Monday, January 14, 2008

Pallimed in Tampa; Patients' recall of cancer disclosure; Much more

If you're going to the AAHPM conference in Tampa, the '2nd Annual Pallimed Happy Hour' will be at Backjack's, Friday February 1st at 7:30PM until at least 8:30PM, but longer if someone buys Christian drinks. Map here - note it is just a short, tree-lined bridge south of the convention center (601 S Harbour Island Blvd - Backjack's is the bar associated with a restaruant - Jackson's Bistro). Tom unfortunately can't make it (we'll miss you Tom) but Christian and I will be there. It will be simple, and casual, and done for mostly selfish reasons: we love to meet people who are part of the community reading this blog. If you want to come to give us a piece of your mind - feel free to - but remember, I'm sure whatever we said that annoyed you was written by Christian or Tom, and not me.

I will also be found at the Job Fair Thursday afternoon, recruiting academic palliative care physicians for openings here at the Medical College of Wisconsin. It's a great place to practice and teach palliative medicine, and if you're interested and aren't going to be at the Job Fair feel free to drop me an email. I'll be the one sitting under a banner depicting Milwaukee's most famous architectural landmark, the Calatrava addition to the Milwaukee Art Museum (featured in
Futurama). Actually, I probably won't be under such a banner, but I figured I'd use the opportunity to 'reprent the 414' as a place which has more to offer than beer-n-brats, and which is a decent place to live (in addition to being a superb place to practice palliative care).

(Christian and Tom, this earns you one free shameless plug on Pallimed for any local program or project or job opportunity of your choosing.)

Blogging on Peer-Reviewed Research2)
The latest JCO presents research about newly diagnosed lung cancer patients' satisfaction with and recall of their doctors' communication about their diagnosis. It involved prospectively interviewing ~70 patients (all Swiss, mean age 68 years, about half with advanced disease at diagnosis whose treatment goals were non-curative) within 3 days of being told they had lung cancer. The study looked at what they recalled about their diagnostic disclosure (type of cancer and stage), what treatment was planned, their understanding of the goal of their treatment (curative vs 'palliative'), and their satisfaction with their discussions with their physicians. The physicians involved were a mix of internists and pulmonologists - nearly half were internal medicine residents.

There was good recall overall for diagnosis (90% had at least partial congruence with their physicians about the diagnosis), and planned treatment (85% had some congruence). However, can you guess what the congruence for treatment goals was? Yes, much worse: 56% of the patients who were being recommended 'palliative' treatment thought it was curative, 42% being offered curative therapy thought it was 'palliative' (this difference didn't achieve statistical significance; there is no mention in the study of any power calculations). Satisfaction with discussions of treatment goal was low (39%) compared with satisfaction with other aspects of communication (~75%) and was not associated with actual treatment goal.

Without further commenting on the remarkable finding that 10% of these patients, fresh from a diagnostic disclosure, were not abl
e to tell the researchers that they have cancer, this is further supportive evidence that many cancer patients are confused about what the point of their treatment is. 56% not understanding is a lot, and thankfully more than the range usually found in cancer patients actually receiving non-curative chemotherapy (often in the 30-40% range), and I wonder if some of this difference is due to half of these patients being just a few days out from an internal medicine resident's disclosure, and had not spoken to a medical oncologist about their care (I say this reflecting on the pallor I've seen in many residents' faces when confronted with a cancer patient's requests for information about the 'big picture'). That said, while satisfaction was associated with having a pulmonologist tell you, they don't mention whether 'goal-congruence' was associated with physician specialty/training; one assumes it wasn't.

As a final note, I quoted 'palliative' treatment goals in the above discussion. This is the language used in the article, but it's language that I find confusing (to patients as well as clinicians) and have stopped using. Cytotoxic chemotherapy, aimed primarily at prolonging life (but not at cure), doesn't seem 'palliative' to me - aimed at improving quality of life/symptoms without necessarily modifying a disease's course. Cancer patients are confused enough by their treatment goals, clearly, and many of them kinda sorta know what 'palliative' means, and describing their emetogenic but life-prolonging cancer treatments 'palliative' just seems needlessly confusing. None of this is to say of course that 'palliative' can't mean life-prolongin
g, and I don't mean to imply a rigid 'palliative=comfort' standard (which is wrong and needlessly confusing but for other reasons), but why not use clearer terms when they're available? I tend to use terms like 'curative,' 'non-curative,' 'life-prolonging,' etc., and am curious as to what others do.

Gabrijel, S., Grize, L., Helfenstein, E., Brutsche, M., Grossman, P., Tamm, M., Kiss, A. (2008). Receiving the Diagnosis of Lung Cancer: Patient Recall of Information and Satisfaction With Physician Communication. Journal of Clinical Oncology, 26(2), 297-302. DOI: 10.1200/JCO.2007.13.0609

NEJM has a couple articles to note. First is a review on the pathophysiology underlying depression from the journal's 'mechanisms of disease' series. The article covers the biochemical mechanisms which are thought to underlie depression, and really doesn't cover much else, but it's an interesting read if you like that stuff.

Second is a look-back at the Dr. Pou case (free full-text available). Dr. Pou is the surgeon accused of euthanizing several patients during the Hurricane Katrina disaster (no formal
criminal charges were brought, although civil suits are still pending). It's a thorough recounting of the allegations and different accounts of the events, but is most interesting for its more general discussion of disasters and 'reverse triage' (evacuating the healthiest and most likely to survive first) - how does one care for those left behind, and what protections are there for those clinicians left behind who no longer have the means to keep those sickest patients alive and who instead try to make sure they are comfortable? (Previous blog posts on Dr. Pou here).

Chest recently published a retrospective analysis of the use of indwelling pleural cathethers for patients with recurrent, malignant chylothorax. It compares the natural histories of those who received indwelling pleural drainage catheters with those who didn't and, for what it's worth, found that those who received the catheters required fewer subsequent 'pleural interventions.'

The Wisconsin Medical Journal recently published a piece about providing culturally sensitive end of life care for Latinos (free full-text here: scroll about half-way down). It's written by a Latina physician who cares for many Latino patients, and is an idiosyncratic (and I mean that in a good sense) overview of Latino end of life care and culture. There is an appendix at the end which talks about funerals and death rituals and Dia de Muertos.

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