Alterations of content of family meetings by medical interpreters

Chest has a fascinating paper looking at how content can get changed by interpreters during family conferences. The data comes from an analysis of transcripts of ICU family conferences in which the family didn't speak English and a certified medical interpreter was used (the study took place in two Washington state hospitals and the interpreters were certified via a Washington state certification process). (All this comes from a larger study which involved tape recording ICU family conferences in which end of life issues/decisions were likely to be addressed - this is a subanalysis of 10 conferences in which an interpreter was used.) Essentially they hired certified medical interpreters (who weren't involved in the study and who didn't know the interpreters involved in the study conferences) to transcribe and translate into English the non-English portion of the tape recorded conferences. What the family 'actually' said was then compared with what the interpreters translated in the conference and vice versa for what the clinicians said. There was some quality control to check the accuracy of the hired interpreters.

They then schematized 'alterations' in content into omissions, additions, and substitutions, or editorializations, and further categorized these into positive or negative alterations in several categories (e.g. medical information - interpreter decreases certainty of prognosis vs. increases certainty of prognosis, interpreter makes an implicit prognosis more explicit or makes an explicit prognosis more implicit; emotional content - interpeter omits emotional language, makes harsh sounding clinician statements softer, etc.).

Major findings are as follows: alterations were common, in over 50% of translated statements. Most were editorializations (which they defined as an interpreted passage which combined at least two of either an omission, addition, or substitution) or omissions. 77% of these were judged to be 'potentially significant' alterations (which could affect the goals of the conference such as sharing accurate medical information, building rapport, eliciting patient values, establishing treatment goals, etc.) and almost all of these were judged to be negative - interfering with those goals. They note that an average of 16 alterations which could affect treatment decisions occurred each conference.

Yikes. Before you flip out, which is what I did when I read the abstract, it's helpful to see examples they gave of these - some are drastic and some are more subtle and (especially given the small sample size and relatively preliminary and potentially subjective nature of the interpretation of these alterations) one shouldn't make too much stock in those numbers. Saying that doesn't take away of course from the overall finding of the study: real-life interpretation is fraught with hazards, even with professional interpreters, and when there seems to be protracted conflict, lack of understanding, or that little voice in your head saying 'boy I don't think they're getting it' or 'something's wrong here' - consider problems in interpretation.

Anyway: the examples they gave ranged from just flat out 'wrong' interpretation to changes in emphasis which remove opportunities to build rapport, establish treatment goals, etc. .

Doctor: I don’t know. Um, this is a very rapidly progressing cancer. Interpreter (translating): He doesn’t know because it starts gradually.

Doctor: Have you spoken to your husband about these kinds of questions before he got sick, what his wishes might be in this sort of situation? Interpreter (translating): Did you talk to your husband before he got so sick about possible situations, what was awaiting him?

The authors recommend:

First, preconference meetings with interpreters might provide an opportunity to address some of the causes of alterations. These meetings might include a discussion of which interpretation approach would be most appropriate (eg, strict linguistic translations or a "cultural broker" approach), and might provide an opportunity to clarify the topics to be discussed and the terminology that will be used. Second, by speaking slowly and using short sentences, clinicians can prevent a situation in which the interpreter has to remember large blocks of information, thereby reducing the chance the interpreter will make alterations and particularly omissions. Finally, physicians should repeat important concepts and ask the family members if they have questions about those concepts to make sure key data are accurately conveyed to the family.

Changing the culture of EOL care in the trauma ICU

The Journal of Trama has an article about changing the culture around end of life care in the trauma ICU. This is a before-and-after comparison of communication and end of life care practices in a single trauma ICU after a structured palliative care program was integrated into this ICU's standard care practices. The program (described in detail here) is summarized as follows:

