Wednesday, March 28, 2007

Fatigue & QOL in cancer; Bleeding in head & neck cancer; Perception of pain control; Palliative feel-goodery in the ICU


1)
Annals of Oncology has an article examining fatigue and quality of life in cancer patients receiving radiation therapy. It looked at 70 patients (breast or lung cancer, average age 64, ECOG mostly 0-1, about half had received chemotherapy) receiving curative-intent radiation. The data comes from a single administration of the ubiquitous EORTC QLQ-C30. Basically they found that fatigue had the highest correlation with quality of life (r of -0.76); fatigue's premiere importance to predicting quality of life withstood multivariate analysis, more than any other single symptom or group of symptoms.

It's long been recognized that fatigue is routinely found to be the most prevalent symptom reported by cancer patients (pretty much in any stage of their disease--even those who are years out from curative therapy). This study finds fatigue is the most important predictor of health related quality of life--at least in this group of cancer patients. The question, for me, is what is fatigue? Is it a discreet symptom (which then has discreet symptom-specific therapy like pain, vomiting, pruritis, constipation, edema, etc.) or is it something else? Because one interpretation of this study is that patients saying they are fatigued is sort of the same thing as them saying "my health related quality of life is bad." "I, globally, don't feel well or whole." This, is a different thing than, say, announcing, "I itch." What all this means, I don't know.

2)
Supportive Care in Cancer has an article looking at the natural history of patients who receive transcutaneous arterial embolization for massive bleeding in head and neck cancer. It reviews the experience of ~60 patients at a single center in Taiwan who received angiography and if possible TAE (which involves femoral artery --> carotid artery catheterization and then embolization with foam, alcohol, or coils to try to stop the hemorrhaging) after 'conservative measures' failed to control their bleeding. Median survival was 16 days and over a quarter of patients died within 48 hours of angiography. Patients who were able to receive TAE lived a median of 26 days vs. 8 days for those who didn't receive TAE. It would have been interesting if they presented the survival of patients who presented hemorrhaging but didn't receive angiography at all but oh well. For me this was an interesting piece of research insofar as it documents the natural history of these unfortunate patients with intractable hemorrhage: it is astonishgly dismal. These uncontrolled data suggest TAE prolongs life (triples median survival in fact) which is notable, but what those extra 18 days were like is unclear to me.

3)
Pain has an article about perception & pain in cancer patients with pain. It looked at ~300 adult cancer outpatients with pain (mean 6.7 on a 0-10 NRS)--they answered questionnaires about their pain. 90% of this group felt that their pain could be controlled & 70% felt like it currently was controlled. The researchers did some fancy statistical modeling (which I didn't understand at all) and conclude that their data suggest that: patients' perceived control over their pain was related to their symptom distress level (but not to their functional status). The authors seem to conclude that their findings suggest that patients' sense of control over their pain can be an important tool to decrease their distress from the pain. Perhaps true, but I remained unconvinced that what they were finding was anything other than a simple relationship: pain poorly controlled/pain causing much distress --> patients' 'perceived control' over their pain was diminished (or its inverse: pain well controlled --> patients feel they have control over their pain). This is distinctly different than concluding that perception of control leads to lower symptom distress. The fact that I remain unconvinced of this of course doesn't mean I'm right--maybe I just don't understand their model.

4)
Quality and Safety in Health Care recently had an article about the development of a 'palliative care bundle' in the ICU. The background on this is that a lot of the quality improvement initiatives in the ICU have been around 'bundles'--a set of practices (ideally evidenced based) designed to improve care/reduce complications/etc. in the ICU. Classic ones are the "ventilator bundle" (semi-recumbent positioning, daily awakenings, dvt prophylaxis, etc.) and the "central line bundle." This group developed their recommendations based on several sources (mostly expert opinion) and proposed their bundle (which includes triggers for communication/family meetings/discussing patient values/wishes/and goals of care, pain and symptom assessments, emotional and spiritual support). They even gathered baseline data in several ICUs to see how well these things were already being done in these units (very mixed results). Who knows where this will go but it is exciting. There certainly does seem to be a growing awareness, coming from within the critical care community itself (as evidenced by the growing amount of palliative care "flavored" research being done in ICUs, issues being devoted to palliative and terminal care in ICU journals, etc.), that great improvements can be made in 1) care of the dying in ICUs and 2) 'humanizing' the ICU experience, in general, for patients and families. This bundle project is very much a part of this trend. The article however also highlights how hard it is to find quality outcome research to base these guidelines in--there's a lot of opinion and experience to base things on but in order for practice to change frequently you need outcome evidence as well--so you can say "See, this really does make a difference. We are not just promoting a lot of empty feel-goodery." Thus, the importance of research like this.

