Tuesday, February 27, 2007

Advance directives maybe do something; Pain & depression; Schrodinger's cat and medical futility

Two from the latest JAGS and one from Journal of Medical Ethics...

1)
First is a mortality follow-back study on advance directives and quality of terminal care. I have expressed skepticism about AD's on this blog before--wondering whether they really improve end of life care etc.--and I'm happy to report that here is a bit of data proving me wrong. The study was a typical, solid Teno mortality follow-back survey of ~1500 bereaved family members. About 70% of patients had AD's before they died; those with AD's were more likely to be older, female, and white. AD's were definitely associated with 'better' terminal care:

"For decedents with written ADs, the last place of care was most likely to be a nursing home. Those with an AD used less life-sustaining treatment in the last month of life, because they were less likely to die in an intensive care unit (11.8% vs 22.0%), to be on a respirator (25.6% vs 36.7%), or to be using a feeding tube (17.3% vs 26.8%) in the last month of life. Family members of decedents with ADs were not more likely to report that the decedent did not receive enough life-sustaining treatment."

In multivariate analysis, having an AD was associated with improved communication with physicians about decision making and better family preparation for death. I would interpret these findings with caution (as do the authors of the article)--they argue that having an AD is associated with 'better' EOL care; this doesn't mean that the AD lead to the better care & in fact in this study those with ADs were significantly different than those without. It could be used, however, as an argument that AD completion is a valid quality marker for EOL care--that debate however is a whole other story....

2)
There's a study looking at pain and how it attenuates recovery from depression in elderly veterans. It does (well, maybe--it's a complicated study which I'm not going to belabor here--it's an interesting read for those of you interested in the topic).

3)
Journal of Medical Ethics has an article proposing a conceptual framework for medical futility. This is a rather erudite treatise which references Hume liberally, as well as has a dash of Schrodinger's cat, and frankly it lost me frequently. That being said its thesis seems to be rather straight-forward: that the futility of a medical intervention can only be evaluated if the goal of the medical intervention is established, but that, you know, there's often disagreement about what a reasonable goal is, and who gets to decide what the goal is anyway...? If there's anything more subtle going on in this paper that I've missed please comment and let me know.

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