Thursday, January 28, 2010

Outpatient rotations to methadone

Cancer has published a paper about rotation to methadone in the outpatient setting for cancer pain. It's a notable paper because very little has been published about this practice (although I think it's widespread in the hospice and palliative care world) - most of the published reports (mostly case series/retrospective chart reviews) have been in inpatients, where close monitoring for safety (and efficacy) can occur. So, while people are doing it, there hasn't been much support in the research literature about, at the very least, the safety of this practice.

This study is a retrospective chart review of a single center's (MD Anderson) experience with this. The paper includes data about patients initiated on methadone (as the first strong opioid), but I'll focus on the rotation data here. The patients (N=89, mean age 58, median baseline oral morphine equivalent daily dose [MEDD] of 100 mg) were rotated to methadone as outpatients, and had median first follow up at 13 days, and second at 37 days. The rotation protocol is not specified in great detail (and they imply there is not a set protocol for this group - instead more of general parameters that are adjusted based on the physician's discretion). It seems generally a start/stop strategy (discontinue prior opioids, initiate methadone the same day) was used. Morphine to methadone ratios that were used were 5:1 for MEDD less than 90 mg/day; 8:1 for 91 to 300 mg/day; and 12:1 for MEDDs over 301 mg/day. What is done with the breakthrough medication is not specified. It's important to note that the range of baseline MEDD was 60-185 mg: these patients were being rotated to methadone at moderate morphine doses, not once patients were taking many hundreds (or thousands) of mg a day.

This was a retrospective chart review, of one group's real-life practice, and the criteria for evaluating the reason for rotation to methadone, as well as its success, were based on the research team's best efforts at abstracting from chart data. They tried to identify why patients were rotated (inadequate analgesia, non-methadone opioid side effects, or both) and then if the rotation was successful upon follow-up (pain improvement greater than 30% or 2/10 on a 11-point rating scale, reduction in the side effects which prompted the rotation, etc.). If these targets were clearly met the rotation was labeled as success; if the methadone was discontinued, the patient was admitted to the hospital for pain or methadone related side effects, or if the patient was lost to follow-up, the rotation was labeled a failure. Everything else was labeled a 'partial success' (indicating, at least, the patient tolerated the rotation adequately to continue methadone and not be admitted with side effects).

The major data on success were positive: 47% had a 'complete success', 38% a partial success, and 15% a 'failure.'*** The best rates of success were for patients rotated only for side effects, although this was only 5 patients. Median methadone doses were 15 mg/day at the first follow up and 18 mg/day at the 2nd. They did plot baseline MEDD with stable methadone dose, and confirmed the previous findings that baseline MEDD is associated with MEDD:methadone ratio (e.g. the higher the baseline MEDD, the higher the ratio, and the lower relative amount of methadone patients need). And in fact the median MEDD:methadone ratio they identified after patients were stable were 5:1 and 8:1 for MEDDs less than 90, and greater than 90 mg daily, respectively (which is of course their conversion ratio, suggesting that these are in fact reasonable ratios for patients with MEDDs less than 200 mg).

Most interesting is that they calculated MEDD:methadone ratios for patients who were rotated for pain vs. those rotated for side effects (with or without pain). In the 'side effect' patients the MEDD:methadone ratio was 9:1, and 6:1 for the 'pain' patients (ie the 'side effect' patients needed less methadone, relative to their baseline opioid dose, than the 'pain' patients).

In discussing the failures, they indicate these were due to non-efficacy, and don't discuss any toxicities.

All of this is good, and represents some of the first data (with a decent N for a study of this type) supporting the safety of outpatient methadone rotations for pain. I doubt a prospective study (even just a natural history one, with modest outcomes of safety at one month) is coming anytime soon. It's confirmatory of the broad trend in previously published chart reviews that methadone rotations are usually (for over 3/4 patients) helpful, although rigorously controlling for the reason for methadone rotation has never occurred and all the data we have is essentially descriptive and based on real-life clinician practice (which has both benefits and drawbacks in interpreting this).

The major caveat here is that this is for patients on moderate MEDDs - less than 200 mg a day. One cannot conclude from this that the practice is safe/advisable for patients on significantly higher doses (ie in the 500 mg and up range). Which raises the question of whether we should routinely be rotating patients to methadone once they're on, say, MEDDs of 100 mg or more, and who have uncontrolled pain or side effects. This research suggests only, of course, that the rotation to methadone in this setting can be successful, not that the patient was better off for it (as opposed to continuing up-titration of the prior opioid assuming the rotation wasn't for side effects, or rotating to a different opioid such as fentanyl). Trying to answer this in a trial would be difficult, but not impossible, and you do kind of wish there was a methadone lobby to support such research. My guess is that there's a wide variation of practice out there, and I'd be curious as to what others do - when, why you switch to methadone - a simple mg cut off (ie propose it to a patient once they're at a certain MEDD regardless of how they're doing) or later? I tend to do it later, but am not convinced that is best: we have no data either way.

