Tuesday, September 5, 2006

Discussing prognosis; Treatment limitation in the ED; Chemoembolization for liver CA

A couple of things

1)
The Journal of Clinical Oncology has twin articles on discussing prognosis with cancer patients ( one focusing on when the patient wants to know; the other on when the patient expresses a reluctance to know ).

They are well written with refreshingly straight-forward language such as:

"One of his colleagues prides himself on being a realist, "I tell patients the truth because they need to know, whether they want to hear it or not." Another colleague feels he must give hope, "I go into cheerleader mode." Neither alternative seems optimal to Dr B—the nurses tell him that the realist tone is a little brutal, and that the cheerleader is more than a little clueless."

They are both quite practical, problem-focused, and directed straight at practicing oncologists, although the principles and techniques discussed are appropriate for almost all prognostic discussions. There is a lot of wisdom in these articles and I would strongly recommend adding them, along with Christian's article, to your teaching files for residents, fellows, colleagues, etc.

2)
Academic Emergency Medicine has a seminar on " withdrawal of treatment" in the emergency department. Should I point out that by 'withdrawal of treatment' they mean 'withdrawal of life-prolonging treatment?' It tries to make an argument that the ED is an appropriate place to consider treatment limitation but then makes the whole 'withdrawal of treatment is morally superior to withholding treatment' argument (treat now; ask questions, and if needed withdraw, later) which I find problematic (as much as I sympathize with the ED staff who are faced with crashing chronically ill patients all the time).


3)
The Journal of Vascular and Interventional Radiology has a position statement from the Society of Interventional Radiology about chemoembolization (free full text) for liver tumors--for the most part it critically appraises the literature supporting its use for a variety of cancer. Many of us I'm sure take care of patients for whom chemoembolization is the only antineoplastic treatment available to them, and at least at my institution the palliative care team has a relatively close relationship with the interventional radiologists as they are often a patient's "last stop" prior to "full" palliative care (yes yes I hate the phrase "full palliative care" too but I can't for the life of me think of another way of writing this now). This position statement, while informative, unfortunately doesn't mention palliative care or difficult decision-making involving patients with far advanced illness who are not infrequently referred to radiologists. It is my dream that one day all (appropriate) position statements will contain such language....

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