Tuesday, October 2, 2007

Communicating prognosis guidelines; Ablations; More opioid angst; Vulnerable elders; BMJ on blogging and assisted death

A few things, in brief, and this time I plan on keeping my promise...

The Medical Journal of Australia has published summary guidelines about talking with patients with life-limiting illnesses about prognosis (free full-text here). Dr. Josephine Clayton, who has done some of the best research on this, is the lead author. The guidelines review the literature and make practical recommendations. Examples of language to use, recommendations for approaching difficult situations/disagreements and DNR discussions are also included making this a great one for the teaching file. (Also: its bibliography probably represents the most up to date survey of this topic, and is valuable in and of itself.)

The American Journal of Clinical Oncology has a case series about palliative (analgesic) percutaneous thermal ablation of painful chest wall masses. It's a single institution study which looks at the natural history of 39 patients (most of whom had already received radiation to their painful masses) who received ablative procedures (radiofrequency ablation, cryoablation, etc.). After a month, mean pain relief was between 'moderately' and 'greatly' relieved, with 70% of patients responding. Many patients had pain flares immediately after the procedure. These are of course uncontrolled data - patients were getting other analgesic therapies etc. - but these are relatively new interventions & very little is known about their effectiveness.

(Image from the NIH's website.)

"It seems then that there are problems with opioids in all directions: overuse, abuse, misuse, and underuse." This is from an editorial accompanying a review article in the current Clinical Journal of Pain on challenges in the development of abuse-deterrent opioid formulations. The article itself is less about these formulations (i.e. adding a parenterally-only-active opioid antagonist to an oxycodone extended release formulation which would 'inactivate' the oxycodone if it was crushed and injected) than the scientific and regulatory issues surrounding developing these formulations. I.e. How do we define successful deterrence? Deterrence for which group of 'abusers' (as there are different issues for people who snort vs. people who crush and inject vs. people who just 'overdose')? Who decides? How would this be labeled so as to not cause an OxyContin-for-everyone-part-II type debacle?

It also contains the obligatory literature review of the issue (opioid abuse and opioids for chronic pain) which might as well be entitled "Exactly How Little We Know About This."

JAMA has a commentary on 'vulnerable elders' and when it is no longer safe to live alone. It's a brief overview of the problem, which is apparently growing, and talks about balancing the rights of autonomous people to do what they want (even if we think it's unsafe) and our obligation to advocate for the safety of our patients.

In my practice, there seems to be a substantial minority of patients for whom the news 'it's not safe for you to go home' (and the concomitant disclosure that the Medicare hospice benefit does not provide for 27/7 supervisory care) is taken much worse - is much more of a blow - than the news of 'you're dying'/'time's short.'

And finally, BMJ:

Has a quick introduction to the world of medical blogging and the diverse styles, objectives, and formats of medical blogs (thanks to Tom Q for pointing this out to me). No mention of Pallimed-style blogging (no rants, tries to critically focus on recent research and other publications).

b) The latest issue also has an editorial by Dr. Timothy Quill about physician assisted death for vulnerable populations, more or less arguing that the 'slippery slope' has not happened, and that rates of 'PAD' aren't higher for vulnerable populations in Oregon & the Netherlands. (Christian blogged about research supporting this conclusion here.)

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