Tuesday, December 31, 2013
As you finish out the year this evening, you may be reminded that you still need to get a few more tax deductible charitable contributions in before the clock strikes midnight. How do I know what you are thinking? Because the data shows that New year's Eve is one of the most beneficial days for charitable giving.
So as you are planning your last few donations, I want to urge you to consider donating to the American Academy of Hospice and Palliative Medicine's Shaping the Future Campaign. To honor the 25th anniversary of the Academy and help impact the next 25 years, the Academy has embarked on it's first every charitable campaign. The goal is $1.5 million dollars to help with advocacy, education and workforce issues.
Tuesday, December 31, 2013 by Christian Sinclair ·
Monday, December 23, 2013
It is really hard to see a randomized controlled trial conclusion that does not support your previously held view of medical practice or education.* Yet it's vitally important to pay close attention when this happens, and try to deeply understand what's going on so you can change your practice, if necessary. So I'm here to pay close attention (and be rather long-winded in the process).
But the JAMA RCT took it a step further with an attempt to determine if the educational intervention would positively impact patient-centered outcomes.
In short: No benefits found in this study. No increase in patient, family, or other clinician rating of quality of communication surrounding end of life care. No improvement in mental health outcomes. In fact, patients exposed to the intervention group's trainees experienced a small but statistically significant increase in depressive symptoms. Let's take a closer look at the purpose and methods of the study.
What's the purpose of the educational intervention?
The educational intervention is designed to give trainees skills necessary to conduct pivotal conversations- to ensure that patients and their families understand where things stand medically (and where things might be going), empathize and provide support when the news is serious, and to align treatments with patient values and goals. While I'm not familiar with the specific simulations used in the intervention, from other experiences with this method, the simulations usually feature patients who are at a pivotal point with their health. A new or relapsed serious illness. Worsening of a condition, indicating that treatments aren't working very well. A transition to the actively dying phase.
Was patient selection appropriate for this study?
All of the patients included in the study had serious illnesses (25% outpatients and the rest inpatients), and one might anticipate that each patient would need to have conversations about serious news, goals of care, and end of life care at some point along their disease trajectory. But at every visit? Likely not. Some of the skills taught could be applied at any visit, but would the full benefit of these skills be felt if the patient was stable without troubling new issues? Could patient stability reduce the importance of applying these skills at many of the visits?
So, how many of these patients were actually at a pivotal point in their disease trajectory during the study encounters? We don't know, exactly. Here's what we know:
- Patients in hospice care were significantly less likely to return surveys (only 26% of patients in hospice care returned surveys). We don't know how many patients in each study group were in hospice or on the verge of hospice referral,which represents one of many possible pivots in a patient's health and care.
- When there was documented communication about end of life issues, patients were significantly less likely to return survey (34% estimated return rate)
- Families of the 16% of patients who died during a hospitalization were dramatically and significantly less likely to return the survey (a measly 29% when the patient died vs. 78% for families when the patient survived hospitalization).
- Among respondent patients who rated their health status as "poor", quality of communication scores were higher in the intervention group.
We have no idea what the subject of the conversation was during each visit. Perhaps the control group had sufficient communication skills to navigate routine patient visits and achieve scores comparable to the intervention group. Reviewing the QOC tool, many of the skills on which patients/families were asked to evaluate trainees are basic skills (making eye contact, etc). Maybe there were enough routine visits to drown out the pivotal conversation visits in the study. There's no way to know.
Confounders for the measurement of trainee skill
Another variable which was not reported was the timing of when patient/family/clinician evaluators filled out their surveys. It's entirely possible that by the time the evaluations were filled out, patients and families might have remembered the face of the trainee. However, as time elapses from the visit, recall bias likely only grows. Think of the number of factors which could impact the rating- the plethora of other clinicians the patient could have seen during the same hospitalization or in the interim. One inclusion criteria for the study was patients who had palliative care consultation, but it's not known how many of the patients received this. You could imagine that being a confounder for patient satisfaction! Also, consider the conflicting messages patients and families receive and the illness experience itself as other confounders.
