Tuesday, January 9, 2007
Most of the December 27th issue of JAMA was notable:
On the prognosis front--there's an article looking at trends in stroke mortality. Rates of stroke are decreasing, as is 30-day mortality in men (14%). 30-day mortality in women has remained stable for decades at ~20%.
There's a coda for the recent Perspectives on Care at the Close of Life on frail, elderly adults.
There's also Perspectives piece about end of life care for homeless patients. This, for me, is the most best of the (overall excellent) Perspectives on care at the close of life series--probably because it's an area I know little about, and the case/story presented in the piece is extremely compelling. It involves an older, homeless, heroin-using man with renal cell cancer. He was told when first diagnosed (and when he possibly had curable cancer) that he couldn't get his nephrectomy unless he quit abusing drugs(!). So after his renal cell spreads everywhere and there's nothing to do about it he is cared for by a palliative care team in San Francisco. He continues to use heroin both 'recreationally' (acknowledging there is nothing recreational or fun about heroin addiction) and for analgesia early on while under the care of the pc service. Then, as he gets sicker, and constantly seeking out heroin becomes more difficult, he quits and is maintained--apparently without incident--on prescription, oral opioids. All the legal, social, and financial issues are discussed at length. It made me hope they dedicate an entire piece in the Perspectives series on caring for people actively abusing substances at the end of life.
And finally, there's a series of letters about the recent Clinicians' Corner discussion of patient refusal of care (which involved a debilitated elderly woman in an objectively unsafe home environment who refused to be discharged anywhere other than home). (I was sure I blogged this but I can't find it anywhere which means I in fact didn't blog it. This is unfortunate given that last week I tried blogging an article only to realize half-way through I had already blogged it. I'll publicly state it now: I don't want a feeding tube.) It's a thoughtful, provocative article about patients refusing (what we believe is) clearly beneficial care.