Friday, February 6, 2009

Pall-Pourri

1)
Journal of Clinical Oncology
has a 'phase II' study of an outpatient palliative care clinic in a Canadian cancer center. It is a prospective observational study of ~150 adult cancer outpatients who were referred to a palliative care clinic and received a comprehensive consultation (90 to 120 minutes; seen by both a nurse case manager and physician as well as at times a social worker and psychiatrist). Baseline, 1 week, and 1 month symptoms and patient satisfaction were measured. This is an uncontrolled observational study of course, and it's impossible to ascribe any changes due to the interactions with the palliative care team, but it provides some interesting natural history data which could provide baseline for further studies. Grossly speaking, most symptoms improved ~10% (across the cohort, there was an average improvement of ~1 point on a 0-10 point symptom scale for most symptoms) at 1 week and month. An accompanying editorial contextualizes the research better than I could.

2)
In a similar vein, Cancer has a descriptive series characterizing ICU patients (at a US cancer center) who receive palliative care consultation. It's an interesting read to see what another team does, at another institution, and to just get a sense of who these patients are - they are quite sick, with a high mortality over 50% in-ICU death rate, and seen by palliative care late (average of 10th day of ICU stay, with mean overall ICU length of stay of 16 days). 'Late' here is meant descriptively, not necessarily as a judgment.

3)
The NEJM continues the discussion about the risk of sudden death with typical and atypical antipsychotics with a retrospective case-control analysis again demonstrating an increased risk of death for patients receiving those agents. An accompanying editorial floats the idea of not only maybe people should be using these less but that there should be outright restrictions on their use (comparing this to the monitoring that happens with clozapine for agranulocytosis, particularly given that the risk of sudden cardiac death seems to be a lot higher than the hematologic risks associated with clozapine) for off-label and 'non-evidence based' uses. I don't know if this is a good idea or not; however it would seem to make the impetus for expanding the evidence-base for antipsychotics for the acute/short-term management of delirium more acute.

4)
Annals of Internal Medicine has a sobering analysis of allocating 'life support' resources (ventilators) during a public health emergency. While wonkish, it's very readable, and given the stakes if something like this ever happened I read it with fascination. Their overall argument that neither age, nor comorbidity, nor likelihood of short-term survival alone should decide how the resources are used (all of which have been proposed at times) - they should all be incorporated. Who actually makes those decisions during a crisis, of course, is another story. If this happens, palliative care professionals will be finding ourselves caring for patients excluded from life-prolonging treatments, and are widely mentioned in planning documents (see this from the feds).

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