Saturday, September 8, 2007

Implantable devices; Statistics; Korean-Americans & dying; & More...

I am traveling for the next week so I'm going to quickly clear out my backlog before I go. I probably won't post again until the middle of the month.

Journal of Medical Ethics has a few articles about implantable cardioverter-defribrillators. First is a discussion arguing that ICD's are neither regular 'medical devices' or treatments, nor are they parts of one's body (as would be a transplanted kidney) but are instead in a unique category: an integral device.

"We submit that a better model is to consider ICDs as integral devices, representing a middle ground between medical device and part of the body. By defining the technology in this way, it is possible to escape the restrictions of the treatment/non-treatment dichotomy, which is not apt to cover ICDs. An integral device, though not organic, is part of the patient. We suggest that where technology has been integrated into the physical being, a patient should retain stronger autonomy than he does with external mechanical devices. Interfering with it unilaterally should not be justified on grounds of benevolent paternalism. Nonetheless, an integral device is not truly a part of the body. Thus, deactivation should be permitted in some circumstances. Furthermore, a patient should have the right to demand that his ICD be disabled, even against medical advice, just as he would have the right to refuse external defibrillation in advance."

A lot of the argument focuses on the idea that a 'regular' medical treatment (like a drug or external device) can be unilaterally discontinued by a physician even against patient's wishes (based on 'benevolent paternalism') and that this is inappropriate for an ICD. Insofar as I agree that a physician shouldn't wrestle a patient to the ground to deactivate their ICD against their wishes this seems reasonable. However the the absurdly low probability of that ever happening makes me suspect that the need to have a new 'ethical category' of treatment just to accomodate it. Medical care/decisions don't happen that way and when they do they are obvious breaches of proper conduct and decision making (i.e. we don't need to make new categories to illuminate why it is improper).

There is a general editorial supporting the rights of patients & physicians to turn off ICDs, which is more in the ICDs=regular medical therapy camp.

Last there's a Swedish study about patient participation in decision making about receiving an ICD: there was no decision-making - the patients were told they needed one so they assented. Discussions about prognosis, magnitude of expected benefit, etc. were absent.

Journal of the American Geriatrics Society has a few notable papers.

First is a look at symptoms of dying long-term care patients. It's based on after-death surveys of family members and caregivers (not the most reliable sources of symptom information to be sure) and found pain, dyspnea, problems with cleanliness were all major symptom concerns, and not well treated.

Next is a trial looking at maintenance therapy (with drugs or psychotherapy) for depressed elderly patients who had already responded to short term drug & psychotherapy (16 weeks). These patients were randomized to receive paroxetine, psychotherapy, both, or neither for a year. Briefly, those who received drug therapy did better - health related quality of life was maintained than those who didn't receive drug therapy suggesting it makes sense to keep this popualtion on SSRI's for a least a year.

Finally there's a qualitative study about Korean-American's knowledge of/attitudes towards end of life care, which involved focus group discussions with elderly Korean-Americans and their caregivers (mostly adult children). Filial piety, family (not patient)-as-decision-maker, communication about end of life care/wishes, misconceptions about hospice care, etc. are all discussed. A good read.

Gerontologist has a well-written book review about a couple books on dying in America.

& if you're wondering what the 'Statistics' reference is in this post's title, it was to the recent JAMA article about medical resident's understanding of medical statistics. It is generally poor, and I had composed many-a-wise sentence about this & EBM & what journal editors should do to make sure statistics used in medical papers are presented in ways that clinicians can use, etc. However Christian let me know that Blogger corrupted my post, destroying most of my text, rendering it unintelligible. Sorry about this; I'm traveling and not up to re-composing anything so we'll leave it at that.

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