(***Addendum Jan 29, 2010: I had originally put in incorrect numbers for the % of complete or partial successes for the rotation; a commenter pointed this out and I've changed the numbers here for posterity. See the comments.)

Thursday, January 28, 2010 by Drew Rosielle MD ·

'First is the widespread and deeply held desire not to be dead...'

It looks like JAMA has closed their series 'Perspectives on Care at the Close of Life,' which we covered extensively the last year, and started a new one 'Care of the Aging Patient.' There have already been two so far, but in addition this week's issue has a 'Clinician's Corner' piece about a patient with cardiac cachexia and hospice care. Thus, a JAMA update today.

1)
First, the Clinician's Corner piece. The case begins succinctly: Mrs H is an 86-year-old retired health care professional and grandmother with severe cardiac cachexia. She is considering the best way to have her life end. The case goes on to describe a patient with advanced heart failure, slowly progressive functional decline, and multiple comorbidities, who considers her current quality of life marginal (ok now, but very worried it will be intolerable if things get any worse), and is making statements about wanting her life to end (although is not overtly suicidal). With the brief case discussion, which includes quotes from the patient herself, you really get to know and feel for this patient:

I’m still doing things and I still enjoy life, but I’m taking so many medicines, and each year I’m a little worse. I’m very afraid that I’m going to be incapable of doing anything—I had a grandfather who used to say, "Why doesn't God take me?" Well, my feeling is "Why doesn't my heart stop beating because it's in such bad shape?" I used to think when I got depressed that I could go and throw myself off the top of the building. Now I couldn't even get there.
I talked with my doctor about the fact that I was interested in the end of life and that I was thinking about discontinuing all my food and liquids and all my medicines, including my insulin. She told me that if I stopped taking insulin I might have a very high blood glucose. My experience with high blood glucose was that I got very, very thirsty. And when I thought about it, I thought, "Well, that means I would die of thirst." I realized that didn't appeal to me.
Her physician recommends a hospice referral. The following wide-ranging discussion is about US end of life demographics and hospice utilization, prognostication in CHF, causes and epidemiology of requests for hastened death, and how palliative care consultation and hospice care could potentially help this patient. Voluntary cessation of eating and drinking is also discussed. Overall it's a balanced, realistic look at the issues, including a description of how hospice and palliative care services can help patients like this, and the article would make a good one for the teaching file, particularly for med students and residents.

2)
The first 'Aging Patient' piece is a look at care in the last years of life, and presents an approach to care for aging patients with potentially years to live - health maintenance, prevention, care coordination, etc. The 2nd 'Aging Patient' review is about falls, a problem very relevant for our field. Good reviews both: for those of us who didn't do geriatrics training, a nice refresher.

4)
And finally, a recent issue had an editorial about advance care planning, 'death panels,' and why ACP just is not finding widespread acceptance by the public. Good editorial, but what really made my night was its citation of a 1999 editorial about a SUPPORT study analysis which discusses in terms which are equally valid now as then as to why this is so difficult. I'm showing my age (youth) here by never having read this before, but it's worth reading, and probably should go into the must-read file for fellows. Most of the editorial unpacks the ideas in this paragraph:
For most patients, 2 fundamental facts ensure that the transition to death will remain difficult. First is the widespread and deeply held desire not to be dead. This is not only existential angst, or the dread of ultimate insignificance, it is also the struggle to avoid annihilation. Second is medicine's inability to predict the future, and to give patients a precise, reliable prognosis about when death will come. When death is the alternative, many patients who have only a small amount of hope will pay a high price to continue the struggle. Several other factors, such as certain societal values or family dynamics, also may make it difficult for a patient to make the transition to dying.

by Drew Rosielle MD ·

Morphine Concentrated Liquid Receives FDA Approval

:Original raster version: :Image:Food and Drug...Image via Wikipedia
The FDA has approved Roxane Laboratories to make concentrated (20mg/ml) morphine liquid for the administration in opioid tolerant patients with moderate to severe acute and chronic pain. 

Others have covered this story including GeriPal, NHPCO (Member-protected link - Why?), and CAPC.  Obviously the hospice and palliative care online communities are welcoming this news given liquid concentrated morphine is an essential tool in good symptom control, especially for patients in the last few weeks of life when swallowing becomes more difficult.

Interestingly, the FDA Press Release says at the end:
"For this formulation of morphine, the manufacturer had to develop a safety program prior to approval to address the known risks of morphine misuse, abuse and overdose."

But there is no link on the FDA site or Roxane to give more information about the safety program.  Given the past concerns about REMS, it would be interesting to see the details of these plans and how they might impact daily hospice care.