Because trauma patients admitted to an ICU have a significant mortality risk (15–20%), and families have consequent, immediate psychosocial needs, the intervention was designed to apply to all trauma patients and their families regardless of their prognosis. Because of the nature of trauma, its sudden onset and rapid trajectory from well to life-threatening illness, the intervention was designed to begin at admission to the ICU, with early communication and family support. The program consisted of five clinical steps grouped into parts I and II in a timed sequence from admission.... In part I, within 24 hours of admission, each patient had a palliative care assessment by physician and nurse. Each family received psychosocial or bereavement support. The palliative care assessment encompassed prognosis, advance directives, family support, and surrogate decision maker, and pain and symptoms. To assess prognosis, physician and nurse were asked the most likely outcome using a score 1-5 similar to the Glasgow Outcome Score, with 1 = death and 5 = independent functional recovery. In part II, within 72 hours, an interdisciplinary family meeting was held regardless of prognosis; during the meeting, likely outcomes, treatments, and goals of care were discussed. These meetings were assessed subjectively by counselors for discussion of goals of care, family understanding of information, and conflict. When the goals of care transitioned from curative to a completely palliative approach, a palliative care order set was implemented.

This paper compares aspects of care between the ~280 admissions in the baseline year with the ~370 in the year after implementation. About 70% of patients completed both steps 1 and 2 of the program.

Many outcomes didn't change: total mortality was the same in both years (15%); rates of DNR orders (~43%) and family meetings were similar (~60%) as was the timing of family meetings (nearly all within 72 hours of admission).

What did change were: rates of withdrawal of life-prolonging treatments were higher after the program started (37% of deaths vs 24% - again, however, overall mortality was the same); timing of DNR orders and withdrawals of life prolonging treatment were earlier; overall length of stay in the ICU and hospital was shorter in those patients who died after the program was implemented (mean hospital stay went from 14 days to 6.5 days in those who died).

Essentially, then, what this intervention did was accelerate the decision-making process between families and ICU staff about transition care goals to comfort in a dying patient - and this happened without any demonstrable effect on overall mortality. What's really interesting here is that even before the intervention this ICU team were having early family meetings at a high rate, suggesting that these were not responsible for the changes in care. Instead one wonders if it was the rapid and structured identification of patients very likely to die along with immediate opening of discussions about prognosis and patient/family values/goals. That, and a general culture shift that attended this formalization of 'palliative care' principles into the care of this population (for instance, the discussion notes that this group also introduced end of life peer review into their morbidity and mortality conference).

I think that these formal, deliberate changes in standards of care/expected practice are one of the best ways in improving end of life care in hospitals, and are particularly suitable to ICU situations where mortality rates are very high compared to the rest of the hospital (so the likelihood of measurable impact is so much higher than, say, a general medical ward). One caveat here is that group is clearly one which already had a culture (and presumably leadership) which was open to examining and improving end of life practice - this isn't something which could be foisted onto an unwilling group. Given the changes that are happening with the Joint Commission regarding end of life care in the hospital, it's possible that hospitals in the near future will be 'incentivized' into 'willingness' in the not-too-distant future. We'll see....

Mosenthal, A.C., Murphy, P.A., Barker, L.K., Lavery, R., Retano, A., Livingston, D.H. (2008). Changing the Culture Around End-of-Life Care in the Trauma Intensive Care Unit. The Journal of Trauma: Injury, Infection, and Critical Care, 64(6), 1587-1593. DOI: 10.1097/TA.0b013e318174f112

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.

Anna Pou Interview

Dr. Anna Pou, the doctor who was accused of murdering patients during the aftermath of Hurricane Katrina gave a rare interview covering her experiences and discussing a new law to cover medical personnel who assist in a disaster. The grand jury and attorney general eventually dropped the charges but she still faces two civil suits.

Here are some quotes from the Associated Press article:

When nightfall came, the hospital and the city were in darkness. Water pressure dropped, toilets backed up and the temperatures began to swelter.

"The smell got to be rancid in no time," Pou said. "It burned the back of your throat."

...

Pou said staff struggled to climb stairwells, carry supplies, and spent two-hour shifts squeezing ventilators to keep patients alive.

"The heat was so terrible, it wore you down," Pou said. "We were trying to keep the patients comfortable. The 9-year-old daughter of one of the nurses even took shifts fanning them."

...

"I felt very alone," Pou said of her year of fighting the criminal accusations. "Even if people were around me I felt an intense loneliness. It was as if no one knew what I was going through."

