Thursday, March 22, 2007

Do not hospitalize orders; Honesty & optimism; Discussing hospice


3 things:

1)
The latest Journal of the American Geriatrics Society has an article on factors associated with 'do not hospitalize' orders in demented nursing home patients. It involved a nation-wide (U.S.) sample of patients (~90,000) and used minimum data set data. Overall 7% of demented NH residents had DNH orders (wide range--0.7% in Oklahoma and over 25% in Rhode Island). Things that were associated with having a DNH order included increased age, being white, being in an urban NH with a wealthier patient mix, being on a special dementia unit, being in a NH with an NP or PA on staff, and having a living will and health care power of attorney. The percent of your NH's patients receiving hospice care was not associated with having a DNH order although being in an area in which fewer NH patients died after passing through an ICU did predict having a DNH. What's interesting to me about these findings is not so much what was associated with having a DNH but the wide variation in practice by geographical region, social class, and type of NH. There are probably lots of reasons behind this but it seems that at least in part local medical culture determines whether a patient (...really their family) gets the choice of not having an ambulance ride in their last week of life.

The same issue also has several articles on preventing falls in nursing home residents (issue's table of contents here).

2)
Supportive Care in Cancer has an article on physicians' reluctance to disclose difficult diagnoses. Specifically, it's a narrative review looking at practices (including patient preference and physician behavior) surrounding disclosure of difficult news (diagnoses, prognosis, etc.) in oncology and psychiatry. For the Pallimed reader it has a detailed, narrative summary of the research into patient's preferences and physician practice surrounding disclosing bad news including some interesting stuff about temporal trends & geographic variation in physician practice. Of interest to me, although I guess it makes sense, is that overall it seems that psychiatrists are more reluctant to disclose difficult diagnoses to patients than oncologists & that psychiatric patients (or at least random people when surveyed) are less likely to endorse wanting to know detailed honest information than cancer patients. This seems particularly true of dementia, which makes sense in a way.

The article also reminds us of this factoid: one study showed that "although 100% of participants wanted doctors to be honest, 91% also wanted them to be optimistic." I still have vivid memories of being a medical student and witnessing this (wonderfully caring) geriatrician crouching at the bedside and clasping the hand of a deaf, demented, dying patient and yelling "WE'RE GOING TO MAKE YOU BETTER." Part of the art of medicine, surely, is to learning the art of honoring both aspects of patients' wishes: honesty and optimism, and not just the easy one. Given that the same group of patients said they wanted both honesty and optimism I'll assume that the patients weren't saying they wanted their docs to say "You have incurable cancer and will likely die within the year but I'm going to fix it anyway. Prepare for a miracle cure!" Instead I'd assume they meant by 'optimism' "You have incurable cancer and will likely die within the year but I will promise you careful, compassionate, and good care. Whatever happens you will not be alone, your family will get the help they need, and I will make sure you are safe and get the right care."

Anyway, enough preaching to the choir.

3)
Annals of Internal Medicine has a piece on discussing hospice with patients. It's aimed at the general physician and provides a lot of basic, nuts & bolts information on hospice services as well as a practical walk-through of discussing hospice in the context of a goal-setting discussion. It's a good article for the teaching file as well as for interested non-palliative care trained colleagues who want "to do it right." It also addresses discussing goals and terminal care with patients who aren't ready for hospice care despite it being medically appropriate.

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