Wednesday, November 29, 2006

Advanced directives in the NY Times; Depression treatment in cancer; Pediatric palliative care education

Some light reading...

A few from this week's Science Times in the NY Times .

First is a discussion of advanced directives and how inadequate they so frequently are. Yet, it seems to perpetuate the myth that having a DNR order means "do not treat". See this: "The admitting physician reading your living will may interpret it as a "do not resuscitate," or D.N.R., statement, meaning you want no treatment for your life-threatening infection, in which case you would probably die. Yet a course of antibiotics and a week or so with assisted breathing could restore you to your previously active state." When this was written I thought to myself, "Oh this is a straw-man which the journalist is going to beat on," but no, she perpetuates this idea. Health care personnel interpreting a DNR order as meaning do-not-treat is the problem, and not the DNR order in and of itself. The article also describes some recent proposals for making advanced directives more effective. All of this is fine but, to me, the problems with advanced directives is not that people don't do them right, it's that there's no good way to do it, to predict what's going to happen, to spell out what you'd want in circumstances X, Y, or Z. Because, frankly, the only good way of knowing what you'd want in circumstance Y is to live it, and to sit down with your loved ones, physicians, and other care providers and talking over the best course of action. AD's have to be vague, and by design, don't work like people expect them to. Additionally there's a decent amount of evidence that, at least as far as AD's have been currently implemented, they haven't really improved medical care at the end of life and are frequently ignored. (I'm not trying to suggest at all that they have no value--they do--particularly in that they can give emotional "permission" to family members to limit certain types of medical care, as well as of course if people have absolute limits to what they'd accept, but they don't really 'direct' much care, such as it is.)

There is also a follow-up article with advice from
Stephen P. Kiernan who wrote "Last Rights: Rescuing the End of Life From the Medical System" about advanced directives which is a little more reasonable.

The other is an article by a physician as to why doctors don't cry much in the hospital. I can't say it answered for me the question as to why doctors don't cry much in the hospital.

Thanks to my mother-in-law, Dr. Linda Thompson, for alerting me to these articles.
NYT articles are usually free online for a week.

Supportive Care in Cancer has a systematic review of treatment of depression in cancer patients. One could almost guess, verbatim, their summary statement in their conclusions...

The evidence for the effectiveness of treatment for MD and other depressive disorders in cancer patients is limited and of modest quality.

Pediatrics had a recent article reporting the results of a needs assessment on palliative care education for pediatric residents. To tie together two themes from earlier in today's blog post...

a) The summary results were dismal, and discouragingly predictable:
First, we found that pediatric residents report minimal training, experience, knowledge, competence, and comfort in virtually all areas of palliative care for children. The responses in no area achieved even a moderate level.

It goes on like this for a while. It reminded me of a phrase my palliative team uses sometimes when we encounter "the wide open gaping jaws of need" in our patients.

b) Thanks again to my mother-in-law for alerting me to this.

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