Propensity scores in palliative research

Chest has an article about the effects of treatment limitations in ICU patients on prolonged survival. I'm not going to discuss the article itself much: it's also well discussed in the July 2008 PC-FACS (although you have to be an AAHPM member to access it) and in an accompanying editorial in Chest. Instead I wanted to focus on its use of propensity scores, as the article is a good introduction to them.

Some background on the article. It's a single institution retrospective cohort study which compared 60 day mortality between patients for whom there was some sort of order/decision to withhold a life-sustaining treatment in the ICU (e.g. vent, dialysis, pressors, CPR, etc.) and patients who had no such decision/order. Patients who had any such treatment withdrawn were excluded, as well as patients who wanted comfort-only care. There were ~2000 patients in the study; ~200 had a WLST decision. As you'd expect, the WLST patients were older, sicker, with a higher in-ICU and in-hospital mortality than the non-WLST patients (16% vs 2%, 30% vs 5%).

The authors then created a propensity score model to describe the likelihood of having a WLST decision. Propensity scores (PS) are a way to try to minimize confounding differences between groups in observational research. Clearly one cannot do a RCT of WLST decisions. Instead all you can do is watch what happens to those who have a WLST decision and those that don't. Of course there are likely many confounding variables in such observations (things that are associated both with having a WLST decision and with death like being older and sicker - it's not fair, say, to compare these older, sicker patients with the younger, healthier ones and conclude that the WLST decision was responsible for increased mortality). What PS try to do is to mimic a RCT by creating a model which predicts the likelihood of a subject getting an intervention (in this case WLST) then comparing outcomes between subjects who got the intervention or not but who had an equal chance of getting the intervention in the first place (i.e. as if they were randomized to the intervention or a control).

To clarify.... A multivariate model is created from as many data points (hopefully) that the researchers have. This model creates a score (PS) which describes a patient's likelihood - within the cohort - of receiving the intervention (in this case a WLST decision). In this paper it was a 69-variable model and included things like demographics, markers of illness severity, etc. - the model was derived from data from the subjects in this cohort, and, again, predicts a subject's likelihood (propensity) of getting the intervention in question. A simplified example could be: a 67 year old white male with Medicare admitted to the ICU on hospital day 4 with an APACHE II score of 30 and gram negative sepsis would have a PS of X. X being some number which means something to statisticians about how likely this patient is to have a WLST decision in this cohort. (A 53 yo woman with diabetic ketoacidosis and an APACHE II score of 14 would have a lower PS, for instance.) What you then do is take a patient with a WLST decision, derive their PS, then match them as closely as possible to a patient in your cohort who did not have a WLST decision but who has a nearly identical PS. The idea is, again, to mimic a RCT in the sense that - as much as your model is accurate - both of these patients had an identical 'chance' or 'risk' of having a WLST decision and it 'just so happens' that one did and one didn't; you then can fairly compare outcomes. You repeat this matching across your entire sample of WLST patients and you can then compare outcomes between the groups because, ideally, the patients in the WLST group and the non-WLST group had an equal 'chance' of receiving that 'intervention' and so it's fair to then compare the outcomes.

So, to keep things concrete, in this study they took their 200 WLST patients and matched them 1:1 with non-WLST patients with nearly identical PS and then compared outcomes between the groups (which now total 400 patients and not the original 2000). What they found is that despite the now very similar baseline characteristics between the groups (age, demographics, indices of illness severity) the WLST patients had higher mortality in-ICU, in-hospital, at 30 days, and at 60 days (16% vs 6%, 32% vs 12%, 42% vs 22%, 51% vs 26%). (The authors were surprised that the difference in mortality extended so long and there is some hand-wringing about whether or not we are causing 'premature' deaths by WLST - see the editorial mentioned above for some common sense reaction to this.)

The obvious problem with PS is that it all hinges on what is included in the multivariate analysis to derive the PS. Only things which are measured can be included, and so if there are important factors which aren't being measured or included, which could influence the outcome, the model breaks down. (For this study the editorialists points out that in this study clinicians' prediction of prognosis was not included).

