Sunday, June 25, 2006

Fentanyl Abuse

There have an increasing number of new reports about the abuse of fentanyl patches which should be very unnerving to the Palliative Medicine community, as it is typically a medicine we go to decrease the potential for abuse from other medicines like morphine and oxycodone. The Cheerful Oncologist and Retrospective do an excellent job reviewing this subject, even adding some information about a fentanyl analogue being used in the Russian-Chechen Theatre Hostage situation back in 2002.

Sunday, June 25, 2006 by Christian Sinclair ·

Thursday, June 22, 2006

Would Widely Implemented Palliative Care Save Money?

As a self-described skeptic, I love discussing challenges to common wisdom. I believe that is part of how I came to appreciate the field of palliative medicine so much. But there is also a common wisdom of palliative medicine that should not be immune to skepticism and questioning. After all that is how we make our field stronger.

A study out of the journal 'Applied Health Economics and Health Policy' came out with a unique analysis comparing ex ante mortality risk with actual end of life costs. While I do not have the article (I am working on it.....I can't find a source that actually has access to this article) for those of you who are interested in this, the authors looked at a retrospective calculation of mortality risk one year prior to death for Medicare beneficiaries. That mortality risk was compared to money was spent on health care at the end of life, and they found that they were inversely related.

Thus, those with the highest risk of dying actually had less money spent at the end of life, while those with the lowest retrospectively calculated mortality risk 1 year prior to death (i.e. those not expected to die) had a higher amount spent on them. The authors conclude that with current physician practice, palliative care's effect on cost saving may be less then previously thought.

Now again I have not read the article myself, and am still actively searching for it, but as loyal Pallimed readers should know from my previous post, I am not entirely excited at using the economic argument for implementation of palliative care. So a study like this might force our field to advocate for our services based on evidence of helping the patient/family unit and less on helping the system (although that could be a noble goal in itself, if it works towards preventing a collapse of health care).

Thursday, June 22, 2006 by Christian Sinclair ·

Wednesday, June 21, 2006

Sudden Death in Children

JAMA has continued the wonderful Perspectives on Care at the Close of Life series with a recent article on Sudden Traumatic Death in Children. The subtitle is quite moving. "We Did Everything, but Your Child Didn't Survive."

The article is well written with perspectives from a physician and social worker involved in a case of an 18 month-old hit by a car. One interesting aspect is the criteria for brain death in children are age-specific, a fact I was not aware (probably having to do with my Internal Medicine background). What surprised me was the robust bibliography (60+ articles) on a subject that does not always get a lot of attention. Of course I hear about cases like this a lot, but not because of my hospice background, but because my wife is a Pediatric Emergency Medicine Fellow (almost done!). When people hear I work at a hospice they often comment on how 'sad it must be.' But from the stories I hear from my colleagues in the Pediatric Emergency Department, I have realized there are more difficult medical cases. So I am glad to see articles like this one to help people like my wife and her peers have some structure to such a difficult situation. Like the physician in the article says:

"...it's like you're trying to have a funeral organized and go on time, in the context of a busy ICU. That's very difficult to have come out well."

Wednesday, June 21, 2006 by Christian Sinclair ·

Sunday, June 18, 2006

The 3rd Pallimed baby

Well the 3rd Pallimed baby to be born this year is here.  Benjamin Arnold Rosielle was born on June 15th.  Baby and Mom are healthy and doing very well.  So is Dad, altough we're all tired. 

I probably won't be posting for a while--Christian it's all yours.

Drew.

Sunday, June 18, 2006 by Drew Rosielle MD ·

Wednesday, June 14, 2006

Constipation in JSO; Transitions in care; Expectations & reality with feeding tubes

A few things in brief:

1)
The Journal of Supportive Oncology's latest issue has several articles about constipation in advanced cancer. These include one about the pathogenesis of constipation in cancer patients which asserts that direct tumor invasion of the bowel is the "most common contributor of cancer to the occurrence of cancer" which strikes me as a statement in need of some backing-up (which the author doesn't provide). Besides that it is an excellent overview of constipation's pathophysiology and I learned a lot. The other two articles are commentaries (no abstracts) which among other things mention the emerging evidence supporting opioid antagonists (methylnaltrexone & alvimopan) for opioid-induced constipation. I'm not sure of the status of these, but I am under the impression that at least methylnaltrexone was headed to the FDA (soon?) for approval. If anyone knows please leave a comment.

