Friday, November 10, 2006

DNR orders; palliative care for the frail elderly; antioxidants for everything

The Journal of General Internal Medicine has a trial of changing a DNR order policy at a hospital in New York. For those of you not familiar with the NY situation--there is legislation there that most hospitals have interpreted to mean that a patient (or their proxy) has to sign a consent form in order for a physician to write a DNR order. These forms are notoriously long and complicated. (In contrast, at my hospital, while there is a special DNR physician order form, patients don't have to sign anything, and there is a policy in place allowing physicians to write a DNR order against a patient's wishes if resuscitation is felt not to be medically indicated.) In this article the hospital developed a new DNR order form and policy which greatly simplified the process, allowed for verbal 'consent**' only, and prompted physicians to consider multiple categories of treatment limitations as well as palliative priorities (pain, psychosocial & spiritual concerns, etc.). The authors compared what happened at their hospital with a similar 'control' institution which did not change their DNR policy. In short they found that the policy was well received and improved some markers of quality of care, as well as rates of DNR orders. Intriguingly, they looked at surrogate (patient family members, etc.) stress regarding DNR orders and found it decreased after the policy change. This is modest empiric evidence for a long-standing clinical observation--that particularly regarding what are viewed as 'life or death' decisions (such as DNR orders, terminal extubations, etc.) family members generally want physicians to make and be responsible for these decisions (so that the family member doesn't feel like s/he is responsible for someone's death--acknowledging of course that they almost certainly aren't responsible for the death, but they don't want to feel like they are being asked to 'choose'). That sentence was too long, I apologize.

**"Consenting" to a DNR order is somewhat of a weird concept. Consent, in medicine, usually refers to a patient understanding and agreeing to a medical intervention. In this case, however, it is about not using a medical intervention which is unlikely to benefit a patient in any material way. Surgeons 'consent' patients to operate; when surgeons choose not to operate because the risks outweigh the benefits of surgery they don't consent the patient to not operate--it's just considered good medical care.

JAMA has a couple of articles this week. First is a ' coda' for the recent Clinician's Corner piece about spirituality & dying. Then there's a new Clinician's Corner/Perspectives on Care at the Close of Life piece about palliative care for frail elderly adults. It's discussion of hospice care for those with a functional decline but no 'clear' 'terminal' diagnosis is good, and good to see in a general journal.

I stumbled across this press release touting antioxidants as analgesics (some researchers gave some mice a whole bunch of antioxidants and then injected formalin subcutaneously and found that the mice exhibited fewer pain behaviors). It's an interesting bit of research but will likely end up on the trash heap of novel human analgesics, although I hope not. The press release is peppered with a lot of "opioids=addictive=bad" language.

On Monday I took the ABHPM's final board exam before it dissolves and is replaced by the new ABMS hospice & palliative medicine board. It's the end of palliative care's infancy (in the U.S.) which is exciting, but sad to see the ABHPM undergo its planned dissolution. It does mean--assuming I pass--that I can proudly tell my palliative medicine fellows ~30 years from now (some of whom may not be born yet) that I am so old that I was boarded by the ABHPM (I'll reassure them that was long before we discovered antioxidants were fantastic analgesics).

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