Thursday, January 29, 2009
The American Journal of Surgery has an interesting read - a qualitative look at medical student 'moral distress.' (Moral distress defined here as 'the negative feelings that arise when an individual believes he or she knows the morally correct response to a situation, but cannot act because of hierarchical or institutional constraints.) It looks at case summaries written by 3rd year medical students and analyzes them for themes surrounding descriptions of moral distress. Issues surrounding death, dying, hope, communication are a distinct part of the discussion. Some of the wisdom of these students is impressive. One wrote, 'But my observation was that more desperately than their need for answers was their need for kindness. And while we may not have had the ability to provide the answer, we certainly had the ability to provide the kindness.'
Thanks to Dr. David Weissman for alerting me to this.
Age and Ageing has a systematic review on the natural history and prognosis of persistent delirium in older hospitalized patients. It adds to the literature on persistent delirium (see related post here) as a major marker of morbidity and early death in older patients. The data here are hampered of course by differences in definitions of delirium, follow-up, etc., and I wouldn't put a huge amount of stock in the actual numbers presented, but the finding that persistent delirium is a poor long-term prognostic sign seems irrefutable. Most interesting to me were the handful of studies which followed patients for multiple months suggesting that many older patients (mean age in these studies was in the early 80s) who are delirious during a hospital stay remain permanently cognitively altered afterwards (the way they define delirium here I hesitate to say they remain 'delirious' as opposed to permanently cognitively impaired, as well as there's a decent amount of variation in the studies between patients who presented delirious vs. those who develop it while hospitalized, as well as the data aren't broken down by who had dementia at baseline). Anyway - a few of the studies which followed patients for 6 months found a substantial minority (~10-30%) remain altered at 6 months. Yikes.
Thanks to Dr. Bob Arnold for alerting me to this.
Pain Treatment Topics (a free, online collection of original publications - often very practical/clinically-oriented papers - along with other resources to do with all things pain), recently published a hard-look at what is known and not-known about the prevalence of opioid-abuse in patients receiving prescribed opioids for chronic pain (free pdf here - page 6), concluding more or less that what research is out there does not support the idea that prescribed opioids cause addiction or that opioid-abuse is inordinately common in these patients. Of course, and unfortunately, none of the research is definitive, but I think this is a good counter to publications such as this one in a highly influential journal: read the abstract (or the full article) which to the casual reader suggests a world of badness and then read my post about what the article actually says about abuse/addiction and chronic opioid therapy. No doubt that abuse/addiction is a problem in patients with chronic pain, but how much of a problem is not yet even well-defined, let alone the role of prescribed opioids in causing/maintaining the problem.
Image is a thumbnail from Pain Treatment Topics 'pain art' page.
There's a new health policy blog out there which has been covering hospice and end of life issues quite well: Health Beat at http://www.healthbeatblog.org. Check out these recent posts about for-profit hospices and the new MedPac proposals to decrease hospice payments for a patient the longer they are enrolled.
Thanks, again, to David Weissman for letting us know about this.