As always, JSO articles are available to all with a free online subscription.

2)
BMC Palliative Care has posted a few articles of late, including one on a topic of great professional interest to me--transitions in care for dying people. That is--transitions in places of care (between home, hospital, hospice facility, etc.) and care-providers (new docs, etc.). It is a mostly descriptive study of patients enrolled at a palliative care center in Halifax. These transitions are often emotionally difficult for patients and families & represent easy opportunities for care breaking down, poor communication, care plans being lost or needlessly reinvented, etc. It's good to see this being studies.

(BMC, or BioMed Central, publishes online-only, peer-reviewed, open-access journals in multiple fields--articles are always available free online).

3)
The American Journal of Medicine has an article about expectations and 'reality' with feeding tubes. It looks at a cohort of a few hundred mostly older adults who received feeding tubes in North Carolina hospitals; this was a mixed population including post-stroke, cancer, and dementia patients among others. Patients' families were interviewed around the time of tube placement to assess what they thought the tube would accomplish. To summarize briefly: families thought patients would get better and most of them didn't--few patients had measurable improvements in ADL's or got out of nursing homes, and mortality was high across the cohort. None of this is medically surprising, usually the receipt of a feeding tube is a marker of advanced illness and disability and high mortality risk, but this study highlights just how dismal we in medicine prepare families for this.

Wednesday, June 14, 2006 by Drew Rosielle MD ·

Friday, June 9, 2006

LMWH in advanced cancer patients; International pain policy fellowship

1)

The current Mayo Clinic Proceedings has a prospective trial about using low molecular weight heparin (in this case dalteparin) in patients with advanced cancer, to see whether it improves survival.  This is a topic that's been discussed before on the blog (should 'palliative' patients receive LMWH to prevent thromboembolic events?), and I'll refer readers to prior posts for some of my thoughts about this (see here & here).

The trial was supposed to be a randomized, placebo-injection controlled trial involving advance cancer patients ("advanced" lung or colorectal cancer or advanced breast/prostate cancer patients who had 'failed' first line chemotherapy).  Some were receiving chemotherapy.  All had ECOGs of 0-2, and no recent history of thromboembolism.  They had trouble recruiting patients and so midway through changed the randomized-to-placebo arm to a randomized-to-usual-care arm as they assumed their accrual problems were due to people not wanting placebo/saline injections.  They ended up with data on 138 patients (which remained substantially below their goal, ie--the study was under-powered to detect a benefit).  The median survival of the group as a whole appears to be about 8 months (this is me eyeballing the multiple Kaplan-Meier curves as the authors don't present this number anywhere), and there was no significant difference in survival between the groups.  The authors performed multiple analyses (blinded LMWH vs blinded placebo, unblinded LMWH vs usual care, all LMWH vs all non-LMWH, etc) as well as looked at only those who lived longer than 6 months and, again, found no differences to speak of.  Toxicities between groups were similar. 

Referring back to the the discussions/posts I mentioned before, I'll reiterate that there remains zero evidence that so-called palliative patients benefit from LMWH, and all the evidence--as poor as it is--points to the fact that they don't benefit.  The patients in this study were presumably healthier than most patients cared for in palliative care (whether in hospice, or in palliative units, or by palliative care consultants), and chances are that for a sicker population it would be even more difficult to demonstrate benefit--if one existed--because the mortality rates would be so high anyway.  But, frankly, there's not much to guide us besides troubled research like the above.

2)
The Soros Foundation/Open Society Institute has announced an international pain policy fellowship.  It is aimed at helping people improve access to pain meds & palliative care abroad, and is coordinated by the good people up the road from me in Madison. The deadline for applications is June 16th (oops). 

