Thursday, December 20, 2007

DNR Goes to School; Patients’ fear of morphine limits use

1)
An article last week in the Chicago Tribune introduced me to something brand new in my experience: DNR orders for kids in schools. So where have I been? Like most people who don’t work in a school, don’t work in pediatrics, and have healthy able-bodied kids, I hadn’t given it much thought. Of course, it makes eminent sense to have this conversation. All children, by federal law, are permitted to attend school and must receive reasonable accommodation given their condition. This includes those with life-limiting illnesses and those with severe disabilities. Kids in both categories live a lot longer these days because of advancing technology and medical knowledge. This has apparently been a hot topic in schools since at least the early 1990’s, although, according to a recent study in the Journal of School Nursing, few school districts have official policies and procedures. In some states, a DNR order is not recognized outside of a health care institution, much less in a school. In others, “out-of-hospital DNR” forms are provided by the state (see sample from North Carolina at right).

The National Education Association published a Policy on "Do Not Resuscitate" Orders in 1994. The American Academy of Pediatrics published a supportive Policy in 2000. Both acknowledge the complexity of the issues and the need for state laws and local school systems to establish appropriate policies.

The issues:

  • General lack of knowledge (among school personnel) about the process and meaning of resuscitating a fragile child; misunderstandings of DNR
  • This is about death—we can’t have children dying in school; this would be a terrible burden on the staff; how would we support and reassure all the other children if we allowed a sick child to die?
  • Liability issues—what if we make the wrong decision on a given day?
  • Should DNR orders in school be limited to those children who have terminal illnesses? What about frail/fragile children with severe disabilities but not progressive illness?

Thanks to the EOL Group at the Yale Bioethics Institute for the article and my title.

2)
There is an interesting UK study, published online ahead of print, in Annals of Oncology. “Strong opioid”-naïve patients with progressive cancer-related pain were interviewed about their willingness to take strong (WHO Step 3) opioids (specifically, oxycodone, which was described to the patients as being “similar to morphine”). Of 29 patients approached to participate, 18 agreed to be interviewed. They were almost uniformly (14 of the 18) reluctant to take a morphine-like drug because they associated it with advancing disease, death, and even hastening of death. They saw morphine as a “last resort” treatment option. Some (12) accepted the prescription because of the severity of the pain or the perceived impact of their pain on loved ones—“they felt they had no choice.” Interestingly, the patients’ relationship with and trust in their oncologist played a role in the decision to accept a strong opioid. If they had confidence in the physician and the physician encouraged the patient to take the prescription (as opposed to offering, then leaving it to the patient to decide), the patient was more willing to take the analgesic.

This study was obviously limited by size and study method. However, the lopsided finding of morphine being so closely associated with death is eye-opening.

An accompanying editorial succinctly reviews the literature on barriers to adequate cancer pain management. The editorialist is troubled by the findings, described above, “from the birthplace of palliative care.” He also sees physician barriers in the way patients reveal the influence of prescribers on their decision to take strong opioids. In at least once case in the study, the physician confirmed the stated fears of a patient’s daughter that the opioid would likely hasten death.

3) Effective today (Dec 19), the DEA has changed its rule on writing sequential prescriptions on the same day, so that stable patients do not need to return to the doctor’s as often for evaluation and new prescriptions. This replaces an extremely controversial DEA ruling two years ago that such serial prescriptions amounted to refills of CII medications, which is illegal. There is a short editorial on the topic on the Pain and Policy Studies Group web site.

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