Quality vs. quantity of life in CHF

The Journal of Heart and Lung Transplantation has a fascinating article looking at treatment preferences in CHF patients. It involved a convenience sample of ~90 patients with CHF (either class II or IV) at a single Canadian center, who were given hypothetical scenarios about treatment options (essentially best medical management, longer life, lingering death; vs. oral inotropes, 4 months of improved symptoms, sudden death; vs. LVAD, improved symptoms and survival, lots of care burdens, lingering death). The basis of this seems to be several trials of oral inotropes which were stopped earlier because of increased mortality in the patients receiving oral inotropes. Despite the increased mortality, patients receiving the inotropes apparently had improved health related quality of life over those receiving best medical care, so the researchers here asked themselves, "Well, is that a reason to stop these trials - maybe some patients would prefer improved symptoms even if it meant decreased survival?" Thus, the current study.

The major findings can be summarized as 1) many patients were happy to take shortened survival if it meant improved symptoms and a non-lingering death and 2) treatment preferences didn't seem to correlate with current CHF severity, symptom severity, or health-related quality of life. While it goes without saying that the scenarios presented to patients were somewhat artificial, the important point here is that there were a substantial number of patients for whom longevity was not the preeminent concern.

This is of course not a surprise, but this paper is written directly at a cardiac research and clinical community and argues research in this population which assume survival benefit as the preeminent treatment outcome is short-sighted, and encourages further scrutiny of oral inotropes as palliative therapy for those patients with quality of life-predominant treatment goals. (Are there any agents currently available? None of the ones they mentioned are commercially available as far as I know. I remember encountering oral inotropes as a resident in research trials but don't know of anything available off the top of my head....)

The other intriguing thing here of course is that preferences didn't seem to be related to current health status or symptoms (the authors had hypothesized that those with the current worse symptoms would be more inclined to receive life-shortening but symptom alleviating treatments). The study wasn't specifically powered to find such a relationship as far as I can tell, however if it exists it is probably not a very powerful interaction. Values may be the more powerful predictor of treatment preferences here.

Predicting in-hospital mortality from CHF

Journal of the American College of Cardiology has a look at predictors of in-hospital mortality for patients hospitalized with heart failure. The study uses data from the OPTIMIZE-HF registry which was a large, US-based quality improvement study/program (i.e. getting patients hospitalized with CHF on more evidence-based therapies, discharged on beta-blockers, etc. - see here) involving 259 hospitals (both academic and community) and 48,000 patients (mean age 73 years, both patients with systolic dysfunction and preserved systolic function were included). The database included ~50 variables: demographics, comorbidities, laboratory (hemoglobin, serum Na, etc.), drug categories (on diuretics, digoxin, etc.), and things like weight, vital signs, etc. In-hospital mortality was 3.8% (about 1800 patients) for the entire cohort.

Using the database, they derived a multivariate prediction model of in-hospital mortality which contained 18 variables. The strongest univarite predictors were serum creatinine (in-hospital mortality increased by 18% for every 0.3mg/dl increase in creatinine), age, and blood pressure (higher being more protective).

They then derived a relatively simple point-system based on the factors which most powerfully predicted mortality (the above 3 plus heart rate, serum sodium, presence or absence of systolic dysfunction, and whether or not CHF was the primary reason for hospitalization) and created a mortality risk nomogram based on that point system (available here - click on the prediction nomogram pdf). (Of note, the model only included patients with complete data so this was based on ~40,000 patients/~1300 deaths.) The model was validated with a within-cohort sample, as well as with data from other large CHF registries, with pretty good results (C-statistics greater than 0.7). As an example, an 85 year old with a pulse of 110, systolic BP of 90, serum Na of 120, serum creatinine of 2.5, and systolic dysfunction would have a ~40% chance of in-hospital mortality based on this model.

To rephrase that, of 100 patients presenting with those characteristics, about 40% would die each hospitalization. I rephrased that to highlight the obvious limits of such models - they can tell us really accurately what will happen to a population of patients but are really limited in telling us what will happen to the patient in front of us. One further caveat about these models is that since it comes from a large QI study there is reason to think that this may overestimate prognosis - patients are likely to do worse outside of such an environment (this is one of the reasons it is helpful to have it validated in outside cohorts, which was done, all of which however were large study registries....). Despite that, they can be used as clinical 'data points' (one of many) in helping us to counsel patients/families as to what to expect. More than this though these are best used as screening tools to identify patients/families with 'acute' palliative care needs (psychosocial/family assessment, prognostic and goals of care conversations, advance care planning, symptom assessment, etc.).

