Friday, February 29, 2008

Pallimed 2008 Annual Survey Results

Thanks to all the readers who took our survey at the end of January. As promised we wanted to share some of the results with you as 'payment' for taking the survey.

We had a pretty good response for a voluntary survey. Of the 600+ readers at the time of the survey we received 87 surveys for a 15% return rate. So next year we are aiming for 25%! Thanks to all of you who participated, we appreciate your input.

88% of responders were in the medical field and 75% of those worked in hospice and palliative care primarily. Figure 1 is the distribution of disciplines. I am pretty surprised we did not have more fellows answer, since I would expect them to be technologically hip to RSS and looking for good articles for journal club. We even got a response from a hospice librarian. I did not know such people existed, but that is great!

Over half of the respondents have been reading Palllimed for over 6 months and most of you accessed Pallimed via the web site directly or email subscriptions (see 2nd Figure). If you don't know what RSS is you can see our First-Time Visitor Page for a good explanation.

Most people preferred the current format of 2-3 posts per week, and multiple subjects in each post. Interestingly this is not the usual blog format, which is one subject for each post, and multiple small posts per day or a few large posts each week. We appreciate the individual feedback about the format and will be taking some of these into consideration in tweaking upcoming posts.

As far as the future of Pallimed many people responded positively to the ideas we floated including calendar function for conferences, PowerPoints, handouts, audio/video podcasts, guest posts by readers/senior faculty, polls, and interviews. Now obviously we cannot do all of those things at once, but since CME and CE did not get a large positive response, we will likely be crossing those off the list for now given the amount of work those take. Drew, Tom and I are trying to keep the core content of high enough quality and figure out how to slowly implement some of these additions. We also don't want to duplicate content that you can get at other sites. If you would be interested in contributing to any of these new prospects, please feel free to email Drew at his gmail dot com address (drosielle).

One function we are interested about is the use of comments. The ability to comment is one of great things about blogs. It allows for near real-time conversations about the topics that we post on. You can even use it as a forum to have a public conversation on something off-topic.

Only 24% of respondents had placed comments on Pallimed. All the blue shades in Figure 3 are the "never commented" responses and the reasons for the response. The other category was filled with answers that could be placed in multiple of the other no categories. A high number of responders (21%) did not realize we had a comments section. Many people felt they had nothing to add. Drew, Tom and I do not profess to be the experts on all the topics we write about. There is a lot of opinion here, which means there is room for debate.

You can find the comments link at the bottom of every post.
To address some of the individual responses to the questions we surveyed:

No. Absolutely not.
Are you serious?
I thought that was pretty funny too.
I never thought of Drew that way before.
Seriously though, some of you enjoy our attempts at wit, others desire a more serious tone. We try to strike somewhere in between to make it informative and accessible/personal. Whatever you think, thanks for reading Pallimed. We have grown from 4 subscribers last January to around 700 in just over one year. Thanks for helping us in our amazing growth. We appreciate the positive and critical feedback, and hope to see more of you in the comments section. (Feel free to practice commenting on this post!)

Thanks!
Drew, Christian & Tom

Friday, February 29, 2008 by Christian Sinclair ·

Wednesday, February 27, 2008

Antibiotics and Treating Infections in the Elderly

ResearchBlogging.org1)
The Archives of Internal Medicine published a significant study regarding antibiotic use in the elderly authored by Dr. D'Agata and Dr. Mitchell from Beth Israel Deaconess. In their article, they review the antibiotic usage in 214 (mostly white, female and over 80yo) nursing home residents with advanced dementia, defined as very severe cognitive impairment, minimal communication, dependent eating/toileting, bowel/bladder incontinence, and inability to walk. This study was part of a larger study called CASCADE (Choices, Attitudes and Strategies for Care of Advanced Dementia at the End-of-Life). (Take that cardiologists with all your fancy acronyms!)

The mean number of antibiotic courses per resident was 4 (range 1-20!), and about 66% of the 214 received at least one course with the majority of residents receiving a course within the 14 days prior to death, indicating the effectiveness of antibiotics to cure an infection in advanced dementia may be limited. This multi-center prospective cohort is probably the best study to demonstrate the limited efficacy of antibiotics in patients with advanced dementia.

The study did not have data representing success of treatment for each course, which makes hampers clinical relevance. If we had information that indicated say 80% of the UTI's were cured, but only 35% of respiratory infections improved or similar info, we could have more informed discussions with staff and family. Also this article does not have information on symptom improvement, since antibiotics may have improved symptoms (although data in elderly says this is not a major effect), but that would be difficult to get workable objective data from someone who by inclusion criteria cannot communicate.

Despite this information, one cannot conclusively make an across the board declaration that patients with advanced dementia should never get antibiotics. We don't yet know what the outcomes might be for those that had antibiotics withheld. There is a general understanding that fever and likely infections are a common pathway towards death for advanced dementia patients. The optimal strategy is not yet clear, and these issues must be decided on an individual basis with open discussions of goals of care. But this study may help nursing home staff, and hospice and palliative medicine staff make more judicious use of a minimally efficacious treatment, that as a secondary gain could potentially help public health by decreasing antibiotic resistance in the community. I would imagine this second point is a bit more challenging to ethically justify. Autonomy versus Distributive Justice...en garde!

Interestingly the CDC is debating on how to advocate influenza immunization of all school age children to protect the children, but also to decrease influenza deaths/infections in the older community. The CDC are not necessarily advocating we "treat the children to save the elderly." So it is interesting this Archives of Internal Medicine study could be spun as "Don't treat the elderly to save the children." I realize I am making broad generalizations, but it is interesting the eerie similarities between the two circumstances. The editorial for this article is highly recommended as well.

(Thanks to Pallimed reader Maria F for the tip!)

D'Agata, E., Mitchell, S.L. (2008). Patterns of Antimicrobial Use Among Nursing Home Residents With Advanced Dementia. Archives of Internal Medicine, 168(4), 357-362. DOI: 10.1001/archinternmed.2007.104

I have had so many things crossing my desk that I have wanted to share, that I have to clear some of these out.