Wednesday, March 28, 2007 by Drew Rosielle MD ·

Tuesday, March 27, 2007

One Of My Favorite Symptoms - Xerostomia (Dry Mouth)

BMJ published a one-pager on dry mouth (xerostomia). Xerostomia, xerostomia, xerostomia. Isn't just a fun word to say? If that is not fun enough for you try these: aptyalism, asialogenesis, asialisis, axerostomasialodesertion (I made the last one up.)

Dry mouth is one of my favorite symptoms. Now I say that it is one of my favorite symptoms, I obviously do not mean that I enjoy having it myself or seeing other people suffering from it. But I do find the symptom very interesting for a few reasons: ubiquity, poorly understood, limited treatments, plenty to educate on, our meds are part of the problem, etc.

Dry mouth is extremely common in the palliative care population, and comes in a range of severity from mildly annoying to very debilitating. Often times the main cause of xerostomia is the medications that we are prescribing to treat other symptoms. Opioids, anti-histamines, anti-psychotics, anti-depressants have all been implicated as contributing to dry mouth. But we have very little evidence for any treatments for dry mouth, so you have to be creative. And it is so common, you would think it would be so easy to study. The only good dry mouth articles were from the dental literature (free pdf here). A search of the palliative literature turned up little.

There is some conflicting anecdotes out there, so maybe some of you Pallimed readers can help clear some of this up by telling us what you advise for xerostomia (giving some evidence where you can).

Artificial saliva: Many articles support it, but staff often don't know about it, and patients find the thought unappealing and when they try it, I have had many patients say they don't really care for it. Do you often prescribe artificial saliva, and if so what brand works best for your patients and in what form (gel, spray, lozenge?)

Cracked lips: Articles encourage use of petroleum jelly, lip balms, carmex, etc to lock in the moisture so that your lips won't crack. But there are some out there who claim any lip balm product may actually exacerbate the problem (although lightly disproved by snopes.com). Most of us know glycerin swabs are out, but some articles I found claimed that a easy saliva substitute is glycerin mixed with water. What do you suggest for cracked lips?

Natural saliva induction using citrus: Some have advocated for pineapple, orange, lemon slices to smell, taste, or chew, but some of the basic science mentions they acidic nature actually causing more harm because of the lack of saliva and the buffering ions. Do you make suggestions about using citrus?

Do you prescribe pilocarpine? I have tried prescribing the eye drops with flavoring added by the pharmacy with minimal improvement of the underlying bitter taste. No patient has been really impressed with the results. I have not gone to Salagen (pilocarpine lozenges) yet, because the few studies I looked at minimally improved salivary output compared to placebo despite costing >$100/month (per HPC Formulary).

Sip water frequently: Makes sense right? Until you look that this may actually reduce the mucus film that builds up from the natural viscosity of saliva. And may increase nocturnal awakening secondary to fluid intake.

Sorry about all these questions, but since there is little out there I thought I would pose some of my clinical dilemmas and get input from the palliative care community. Never thought spit would be so perplexing.

As a bonus question tell us your "favorite symptom." And maybe we'll devote a post to it later.

Picture courtesy of More Altitude via flickr.com

Tuesday, March 27, 2007 by Christian Sinclair ·

Thursday, March 22, 2007

Oregon DWD 2006 Report;

Oregon has released the 2006 annual report on the Death With Dignity Act. If you are not familiar with this report, the Department of Human Services reviews important data collected from physicians about how the physician-assisted suicide/death law is enacted. Particularly they collect demographics about the patients who receive prescriptions and track how the patients die (natural causes vs. taking the prescribed dose of barbiturate).

During 2006, 65 prescriptions for lethal medications under the provisions of the
DWDA were written (figure 1). Of these, 35 patients took the medications, 19 died
of their underlying disease, and 11 were alive at the end of 2006. In addition, 11
patients with earlier prescriptions died from taking the medications, resulting in a
total of 46 DWDA deaths during 2006. This corresponds to an estimated 14.7
DWDA deaths per 10,000 total deaths.
Most of the patients had cancer and almost all of the 46 were insured, and many had a higher education (BA/BS). Of note, 4 people had complications which included regurgitation.

As in past years the requests mainly had a foundation in issues surrounding autonomy, being a burden and loss of dignity/independence, which are things that do not have a successful medication available like for depression, anxiety and pain. Issues of autonomy and dignity are deeply rooted and require much attention and human capital to make sure they are protected.
As many who work with patients near the end of life, requests for hastened death are not uncommon, and require a delicate and compassionate response that is in line with your state laws, but at the same time does not abandon the patient when they most may need support and care. Check out the two-page report (4 minutes of reading tops) and some of the other files on the website.

And for homework, I have a question from a medical student that I could not answer. maybe Pallimed readers could help me.

If a person dies by physician-assisted suicide, can the family still collect on the insurance policy, or was that even considered when the law was legislated?

