Wednesday, March 15, 2006

Delirium review; depression maintenance therapy; palliative sedation controversies

1)
NEJM has a review of delirium in elderly patients. It's pretty basic. The author claims that 30-40% of cases can be prevented in the hospital, via multidimensional interventions, but interestingly fails to mention a recent randomized, controlled trial of haloperidol which substantially reduced delirium length and morbidity amongst hospitalized hip fracture patients. In addition the author suggests that pharmacologic treatment of delirium should be reserved for only those patients whose delirium threatens their safety or interferes with medical care. This seems a bit extreme and unsupported by the literature--the aforementioned haloperidol trial showed a decrease in hospital length of stay by 5 days which is nothing to sneeze at. Granted this was a study of giving haloperidol prior to (as well as then during) delirium--but it's suggestive--and if anything argues that pharmacologic therapy should be started in all high risk patients prophylactically--not reserved for the most extreme cases! More research is needed, which is the truest cliche in all of medicine...

2)
There's also (in NEJM) a randomized-controlled trial looking at maintenance therapy for depression in the elderly. It randomized elderly patients who had responded to paroxetine and psychotherapy to combinations of placebo, ongoing paroxetine, and maintenance psychotherapy. To be brief, ongoing drug treatment was clearly best--the risk of recurrence was 2.4 times higher off paroxetine than on with a number needed to treat of 4 to prevent a single recurrence (4 is an excellent NNT). Psychotherapy didn't seem to make much difference one way or the other.

3)
JAMA has published letters responding to the recent palliative sedation article which I posted about previously. One raises the same concerns that I did in my post about the original article's claim that in some circumstances palliative sedation was acceptable even for those with life expectancies of several months (they cited the principle of proportionality among other things to support this). Here is the authors' response to that concern:

Fulfilling the ethical requirement of proportionality requires a balancing of quantity and quality of life. This weighing will depend not only on the severity and intractability of symptoms but also on the particular patient's values and preferences. Individuals interpret the idea of the sanctity or intrinsic value of life in different ways. Dworkin stated that "People who want an early peaceful death for themselves or their relatives are not rejecting or denigrating the sanctity of life; on the contrary, they believe that a quicker death shows more respect for life than a protracted one." In our view, it is not unreasonable for a terminally ill patient who is informed of the options and their consequences to choose relief of suffering over the prospect of additional months of survival burdened by severe pain or other symptoms.

It seems they are saying that proportionality is in the eyes of the beholder. And wanting a quicker death being evidence of "more respect for life" seems like rhetorical chicanery to me, and death-denying. "Death-denying" in the sense that the process of death is 'natural' (I hate that word...how about 'a normal part of life') and cutting that short because you couldn't be bothered doesn't smell like life-affirmation to me. These circumstances are probably extraordinarily rare, at least in the US, and perhaps part of my problem is I'm having trouble imagining a scenario in which a person with a life expectancy of months has no options left to relieve physical suffering other than someone putting them into a pharmacologic coma until they die. (Granted, my lack of imagination should not be grounds for anything). This is why I suspect this discussion is about palliative sedation for existential suffering, which is something I have trouble with ethically, but that's a post for another day, or for the comments section.

(I am sick with pharygitis and sinus headaches and I find it interesting that I made two gratuitous nasal references in the above post.)

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