Why am I rambling on about PS? They have been proposed and promoted within the palliative care research community as one 'get around' for the fact that controlled trials are often impossible or impractical for our patient population (like for instance this trial, or one looking at the effects of G-tube feedings in dementia, or the effects of early palliative care consultation on some outcome, etc.), and PS have some appeal because they approximate randomization (again, only as well as the models contain all relevant variables, which is a significant issue). They have been discussed in J Palliative Med here, and were the subject of a concurrent session at AAHPM last winter, and I've begun to see them used more often. I have been waiting for a good article to introduce into my program's palliative care-EBM curriculum about PS and this is the one I'm probably going to use (as it's relatively easy to understand and a little controversial which gets people excited and interested).

PS are not without controversy, not only because of the issues mentioned above, but there's some debate whether they actually add anything to 'routine' multivariate analysis; however this debate is quite statistical and well above my head. I haven't found any really good, simple (casually readable) summaries on PS: this one is OK.

The ProVent Prognostic Score: Helpful?

Palliative Care Nurse: "We got a new consult in the ICU. A 55 year old who has been on the vent for 4 weeks with platelets of 75, on levophed and hemodialysis."
Palliative Care Doctor: "Sounds pretty serious. I wonder how he is going to do?"

Have you ever faced this dilemma of prognostication? If so, there is a new prognostic test developed for just this situation. If you are asking yourself, "Where is the prognostic dilemma? I already have a pretty good idea of what is going to happen" then you can go to the head of the class.

A reader sent me a well-executed study demonstrating the development and validation of a prognostic scoring system. This NIH funded study from UNC, Duke, and ECU was completed over 4 years (3 for the development cohort of 200 patients and 1 for the validation cohort of 100 patients).

The researchers choose to study patients requiring prolonged mechanical ventilation (greater than 21 days), a population notable for a high mortality and symptom burden. The reason for the study was noble in trying to enable physicians to have an easy to use, highly specific prognostic score to encourage open discussions about prognosis with patients and surrogate decision makers. They cite two studies in the discussion for the severe lack of prognostic disclosure in critical care situations (12% and 40% (SUPPORT)). (Hint: get a palliative care consult)

They identify the four variables with the highest relative risk: Age older than 50y, vasopressors, platelets less than 150, and hemodialysis. Each is assigned one point to get your ProVent Score. (I give one point for cleverness on the name for the score!) A score of 3 or 4 indicates a roughly 95% one-year mortality risk and a 85% 3 month mortality risk. (Disclaimer:Read the study for more details before you take this information and apply it clinically.)

Do you find this score to be clinically relevant? Would you use it to inform your decisions/prognostic estimates? Would you quote it to the family or patient? How about discussing with other clinicians? Personally, I am not too sure it is clinically relevant. We rarely see patients on vents longer than 21d still in the hospital. They are often already at the long term acute care hospital. I plan to give it a try and see how it compares with my own clinical judgement and that of my peers.

The authors conclude:

"Simple clinical variables measured on day 21 of mechanical ventilation can identify patients at highest and lowest risk of death from prolonged ventialtion."

The best part about actually reading an article is you can come to completely different conclusions (beware quoting abstracts!). For me (and you if you have read this far) the take home points to this article are really hidden and have numerous implications:

for clinical care (to be further validated):

• 40-50% of patients on prolonged mechanical ventilation (more than 21d) will die in the hospital (i.e. consider a palliative care consult trigger to discuss prognosis)
• If you survive the hospital stay, your mortality is only 17% at one-year (Graph)
• If you have a ProVent score of 2 or more you have minimal chances at being alive and independent in all ADL's at one year.
  

for future prognostic studies:

• Obtain clinician estimates for survival as a measure to compare your calculated prognostic score. Otherwise you risk making a score that is no better than current practice (communicated or not).
• Condeming all clinical estimates of survival based on a small handful of poorly designed studies does not qualify statements like "we know that prediction of mortality by clinicians using clinical probability of ICU survival is not accurate." We have too much to learn about the practice of clinical prognostication to come to this conclusion.
  
