More on “futility”

A couple of weeks ago Drew blogged on a short essay/case report in Journal of Clinical Oncology that addressed a physician’s struggle in prescribing chemotherapy that he considered to be futile. The same day I got my latest issue of Oncology with an article (with 2 invited responses, here and here) on patient demands for chemotherapy that clinicians feel is futile. I believe this is the inaugural offering in the new feature, “Areas of confusion in oncology.”

The Oncology article is a fairly wide-ranging piece that begins by addressing what is meant by “futile care.” The authors point out that there is no common or consensus definition [I imagine that at least some of this is one of those “I know it when I see it” phenomena]. A recurring theme in this paper is discordance of perceptions and perspectives between patient and physician. Expert panels struggling over guidelines, a physician facing a desperate or resolute patient, children not willing to contemplate “giving up” on Mom, a patient with a religious belief that “everything” must be done, third-party payers—whether private or government, and John Q. Public (i.e., “society”) in the grip of a compelling drama may have varying and conflicting perspectives.

The authors quote a 1993 article in which the reader is advised to distinguish an effect from a benefit. That dovetails nicely with an observation later in the paper that some patients overestimate prognosis because they confuse response with cure.

Not surprisingly, a major cause of the disparate perceptions is assigned to inadequate communication between patient and physician. And not all the blame falls on the physician. When each is waiting for the other to bring up discussions of goals, values, quality of life, prognosis, end-of-life issues, etc., “misalignment of perceptions” can be expected. The physician may even have thought that s/he provided adequate information on prognosis. But if they provide too wide a range of outcomes, don’t periodically come back to the discussion, or don’t check in with the patient to see what was understood, the discrepant perceptions can grow ever wider. “Lack of patient-provider communication regarding prognosis, goals of therapy, and benefits of aggressive symptom management (hospice) all play a role in the delivery of futile chemotherapy.”

There are several interesting tidbits provided that may be helpful to both experienced clinicians and to students or junior clinicians who are trying to get their heads around the issues related to futility dilemmas.

• Over 20% of Medicare patients begin a new chemotherapy regimen within 2 weeks of death
• A recent survey of oncology practices showed a range of 0-34% giving chemotherapy within 2 weeks of death
• At least one study has shown that some patients with previously treated non-small cell lung cancer would accept chemotherapy with a survival benefit of as little as one week, while others would not take it even for a benefit of two years
• Another study showed only a 25% concordance between what patients said their decision-control preferences were and the provider’s perception of the preference.
• Some patients appear to be willing to discuss hospice with a physician other than their oncologist, but not with the oncologist [is it too hard for the patient; does the patient think it will be too hard for or hard on the oncologist?]
• In one study, physicians initiated a hospice discussion 50% of the time, patients or families one-third of the time
• One-quarter of physicians will occasionally administer futile chemotherapy to maintain patient hope.
• The median length of hospice stay is no longer lengthening, but getting shorter (down to 26 days in 2005 vs 29 days in 1995); one-third enroll in the last week of life and 10% on the last day.

An important observation that I have never heard invoked in discussions among clinicians about futility, is that there insufficient information available for patients with advanced disease to access independently. Accurate but vague statements such “current treatments do not cure the cancer” are not helpful for a patient struggling with finding their own process for decision-making. There is very little to be found about the advantages and disadvantages of chemotherapy at this stage, what a patient might reasonably expect, or alternatives such as palliative and hospice care. These points relate to patient questions such as “will I feel better or worse?” (if I take the chemotherapy); “will my cancer shrink [and what does that mean in the short & long term]?;” “how do other people make decisions about these things?”

The authors’ recommendations:

• Don’t go it alone—use trusted colleagues to share concerns, avoid isolation and burnout
• Ask the patient how much they want to know, how they want to make decisions
• Bring up hospice early as a future possibility; emphasize nonabandonment and aggressive symptom management; avoid euphemisms: use “death” and “dying” [while I personally agree with that philosophy, there are cultural overlays and sensitivities than need to be considered.]
• Use family conference as a way to get the same information simultaneously to multiple people who may be family decision-makers; be prepared to share actual studies to bolster your position that there is little or no benefit to further chemotherapy and that there may be significant burden or harm [is “symptom burden” a useful construct for patients who have been focusing on tumor shrinkage? I think it is.]

