Friday, March 3, 2006

Patients' knowledge of cancer treatment intent; caregiver depression; DNR discussions; home death

Things are really stacking up so here's several brief articles of note...

The European Journal of Cancer Care has a paper about cancer patients' understanding of the intent of their cancer treatment (that is--whether it's intended to cure them or not). It's a single institution study of people with advanced (that is--incurable) cancer in Australia and results are consistent with previous studies: half the patients didn't know that their chemo or radiation was 'non-curative.' They either didn't know one way or the other or thought it was curative. Twenty percent of the patients did not realize they had life-threatening malignancies. Married patients and sicker patients understood treatment intent better. This is an interesting and well-established phenomenon which is probably not simply a consequence of 'poor communication' on the part of oncologists (although it would have been interesting if the authors had looked to see if particular oncologists were 'risk factors' for patient understanding or misunderstanding). Patients hear what they want to hear to an extent, and discussions of prognosis and 'the big picture' often occur slowly, dance-like, with unspoken agreements about what can and cannot be said between patients and their oncologists, and often this is completely appropriate. How then to measure 'appropriate' or 'inadequate' communication?

American Journal of Geriatric Psychiatry has a study about length of hospice enrollment and subsequent depression in family caregivers. 175 caregivers were studied, prospectively (horray!), and shorter length of hospice stay did not seem to be associated with depression in the bereavement period.

Two articles in different issues of recent BMJ's:
1. A single-institution study about asking patients about resuscitation wishes suggests that often patients being admitted to hospital medical services cannot participate in these conversations because they're too sick or busy getting tests. It also suggests rates of DNR discussions are so low because patients don't want to talk about it. They derive this latter conclusion though based on the fact that most patients didn't want to participate in their study about DNR conversations which is a different matter. The whole thing rather bothered me and somewhat perpetuated the idea that DNR discussions are some separate entity which can/should be tacked onto a history and physical upon hospital admission instead of being a part of a larger discussion of goals of care.

2. A systematic review on factors predicting whether cancer patients die at home. Nothing surprising--low functional status, patient preference, family support were strong correlates of a home death--but a nice review of the topic.

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