Saturday, February 3, 2007
Informal caregivers; Constipation meta-analysis (ahem); CRP & prognosis; Truth-telling in oncology; Palliative care in resource-poor areas; Fast Facts
I have a rapidly escalating pile of articles to blog that it looks like I'm not going to be able to get into in depth. So, superficially speaking...
A recent Archives of Internal Medicine had an article surveying informal caregivers of dying patients in the US. It gives a sense of the demographics of informal caregiving, what sort of services they used, how they felt about their role, etc. In short, most found the experience taxing, but also personally rewarding & meaningful.
Cochrane recently published a metaanalysis of constipation treatments for palliative care patients. (Image is of cupping points for constipation [a therapy not mentioned in the metaanalysis]--click on the image for its website if you're interested.) I bet you can't guess their conclusions: only a few articles met Cochrane metaanalysis standards, overall scant evidence for anything, poor quality trials, etc. etc. Overall not much is added to the knowledge base other than another cry for quality symptom research.
On the prognosis front Supportive Care in Cancer has a look at C-reactive protein (CRP) & prognosis in terminally ill cancer patients. This was a tiny (n=44) single-institution study. Median survival for those with CRP levels >2.2mg/dl was 9 days; under 2.2mg/dl was 30 days. This association withstood multivariate analysis for what that's worth. Interesting to be sure, but I'm not sure how this is really going to improve clinical management at this point.
The current Journal of Clinical Oncology has an Art of Oncology piece on "truth telling" (article here; supporting editorial here). It tells the story of a young man dying of leukemia and the silence surrounding the fact that he was dying. There's some very good writing here:
Though we may not know the truth of any patients' death, we are deeply woven into their journey. As oncologists, we provide the matrix against which decisions regarding life and death are made and through which communication travels. If we do not serve as open conduits, surely the perilous roller-coaster ride that bends and turns with mortality at every twist will be darker and more terrifying. If we do not speak freely of life and death, we shelter the truth that life and death complete each other's expression. Like light and darkness, they are a pair, as a foot before and a foot behind when walking. As physicians, if our own bodies house fear—fear of death, fear of the unknown—we will subversively transmit this to those for whom we care. By doing so, we hinder the very life we intend to care for, with our own stories. If honesty is a goal, then truth is the wave that carries us there. It is not an easy truth to face, and yet it is our work. We have each signed up to bear witness to the ultimate mystery, the transition from life to death. It falls to us to unravel the reins of paternalism and say what is so.
Thank you, is all I can say, to the author, for writing this.
Lancet Oncology has an editorial asking whether palliative care should replace palliative treatment for cancer in poor countries (no abstract, link here). Despite its provocative theme, it's more or less a plea for increased palliative care training, resources, infrastructure, & know-how in the developing world, and less of an argument that palliative care should replace cancer treatment in resource-poor areas. The reality is, unfortunately, that frequently neither are available. Thanks to Christian "12 days of AAHPM SLC" Sinclair for alerting me to this.
I am now the editor of Fast Facts. David Weissman (my boss, mentor, and all around palliative care go-to guy), who has edited Fast Facts pretty much since their beginning, deeply honored me by offering me their editorship. Fast Facts are a tremendous compendium of palliative care know-how and I look forward to continuing David's tradition and high standards. If any of you have ideas for Fast Facts, or are interested in writing one, please email me.