HT to Bob Arnold.


ABRAHAM, W., FONAROW, G., ALBERT, N., STOUGH, W., GHEORGHIADE, M., GREENBERG, B., OCONNOR, C., SUN, J., YANCY, C., YOUNG, J. (2008). Predictors of In-Hospital Mortality in Patients Hospitalized for Heart FailureInsights From the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Journal of the American College of Cardiology, 52(5), 347-356. DOI: 10.1016/j.jacc.2008.04.028

Prognostic awareness in CHF

JAMA has a really interesting article comparing heart failure patients' perceptions of their prognosis with their 'actual' prognosis. 'Actual' in quotes because they looked at their predicted survival with the Seattle Heart Failure Model and not the cohort's actual survival (although they tried to look at that as best they could.) The study involves ~120 patients (median age 61 years) from a single US cardiac center (Duke) with a broad range of heart failure severity (about half NYHA III-IV). They were asked in a couple different ways how long they thought they'd live; this was compared with predicted prognosis.

Median self-reported anticipated life-expectancy was 13 years, whereas the median predicted survival by the SHFM was 10 years, and 60% of patients thought they'd either be cured or have a normal life expectancy. Overestimation of prognosis was not associated with actual prognosis, nor with reporting that one's physician had discussed prognosis with them (which was ~2/5 of the cohort). In multivariate analysis younger age, lack of depression, and worse heart failure class were all associated with more extreme over-estimation of prognosis. (This, then, represents another study finding that depressed medically ill patients may have more accurate understanding of their illness than non-depressed patients.). The sickest, class IV, patients particularly overestimated their prognosis: as a group they gave a number similar to the overall cohort's 13 years (whereas their SHFM prognosis was ~4 years).

Looking only at those who actually died during the (median of -) 3 year follow-up from the study (about 1/3 of the patients): the authors don't give their actual self-reported prognoses, but just note their overestimation was of a similar proportion to the overall cohort's (i.e. by ~40%).

That patients with CHF overestimate their prognosis is not much of a surprise; that over half of them didn't appreciate that their disease is life-limiting is not surprising either, although more troubling (to be fair this study looked at everyone at this center, including those who might have transient/reversible cardiomyopathies, although this was likely a tiny percentage of the overall cohort). The number of patients with relatively short prognoses (~few years or less) is small in this study, which makes it tougher to know what this says about patients likely to be 'of interest' to palliative care clinicians, other than reinforcing our already-established impression of generalized prognostic ignorance. Most disturbing to me is the fact that even those patients who said their docs had talked time with them were as wrong as everyone else, making one wonder what their docs said vs. what these patients heard/chose to hear/chose to believe/etc. In my experience the biggest 'hurdle' is just helping patients appreciate that their class III-IV CHF is a life-limiting disease.

There's also an accompanying editorial, which asks the obvious question of Well, why do these patients need to know their prognosis?

However, a relevant question is "Why is it important for a given patient to be aware of precise quantitative prognostic information?" There are several treatment decisions for which this is important—if anticipated survival time in heart failure is short (<1> referral for heart transplantation or mechanical support needs to be considered. Similarly, referral for hospice or palliative care would be greatly facilitated by an accurate estimation of even shorter-term survival (approximately 6 months or less); conversely, if the expected survival time is at least 1 to 2 years, referral for implantation of a cardioverter-defibrillator would be appropriate. However, beyond these specific examples, no other therapeutic interventions for heart failure exist for which precise knowledge of the likelihood of survival matters in the decision-making process.

I've been thinking of this too, and I don't have any great answers to this. Having a sense of one's prognosis certainly becomes more important the shorter one's likely time is, and one could argue (although I have no 'data' to back this up) that knowing that it's likely to be a few years or less (like the Class IV patients) rather than 13 could make a major difference in how one spends one's time and I think should be disclosed (to most patients). But for patients with longer prognoses, what exactly is the impetus, other than if the patient wants to know him or herself? I'm curious as to readers' thoughts about this....