And for how the FDA actually reversed course from nearly taking concentrated liquid morphine off the market, you Pallimed readers along with other social media platforms were part of the grass roots support that helped give support to the larger organizations. 


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by Christian Sinclair ·

Tuesday, January 26, 2010

Historical Pallimed: January 2006

Now that Pallimed is embarking on the 5th calendar year of existence, we thought it would provide a good opportunity to look back at some of the older blog posts. This will be a monthly column and for the first month we will look at January of 2006. Back when it was at pallimed.blogspot.com. Back when the colors were blue and sea foam green. Back when Twitter did not exist (March 2006 for you trivia hounds). Back when the only people reading were Drew and me. Well to be honest I was doing most of the reading and Drew was doing most of the writing since he out-posted me 19 to 3.

So here are some highlights from Pallimed circa January 2006:

In addition to posting a few highlights from the month, I will be going back to add more labels/tags to each of the older posts so they will also show up in searches for any of our keywords here. You are welcome! And if you comment on any of those OLD OLD posts we still see the comments so they may be new to you so feel free to make your opinion heard.

And for those who would like to know what was going on in the rest of the world, Wikipedia oddly has an entry for January 2006.

Tuesday, January 26, 2010 by Christian Sinclair ·

What is the Role of Palliative Care in Haiti After the Earthquake?

In hearing about all the tragedy and occasional stories of hope and amazement with the recent earthquake in Haiti, I have been wondering about the role for a hospice/palliative care philosophy in the treatment of those injured and killed during and after the earthquake. Locally, I have not heard of any hospice or palliative care staff taking leave of work to embark to Haiti. (And if anyone does know of someone with a palliative background who has recently gone to Haiti I would love to interview him/her for Pallimed.)



I have also considered how my skill set might be best applied if I myself had decided to go to Haiti with the relief efforts. Would I fall back to my Internal Medicine training or would the specialized palliative care training be helpful? NPR's health blog 'Shots' recently covered some of the triage dilemmas being dealt with by health care staff on the ground. An excerpt:
A pediatric surgeon raised a tough question about when people should be taken off equipment to help them breathe. "Today the issue was ventilators. We ran out," he said. "What do you do then? We need a reality check. Some people might have to get off the ventilator before you would take them off elsewhere. That ventilator could save the life of someone who is much more salvageable."

But other doctors appeared incensed at the idea of stopping short of using every tool available on even the chance to save a life.

Palliative care staff help families and other medical staff sort through these tough decisions all the time in hospitals across the country, so maybe we as a field should make a concerted effort to be included in the 'essential' staff that might be needed in the next major disaster. Imagine an administrator making a list of the 'expertise' she would like to have in the field. As I think/write more, it does not appear to be such a stretch to consider having medical staff with a hospice or palliative care background on the ground in a major trauma/disaster zone.
  • Pain and symptom control
  • Skillful communication to traumatized/grieving families and patients
  • Whole patient/family approach to care, support to other staff
  • Prognostication awareness/skill
  • Grief and bereavement counseling (like Alive Hospice and Hope Hospice (Florida) are already doing)
  • Ability to engage with one's spiritual support
  • Willingness to think outside the box and work in conditions that are not considered ideal medically (i.e. like hospice staff do daily in patient's homes).

Sounds like a good skill set in a disaster zone to me.



In the NPR story, they even mentioned palliative care but it was quickly shot down. (Guess which specialty shot it down?)

Referring to the patients likely to die, one medical planner offered a solution, "What about having palliative care facilities at the intake sites on shore?" A surgeon responded, "And have five hundred tents of dying people in a field right next to a medevac site? We can't do that."

But surely something is better than nothing. "Even if we just give them some painkillers and a comfortable bed, it'll be better than them dying in the street under the sun like a dog," a nurse offered.

But a surgeon argued that easing the death of a doomed person would take a bed that could be used for someone with a real chance of being saved.

Shouldn't we make a more concerted effort to be included in the list of specialists available to help in a disaster? Would we be welcomed or instead shunned given our comfort in discussing issues around death and dying when everyone else is in rescue mode? And what about the patients who were already on hospice. They still need specialized care as well.

(Pictures via Boston.com Big Picture)
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by Christian Sinclair ·

Monday, January 25, 2010

Overdose in Patients Prescribed Chronic Opioid Therapy

The rate of overdose in patients who have been prescribed chronic opioid therapy is not known and neither is the relationship between the prescribed dose and the risk of overdose. The Annals of Internal Medicine published a cohort study which attempts to provide more data on this question in a population of patients with chronic, non-cancer related pain (unfortunately entitled Opioid Prescriptions for Chronic Pain and Overdose). It's funded by the National Institute of Drug Abuse.

