Comments on Pallimed: A Hospice & Palliative Medicine Blog: Race and hospice revocation; COPD; Nabilone for pa...

Hi Guys,Great post & interesting F/U discussion on...

2008-02-07T20:33:00.000-06:00

Hi Guys,
Great post & interesting F/U discussion on race & hospice/medical care. And I missed me in Tampa, too.

I'm commenting on the nabilone vs opioid piece. In my opinion, your last sentence (RE: "weak opioid") says it all. It seems a little silly to me to be studying, at this stage of the science, a weak cannabinoid vs a weak opioid for neuropathic pain. All indications from clinical practice are that strong opioids, at higher doses than would be "expected" for nociceptive pain, are needed for neuropathic pain. So why even conduct a trial with a weak opioid? In addition, the relatively scant but increasing literature on cannabinoids for pain don't show a strong association with successful treatment of neuropathic pain. Even by pain study standards, this was a pretty small study (N = 96). A critical editorial accompanying the study states "Before embarking on large scale trials designed to establish who will benefit most from an intervention, investigators should first ensure that trials demonstrate internal validity because failure to do so threatens to undermine the very concept of any new treatment. Even if a subgroup of patients might have benefited from nabilone, the current study design was not powered to identify them." Patients were allowed to stay on any other analgesics they were already taking (which is appropriate), but it would have been nice if they included a list of those drugs. Also, they pretty much took all comers--results were not stratified by specific syndrome. All in all it was disappointing; not in the sense that they had a negative result--I think that should have been anticipated. But the design was weak and a lot of time & energy went into something that predictably would not add much to our clinical knowledge.

Drew,On the social vs. medical models of disabilit...

2008-02-07T13:59:00.000-06:00

Drew,

On the social vs. medical models of disability, I refer readers here:

http://www.medhumanities.org/2006/11/social_model_of.html

One of the things that I have never seen well expl...

2008-02-06T20:49:00.000-06:00

One of the things that I have never seen well explained in any medical article on this topic is the apparent difference in where the trust lies between the health care system and the African-American community. On one hand, you can observe that African Americans mistrust the health care system to advocate for the most aggressive medical care and hopefully the best outcomes. On the other hand there is a significant amount of trust from the patient to the physician/nurse/health care system to perform whatever task necessary to be aggressive. I am not sure if what I said comes thru clear, but basically the mistrust may not lie in the actual provision of health care but the view that health care is being withheld.

For example, a patient may not trust the surgeon's recommendation to not perform a surgery, and therefore insists the surgeon perform the surgery. The first part indicates lack of trust in the surgeon's decision making/advocacy, but the second part indicates trust in competency of the surgeon. Has anyone seen this concept explored in the literature?

"the responsibility for changing mistrust in healt...

2008-02-05T16:44:00.000-06:00

"the responsibility for changing mistrust in healthcare rests with the system that created it."

Agreed. Frances thanks for your follow-up: can you email me at drosielle {at} gmail dot com. I'd like to talk with you about a project I'm working on & I can't find your email.

Mistrust has become embedded in the African Americ...

2008-02-05T14:08:00.000-06:00

Mistrust has become embedded in the African American culture as a coping response to a long history of institutionalized racism. It is only one of several cultural values impacting decisions on what is appropriate care for the dying. Religion, family, geography, etc. all play roles. People make their decisions based on what they feel best meets their needs.

Regarding the statement “If only 'they' would trust us we could give them the care that they 'should' be receiving,” the responsibility for changing mistrust in healthcare rests with the system that created it. The system includes all the people in it, regardless of what jobs they do. This is not only a healthcare issue, but also a moral one.

Frances thanks for your comment. My feeling is th...

2008-02-05T11:44:00.000-06:00

Frances thanks for your comment. My feeling is that a lot of the rhetoric about trust has an underlying flavor to it of implying irrationality on the part of African American patients: if only 'they' would trust us we could give them the care that they 'should' be receiving. While trust is an issue, to be sure, I'm not sure it's irrational; and it also can undermine the possibility that the issue may be one of a straightforward difference in emphasis in cultural values surrounding what is good, appropriate care for the dying, as opposed to mistrust.

I'm curious as to your thoughts on this further.

BTW to other readers who haven't seen Ms Shani Parker's blog it's at:
http://hospiceandnursinghomes.blogspot.com/

My comment refers to this statement:“The authors d...

2008-02-05T10:37:00.000-06:00

My comment refers to this statement:

“The authors discussed possibilities as to why African-Americans may revoke hospice care more than whites (and thankfully avoid pathologizing these decisions as due to 'mistrust' which implies a sort of irrationality).”

I am an African American who supports the hospice philosophy. There are various reasons why many of us revoke hospice care more than whites. The “mistrust” factor, which is historically based and documented, is a valid one. The real “irrationality” lies within a healthcare system that continues to be plagued with racial-ethnic disparities.