Monday, April 30, 2007

Palliative care in developing countries; Patients' talk on CPR; History of palliative care

Sorry about the sparse posting last week, I've got a stack of items piling up that I'll try to get thru this week.

The current Journal of Public Health Policy has a special section on palliative care in developing countries (free full-text is available). The articles are mostly short and descriptive, or calls for more palliative care. The shocking (at least to naive me) lack of availability of opioids in many countries is frequently cited. I assumed there would be discussion of the debate over increasing resources for palliative care in areas where many people die of treatable--if not curable--diseases (e.g. HIV, many cancers) but this is completely absent from the issue. In resource-poor environments--where should the resources go? I'd love to say that, for instance, improving access to antiretrovirals and palliative care should occur simultaneously. Acknowledging this isn't going to be the case I personally am not sure how those precious resources should be divided. The fact that this is a zero-sum game is itself the problem of course; identifying it as such however does not bring one any closer to a solution. I'll nevertheless proffer one though in the spirit of Christian's recent US political speculations: the US goes single-payer, sends the money it saves abroad to improve the health care of developing countries, including palliative care.

Qualitative Health Research has an interesting article about dying cancer patients' 'talk' on CPR and DNR orders. As the journal's name would imply, this is qualitative research, involving a single researcher interviewing 28 dying Australian cancer patients about CPR and DNR orders (most, but not all, subjects had DNR orders). The paper itself involves a 'discourse analysis' of the subjects' talk on CPR, looking at themes that emerge. I'm in no way qualified to critique the paper, and so I won't. I will say it's an interesting look into a world (talking with patients about CPR and code status) most of are are probably familiar with, and there's much there that I recognized. I was particularly struck by this (it is describing a patient):

...[H]e drew on some concept of quality of life ("the way I feel today ...I've got tomorrow to look forward to") to justify a current preference for resuscitation, construing his assessment of his life as the pivotal issue. Invocation of these factors works to reaffirm the primacy of patient autonomy in these decisions, as well as prioritizing subjective judgments about the value of life: having something to live for justifies resuscitation. One consequence of this is that the mere assertion by the patient that some aspect of their life holds worth will suffice to stymie moves to establish DNR orders....


Lancet Oncology has a lovely review of palliative care's history in oncology. It opens with this:

In only four decades, the care of patients with advanced malignant disease and the management of their symptoms during the trajectory of illness has moved from the margins of oncological practice to the very centre of modern cancer care.

While that seems a little grand to me, the remainder of the article is really interesting and actually quite a whirlwind summary of palliative care's history and the current scope of palliative care services and programs worldwide, complete with full-color pictures.

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