The depression result
First off, it's not clinically significant by the pre-defined minimial clinically significant difference of a 5-point change in the PHQ-8. Granted, it was statistically significant, with a covariate adjusted 2.2 point increase between the groups.
What to make of this clinically insignificant increase in depressive symptoms? We know sadness comes with some of the messages we have to give to patients and their families. But none of us want to make someone more depressed, if we can help it.
PHQ-8 was measured at a a single time. And we don't know when that was, and whether timing varied for some reason between the intervention and control group. But let's assume measurements occurred at exactly the same time in each group.
We have empirical evidence to suggest that the elements of grief have "average" trajectories, with depressive symptoms being an expected element of that grief. Assuming that trainees in the intervention group were having more end of life discussions (a leap, because we don't know for sure), is it possible that the "arc" of the anticipatory grief experience was modulated somehow? More depression earlier on, with greater acceptance to come when the control group was hitting the peak of their depression?
This is merely a hypothesis. But I think simultaneously while we ponder the possibility of harm, alternative hypotheses need to be considered as well.
How might this mesh with another highly regarded communication intervention trial?
Previously, Lautrette (and Curtis) et al. demonstrated the effectiveness of a communication strategy at reducing depression, anxiety, and PTSD symptoms in bereaved family members three months after the loss of a loved on in an intensive care unit. One of the core interventions was a structured family meeting that involved clinicians using the VALUE mnemonic. While this particular mnemonic was not central to the educational intervention in the JAMA study, the intervention helps trainees gain the skills necessary to accomplish the goals central to the mnemonic. Why the difference in outcomes, then? I hypothesize that it comes back to patient selection. All of the patients in Lautrette were clearly at a pivotal point in their care when the intervention was applied.
Anecdotes remain powerful
A critical care fellow sends an email noting that after an impromptu late night family meeting, the nurse commented on how smoothly the meeting went and the resident told her he hoped he could communicate like that one day. Another fellow sends a text with a report that in a difficult conversation, he made a statement admiring the care the family gave to the patient, and the emotionally charged family calmed down, becoming more able to focus on the difficult conversation at hand. You observe one of your fellows find a new way to align herself with a patient asking for treatments that won't be beneficial, and she remarks afterwards about how she wasn't doing that just a few weeks before, and how useful she has recently found the new technique.
All of the above fellows participated in a communication course conducted using the Vital Talk teaching methods studied in the JAMA RCT. Multiple studies (including the recent JPM study linked with this RCT) have now demonstrated change in behavior from this intervention. It's possible that the change is not long lasting. If we were to set aside some of the methodological issues of the JAMA RCT and believe the conclusions (no improvement in patient outcomes), it's possible that the trainees didn't have adequate reinforcement to change their behavior permanently. It's also possible that some of the anecdotal success comes from viewing this as an iterative process with high level learners who are a different audience than the intervention group of the study. For more on that and further commentary, here's Drew...
Like Lyle, I have been trained in and use the techniques used by the Oncotalk/Vitaltalk crowd, and, via first-hand experience, strongly believe they are effective in improving the quality of communication. I watch communication skill acquisition happen rapidly, in a way that is nearly giddying (as an educator) to watch. In my own fellows, I perceive that these improvements have a lasting effect on the level/quality of my fellows' communication skills. So, for me, it was disheartening to see such a well-designed study of these techniques be so 'negative.' Admittedly, my first-hand experience with this is has been so positive that I find it nearly impossible to believe that the techniques aren't effective.
That said, as I have thought about this investigation, one of my conclusions is that perhaps the reason I perceive the techniques to be so effective is that I have been using them, myself, to train palliative care fellows (not medical interns). My fellows 1) are physicians who are very, very motivated towards excellence in physician-patient/family communication, and 2) after the Vitaltalk-style workshop they continue to have close supervision and feedback from me and my faculty on their communication. Effective, empathetic, patient-centered communication is a huge, explicit part of their curriculum, as opposed to ineffective, aloof, and pathology-centered communication being a huge part of the "hidden curriculum" as it is for too many other medical trainees. I think it's possible that those phenomena may, in part, explain the disconnect between the apparent ineffectiveness of the Curtis trial vs my own experience with these training methods.
