Wednesday, November 15, 2006

Katrina editorial; terminal sedation; palliative radiotherapy; quality measures

NEJM has an editorial about the Katrina physician/nurse homicide charges. It's written by a physician who worked in New Orleans during the disaster, and makes the very reasonable suggestion that decisions on how to care for moribund patients in similar disasters should be made prior to the disaster, not haphazardly during one.

Nathan Cherney has a review on terminal sedation in the current Nature Clinical Practice Oncology. I can't actually access the full text of the article but I appreciated his succinct summary of some people's ethical concerns with terminal sedation: Sedation is controversial in that it diminishes the capacity of the patient to interact, function, and, in some cases, live.

2 on radiation therapy from Supportive Care in Cancer. First is a review on attitudes towards palliative radiotherapy (to treat painful bone metastases) regarding the 8 Gy in a single dose vs. 20-30 Gy in multiple fractions controversy (multiple studies have shown that they are more or less equally effective, although duration of analgesia is clearly longer with with fractionated therapy). They found a wide variation of preferences among different constituencies (radiation oncologists vs patients) and locations. The study clearly supports the idea that use of single fraction therapy is not widespread, despite evidence for its use, and (surprising to me) some studies have shown that patients would prefer multiple fractions over a single dose. Perhaps it feels more like they're receiving 'real' treatment?

Along these same lines, the same issue has a prospective study looking at pain flares from palliative radiation therapy for painful bone mets. The data is from a randomized study comparing, guess what, 8 Gy single dose vs. 20 Gy fractionated therapy. Patients completed pain diaries during their treatment (this was a relatively small study of about 100 patients and only half of these agreed to do the pain diaries). Depending on how a 'pain flare' was defined it seemed to occur in 35-40% of patients overall (and a flare appeared to be more common in patients receiving single dose therapy). There was a trend toward prevention of a pain flair with concurrent dexamethasone use, although this was not statistically significant. They didn't actually talk about when the flares occurred, although presumably it was early on. This study brought to my attention the interesting research question of how does one define a 'pain flare.' They actually used a couple of definitions in this study, but basically it was at least a 2 point increase in pain score on a 0-5 Likert pain scale for at least 2 days in a row (in the absence of decreasing analgesic use) or a 50% increase in analgesic dose without an associated decrease in pain. The first criterion seems to be too conservative to me--assuming you can translate a 0-5 Likert scale to a 0-10 NRS (and yes, maybe I shouldn't be assuming this) their criterion would be at least a 4/10 increase on the NRS which seems like a lot, and one wonders if 'milder' pain flares are much more common.

A recent Journal of Clinical Oncology has a review on quality measures for symptoms and advanced care planning in cancer patients. To make a long story short, there are many measures, most of them seem reasonable (that's my gloss), however there's little evidence (yet) that implementation of these quality measures improves quality of care. The article does provide a nice collation of the many articles trying to develop quality measures, and may be a useful starting point for quality improvement projects.

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