Equally valuable as the main article, the reviews provide valuable nuance and perspective. One practical idea is the "differential diagnosis" of a patient request that the oncologist thinks is not in the patient's best interest. What underlies the request--unrealistic expectations? Fear of abandonment? Present hospice as a treatment [reminiscent of Andy Billings' statement that family meeting is one of palliative care's most important procedures]. "A 20-60 minute conversation between an oncologist and a patient . . . is miniscule when weighed against a lifetime of family values, traditions, culturally held beliefs, and deeply entrenched religious beliefs."

Khatcheressian J, Harrington SB, Lyckholm LJ, Smith TJ. 'Futile Care:' What to Do When Your Patient Insists on Chemotherapy That Likely Won’t Help. Oncology 2008;22(8):881-887 (free full text) http://www.cancernetwork.com/cme/article/10165/1168027

A Palliative Care View of "Hopkins"

ABC has been featuring residents from Johns Hopkins University on the reality docudrama "Hopkins" on Thursday nights. The show goes to where the action is by focusing on the emergency department, surgeons, and pediatric ICU. Overall the show manages to capture life as a resident pretty well even following the difficulties outside the hospital for one of the physicians going through a divorce. I had high expectations of palliative medicine being featured during the show given that over 6 hours there would likely be some end-of-life issues cropping up. But after 4 episodes the demonstration of palliative care skills has been mixed.

Have any Pallimed readers been watching this show?

I am curious to how some of you responded to a pediatric intensivist* who suggested to "just let the child die" during a informal doctors conference about a toddler with a dilated cardiomyopathy who had a cardiac arrest during anesthesia induction about to be put on ECMO? You can watch it yourself...EPISODE 4 available online; move to a little less than a quarter of the way through the episode. You have been warned by the way, seeing the child unresponsive and actually coding was very difficult to watch for me even being through lots of codes and seeing deceased, lifeless patients.

Here is the full text of what he said on air (after what was edited I presume by the TV producers):

(In hallway with cameras, alone)

PICU Attending #1: We don't know hom much damage has been done. And there is some disagreement as to whether we can save the heart or not.

(Cut to conference room with lots of doctors, no patients/families)

PICU Attending#2: It is my opinion that we just let the child die. ECMO would be a bad idea. But I suspect that I am in the minority.

#1: Why would you say that? We don't have the biopsy back yet. If the biopsy shows that he has acute myocarditis...then we could...uh..ride him thruough this storm. Now if it shows that he has got..uh you know scar there..well..yeah...then we got a problem.

#2: What do you think the biopsy is going to show?

#1: I agree that this is likely to be old.

(fade to black after seeing them both stand quietly not looking at each other, appearing demoralized.)

Interestingly this is how the above situation is described on the website synopsis:

"let him deteriorate and provide palliative care or attempt a risky heart transplant if one becomes available."

But they never actually talk about palliative care on the show. Can someone else remember where they said 'palliative care?' I can hear those words in the media from a thousand paces.

I think it is important to realize this scene and the doctor's words got a lot of outrage on the Hopkins/ABC website in the Episode 4 Talk Back Q& A section. People are calling for his firing, and saying he should not be a doctor. The child eventually made it through the situation causing more outrage on the message boards. And further anecdotal evidence for the public that 'doctors can be very wrong.' To me this scene is part of the frank discussions physicians may have every day, especially doctors in the ICU. Sometimes opposing views need to be heard even though they may be unpopular to make sure there is justification for the current plan of action. The attending even pointed that out by acknowledging his 'minority' view point.

While palliative medicine as a specialty is lacking on the TV show (Hopkins surprisingly does not have a palliative medicine fellowship), the Hopkins/ABC website has video responses from Dr. Holly Yang from San Diego Hospice about different situations in each episode that could have been approached in a different way. You sometimes might have to scroll through the responses to find Dr. Yang. Too bad they had some audio difficulties with some of her segments.

Hopefully we may run across good examples of palliative care in the last two episodes this Thursday night and next Thursday night on ABC. Check your local listings. (There I have finally said it. Now I need to cross off "Stop the Presses!") All the episodes are also viewable online and on Itunes.

We may have to do a code count for the show to see how they portray CPR. Any volunteers?

* One commenter dubbed him a "insensivist" I got to remember that one.

Opioid vs Narcotic; ABCs of Medicine; Hyperalgesia; Required Reading

1]
Several times in this blog we have discussed our preference for the term ‘opioid’ rather than ‘narcotic’ when referring to the substances (natural, synthetic, endogenous, exogenous) that occupy the mu receptor. See here and here for a couple of examples. Note the comments, as well. An interesting small, simple, and direct study from the Pittsburgh Veterans Administration Hospital has addressed the important issue of what patients understand when they hear the terms ‘opioid’ and ‘narcotic.’ One of our readers previously commented that using ‘narcotic’ makes sense since that’s the term patients (and other lay people) use and understand. On the basis of this study’s findings, she’s right. The researchers asked 4 (almost) identical questions of 100 people in a clinic waiting room. The “almost” part means that half the patients were asked about the term opioid and half about the term narcotic. The questions: “What is a narcotic/opioid?” “Give an example of a narcotic/opioid.” “Why does someone take a narcotic/opioid?” “What happens when someone takes a narcotic/opioid for a long time?”