• Inclusion of the prognostic score is vital as a core part of the research to be examined and discussed amongst peers.
• Clinically relevant prognostic time frames are important and are very situation dependent. Discussing the chance that someone may have a 90% chance of dying within 1 year or even 3 months is not typically being discussed in ICU palliative care family meetings. The range may be hours, days or maybe a couple of weeks.
  

and for ICU studies of mortality:

• Include palliative care consultation and decisions to withdraw or withhold key life support measures as baseline demographic or outcome variables. These two issues could have major repercussions on validity of data sets concerning mortality.
• Consider using the ProVent score to stratify different risk groups in this select patient population.
  

(HT: B. Arnold)
Carson, S.S., Garrett, J., Hanson, L.C., Lanier, J., Govert, J., Brake, M.C., Landucci, D.L., Cox, C.E., Timothy, S.C. (2008). A prognostic model for one-year mortality in patients requiring
prolonged mechanical ventilation. Critical Care Medicine, 36(7), 2061-2069. DOI: 10.1097/CCM.0b013e31817b8925

Pal Pourri

Some palliative highlights from the web:

The New York Times published an article on nurses being attacked on the job. 12x the rate of violent injuries compared to the rest of the private work force! I know many nurses could share stories about being a victim on the job. In March there was even a murder of an ICU nurse in the ICU as a retaliation by a son for the death of his mother. Sadly it was a case of mistaken identity. What implications it has for those who deal with dying patients all day no one has ever commented.

A team blog called Mothers In Medicine had a highly commented post on crying in medicine. They had another good post this week on being the child of a doctor. With a good follow-up post from a commenter.

Maggie Mahar updates us all on the wild action in Congress around the Medicare physician fee cuts which would be a large impact on hospice and palliative care doctors. Long but important reading if you get paid for being a doctor. (HT: Kevin MD)

The WSJ highlights the financial obligations oncologists are going through to obtain expensive (100k/year) meds for their patients. Surprise, now cost is being discussed upfront with patients!

Jennifer Bunn, RN blogs about a BMC article (open access) on how health care workers would respond during a pandemic. Think about if your city was flooded, or had a aggressive contagious deadly virus, or had a biohazard catastrophe? What would you do?

JAMA has an opinion article about being stalked online by patients (sub required). You may not think you have an online footprint, but try Googling yourself and see what you get. And no I am not the director of Middle Eastern studies for the School for International Training in Vermont.

Never Extubate a Dying Patient?

Being familiar with other medical blogs is a great way to keep up on how other doctors and nurses approach care for the dying. In fact, many of the most popular posts always seem to involve frustrations of medical futility, or the emotional impact of caring for dying patients. The range in tone for these posts is quite wide, from derogatory and demeaning of patients and families to eloquent and demonstrative of the great compassion in medicine.

A recent post by the anonymous blogger, the Buckeye Surgeon, highlighted his surgeon's view of palliative care. I came across the post from Kevin MD, a popular medical blog aggregator. Here is how he highlighted the post:

"Unrushed on his journey toward death"

Well put. That should be the goal of palliative care.

Seeing a palliative care post got me pretty excited. As I read the post I was glad to see a surgeon espousing viewpoints on palliative care areas. The Buckeye Surgeon highlights how many elderly patients with very devastating injuries may be able to get to surgery but have many co-morbidities that prevent recovery. With much wisdom, it is pointed out that seeing the few who do really well should not blind one to the many who do not recover.

In reading the post, it appears the surgeon may not have access to an involved palliative care team. I am very glad to see the mindfulness of palliative care, but there are some misconceptions to be addressed.

The post highlights that terminal extubation is something this surgeon actually forbids from happening in the orders:

-DNR-CC
-Do not extubate
-Morphine 4 mg IV q 15 minutes
-Propofol drip titrated to complete sedation/unconsciousness
-Turn down the sound on all monitors.

(DNR = Do Not Resuscitate CC = Comfort Care.)

There are times when extubating a patient can cause more distress - an obstructed airway, a high risk for hemorrhagic bleed, inability to control tachypnea with medications, feel free to add others. But in my palliative care reading and experience, leaving a patient intubated is the exception, and not the rule. So I was very surprised to hear this approach of keeping patients intubated.

Have any Pallimed readers run into this with consulting physicians? My guess is probably not a lot, because these physicians may not consult palliative care as they would not want a palliative care team to extubate their patient.

