Saturday, March 11, 2006

Decision making; supportive care vs. nano-technology; the DEA FAQ; force-feeding prisoners; AAHPM PIT-SIG

I don't know if it's because I'm too busy, or because so much stuff is coming out, or because Christian is semi-out-of-commission with his fatherly duties, but I'm having a hard time keeping up with everything pouring out right now. Thus you are being treated to more digest like summaries of publications. I will get back to cranky reviews at some point hopefully soon.

So, in brief...
Journal of Clinical Oncology has an article on patients' decision making processes regarding chemotherapy for metastatic breast cancer. Among other things it looks at patients' perceptions of being active, passive, or collaborative decision makers, with some interesting findings (about half the cohort described themselves as passive decision makers--doing whatever the doctor recommends). However this is a relatively small single institution study & I'm not sure if much can be made of their findings. Studies like these are interesting snap shots into some of the contingencies of difficult medical decision making, but I'm generally not sure what can be done with their findings other than than communication and decision making support should be honest, empathetic, individualized, etc.

The March 10th JCO is all about neuro-oncology and has a couple of articles to note, especially us non-oncologists who help care for these patients at the end of life--good background information, etc. One is a review of current treatment of high-grade astrocytomas (which, as far as I can tell, means glioblastomas). It is a nice overview of the field. Continuing my score-card of noting how much of a nod palliative/supportive care gets in oncology review articles of highly-lethal cancers, this piece gives pall/supp care a small paragraph (approximately the same amount of column space as nano-particle technology). Perhaps this should become my new standard of 'equal coverage'--supportive care vs nanotechnology. There's also a nice, general review of whole brain radiotherapy for brain mets.

Also the law...
The current Pain Medicine has a special section on the DEA and pain medicine, focusing mostly on the infamous DEA FAQ (Table of Contents here--the articles are 2/3 of the way down under "Forensic Pain Medicine Section"). The section has multiple commentaries by pain docs (including Steve Passik) about this; a lot of them focusing on the controversies and confusions surrounding "Do not fill" prescriptions (for example--writing a prescription dated March 10, 2006 but noting on it "Do not fill until April 10, 2006"). Of particular interest in a brief legal history of the DEA surrounding DNFs by a lawyer. The general consensus seems to be that the DEA is not genuinely interested in an honest dialogue with docs or patients about this, and that the DEA is perpetuating a climate where docs are hesitant to treat pain with controlled substances. Perhaps things will get better in 2009 (ahem)....

While we're there there's also a case report about botox for post-herpetic neuralgia.

NEJM continues the DEA trend with a legal exegesis of the Supreme's Court's physician assisted suicide/Controlled Substances Act decision by GJ Annas (free full text is available).

As well as ethics...
Lancet has published a letter about the practice of force-feeding inmates at Guantanamo Bay (and yes, I know I vowed never to directly link to the Lancet website again because of their policy of forced sign-ins, but this is not listed in PubMed yet and I'm not organized well enough to keep track of this until it is).

Oh yes and the PIT-SIG...
By the way if you're a palliative care professional in training (medical students, residents, fellows, as well as allied professionals) the AAHPM's Professionals In Training Special Interest Group has a blog (pitsig.blogspot.com) about the group's activities. The PIT-SIG also has an email listserv, and we are generally very interested in hearing from PITs about what's going on, how the PIT-SIG can help people, whatever. Drop Christian or me a note if you're interested.

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