Thursday, July 27, 2006

Palliative care made law in NY; AAN on coma prognosis

New York State has passed legislation designed to encourage and promote improvements in palliative care and pain management. The Palliative Care Education and Training Act has the following goals:

  • Establish a statewide advisory council on palliative care and pain management;
  • Create undergraduate and graduate palliative care training programs;
  • Establish state Department of Health-designated Centers for Palliative Care Excellence; and
  • Authorize the Department of Health to certify one or more palliative care resource centers to assist physicians in the treatment of patients in pain
What can I say other than wow (that a state legislature is doing this), and great, and that I hope the $4.5 million appropriately annually is well spent.

(Thanks to David Weissman MD for alerting me to this.)

The American Academy of Neurology has published evidence based guidelines for predicting neurologic outcomes for comatose survivors of cardiac arrest in Neurology. For those of you who know the (surprisingly scant) literature on this topic, there are no surprises: the best predictors currently are certain neurologic examination findings in the first few days after the arrest (I won't belabor these here--they're in the abstract). What's interesting, and appreciated, is that the position statement also talks specifically about the role of the neurologist in breaking bad news to the family and helping them make decisions about treatment options, 'comfort care,' etc. Even more interesting, though, is this sentence:

The neurologist can explain that the prognosis is largely based on clinical examination with some help from laboratory tests. In a conversation with the family, the neurologist may further articulate that the chance of error is very small.

There isn't much follow-up given to this sentence, but my interpretation of this sentence is that the position statement is trying to give neurologists permission to make (accurate but) dire & firm prognostic predictions--instead of, say, (technically accurate but) overly general and not-so-dire predictions such "Only God can know what will happen." True enough, but not helpful to a grieving family trying to make decisions. The position paper doesn't say neurologists should be giving firm predictions (ie "the chance of error is very small") but at least it says it's ok that they may.

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