The cohort is derived from the CONSORT (Consortium to Study Opioid Risks and Trends) study with all subjects belonging to the Group Health Cooperative (GHC) in Washington State at the time of enrollment. Subjects were eligible for inclusion if they were prescribed three consecutive months of opioids at the onset of opioid therapy and if they were given a diagnosis of chronic pain within two weeks of starting therapy. Patients with cancer were excluded. Information on opioid prescriptions was obtained from the GHC automatied pharmacy files. Potential overdose* cases were identified from the electronic medical record using one of two definitions, both relying on ICD codes (or combinations of codes) that might suggest opioid overdose. The first definition includes codes related to "opioid-related poisoning." The second definition includes a combination of codes that indicate an adverse opioid-related event plus a diagnosis code on the same date "considered to identify an overdose." Examples of the latter codes include the ICDs for drug induced delirium, altered mental status, pneumonia, and dyspnea. Thus, a patient on a stable, well tolerated opioid regimen who presents to the hospital with delirium and pneumonia might be a potential overdose case if given both the ICD for "adverse effect of opioid" and "pneumonia." (Even if the opioid was not the cause of delirium.)

After finding potential cases, they reviewed charts to classify the likelihood of each case being an overdose (definite, probable, uncertain, probably not, and definitely not), relying largely on the assessment and documentation of the treating clinician. (So a case like the one above, if documented "delirious secondary to morphine, community acquired pneumonia" would likely be labeled as a probable or definite overdose.)

They stratified opioid "exposure" using an "average daily opioid dose dispensed" over a 90-day exposure period: none, 1 to 19 mg, 20 to 49 mg, 50 to 99 mg, or >100 mg.

Here's more about the cohort:

  • 9940 subjects included (Average age 54 with 60% females).
  • Mean follow up was 42 months. 61% of subjects completed follow-up with most of the rest leaving the cooperative during the study.
  • 2/3 of cohort had diagnosis of back or extremity pain.
  • Mean daily dose of opioids prescribed was 13 mg (oral morphine equivalent) and most common opioid was hydrocodone.

And here's what they found:

  • 6 fatal overdoses were identified (a rate of 17 per 100 000 person-years). Characteristics of this group of subjects are not described.
  • 51 total overdoses (fatal + non-fatal) were labeled as "definite" or "probable" (a rate of 148 per 100 000 person-years).
  • Many of the overdoses involved patient misuse of the prescribed opioids (suicide attempts, accidental excess ingestion, using opioids not prescribed, and misusing fentanyl patches).
  • The most common adverse effect was delirium (in 23 patients).
  • Average daily opioid dose dispensed seemed to correlate with the rate of overdose. Estimated annual overdose rates were 0.2%, 0.7%, and 1.8% among patients receiving less than 20 mg/d, 50 to 99 mg/d, and more than 100 mg/d of opioids, respectively.
  • Having recently received sedatives/hypnotics correlated with increased risk of OD
  • A history of depression was the only covariate examined that correlated significantly with an increased OD rate. The youngest and oldest (under 45 years, over 64 years) patients were at higher risk for OD than those in the middle, but this was not statistically significant. When comparing subjects who were in the "high dose" group to the "low dose" group, the high dose group had more men, smokers, history of depression treatment, substance abuse, and a higher Charlson comorbidity score. The relationship between comorbidity and OD was not reported.
It would be tempting make the plausible conclusion that higher doses of opioids cause more overdoses but as the authors state, the difference may be related to patient characteristics (and this is where I'd like to see more about the OD group, especially comorbidity scores). Additionally, I'm not sure how I feel about the use of physician documentation to determine the likelihood of OD. The palliative care practitioner routinely sees patients that have 2-3 simultaneous causes of delirium, and I think I'm less prone to blaming the opioid than other non-PC colleagues (whether that is due to experience or bias or both, I can't say for sure). How that clinical experience applies to this "healthier" population is unclear to me without seeing how frequently delirious subjects in the study had comorbid causes of delirium or other adverse effects that bought the label "overdose." On the other hand, it is possible that this method misses some OD subjects because the clinician may have missed it.

Speaking of a more classic palliative care population, I wonder how that group would differ from the results above (including patients with advanced cancer who may be on much higher average daily doses of opioid). Since that population is at higher risk for many of the diagnoses that were thought to be indicative of possible overdose (delirium, dyspnea, falls, others), I suspect the number of patients who would "rule in" as possible subjects would be much higher. This might in turn lead to more confirmed cases, although the importance of accurate diagnosis and documentation becomes an even bigger issue.

The 6 fatal overdoses are a concern and really I'd like to see more information about patient characteristics as well as evidence of aberrent opioid use in those specific cases.

