Thursday, September 20, 2007

Vatican & tube feeding; More on Abigail; Nausea review in JAMA

I apologize for the scarcity of posts this last week. It sort of feels like 'school's back in session' here and things have gone nuts. I'm going to quickly post a few things here and hopefully will get to some more on the weekend.

1)
A NY Times blog recently posted about the Vatican's new statement on tube feeding for people in persistent vegetative states:

“A patient in a ‘permanent vegetative state’ is a person with fundamental human dignity and must, therefore, receive ordinary and proportionate care which includes, in principle, the administration of water and food even by artificial means.”

My question is since we're all people with fundamental human dignity shouldn't we all then 'receive...water and food even by artificial means." Even if we're not in a PVS and don't want it? Because if someone in a PVS has to get it then surely we all do? For example - if we have an inoperable malignant bowel obstruction and don't want our dying process prolonged artificially do we have to still (if we are to abide the Vatican's statement) receive TPN? (Assuming we are one of the few percent of patients whose lives are likely to be prolonged by TPN in this case.)

(Thanks to Dr. Paul McIntyre for letting me know about this.)
(NY Times articles are now free, all free, all the way back to 1987!)

2)
BMJ recently published a 'head to head' about whether terminally ill patients should have the right to experimental drugs? (Yes here; no here.) This is prompted by the Abigail ruling which we've blogged about a few times before (posts here): basically it's about a group's attempt to give terminally ill patients the right to experiemental drugs (ones that have passed phase I testing). Note: this is not about allowing them access to the drugs but a right to them. From the 'Pro' position:

"In summary, patients with advanced cancer and limited life expectancy should have the same privilege as all individuals in a free society—that is, to decide their own benefit:risk ratio. It is tragic that regulatory bodies have created a circumstance where people have to live in an aura of hopelessness even though they have the will, the resources, and the ability to expose themselves to the risk of participating in investigational studies and to enjoy the potential for benefit. The solution is legislation or judicial action to permit expanded access to experimental treatments for patients with limited life expectancy."

A couple things about this statement. First, note what they are actually arguing for is to 'permit expanded access' to these treatments. Liberalizing the rules about compassionate use of experimental cancer therapies is, in fact, a much different concept than giving people a
positive right to them which is what the Abigail decision was about. The first statement - about patients deciding their their own risk:benefit ratio - also strikes me as a difficult one to swallow. Why not then let all patients decide on the risk:benefit ratio of all drugs and do away with the FDA, pharmacies, prescription drugs, and physicians altogether? After all, individuals in a free society should be able to read about the drugs themselves and make well informed decisions about using them, right, so why have all these intermediaries? And finally the statement about letting people live with an 'aura of hopelessness' by denying them the right to demand taking substances with unknown benefits/toxicities seems absurd. It is our obligation, as physicians, to provide the best medical care we can for patients - that's rooted in science, likely to help them more than harm them, and takes into account the patient's values and goals. We are not charged with the task of stamping out 'auras of hopelessness' or giving our patients everything they ask for like they're medical consumers...

(Annas' review of the matter in the NEJM is the best thing yet written about this.)

3)
JAMA is continuing their 'perspectives on care at the close of life' series with one on nausea and vomiting. It's a good review of the subject, and focuses particularly on nausea/vomiting in advanced cancer patients. It also gives what is probably the first mention of the widely-used, and controversial, ABHR gel in a major general medical journal:

"The ABHR suppository, a combination preparation of lorazepam (Ativan), diphenhydramine (Benadryl), haloperidol (Haldol), and metoclopramide (Reglan), is often used for home hospice patients, although there are no data to support its benefit. It is well tolerated, but, in our experience, exerts its effect mainly through sedation."

While I'm no proponent of ABHR gel (I'm agnostic about it despite the number of times trusted hospice nurses have sworn to me it is effective), it's unclear to me how something can be both well tolerated and effective mainly through sedation. Anyway, given its widespread use it would be interesting to see an efficacy trial of ABHR but who's going to fund that?

(Thanks to Dr. JP Pinzon for the heads up about the article.)
(The same issue has a follow-up to the perspectives piece about ALS.)

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