(See also the comments on another recent post about prognostication in CHF if you're interested.)

Allen, L.A., Yager, J.E., Funk, M.J., Levy, W.C., Tulsky, J.A., Bowers, M.T., Dodson, G.C., O'Connor, C.M., Felker, G.M. (2008). Discordance Between Patient-Predicted and Model-Predicted Life Expectancy Among Ambulatory Patients With Heart Failure. JAMA: The Journal of the American Medical Association, 299(21), 2533-2542. DOI: 10.1001/jama.299.21.2533

Deactivating ICD guidelines

Continuing our intermittent practice of reviewing of treatment guidelines/consensus statements for mentions of terminal care/palliative care, a multiple-organization consensus guideline about implantable cardiac devices has recently been published in Europace (free full-text here). There is a lengthy section on ethics of device deactivation, decision-making around that, etc. It is pretty straight-forward, and treats implanted devices as medical therapies like any other, and can thus be discontinued after careful consideration like other therapies (it avoids the whole these-things-are-implanted-therefore-become-part-of-you-and-thus-subject-to-unique-ethical-analysis debate).

In addition the panel argues that continuation of ICD therapy may be indicated even in patients with DNR orders under these conditions:

• The arrhythmias being treated reflect the primary cardiac condition and not an irreversible secondary medical illness;
  
• Prompt ICD therapy confers the likelihood of added survival with meaningful quality of life and without post-arrest disabilities (e.g., cognitive); and the patient concurs with this approach.

There seem to be two distinctions being drawn here.

First if patients are dying of another condition (e.g. cancer) who also have a cardiac condition (recurrent V. fib) and who don't mind being shocked if their 'fib acts up' it may make sense to keep the ICD activated.

Second, there seems to be a distinction here between a patient having an arrest/arrhythmia which is ICD-shockable and them having a 'real' arrest (becoming pulseless, etc. - something someone would want to do CPR for). I.e. there's a difference in prognosis/likely outcome between the two scenarios: this makes sense on its face but I'm not 100% sure that that's accurate. In my experience the frequency of either of these two scenarios occurring is very small (e.g. the patient's prognosis is so short when the DNR order is being established that the likelihood of the patient benefiting from ICD therapy is negligible), but it's a big world out there and I'm sure there are cases in which this would make sense.

One thing they didn't mention, which I'm still looking for in a publication, is how to counsel families how to deactivate them in emergencies (cancer patient is rapidly dying at home; burden of transport to ED or clinic to deactivate ICD is great; family - with presumably treating physician support - wish to deactivate ICD in-situ). I get asked this from time to time, mumble something about a magnet, but never know how strong of one, etc.

(Incidentally, there was also this recent paper in Pacing and Clinical Electrophysiology, which is a survey of clinicians about practices regarding discontinuation of device-therapy - I have only read the abstract. These subjects reported that about half the time it's the manufacturer's rep who does the deactivation.)

Identifying CHF patients eligible for hospice care

First - a note on format.

As you may have noticed with Christian's last two posts, and mine today, we are changing the format a little. Instead of having ~3 long posts a week, each of which (usually) references many articles, we are going to be splitting up the content into separate posts but will still be updating the content approximately 3x a week. The same volume of content will still be there; just in multi-post form (usually a 'major'/long post and one or more 'minor'/shorter posts).

We're doing this to make the blog easier to navigate and search - a post's title will more closely reflect its content. In addition it will make it easier for readers to skip topics they're not interested in - you won't have to scan a long post to see what's in there anymore.

We are not going to increase the number of emails a week (this will still be, on average, 3 - the emails will be about the same length too - it'll be the same amount of content just divided up more rationally). All the posts will be clustered together so they'll go out in a single email. RSS readers will just notice several posts coming up at once and can pick and choose which to read. The major difference this will make will be for people who go to the blog directly (which is sooo 2005); if you do just be sure to scroll down to make sure you haven't missed any posts.

Give us feedback about how you like this, or not.