For our chaplain readers, you may be interested in the recent Religious Landscape Survey by the Pew Forum on Religion and Public Life. The site has some good demographic maps to look at the different faith communities in the US and by states. The full report is here. The media's take on this has been focused on how people change religions more often.

The British Medical Journal recently published a clinical review on treatment of adult depression. Dr. Shock (a blogger) reviews it nicely. Obviously the article is not focused on palliative medicine, but a good general background on current views on depression management (and not just pharmacological management). But before you prescribe that Prozac, a recent study (free pdf) in PLoS Medicine suggests that antidepressants may be no better than placebo. James Hrynyshyn at Island of Doubt has a nice blog post summarizing the study and the drug-placebo controversy.

Thomas LeBlanc and Amy Abernathy (of PC-FACS) explore research in hospice patients in an ethics forum for American Medical News. A good conversational review on a desperately needed area.

And finally with the recent movie "The Bucket List" about making a list of things to do before you die comes this very helpful blog post about priorities in life and how to 'manage' your bucket list.

Wednesday, February 27, 2008 by Christian Sinclair ·

Monday, February 25, 2008

Reasons for PAS; Prognosis in TBI; More

I'm traveling the rest of the week & this will be my only post until March, which I'm hoping will host fewer record-breaking snowfalls in the upper Midwest than January and February have.

ResearchBlogging.org1)
The Journal of General Internal Medicine has an article about family perceptions of why their loved ones pursued physician assisted suicide. It involved interviews of ~80 patients who had pursused PAS in Oregon (about 50 actually received prescriptions and 30 went through with ingestion of the lethal prescription). Family members were interviewed between 3 months and 3 years after the patient died. It's somewhat unclear to me how these people were identified: it looks like an advocacy group has a database of people who had inquired about PAS and the family members were identified that way (it doesn't seem like it was an exhaustive list of everyone who pursued to whatever extent a lethal prescription in Oregon in the time frame of interest for the study). 38% of family members approached participated in the survey.

The general demographic profile of the patients underscores previous findings that people who pursue PAS are white, predominantly male, and overwhelmingly receiving hospice services (87%). Family members perceived their loved ones pursued PAS for reasons of autonomy/control and fear of future suffering: wanting to control the circumstances of death, not wanting to be a burden in the future, fearing loss of independence and dignity in the future, and fear of symptoms in the future. The importance of current symptoms (current at the time the patient initiated pursuing PAS) were, however, minimal.

There are a lot of limitations to the study: retrospective, relies on family reporting long after the fact, and a low response rate. Nevertheless the findings are consistent with other studies examining why people pursue assisted suicide - it is very much for existential reasons - people who cannot conceive that the decline and indignities of dying could be meaningful or valuable in any way - and not because people's current physical suffering is driving them towards 'desperate' measures. I think this has importance to the debate about PAS, especially since its proponents often tout it as a necessary safe-guard against dying in agony. Besides not being true, that's also not why people seek it, and the only debate about it which makes sense to me is one that centers on rights & autonomy (the rights of an individual to decide what constitutes a good death for them by controlling its circumstance) but not a debate about preventing (physical) suffering. The vast majority of physician proponents of PAS of course are not promoting it as a safe-guard against physical suffering, but some of the patient/'consumer' advocates of it are, and aren't afraid to bring out the scare-mongering language.

I'll also note that this article calls PAS 'physician assisted death' (as does the AAHPM position statement - although I'd encourage you to click that link then actually look at what the URL of that page says!) throughout. While the article, and the AAHPM statement, are explicitly about the practice otherwise known as PAS, others use 'PAD' (or at times, 'assisted death') as a blanket term to include both assisted suicide and euthanasia, making the use of PAD strictly for PAS confusing. I agree with the AAHPM statement that the word suicide is emotionally charged but that doesn't necessarily make it inaccurate and insofar as there are others using 'PAD' to include euthanasia one wonders if changing the language in this way is actually helpful. Curious as to readers' thoughts about this. I'm sticking with PAS for the time-being.

Ganzini, L., Goy, E.R., Dobscha, S.K. (2008). Why Oregon Patients Request Assisted Death: Family Members Views. Journal of General Internal Medicine, 23(2), 154-157. DOI: 10.1007/s11606-007-0476-x

2)
BMJ has a study about developing a prognostic model for traumatic brain injury. The data were prospectively gathered and come from an international study of TBI (10,000 patients with a 20% 14 day mortality and a 37% 6 month 'poor outcome' across the cohort). Poor outcome here is defined as death or severe disability & severe disability is defined as 'able to follow commands/unable to live independently' or worse. All the usual prognostic model derivation and validation hoops were jumped through (well, most of them) and they created a couple prognostic models (a simple one and a more complex one using specific CT scan findings). Given the large size of the studythey achieved a tight fit between their derivation and validation cohorts. The simple model uses easily available data: Glasgow coma score, age, presence of major extracranial injury, and pupil reactivity upon presentation. They created a handy web-based calculator for 14 day mortality and 6 month 'poor outcome' prediction.

While death is an easily agreed upon 'poor outcome,' the 6 month outcome is more problematic. Assuming this model is incredibly accurate, and you could use it to predict a 95% chance of a poor outcome at 6 months, this still represents a wide spectrum of cognitive and functional disability (from death to persistent vegetative state to, presumably, a cognitively intact or nearly intact patient whose medical issues were sufficiently complex to prevent a return home). I imagine this is going to be insufficiently precise to be sufficiently helpful to many family members and clinicians for improving decision-making (it would be more helpful if it gave an outcome for PVS and death alone, for instance). What we need, of course, is a prognostic model which will tell your family if your outcome will be sufficiently positive that you'd want ongoing life-prolonging care after a severe TBI; this is also known as a crystal ball and one has to forgive these researchers for not coming up with it.