I'll also note that I don't necessarily believe patients are the best judge of physician communication quality. Certainly, patient satisfaction with physician communication cannot be the sole measure of quality (note: I'm not suggesting that the Curtis trial judged the quality of communication uni-dimensionally). I am reminded of the CanCORS study, which showed patients with metastatic lung or colon cancer who did not understand that their chemotherapy was not going to cure them, were more satisfied with their oncologists' communication than patients who were better informed. Sobering stuff.
While the results of this trial are disappointing, the negative results may reflect how challenging it is to study patient centered outcomes of educational interventions. This study also gives us an opportunity to reflect on how to define the patients who benefit most from communication training interventions, when the benefit is most likely to occur, and which trainees/practitioners might be in the best position to receive the intervention. No doubt, there are other interventions which may improve clinician communication in pivotal conversations, and we should also reflect on ways to improve the studied intervention. As a palliative care community, we should be interested in a multi-faceted approach that involves changing both practitioner behaviors and early patient/family preparation for pivotal moments near the end of life. Evidence supports the notion that we can help trainees grow their communication skills. Fortunately, we don't need FDA approval to disseminate medical education interventions which help trainees develop skills that most would agree are valuable. This intervention remains an integral part of the equation.
For other perspectives on this study, see the JAMA editorial by Chi and Verghese, Vital Talk's commentary, and Geripal's commentary.
*Disclosure: Lyle currently receives funding from an IU Health Values Grant to use these teaching methods with various fellowships at IU School of Medicine. All opinions expressed in this post are solely those of the authors.
Monday, December 23, 2013 by Lyle Fettig ·
Wednesday, November 27, 2013
Wednesday, November 27, 2013 by Christian Sinclair ·
Wednesday, October 30, 2013
- Increased # of patients served* (1.5M)
- Increasing average length of service (71.8d)
- Decreased median length of service (18.7d)
- Slightly higher percentage of elderly patients served
- Higher diversity of patients served
- Increasing percentage of non-cancer diagnosis led by debility and dementia
- Increasing number of hospice programs (5,500)
- Increasing percentage of for-profit hospice programs
- Increase in Inpatient Hospice (GIP) days
- Declining satisfaction rates (although still high)
- 2013 http://www.nhpco.org/sites/default/files/public/Statistics_Research/2013_Facts_Figures.pdf
- 2012 http://www.nhpco.org/sites/default/files/public/Statistics_Research/2012_Facts_Figures.pdf
- 2011 http://www.nhpco.org/sites/default/files/public/Statistics_Research/2011_Facts_Figures.pdf
- 2010 http://www.stjosephhospice.com/wp-content/uploads/2011/01/Hospice_Facts_Figures_Oct-2010.pdf
- 2009 http://ebookbrowsee.net/nhpco-facts-and-figures-pdf-d146287250
- 2008 http://www.lovinghandshospice.com/pdf/nhpco_facts-and-figures.pdf
- 2007 http://web.archive.org/web/20081001182409/http://www.nhpco.org/files/public/Statistics_Research/NHPCO_facts-and-figures_Nov2007.pdf
- 2006 Summary http://www.allhealth.org/briefingmaterials/NHPCO-NHPCOsFactsandFigures-2005Findings-760.pdf
- 2006 State Supplement http://www.hpcai.org/documents/filelibrary/documents/pdf/NHPCO_NDS_2006_State_Report_FINAL.pdf
Wednesday, October 30, 2013 by Christian Sinclair ·
Thursday, October 24, 2013
I had just begun reading Dr. Danielle Ofri's latest book, "What Doctors Feel: How Emotions Affect the Practice of Medicine", when I opened The New England Journal of Medicine to find David Korones' essay "What would you do if it were your kid?" As he points out, nearly all of us have been asked, have heard this "plea to share with them, as a partner, the heavy burden of decision making." And nearly all of us have squirmed in our seats a little each time.
