Monday, February 11, 2008

The 'Imminence Condition'; PHN; More

2 from Journal of Medical Ethics:

  • First is one on terminal sedation and the 'imminence condition'. It's a difficult-to-summarize paper whose main point seems to be that the 'imminence condition' (continuous sedation to unconsciousness without fluids/artificial nutrition is OK as long as the patient is imminently dying and so withholding sustenance is unlikely to hasten death by much), which is endorsed by some proponents of TS, has not been fully explored in the literature and is full of holes (ethical analytical holes, you know the type). Never one to avoid whacking my clinician's head over an ethical analysis, the major issue I had with this is that the author repeatedly states that the imminence condition is not supported/explained by ideas of autonomy, proportionality, or double effect. However he never explains how proportionality fails to support the 'imminence condition.' I mention this because when I lead discussions on this I make the argument that it does (all of this is my opinion of course):
    • Imminently dying (likely prognosis less than ~~few weeks) & intractable symptoms; potentially hastening death by providing deep sedation without artificial nutrition/hydration is proportionate to the alleviation of intractable suffering and the loss of several days of life. Vs.
    • Not-imminently dying (prognosis of months) and intractable symptoms (existential or otherwise) --> here I think one can make a good argument for lack of proportionality between shortening life by months and alleviating the suffering. (Lord knows not all would agree with this, or with my first point above; my point however is that the concept of proportionality informs this discussion.)
  • Second is a study on physicians' confidence in discussing DNR orders. In case you have any any doubts about its results, it indeed did find that we are far less confident in discussing 'code status' than other medical procedures, and that housestaff are less comfortable than attendings.
Journal of Pain recently had a supplement on all things post-herpetic neuralgia. It has articles on the diagnosis, natural history, prevention (vaccination), etc. of PHN. The supplement is industry funded. A couple things to note:
  1. The treatment article lists (in its summative drug treatment table) levorphanol as one of the opioid treatments (and not hydromorphone, fentanyl, or oxymorphone). This seems to be an idiosyncratic choice by the authors (i.e. not because levorphanol has been particularly studied for PHN). When was the last time you saw levorphanol mentioned in an article like this (except in an article suggesting it should make a comeback)? Anyway it's a good review article and mentions numbers-needed-to-treat as much as possible (although frustratingly fails to define what the NNT was for: e.g. 50% pain reduction?). One for the teaching file.
  2. The mechanisms of pain and itch in PHN article is very readable, and morbidly fascinating (read the itch part). It has a lot of history and in some ways traces the history of thinking about chronic pain via examining the evolving understanding of PHN.
Journal of General Internal Medicine has a series of articles on discontinuing implantable cardioverters/defibrillators (all full-free text). One on the ethics of doing so; one on patient attitudes about it (an incredibly depressing but thankfully small qualitative study in which none of the patients had discussed ICD deactivation or knew it was an option and seemed freaked out by even discussing it); and one on clinician attitudes about discussing ICD deactivation. Quote of the year:

"That’s like an act of suicide. It’s a threat to your life. That’s like cardiac arrest. That’s insane."

A provocative little letter in CMAJ (free full-text here) about decision-making in impaired adults:

"Our colleagues in pediatrics, who face an equally limited decision-making capacity among their patients, have taken a more nuanced approach based on the following principles: children have dignity, intrinsic value and a right to medical treatment that serves their best interests; children should be involved in decisions that affect them; information should be presented truthfully and with sensitivity; decision-making should be interdisciplinary and collaborative; and the best interests of individual children should be of primary concern. We at CMAJ are surprised that such principles are not considered for adults with diminished decision-making capacity."

Their argument is that decision making capacity is not an all-or-nothing thing, and we should stop treating it as such. My feeling is that in real-life the above-mentioned principles are often considered for impaired adults, even if not explicitly stated (at times my group discusses the need for assent from our impaired adult patients even if we cannot obtain 'informed consent'). It's nice however to see these ideas in print.

On the EBM front....

NEJM recently published a piece looking at publication bias in antidepressant trials (it looked at all trials of antidepressants which were registered with the FDA and compared those which were published in the literature and those that weren't). They found that the unpublished trials were much more likely to be negative ones, and that even several trials which the FDA deemed negative (not supporting the efficacy of antidepressants) were published with positive sounding results. This is not to say they aren't effective but that the magnitude of benefit may be over-estimated, and also sounds a (general) cautionary alarm when interpreting systemic reviews or meta-analyses which rely only on published research (particularly in areas in which there is a lot of industry-sponsored research and thus perhaps a lot of research which is never published).

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