(BTW this question was not offered to me with a focus on greed/money/etc., but rather in discussing the systems issue of even considering something like PAS in the first place and how the practice may have repercussion outside of the immediate medical situation)

(My Standard Disclaimer: Dr. Sinclair and his current and former employers and states do not endorse or practice euthanasia or physician-assisted suicide, but do encourage the open, non-judgmental discussion of these topics for educational and ethical discourse about this controversial area of medicine.)

Picture from Flickr.com, user SeamusMurray

Thursday, March 22, 2007 by Christian Sinclair ·

Do not hospitalize orders; Honesty & optimism; Discussing hospice


3 things:

1)
The latest Journal of the American Geriatrics Society has an article on factors associated with 'do not hospitalize' orders in demented nursing home patients. It involved a nation-wide (U.S.) sample of patients (~90,000) and used minimum data set data. Overall 7% of demented NH residents had DNH orders (wide range--0.7% in Oklahoma and over 25% in Rhode Island). Things that were associated with having a DNH order included increased age, being white, being in an urban NH with a wealthier patient mix, being on a special dementia unit, being in a NH with an NP or PA on staff, and having a living will and health care power of attorney. The percent of your NH's patients receiving hospice care was not associated with having a DNH order although being in an area in which fewer NH patients died after passing through an ICU did predict having a DNH. What's interesting to me about these findings is not so much what was associated with having a DNH but the wide variation in practice by geographical region, social class, and type of NH. There are probably lots of reasons behind this but it seems that at least in part local medical culture determines whether a patient (...really their family) gets the choice of not having an ambulance ride in their last week of life.

The same issue also has several articles on preventing falls in nursing home residents (issue's table of contents here).

2)
Supportive Care in Cancer has an article on physicians' reluctance to disclose difficult diagnoses. Specifically, it's a narrative review looking at practices (including patient preference and physician behavior) surrounding disclosure of difficult news (diagnoses, prognosis, etc.) in oncology and psychiatry. For the Pallimed reader it has a detailed, narrative summary of the research into patient's preferences and physician practice surrounding disclosing bad news including some interesting stuff about temporal trends & geographic variation in physician practice. Of interest to me, although I guess it makes sense, is that overall it seems that psychiatrists are more reluctant to disclose difficult diagnoses to patients than oncologists & that psychiatric patients (or at least random people when surveyed) are less likely to endorse wanting to know detailed honest information than cancer patients. This seems particularly true of dementia, which makes sense in a way.

The article also reminds us of this factoid: one study showed that "although 100% of participants wanted doctors to be honest, 91% also wanted them to be optimistic." I still have vivid memories of being a medical student and witnessing this (wonderfully caring) geriatrician crouching at the bedside and clasping the hand of a deaf, demented, dying patient and yelling "WE'RE GOING TO MAKE YOU BETTER." Part of the art of medicine, surely, is to learning the art of honoring both aspects of patients' wishes: honesty and optimism, and not just the easy one. Given that the same group of patients said they wanted both honesty and optimism I'll assume that the patients weren't saying they wanted their docs to say "You have incurable cancer and will likely die within the year but I'm going to fix it anyway. Prepare for a miracle cure!" Instead I'd assume they meant by 'optimism' "You have incurable cancer and will likely die within the year but I will promise you careful, compassionate, and good care. Whatever happens you will not be alone, your family will get the help they need, and I will make sure you are safe and get the right care."

Anyway, enough preaching to the choir.

3)
Annals of Internal Medicine has a piece on discussing hospice with patients. It's aimed at the general physician and provides a lot of basic, nuts & bolts information on hospice services as well as a practical walk-through of discussing hospice in the context of a goal-setting discussion. It's a good article for the teaching file as well as for interested non-palliative care trained colleagues who want "to do it right." It also addresses discussing goals and terminal care with patients who aren't ready for hospice care despite it being medically appropriate.

by Drew Rosielle MD ·

Pallimed Passes 100 Subscribers!

Since the Pallimed site re-design and the AAHPM conference, the site has really taken off. Pallimed now has over 100 daily readers through our subscription services. We had been bumping up against 100 for a while, but all of a sudden we just busted on through with an upsurge in RSS Reader subscribers. As of this post we have 121 subscribers!

So Drew and I just wanted to take a moment to say thanks for coming to the site. As always feel free to spread the word. If you would like Christian to email you some Pallimed cards to pass out to your hospice team or your palliative care team, he would be happy to mail them to you for free. Again this site is not-for-profit and we pledge to keep it that way.

If there is anything that you think we should add, change, or remove, or you just want to complement or criticize please feel free to leave a comment on this post or email us directly at:

drosielle @t gmail dot com
ctsinclair @t gmail dot com

We are going to roll out a new feature in the next few weeks so look for that soon. Nothing major, just something new.

(Email addresses look weird to prevent spam bots from hammering our emails!)

by Christian Sinclair ·

Tuesday, March 20, 2007

Ethics in the ICU; Prognosis; Computers to tell us what patients believe


Many, many items in brief....