One of the accompanying editorials talks about the limits of the model, and cautions against using it in clinical care (instead promoting it for risk stratification of patients for further research). I think the cautions are valid, however prognosis is always limited, human, and incomplete and suggesting that we need perfect prognostic powers before making decisions is strange to say the least. A quote:

Far greater caution is needed if such a model is to be used for making decisions about treatment in individual patients. Estimates of outcome probability from the 10 000 patients in the CRASH trial are based on collective clinical experience beyond that achievable by any individual clinician, and these estimates may help educate clinicians and support clinical decision making. They cannot be used in isolation, however. Models can estimate the probability of a given outcome for a group of clinically similar patients with a high degree of accuracy, but they cannot reliably predict outcome for individuals. At least in the context of deciding whether or not to treat individual patients, it is important to continue to acknowledge, as did physicist Niels Bohr, that "prediction is very difficult, especially about the future."
Thanks to Dr. Bob Arnold for alerting me to this.

3)
And very briefly:
  • JAMA has a study about survival of in-hospital cardiac arrest. The paper uses prospectively gathered data on ~80,000 in-hospital arrests (from a national registry) and compares outcomes for pulseless cardiac arrests that occur during weekdays vs. those that occur on nights or weekends. Overall survival to discharge was 18%; 14% survived and had good neurologic outcome (how this was actually determined is unclear to me). Pursuant to a recent conversation on the blog, the best outcomes were intraoperative arrests during the day (night ones weren't too good presumably because these were emergency surgeries on unstable patients): 36%. (For the record, outcomes are modestly better during weekdays than nights/weekends.) These figures are in the ballpark of previous studies. I'm curious as to whether in the next decade or so rates of in-hospital arrest will start improving due to better patient selection (fewer resuscitations of the otherwise dying); that of course assumes such trends are actually occurring....
  • Scanning through the references from the JAMA piece I noticed this one from a few years back that I had never seen. It caught my attention because they evaluated outcomes of arrests for people with 'limited resuscitation' status (e.g. 'partial - as in not 'full' - code status: people whose code status limits intubation, shocks, or chest compressions but not all three) - I had never seen a study looking at this. None of the patients who had a 'limited code' status survived an arrest to discharge, which is at least a wee bit of evidence to support the long held adage that partial codes make no sense. A long time ago I had a (very sick, but smart and seemingly well-informed) patient who could not understand why her code status couldn't be "one shock, nothing else."
  • The Journal of Clinical Gastroenterology has a study about prognosis in advanced pancreatic cancer based on retrospective analysis of data from a Korean cancer center.
  • To the Best of Our Knowledge, a public radio show, this week has an hour long segment on the good death. It's worth listening to (you can stream it online; there's also a podcast available at iTunes).

Monday, February 25, 2008 by Drew Rosielle MD ·

Wednesday, February 20, 2008

Pediatric Palliatve Care Barriers; Palliative Med Salaries

ResearchBlogging.org1)
Pediatrics, the journal of the AAP, occasionally features palliative care issues, so when my wife's copy arrives I usually take a quick look at the table of contents. In the February issue they feature an article on the Barriers to Palliative Care for Children as perceived by health care providers. Davies et al polled all staff members (698) at UCSF Children's Hospital, and reviewed the results from the 117 nurses and 81 physicians who replied. Of the remaining 42 respondents they were from other disciplines and there were not enough to make significant comments as a group. The majority worked in NICU and PICU where you would expect they would see at least a few pediatric deaths per year, and only 9% of the respondents said they had cared for zero patients who died in the previous year. About 25% of the physicians had experience with more than 10 pediatric deaths in the past year, which makes the 'rarity' of pediatric deaths seem not so rare, at least in the hospital setting.

The bulk of the article is dedicated to reviewing the frequency of multiple barriers identified by the staff. #1 - Uncertain prognosis - was not too surprising, and ties in closely with the #2 reason - Family not ready to acknowledge incurable condition. These two reasons are intimately related and are joined by the skill to adequately communicate medical information, probabilities and uncertainties, and the ability (for staff and patient/family) to hold out for hope but accept the probability of decline. Given the plasticity of children to rebound from devastating illness and trauma, and the myriad of rare congenital conditions it is understandable to see why prognosis is difficult to outline for any one patient. Just because it is difficult doesn't mean we as a field should not try to make a larger commitment to finding what prognostic factors bode for good and poor outcomes across various disease entities. And if it comes down to the clinician's prediction of survival, we need to know the accuracy, precision and biases for pediatric predictions just as much as we need to study medical predictions in adults. These two reasons also make it much easier to advocate for early concurrent palliative care involvement. But I know from talking to pediatric palliative care colleagues is they suffer from 'We're not ready for you yet, because they aren't dying." similar to adult palliative care teams.

The authors explain this well:

"We think that clinicians need to realize that uncertainty is not something to be avoided but rather is an inherent dimension of care. An uncertain prognosis should serve as a signal to initiate palliative care, rather than to avoid it, even when it is not yet appropriate to begin EOL care."
One large difference between adult & pediatric palliative care barriers highlighted is pediatric staff do not identify addiction fears, hastening death or legal action as significant or frequent obstacles. Some of these results seem discordant, for example: less concern with hastening death does not seem to fit with a large concern with an uncertain prognosis. Both have to do with the predicted timeline, and if you are uncertain where on that timeline death will occur, then by extension you may be concerned that your actions may hasten death. I do commend the researchers on using the neutral and descriptive term of 'hasten death' as opposed to the oft-confused terms euthanasia and physician assisted suicide, which we have covered here at Pallimed before.

Overall the study was well done, and had a good response rate, although it was only at one institution so hospital culture issues may exist as biases in this study.

Davies, B., Sehring, S.A., Partridge, J.C., Cooper, B.A., Hughes, A., Philp, J.C., Amidi-Nouri, A., Kramer, R.F. (2008). Barriers to Palliative Care for Children: Perceptions of Pediatric Health Care Providers.. Pediatrics, 121(2), 282-288. DOI: doi:10.1542/peds.2006-3153

2)
As fellows start looking for future jobs, it is important to understand what physician salaries are like out there. These few links provide some basic information across different specialties (not palliative care) and as you can see the variation is wide. There is currently a MGMA survey for Palliative Care physicians (via AAHPM). I went through some of the initial steps, but as you get further into the survey it looks like your billing/administration department needs to be able to answer some questions. It is a bit more complex then how much did you make, and how much does it cost to employ you. I may put some of the areas for questions in the comments section if people are interested.