Friday, June 9, 2006 by Drew Rosielle MD ·

Thursday, June 8, 2006

Pallimed - One Year Anniversary!

Hooray! Pallimed is proud to celebrate the one-year anniversary of bringing you a variety of resources from the world of hospice & palliative medicine. I would like to thank Drew for allowing me to be part of his creation and hope that it has many successful years to come.

Just some highlights:

  • Over 200 posts in one year! No other Palliative Medicine oriented blog comes close!
  • Studies presented from a number of journals and sources!
  • Witty and snarky commentary designed to enlighten and entertain!

Please comment or email Drew or Christian to let us know how Pallimed helps you or to give us suggestions.

And help us celebrate our one-year anniversary by supporting:

"National Tell-a-Colleague about Pallimed Week"

We have not yet applied for official government recognition for our declaration, but it is still okay to tell your colleagues about Pallimed.

Thursday, June 8, 2006 by Christian Sinclair ·

Tuesday, June 6, 2006

Chemo, ICU, ER visits at the end of life and follow-up

The AP released an article that made the front page of the Kansas City Star this past weekend highlighting a study from ASCO. The data showed the number of ER visits, ICU stays and chemo use in the last few weeks of life had all increased throughout the 90's. Interestingly in the same article they mention another study that shows not enough patients with cancer get offered chemotherapy. Unfortunately the article did not have the space/time to go into all the complex details as to why this is, so I am afraid the message comes out confusing for those who read the whole article. Kind of like one of those coffee/wine/fat/carbs/mammograms are bad for you...wait...wait...no they are good for you scenarios we see all too often in media reporting on medical matters.

I am just glad to see that these topics are being addressed at ASCO.

---------------------------------
Here is a follow-up on my concern about the Wall Street Journal article on the cost-savings argument for palliative care teams being implemented...

My letter to the editor did not get published. Oh well. But if you are going to get published you have to expect to get denied. That wisdom was shared with me by Ira Byock, MD, who has published a few things, and as he shared been denied a few times.

But the nice thing about having a blog (Thanks Drew!) is that you can post your denial letters. Happy reading!

RE: Care Varies Widely at Top Medical Centers - May 16

The selected quote from the NYU Medical Center Chief Medical Officer, Dr. Cohen, regarding the utility of palliative care services as "effective in limiting overuse of resources" was grossly misrepresentative of many palliative care teams in hospitals across the country. Palliative care teams have the primary goal of supporting and comforting the patient/family unit during the course of a hospitalization, especially when the patient may be facing a life-limiting illness. Often times this occurs by slowing the overwhelming clinical inertia of more diagnostic tests and therapeutic options to allow the patient and family time to ask questions and understand their diagnosis and prognosis. After sitting with and listening to patients and families, sometimes for hours over days, the goals of care may be adjusted to reflect the patient's wishes, which may be to limit aggressive measures.

Dr. Cohen's statement reflects the hurdles palliative care teams have to overcome to justify their services to hospitals. The time and cost of having a multi-disciplinary palliative care team is high, and reimbursement for talking and listening to patients is miniscule compared to medical procedures. Palliative care teams will hardly ever cover the costs, so hospitals should employ palliative care teams primarily for the quality service and symptom control given to patients. If palliative care teams are to retain any trust with the community, any cost-savings from a change from curative to palliative should merely be viewed as an unintended benefit and not a mandate from the hospital.

Tuesday, June 6, 2006 by Christian Sinclair ·

Monday, June 5, 2006

Ron Cranford has died

Ronald Cranford MD, a neurologist at Hennepin County Medical Center & the University of Minnesota, died last week in a hospice in the Twin Cities. He was deeply involved with the movement to establish ethics committees at US hospitals, in defining the persistent vegetative state, and was personally involved (as an expert witness and advocate) in the Nancy Cruzan and Terri Schiavo cases, among many, many others. He was also one of the first to describe DNR orders in the medical literature. He was an unapologetic (and at times undiplomatic) advocate of the rights of people, even incapacitated people, to refuse unwanted medical care at the end of life, and didn't mince words when speaking about it publicly ( e.g. calls Fox News' Joe Scarborough stupid here). He was widely reviled in the right-wing & "right-to-life" press because of this, and despite publicly proclaiming his opposition to euthanasia and physician assisted suicide all his life was widely branded by his enemies as an "euthanasia doctor," Dr. Death, etc.

