Wednesday, June 10, 2009

Pall-Pourri: Video ACP, Palliative Sedation, & More

BMJ has published a randomized controlled trial of a video-based decision support tool for advance care planning in dementia (related to this trial we blogged on a couple years ago; see also here). The video used is available in the free-full-text version on the BMJ website. This study invovled older patients who were randomized to a narrative description of advanced dementia vs. a video depicting a patient with AD, and asking subjects what sort of care they'd want. This is similar to the prior study but this study uses a separate control group (the prior one compared subjects' responses before and after seeing the video). As in the prior study, after seeing the video, the vast majority of subjects reported they'd prefer comfort-only measures and no life-prolonging treatments (86%, vs 64% in the written group). The video group's knowledge of dementia was better afterwards, and their treatment preferences were more durable (didn't change over time) compared with the written group.

This research is quite compelling: very simple and elegant in its design and execution, with compelling results. I am curious as to how it will be received in the general community (I guess I mean in primary care clinics where presumably this ACP should be happening) and if it will change anything, or if there are plans to bring this sort of ACP to the masses (e.g. public education campaigns, etc.). I don't do a lot of ACP for dementia (I get consulted on patients after they have dementia and family members are struggling with decisions) but do do a lot of 'ACP' about, for instance, CPR and it looks like Angelo Volandes (the doc primarily behind most of this research) is working on that very thing: I'm very much looking forward to the videos and what the research shows about their impact.

The same BMJ issue has another part in the series I mentioned before on prognostic research: this one is on validating prognostic models, which is a relevant topic for Pallimed readers as we frequently discuss research on prognostic models and wonder how one can really judge their clinical relevance.

There's also a fascinating speculative article for pharmacology wonks out there and the generally curious about how psychiatric drugs work. I do not know if what the authors propose is 'correct' however it's always good to have one's paradigm's challenged. The core of their argument is as such:

An alternative, drug centred model of drug action, stresses that psychiatric drugs are, first and foremost, psychoactive drugs. They induce complex, varied, often unpredictable physical and mental states that patients typically experience as global, rather than distinct therapeutic effects and side effects. Drugs may be useful because some altered states can suppress the manifestations of certain mental disorders. The disease centred model of drug action developed in the 1950s and 1960s and replaced a drug centred understanding of how psychiatric drugs worked. For example, the early investigators of neuroleptic or antipsychotic drugs suggested that they worked by inducing a neurological syndrome consisting of physical restriction and mental symptoms such as cognitive slowing, apathy, and emotional flattening, which resembled Parkinson’s disease. These effects also reduced the intensity of psychotic symptoms. Thus, extrapyramidal effects, and their conjoined mental effects, were not regarded as side effects but as the mechanism by which the drugs produced their intended outcome.
Lancet Oncology has a wonkish discussion of 'palliative sedation.' It's a somewhat searching, philosophical (literally: discusses personhood in the context of Descartes, Locke, Kant, and others), and meandering walk through the ethical controversies surrounding PS (they call it 'deep and continuous palliative sedation' when referring to the practice of deliberately pharmacologically inducing a coma with the intention of maintaining a patient in it until death in order to relieve intractable suffering). A lot of it focuses on the question of if inducing a coma extinguishes thought, does it therefore extinguish self-hood/person-hood, and if there's no intention of lightening the coma, is not one then 'killing' a person, and so is PS just a form of (or philosophically/morally equivalent to) euthanasia? Yes, I said it's wonkish, and while I don't think these Big Ideas are meaningless (and frankly enjoy thinking about them), and probably become more relevant the further PS gets away from a strategy to treat intractable somatic symptoms in otherwise dying patients, I also struggle with where the 'fancy' ideas get us.

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