Regardless most people will tell you that you probably should not be going into palliative medicine if you are expecting to make loads of money. It is a 'thinking' and talking' medical specialty after all, but there are many other tangible rewards in the work that you can do. (links from A Physician on Job Search and Practice via KevinMD)

Wednesday, February 20, 2008 by Christian Sinclair ·

Tuesday, February 19, 2008

Genetics and morphine toxicity; Prognosis articles

A rather academic post: genetics and some prognostically relevant papers.

ResearchBlogging.org1)
Cancer
has a study on genetic variations and response to morphine in cancer patients. The data comes from a prospective study of ~220 advanced cancer patients who were receiving morphine for pain. They were treated per a palliative care team's protocol and about 60 of them were rotated off morphine due to inadequate analgesia +/- intolerable side effects. This analysis compares rates of certain genetic polymorphisms between patients who 'did well' with morphine with those required rotation (it is unclear from this paper if the clinicians treating these patients were blinded to the genetic analysis or even when those analyses were done in relation to the patients rotating off morphine). They were looking at certain (known) variations in the multidrug resistance (MDR-1; it is implicated in penetration of drugs across the blood brain barrier amongst many other things) and catechol-O-methyltransferase (COMT; involved with monamine metabolism and implicated in pain modulation) genes.

Responders and switchers were were matched demographically at baseline. Before we get to the genetics the differences and similarities between the groups are worth noting. Obviously switchers reported less pain relief and more side effects and particularly drowsiness, confusion, and hallucinations were associated with switching in regression analysis. Morphine doses however were similar between groups however morphine serum levels were lower in the switchers. There were no correlations between morphine dose, analgesic response, or morphine/morphine metabolite serum levels. All of this reinforces the long-held observation that analgesia (or for that matter dose limiting side effects) don't per se have much to do with morphine dose, serum levels, etc. (The one exception here is that myoclonus was associated with total morphine level).

I'll be the first to admit here that I am not qualified to judge the genetic analysis segment of the article (please comment though if you've read the article and have the requisite background to comment intelligently on it). I think it's safe to say the results are intriguing and hypothesis generating. Essentially they found that certain COMT polymorphisms were associated with the need to switch; MDR-1 variations weren't; however certain MDR-1 variations (as well as COMT ones) were strongly associated with CNS toxicities like drowsiness, confusion, and hallucinations. A few things to note here: all switchers were changed to oxycodone and they (off-handedly) mention that most of these patients did well with the switch (suggesting that this is a morphine and not an opioid-class effect; which is not to say that oxycodone is 'better').

The astonishing individual variation in response to opioids is a fascinating thing and a clinical challenge, and maybe one day we will be able to rationalize it. One patient can be crippled (literally) by painful bone mets and fractures and have their pain well controlled with 25mcg/hr of transdermal fentanyl with a few doses of 15mg of morphine for breakthrough; the next patient with a similar clinical picture is on 5mg/hr of intravenous hydromorphone. I had a patient once who was on ~2 grams a day of oral oxycodone (with pretty good analgesia); the moment he got into the hospital and got a whiff of intravenous hydromorphone he would be delirious (and didn't get much pain relief). I am hopeful that in the next couple decades why this happens will be much clearer, and research like this (and this) will help clarify things further; it seems that pretty soon all our patients will be getting shot-gun genomic analyses anyway and maybe this will provide our profession some useful information regarding drug selection and toxicity.

Ross, J.R., Riley, J., Taegetmeyer, A.B., Sato, H., Gretton, S., du Bois, R.M., Welsh, K.I. (2008). Genetic variation and response to morphine in cancer patients. Cancer DOI: 10.1002/cncr.23292

[Cancer also has a study on symptom burden after autologous stem-cell transplants for myeloma: things get bad really fast, then get better, and pre-existing symptom burden was the best predictor of symptom burden 30 days post transplant.]

2)
Lancet Oncology has a study relevant to prognosis in pancreatic cancer. It looks at the prognostic utility of CA 19-9 response in patients with advanced pancreatic cancer (did those whose 19-9's dropped dramatically do better than those whose didn't). The data come from a prospective chemotherapy trial involving ~350 patients (~250 of whom had CA 19-9 elevations at baseline). Median overall survival was 7.7 months and which was similar between those with baseline normal and baseline elevated 19-9's. 19-9 drop, neither velocity nor magnitude, was not associated with improved survival. However, those patients whose 19-9's were above the median 19-9 level of those with elevated 19-9's had significantly worse survival (6 month 50% survival vs. ~11 months). Let me clarify that sentence: looking only at those with elevated CA 19-9's, the median elevation was 59 times the upper limit of normal (~2000U/mL); those patients whose 19-9's were higher than that median elevation had a worse prognosis (despite, intriguingly, having a similar response to chemotherapy). This was a large trial with prospectively gathered data and it is good supporting evidence that very high CA 19-9 elevations predict worse survival (average ~6 months) in pancreatic cancer.

3)
Mayo Clinic Proceedings has a small study about a single center's (the Jacksonville Mayo) experience with liver transplantation (its focus is on what happens to those patients who the transplant committee declines to list). It mentions the outcomes of those who were initially listed including the number who die while listed: 5% (the mean time to transplant was 46 days which seems really short to me). Frustratingly it doesn't mention what happened to the patients who were denied transplants due to significant comorbid medical illness.

4)
BMJ has an article relevant for long-term prognosis in stroke. It is based on data from 3 large cohort studies on the natural history of ischemic stroke in patients in the UK (involving over 7000 people; overall survival at 6 months was ~75%). This study looks at those patients who were alive at 6 months and sees if their functional status at that point predicts prognosis. Not surprisingly, it does: the most disabled patients who made it 6 months had a median survival of 2.5 years; those patients who weren't functionally dependent had a median survival about 6 years; functionally independent patients lived ~10 years. (They used Rankin Scores to define disability).