The findings are both surprising and not. 83% of the patients in the opioid group did not know what it means; only 10% did not know what narcotic means. Actually both numbers sound high to me. Strikes me as nearly impossible to get well into the adult years without knowing what a narcotic is. I guess its more disappointing than surprising that so many patients don’t recognize the term opioid. Subjects in this study were recruited from outpatient primary care and surgical clinics. There was no breakdown of answers by clinic reported. Of the patients who recognized either term, only half in each group associated it with pain management in their definition and again when asked why someone would take an opioid/narcotic. Again, that is disappointing, but in my somewhat jaded view that may well be higher than the results you’d get polling reporters, DEA agents, politicians, politically-inclined prosecutors, and maybe some strata of the general population.

One of the major concerns expressed by those of us who worry about the negative legal and addiction associations of “narcotic” when applied to pain management was confirmed, but the numbers weren’t too bad, considering. 19 of 50 respondents associated abuse and illegal drugs with the term narcotic. The bad news is that 90% of the people who answered the question on what happens when someone takes an opioid/narcotic for a long time referenced addiction or an adverse outcome and the vast majority of those specified addiction.

The bottom line is that, if these results are generalizable, we have a lot of educating to do, at all levels and via all media.

2]
This must be VA day at Pallimed. Paul Rousseau, a well-known palliative care doc at the Phoenix, AZ VA hospital wrote a short essay for The Left Atrium column in the Canadian Medical Association Journal called ABCs of Medicine. Seemed like the kind of piece you might write after a long day—or week—of tiredly swimming against the continually rising tide of depersonalization that “the System” has become. The trigger is an admission note that begins: “62-year-old male admitted for hospice placement with the diagnoses of HIV, DVT, PTSD, GERD, BPH and PUD.” Digging a bit, he is able to conclude that the patient is a “pleasant and alphabetized man who is dying, no longer smokes, and lives with his wife.” He muses on the various reasons for the “psychosocial silence in this chart.”

3]
One more from the VA: this is a short review of opioid-induced hyperalgesia. It’s not very meaty and it is not a how-to article, but it succinctly lays out the prevailing theories/models of opioid-induced hyperalgesia and the three thus-far-identified interventions: opioid rotation (enough evidence to recommend it as a first line intervention); addition of an NMDA receptor antagonist such as ketamine or dextromethorphan (evidence not very strong and not recommended); addition of an ultra-low dose of an opioid antagonist (again, evidence noy very strong and not recommended). The authors point out that there is an investigational agent (Oxytrex) currently in clinical trials that combines oxycodone and naltrexone for pain management.

4]
Check out this title: “A matter of definition—key elements identified in a discourse analysis of definitions of palliative care.” Sounds terribly dry, but it turns out to be surprisingly readable and so well put together that I will make it required reading of my students next semester. The article is fascinating from an historical, etymological, sociological, and cross-cultural perspective. The authors are all palliative medicine physicians (turns out there is no translation for palliative care other than ‘palliativmedezin’ in Germany) affiliated with German universities. They searched for definitions of ‘palliative care’ and ‘palliative medicine’ in Google and in textbooks, finding a total of 35 definitions in English and 26 in German. They then used discursive practice—“a process by which cultural meanings are produced and understood”—to analyze the definitions.

Key elements identified were target groups, structure, tasks, expertise, theoretical principles, and goals of palliative care.

Among the conclusions:

• The term palliative care is a pleonasm (a new word for me—means redundant) since both palliative and care are concerned with the issue of protection.
• Palliative care/medicine is unlike any other specialty since it doesn’t have a specific object of study nor define itself by the age of its patients
• In fact, it has a hard time defining its population of focus at all. Protection of the patient “means a comprehensive and at the same time diffuse orientation.”
• Only a very few definitions explicitly describe the philosophy of palliative care.
• Having the family and patient as both the unit of care and as members of the care team creates some inherent role difficulties
• There is no consensus on the meaning of the terms multidisciplinary and interdisciplinary
• There is an emphasis on symptom control, but Kearny is quoted as warning against becoming a ‘symptomatologist,’ as symptom management is only the beginning of palliative care therapy.
• In that context, the human being is the focus of care, the goals address suffering and quality of life, and emphasizing wholeness through a respect for autonomy and dignity is a defining value.
• Interestingly, the current American definitions are seen to de-emphasize death and dying as compared to historical and some European definitions.
  