1)
Critical Care Medicine had a supplement in February about ethics in the ICU. Many articles here, including one on end of life ethics in the unit. It opens with this rather remarkable salvo:

"Originally conceived and operated as short-term, life-saving vehicles for acutely ill or injured patients, modern intensive care units (ICUs) have expanded into entities that care also for chronically, although seriously, ill people; in fact, ICUs often become repositories for patients who have little or no chance for survival. Sophisticated technology frequently takes on a life of its own; the sheer momentum of processes inherent to ICUs may prevent healthcare providers from taking a step back to make well-considered decisions, especially at the end of a human life."

The rest of it is not quite so colorful but a good read; covers the ethics basics, illustrates them with some real cases, and talks quite frankly about the culture of the ICU, power relationships between medical people & patients/families & between physicians and non-physicians. The article, which is written by a single person, benefits from straightforward, idiosyncratic, and at times informal language--none of this formal, committee-written prose. I guess what I liked most about the article is that rather than being a dispassionate discussion of end of life ethics in the ICU, it is a passionate, personal (but well-researched and -informed) reflection on the vagaries & missteps of ethics, informed-consent, decision-making, autonomy, etc. as they apply to very real & really suffering people & families in our ICUs. Stuff like this:

"Healthcare providers are human beings. Patients are human beings. The provision of health care takes place in an elaborate, intricate, imperfect, and unpredictable human society. Medical clinics, hospitals, and, especially, ICUs are bewildering, frightening, and incomprehensible to the vast majority of people. The essential workings of the ICU—all the participants, the hierarchies, the machines, the medical code, the severity of illness—are completely foreign to lay people; they have nothing in their experience, educational or otherwise, to use as an anchor for making sense of their surroundings."

2)
Archives of Gerontology and Geriatrics has a report on mortality in elderly adults with bedsores. It's observational data from an Italian cohort of frail, community dwelling older adults; 18% of these patients had bedsores & 29% of these patients had died within the year. It's a relatively small study, and likely not very generalizable, but there's not too much out there on the natural history/prognosis of bedsores in the elderly so any information is notable.

3)
A recent Archives of Internal Medicine has an outcomes article about the Oncotalk program (it's an educational program aimed mostly at oncology fellows about communication skills surrounding breaking bad news, discussing goals of care, etc.). It was effective & it's gratifying to see these outcomes presented in a major general medicine journal: it furthers the message that these skills, and projects to improve these skills in medical trainees, are of interest to the general medicine audience--at least internal medicine.

4)
The same issue also has an article on shared decision making in the ICU. It comes from a project where physician-family conferences in the ICU were recorded and evaluated. It found that 'more complete' shared decision making was slightly predictive of improved family satisfaction, and that 'less complete' shared decision making occured with lower educational levels of the family. For those of you wondering what shared decision making is, there is not, actually, a consensus on what it really means: the authors define it as including "(1) discussing the nature of the decision to be made, (2) exchanging relevant medical information and information about a patient's values, (3) checking for understanding of information, (4) discussing preferred roles in decision making, and (5) achieving consensus about the treatment course most consistent with the patient's values and preferences" (i.e. it's good decision making).

5)
The same issue has another article about CHF mortality and prognosis: in a cohort of patients in Massachusetts hospitalized with CHF (average age 76 years) 1 year mortality was 38% and 5 year was nearly 80%. This is what people mean when they CHF has a worse prognosis than many cancers....

6)
PLOS Medicine has an article about using computer-based decision-support to determine what incapacitated persons' medical decisions would be . (PLOS Med is an online open-access journal.) The article is mostly a hypothetical exploration of the idea that, based on the previously published research, one could create a program that (after entering patient demographic data) would tell you pretty accurately if the patient would want treatment X (like CPR if they were in a permanent coma). Part of the reason this could be successful is, of course, that family members do a pretty poor job of identifying patients' treatment preferences. Yes, this idea sounds batty and dangerous, and the authors aren't endorsing going out and implementing such a decision-aide currently (the science just isn't there among many reasons why this couldn't work now) but they are proposing, in principle, that it could be done and, in principle, be more accurate than family members. My counter-proposal to this would be a time-machine--going back in time and just asking the patient would be most reliable.

7)
Well I'm not even done with the list I had accumulated but that's enough for tonight. Happy Spring--Drew.

Tuesday, March 20, 2007 by Drew Rosielle MD ·

Thursday, March 15, 2007

NYT and Washington Post EOL articles and more

Sometimes a lot of good stuff comes our way here at Pallimed but we just don't have time to get to a full commentary but we want to bring what we feel is important issues to the readers. Here are a few digest items from the past week, that I just need to get out of my to do box:

1) Washington Post writer Rob Stein wrote an insightful article on race and end of life issues. Catch it on Washington Post while it is free (a few more days I believe). Some of the highlights of the article:

"I think we need to be very attentive to attending to suffering in our patients and do everything we can to help minimize and ameliorate it," said Richard Payne, who runs Duke University's Institute on Care at the End of Life. "African Americans and other minorities are at greater risk of not dying well."
The article brought forward a point that Drew has made a few times here lately. Death is not pretty. It is a hard, transformative experience for all of those around it because of the difficult nature of the beast. This point about what is a 'good death,' highlights that we need to be patient adovcates in this field, as much as we are patient educators. A militant hospice philosophy is bound to end of being unsuccessful because it imposes the health care professionals values on another.