Good point of using morphine every 15 minutes as that fits with the knowledge of the T-Max of the concentration after an IV dose, but it is not specified as a PRN, so is it scheduled? Many palliative care providers advocate for a combination of opioid drip and rescue bolus to anticipate dyspnea.

Instead of turning down the sound of the monitors, most have the ability to be turned off in the room and continue monitoring at the staff station. This also avoids the constant monitor watching in addition to having unnecessary alarms.

So why does the surgeon advocate leaving a patient extubated? Basically because it is more comfortable. It is explained in the post with the following passage:

...it isn't ethical to merely "turn everything off". They've decompensated beyond the stage of self-sustaining life. Unplugging everything and stopping all the drips is about as cruel a thing as I can imagine. I never terminally extubate a patient. There's nothing more gruesome than watching a patient suffocate after terminal extubation. A wise old nurse made me experience it when I was a resident. No reason to pull that tube out. The dead bowel or the fecal peritonitis is going to stop the heart soon enough. No reason to expedite the death with unnecessary agony.

I agree with the blogger that it is unethical to be cruel, but I disagree that terminal extubation has to be gruesome, cruel, or cause suffocation or agony. There are reasons to pull that tube out. Not prolonging suffering is probably the most common reason given for extubation. Not continuing aggressive measures when you can no longer reach the goals set by the patient, family and medical staff is another reason.

Euphemisms and broad generalizations about withdrawal of life-support technologies are common with families, patients and medical staff, especially for the ability to make difficult situations more tolerable. 'Pull the plug', 'turn everything off', 'take him off the hook', 'stop treating her', 'withdraw care.' One role for a palliative care team is to highlight all the things that are being done for comfort, for emotional support to patient, family and staff, to prepare for death, to conduct religious and family traditions, to reminisce.

Many palliative care providers have worked in ICU's with dying patients and are therefore very familiar with the very involved process of terminal extubation of a ventilated patient. In palliative care, extubation is elevated to a procedure not just an order written for the respiratory therapist. Terminal extubation can be done well with a team approach, managing expectations, and aggressive symptom control for dyspnea and anxiety. Check out some of our 31+ posts on palliative care and the ICU to see some studies that talk about common ICU dilemmas.

Head & neck cancer; Vitamin D; Do not 'METuscitate'; More

Many items....

1)
From JAMA:

First is one in their ongoing series 'perspectives on care at the close of life' on palliative care for patients with head & neck cancer. Besides being a solid review of the topic, as are most of the 'perspectives' pieces, this one stood out for two reasons. It's the most 'supportive care-y' one in this piece, and really reflects a broad perspective of palliative care as not just for the dying (despite the name of the series). The other is this wonderful (and rarely seen in the medical literature) discussion of self-image and blame:

Although some patients may blame themselves and feel they caused their own illness, patients may also feel guilt about the toll that the illness takes on their family and caregivers. Eating is a major social, cultural, and religious ritual in society, and patients with head and neck cancer often cannot participate in this activity. Even going out to dinner can become an impossible task, and patients may often be concerned about the impact this has on their family. Likewise, facial disfigurement—even if only temporary—may make it emotionally difficult for patients to leave the house, which can change the dynamic between patients and their loved ones. Feelings of guilt and self-blame in patients with head and neck cancer are therefore not only related to their own role in their illness but also to the belief that they are to blame for the impact the illness has on the quality of life of their loved ones. Physicians can assist patients with these feelings by encouraging them to talk about them with their loved ones, and even facilitating these conversations. For example, if a patient is accompanied to an office visit with a caregiver, the clinician can ask both of them, "What role has the illness taken on your relationship?" or even more directly, "Are you finding it difficult to eat out in public? How are you handling the changes imposed by the cancer on your social life or religious practices?"

The same issue also has a 'coda' for a previous perspectives piece about nausea and vomiting from last year.