There is much more and I can’t do it justice in this space. This is a great journal club article, and can be grist for both introductory discussion and reflection on practice and meaning for veterans and their teams.

References:
Mangione MP, Crowley-Matoka M. Improving Pain Management Communication: How Patients Understand the Terms "Opioid" and "Narcotic." J Gen Intern Med. 2008 May 31. [Epub ahead of print]

Rousseau P. ABCs of medicine. CMAJ. 2008 Jun 3;178(12):1580-1581.

Leonard R, Kourlas H. Too much of a good thing? Treating the emerging syndrome of opioid-induced hyperalgesia. J. P-harm Pract 2008;21(2):165-168.

Pastrana T, Jünger S, Ostgathe C, Elsner F, Radbruch L. A matter of definition - key elements identified in a discourse analysis of definitions of palliative care. Palliat Med. 2008 Apr;22(3):222-32.

American Pain Society Meeting

I attended the first two days of the American Pain Society Annual Scientific Meeting in Tampa, Florida. It is a big affair, over 1300 people. I was quite impressed by the quality of the speakers--not just the the content of the presentations, but the speakers were, for the most part, good presenters.

The most prevalent recurring theme in the clinically oriented (as opposed to the basic science) presentations was the issue of prescription opioid abuse. It got a bit wearisome after awhile, perhaps because I presented on the same topic at the Nursing SIG session! Kinda reminded me of a recent cautionary comment by Kathy Foley at another meeting that pain management is being eclipsed by risk management. The most controversial session, on the Washington State opioid guidelines (see previous mention), was well managed and avoided descending into a shoving or shouting match. I'm still left unconvinced that the identified problem (an increase in opioid-related deaths in workman's comp patients) will be solved with the institution of the guidelines. They have been identified as a pilot and an educational endeavor, but one person from the audience said that he had been denied insurance payment for a patient on opioid doses greater than 120 mg unless additional justification was provided (perhaps an inevitable and predictable but unintended consequence). The "education" is being provided by the medical director for the department that handles workman's comp. He was obviously well-meaning and very concerned about safety issues, but he is not a pain specialist, and as far as I could tell, had no special training or experience in pain management.

The exhibit hall also had it's share of substance abuse-related products and give-aways. There were several urine toxicology companies there and multiple free "risk-reduction" education pieces, all sponsored by pharmaceutical companies.

There was an entire session (which I did not attend) on new tamper-resistant formulations of opioids.

Other new products and products in clinical trails of interest to this readership: Subcutaneous methylnaltrexone (Relistor) for opioid bowel dysfunction (see previous post); an oral form is just entering phase 2 trials; a pegylated oral form of naloxone is just entering human trials; an oxycodone-morphine combination tablet has just completed its first phase 3 trial; a sustained-release hydrocodone-acetaminophen tablet has completed a phase 3 trial; a cannabinoid is approaching clinical trials. Most of you are probably aware that there are new dosage strengths of OxyContin (15, 30, & 60 mg), and that all of the generic CR oxycodone products are off the market. There are also new dosage strengths of oxymorphone ER (Opana ER; 7.5, 15, & 30 mg).

There was a lot of exciting new basic science regarding pathways, receptors, neurotransmitters, and other cool stuff that was mostly over my head, but by implication provided new therapeutic targets.

One of the most interesting sessions was on rational approaches to multidrug treatment of neuropathic pain. It's all about patient assessment and pharmacokinetics.

On to the nursing (American Society for Pain Management Nursing) pain meeting in the fall!

L'Envoi by George E. Ehrlich

The following essay was first published in Prognosis: Contemporary Outcomes of Disease, published by Charles Press, 1981. Permission granted from Dr. Ehrlich to reprint on Pallimed.

Prognosis is the essence of Medicine. It gives purpose to diagnosis and helps the physician ascertain what might happen and decide what ought to be done about it. It lends rationale to treatment. All therapeutic decisions, the popular cost-benefit ratio, and various equations that determine choices are based on what we understand about prognosis. It is bewildering, then, that prognosis receives only passing mention in the disease descriptions found in most textbooks and that its study has not yet been dignified by designation as a major scientific discipline.