Tuesday, February 19, 2008 by Drew Rosielle MD ·

Saturday, February 16, 2008

GAO Report on end-of-Life Care; Oxycodone review; problems with Duragesic and Oxycontin

1)
End-of-Life Care: Key Components Provided by Programs in Four States is a report commission by Sen. Ron Wyden. Using descriptions from last decade’s IOM Report and a 2004 AHRQ study, as well as interviews with NHPCO and NAHC, and interviews with 10 EOL researchers, GAO identified 6 “key components” of end-of-life care.

  • Care management to coordinate and facilitate service delivery
  • Supportive services for individuals residing in noninstitutional setting
  • Pain and symptom management
  • Family & caregiver support
  • Communication among individuals, families, and program staff
  • Assistance with advance care planning

They then visited 4 states (Arizona, Florida, Oregon & Wisconsin) to determine how these key components are addressed in practice. They interviewed practitioners and administrators in PACE programs (state-administered care programs for elders supported by Medicare); similar but state-specific programs in Wisconsin & Arizona; and 12 palliative care programs of varying designs (at least 2 in each state).

Examples of the key components in practice:

  • Care management: case managers; interdisciplinary teams
  • Supportive services for patients: adult care programs; meal delivery; housekeeping services; transportation for medical care
  • Pain and symptom management: either integral part of the care model, or established referral patterns with low threshold for referral
  • Family & caregiver support: respite care; bereavement support; assistance with decision-making; in-home support
  • Communication: team meetings; integrated electronic medical records; early and/or continuous conversations with patients to ensure their wishes for care and advance planning are current; use of standard tools to assess patient condition
  • Advance care planning: an integral part of each program, usually beginning early in the relationship with patient; includes family; assist patients with completing advance directive documentation; Physician Orders for Life-Sustaining Treatment (POLST)

The two barriers (“challenges”) to delivering the services described that are highlighted in the report are trying to deliver any services in rural areas, and physician training and practices. The rural issues range from distance and poor roads to lack of pharmacies and other collaborating services, as well as lack of qualified nursing and other personnel. “Physician training and practices” will have a familiar ring: lack of training in pain & symptom management & communication skills, especially those related to EOL discussions & decisions; lack of training regarding EOL services such as hospice and palliative care [here they cite the NEJM article that Christian blogged on last year].

This is not like reading a study in a medical or nursing journal. It is intended for a lay audience (specifically, Sen. Wyden & his office), does not belabor demographics or other statistics, has no tables or charts, is quite repetitious, and is simply descriptive with no attempt at analysis or recommendations. Nonetheless, the services and issues described across these diverse states and programs are quite comparable. This makes it useful information for policy makers and legislators (as was its intent), as well as folks like newspaper editorialists, health columnists, and teachers in public health and clinical programs, especially at the undergraduate level. For those looking for something a little more meaty, the IOM and AHRQ reports cited by the GAO may be helpful. While looking for the AHRQ report, I found a more recent one by the same authors. I'm also reminded of a more recent IOM report on palliative care for cancer, and the very recent report on psychosocial care for cancer patients.

2)
There is an extensive review of oxycodone in Current Medical Research & Opinion . This is not a meta-analysis, but a pretty thorough literature review. At first I was concerned that the authors were not taking a particularly critical look at the studies they looked at, but they do indicate weaknesses in individual studies and as well as the general lack of head to head studies with other opioids. After the umpteenth clinical trial of oxycodone in one form or another (including parenteral in Europe) vs placebo, I begin to wonder why there isn’t more solid research basis for what is obviously a very effective analgesic. The article mostly focused on clinical uses; I would have liked a bit more pharmacology. Maybe not one for the teaching file, but it probably has a place in the oxycodone folder because of its very long reference list.

3)
Problems with fentanyl patches and Oxycontin

All Duragesic 25 mcg patches have been recalled, due to a leakage problem.

This one is a little less clear to me, but it seems all the generic extended release oxycodone products are no longer available. This is because Purdue Pharma won a patent infringement lawsuit. This is apparently not news to the legal crowd or the pharmaceutical industry watchers, but it has caught many clinicians unawares. There are reports of shortages of Oxycontin because of the increase in demand for the branded product. I don’t know whether 3rd party payers who mandate generics have caught up with this.


Saturday, February 16, 2008 by Thomas Quinn, APRN ·

Tuesday, February 12, 2008

Confused about DNR's in Time Magazine; NYT on Assisted Suicide

1)
This past week has had two fairly prominent major media articles focusing on significant end of life issues. In Time Magazine, Dr. Scott Haig (an orthopedic surgeon) writes about the difficulties physicians encounter when contemplating the appropriateness of Do Not Resuscitate (DNR) orders. (Or more appropriately Do Not Attempt Resuscitation, since we cannot promise any guarantees.) Dr. Haig has written a few pieces for Time before, one of which we noticed here at Pallimed about the VAS for pain being inadequate.

In this recent Time article, Dr. Haig reviews the case of an elderly Italian woman (described as spooky, wacky, cute, and vivacious) who broke a hip and required a lot of medical care before she could undergo the procedure. His description of the tricky balance of caring for geriatric patients is very accurate:

"It took a few days, many medicines and quite a few units of packed red cells to get her blood counts up to the point where she could have the hip operation safely. This is a dicey business with the very old. The transfusions put them into heart failure (the heart can't keep up with the fluid overload, which backs up into the lungs), which has to be treated with diuretics, which drop their pressure, which ruins their kidneys, which makes the heart failure worse. Pneumonia, bed sores, blood clots and dementia nip at them too, along with the paralyzing pain of the broken hip, almost from the minute they fall. It's dangerous to let hip fractures go too long pre-op — and somewhat inhumane. Ask anyone who has had one; the operation relieves a terrible pain."
The family had requested a DNR for the patient, but there was no clear evidence that she lacked medical decision making capacity, but she was inferred to be 'high-functioning', so maybe it was a language barrier that precluded direct discussion with her. Anyway that is not the point of the article, but an important one for the public in reading this, because it implies doctors and families can make these important medical decisions for' cute old people who have difficulty communicating (for any reason). Not exactly the message that provides trust in the medical community.

