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."
14 Responses to “Just say 'Die'; Urine drug testing; More”
January 03, 2008
in light of drew's inclusion of an article on drug screening, i would ask how often are people using drug screening in a palliative care setting?
norb weidner
January 03, 2008
That's a good question, Norb, and I'd like to hear how others respond. "Palliative care setting" covers a lot of territiory. We have discussed the issue of opioids and abuse in Pallimed several times, mostly from the perspective that over regulation, fear, and ignorance are barriers to appropriate use of opioids. I would point out though, that Steve Passik & Russ Portenoy take the position that active abuse or addiction interfere with (can even negate) appropriate disease-directed and palliative care. Abuse or addiction should be addressed systematically (urine screening might be part of that) along with the patient's other palliative care needs.
January 03, 2008
I agree with Tom - 'palliative care setting' can mean a lot of different things but there's a lot of overlap in clinical practice between palliative care settings, chronic pain settings, and general supportive cancer care/symptom management settings and certainly pain, substance abuse/addiction, concerns about diversion, cancer, and impending death can and do all coexist (and probably most of us have had a couple patients who had all of those characteristics at once).
Personally I rarely do them - just a handful of times a year.
January 03, 2008
Drew, I know your witticisms well, but just to clarify, is it:
you personally have a few drug tests a year?
or
you order a few urine drug tests on patients a year?
Just me and my semantics wondering... It reminds me that I try and encourage medical staff to say "I prescribe/dispense morphine/oxycodone, etc.," rather than "I use morphine/oxycodone, etc." Small point. Could be called trivial, but when you are battling big big stigmas it may take a little chipping away via professional and wise choice of words. Much like the "Just Say Die" article. Say death when you mean it. (BTW nice Simpson's ref)
Norb,
In my 50% hospice 50% Palliative Hospital Consult practice, I see a few done in the ED, but have not ordered but one or two in the past year.
January 04, 2008
Personally I prefer 'using narcs' to 'prescribing opioid analgesics.'
January 07, 2008
Life life beautiful without pain and cancer.I too agree with Dryu and Tom that care this the most important!!
January 15, 2008
Lots of good comments here, but I have a question. What about the patient who has a history of using street drugs, but is now dying of metastatic cancer (multiple bone mets), and is suffering, physically and mentally. He has Fentanyl patches (400 ug) which he has to pick up in person daily (he has 4 x 100 ug patchs which are being rotated daily). He is being given nothing for breakthroughj, when prior to hospitalization in December, he was taking Morphine 250 mg Q2H. The doc in charge is accusing him of manipulation, but I am wondering if right now he is going through withdrawl (diaphoretic, hot and cold, nausea and vomiting, diarrhea, diffuse pain). At any rate, yesterday the doc agreed to admit him to the hospital, but this was done in December. The discharge summary reads that he was being prescribed the Fent. patches, Morphine for BTA, Ativan, Elavil and Imovance. In fact, he was dischared with only 10 Morphine tabs, and no other po meds.
Help? Does anyone out there have any words of wisdom. I truly feel we are doing this man a disservice.
January 15, 2008
Cherriwh: sounds like a terrible situation for the patient and you. Without knowing the specifics of the case my recommendation would be to treat his pain using the same techniques/principles you'd use with any other cancer patient. It's not clear to me from your description if the 'problem' is with the patient or with his treating physicians.
January 15, 2008
Cherriwh,
As Drew said, it's hard to draw conclusions and we certainly can't give medical advice in a particular case. However, I have no problem asking the questions that this raises for me, nor of stating some general principles. Also, from a standard opioid rotation perspective, 250 mg oral morphine per hour is more total opioid than 400 mcg transdermal fentanyl--so if the numbers are right, yes, he may be in withdrawal. But that is a temporary, if very uncomfortable, condition. The cancer and addictive illness will be with him until the end.
Principles
1. People with addictive illness should have their pain treated as aggressively and appropriately as people without addictive illness.
2. It is appropriate to use very strict controls (like daily dispensing) for a patient with active or recent sustance abuse behaviors.
3. Frequent reassessment of pain, function, and drug use behaviors is a responsibility of the prescriber.
4. People with advanced illness and co-occuring substance abuse should be treated concurrently for both. At the very least, 12-step programs or similar supportive programs should be enlisted.
5. Active substance abuse can interfere with appropriate palliative care. That does not mean, however, that otherwise appropriate care should be withheld or withdrawn. It does mean that a significant amount of time and emotional energy will need to be invested in the care of such patients.