And yet this should come as no surprise. The forbidden kernel in the gift of Prometheus was foreknowledge. Adam and Eve were expelled from Eden because they wanted to know what would happen next. Primitive instinct, which causes animals to respond with fear and flight, detects the danger without understanding it; only Man seeks to scan the future. Prognosis is the forbidden fruit and its pursuit is cloaked in magic. Laocoön perished with his sons in its service, and the gods assured Cassandra's warnings would not be heeded. Logic could infer that it was not too much to expect that the victorious general, Macbeth, would be awarded the traitor's earldom and an elective kingship upon death of the elderly Duncan; voicing the obvious could not come from Banquo or Macduff, however, but had to be pronounced by the three mysterious witches. Three sisters - the magic number: an exclamation point lest one not realize the terror implicit in knowing the future.

To learn what would be, Wotan was willing to sacrifice an eye. The malign, one-eyed Hagen was able to capitalize on this distinctive physical similarity to dominate the Nibelungenleid and to become the instrument that determined future events. The pallid Siegfrieds haven't a chance - the present is ephemeral, the future vast. Mephistopheles, Iago, Edmund, and Goneril and Regan - the villains move the piece and fascinate us - their actions become their prognosis. Alfred North Whitehead proclaimed that "It's the business of the future to be dangerous." The more one understands what the future will bring and the more one sees what might be, the more rationally one can behave. Early caveman developed society to aid in withstanding the rigors of existence and he developed agriculture because inclement weather was to be expected. Survival depended on the understanding that putting in stores during the good years and the good days would anticipate the bad. The dream of Joseph saved the peoples of the Mediterranean litttoral. Long before, hunters learned to follow spoor that would lead them to their prey, and the development of this ratiocination determined the optimal place to settle in order to survive. Like Brigham Young, they could say with certainty, "This is the place."

The pursuit of knowledge of the future comes dear and the knowledge itself dearer. The man that once did sell the lion's skin/while the beast liv'd was kill'd with hunting him," says Henry V. Croesus sought to know whether he ought to oppose the might of Persia or offer tribute. The Oracle informed him that, if he went to war, he would destroy a mighty empire. Thus emboldened, he fought the Persians, only to see his own empire destroyed. In reading the future, one must be certain not to be misled. Santayana warns that not to know the past is to be condemned to repeat it. I prefer Aubrey Menen's studious locust, as he became enlightened in the irreverent retelling of the Ramayana: "After titanic study he was satisfied that a thorough knowledge of the past could lead a profound scholar to predict the future course of history with great accuracy provided that it does not turn out quite differently."

The annals of prognosis are cloaked in mystery and feature a faintly disreputable cast. From the Witch of Endor to Nostradamus, from Heraclitus to Spengler, from Confucius to Malthus, being able to see more clearly assures immortality and hostility in equal measure. Yet the capacity to understand the future helped to create Man. The sibship of the correct prognosticator survived to become our ancestors. It is the knowledge of the future that is powerful medicine and thus it is of the Medicine Man that the tribe stood in awe. Empirical observation produced the skill. But how many pharaohs had to undergo trephining of their skulls because it once relieved the intracranial pressure in one?

The responsibility the physician assumes is great. The Ius Talionis saw to it that risks attended the rewards. The physician who cost the patient an eye suffered the loss of his hands. Codified by Hammurabi, the balance implies a sureness, a guarantee, that we have not achieved to this day. Scribonius made the doctor a productive servant of God from whom all healing comes and who imparts to medicines their power. Immortality was longed for, but mortality assumed. Maimonides set the span of life at one hundred and twenty years and argued that it was man who shortened it. How prescient, as Hayflick's cell division gives a figure only slightly lower! Can we determine the factors that shorten life in order to conquer them? Empiricism and the combination of simplistic holisms have given us a start in that direction. But the mischief of irresponsible prognostics is still with us and the task of sorting out only just begun.

The modern science of prognosis is based on analysis of groups of people. In most instances, it is not yet possible to extrapolate from the general to the specific in order to arrive at a correct prognosis in a single instance. Obviously it is more important to the patient to know what is going to happen to him than to know that eighty or ninety percent of people like him fare a certain way and the remainder another. Right now prognostication is based on probabilities, but perhaps this book will serve as a start toward a more active search for prognosticators that better characterize the individual. Γνϖδι σαντον, said the Greeks; "Know then thyself and seek not God to scan, the proper study of mankind is Man," echoed Pope. It is the certain knowledge of the future that separates the godhead from Man, and it is the pursuit of that knowledge that ennobles Science. And yet there is just the element of chance that must remain: . . . . "We doctors know a hopeless case if - listen: there's a hell of a good universe next door; let's go!"