A important fact that is skipped over is the conflicting issue of what to do with a DNR order during an operation. In the article it sounds like they did resuscitate her:
"As we worked on the hip, her ancient heart got balky. So they gave her the same drugs and used the same electrical devices they might have used in a code. And it worked."
So did they rescind the DNR during surgery and was this done with informed consent. I would be very interested to hear from other health care professionals on their opinion on D
NR's in the OR.

If a DNR order is in place, and it will be rescinded during the time in the OR (and for that matter does it extend to the pre-op or PACU?) it is important to have that discussion with the patient/family before that happens. If someone has a cardiopulmonary arrest while undergoing a procedure does that condition change the underlying understanding of the DNR order? Most surgeons and proceduralists would say something to the effect:
"Yes, it does. If I am trying to 'fix something' and the patient arrests while I am fixing them, I have a moral imperative to do CPR, so that the patient does not die as a consequence of my actions."
But if the patient understand they may die on the OR table and is OK with that risk, could they still be DNR? Or would the surgeon/proceduralist refuse on mo
ral grounds? Or statistical grounds since this may affect their mortality rate with surgery? Do bath aides get to rescind a DNR if a patient dies during a bath? That sounds absurd but you have to extend the ethical argument to the simplest form:
While operating on/bathing/touching/talking to a patient, they cannot arrest without an attempt to resuscitate them, otherwise I am culpable in their death, regardless of their preferences of resuscitation.
That ethical conundrum happens all the time in hospitals, but is rarely discussed in an academic or patient-centered fashion.

One of the more confusing or biased sentences was this one:
"How great it would be to send her off to rehab now, close the case and blast the DNR commies to hell." (emphasis mine)
Who are these "DNR commies" of which he speaks? Is it the family who advocated for the DNR in the first place? Or is it the dreaded Palliative Care Team with 'Dr. Greg Reaper', and Nurse Mel Anne Coley' who spent 90 minutes with the patient and family talking about what their goals are? If someone can point out the "DNR Commies", let me know who they are. You might be able to identify "DNR Commies" by their obvious use of symbols. Instead of a Hammer & Sickle they have a Defib Paddle and a ET tube.

After the surgery she had complications, and the family put limits on the amount of aggressive care to pursue and she ultimately died. Dr. Haig recounts the phone call from the night nurse and then reflects on the actions and events that before her death.
"A waste of effort, of time, money and blood is how many in my medical community would have described our dealings with Carmela over those three weeks."
The author is probably being a bit pessimistic about health care, as I think many in the medical community would actually say that he and the other doctors tried to do what they could given the goals set by the family (and presumably the patient). Aggressive but not too aggressive is an option, and shows good doctor-patient-family communication over goals. Compromise is not always a bad word.

The last paragraph left me flummoxed.
"But was it the DNR that killed her? Indirectly, maybe. I think it was realizing that her daughters planned to withhold care that made her give up."
Followed by:
"An old teacher of mine explained it this way: "I will neither give a deadly drug nor will I make a suggestion to this effect.""
Now he is mixing metaphors; Withholding, euthanasia, and physician-assisted suicide are all implied in this last paragraph, leaving the reader more confused. While I think this is an important topic, I am surprised it came out so ethically and emotionally confused. Maybe that was the point of the article, is that dealing with death in medicine is awkward and confusing for many.

Luckily for Pallimed Readers we have an upcoming interview with Dr. Pauline Chen, the author of FINAL EXAM: A Surgeon's Reflection on Mortality (now out in paperback). So look for that in the next few posts, and if you have read the book (or not) and have any questions for her, feel free to email me at ctsinclair @t g.m.a.i.l d0t c0m.

2)
Jane Brody, health columnist in the New York Times, made a personal appeal to encourage readers to look closer at the underlying issues of requests for hastened death in dying patients. She presents personal anecdotes and is fairly balanced on the issue, but leans more towards considering legalizing PAS. She does highlight Dr. Timothy Quill's 2004 NEJM article on helping his own father die (subscription req'd). For newer people to palliative care, Quills article is an important one to read if you have not yet already. As palliative care practitioners we are asked about hastened death by patients and families all the time, and given that it is only legal in Oregon (PAS only), we must understand how to respond compassionately to these requests, understand their root causes, and practice within the full scope of our legal guidelines.

Medicare Hospice Cut?
Hospice Guy at Hospice Blog has a good review post about the "cut" in the expected hospice reimbursement for the Medicare Hospice Benefit in the President's proposed budget. His final take is don't get too riled up about it.

ECMO Prognosis
ECMO survival is hard to predict, but do note the high 30-day mortality rate of 37.5% in this study which looked at possible prognostic factors for survival on ECMO. The researchers did not find any, but they did get 80 patients. Unfortunately it took 16 years to get that many, so I don't expect to hear much about prognosis in ECMO for some time given the difficult accrual numbers.

Nude Hospice Calendar
Some hospice patients are so dedicated to raising money for their hospice in the UK that they are planning a "tastefully done" nude calendar. (via mental floss and Wigan Today) Wigan and Leigh Hospice seems to be a pretty progressive hospice seeing as how they also have a Hospice Real Ale made for them by a local brewer, and are the charity of choice for a local Starbucks. Good development department there!

"DNR Commie" Image Created by Christian Sinclair

Tuesday, February 12, 2008 by Christian Sinclair ·

Monday, February 11, 2008

The 'Imminence Condition'; PHN; More

1)
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.
2)
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.
3)
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."

4)
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.

5)
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).