And on the general cancer front JAMA also recently published the results of a randomized, controlled non-blinded trial comparing chemoembolization with radiofrequency ablation with both in patients with hepatocellular carcinoma. The study involved ~290 patients with unresectable (but not metastatic) hepatocellular carcinoma, at least one lesion greater than 3cm (as well as certain other tumor-specific entry criteria) & they were randomized to one of the 3 arms. I'm mentioning the trial for a couple reasons. First, there aren't too many therapies out there which have been shown to significantly improve survival in these patients and second, the study provides some general prognostic information for outcomes in this population: median survival was 24 months in the chemoembolization group, 22 months in the RFA group, and 37 months in the combined treatment group; 1, 3, and 5 year survivals were 75%, 32%, 13% in the chemoembolization group (very similar to the RFA group) and 83%, 55%, and 31% in the combined therapy group.

I'm curious how many other palliative clinicians are seeing these patients - my group sees a good number of them (usually referred by interventional radiology) as they near the end of their treatment course (or earlier if they're having a lot of symptoms) - and some relatively solid prognostic data are helpful.

2)
Archives of Internal Medicine has a research letter furthering the Vitamin D For Everything consensus that seems to be gathering in the last several years (falls, frailty/muscle weakness, cancer prevention, cancer therapy, and chronic generalized pain are just a few topics off the top of my head that vitamin D has been shown/purported to impact). This is about vitamin D for neuropathic pain; the letter presents uncontrolled observational data from giving 50 patients with painful diabetic neuropathies (and low serum D levels) ~2000 IU of vitamin D for a few months. The pain got quite a bit better. This is swell, and hypothesis generating to be sure - clearly controlled research is needed.

3)
Two from Journal of the American Geriatrics Society:

First is one looking at 6 month mortality after hospitalization for a COPD exacerbation. This was a single institution (Italian) prospective cohort study of ~240 elderly inpatients (mean age 82 years) with COPD exacerabations who were followed for 6 month mortality. For some reason patients with a previous history of 'chronic hypoxia' were excluded (???). Of note, the study cohort had 'nonacidemic' exacerbations which they defined as an arterial blood pH of greater than 7.34 (they don't clarify if they also excluded chronically hypercapneic patients who had high pCO2 but weren't actually acidemic). 2% died during the hospitalization (seems a touch low to me, given the age of the cohort) and 20% died by 6 months. They found a lot of the usual suspects were associated with a higher chance of death at 6 months (low BMI, poorer performance status, greater severity of COPD exacerbation) in univariate analysis. (None of the data were robust enough or presented in a way to affect clinical decision making, however.)

The one particularly interesting finding was that the functional status (measured via the Barthel Index) at the time of discharge (not at baseline) was predictive of 6 month mortality in the multivariate analysis - the authors comment on this too as it suggests (maybe) that the 'functional hit' one takes during the exacerbation is of particular prognostic importance. This makes sense but it's the first time I've seen it show up and I hope the authors/others look into this.

The other one is really for the prognosis completists out there: it looks at long term survival and functional outcomes for elderly patients who have already survived 1 year after 'planned or unplanned surgery or medical intensive care unit treatment.' Why one would want to study this exact population (both unplanned surgery or MICU stay? already survived one year?) remains unclear to me. Most people were doing fine, but of course they were since they'd already lived a year....

4)
Journal of Trauma has a paper looking at outcomes in elderly patients who suffer cervical spine fractures. This is a retrospective review of a single trauma center's experience with these patients. I have encountered only a very few elderly patients with cervical spine fractures (at least high C-spine ones) who have done well so this paper caught my eye. Acute mortality was ~25%, higher for high C-spine injuries and for those presenting with neurologic deficits (40-50% range). They also looked at the role of having an advance directive (they don't specify at all what they meant by this - POA forms, living wills, treatment limitations or not, etc.) and found that overall hospital length of stay was about 6 days shorter for these patients (despite having worse injury severity scores). They speculate that it may be because these patients' care goals were more palliative focused and so didn't linger in the hospital too long (although their ICU length of stays were identical to patients without ADs). Perhaps, but having an advance directive may also be a marker of increased family/social support, or preexisting nursing home residence, or other factors which could shorten a hospital stay....

5)
Resuscitation has a letter about the (what sounds like informal) development in one Canadian institution of "Do not MET" orders (MET being medical emergency team which sounds like what are frequently called rapid response teams in the US - essentially teams called in to rapidly assess/stabilize/transfer 'crashing' hospitalized pati