How to Submit A Presentation for a Medical Conference

Submitting a presentation to a medical conference can be a daunting task. It can be so intimidating many qualified people feel they should not even bother, because who are they to 'act' as experts in the field. Or one may have been rejected in the past and figured the odds are against you, so don't bother making an effort again. Others just enjoy going to the conference and not having to 'work.'

Well, I want to encourage you to submit a talk. If more people submit talks, an increased variety of talks can be selected. If more people submit talks, new viewpoints can be heard. If more people submit talks, new leaders can emerge. If more people submit talks, more professionals gain the confidence of speaking on international, national and regional stages.

So what is the best way to submit a presentation? Here are some tips I have gathered from submitting many talks to national and regional conferences, speaking and attending those conferences, and being on the committees to select from all the submissions. None of these tips are guaranteed to get your submission selected, but they may increase your chances.

What Topic to Choose?

Start Early
The time to start contemplating the talk you plan to submit, is actually at the conference you are attending. If you are planning on going next year, look at all the titles and see what areas are not covered well in breadth or depth, and see what areas have way too many offerings. This will help you gauge what area/topic may receive increased consideration from next year's committee. Be creative and think outside the box. What topics are important but often overlooked? That is how I have come to love prognostication; rarely taught, often misunderstood, used daily in medicine.

Start with Something Familiar
It is always easiest to start with something you know well, so you can at least decrease the amount of background work you must do. And if you have a lot of experience in that area, you can likely perform/improv better at your presentation as you can pull from a vast knowledge base. The corollary is...

Start with Something You Want to Understand More
Giving a presentation should not just be regurgitating facts and stories you know too well. Stretch your horizons and use this opportunity of an external deadline to learn more about some new area. That area should pique your curiosity, so you will be engaged with the material, otherwise the talk risks coming off very flat. And hopefully you have some experience with the topic, even if tangential. I can read all about llama farming in the hills of Peru, but since I am at least 3 degrees of separation from that topic, I probably would not give a sincere presentation (at least not without a lot more work).

Pick an Under-served Category
Many times conferences will post categories for desired talks. Look for the category you don't think will be popular. Chances are the committee will not have a lot of selections to choose from and your talk may be picked.

Don't Be Afraid of Bread and Butter
Being unique can get your talk selected, but often times at medical conferences there is a need for some of the basics. If you notice a topic has not been covered in the last two years of the conference, throw it out there. You can email the conference coordinators to get the last few years of programs, and then sort through what has been presented. If you are trying hard to get your talk selected, stay away from the topic that has been given yearly by the same person. Not likely to change, but sometimes change is good.

How Many Talks to Submit?
Honestly, it depends on your goal for presenting at the conference. If you really want to speak about the one thing you are passionate about, just submit one talk. If you want to get more national/regional/local exposure, submit three and hope two will get chosen. If you ever have three or more talks at a conference, you will not enjoy the conference. You will miss out on many opportunities because you will be planning your talk. So if you get all your talks selected, do not be afraid to tell the committee you would like to decrease the number of talks you will present. They may be sad, but I doubt they will seek retribution.

Submitting Your Talk

The Title
The title shouldn't be that important. It is just a few words. My talk is 60 minutes, but my title can be said in 6 seconds. Big deal. But the title is very important! This is your calling card to the selection committee and to the attendees. Think of it like a newspaper headline. In 8 words or less do you want to know more about something. And do try to use less than 8-10 words, because a title that is too long tells your audience you may not have good editing skills and your talk is bound to go too long, and have too many slides that you don't have time to get to.

Choose your words wisely and your title can shine. Pick bland but descriptive; your chances are so-so. Pick flashy but confusing; good luck. Pick creative and informative; bingo. Stay away from cliches and puns. Sinclair's Maxim: There will always be at least one presentation using 'the good, the bad and the ugly.' Alliteration is good but don't go overboard. The colon (punctuation, not the anatomy) seems to be very popular these days. It allows for something punchy and catchy on on side of the colon and something serious on the other side. Kind of like a grammatical mullet: business in the front, party in the back.

A good title gives some information, but is slightly provocative poking the learner to want to know what you are up to. That way they come to your talk. 'Evidence-based' is a buzz word, but it may start to be overused for when the speaker wants you to know, "Hey, I looked some of this stuff up." (Yes, I am guilty of using EB in my titles.)