The authors' modest conclusion is that in a chronic pain population, patients require careful observation and instruction on appropriate use. Although it's pretty nice to have some data on the topic, hopefully you've reached the same conclusion before reading this. The associated editorial suggests that it's " time to change our prescribing practices." Certainly, we need more research in this area to guide practice (more research into novel non-opioid pharmaceuticals, non-pharmaceutical therapies, and the management of pain in patients with depression or substance abuse, plus lots more). We also need better systems for monitoring chronic opioid use/prescriptions and to prevent diversion (which seems to be implicated in the majority of accidental overdoses, at least based on this study). And we already know that patients with chronic pain shouldn't be continued on opioid medications if they aren't leading to some reasonable, agreed upon outcome. So I don't think this article should result in a sea-change in practice or attitudes, unless you're a provider who has mistakenly believed that opioids don't have potentially serious adverse effects (just like many other medications that doctors prescribe).

For more Pallimed posts that touch on issues related to the topic of chronic pain, see here, here, here, and here.

*Rhetorical question: If a patient takes 15 mg of morphine and becomes delirious, is this an "overdose" or an "adverse effect"? What about the same response to 25 mg of amitriptyline?

Monday, January 25, 2010 by Lyle Fettig, MD ·

Monday, January 18, 2010

Pallimed Prize for Hospitals Announcement

Sometimes great challenges need great support to be overcome.  Palliative care services in hospitals are overshadowed in marketing efforts by other revenue producing, prestige enhancing, feel-good medical 'product lines.'  We have all seen the billboards and magazine/newspaper inserts touting the newest technology, doctors and nurses with the best smiles and vague proclamations that nothing bad could ever happen to you at 'Our Medical Center.'  The same hospital administrations and staff who praise the good work of the palliative care internally would likely turn pale at the thought of trying to promote quality palliative care to the wider public.

Based on the successful premise of the X Prize for I am formally announcing the  

Pallimed Prize for Hospitals

The challenge: To overcome the fear of hospitals to skillfully market palliative care
The goal: A hospital or hospital system/chain must produce and publicize a multi-media marketing campaign featuring the palliative care team(s) for a period no less than 6 months and must include the following media platforms external to the hospital or hospital system/chain's own media sources : television, radio, newspaper, internet, billboard.
The prize: Starting with $1000 of my own money. 
The time frame: Any submissions for the prize must have started their marketing campaign after March 1, 2010.  If the prize is not claimed before December 31, 2012 the money will be donated to a scholarship fund to advance palliative care (yet to be determined).

What we need now is a few volunteers to be on the prize committee to help review any submissions and track donations.  Don't laugh. This is not a joke/farce/parody.  This is real and could be a big change if you would like to be part of it.  A more fully detailed post will be coming in the next few weeks for those individuals and organizations that would be interested in contributing to increase the size of the prize pool.  If you are inspired enough to join me on this quixotic quest, please email me at ctsinclair@gmail.com

A formal set of rules and eligibility requirements will be announced on this blog in mid-February.

Monday, January 18, 2010 by Christian Sinclair ·

Judy Chamberlin, Hospice Patient & Blogger Died January 16th

Judy Chamberlin who openly blogged about her experiences as a hospice patient died Saturday January 16th, 2010 at her home in Massachusetts.  Her blog started in December 2008 and she shared many great stories about her difficulties with COPD, interactions with her hospice team, and a few interactions with the Boston Globe. 

She and her blog were featured here at Pallimed in December 2009.  Her story will be featured on NPR's Morning Edition Tuesday morning.

She expressed concern for the lack of a voice for the hospice patient often being supplanted by the family or friends or medical staff.  We at Pallimed are thankful for her contributions to the voice of the hospice patient and hope her blog will stand as demonstration of the impact one voice can have.

by Christian Sinclair ·

Monday, January 11, 2010

Paradoxes in advance care planning

Journal of Clinical Oncology has a paper on cancer patients' attitudes about discussing advance directives. The study is posited as a follow up to one published 10 years ago which suggested that cancer patients did not want to discuss ADs with their oncologists. The data come from a prospective study involving all patients consecutively admitted to an academic hospital's inpatient oncology service over several months; patients (N=75, mean age 51 years, 23% African American; the majority had hematologic malignancies) were interviewed about AD completion and preferences.

41% of patients reported having completed an AD (all were given a description of what was meant by an AD); in multivariate analysis older age was the only predictor of AD completion. 75% of the patients had discussed an AD with someone - mostly family (23 patients reported a discussion with a physician). Only 5 patients reported a discussion about ADs with their oncologist. When they asked patients if they would like to discuss ADs with their oncologist, only 23% said they would (this is similar to the finding in the study 10 years ago). When, however, they asked patients which, of all their doctors, they would prefer to discuss ADs, a plurality said their oncologist (48%). That is, if they have to do it, they'd prefer their oncologist. Notably the vast majority of patients (87%) thought that physicians admitting a patient to the hospital should ask about ADs (they indicated this was not only ok but an important thing to do). Thus, the title of their article, and this post - 'Paradoxes in ACP....'

