Wednesday, April 16, 2008

Hastening death vs palliative care; Preventing aspiration; more

I am writing this on my front porch as it gets dark - it appears spring is finally arriving to the upper Midwest! I will likely be posting a little less frequently than usual the next couple of months - among other things the 4th baby to be born to a Pallimed contributor since the inception of the blog is heading my way next month and my quiet evenings blogging are fading away for a while.

Today is National Health Care Decisions Day, which I'm sure is a good thing, but as Christian pointed out to me why did it have to come the day after Tax Day? Do 'death & taxes' need to be so closely aligned on our national calendar as well?

Critical Care Medicine has an article about hastening death vs. alleviating suffering in European ICUs. The data come from a large, multinational, prospective study in European ICUs in which aspects of end of life care were measured including, apparently, circumstances in which the treating physicians themselves reported that they made specific treatment decisions to actively hasten death for dying ICU patients. These accounted for ~2% of all deaths in the study. This paper presents the meds which were used (varying doses of opioids, benzodiazepines, and barbiturates mostly) and makes the point that the doses used in the intentionally hastened death patients were similar to doses used in about a third of the patients who died receiving comfort-only care but without intentionally hastened death. That is - if one only looked at drug doses one wouldn't be able to tell the difference between 'palliative care' and 'attempted euthanasia' in many of these dying ICU patients.

Well - true - but so what? First, the absolute magnitude of opioid & benzodiazepine doses doesn't mean much, particularly in opioid tolerant patients (someone giving me 50mg of IV hydromorphone would likely kill me; I've had a few patients who take that much before breakfast), and the fact that there is overlap is not surprising at all. In addition, it's likely that a certain number of these physicians were incompetent both at estimating a lethal/death hastening dose in these patients, as well as appropriate doses for alleviating symptoms (I'm sure the latter is true) and the overlap is, again, not surprising. The real issue here is one of intentionality, and intentions matter, pretty much always, but especially here. If I sneak into an ICU and stop someone's vent in order to kill them - that's murder. If I'm that person's physician, and stop the vent after an informed decision is made by the patient/proxy because the vent is no longer meeting a care goal etc. - that's good medical care, even if the outcome is the same in both cases (the patient dies earlier than they would have if they remained on the vent).

Anyway, that's sufficiently didactic for one post. The paper has a good discussion about intentions and perceptions and talks through the reality that 'palliative care' and deliberately hastening death can look very similar on the surface, which is certainly worth discussing, and is certainly a perception that many lay-people have of what we do (and I'm sure, some of our colleagues). We've commented before on having conversations with well-educated, savvy friends and family members who don't realize that (at least in our world) there is a difference between 'assisted death' and not flogging the dying.

Annals of Internal Medicine has an article looking at interventions to prevent aspiration pneumonia in patients with dementia or Parkinson's disease. Patients (over 500, median age 81 years) were from hospitals or subacute rehab centers and demonstrated aspiration of thin liquids on a video swallow evaluation and were randomized to thin liquids taken in a chin-down position vs. honey thick vs. nectar thick liquids. Primary outcome was pneumonia at 3 months and there weren't major differences between the groups, and a few more adverse events (dehydration) in the thickened liquid group. The authors' discussion addresses this as a quality of life issue: thickened liquids aren't as palatable and don't seem to help (in the specific population they studied) so why not stick with thin liquids?

The question I have after reading this is is there any intervention that has been shown to reduce pneumonia in patients who aspirate? These interventions all seemed equal in this randomized study - and it's possible that none of these interventions was actually offering any protection (that is - if there was a 4th 'control' arm of no intervention - would they have done just as well?). Please comment if you know of any controlled study showing a protective effect of any intervention for aspiration.

Gerontologist has a couple pieces about hospice care....

First is an overview of characteristics of hospice agencies in the US which has some consonance with the last post. The data are from an unfortunately old survey (2000 - these may be the most recent comprehensive data to be sure but things can change pretty fast - in the few years I've been in Wisconsin many local hospice agencies have altered their palette of services) of US agencies providing 'formal' or 'informal' hospice services. The study suggests there are a lot of gaps in the services provided by these agencies (particularly in psychosocial-spiritual realms) - but it looks like most of the gaps are in agencies which aren't (or don't include) a Medicare certified hospice service. My initial question from seeing this was so what?, but in reflecting on the last post maybe it's these agencies which are providing the 'informal' hospice care in regions without hospice coverage. Anyone have experience with this?

The second looks at race and hospice use place of death in nursing home patients, using Florida Medicare & Medicaid data. Consistent with prior research it showed that African American patients were less likely than whites to be receiving hospice care when they die and more likely to die in a hospital. Interestingly, these differences were really among patients who didn't have cancer (such as dementia).

BMJ has a piece about teaching self-reflection in medical trainees. It's a brief, chatty piece about on-the-fly feedback and teaching of this skill. One for the teaching file.

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