Questions
1. Is this man still using "street drugs?"
2. What does the doc mean when he uses the term "manipulation?"
3. The practical elements of taking any drug every two hours is kind of boggling--how does that work in reality?
4. What is the prognosis (if he has mets, by definition he has advanced cancer, but one does not usually die from bone mets)?
5. Is there an alternative to daily visits to the clinic (or where ever he gets the meds)? For example, home hospice nurse who could do a daily assessment as well as bring meds. Maybe split the difference & do every other day?
6. Any chance doc & patient can clear the air with a frank conversation, get past their mutual distrust & work collaboratively, perhaps with a
3rd party? Wouldn't mean less strict conditions, but clearer, more open communication would go a long way to making this more emotionally satisfying for both, and they might be able to discuss mutually agreed treatment goals & treatment plan. Maybe he can even do some work on the suffering that extends past the pain.
January 15, 2008
Excellent points Tom. I agree with the clarity and content. A must read.
March 27, 2011
Cherriwh,
As Drew said, it's hard to draw conclusions and we certainly can't give medical advice in a particular case. However, I have no problem asking the questions that this raises for me, nor of stating some general principles. Also, from a standard opioid rotation perspective, 250 mg oral morphine per hour is more total opioid than 400 mcg transdermal fentanyl--so if the numbers are right, yes, he may be in withdrawal. But that is a temporary, if very uncomfortable, condition. The cancer and addictive illness will be with him until the end.
Principles
1. People with addictive illness should have their pain treated as aggressively and appropriately as people without addictive illness.
2. It is appropriate to use very strict controls (like daily dispensing) for a patient with active or recent sustance abuse behaviors.
3. Frequent reassessment of pain, function, and drug use behaviors is a responsibility of the prescriber.
4. People with advanced illness and co-occuring substance abuse should be treated concurrently for both. At the very least, 12-step programs or similar supportive programs should be enlisted.
5. Active substance abuse can interfere with appropriate palliative care. That does not mean, however, that otherwise appropriate care should be withheld or withdrawn. It does mean that a significant amount of time and emotional energy will need to be invested in the care of such patients.
Questions
1. Is this man still using "street drugs?"
2. What does the doc mean when he uses the term "manipulation?"
3. The practical elements of taking any drug every two hours is kind of boggling--how does that work in reality?
4. What is the prognosis (if he has mets, by definition he has advanced cancer, but one does not usually die from bone mets)?
5. Is there an alternative to daily visits to the clinic (or where ever he gets the meds)? For example, home hospice nurse who could do a daily assessment as well as bring meds. Maybe split the difference & do every other day?
6. Any chance doc & patient can clear the air with a frank conversation, get past their mutual distrust & work collaboratively, perhaps with a
3rd party? Wouldn't mean less strict conditions, but clearer, more open communication would go a long way to making this more emotionally satisfying for both, and they might be able to discuss mutually agreed treatment goals & treatment plan. Maybe he can even do some work on the suffering that extends past the pain.
March 27, 2011
Life life beautiful without pain and cancer.I too agree with Dryu and Tom that care this the most important!!
March 27, 2011
Lots of good comments here, but I have a question. What about the patient who has a history of using street drugs, but is now dying of metastatic cancer (multiple bone mets), and is suffering, physically and mentally. He has Fentanyl patches (400 ug) which he has to pick up in person daily (he has 4 x 100 ug patchs which are being rotated daily). He is being given nothing for breakthroughj, when prior to hospitalization in December, he was taking Morphine 250 mg Q2H. The doc in charge is accusing him of manipulation, but I am wondering if right now he is going through withdrawl (diaphoretic, hot and cold, nausea and vomiting, diarrhea, diffuse pain). At any rate, yesterday the doc agreed to admit him to the hospital, but this was done in December. The discharge summary reads that he was being prescribed the Fent. patches, Morphine for BTA, Ativan, Elavil and Imovance. In fact, he was dischared with only 10 Morphine tabs, and no other po meds.
Help? Does anyone out there have any words of wisdom. I truly feel we are doing this man a disservice.
March 27, 2011
I agree with Tom - 'palliative care setting' can mean a lot of different things but there's a lot of overlap in clinical practice between palliative care settings, chronic pain settings, and general supportive cancer care/symptom management settings and certainly pain, substance abuse/addiction, concerns about diversion, cancer, and impending death can and do all coexist (and probably most of us have had a couple patients who had all of those characteristics at once).
Personally I rarely do them - just a handful of times a year.
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