(They also asked patients about knowledge of hospice care and palliative care. 21% of patients reported knowledge of 'palliative care' vs. 81% for 'hospice care,' and hardly anyone said they knew anyone who had received palliative care.)

Basically these patients, most of whom did not have an AD, weren't particularly interested in talking about them with doctors (oncologist included), while recognizing that when you are admitted/acutely ill it's good to bring it up with a stranger...but that if they had to discuss them with a doctor most preferred their oncologist. This is summarized by the authors as: "while most patients would not like to discuss ADs with their oncologist, they would prefer to discuss them with their oncologist."

I've been mulling over these findings for a couple days now, trying to make sense. I wonder whether the fact most of the patients had hematologic malignancies was a factor; while many of the patients had a low likelihood of long-term survival, it is still likely that most of the patients at the time of the interview were expecting long-term survival/cure and whose treatment intent was essentially curative (as opposed to patients hospitalized with advanced solid tumors who, one hopes, understand their cancers are incurable). I think having more solid tumor cancer patients would have attenuated the findings, but not necessarily changed the paradoxes.

In some ways it's a testament to the importance of how questions are worded in research (as in real life): Would you like to talk with your oncologist about ADs? is a different question than Which of your doctors would prefer to talk with about ADs? (This is the Journal Club teaching point of the paper.) Granting that difference, however, doesn't mean that these patients resoundingly endorsed routine AD discussions in general.

We've expressed some AD skepticism on the blog before (e.g. where's the data they do anything), and I sometimes wonder when reading research like this that patients view ADs as some sort of abstraction and don't really understand why us clinicans care about them so much. Which is not to say that most physicians do care about them much. Part of what I'm saying is that for us as doctors to tell patients they should consider an AD we also need to be talking with them about their expected future, and that the AD is less important to patient care than that actual discussion about what's going to happen, or what will happen if consolidation chemotherapy for your acute leukemia fails. It's those discussions, and not the recommendation to do the paperwork, that I *think* improves care (and indeed the authors cite some of the Coping With Cancer Study outcomes - that study showed improvements in care associated with EOL discussions, not per se with AD completion). I wonder if patients kinda get that too, and if they've had some 'AD discussions' which were along the lines of 'you really oughta fill out this paperwork' without the context of the broader talk or at least broaching of the topic of prognosis/expected course, they don't really report the need to engage with their oncologists about the paperwork...?

Monday, January 11, 2010 by Drew Rosielle MD ·

JCO round-up

In addition to my prior post, a handful of additional articles from recent Journal of Clinical Oncology issues:

1.
JCO has a paper on video-assisted advance care planning for cancer patients (see here for a prior post; see here for lots more). This study involved outpatients with aggressive brain cancers (n=50, mean age in 50s, over 3/4 rated their current health status as good or better, about 50% reported they would not want CPR at baseline) who were randomly assigned to either a verbal description of advanced cancer and different treatment options or that plus a short video showing the different treatment options in real life. Advanced cancer "was defined to participants as being "very sick" in a situation where they may or may not be able to speak for themselves" (as far as I can tell no discussion of time-based prognosis or inevitability of death). The treatment options given were 'comfort care,' 'basic medical care' (essentially life-prolonging treatments short of ICU-level care), and 'life-prolonging care' (everything including ICU level care, CPR, mechanical ventilation, etc.).

The video (no sample available unfortunately**) is described as the following:

In the video, life-prolonging care images included: an intensive care unit with a ventilated patient being tended to by respiratory therapists; a simulated code with clinicians illustrating CPR and intubation; and various intravenous medications including vasopressors administered through a venous catheter. Visual images to depict basic medical care included: a patient getting antibiotics via a peripheral intravenous catheter; scenes from a typical medical ward service; and a patient wearing a nasal cannula. The video depiction of comfort care included: a patient on home hospice care receiving pain medications; a patient with a nasal cannula comfortable on oxygen at home; and a medical attendant assisting a patient with self-care.
There were marked differences in levels of care that the patients said they'd wish for themselves: for the verbal-only patients 22% said they'd prefer comfort care, 52% basic care, and 26% full life prolonging care. For the video patients, 91% said they'd prefer comfort care, 4% basic, and one uncertain. More patients changed their mind about CPR in the video group as well (48% declined it at baseline, wheras 91% declined it after the video). (Yes this means the patient who wanted basic care also said, presumably, they wanted CPR.)

**Angelo Volandes, the senior author of the article, has a website with his videos, but they are behind what I think is a paywall. I've seen one of his early videos on advanced dementia and it is very reasonable and well-balanced.