Monday, February 11, 2008 by Drew Rosielle MD ·

Thursday, February 7, 2008

Symptoms in dying LTC patients; More

Too many items noted too briefly:

1)
A few from the Journal of the American Geriatrics Society:

  • First is a paper looking at the symptom experience of dying long-term care residents. This was a multi-institutional study involving interviews of family and staff caregivers of deceased LTC residents (~670 patients, mean age 85 years, most cognitively impaired). Pain and dyspnea were significant in about half the patients prior to death: and significantly while almost all patients had meds for pain about a third had none for dyspnea. The most commonly reported symptoms were issues surrounding cleanliness. From a research perspective, this paper found pretty good agreement between staff and family caregivers about symptoms (in fact, they found generally better agreement between these groups than other research has found between patients themselves and family caregivers). (Thanks to Dr. Robert Arnold for alerting us to this article.)
  • A related article (same data set as above) is a brief report on pain, dyspnea, and perceived quality of dying in LTC residents. Caregiver related quality of dying was compared between patients with and without pain and with and without dyspnea. Presence of pain had no bearing on caregiver rated quality of dying; increasing dyspnea actually was associated with better quality. Weirdly, low dyspnea and severe dyspnea were related to better quality of dying; 'medium' dyspnea wasn't, which makes one wonder whether these results are picking up a lot of noise. One also wonders what the severely dyspneic patients themselves would say about the 'quality of their dying.' Authors' conclusion: "These findings suggest the need to look beyond physical symptoms to understand the quality of dying," which seems pretty reasonable. I still haven't figured out what QOL actually means (besides whatever a patient says it is) and don't know how to begin to conceive what the bereaved's reporting of 'QOD' actually signifies.
  • Third is another mortality follow-back study looking at the impact of palliative care consultation on many care outcomes/family satisfaction. This one involved interviewing caregivers of deceased veterans who had received care at a VA; after multiple adjustments family satisfaction/perceptions of care quality were compared between those vets who received palliative care consultation and those who didn't. PC consultation was associated with better outcomes in most domains (satisfaction with communication, pain, well-being/dignity, etc.). They also looked at the role of earlier consultation and didn't find that that seemed to make much difference in satisfaction.
  • Finally is a small but intriguing study of methylphenidate to prevent falls. It's actually a small, placebo controlled trial looking at the effect of a single dose of methylphenidate or placebo on certain fall-risk tests (e.g. the timed up and go test) in 26 elderly subjects. Methylphenidate significantly improved one (out of 4) of the 'fall-risk tests' (by a small amount) and not much else. Despite the positive spin on this in the abstract this modest finding does not seem promising that methylphenidate will have any salutary effects on fall risk in this population.
2)
BMJ has a study providing some generic prognostic information about dementia. The data come from a large, population based study in the UK in which ~13,000 patients were interviewed every 2 years for 14 years and, among other things, were given dementia screens (mini mental state exam among others; they note that a 'validated algorithm' was used to diagnose dementia). The relative novelty of this study was that they could pick up on incident dementia (they identified 438 cases of incident dementia), in real time so to speak, and thus hopefully get a more accurate assessment of survival. Median age of onset of dementia was 84 years and survival was 4.6 years for women & 4.1 for men. As expected, age predicted survival: women less than 70 years had a median survival of 7.5 years; men over 90 had a median survival of 3.4 years. Male sex and functional status were also predictive of survival. Of note these findings probably overestimate survival (a little) as those patients who developed dementia and then died before their next interview were not counted.

3)
A couple from the Clinical Journal of Pain:
  • A pre-clinical, proof-of-principle, trial of mirtazapine for pain. Pre-clinical insofar as it involved inflicting pain on healthy volunteers (given 30mg of mirtazapine or placebo) and then seeing if there was any difference in those who received the active drug. There was, with increased tolerance to painful stimuli in the mirtazapine group, although maybe they were just experiencing a deep sense of contentment and peace... We'll see where this leads: most of the neuropathic pain I treat is cancer-related and I'll just throw out the observation that I haven't found antidepressants (of any subclass) to be routinely or convincingly effective for most patients.
  • The second is one on geographic variations in opioid availability. It is based on a survey (60% response rate) of opioid availability in outpatient pharmacies in Washington state. Notable findings: 1) more pharmacies stocked meperidine than hydromorphone, 2) most pharmacies stocked most available opioids (unlike in similar studies in other areas), 3) however in multivariate analysis not stocking opioids was associated with being in a zip code with a higher non-white resident percentage (this was a small, but statistically significant association).
4)
Health and Quality of Life Outcomes has a study on changes in quality of life as death approaches (free full-text here). It uses data taken from a study done in the Seattle area using complementary therapies in those with short prognoses (most in hospice) and uses some of the most maddeningly complex data manipulations I've seen for a long time. Ok, it's not the most complex, but it struck me as unnecessarily complex; this may be frank ignorance on my part and if someone smarter than me reads the article and can tell me why they did the data manipulations they did I would genuinely appreciate it. (To be fair, this was one of those articles which was as much about demonstrating the feasibility of its methods as it was about its actual results: i.e. it's written as much for biostatisticians as anyone). Anyway, their major finding, looking at QOL in the 10 weeks prior to death, is that most people rated their's good for most of those weeks, but with a rapid drop off in the last 3 prior to death, which fits my gestalt about what happens with many people. (Their QOL measure was a simple, one-item, "rate your quality of life on a 10 point scale" measure).

5)
Supportive Care in Cancer has a systematic review on the treatment of dyspnea in cancer patients. Good one for the teaching file and a nice reference list for every trial imaginable on the topic. It downplays the results of this trial, which actually changed my practice a bit (I have begun adding benzodiazepines as adjuncts for dyspnea not immediately responding to opioids), which I found interesting (the abstract implies that there's no support for using benzos for dyspnea; my reading of this trial is that they are effective adjuncts to opioids).

Thursday, February 7, 2008 by Drew Rosielle MD ·

Monday, February 4, 2008

Back From the AAHPM /HPNA in Tampa

Drew and I appreciate all of the wonderful feedback we received while in Tampa at the AAHPM/HPNA Annual Assembly last week. Thanks to all the readers who proudly wore the "P" sticker and who came to Backjack's to meet with other Pallimed readers. It was good to match faces to names. If I missed you there or didn't have much time to chat, I apologize. For being there less then 24 hours it was quite an exhausting pace.

We heard a lot of interesting comments about the conference as well. I wished I could have made it to more than just the Case Conferences on Saturday (which were great BTW). So to make up for all of my lengthy posts about what I thought were interesting talks, I would like to turn the rest of the post over to the readers.

Please comment on the talks that you thought were remarkable or avoidable or what would you like to see next year, etc. Remember we are not an official part of AAHPM/HPNA, but just wanted to open some discussion about what Pallimed readers thought was important. (And if this is your first time to Pallimed, welcome!)