JAGS has a paper on predicting 6 month mortality / hospice eligibility in hospitalized patients with CHF. The data used comes from a prospective trial (done, unfortunately, in the mid 1990s) looking at a case management intervention in heart failure mortality. There were ~280 patients, all over 70 years old, and all were enrolled at the time of discharge from a hospitalization for CHF (mean NYHA heart failure class of 2.5, mean EF of ~40%). The researchers looked at characteristics of subjects at the time they were enrolled, compared differences between those that were dead at 6 months (n=43) and those that were living, and created a scoring system to predict 6 month mortality.

The four characteristics which independently predicted 6 month mortality were: BUN over 30mg/dL, systolic blood pressure less than 120 mmHg, presence of peripheral vascular disease, and serum Na less than 135 mEq/L. Patients who had 3 or 4 of these risk factors had a 66% 6 month mortality (41% for 2 risk factors, 16% for 1, 4% for none). Only 9 patients, however, had a 3-4 risk factors. The negative predictive value of a score of 3-4 was 86% (86% of patients who had scores less than 3 were in fact alive at 6 months).

Some comments.... The need for such an index/risk score is compelling, as there are no decent, objective (i.e. not clinician assessment) indices/ways of predicting 6 month mortality in patients with CHF, and a relatively simple scoring system like this could be useful for 1) establishing hospice eligibility, but more importantly 2) helping clinicians identify CHF patients who have 'acute' palliative care needs (need for discussions about prognosis, code status, advance care and terminal care planning, etc.). CHF is devilishly difficult to prognostic in, so any objective, data-backed guidance is welcome. On the other hand this index is not ready for clinical use. The data come from the mid-1990s and while CHF mortality hasn't improved dramatically (I think) in that time there have been more widespread identification and use of interventions which incrementally improve survival (ICDs, resynchronization therapy, spironolactone, etc.). And while an N of 43 (dead patients) is unfortunately not atypical for these sorts of studies, it's pretty low, and the N of 9 for patients who actually had 3-4 risk factors is low enough to immediately halt any clinical application of this (other than to reinforce the prognostic importance of PVD, hyponatremia, etc.). 'Further study is needed' (of course, but when can you not say that?).

The NHPCO guidelines for hospice eligibility for CHF patients are well-recognized for being largely...empiric (to be polite about it - although based on the best available data and wisdom at the time). Perhaps the NHPCO could fund a validation study using contemporary data from multiple institutions and many more patients? Unlike my ramblings in my prior post about cancer and prognosis, I perceive prognostic uncertainty to be a real issue in limiting the availability of hospice/palliative care in CHF.


Huynh, B.C., Rovner, A., Rich, M.W. (2008). Identification of Older Patients with Heart Failure Who May Be Candidates for Hospice Care: Development of a Simple Four-Item Risk Score. Journal of the American Geriatrics Society, 56(6), 1111-1115. DOI: 10.1111/j.1532-5415.2008.01756.x

Oregon's Death With Dignity Annual Report 2007

2008 marks the 11th year of the nation's first physician-assisted suicide (PAS) state law, also known as the Death With Dignity (DWD) Act. Every year by law, the Oregon Department of Health Services releases an annual report and characteristics of the patients who died and received prescriptions for the intended self-administration to hasten their death.

The summary of the 2007 annual report is now available for pdf download as well as the supplementary data and all annual reports from the Oregon DHS website. Since this may hit the news and your patients and colleagues may ask how this relates to palliative care where you practice it is important to become somewhat familiar with this report.

For background, here are the Pallimed posts from Annual Report 2006 and Annual Report 2005, as well as a primer on confusing hastened death terms.

The basic summary highlights that the small increase in the number of deaths under the DWD act. There was a fairly significant increase in the number of prescriptions given in the past year, but without a similar rise in the deaths via PAS.

It is important to look at the other outcomes of patients who receive a prescription, because it is not just life or death by DWD. The other outcome is that a patient dies by natural means without ever ingesting meds for physician-assisted suicide. The graphs with the annual reports do not show this trend well, which is why I have laid them out in two different ways.

The first graph shows the change over the past 10 years in absolute numbers and the second shows the change in percentage. The three outcomes are: death via physicians-assisted suicide/DWD (red), death by natural means (beige), alive (green). As you can see there was a larger amount of patients who died by natural means in 2007 after receiving a prescription. Most people interpret this as reinforcing the control a patient has in a situation with increasing loss of control, dignity (86%) and autonomy (100%) % indicates number of prescription recipients whose physicians marked these reasons for the request for PAS. These existential sufferings are not exactly manifested as a simple depression and inherently difficult to treat with medications or intense human interventions as any palliative care person will tell you. I quote Drew from an earlier Pallimed post:

"Death, pretty much by definition, sucks--full of anguish in even the best of circumstances--for patients, families, and frequently clinicians."