The Speakers
Should you present alone or with others? Speaking with other people sounds like a great idea in the planning stages. 'Sara will take this part, and Dave will finish the talk, and I will cover the medicines. ' But in reality the coordination makes collaboration on presentations should cause hesitation. For a multi-presenter talk to go well, you should plan on a lot more time for ensuring the multiple presenters actually enhance one another and not turn into the Keystone Cops. Having speakers from different disciplines or different regions can help in raising the level of credibility for a talk, but that should not be the only reason to collaborate.

The Abstract
Follow the rules.

The Abstract (part two)
Did you read the section above? I mean it. Word count rules, figure rules, title format rules. Look them over again and again. And hand check the spelling after your computer does it for you. Eye now these form personnel experience. Please hand check your spelling!

Understand if the abstract is what is going to be printed in the brochures and other printed materials for the conference. Are you writing for the selection committee or for the selection committee and the learners? If #1, you can add in some commentary, if #2, it is more marketing than explanation. Don't waste your word count on what other people know about the subject by endlessly quoting others or adding references. If you can't fill up more than 80% of the word count with your original thoughts, why should they give you 60 minutes to talk?

The Deadline
Finish it early. This way you can have others look it over before the real deadline and give you critical feedback.

If there are any other lessons I missed or parts you disagree with, please feel free to leave them in the comments section.

Crying Doctors? How to Be A Good Palliative Care Doctor

This is part one in a planned ongoing series of how to be a palliative care doctor. Why doctor and not nurse or social worker? Because I am a doctor, so I can only speak of what I know, but some of the same ideas probably apply regardless of discipline. If someone wanted to submit this from a SW or RN or other perspective, I would be willing to guest post it here.

The New York Times published an essay by a frequent NYT contributor, physician Barron Lerner about the role of emotions in caring for patients. As one may imagine the piece had much to do with working with patients diagnosed with cancer, and those who were dying, familiar arenas to an experienced palliative care doctor. The question in the essay is rhetorical: Should doctors display emotion? The answer to be found in the essay is a good one: If it fits for you and for the situation it can be powerful and potentially strengthen existing bonds. If crying in public is not your thing, don't go there.

In palliative medicine we encounter many sad, difficult and trying situations which test our emotional stamina daily. In fact for some of us, it may be that visceral connection from human to human attracting us to this specialty. I was surprised in residency when I first discovered 'breaking bad news' and 'compassionate honesty' actually led to praise and gratitude from patients and families who would cry, be angry, and eventually come to a certain peaceful but sad acceptance of dying. Using my medical knowledge to guide patients and families through this was personally rewarding and occasionally emotionally difficult, but I never cried in these meetings. In residency I would have these talks once a month or maybe once a week, but once you start doing palliative medicine full time you do this three to four times a day, sometimes 6 or 7 times.

Withdrawal of a ventilator in the ICU on an inpatient palliative consult service. The prolonged waiting of a slow decline in an inpatient hospice unit. Helping a family understand symptom control on home hospice visits. Three to five times a day you are experiencing the sadness, grief, anger, and stress of others as they approach death. Each time is not an intense 90 minute family meeting, but even if you briefly unleash those raw emotions from a patient or family, and the rest of the visit is upbeat and friendly, you as a palliative care doctor are still using some of your emotional stamina.

For some doctors crying at the bedside of a patient is acknowledgment of grief, impending loss, and the connection that has been built. If crying can restore some emotional stamina by releasing pent up negative feelings then this can be worthwhile. If crying at the bedside starts to become something you do more often than not, or start to feel as though you must or should cry, then you might need to look at other ways to replenish yourself and see if your team notices any signs of compassion fatigue/burn-out.

What a good palliative care doctor should not do is allow the crying to change the focus from the family or patient to the physician. This is a good built-in boundary check: If the family is more concerned about you then themselves, you might have gone too far. Some palliative care providers have also used their emotions to make a quick connection to the patient or family. In the guise of 'I lost my (insert relationship here) too,' the palliative care provider avoids the natural trust building and jumps right for the emotional connection. This also turns the focus away from the patient and family and to the provider. Building trust quickly is important in palliative care when you sometimes go from "Zero-to-Death and Dying in 5 minutes", but not at the expense of changing the focus away the patient/family unit.