2) The New York Times (now available free to anyone with a .edu email! Not me.) has yet another pro-hospice article, this time focusing on pediatric/perinatal programs.

And if I really wanted to get on a box about shortages, I would begin to complain about the shortages of pediatric palliativists (that word grows on me everytime I use it). As an adult HPM doctor, I see the pediatric patients at home for our pediatric hospice program because they deserve access and need assistance just as much. And as much as people say 'kids are different, kids are more emotionally difficult, kids are not little adults' I have to disagree. They have much more in common with adults then we ever give them credit for, and palliative care principles apply just as well in the pediatric field. Not to say there is not more to learn, but if you are afraid of dealing with children and dying, but not adults and dying, is this ageism? (Another topic for another day, and besides not the point of the great piece by the NYT.)

If you have 7 minutes (you do, trust me) watch the video on the NYT website on perinatal hospices and the families that work with them.

Thanks to Tom Q, for the tip on this one and the next one.

3) On the pediatric front, CMAJ has a personal article by a nurse about her role in helping be present with infants and children at the end of life. Very short, very poignant.

4) the impact of Terri Schivao's care is still reverberating in the run up to the '08 Presedential Election. Mitt Romney has said the government should not have intervened as they did in Florida. The article on Lifenews.com is an interesting read, given the multiple references to euthanasia, again further making this complex issue even more difficult to understand with terms used in completely different situations then understood by classic medical ethics.

More in the next day or two, my twins are calling/screaming for me.

Thursday, March 15, 2007 by Christian Sinclair ·

Wednesday, March 14, 2007

Shortage of Oncologists!? What about Shortage of Palliativists!

The US media has been hot on the article out of the Journal of Oncology Practice by Erikson yesterday about the forecasted shortage of oncologists. The study was well done and should be replicated by many disciplines, including hospice and palliative medicine, but since I don't have the time to write that article I will do a hastily written, poorly designed, non-blinded, utterly biased, uncontrolled case report of my opinion.

First looking at the JOP study (available free, so you don't have to rely on NBC news or USA Today to get your facts.), they looked at the following numbers*:

Existing Oncologists: 10,000
Annual Graduation of Fellows: 500 from 250 programs
2005 Capacity of Oncology Visits: 42 million
2020 Expected Demand of Oncology Visits: 65 million
2020 Expected Capacity of Oncology Visits: 47 million

They attribute much of the rapidly increasing demand to increased survivorship and increased incidence of cancer in a graying baby boomer population.

Well, in the hospice & palliative medicine world we already have a shortage of MD-patient interaction, but lets look closer at the numbers:

My hospice has this many doctors that do clinical visits with patients: 4
We see (optimistically and approximately) 20% of patients admitted to our hospice.
Hospices see roughly 30% of all patients who die (2.2mil non-traumatic) in the US.

So if all hospices had a single board certified physicians (they don't)
And that MD made home visits (very rare) or rounded at an inpatient hospice (kinda rare):

optimistically
only 132,000 people (6%) who die each year
see a physician specialist
who could ease their suffering before they die!


Sinclair Formula for Estimating MD-Patient Interaction at the End of Life
2.2mil * 30% * 20% = 132,000


So we don't need to forecast a shortage, we already have one. Also with over 4,000 hospices nationwide, and with only 2,000+ board certified HPM docs, you have a pretty good chance your doctor running your hospice is not board certified.

Limitations of this crummy study include that I did not say a thing about hospital based Palliative Medicine, and a lot of people die in hospitals. Well, hopefully those docs are referring those patients to hospice so I did not want to double dip, and if they are seen by a HPM doc in the hospital and never make it to hospice that does not really bump that number up to high.

So why do I bring this up. Because I just got back from the AAHPM-led Fellowship Director's conference and it was very inspiring to be with such a great group of people who are going to teach all the future specialists in our field. I would encourage any of you who read Pallimed, and are not affiliated with any HPM Fellowship Training Program, to find your local one and ask them what you can do to help, time wise or money wise. Trust me they can use the support from and individual or your organization.

Post-script:

Also, I have nothing against oncologists. I am not trying to say their cause is frivolous, it is just that we already have a shortage and no one is making a big deal out of it. Besides some of my best friends are oncologists! Also, I am not advocating that everyone needs to see me or someone like me before they die, but we (HPM docs) should at least be available.

And if you decide to do this study in a decent way, feel free to give me some original idea credit!