But as he goes on to say in the post, it doesn't mean we need to stop trying to work with dying patients and families to make the most of bad situations. As more PAS legislature get presented in states across the US, how will our field respond when they look to us for advice? (By the way Kevorkian is running for Congress. Hold on to your hats, the media should have fun with that one.)

Another way of looking at the proportion of PAS deaths is there are 15.6 PAS deaths for every 10,000 deaths in Oregon or 0.156% Oregon deaths. Other interesting data to review is that no African American has received a prescription from the PAS despite being 1% of all deaths in Oregon. And although the numbers are small so it is hard to draw a conclusion, Asians have had a larger proportions of PAS deaths compared to all Asian deaths in Oregon (54.6 Asian PAS deaths for 10,000 Asian Deaths in Oregon). Email me if that last sentence doesn't make sense.

The other demographics show most were older 55-84 year olds making up 75% and most ahd some college and all had insurance, so less likely to reinforce a poverty/low SES discrimination slippery slope argument against PAS. In fact the most heavily weighted non-disease demographic likely to use PAS were those with Baccalaureate (83/10,000 deaths) or Post-Bacc degrees (113/10,000 deaths). Any hypothesis on why the advanced degrees are more likely to make use of PAS? We don't know how many of those people are also health care professionals.

HIV/AIDS, ALS are the diseases that more associated with PAS with oral cancer being the highest odds ratio of using PAS. Interestingly CHF and COPD are very very underrepresented in PAS deaths, possibly secondary to the more fluctuating course of the disease?

Complications (yes this could go wrong) were few, including regurgitation in 3 and a unexpected length of 3.5 days after ingestion before death occurred.

So I hope this enlightens some to what is often glossed over or misunderstood or not even realized at all. I cannot tell you how many medical students, residents, nurses and other health care professionals lack basic background knowledge on this subject. Make up your mind either way, but start with some facts to make sound reasoned arguments for or against.

Homework question given to me from a medical student with a small Pallimed prize to anyone who can answer this correctly for me (in the comments). Drew has speculated on an answer but we don't have anything definitive yet.

If a person dies by physician-assisted suicide, can the family still collect on the insurance policy, or was that even considered when the law was legislated?

The 'Imminence Condition'; PHN; More

1)
2 from Journal of Medical Ethics:

• First is one on terminal sedation and the 'imminence condition'. It's a difficult-to-summarize paper whose main point seems to be that the 'imminence condition' (continuous sedation to unconsciousness without fluids/artificial nutrition is OK as long as the patient is imminently dying and so withholding sustenance is unlikely to hasten death by much), which is endorsed by some proponents of TS, has not been fully explored in the literature and is full of holes (ethical analytical holes, you know the type). Never one to avoid whacking my clinician's head over an ethical analysis, the major issue I had with this is that the author repeatedly states that the imminence condition is not supported/explained by ideas of autonomy, proportionality, or double effect. However he never explains how proportionality fails to support the 'imminence condition.' I mention this because when I lead discussions on this I make the argument that it does (all of this is my opinion of course):
• Imminently dying (likely prognosis less than ~~few weeks) & intractable symptoms; potentially hastening death by providing deep sedation without artificial nutrition/hydration is proportionate to the alleviation of intractable suffering and the loss of several days of life. Vs.
  
• Not-imminently dying (prognosis of months) and intractable symptoms (existential or otherwise) --> here I think one can make a good argument for lack of proportionality between shortening life by months and alleviating the suffering. (Lord knows not all would agree with this, or with my first point above; my point however is that the concept of proportionality informs this discussion.)

• Second is a study on physicians' confidence in discussing DNR orders. In case you have any any doubts about its results, it indeed did find that we are far less confident in discussing 'code status' than other medical procedures, and that housestaff are less comfortable than attendings.
  