Do I cry at the bedside? No, I don't, but have I felt a surge of sadness come to me? Sure I have and I later addressed those feelings away from the bedside. How I maintain my emotional stamina in this field is by becoming a professional chameleon, or some may say actor. By professionally adapting to the situation in front of you, your emotions can be sincere, but protected from your core by what I term a 'professional mask.' It is much like a two way mirror. Things come through the mask in both directions; I am able to outwardly display genuine compassion and concern to the level needed without compromising my emotional integrity. But when someone turns the lights on the other side of the two-way mirror, the emotions of the meeting can come through that 'mask' as well to affect me. I am sincere in my concern and compassion I display for my patients, I know because at the end of some days, I can tell my wife I don't feel much like talking and she understands. I am drained. A check of my emotional stamina is thinking about how opaque the mask is.

Is this just a guy thing? Maybe. I would like to hear what some of the female palliative care docs think of crying at the bedside. IS there a different social norm? I don't think the issue can be simplified to a male who is not allowed to show emotions or not in touch with his emotions. I am very familiar with my emotions because of palliative care, more so then I would expect without being in this field. The article also mentions the role of hugging. For me as a male physician, I don't go around giving out hugs to everyone I see, but I have pretty good Hug-dar when a family member is coming in for a hug, so I would not deny that. I am actually a big fan of free hugs from family members. So much so that if I know a family to be particularly generous with their hugs, I will make sure to take the stethoscope off my shoulders so they don't get a face full of ear pieces.

Emotions, crying, boundaries, and self-care are important to avoid burnout and depression. Newsweek recently published an article about physicians, depression and suicide risk, cheerfully titled, "When Doctors Kill Themselves." The article highlights an upcoming PBS special, "Doctors with Depression*", that features a palliative care fellow. I am hoping it highlights self-care training in his fellowship. As a fellowship director, I 'stress' self-care activities for fellows, and letting me know if they are pushing themselves too far. In a fellowship, I think it is actually a good sign if you can recognize when this happens, so don't be afraid to identify that in yourself. The work of a palliative care physician is emotionally taxing, which is why as we must look out for ourselves and each other.

How do other palliative care doctors (or other disciplines) deal with emotions, depression, burnout? What is the ideal approach to outward display of emotions for our field and disciplines?

Other bloggers have posted about crying physicians here and here and here.

*Sponsored in part by Wyeth, makers of Effexor

Hastening death vs palliative care; Preventing aspiration; more

I am writing this on my front porch as it gets dark - it appears spring is finally arriving to the upper Midwest! I will likely be posting a little less frequently than usual the next couple of months - among other things the 4th baby to be born to a Pallimed contributor since the inception of the blog is heading my way next month and my quiet evenings blogging are fading away for a while.

Today is National Health Care Decisions Day, which I'm sure is a good thing, but as Christian pointed out to me why did it have to come the day after Tax Day? Do 'death & taxes' need to be so closely aligned on our national calendar as well?

1)
Critical Care Medicine has an article about hastening death vs. alleviating suffering in European ICUs. The data come from a large, multinational, prospective study in European ICUs in which aspects of end of life care were measured including, apparently, circumstances in which the treating physicians themselves reported that they made specific treatment decisions to actively hasten death for dying ICU patients. These accounted for ~2% of all deaths in the study. This paper presents the meds which were used (varying doses of opioids, benzodiazepines, and barbiturates mostly) and makes the point that the doses used in the intentionally hastened death patients were similar to doses used in about a third of the patients who died receiving comfort-only care but without intentionally hastened death. That is - if one only looked at drug doses one wouldn't be able to tell the difference between 'palliative care' and 'attempted euthanasia' in many of these dying ICU patients.

Well - true - but so what? First, the absolute magnitude of opioid & benzodiazepine doses doesn't mean much, particularly in opioid tolerant patients (someone giving me 50mg of IV hydromorphone would likely kill me; I've had a few patients who take that much before breakfast), and the fact that there is overlap is not surprising at all. In addition, it's likely that a certain number of these physicians were incompetent both at estimating a lethal/death hastening dose in these patients, as well as appropriate doses for alleviating symptoms (I'm sure the latter is true) and the overlap is, again, not surprising. The real issue here is one of intentionality, and intentions matter, pretty much always, but especially here. If I sneak into an ICU and stop someone's vent in order to kill them - that's murder. If I'm that person's physician, and stop the vent after an informed decision is made by the patient/proxy because the vent is no longer meeting a care goal etc. - that's good medical care, even if the outcome is the same in both cases (the patient dies earlier than they would have if they remained on the vent).

Anyway, that's sufficiently didactic for one post. The paper has a good discussion about intentions and perceptions and talks through the reality that 'palliative care' and deliberately hastening death can look very similar on the surface, which is certainly worth discussing, and is certainly a perception that many lay-people have of what we do (and I'm sure, some of our colleagues). We've commented before on having conversations with well-educated, savvy friends and