*all numbers are rough for ease of understanding, look at the original article for exact numbers

Wednesday, March 14, 2007 by Christian Sinclair ·

Monday, March 12, 2007

Pharmacogenetics of opioids; Pain meds & race & palliative care; Society-wide advance care planning; Addiction


1)
The latest Clinical Pharmacology & Therapeutics has an article on the pharmcogenetics of opioids (related Pallimed post here). I have to admit my excitement for this article waned as I read it: it's incredibly basic-science heavy and difficult for the average clinician (at least me) to read (another article in this issue about methylphenidate and alcohol caught my eye although I realized I couldn't even make it through its abstract before going cross-eyed). In retrospect I don't know what I was expecting. I find the topic interesting, I guess, because it offers a promise of "hard" answers to many of the vagaries and seemingly-random hazards of my clinical practice; this, however, is currently wishful thinking on my part.... Anyway, for those of you who share my curiosity about this topic this review is an exhaustive, albeit exhausting, reference. The authors' penultimate words summed things up nicely:

"Many of the studies described in this review have increased our knowledge and understanding of how pharmacogenomics can influence the response (efficacy, toxicity, pharmacokinetics, metabolism, transport) of the opioid drugs and contribute to intersubject and interpatient variability. It is another matter for this to be translated into clinical practice."

2)
A recent Cancer had an article on insurance, religiosity, and palliative care in urban African-American and Latino patients. This was an incredibly complex (for me, too complex) study involving patients receiving community-based palliative care which looked at an interesting outcome: pain medication "stress." That is--not access to pain meds or happiness with pain control but levels of 'stress' and 'hope' surrounding their pain (meds). How they actually measured this--what this really meant--remained obscure to me after reading the article--perhaps explaining my initial reaction above. One of their major findings is that a lack of insurance predicted less 'stress' about pain meds. Huh? I'm coming off a week-long illness and perhaps my brain remains addled, but I remain perplexed. Perhaps I need a guide.


3)
BMJ, in an article related to one I recently blogged, has a nice piece about providing appropriate/timely services for those with advanced/chronic or terminal illnesses. It's mostly a concise and incredibly valuable summary of what I (lazily and unfairly to all those others who have helped develop it) call the Joanne Lynn model. What's nice is to see this discussion in a widely read general journal like BMJ. What is discussed is true, society-wide "advance care planning." Some choicer quotes:

"Most people believe their lives will be relatively healthy, punctuated by episodes of illness that last no more than a few weeks. On the rare occasions that we think about dying, we imagine short and overwhelming illness in old age. Healthcare systems are designed as if disability and ill health were aberrations, rather than a phase that lasts months or years near the end of our lives, despite the contrary evidence all around us."

"Although hospice programmes have been an important and instructive
initial response, they do not meet the needs of most patients who are sick enough to die. A minority of people who die with chronic conditions use hospices, and then only for an average of a few weeks. In the US, enrolling in a hospice requires acknowledging a prognosis of "less than six months" and forgoing "curative" treatments. The inability of doctors to prognosticate with precision and the reticence of patients and doctors to accept these conditions restrict the use of hospice services. This has led to the conclusion, in the US and in the United Kingdom, that "end of life care" should encompass all people sick enough to die soon, even though some will live in fragile health for some years."

They go on to describe programs developed to care for people, in ways that focuses on quality of life, staying at home, etc., who are experiencing different illness trajectories nearing the end of life.

4)
The NIH & Robert Wood Johnson Foundation (& affiliated organizations) are releasing a variety of media & publications (including an HBO documentary) on addiction with an eye, it seems, to improving public awareness and rates of treatment. The tone of the project seems to be, very much, one of "addiction is a brain disease that can be treated" (a quote from the promotional material). True--although that may imply to the casual observer that it can be easily & successfully treated & while that's better than suggesting those with addiction problems are moral failures it may end up implying that those who get 'brain treatment' and still aren't 'cured' are nevertheless in some way failures. News releases here (NIH), here (RWJF), and here (NIDA/NIH).

Thanks as always to Tom Quinn for letting us know about this.

Monday, March 12, 2007 by Drew Rosielle MD ·

Thursday, March 8, 2007

A randomized trial of smoked marijuana for painful HIV neuropathy


Neurology has a randomized, placebo-controlled, double-blind trial of smoked marijuana/cannabis for painful HIV-associated peripheral neuropathy. The study involved 50 people with HIV who had at least 3/10 pain from their neuropathy. They were randomized to a standardized marijuana cigarette or a placebo joint (marijuana with the THC extracted out): for those of you who follow these things the cigarettes were an average of 0.9oz and each contained 3.56% delta-9-tetrahydrocannabinol (delta-9-THC)--I think they were provided by the US government. Subjects smoked one cigarette three times daily for 5 days in an inpatient research setting; they were subject to the usual pain research tortures ("long thermal stimulation" etc.). Thankfully though the primary outcome was straightforward: subjects' rating of average pain for the preceding 24h on a 0-100mm visual analog scale. Intention to treat analysis was not used, but there were equal drop-outs in each group after randomization (2 each; 50 people completed the study).