2.
There is an updated clinical practice guideline on chemotherapy for stage IV non-small cell lung cancer (free full-text here). It's an interesting read for, in particular, beginning fellows who need some sort of introduction to the anti-neoplastic approach to this cancer we see all too-commonly in palliative care practice settings. Note that this is a CPB about chemotherapy for NSCLC, and basically ignores other aspects of care. It does represent a concise summary of the benefits (such as they are) of newer, targeted agents (erlotinib, etc.). On the ASCO website there is an unabridged version of the recommendations (pdf here) which ends with a few pages on discussion chemotherapy with patients, including how to discuss risks and benefits, which also specifically mentions the problems with discussing median survival data (using the infamous bevacizumab example - which is basically that most patients got no benefit, but the percent who did got a lot of benefit/life-prolongation, meaning that the median survival for the study population increased by 2 months but that is an incredibly poor way of actually communicating to patients what they can expect).
Although most clinical trials report the median survival time of the control arm and the experimental arm, it is the consensus of the Update Committee that quoting comparative median survival times to a patient can be misleading. For example, a patient who is considering whether to take bevacizumab with carboplatin/paclitaxel may learn that bevacizumab improves median survival by 2 months (from 10.3 to 12.3 months). A common misconception of an individual patient is that taking bevacizumab will allow him or her to live 2 months longer. On the contrary, some patients experience treatment- related death related to bevacizumab, whereas other patients may live many months longer as a result of the beneficial effects of the drug. Patients who request statistics must be reminded that these numbers are based on the experience of thousands of patients, with median survival time representing the experience of the majority of patients. Physicians can explain what median survival time means—that is, half of the patients live longer, and half die sooner. However, there are patients who live much longer or much shorter than the median survival time.
3.
There's a review of depression screening/diagnosis instruments in geriatric cancer patients. Believe it or not, 'there are insufficient data to...' etc. etc. It's a tidy overview however of many of the most common scales, and how they've been evaluated. Anyone out there using a specific scale for older cancer patients?

4.
There's a look at emotional distress experienced by bereaved family members of patients who died in Japanese palliative care units. There's an interesting finding that overhearing conversations between medical staff outside the room at the time of the patient's death was one of the strongest predictors of 'high level distress' in bereaved family members. I'm curious as to why they chose to even ask that question (they describe how their questionnaire was created but it's not clear where individual questions came from).

5.
There is an exploratory study of parents of children with cancer who were likely to die and nearing death (the parents had made a decision for either enrollment in a phase I study, a DNR order, and or initiated a plan for end of life care) - looking into how these parents conceptualized being a 'good parent' as they made these decisions.

6.
And finally, a few supportive care articles I'll mention in passing: one on case management (and related) programs for symptom surveillance (didn't do much); another on a home nursing program to monitor symptoms for patients on oral chemotherapy which seemed to be helpful; and another on the frequency of insomnia in cancer patients on therapy.

by Drew Rosielle MD ·

Wednesday, January 6, 2010

Palliative Care Grand Rounds Vol 2.1

Welcome to the second year of Palliative Care Grand Rounds, the monthly review of the best of hospice and palliative care content from blogs. 


When I first thought of adapting the popular Grand Rounds concept to our field, I was not sure if Pallimed would be hosting every other month.  I had some doubts about the longevity of the idea, but I really wanted to be able to feature all the great writing that may lie undiscovered.  There are over 40 active hospice and palliative care related blogs in addition to all of the other blogs who may not focus on this specific area but may occasionally write significant posts which would resonate with our readers.

Well one year later Palliative Care Grand Rounds is still here and we had 11 different blogs participating last year (we started in February).  So I would call that a success.  I am currently taking offers for anyone who would like to host an upcoming PC Grand Rounds. (email: ctsinclair@gmail.com).


In this edition I will also add some interesting Tweets culled from searching Twitter using the words 'hospice' and 'palliative.'

Image representing Twitter as depicted in Crun...Image via CrunchBase

I found this Tweet from Andrea Gauster, a singer/songwriter from Canada (and a pretty good one too):




  • @fevadivadork: Sucks when someone who is fully aware and walking gets told that theres nothing they can do and the hospice will be making visits now. ugh from txt
  • @mxmlxviii: The area hospice has decided to kill Mr. Brown. Assholes. Worst part they sent him home and my mom is on the crew that is doing it. from web
  • @mxmlxviii: Mr. Brown, MS, and non specific seizure disorder. Average life expectancy = 30. Dr.'s pulling nutrition at 37 so as not to blow the curve. from web


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Wednesday, January 6, 2010 by Christian Sinclair ·

Monday, January 4, 2010

Catholic Directives on Artificial Nutrition and Hydration

In November of 2009, the United States Council of Catholic Bishops voted to approve and update the Ethical and Religious Directives for Catholic Health Care Services.  Some of the wording changes have begun to worry some in health care about how to handle delicate discussions in Catholic health care facilities that may be caring for patients wishing to forego artificial nutrition and hydration.  The most vocal group thus far is Compassion & Choices.  The NHPCO, AAHPM and HPNA have been relatively silent on this matter either way to my knowledge.

