Tuesday, May 8, 2007

Vent discontinuation; Pleurodesis; Insomnia; SVC Syndrome; QI for everyone


In no particular order:

1)
Critical Care Clinics has an ethical review of discontinuation of mechanical ventilation at the end of life. It’s actually a rather free-wheeling review of the U.S. legal and ethical framework for withdrawal of life-prolonging treatments in the dying. It’s a good one for the teaching file.

The same issue has a review of noninvasive ventilation (such as BiPap) which references its use in dying patients.

For the terminally ill patient, dyspnea is one of the most distressing and common symptoms. The most widely used treatment for this has been narcotics and anxiolytic medications. These medications are effective in relieving dyspnea, but they also have adverse effects. Noninvasive ventilation presents as an alternative measure to treat dyspnea; it can be used as both treatment and symptomatically. Dyspnea at the end of life is a very common and upsetting symptom for the patient and family. Very few data are available regarding the use of noninvasive ventilation. Hill evaluated the efficacy of nocturnal noninvasive ventilation in symptom relief of patients with terminal illness. Devices were used for 1 week and routinely at night for sleep disorder breathing. These patients noted improvement in fatigue. The patients who had terminally ill cancer noticed improvement in fatigue and reported fewer headaches, less sleepiness, and improved energy.”

I am glad the author mentions the lack of data. In my experience unless the patient has actually both accommodated to noninvasive ventilation and identifies it as something that makes them feel better it is not helpful at all.

2)
The current Lancet presents an observational study of the safety of talc pleurodesis for malignant pleural effusions. There have been concerns with talc pleurodesis causing acute respiratory failure and ARDS which this study tries to answer. It was a multicenter, European study of over 500 people who received thoroscopic talc poudrage. Basically the pleurodesis was very safe: no episodes of ARDS and very few serious immediate complications. The authors conclude it is safe.

Poudrage, from some free online dictionary:

The surgical application of powder, such as the dusting of opposing pleural surfaces with a slightly irritating powder in order to secure adhesion.

3)
Community Oncology has a review on the evaluation and management of insomnia in cancer patients (CO articles are always free). The article makes its management sound so easy, which it never is for me. The same issue has a supplement with an update on current guidelines for chemotherapy related nausea and vomiting. The supplement doesn’t seem to be available online however…?

4)
The current NEJM has a review on the superior vena cava syndrome, one of the least welcome consequences of thoracic cancers. It’s pretty straightforward and has some of the most colorful appearing PET images I’ve seen for a while.

The same issue also has letters (free full-text) about the recent article on religion and controversial practices (the original article mentioned terminal sedation but mostly it, and these letters, are about reproductive issues such as contraception and abortion).

5)
Annals of Internal Medicine has an important discussion of the ethics of quality improvement methods. QI work is important across health care and particularly in palliative care as our field (at least in the US) has traditionally been driven by QI efforts (improving cancer pain assessment and management, etc.). One of the more interesting assertions in it, at least to me, was that unlike for research in which patients have no responsibility to participate in (i.e. it should be completely voluntary), the authors argue that patients are obliged to participate in QI projects. “Because QI activities are, and should be, part of normal health care operations patients also have a responsibility to participate in quality improvement, which often requires direct cooperation (for example, permitting collection and use of data about the medical conditions…).” This applies only to QI work has minimal incremental risk to patients of course (e.g. involves data collection). Along these lines they argue that QI, unlike research, “generally aligns with patients’ interests, presents lower risks than continuing with usual care (and certainly less risk than making the same changes without collecting data to monitor its impact).” The article goes on to discuss differentiating between QI work and research, and gives recommendations about ensuring QI work is ethical.

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