Tuesday, December 4, 2007
A couple notable reviews, both ones for the teaching file:
First is one in JAMA on dementia and eating problems (from their 'Clinicians' Corner' series). It uses a case of a man with advanced dementia and poor oral intake to discuss palliative care in dementia, focusing on the problems with oral intake, lack of data to support tube feeding, problems with communication about tube feeding, etc. Part of the 'Clinician's Corner' style is to have Q&A and I found this bit from the end as to why even tube feeding is brought out as an option to be interesting (even when the clinician has no intention of recommending it...it's as if it's considered a standard of care [demented, don't eat well --> gastrostomy] that has to be acknowledged):
"QUESTION: I wonder if you could reflect for a moment on what I see as a big failure in US medicine. One of the things we are supposed to do as physicians is present options. But with everything we know about this situation, why in the world would we be presenting tube feeding as an option to a patient like Mr P?
DR MITCHELL: In my personal practice, I don't introduce the option of tube feeding for a patient with advanced dementia, unless the health care proxy specifically brings it up as a possibility. However, once the option of tube feeding is raised, physicians must be prepared to counsel the family through the decision-making process.On a broader level, there are several possible reasons why tube feeding remains an option that is commonly presented to patients with end-stage dementia in the US health care system. These reasons include the strong symbolic significance of feeding, an emphasis on individual autonomy in medical decision making, the wide availability of medical technology, discontinuity across health care settings, fear of litigation, and health care policies that may facilitate curative treatments over palliation. Of note, tube feeding in advanced dementia is less common in other developed countries (eg, Canada), where different health systems and cultural attitudes toward death and dying may facilitate a greater willingness to forgo aggressive end-of-life interventions."
Damn those reasonable Canadians once again. (Canadian readers: is this true?) Anyway, the subject which I was hoping would be brought up, which a bright resident asked me the other day after talking about this topic, is Why even get swallow studies on this patient population? I told him it was a great question, and there are certainly reasons to do it (defining a diet that doesn't make you have a coughing fit every time you eat is a good quality of life intervention), but the knee-jerk leap to doing a swallow study (leading to an NPO recommendation --> hour long conversation with family about how you think we should ignore the NPO recommendation) is in no one's best interests. I'm looking for a reference that talks about this topic, and this wasn't it, which is OK, since I doubt it was written with my idiosyncratic didactic needs in mind, but if anyone knows of one, please leave a comment.
The other is from the NEJM and is about the management of depression in the elderly. It's practical and general review and quite positive about ECT for refractory depression. It had this interesting nugget:
"However, a recent study suggests that a full response [from first line pharmacotherapy] is expected in two thirds of patients who have partial improvement after 4 weeks of treatment, as compared with about one third of patients without a response at 4 weeks. Even under the best of circumstances, only 40 to 65% of patients have an adequate response to any given antidepressant, and trials of alternative antidepressants or combinations of antidepressants, with or without psychotherapy, are required in a substantial number of patients."
BMJ recently had a research letter about overly-pessimistic prognostication, by physicians, for COPD & asthma patients being admitted to ICUs in the UK. It involved ~800 patients (over 45 years old) being admitted to numerous UK ICUs for exacerbations of obstructive lung disease (some had asthma); their physicians were asked to predict their ICU, in-hospital, and 180 day mortality. This is a relatively brief letter, and the results weren't given in great detail, but the overall results were that physicians were overly-pessimistic. Overall survival was 80% ICU, 70% hospital, and 62% at 180 days. There is a figure that graphs actual with predicted survival which is tough to summarize in words other than to say predictions were consistently pessimistic and particularly so for the patients at highest risk of death (predicted 180 day survival 3% - actual was 36%).
Much of the discussion of the paper (including in this accompanying editorial) has to do with UK-specific concerns with ICU bed shortages, etc. While I'm sure the findings are valid, one also has to wonder what they actually mean. These were patients, after all, that these same pessimistic clinicians were transferring to an ICU despite their pessimism, so it wasn't actually changing their care, at least as far as that goes. What is the survival of patients who weren't admitted to the ICU (due to poor prognosis, and how would one even begin to ethically identify those patients for a research study?)?
Anyway, a tantalizing bit of research and one that highlights the perils of prognosticating time in patients with COPD. Where to begin? No robust, evidence based method of predicting prognosis with precision greater than a year or two. For patients hospitalized with COPD we have pretty good ways of saying who are almost certainly going to survive, and who are at relative high risk of death, but still for those it's pretty much a coin toss. Physicians making decisions about COPD patients prognosis and care are, at least in the hospital, seeing these patients at their absolute worst/sickest, and while COPD is an unrelentingly progressive disease, and when people get sick they can really get sick, they also often recover a substantial amount. That's why, to me, it seems making these sorts of predictions is a losing battle, and decisions about 'aggressiveness' of care shouldn't be made (usually) because we are confident that, for instance, intubation isn't going to help but for other reasons (such as the patient's baseline status, perceptions of quality of life, and goals; e.g. the patient who says 'if all intubation is going to do is potentially restore me to being nearly bedbound then I'd rather not come into the hospital at all'). I hope to be proved wrong, but I think COPD is, by its nature, inherently unpredictable (unlike, relatively speaking, many cancers), and decision-making should be based things other than a confident prediction of time. Where this leaves our hospice colleagues is another question....
Thanks to Dr. Bob Arnold for alerting us to this paper.
The NY Times Sunday Magazine this week has a feature on assisted suicide. It's mostly a broad look at it through a handful of personal stories (the major one involves a former governor of Washington state who has Parkinson's and is campaigning for a PAS law). The focus is, interestingly, the non-"pro-life" arguments against assisted death - focusing on concerns about the disabled, those without insurance, women, the most vulnerable. So the 'slippery slope' arguments - not the it's wrong/life is precious at all costs arguments. The article mentions that in Oregon there has been zero evidence to suggest that those groups (the vulnerable) are being disproportionately affected by PAS but then goes onto to treat these as major concerns - it's rhetorically dishonest in my opinion with the way it treats the research findings (acts like they are real problems when they aren't). I'm no fan of PAS, but I think we have to be honest about what has happened with it in Oregon: it's hardly been used, it has not been used disproportionately by the vulnerable, and the concern that PAS was going to be heaped upon the poor, the disabled, etc. just has not panned out. One assumes this is because the Oregon model is, by design, patient-driven - and concerns that docs, insurers, etc. would suggest to people that their lives weren't worth living, and the patients themselves would go "You know, you're right, can I have some of that PAS?" just haven't come to pass, for obvious reasons. There a reasons to object to legalizing PAS but the slippery slope concerns shouldn't be part of it (at least based on the Oregon experience).
The article is also a premiere example of why some/most are interested in PAS: it's not because of actual physical suffering/pain, but because of perceived future pain/suffering/loss of control & lack of finding meaning in the inevitable disability, dependency, and contraction involved in dying. "My life, my death" - that sort of conception of dying....