Wednesday, January 2, 2008

Just say 'Die'; Urine drug testing; More

Happy New Year and welcome to 2008, which is Pallimed's 4th calendar year (we've been around since 2005), which seems like a long time to me, and perhaps should warrant a more festive or at least reflective post that the one I'm composing, but oh well.

1)
Journal of Clinical Oncology has an 'Art of Oncology' piece with the not-too subtle title and message 'Just Say Die.' That is - when you think a patient is in fact dying, or death is nearing, or whatever, to tell them that, D-word and all. It has the cheekiest table I've seen for a while in the article: column 1 contains actual quotes from oncologists to a dying patient (most of them awkward, and wordy), column 2 is labeled 'What the physician meant' (the translation of column 1) and every entry is 'You are dying.'

The question, at the heart of editorial, is essentially - is important to say die/dying/death to a patient if that's what happening - as opposed to some euphemism ('time might be getting short,' 'this may be entering a terminal phase') - as long as the patient understands what we mean? The author emphatically (although not dogmatically) that the answer is Yes to the above question, and gives several reasons, which go beyond 'it's the right thing to do,' and I'll excerpt my favorite:

"Clearly, the quality of an end-of-life discussion may influence the quality of the relationship we have with a patient. Forthright and clear exchanges will help nurture and develop better relationships while confusing discussions could cause irreparable harm. Death and dying are painful and emotionally charged issues. These words cannot just be thrown into the discussion for clarity's sake; they must be used with care and understanding to let patients know what physicians really mean. As Loprinzi et al suggest, "Such stark and life-changing information needs to be shared sensitively if it is to deepen, rather than injure, trust between patient and physician." Some of the most important talks we have with our patients will be those where we need to discuss their approaching death. These discussions help us understand how they view their future and their prognosis. Oncologists get to know their patients’ personalities well as they care for them, and our conversations (and the words we use in those conversations) are tailored for that individual. Will using the words "death " or "dying" be the right thing for every patient or conversation? No. But used appropriately, these words could help improve our discussions about death with many of our patients."

It's my favorite because it frames the conversation in reverse to how it's often conceived: as a way to build trust/relationship with a patient as opposed to a way of undermining trust (because we've failed them, because we are hurting them by telling them unwelcome information, etc.). It reminds me of times during my training when I was discernibly scared of telling a patient the truth, so much so that on several occasions I was patted on the arm by the patient him/herself and told, in as many words, 'There, there, I know this is tough for you.' Humbling moments, to be sure. Facing decline and death is frightening enough that most patients probably don't benefit from seeing their physicians fumbling for words in talking about it, afraid to name the facts of a situation....

As a perverse aside, I'll also note that when I first saw the title of this article I was instantly reminded of a Simpson's episode when Bart's arch-nemesis Side-Show Bob denied homicidal intent behind his writing of "Die Bart, Die" by claiming he was merely writing in German "The Bart, The."

The same issue also has an article about age as a prognostic factor for patients receiving treatment for non-small cell lung cancer (the data are taken from a couple therapy trials). The conclusion is that comorbidity but not age, per se, was associated with worse prognosis.

2)
Multiple from the last couple issues of Mayo Clinic Proceedings....

Most welcomed, to me, is a practical/clinical review of urine drug testing. It's readable and thorough, and answers many of the questions that come up (at least in my experience) regarding drug testing - ones that I'm asked a lot (e.g. oxycodone and methadone are not picked up by routine 'opiate' screening, sertraline can cause a positive test for benzos, and poppy seeds can lead to 'false' positives for opiates). As to that last point, they cite one analysis which suggested that a poppy seed bagel can have 1.5mg of morphine in it! Anyway, a good one for the teaching file.

There's also a brief discussion about engaging the 'hostile patient,' a situation familiar to all of us. It provides straight-forward, practical advice, and gives examples of language to use. Most appreciated is the discussion that defusing these situations and forging therapeutic alliances with patients can take just a few minutes. It's a teaching point I try to make again and again to residents when we're talking about communication skills: good communication does not take a long time (usually) - sitting down, pretending you have all the time in the world, asking the patient's understanding of what's going on, and sharing info with them/making recommendations can all be done in a matter of minutes in a lot of cases. Careful communication saves time in the long run. (Ok, I'll admit it, that's a 'talking point,' and one that I can't back up with data, but I believe it with sufficient confidence that I promulgate it. I often show little videos of breaking bad news interactions with patients - the 'bad example' is 2.5 minutes long & the 'good example' is 3.5 minutes long and includes therapeutic silence etc. I often ask residents how long they thought the interactions were, and they tend to substantially overestimate how much time was spent - especially the therapeutic silence - 10 seconds - it seems like 30 when you watch it. Anyway, the 3.5 minute video, which is a great demonstration of compassionate, patient-centered communication in which the clinician gives the sense that he has all the time in the world for the patient, is a great example for the residents that all these good communication skills are not time-consuming.)

And super briefly: there's also articles on hospitalized patients' expectations about interactions with chaplains (what they want out of their visits with them, how frequently they want those visits, etc.); on the content of patients' advance directives (i.e. whether they designate a proxy, whether they empower their proxy to withhold or withdraw treatment, etc.); and a single institution study about the prevalence of advance directive completion amongst health care providers at a cancer center.

3)
JAMA has an article comparing opioid prescribing in emergency rooms by race - white patients were more likely to receive an opioid for pain than African-Americans, Hispanics, and Asian-Americans, even after adjusting for pain severity and diagnosis (even, for instance, long-bone fractures). An associated editorial surveys global disparities in pain treatment, and doesn't mince any words:

"The overregulation of medicinal opium is an enduring and critical problem that contributes to the global undertreatment of pain."