Tuesday, June 5, 2007

Fatigue-o-rama at ASCO; Surgery for back pain; Kevorkian; Ethics Consults

Thanks to everyone at the CSPCP conference last week for being so friendly - particularly the Nova Scotian crew (DH & family, RH, PM) for your hospitality and generosity. Halifax, for those of you who are curious, is as lovely as billed (but watch out for hurricanes). I'm still re-orienting myself and so this is going to be a post of 'quickies.'

ASCO occurred last week & Medscape reported on a session on new research on cancer-related fatigue. It's of course impossible to really get a sense for the quality of this research based on a reporter's summary of a conference session but the research presented suggested 1) ginseng may be helpful, 2) modafinil may be effective for chemobrain, 3) donepezil is not effective for fatigue.

(Medscape articles usually require you to sign-up - it's free however.)

On the chronic pain front NEJM this week presents two trials of surgery for chronic back pain (one for severe sciatica lasting at least 6 weeks, the other for spinal stenosis from spondylolisthesis). Both trials were randomized & controlled (surgery vs. conservative treatment) but not blinded (for obvious reasons) and both suffered from a lot of cross-overs. In the spinal stenosis trial almost half the patients assigned to non-surgical care had received surgery by the end of the first year, and - not surprisingly - there were no differences between groups by intention-to-treat analysis. By as-treated analysis (comparing those who actually got surgery to those who didn't - this is essentially non-controlled observational data) surgery came out better (decreased pain, better function). The sciatica trial had some similar troubles (39% of the conservative group patients received surgery) and the 1-year outcomes were similar in both groups. The surgery group had distinctly faster time to pain relief and functional recovery however. Despite the different ways the studies were presented (sciatica as a 'negative' study and spinal stenosis as a 'positive' one) my interpretation is that early surgery for severe sciatica makes sense (speedier functional recovery and decreased pain) despite the similarity of both groups at 1 year; 'early' surgery for spinal stenosis however cannot be endorsed given the lack of benefit in the intention to treat analysis. All of this really highlights the difficulty of doing research like this - can't be blinded, patients (& who can blame them in the absense of no evidence one way or the other) can pull themselves 'off-protocol' which may be the right thing for them but makes interpreting the studies so much harder.

(Image from Wikipedia's laminectomy article which I'm not otherwise endorsing).

The NY Times has an editorial today triggered by Jack Kevorkian's release urging passage of physician assisted suicide legislation (legalizing/creating a mechanism for it). Their take: legislation is needed not because what Dr. Kevorkian did was right but because what he did and how he did it was so reckless and wrong. It gives a nod to 'aggressive' palliative care:

'The fundamental flaw in Dr. Kevorkian’s crusade was his cavalier, indeed reckless, approach. He was happy to hook up patients without long-term knowledge of their cases or any corroborating medical judgment that they were terminally ill or suffering beyond hope of relief with aggressive palliative care. This was hardly “doing it right” as Dr. Kevorkian likes to believe.

By contrast, Oregon, which has the only law allowing terminally ill adults to request a lethal dose of drugs from a physician, requires two physicians to agree that the patient is of sound mind and has less than six months to live. Now California is about to vote on a similarly careful measure. One of its sponsors cites Dr. Kevorkian as “the perfect reason we need this law in California. We don’t want there to be more Dr. Kevorkians.”'

Mayo Clinic Proceedings has a case series describing 10 years of their institution's ethics consults (255 in total). Despite not being generalizable to other institutions there are many interesting findings. Most compelling to me was that 9 patients had more than one ethics consultation - one can only imagine those situations. Most patients had 'poor' or 'terminal' prognoses (as recorded by the ethics team) and being the subject of an ethics consult, based on this case series, is one of the worst predictors of in-hospital mortality (similar to having 2 ICU stays but not as bad as in-hospital arrest): 40% died (and another 9% died within a month of discharge). Their ethics consultations also sound very similar to my own team's consultations, reflecting the overlapping and differing roles ethics teams and palliative care teams have at different institutions: over half their consultations addressed some combination of withholding/withdrawing treatments, goals/futility, quality of end of life care, and staff or professional conflict (a full 76% of consults involved this). Actually, the most common issue addressed by the team, in over 80% of consults, was patient decisionality.

I particularly appreciated this comment:

"Ethics consultants, while gathering data for the structured questionnaire, interviewed all interested parties, including the patient, the patient’s family, and members of the health care team. This process alone frequently resulted in resolution of ethical dilemmas (eg, discovery of a previously unknown advance directive that articulated a patient’s wishes about life-sustaining treatment during terminal illness). In fact, of the 255 ethics consultations in our series, 179 (70%) were resolved before assembling the full multidisciplinary team to review the case...."

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