2)
Journal of Pain recently had a supplement on all things post-herpetic neuralgia. It has articles on the diagnosis, natural history, prevention (vaccination), etc. of PHN. The supplement is industry funded. A couple things to note:

1. The treatment article lists (in its summative drug treatment table) levorphanol as one of the opioid treatments (and not hydromorphone, fentanyl, or oxymorphone). This seems to be an idiosyncratic choice by the authors (i.e. not because levorphanol has been particularly studied for PHN). When was the last time you saw levorphanol mentioned in an article like this (except in an article suggesting it should make a comeback)? Anyway it's a good review article and mentions numbers-needed-to-treat as much as possible (although frustratingly fails to define what the NNT was for: e.g. 50% pain reduction?). One for the teaching file.
2. The mechanisms of pain and itch in PHN article is very readable, and morbidly fascinating (read the itch part). It has a lot of history and in some ways traces the history of thinking about chronic pain via examining the evolving understanding of PHN.
   

3)
Journal of General Internal Medicine has a series of articles on discontinuing implantable cardioverters/defibrillators (all full-free text). One on the ethics of doing so; one on patient attitudes about it (an incredibly depressing but thankfully small qualitative study in which none of the patients had discussed ICD deactivation or knew it was an option and seemed freaked out by even discussing it); and one on clinician attitudes about discussing ICD deactivation. Quote of the year:

"That’s like an act of suicide. It’s a threat to your life. That’s like cardiac arrest. That’s insane."

4)
A provocative little letter in CMAJ (free full-text here) about decision-making in impaired adults:

"Our colleagues in pediatrics, who face an equally limited decision-making capacity among their patients, have taken a more nuanced approach based on the following principles: children have dignity, intrinsic value and a right to medical treatment that serves their best interests; children should be involved in decisions that affect them; information should be presented truthfully and with sensitivity; decision-making should be interdisciplinary and collaborative; and the best interests of individual children should be of primary concern. We at CMAJ are surprised that such principles are not considered for adults with diminished decision-making capacity."

Their argument is that decision making capacity is not an all-or-nothing thing, and we should stop treating it as such. My feeling is that in real-life the above-mentioned principles are often considered for impaired adults, even if not explicitly stated (at times my group discusses the need for assent from our impaired adult patients even if we cannot obtain 'informed consent'). It's nice however to see these ideas in print.

5)
On the EBM front....

NEJM recently published a piece looking at publication bias in antidepressant trials (it looked at all trials of antidepressants which were registered with the FDA and compared those which were published in the literature and those that weren't). They found that the unpublished trials were much more likely to be negative ones, and that even several trials which the FDA deemed negative (not supporting the efficacy of antidepressants) were published with positive sounding results. This is not to say they aren't effective but that the magnitude of benefit may be over-estimated, and also sounds a (general) cautionary alarm when interpreting systemic reviews or meta-analyses which rely only on published research (particularly in areas in which there is a lot of industry-sponsored research and thus perhaps a lot of research which is never published).

AAHPM Pre-Conference Preview - Part II (HPNA Sessions)

The American Academy of Hospice & Palliative Medicine and the Hospice and Palliative Nurses Association Annual Assembly is coming up next week. I started doing the preview because one of my favorite things about conferences is talking to other people to see what they are interested in, so feel free to tell us what you are going to and why. If you are giving any of these talks, I encourage you to leave some comments to get more people aware of your talk. I am not as familiar with some of the HPNA speakers and their experience so please feel free to leave comments.

Previous entries:
Preview of AAHPM Pre-Conferences - Part I

Wednesday January 30, 2008
8a-5p

Generalist Clinical Review: Train the Trainer
by Grandovic

Train the Trainer sessions are an essential part of spreading information in a consistent manner. they usually follow a script to some degree as a means to ensure the consistency. Usually they are taught by a few experts in the field. Nancy Grandovic is the director of education for the HPNA, so that is a pretty good qualification. While the course is $200, you do get quite a few resources for the price. Might be a good resource for getting more certified Hospice & palliative Care RN's.

8a-Noon

APN Billing: The Good the Bad and the Ugly
by Dahlin

As anyone who has started to work through billing issues with advanced practice nurses knows there is a lot of variation from state to state, and things that seem clear end up being pretty cloudy. For anyone who has an advanced practice nurse working in your hospice or palliative care program, this one is a must to make sure that you are optimizing a great resource. Tom, any comments on how nurses can make the acronyms less confusing or what the origins for all the different levels are? (APRN, APN, APNP, CNS, etc, etc.)

