Tuesday, August 10, 2010

A few items: PC in ED, delirium prognosis, pneumonia & comfort

A few items about palliative care in the ED, prognosis of delirium, and whether antibiotics improve symptoms in pneumonia.  See below the fold.  I'm traveling next week, so probably won't blog again myself until later on in August.  Summer, ugh, is rapidly fading....

Joanne Kenen from the New Health Dialog blog (a health policy blog which frequently discusses palliative and end of life care issues) published a piece recently in Slate about efforts to improve prognostication and goal setting in the emergency department.   (It's provocatively subtitled 'How to tell emergency room patients they are dying.')  The piece combines real patient stories (following Tammie Quest from the EPEC-EM project) and gives a good sense of what ED clinicians are up against as they encounter acutely ill, terminally ill patients who are often unprepared to talk about what's really going on.  This is an issue which is rarely spoken about in the general media.

JAMA has a meta-analysis looking at the long-term outcomes of delirium in older patients.  They are 'poor' to be sure: higher risk of death, institutionalization, permanent cognitive impairment.  It's a relatively involved meta-analysis and I'll leave the details for those of you who follow these things closely - it'd be a good starting point though for anyone looking to do a literature review on the topic.  Most of the studies were from the last 10 years, affirming the observation we've made on the blog that the prognosis of delirium in older patients has been the stubject of extensive investigation recently.  Unfortunately, the prevention and treatment of delirium have received less scrutiny. 

Archives of Internal Medicine  last month had a paper which I regret neglecting to blog about, as well as the short space I'm giving it now.  It is an attempt to look at if antimicrobial therapy is associated with decreased symptom burden in nursing home patients with advanced dementia and pneumonia.   This is probably the best study ever done to try to answer this question; that said, it's a bugger of a question to try to answer with any sort of rigor, and while this paper provides some support to the idea that antibiotics aren't needed to ensure symptom control, one can't conclude we've closed the book on the question.  The data come from a large, prospective, regional study of nursing home residents with advanced dementia.  Data about symptoms were, however, collected by proxy reporting and after the fact (using standardized questionairres filled out by nurses, etc.).  So, while this is a prospective data set, it's important to recognize there wasn't anyone there, at the bedside, prospectively gathering symptom data during these episodes of pneumonia.  It's also important to know that most of the patients who did not receive antimicrobials did not die immediately and the study is not comparing, for the most part, nurses recollections of symptom control for patients who were imminently dying with 'comfort' orders vs. those who were expected to live.  Anyway: comfort/symptoms were not reported to be better controlled with antimicrobials than without, although receiving antimicrobials was associated with longer survival. 

For me, this just reinforces the idea that antibiotics for pneumonia for symptom control (in advanced dementia patients) is just simply the wrong conversation to be having.  The real question comes down to whether a patient would want their life prolonged medically in their current condition, and with their prognosis.

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