this is an interesting study to think about, otherwise...I guess it's got me thinking about MS Contin as a breakthrough analgesic (ha ha).

Monday, October 30, 2006 by Drew Rosielle MD ·

Pallimed | Blogger Template adapted from Mash2 by Bloggermint