Wednesday, December 26, 2007

Oncologist communication about emotions; 'Mac Tilt'; Much more

More quickies; will likely start blogging in earnest again after the new year.

Multiple articles from Journal of Clinical Oncology:

a) First is one on oncologist communication about emotion during visits with cancer patients. It's a fascinating study, including from a research perspective: it involved audio-taping nearly 400 oncologist-patient clinic encounters (all patients had 'advanced' cancers). In this analysis (one assumes/hopes there will be subsequent ones) the researchers looked at patient disclosure of negative/ambivalent emotion, which they defined as creating an 'empathic opportunity' for the physician, and then looked at what the physician actually did. (Obviously there is room for interpretation as to whether a statement created an empathic opportunity or not, however the interrater agreement had kappas over 0.7 for almost every item they looked at.) Physicians gave responses supporting continued discussion of emotions for only ~1/4 of the opportunities presented them; younger physicians (who were more likely to be women than the older physicians and to rate themselves as responsive to the 'socioemotional' side of medicine) tended to give more 'continuers.' It would be interesting to see how patients rated their physicians' communication effectiveness, and how much they wanted physicians to attend to their emotions (although one imagines that a certain number of patients wouldn't be aware, explicitly, of those needs)....

b) There's also a trial of a 'psychoeducational' intervention for patients with melanoma. It involved 6 group sessions involving "education in health behavior with regard to malignant melanoma, stress management, problem-solving, and mutual support" (a control group received no intervention). This study was to look at long term survival, which didn't differ between groups. An accompanying editorial concisely looks over the ongoing debate as to whether psychotherapy improves cancer survival (it's cheekily titled 'Letting go of the hope that psychotherapy prolongs cancer survival').

c) Also: a study of cancer outpatients correlating feeling that one's spiritual needs are not being met with a poorer assessment of global quality of care & satisfaction with care; and in lung cancer patients, increased use of primary care services is associated with better survival (this is certainly a hypothesis-generating observation, however those with zero PC visits had a median survival of less than 4 months raising the possibility that being dead was a confounder for not utilizing your primary care physician!).

Clinical Journal of Pain has a couple:

First is one on physician attitude towards opioids for chronic non-cancer pain. This was a single institution survey of ~140 internal medicine physicians (sample included housestaff and about 20% geriatricians) about opioids for CNCP. There were some general differences between general medicine docs & geriatricians (as well as housestaff vs. attendings), but one wonders if some of these differences were because the study is from Mount Sinai in New York, where the palliative care program is housed within the geriatrics division.

The other is a natural history study of advanced cancer patients who were switched to intrathecal opioids for pain. It followed 55 patients who had 'failed' systemic opioids (inclusion criteria were trials of at least 3 strong opioids by at least two different routes) - they were then treated with intrathecal morphine with levobupivacaine. Starting 24hour morphine IT dose was 1/100th of their 24hour PO morphine equivalent dose. Mean oral morphine (equivalents) dose was 466mg/day for these patients; mean survival was 71 days - these were sick patients. Basically they found that pain decreased (8/10 - ~3.5/10, as did systemic opioid use, as did confusion and drowsiness), and the 1:100 ratio was probably too conservative (but safe - most patients went through an initial doubling-tripling of their IT dose prior to discharge which then remained relatively stable). Complications were rare. They do not comment on 1) quality of life or 2) ambulation. The notable aspects of this study was that they really tried to include only patients who had not done well with multiple attempts at systemic opioid use as well as the fact that they included incredibly sick patients. Along those lines mean hospital stay was 12 days, with an average of 7 after IT pump implantation - without measuring quality of life it's unclear to me whether the hospital stay was worth it for these patients given their short prognoses....

QJM has an article about communication with hospitalized patients who are likely to die. It attempts to outline, in a practical manner, a step-wise protocol in communicating with patients/families when there is a high likelihood life-prolonging measures may fail. Its major theme is one of proposing a 'trial' of life-prolonging therapy (as well as an option of comfort-only care) from the outset, and then walks the clinician through communication steps to take if the trial doesn't work. A good one for the teaching file.

Journal of Pain has a trial of dronabinol added to opioids for chronic pain. It involved 30 patients receiving opioids for chronic pain who still had pain at least 4/10 - they blindly received placebo, 10mg, or 20mg of dronabinol as a single AM dose and had pain/side effects measured hourly for 8 hours. Each patient blindly received each treatment once on different days. Then the patients were invited to continue in an open-label fashion. Dronabinol appeared to be mildly-moderately effective in both phases of the study, however clearly long-term, controlled/blinded data are needed. This is one of a growing number of studies, recently, re-looking at cannabinoids for pain.

Lancet has a review about bereavement & health outcomes. It's a comprehensive, narrative review of the research looking into this (mortality in bereaved spouses, etc.) - another good one for the teaching file.

BMJ has its annual holiday 'funny' issue out, which usually contains light-hearted & joke research and opinion pieces. Highlights from this one:

a) From an article on medical slang: "Mac Tilt": "The lateral movement of the head to an angle of 45° to the vertical by a palliative care nurse specialist. It is intended to convey sympathy and understanding. (Mac from Macmillan nurse—a specialist palliative care nurse—and tilt.)"

b) A thoughtful piece on PowerPoint: "The background colour scheme and logo for your slides should be selected for maximum emetogenic potential."

c) A case series on 'death delusions' (a fixed belief that one is dead) as a side effect of valacyclovir.

d) A profile of different physician communication styles when they are talking about death/dying with patients (e.g. the grim reaper, the evangelist, the deflector, etc.). They take pot shots at cardiologists:
"Cardiovascular specialists segregate most often as precisionists and are seen touting statistics gleaned from clinical trials that bear fortuitous acronyms such as HOPE, CARE, CURE, VALIANT, COURAGE, and MIRACLE."

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