Thursday, July 26, 2007

Prognosticating Cat; NEJM covers hospice

The New England Journal of Medicine is on a roll with relevant hospice & palliative medicine content lately. This week they have 4 key hospice related pieces, an audio piece and an article by one of the top prognostic researchers.

Some of you may have stumbled upon Oscar the death-predicting cat via a NPR radio lead-in on Morning Edition, or in various newspapers. The human (animal?) interest story is about an anthropomorphized cat who appears to be able to prognosticate death within a few hours at a nursing facitily (Steere House) in Rhode Island. Can animals predict death? Like animals predict weather? or earthquakes? Should we fund more studies into Oscar and his animal breatheren? Or are we reading too much into his actions? There are plenty of biases that could be brought up here: recall bias, selection bias, groupthink, information bias, attentional bias, and so on and so on. But despite all my skeptical skepticism, the point of the story is that Oscar's efforts at prognostication and the compassionate presence he provides is appreciated by staff and families. Which is the real lesson here is that prognostication and compassionate presence can be important human efforts as well. Just because the cat does it, does not mean we should neglect those duties ourselves. (I do have problems with the anthropomorphizing nature of all this, I mean c'mon it is a cat. Now if this was a dog, I could understand it.)

Dr. Gazelle has a nice piece that should be part of any hospice 101 talk given to medical students, residents, and attendings when being introduced to hospice. Probably to simple for this focused audience but a good teaching file article. And a free pdf too! I do like that the table with eligibility guidelines has a asterisk noting they are not hard-and-fast requirements, just guidelines.

Also take a quick listen to Timothy Quill's audio interview. Nothing groundbreaking but also good to help anyone make a hospice 101 talk.

Dr. Annas, NEJM's resident lawyer-doctor does an excellent job again with a good analysis of use of investigational medications for potentially fatal diseases before adequate research has been done. The paper covers the Abigail Alliance court efforts to allow terminally ill patients the constitutional right of access to investigational medications. Fascinating reading even if you are not fluent in legalese.

And the final piece in NEJM, is a pretty good article on why hospice maybe underutilized, with some minor discussion of open access and the barriers to implementation. There is one really great table which should be required coffee shop chat material for an oncologist and palliativist to discuss one brisk evening. Here is the table, click on it to get to the article which is also available in a free pdf.

One minor concern I have is that the well-written piece was not written by palliative medicine fellows. Dr. Wright and Dr. Katz are a hematology-oncology fellow and a infectious disease fellow. Now I am very glad these two fields want to discuss hospice & palliative medicine, but hopefully some of our field's fellows will start stepping up to the plate to write more articles like these, especially now that we are an official specialty. So if there are any journal editors out there wanting pieces on hospice and palliative medicine topics let me know, and I will round you up some palliative medicine fellows.

A quick video game-palliative medicine connection:

A new video game called Sabotage is debuting an in-game do-over mechanism called 'the morphine effect':

The game's morphine mechanic is particularly interesting, seemingly taking inspiration from Unbisoft Montreal's excellent Prince of Persia: The Sands of Time. If you die and happen to have morphine at your disposal, you can inject some and essentially give the situation another shot. Time freezes and the environment is rendered in a ghostly white, washed-out style, at which point you can reposition Summer in a more advantageous position--for example, right behind an enemy--and return to real time. What's that have to do with morphine? The idea is that Summer is lying in a hospital bed, telling her story--that is, the game itself--and a strong injection of morphine has caused her to distort the facts in her own head, after which she recants and tells it again.

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