Monday, February 4, 2008 by Christian Sinclair ·

Race and hospice revocation; COPD; Nabilone for pain; Much more

This is my first post for a couple weeks and I have amassed a large backlog so my next few ones will likely focus on a single article and then mention others only in passing.

Thanks for everyone who said Hi in Tampa, or who came to the happy hour (M. sorry about the loud music - it's too bad Wham! is not your cup of tea). Tom Q - we missed you.

A quick note about the Blogging on Peer-Reviewed Research and Research Blogging system that we have alluded to before. The Research Blogging website is now officially up and running. It is, among other things, an aggregator of all blog posts by bloggers who use the BPR3 standards - it's an organized attempt to promote 'serious' academic blogging & we are hopeful it will be successful.

ResearchBlogging.org1)
Archives of Internal Medicine has published a fascinating article about race and hospice revocation to pursue 'aggressive' care. It is a retrospective analysis of data from a multi-state hospice group and compares characteristics of white patients who revoked their hospice enrollment to pursue aggressive care (the hospice agency prospectively gathered data on reason for hospice revocation at the time of discharge).

In some ways, simply the epidemiologic data are interesting: over 5 years 167,000 patients were discharged alive and only 2.8% of these were to pursue aggressive care, a median of 22 days after enrollment. This is, then, a rare event. African-American patients were more likely to disenroll to pursue life prolonging care (4.5% vs. 2.5% of whites), and this difference survived controlling for age, income, diagnosis, and other demographic variables. Length of stay, age under 65 years, non-cancer diagnosis, and not having an identified caregiver were also associated with revocation to pursue life-prolonging care.

What I found most notable was the 1 year survival amongst those who revoked hospice to pursue life-prolonging care: 48% (for both African-American and white patients). Those who died after revocation did so relatively quickly (~40 days), but almost half were alive at the end of a year. The authors note that those 40 days of survival are only a couple weeks longer than median survival in hospice, suggesting that those who died probably didn't have their lives prolonged much by revoking hospice. The relatively long survival of the others suggest that the decision to enroll in hospice was wrong (at least from a prognostic perspective). This data may be out there, but I know of no other good study looking at long-term outcomes for those who voluntarily revoke their hospice benefit. Of course, there are other important outcomes than 1 year survival, and we don't know what those years looked like, but that's for another study.

The authors discussed possibilities as to why African-Americans may revoke hospice care more than whites (and thankfully avoid pathologizing these decisions as due to 'mistrust' which implies a sort of irrationality). They do propose this explanation, which is pure speculation, but quite novel I thought:

"However, because African American patients are less likely to participate in advance care planning, they may spend less time thinking about or discussing their preferences for end-of-life care before enrolling in hospice. Because hospice care facilitates advance care planning, hospice enrollment may provide African American patients with the opportunity to solidify and discuss their treatment preferences. When these preferences conflict with the hospice philosophy of care, they may withdraw from hospice."

Johnson, K.S. (2008). Racial Differences in Hospice Revocation to Pursue Aggressive Care. Archives of Internal Medicine, 168(2), 218-224.

2)
Clinics in Chest Medicine recently had a review on 'end of life considerations' for chronic lung disease (mostly COPD). It's a general overview, well written, and notable for its very practical, straight-forward discussion of end of life communication towards its end. It is quite matter of fact about things, and directly addresses physicians' own discomfort in discussing death and dying (something that is often missing from such discussions; it's great to see this in a journal like this). This paragraph was also appreciated:

"Frequently, part of the decision for patients with lung disease is whether they want to receive CPR in the event of cardiac arrest. In our opinion, in helping patients make this decision, it is important that advanced cardiac life support not be broken into components but rather presented as a package. Breaking advanced cardiac life support into components (chest compressions, antiarrhythmic drugs, vasopressor agents, intubation) makes these decisions unnecessarily complex and can lead to an absurd resuscitation status, such as compressions and all drugs but no intubation."

3)
BMJ has a trial of a cannabinoid vs. an opioid for chronic neuropathic pain. It is a randomized, blinded, placebo controlled cross-over trial which compares nabilone (a synthetic cannabinoid) with dihydrocodeine (an opioid unavailable in the US about which I know little). Each patient was randomized to 6 weeks of the study drug and then crossed over to the other drug after a 2 week washout; patients could go through a dose titration protocol for each drug as needed for pain control. Both groups had lots of drop outs and the authors present per protocol analyses mostly. Dihidrocodeine did a little better than nabilone, although frankly both come off as crummy analgesics (few in either group achieved a 1 point drop in their pain on a 0-10 scale). Not a great endorsement of either cannabinoids or weak opioids for neuropathic pain.

4)
Very briefly:

  • Social Science & Medicine has a recent article about hospice & Medicare cost savings (it's a case control study and tries to establish what is the ideal length of time for someone to stay in hospice, from a Medicare cost savings standpoint - the answer, thankfully, is much longer than the median hospice stay).
  • JAMA recently had a commentary about definitions of disability. It was placed in the context of an 'impending wave' of population disability. There was something in the way the authors discussed how disability is conceptualized and medicalized which seemed, to me, consonant with how death is medicalized. I'm not suggesting this is a perfect analogy, at all, but thought I'd throw it out for the more anthropologically minded reader. See here:
    • "By the late 19th century, the medical model of disability was firmly entrenched. "The medical model views disability as a problem of the person, directly caused by disease, trauma or other health condition. . . . Management of the disability is aimed at cure or the individual's adjustment and behaviour change. Medical care is viewed as the main issue." The medical model thus built upon 2 assumptions: first, that individuals should strive, largely through their own efforts guided by physicians, to overcome disabilities; and second, that physicians know what is best for patients. Both assumptions often made disability a lonely state—defined and frequently stigmatized by others, with individuals required to "cheerfully and unselfconsciously" make their own "good adjustment."
  • Radio Lab, a public radio show which is usually about science, thought, and Big Ideas, recently put out a podcast about music written for a morgue of sorts (a viewing chamber at a hospital for the family to see the recently deceased). You can listen/download here.

by Drew Rosielle MD ·

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