The section on End of Life starts on page 29 and begins with an introduction reviewing Catholic teachings on matters pertaining to death in the modern medical age.  From the intro:

While medically assisted nutrition and hydration are not morally obligatory in certain cases, these forms of basic care should in principle be provided to all patients who need them, including patients diagnosed as being in a “persistent vegetative state” (PVS), because even the most severely debilitated and helpless patient retains the full dignity of a human person and must receive ordinary and proportionate care.

Following the intro are the directives which I have highlighted a few pertaining to artificial hydration and nutrition.

58. In principle, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic and presumably irreversible conditions (e.g., the “persistent vegetative state”) who can reasonably be expected to live indefinitely if given such care.40 Medically assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be “excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed.”41 For instance, as a patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore not obligatory in light of their very limited ability to prolong life or provide comfort.
59. The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching.

The main revision comes in ERD #58 which changed the wording from "presumption in favor of providing nutrition and hydration to all patients" to "[moral] obligation" to provide food and water.  other clarifying points was to highlight those in a chronic condition or the chance to live chronically with the assistance of artificial nutrition and hydration (ANH) cannot forego or refuse ANH in a Catholic Health Care Facility.  

Most of the hub-bub has focused on patients in a persistent vegetative state, but since those cases are actually pretty rare, I think where this might be more likely to be a potential ethical conflict is in the care of patients after a stroke or those who become chronically critically ill.  In those patient groups predicting death or the impending nature of death become much more difficult especially if you factor in the variable of +/- ANH.    If you think having members of the church directly becoming involved in health care matters seems theoretical or indirect at best, consider the case of Mr. Welby in Italy in 2006, or Steven Becker in St. Louis in 2000.


The Catholic Health Association of the United States (CHA) issued a clarifying statement.  And in other statements has said if a resolution could not be found, the patient would be transferred to another facility.

For more information on this you can read a good synopsis with interviews from Charles Stanley at Atlanta's The Sunday Paper.  Also on the Compassion and Choices blog. And the San Francisco Examiner. Or from the blog otherspoon.

I would encourage anyone who does work with a Catholic hospital, nursing home or hospice to proactively address the handling of this directive so there is some clear understanding of the implications and the channels any decision making should go through.  Maybe it is a good time to convene the ethics committee to review the directive and current practices regarding ANH.  I do palliative care consults at a Catholic hospital so I know I will be meeting with the administration and ethics committee within the next few weeks to review this issue.  If you have any experience with this please feel free to post in the comments or email me at ctsinclair@gmail.com.

Monday, January 4, 2010 by Christian Sinclair ·

Welcome listeners from the Walt Bodine Show!

If you are visiting Pallimed for the first time after hearing about us on the Walt Bodine Show (NPR radio station KCUR out of Kansas City, Missouri), I would encourage you to look around at a few of our sections to get a better feel of what we write about here.

About Pallimed
Our Arts & Humanities blog
Lists of other hospice and palliative medicine related blogs

For the caller who called in after me asking about finding time to do the blog and if we are giving our skills/knowledge away or if we are compensated, I can answer those here since I won't be able to call back in since the show is now over.

Finding time to do the blog: For me (Can't speak for Drew, Lyle, Amber or Amy), I blog in my off time from work.  I don't blog during the clinical hours of the day.  Like for example today I am off work, which is why I was able to call in and post to the blog right now.  You will notice that most if not all of our blog posts are published between 7:30pm and midnight because that is when we are writing.  Each major blog post takes 2-3 hours to write, and each minor post may take 30-60 minutes.  This doesn't count the reading, researching and other time thinking about how to write up a post.

Giving away our skills/knowledge:  Part of the purpose of this blog is to openly discuss our skills and knowledge to hopefully make them better as we get feedback from others.  In addition we want to share the interesting things we find about the hospice and palliative medicine worlds.  I would like to think we are reducing some of the information asymmetry between medical professionals and our patients and families as well and hopefully making more informed so they can approach these difficult issues with confidence.

Compensation: Financial compensation: none.  We are committed to a no-advertising policy and have been since our establishment in 2005.  I am not reimbursed by employer for these activities either in time or money and I do not believe any other Pallimed bloggers are either. We won an award last year and we turned around and gave most of it back to our readers in the form of a party at the AAHPM meeting.  There are minimal expenses for this blog to be run daily.  Mostly we just spend blood, sweat and tears.  Our true compensation comes in the exchanges from the community that has developed around Pallimed and other related blogs.  Writing for a blog has offered great opportunities for collaboration which has been the greatest reward.


If you have any questions, please feel free to comment or email ctsinclair@gmail.com

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by Christian Sinclair ·

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