Wednesday, December 19, 2007

Pain in CHF; Methadone & QT; Caring for Patients vs Caring for Organs; More

I'm probably not going to be able to blog anything seriously this week, so will probably do a couple of quickie posts about articles from my pile.

1)
Multiple notable articles from the most recent Archives of Internal Medicine:

a)
First is an observational study on symptom prevalence in patients with COPD and CHF. 133 patients (community dwelling, mean age ~73 years, a little over a third had at least one limitations in ADL's) underwent quarterly symptom interviews for 2 years. ~40% of the cohort died during the study. Dyspnea, pain, discomfort, fatigue, appetite problems, depression, and anxiety were all quite common, and many increased in either prevalence or severity across time. Notably, pain was quite common in the CHF patients and increased in severity over time (% reporting moderate to severe pain increased from 20% to 42% over the study). More indication (not that it was really needed) that pain is by no means a problem of advanced cancer....

b)
Next is a follow up to this landmark study about the 'chronically critically ill' (more or less patients needing long term ventilation after a critical illness), looking at the information families/patients received about it, prognosis, etc. This study involves data collected at the time of the first study, and looked at the information families (and the few patients who were communicative) received about their care. They looked to see if these domains were discussed:

1) nature of the patient's illness and treatments; (2) prognosis for outcomes including ventilator independence, function, and quality of life; (3) impact of treatment on patient experience, including symptom burden; (4) potential complications of treatment; (5) expected care needs after hospitalization; and (6) alternatives to continuation of treatment.

The results are, simply put, dismal/disheartening, and suggest that 1) prognosis was frequently not discussed (this was a cohort of patients with a >50% 6 month mortality) and 2) alternatives to the current care plan, something which is technically necessary for informed consent, were rarely discussed. 83% of families reported not hearing alternatives to continued mechanical ventilation; 93% weren't given a survival estimate; 80% reported hearing no information about expected functional status after hospitalization. It goes on like this....

c)
There's also a paper about the development of a prognostic index for patients with peripheral vascular disease. It's mostly useful though for predicting mortality on a long-term (5-10 year) basis.

d)
Finally there's an important paper looking at the natural history of QT prolongation with methadone. It's taken from a randomized trial comparing methadone (patients received 60-100mg daily) with levomethadyl or buprenorphine for patients with opioid addiction; patients in this trial had their QT interval monitored with EKGs. Depending on how they defined 'significant' QT prolongation (they looked at it in several ways), methadone signficantly increased the QT in ~12-30% of the patients receiving it over the course of many weeks. (Buprenorphine, not surprisingly, didn't increase the QT). 12% of the methadone patients, at some point in the trial, had a QTc greater than 500 msec. Notably, the QT interval continued to increase over time (4, 8 weeks), even for those patients on steady methadone doses, suggesting that an EKG done when patients should be at 'steady state' (which, with methadone, can easily be a week) is not necessarily reassuring that the QT isn't going to widen further.

2)
The most recent Annals of Internal Medicine has an article about some ethical concerns with the Uniform Anatomical Gift Act (this is model legislation which states are being encouraged to adopt to improve rates of organ donation - several states have already adopted it). The authors define the concerns with a terrifying case, apparently real:

"A man has a stroke and has irreversible brain injury, but he is not brain dead. The family want to honor his wishes to "not be kept alive on machines if there is no hope," something he put into an advance directive. However, he designated himself as a donor on his driver's license. The physician wants to discuss what to do next, and how to prioritize care, but he is stopped by a new state law, modeled after the new Uniform Anatomical Gift Act (2006). The law states that, because the patient is an organ donor, his end-of-life care must be managed in a way to promote donation, even if it compromises comforting care. His do-not-resuscitate order is reversed, and he is resuscitated when he becomes hypotensive and loses pulse. Mechanical ventilation, blood sampling, and other critical care are continued. The physician cannot discuss options, because according to the Organ Procurement Organization, the family does not have the option not to donate. Therefore, any decisions regarding terminating critical care are vetoed per statute. Twelve hours later, the patient is taken to the operating room, life-sustaining treatments are removed, he dies, and his organs are procured. This is a true story. We believe it represents an unintended consequence of new language incorporated into the Uniform Anatomical Gift Act (2006)."

There has been a revision to the language noting that such actions should not conflict with 'appropriate end of life care,' but many state statutes don't reflect this. Yikes.

3)
There's an interview with me that's currently on ReachMD, an XM satellite radio channel for health professionals (channel 157). It's mostly about Pallimed, with a little bit about HPM in general. I can't bring myself to listen to it, although I don't recall saying anything too humiliating.

Podcast of the interview, and broadcast schedule, is here.

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