I went to school at the University of Minnesota and Dr. Cranford was my attending while I was on my neurology clerkship. My memories are of doing more ethics consultations than neuro consultations, and the first several family meetings I sat in on as a fledgling doctor were lead by him. I remember strongly his humor, gentleness, and brash personality.

Obituaries here & here.

Monday, June 5, 2006 by Drew Rosielle MD ·

Saturday, June 3, 2006

Pain as the "5th Vital Sign" doesn't seem to help

Two recent articles in the Journal of General Internal Medicine address the effects of institution-wide pain management programs.

The first looks at the effect of implementing pain standards on pain control in a hospital.  It is a retrospective review of a single hospital's experience with implementing "pain standards" hospital-wide as part of a JCAHO compliance effort (the article's describes hospital-wide nurse and physician education measures and the introduction of nursing pain assessment, recording, and reaction standards).  They compared patients before and after and, to make a very long story short* they found no differences to speak of with regards to pain assessment, documentation, or control. 

The second looks at the policy making pain as the "5th vital sign" on pain control at a VA hospital.  This article was set in the VA's outpatient clinics and compared pain management practices (pain assessment, evaluation, and treatment)  before and after the "5th vital sign" policy began.   The authors found 1) no difference before or after, and 2) that pain management was generally of poor quality.

Neither of these studies should be a surprise, particularly in light of the recent Mt. Sinai pain management improvement project .  While it's tempting to interpret these findings as a condemnation of bureaucracy-driven quality improvement, even the Sinai study which was a well-thought out, rational, aggressive, and comprehensive effort to improve pain management hospital-wide did not demonstrate an actual improvement in pain control (as measured by patient self-reported pain levels).  (The Sinai study did show improvements in other areas such as pain assessment and opioid prescription.)  This goes to show just how difficult it is to demonstrate improvement of pain control across an institution, and why simple solutions probably don't help much.  The problem is, what if careful, data-based, "non-simple" solutions don't help much either?  I did much of my internal medicine training at a VA and while I was aware than pain was the 5th vital sign, and had a vague sense that that means someone takes it seriously, few of my attendings or peers in the clinic or wards seemed to care about it--pain control wasn't part of the culture for the most part, and that's not something that's going to change because there's a new box to fill out on a vitals sheet.  That sentence was too long, which tells me it is too late, and I should stop writing.

*And I mean very long story--this article's methods section was over two journal pages long!

Saturday, June 3, 2006 by Drew Rosielle MD ·

Thursday, June 1, 2006

Erythropoietins and thromboembolism; palliative care in multiple sclerosis.

1)
On the supportive cancer care front...the Journal of the National Cancer Institute has published an updated meta-analysis on erythropoietin use.  (It is an update of this analysis.)  The update isn't exactly great news--it continued to confirm that erythropoietins reduce transfusions and increase serum hemoglobin, but the new analysis demonstrated a statistically significant increase in thromboembolic events with erythropoietins.  In addition there was a non-statistically significant trend for increased mortality with erythropoietins; at the very least there was no evidence of mortality benefit.  The authors wonder if recent trials using erythropoietins in non-anemic or mildly anemic patients are to account for this; that is--the risks of erythropoietins in these populations outweigh any benefits.

2)
The UK Multiple Sclerosis Society has published a guide on palliative care for people with multiple sclerosis (.pdf of the report here).  It is quite long & I'll admit I haven't read the entire thing but I thought I'd mention it as it may be a valuable resource for some patients & clinicians. 

3)
May's PC-FACS are out.

Thursday, June 1, 2006 by Drew Rosielle MD ·