Thursday, February 22, 2007

Anger in palliative care; JCO on CAM, spirituality, & empowering patients

Internal Medicine Journal has an article about anger in palliative care. It is a qualitative & narrative article reviewing anger in palliative care and is based at least on part on interviews with palliative care clinicians (docs, nurses). It's an issue which isn't frequently written about specifically--usually conflict in general is addressed--and for those of you who follow these things it might be interesting. It has this quote near the beginning:

In cancer care, despite being considered a normal reaction, anger is often seen as a negative emotion, which is tolerated, as it may presage a future, more constructive response.

I was hoping when I read this that the article was going to thoroughly de-pathologize anger, but it didn't really.

Journal of Clinical Oncology has kept my inbox busy as of late...

First are a couple of articles about complementary and alternative therapies in cancer care. One is a randomized trial of aromatherapy massage (which is exactly what it sounds like) for depression and anxiety in cancer patients. It was a multi-center non-blinded trial in which 288 cancer patients were randomized to four one-hour sessions of AM or 'usual care.' How these patients were identified is unclear, they apparently met 'modified criteria' for 'clinical anxiety/depression' according to DSM-IV criteria. I don't have a DSM in front of me but the last time I checked 'clinical anxiety' or 'clinical depression' weren't diagnoses in the DSM--GAD, major depressive disorder, adjustment disorder etc--but not 'clinical anxiety.' This sort of stuff worries me when I see it in an article. Their primary outcome was depression and anxiety symptoms at 10 weeks post-randomization and intention to treat analysis was used. (After reading the article a couple of times I'm still a little fuzzy on how they actually defined anxiety and depression). They found modest improvements in anxiety and depression 6 weeks post-randomization (2 weeks after the intervention was done) in the AM group; no differences in anxiety/depression between the AM & usual care group at 10 weeks (this was the primary outcomes); and no differences at any times between the groups regarding pain, fatigue, nausea, or global quality of life.

Problems aside (and, frankly, supportive cancer/symptom trials tend not to be of the highest quality in most instances), this was the best designed and executed CAM trials I've seen for a while, and I commend the authors for publishing its severely underwhelming findings. In their discussion they noted some of the difficulties in undertaking the trial--typical stuff about patients getting sick etc.--but they also mentioned how none of the study sites actually had infrastructure supporting research into supportive cancer research which was a problem for them. This is the real story here.

Second is another CAM study. This one looked at the use of complementary and alternative therapies in cancer patients starting phase I trials. About 200 patients were interviewed at the University of Chicago as they were enrolling in phase I trials about their CAM use. Their most interesting findings, although not surprising I guess, is that CAM use seemed to increase with decreasing quality of life and increasing certainty of death (it was much more common in patients who thought they were likely to die within the year).

Third in JCO is a study looking at advanced cancer patients' religiousness & spiritual support & how it relates to quality of life and end of life treatment preferences. This was another interesting article to come out of the Coping with Cancer Study (a multi-institutional U.S. study of advanced cancer patients and their caregivers). 230 patients were interviewed about spirituality, religion, and sundry other things. Not surprisingly most patients felt like the medical system provided inadequate spiritual support; more surprising was that almost half of patients reported their own religious communities provided inadequate support. This finding was attenuated for African-Americans & Hispanics. Spiritual support was associated with improved quality of life (this finding survived multivariate analysis). In multivariate analysis increased religiousness was associated with wanting all possible measures to extend life 'even if you were going to die in a few days' but not decreased rates of advance directive completion. Being 'non-white' was associated with decreased completion of advance directives and a DNR order (being in the Northeast was also associated with not having a DNR order--no comment on that). Most of these findings are consistent with previous ones. What was striking to me was how, it seems, patients felt like their spiritual needs were not being met by either the medical system or their own religious communities--perhaps part of the progressive isolation many patients undergo as they become increasingly disabled?

(Supporting editorial by Betty Ferrell here.)

Fourth and finally is a randomized controlled trial to help advanced cancer patients ask their physicians about prognosis. Basically a bunch of cancer patients were given a booklet with potential questions to ask their physician about, among other things, prognosis, what to expect in the future, support services, etc. The booklet intervention did seem to raise the number of questions patients asked and topics discussed, although in the long run it's not clear it significantly improved the amount or quality of info patients got. The physicians didn't seem to mind the intervention too much, although I did find this quote notable:

However, five of 13 physicians stated they had some reservations; namely, fear that the patient may not be ready to discuss end-of-life issues, and concern that it may put the onus on the patient to ask questions rather than on the physician to respond to patients' cues.

Because, as we all well know, physicians are the ones who should be deciding when it's time to discuss end of life concerns, and are famous for our ability to pick up on patients' cues, particularly when it comes to discussing uncomfortable information.

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