I still remember the child in the ICU, sedated and on a ventilator as her parents waited for the fungus in her lungs to clear. The note on her door said, “Docs, if ‘Plan A’ didn’t work, the alphabet has 25 more letters! So stay cool.” Yet, the infection was persistent, and her parents were asked to decide – continue as is, perform surgery to remove the fungal ball, or to withdraw the ventilator support and keep her comfortable as she died. The whole team gathered with the parents – the ICU doc, the BMT primary, the infectious disease specialist, the cardiothoracic surgeon, and me, the palliative care doc. The options were presented. The table fell silent as the parents processed the decision before them. Then the father asked, “What would you do?” And after a few furtive glances, one-by-one every provider around that table shared their opinion.
There was not a unanimous response from the providers at the table. But everyone sat with the parents as they faced a heart-wrenching decision. Two years after her death, her parents sat before a group of second year residents and reflected on that family meeting, and on the empathy they felt. It buoys them on their waves of grief to this day.
While the word "empathy" does not appear in Korones’ essay, I think it is at the heart of everything he says. Perhaps it is because I was reading Ofri’s book, and on page 48 she explains,
“Empathy is a cognition, a thought process that allows you to understand the patient’s feelings while not necessarily feeling them yourself… and the empathic doctor needs to be able to clearly communicate that understanding” (p48).When a patient or a family member asks, “What would you do?”, they are inviting empathy.
1. Korones DN (2013). What would you do if it were your kid? The New England Journal of Medicine, 369 (14), 1291-3 PMID: 24088090
2. Meyer EC, Lamiani G, Foer MR, Truog RD (2012). "What would you do if this were your child?": practitioners' responses during enacted conversations in the United States. Pediatric Critical Care Medicine 13 (6) PMID: 23034458
Thursday, October 24, 2013 by Jenni Linebarger ·
Friday, October 11, 2013
- European Association for Palliative Care (EAPC)
- International Association for Palliative Care (IAHPC)
- Worldwide Palliative Care Alliance (WPCA) and
- Human Rights Watch (HRW)
As a palliative care doctor, I have seen suffering damage people and families, but I have also seen the ability for skilled clinicians taught the basics of palliative care, who are able to relieve that suffering. In that act of relief, those clinicians also create a healing process for patients and families even in the face of serious illness. With access to critical pain and symptom medications and the proper education more clinicians can make a true difference in people's lives around the world.
Friday, October 11, 2013 by Christian Sinclair ·
Friday, October 4, 2013
In the face of a crisis, many people are challenged to find constructive and meaningful ways to engage in conversation and so often they fall back on platitudes. Simple, hopeful, semi-philosophical phrases we have heard in many other situations may sound important to the speaker, but the receiver finds them meaningless and tone deaf. I'm sure you have heard many of these uttered to patients by well-meaning family friends, and even health care professionals:
"This too shall pass."
"I'm sure it will be OK."
"It is what it is."
"God won't give you more than you can handle."
"Limp, anemic sentiments will not stand in the face of a world that is not as it should be."Pyle explains that this phrase is often sourced to the Bible but the original statement is about temptation not suffering. I think this is a great post to bring to team and discuss how we as professionals who see the intersection of suffering and spirituality everyday deal with statements like this. I posted the article earlier this week to the Pallimed Facebook page, and it garnered a lot of responses. Here is one that I think many in palliative care will agree with:
Call it what you will, but someone people hang on to this for their hope and sanity. Even though I agree with this blog, even his blatant use of calling it what it is, sometimes to "correct" those (in the moment) who are holding on to this falsity as their hope and sanity, it is equivalent to pulling the chair out from under them.When you hear, "God doesn't give you more than you can handle," how do you respond?
