Friday, December 29, 2006
A little New Year's clean out of my back-log of 'to-blog' articles, plus some news articles...
Chest recently had an article about patients' & families' understanding of CPR. The study involved interviewing ~400 hospitalized patients (and some of their families) with advanced cancer or medical illness (CHF, COPD, cirrhosis). It was a multicenter study in several Canadian teaching hospitals; just under half of the patients had a pre-existing DNR order, and in follow-up over half the patients were dead at 6 months. Some of the results were pretty shocking, most notably that almost half (44%) of the subjects couldn't identify a single element of CPR (artificial breathing/intubation, chest compressions, shocks, drugs). Less surprising is that <5% of patients could accurately state their own prognosis for survival of CPR (most stated they didn't know or were wrong). A good third of the subjects said they didn't want to talk with their doctors about resuscitation (although this is difficult to interpret since most didn't really know what it meant anyway). Most patients endorsed some sort of shared decision making (with doc & family) about performing CPR or not, although a fifth said they thought the decision was theirs alone. Patients generally ranked prognostic outcomes as the most important information they need to know about CPR. There are lots more findings and it's a recommended read. I've long thought the problem with CPR discussions with patients etc. have been due to misconceptions about it, but this research suggests it's more that patients have no conceptions about it. I'm trying to decide whether this will change the way I speak with my patients about it and I'm not sure if it will. However, I'll likely incorporate it into how I teach housestaff/medical students how to have these discussion: assume the patient knows nothing, what they do know is wrong, and what they want to know is the expected outcome (not the gory details of the intervention).
Geriatrics this summer had a review article on feeding tubes in advanced dementia, reviewing the evidence, ethics, and communication challenges surrounding them. It doesn't add much to the debate, but it is a good, comprehensive review of the issues involved and it's a good addition to one's teaching file (it's actually quite plainly written and would be easily understandable to non-medical colleagues--chaplains, social workers, etc.).
Seminars in Oncology recently had two reviews of note: one on the management of spinal cord compression, the other on neoplastic meningitis.
It's been a busy week in the NY Times. First is an op-ed about the "most-avoided conversation in medicine " (that would be the one about how the patient is dying). It's written by a surgeon, strongly advocates not avoiding the conversation, and liberally references the SUPPORT trial. Thanks to Dr. Lynn Bunch for alerting me to this. I'll also recommend the recent article about Dr. Michael DeBakey's aortic dissection repair at the age of 97--it's a fascinating story involving pseudonyms and late night emergency ethics meetings and discusses among other things the ethics of extraordinary care for the oldest old (and VIP's).