Tuesday, April 24, 2007

Video-assisted advance care planning; Drug burden in the elderly; Pain doc trial; Death & the media


1)
Archives of Internal Medicine has a couple notable articles. First is an intriguing one on using instructional videos in advance care planning for patients with dementia. 120 adult outpatients (median age 58, 70% women, over half non-white) who didn’t have family members with advanced dementia were given verbal information about advanced dementia and asked, essentially, if you were in this state would you want full, aggressive life prolonging care, less aggressive life prolonging care (hospitalization, antibiotics, etc. but no CPR, vent, or ICU level care), or comfort-only care? Then they were shown a video of a patient with advanced dementia being cared for (you can watch the clip here) and then were asked the same thing.

After hearing a description of dementia, about half said they’d want comfort care and 21% said they’d want ‘full’ life-prolonging care. After the video 90% said they’d want comfort care and none said they’d want ‘full’ life-prolonging care. Before the video, somewhat more Latino and African-American subjects said they’d want full life-prolonging care; this was also true of the more religious and less educated subjects. After watching the videos there were no differences between any groups (ethnic, religious, education-level) regarding preferences.

These are quite dramatic findings, and quite exciting. Not only were the outcomes quite pronounced, they also were strong enough to nullify religious/class/racial differences in treatment preferences which are frequently identified in the advance care planning/treatment preferences research literature. I’m excited to see where people take this. One has to be somewhat cautious. You can look at the video yourself and decide how accurate or frightening it was—to me it seemed a rather accurate and straightforward depiction of someone with far advanced dementia—but one wonders if there was something about this particular video to generate such dramatic outcomes. You’d like to see these findings repeated with different videos, as well as with different disease categories. Of course this sort of intervention lends itself well to dementia; I’m trying to think of other terminal illnesses for which it may be amenable. It would be tough to depict in this way CHF or COPD or cancer for that matter…. It could be done with CPR itself though but the problem there is a focus on the intervention and not its outcome….

The other article is about the development of a “drug-burden index” in the elderly. It involved analyzing the drug use of >3000 elderly (average age 73) community-dwelling adults along with their functional status. Interestingly, these subjects had to have pretty good function in order to be included in the study; they had to be able to walk a quarter mile and be independent in their ADL’s. Anyway the authors found that function (both physical and cognitive) declined in this group in the patients on a higher number of drugs, but that this association was all caused by sedative and anticholinergic drugs—once they removed these from the mix the actual number of drugs didn’t predict functional status. Comorbid illness didn’t have any effect either independent of anticholinergic or sedative drugs. The take-home point is a well-established one: anticholinergic and sedating drugs cause problems in the elderly. Taking a skeptical stance, however, you could argue that this research simply establishes an association between these agents and poorer functioning—causality is not established—and you could argue that, perhaps, maybe the poorer functioning adults were that way because of pain and because of their pain they took more sedating/anticholinergic meds.

2)
The NY Times has an article on the Hurwitz trial & some of the testimony recently given about his practice. It’s quite dramatic and includes the story of a patient that was treated both by Dr. Hurwitz and by one of the prosecutor’s expert witnesses (another pain doc). The two doctor’s treatment approaches are starkly contrasted; it’s pretty damning of one of them (I’ll let you read the article to find out who).

(NY Times articles are available free online for about a week.)

(I was sure we had blogged about this trial before although for the life of me I can’t find it—he is a pain doctor who was criminally convicted of conspiring to distribute opioids etc etc whose conviction has recently been overturned and is going through a re-trial. An overview is here.)

3)
Continuing the last post’s thread about death and its place in our society, the Guardian recently published two editorials about death, mourning, and the media (triggered by last week’s mass murders in Iraq and Virginia). Paul McIntyre, who let me know about these, pointed out that they have a rant-like quality—written from a sense that something is deeply broken with our culture & death. Given that, it is interesting to see palliative care mentioned in the midst of these (not necessarily inaccurate) rants....

“Attitudes to death and mourning grow odder the rarer dying young becomes. There is less sense of proportion about the risks of dying, or about the inevitability of death itself, even when people die in old age. The temptation is to regard every death as avoidable, deny any accident is ever accidental, always find someone to blame, and hunt down that doctor in charge. …At the same time, the public dare not face up to the reality of the prolonged agony modern medicine imposes on the dying. Until it happens to them or their parents, people fondly imagine morphine or palliative care will always ease the end. That fallacy means many will enter the grave via the torture chamber, for failure to demand the legal right to die at a time of our own choosing. People no longer know how to approach death and its rituals….”