Average age was ~50, most were male, ~35% were African-American, baseline pain scores were ~5/10, and almost all subjects were current cannabis users (they were requested to abstain prior to the research). The study's primary outcome favored marijuana: 52% of marijuana subjects vs. 24% of placebo subjects had at least a 30% reduction in mean pain scores (median reduction was 34% in the marijuana group vs. 17% in the placebo group). The number-needed-to-treat for a 30% pain reduction was 3.6. If 30% doesn't sound like much to you this is actually a really good, positive finding in the world of pharmacologic treatments for neuropathic pain: most trials that show any benefit show in at roughly this magnitude. Cannabis looked good in the experimental pain model part of the trial as well.

So this is some good, real-patient evidence furthering the finding that cannabis/THC is an effective analgesic. The trial was short unfortunately, but in order to control everything this was perhaps necessary (the researchers actually weighed the cigarettes after they were smoked to, I guess, ensure that the subject actually got the THC). The big problem with this is its generalizability. These patients were regular marijuana smokers--they were self-selected to 1) be able to tolerate the side effects, and 2) to perceive benefit--of whatever nature--from marijuana's CNS effects. Even with prescription forms of THC, the CNS/psychotomimetic side effects are often dose-limiting, particularly for older, frail patients. The next study should be using similar quantities of prescription THC for people over 50 years old with painful diabetic peripheral neuropathy who don't smoke marijuana at baseline--good results from that might be practice changing.

Thursday, March 8, 2007 by Drew Rosielle MD ·

Wednesday, March 7, 2007

Slate on why doctors don't do death very well


Slate's Medical Examiner column has a recent post on "Why doctors are bad at mortality" by Kent Sepkowitz (a physician) (Slate articles are available for free). It's a provocative essay and worth a read. (It's is somewhat of a book review of the books Final Exam by Pauline Chen, and The Lonely Patient by Michael Stein.)

Sepkowitz's major thesis seems to be that doctors are bad at death because it's human nature and therefore it's ok to flee from the deathbed. He makes some remarkable claims:

"In fact, doctors aren't bad at handling the details of dying. We know how to ease pain, promote comfort, and arrange the medical particulars. But we are disasters when it comes to death itself, just like the rest of the human species.... I admire Chen's and Stein's pep-club optimism, but they might have integrated Ernest Becker's seminal Denial of Death into their discussions. Becker's basic point is that all of human behavior can be traced to our inability to accept our own mortality. Cowards that we are, we not only refuse to consider our own inevitable death, but our patients', too: We duck the tough discussions, flinch and flutter and order another test, and finally leave it to a (usually much younger) colleague to sit down with the family. We don't slink away because we are bad people; we slink away because we are people."

I choked on my bagel when I read the first two sentences which seem patently false, based on decades of good documentation of bad pain & comfort mangement at the end of life in the US. That aside, he uses this premise to make this closing argument:

"I agree with Nuland that doctors' failure to deal well with their patients' deaths is not a bad habit that can be corrected by medical-school remediation. Doctors and patients would be better served if we stopped sophomorically pursuing the "good death" reassuringly reducing the end of life to another commodity subject to adjustment and negotiation. Instead, we should do what we can to make the dying and those who survive a tiny bit more comfortable when the time comes."

I've blogged before about my disdain for the (at least rhetorical) consumerization of dying and death ("It's all about choice!") that accompanies some discussions of dying & palliative care, but he is using this to claim essentially 1) physician behavior around death is somehow inate, not learned, and therefore not subject to improvement/education ("medical-school remediation"), and 2) we can't really do anything to ease the suffering and dislocation of death anyway (other than make people a tiny more comfortable which apparently is super-easy for most doctors). This seems to be shaky ground on which to excuse what is essentially physician abandonment of the dying (which he describes in the first quote). Death, pretty much by definition, sucks--full of anguish in even the best of circumstances--for patients, families, and frequently clinicians. To pretend otherwise is naive (& I doubt that is what Chen & Stein claim), but to pretend that we can't train future generations of physicians to care for dying patients and families in better and better ways just because we can't fix the existential finality of death is dead wrong and a little weird. Anyway, I guess I'll throw those books onto the "to read" pile.

Wednesday, March 7, 2007 by Drew Rosielle MD ·

Monday, March 5, 2007

Deaths Secondary to Opioid Poisoning; Nonagenarians & Dialysis; Pregabalin & Hot Flashes

Some of you may have seen an email circulating from the Wisconsin Pain & Policy Study Group (PPSG) about an article from last summer's Pharmacoepidemiology and Drug Safety. The email highlights an article and two commentaries regarding a causal association between increasing opioid prescriptions and increasing deaths from opioid 'poisoning*.'