H/T to Rick Bauer (@nvrflycoach) for posting the original blog to Twitter
Photo Credit: Not attributable after using Tin Eye Reverse Image Search
Friday, October 4, 2013 by Christian Sinclair ·
Tuesday, September 24, 2013
Back to the Sanderson’s study and article. Sanderson and her colleagues David Zurakowski and Joanne Wolfe wanted “to identify clinician attitudes regarding the meaning, implication, and timing of the DNR order for pediatric patients.” Literature exists for adult populations, but this was the first specifically targeted at the pediatric realm.
Sanderson A, Zurakowski D, and Wolfe J (2013). Clinician Perspectives Regarding the Do-Not-Resuscitate Order. JAMA Pediatrics PMID: 23979224
Other cited works:
Birds: Audubon "Illustrated Birds of America"
Bridge: Emily Riegel Personal
Child: Emily Riegel
*Links are Amazon Affiliate Links. Any proceeds from sales using these links support Pallimed outreach efforts.
Tuesday, September 24, 2013 by Emily Riegel ·
Friday, September 20, 2013
Patients attending an ambulatory consulting service in Adelaide, Australia were queried regarding their feelings about stopping medications, and the results were reported in JAGS recently. The subjects, age 71 on average, were taking an average of ten medications. Most subjects thought they were taking a "large number" of medications and 92% said they'd be willing to stop one or more medication "if possible."
Big shocker for Pallimed readers, I'm sure. Who wants to take ten medications?
This survey included a geriatrics population and was published in a geriatrics journal. But if you practice palliative care or see patients with limited prognoses, you should take heart in the notion of slashing medication lists, especially when you can see no clear indication for the medications. I'm looking at you, primary and secondary preventative medications.
A few hypotheses for why it's so difficult for some physicians to discontinue medications:
- Inertia: It's easier to continue with the status quo.
- It may require a discussion about overall prognosis: "Wait a second, doc. My doctors have been telling me for years to take that orange pill. Are you sure it's OK to stop now?" In other words, patients want to do the right thing, even if that means being burdened with taking a boatload of meds. This is evidenced in the JAGS study by the fact that 71% of patients said they'd accept taking more medications, if necessary. However, if a prognostic discussion has occurred (e.g. related to advanced cancer, etc), it's then easier to say "I think that medication has done it's job, I admire your commitment to taking it, and now it's OK to give it a rest."
- Overestimation of actual benefit of medications: "He had an NSTEMI five years ago. What if we stop the simvastatin and he has another MI? Sure, he's probably going to die from lung cancer in the next several months, but I don't want him to die from an MI. No, he's not having any coronary artery disease symptoms now, but I think it's best just to continue it." Look at a meta-analysis of several studies evaluating the benefit of statins for primary and secondary prevention of cardiovascular events. The number needed to treat to prevent one major coronary event was 28, which isn't horrible. Yet it's not exactly dooming your patient to angina/MI before he dies, especially if you consider that the five studies evaluated in the meta-analysis followed patients for 5-6 years to look for the outcomes.
Use a shared decision-making approach with patients. Even though it's OK to discontinue meds, it's also OK to not be dogmatic about it if the patient prefers to continue the med (as long as it's not harming them).
As hard as it is to stay on top of the deluge of new research (just even in your own specialty), it also never hurts to remain aware of research regarding the indications for primary/secondary prevention. A good example would be a recent cohort study from the Annals of Internal Medicine which suggests the optimal BP in patients with chronic kidney disease may be 130 to 159/70 to 89 mm Hg, with patients in that group having lower mortality rates.
If you're reading this, you're probably part of the choir already. If so, here's a pat on the back to you for being vigalant about polypharmacy!
For more related to this topic, see my post from a few years ago about "Minimally Disruptive Medicine" (and some other related links in that post).
Edit 9/22/2013: Also, I just found some recent American data published in Journal of Palliative Medicine on statin use near the end of life in patients with cancer (along with a letter to the editor on the JPM study). Bottom line: Statin use common in this population right up until time of death, unclear how appropriate the use is in each individual patient, but opportunities to deprescribe were likely missed.
Friday, September 20, 2013 by Lyle Fettig ·