Wednesday, July 25, 2007

Ketamine; Steroids; Katrina; Caregivers; Dialysis; Online resources

Several things in brief...

Pain Physician has a case based review on ketamine as an adjuvant for pain (free full-text available). Reviews the pharmacology and some of the data and provides very practical suggestions for its use. Good one for the teaching file.

Supportive Care in Cancer has an interesting case series on using very high dose corticosteroids for palliation of dyspnea from malignant upper airway obstruction (in otherwise dying patients). The authors' argument is that this can be effective but very high doses need to be used (on the order of 40mg of IV dexamethasone daily).

Some closure on the Hurricana Katrina physician murder charges: Dr. Anna Pou has been cleared of criminal charges after the grand jury failed to find evidence of a crime. AMA press-release here. The nurses' charges were dropped a couple of months ago. Interestingly the local New Orleans DA agreed with the decision to drop the charges while the state Attorney General lamented the decision. She still faces civil suits from family members of the patients she tried to keep comfortable as they died in the 100 degree horror post-Katrina. We have posted on this case several times before.

British Journal of Psychiatry has a randomized controlled trial of an intervention to reduce emotional distress in family caregivers of palliative care patients. The intervention was given to ~270 family caregivers of cancer patients receiving community-based palliative care services; the caregivers included in the trial were pre-screened to have 'distress' based on a survey. Subjects were randomized to receive usual care or weekly contact with a trained 'adviser' who usually met with the caregiver one-on-one to discuss their own needs (emotional and otherwise). The advisers were trained to give support/advice. This went on for 6 weeks.

Results: the intervention didn't do anything. Both groups improved equally. The authors' interpretation of their findings:

"There are several possible reasons for our negative result. First, the intervention might have been too brief. Qualitative data collected after the death of the patient suggested that carers experienced some subjective benefit from the advisor visits, but also a sense that the intervention was too brief. Second, informal carers of patients with cancer might already have been receiving considerable input from specialist palliative care services and the care advisor’s extra help might have had little additional advantage; for example, our intervention might have had greater impact in cases of chronic cardiac failure where routine support for patients and carers is less well developed. Third, caring for a dying relative is extremely stressful and no amount of support is going to make it much better. Fourth, our intervention might simply have been wrongly planned and thus unhelpful; however, our qualitative results do not support this possibility. Fifth, our outcome measures might have been insensitive to change or there was simply too much variance in the trial to allow detection of important change. Finally, given that nurses in the ‘treatment as usual’ group were aware of the nature of the trial and the intervention under evaluation, they might have tried harder to provide carer support. Given what we know about the workloads for nurses in these teams, we believe the last possibility is unlikely."

I was rather charmed by the succinct and frank nature of this paragraph. The one thing I'd add to this, also, is that it's telling that both groups improved similarly - this could suggest that there is a 'regression to the mean' phenomenon going on here. Only people who were particularly emotionally distressed at the time of their family member's palliative care enrollment were studied and maybe these people get better with time anyway - these may not be the people that interventions like this are helpful for. Anyway, there aren't too many controlled trials of these sorts of interventions, the field is still very young, and so any trial, negative or not, is notable & I'm glad the authors and BJP published it.

Seminars in Dialysis has an overview (it's somewhere between an editorial and a review) on palliative care & dialysis & dialysis abatement - more or less urging for a more thorough integration of palliative care principles/priorities into the care of the dialysis patient. Of interest, the author cites some research suggesting that older patients (>80 years old) with worsening renal function and poor functional status don't actually live longer if dialysis is initiated. The research seems preliminary (a couple of institutional studies) - here & this one not yet published so there's no link:

Murtagh FE, Marsh JE, Donohoe P, Ekbal JN, Sheerin NS, Harris FE: Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant, (in press).

Pallimed reader Tammy McKluskey introduced me to a swell internet resource: palliative care case discussions from the Institute to Enhance Palliative Care at the U of Pittsburgh. They are brief case discussions followed by topic reviews - good educational resources. Thanks Tammy.

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