The conclusion of the article is that we have entered a national epidemic of drug poisoning deaths, around the same time as increases in prescription opioid dispensing, and these may be related (inadvertently). Of the increase in unintentional deaths from poisoning, the opiate group had one of the largest % changes (+91%). In 2002, prescription opioids were implicated in more poisoning deaths (5528) than heroin (1937) or cocaine (3909). (For comparison, I have listed some CDC mortality data from 2002, so you can see the relative impact.)

Some interesting data from this study and others found that the demographics of those dying from opioid poisoning match the demographics of those dying from heroin and cocaine, mostly middle-aged males. And that most did not have a prescription for the opioid.

Well, as you can probably guess, a study like this can be intimidating to those who advocate for fair and appropriate prescribing of opioids. But as we all know:


Or 'Correlation does not imply causation.' But it does not mean we should ignore or dismiss this data. We need to read the paper and understand what it may show us. Luckily the journal that published this study included two excellent commentaries to fit along side this piece, but for those who are not keenly interested in this, I presume the abstract with the conclusion will be the only thing read which is a lazy and dangerous step. Scott Fishman, MD provides a good history of law and pain control, as well as a good summary of the problems of 'correlation equals causation.'

Joranson and Gilson provide a critical review of why this database association is difficult to translate into action, and how too much publicity of this article could cause harm:
Unwittingly, publicity about simple associations can exacerbate fears of appropriate medical use of prescription drugs among pain patients and the public, trigger more drug control, and increase fears of regulatory scrutiny among legitimate prescribers and dispensers. All of these can lead to further under-treatment of pain.
But both commentaries do address that the increase in deaths is concerning, but that we need open funding for well-designed studies that look into the complexity of drug diversion, the reasons for abuse, and not necessarily the breakdown of the prescriber-patient dyad that allows for the appropriate treatment pf pain.

For those of us in palliative care and hospice this should be an issue that you talk with your colleagues about, because as a new field we risk being defined by others, and this is not how I envision our field. Better to partner with future studies and make efforts to help address any of these problems of diversion where we are able.

*Poisoning is referred to in the article as: 'the damaging effects of ingestion, inhalation, or other exposure to solids, liquids or gases'

2) Two quickies here that I have been meaning to get off my to do list for Pallimed:

Annals of Internal Medicine had an article by Kurella looking at 80 and 90 year-old patients on hemodialysis. The number of octogenarians and nonagenarians has been increasing steadily with almost 14,000 receiving dialysis in 2003!! 1-year mortality was an impressive (impressively good I thought) 46%.

Community Oncology has a brief communication on using pregabalin (Lyrica) for vasomotor instability or 'hot flashes' for menopause, breast cancer and prostate cancer patients, and those on hormonal chemo. They gave pregabalin (open-label) to 12 patients and had some pretty impressive treatment scores with 75% of people reducing their hot flash severity by 50% or more. Although some people did experience unwanted side effects, namely sedation and altered mentation, this may be another tool to consider.

And if you have never checked out Community Oncology or the sister journal Supportive Oncology, you are missing out on some great free journals that have well-written informative accessible articles that are available online...FREE!! Go sign up. Well. Go.

Monday, March 5, 2007 by Christian Sinclair ·

Friday, March 2, 2007

Opioids and heart disease freak out; Research issues; Morphine & hastened death


A few quickies before the weekend...

1)
The American Heart Association is releasing guidelines on pain management in patients with coronary artery disease which places opioids in front on NSAIDs & COX-2 inhibitors as preferred agents (Guidelines here--both BMJ & Medscape have good news articles about them). (Medscape articles are available with a free registration.) The Medscape one has a good discussion of the already rough-and-tumble fight that is breaking out due to the prominence opioids get. From BMJ:

"First line drug choices include paracetamol (acetaminophen), aspirin, tramadol, and short term use of other narcotic analgesics. If these fail to achieve adequate pain control, the next option is non-acetylated salicylates, such as naproxen."

First line. As you can imagine there is going to be general freaking-out about this. The fight is going to be, it seems, over whether naproxen should be considered before or after "narcotic analgesics." Anyway I welcome this--it is another event main-streaming opioids as effective analgesics with relatively well-defined risk:benefit profiles, and whose risk:benefit profiles happen to be, per the AHA, more favorable than NSAIDs and COX-2's for most heart disease patients.

2)
BMJ also has a qualitative article on research barriers to studying the quality of terminal care. It's based on focus groups with end of life researchers & clinicians and covers most of the usual suspects: trouble identifying dying patients; perceptions that researching dying patients does them harm; informed consent issues, etc.

3)
There's also a letter about the case I mentioned a while back about the woman going to court in order to receive...something...which sort of sounds like assisted death. Anyway the letter is about one of my favorite topics: the myth (or at least the overselling) of morphine and hastened death.

Friday, March 2, 2007 by Drew Rosielle MD ·

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