Psychiatric Illness and the Dying
by Morgan

Covering an important area in hospice care, Betty Morgan delves into PTSD, substance abuse, and other complex psychiatic co-morbities as they relate to patients and families. From the abstract it sounds like it will cover more then just depression and anxiety for sure.

From Grassroots to Inside the Beltway: Policy Advocacy for Hospice and Palliative Care Professionals
by Buck, Rogers, Coyne
(Ha, Ha...Buck and Rogers, that is funny)

While not an area that many small palliative care programs and hospices may be able to enter, this is a subject that has not been covered much in recent conferences. I am glad to see policy programs such as this. One interesting thing that came up in a recent discussion of future avenues for expanding hospice programs was for individual programs to collaborate for local and regional legislative initiatives. Given some of the very competitive markets for hospice this would be a nice area to see some collaboration.

1-5p

History and Physical Findings Related to Drug Therapy Management
by McPherson and LaPenta

This session would be very helpful for nurses in the field since they act as eyes and ears fro all things clinical in programs that do not have the luxury of physicians that make home visits. Even when you do have more active physician involvement in the home, the level of nurse-MD collaboration seems to increase necessitating better H&P skills for the nurse.

Challenges with Family Dynamics in End-of-Life Care
by Owens and Stellrecht

For most palliative care practitioners, family dynamics are really on-the-job training. Having a MSW (Stellrecht) as part of this session may be an important piece to setting up a systematic way to address family conflicts. Interestingly it is listed as a workshop but there is no mention of role-play, maybe because that usually scares people away because of fear of participation?

Implanted Cardiac Devices and End-of-Life Decisions
by Luebke and McKee

This description of this session starts out by describing pacemakers and defibrillators, but the rest goes on to only address ICD's and the withholding of ICD therapy when near the end-of-life. I have noticed the general opposition to ICD reprogramming at EOL has been much less recently, but the issue of whether or not to withdraw/withhold pacemaker therapy seems to be more controversial in the cardiac field. I hope they go into more discussion about pacemakers as well since they have 4 hours.

Look for the rest of the conference this week. There are a lot of sessions so expect a few posts.

Photo by Flickr.com user Damgaard

Pain in CHF; Methadone & QT; Caring for Patients vs Caring for Organs; More

I'm probably not going to be able to blog anything seriously this week, so will probably do a couple of quickie posts about articles from my pile.

1)
Multiple notable articles from the most recent Archives of Internal Medicine:

a)
First is an observational study on symptom prevalence in patients with COPD and CHF. 133 patients (community dwelling, mean age ~73 years, a little over a third had at least one limitations in ADL's) underwent quarterly symptom interviews for 2 years. ~40% of the cohort died during the study. Dyspnea, pain, discomfort, fatigue, appetite problems, depression, and anxiety were all quite common, and many increased in either prevalence or severity across time. Notably, pain was quite common in the CHF patients and increased in severity over time (% reporting moderate to severe pain increased from 20% to 42% over the study). More indication (not that it was really needed) that pain is by no means a problem of advanced cancer....

b)
Next is a follow up to this landmark study about the 'chronically critically ill' (more or less patients needing long term ventilation after a critical illness), looking at the information families/patients received about it, prognosis, etc. This study involves data collected at the time of the first study, and looked at the information families (and the few patients who were communicative) received about their care. They looked to see if these domains were discussed:

1) nature of the patient's illness and treatments; (2) prognosis for outcomes including ventilator independence, function, and quality of life; (3) impact of treatment on patient experience, including symptom burden; (4) potential complications of treatment; (5) expected care needs after hospitalization; and (6) alternatives to continuation of treatment.

The results are, simply put, dismal/disheartening, and suggest that 1) prognosis was frequently not discussed (this was a cohort of patients with a >50% 6 month mortality) and 2) alternatives to the current care plan, something which is technically necessary for informed consent, were rarely discussed. 83% of families reported not hearing alternatives to continued mechanical ventilation; 93% weren't given a survival estimate; 80% reported hearing no information about expected functional status after hospitalization. It goes on like this....

c)
There's also a paper about the development of a