BMJ series on qualitative research

BMJ has a series of articles about reading, understanding, and appraising qualitative research - a good set for the teaching file. BMJ has a complex online <-> print publishing system which I don't exactly understand and I can't exactly tell which issue these are from (the were all grouped together in a recent table of contents announcement from BMJ) - so here are the individual articles:

1. An introduction to reading and appraising qualitative research.
2. Grounded theory, mixed-methods, and action research.
3. Discourse analysis.
4. Why use theories in qualitative research?
   
5. Ethnography (from the text: "ethnography is the study of social interactions, behaviours, and perceptions that occur within groups, teams, organisations, and communities").
6. Critically appraising qualitative research.
   

Articles 1, 2, and 6 will likely be of most interest to readers of the blog and their trainees. Grounded theory comes up a lot in palliative care research, and I was hoping #2 would be illuminating, but is unfortunately a relatively brief introduction to it. Does anyone have a good overview of grounded theory research and how to interpret it (one that's written for clinicians, and not researchers, social scientists, etc.)?

Review of heroin dependence

JAMA has a Clinician's Corner review on heroin dependence. It's a chatty, narrative review which covers the history of heroin abuse in the US, its epidemiology, the history of and research supporting methadone therapy, buprenorphine and naltrexone treatment, as well as a Q&A at the end which addresses some of the language used:

When I was on the American Psychiatric Association DSM III-R...committee, the problem that we had when we were designing a diagnostic classification scheme was that we were trying to come up with a scheme that applied to all drugs of abuse. So that meant nicotine, alcohol, cocaine, heroin, and so forth. People who work primarily with alcoholics don't like to use the word "addiction" regarding alcohol. But it absolutely fits. All of the drugs of abuse activate the reward system, but through different mechanisms. The reward activation produces learning, which results in long-term behavioral effects that increase the probability of relapse. The major problem with terminology is the tendency to stigmatize. However, as more public figures have admitted to addiction problems, we see that it can happen to anyone. I think it is better if addiction is dealt with as an illness instead of as something that implies bad character. Addiction is just another medical problem. I think the stigma is a holdover from the time when addiction was thought of as weakness of will or bad character or criminal activity. Addiction is a chronic disease of the brain with strong heredity components, and it ought to be approached as a medical illness.

'Averages are dangerous statistics'

Continuing a theme from the above Cancer article, BMJ has a study looking at oncologists' disclosure of the survival benefit of 'palliative'** chemotherapy. This is a small (37 patients, 9 oncologists), single-center (Bristol, UK), qualitative study which involved audio recordings of patients' initial meetings with an oncologist to discuss treatment options after a diagnosis of either advanced non-small cell lung cancer, pancreatic cancer, or colorectal cancer. These conversations were also personally attended by a research assistant who sat (silently) in the room: this person had already met the patient and received permission to be there, etc. The conversations were analyzed via a grounded theory approach.

The researchers describe that the incurable nature of the cancer was nearly always explained, however solid information about survival benefit of treatment was not. They summarize their findings here:

This ranged from giving numerical data, such as "about four weeks"; through an idea of timescales, such as "a few months extra"; to vague references, including "buy you some time"; to not being mentioned at all. During the recorded consultations, only six of the 37 patients were given numerical data about the survival benefit of treatment. These included three of the 23 patients who accepted palliative chemotherapy. In most consultations (26/37) the discussion of survival benefit was either vague or non-existent.

This is in contrast to the patients receiving detailed information about side effects and risks of treatment. The remainder of the paper is a fascinating look into these real conversations - with direct transcripts of excerpts of many of them along with a great discussion about aspects of these conversations: patient/family members blocking of prognostic information, how oncologists responded to direct questioning about survival benefit, the distinction between discussing overall prognosis and just survival benefit from chemo, etc. It's a good one for the teaching file - to look at real-life language and how it's used in these situations. I thought this exchange was notable:

Patient’s wife: You’re going to fight it. You said you would.

Patient 315: Yeah but it doesn’t mean to say it’s only going to be nine months I mean it might be 12, it might be 15, it might be.

Oncologist 103: Averages are dangerous statistics.

Patient 315: Yeah, you never know. I said to you before I’d sooner have a short amount of time with a bit of bonus to it, a bit of benefit. If I had to go into hospital for five weeks every day and, and not benefit from it and even catch something worse and end up back in hospital for the rest of me life basically, then I’d have to top myself.

Chemotherapy was offered and refused; the patient died three months later.

There's a supporting editorial here.

**We've griped on the blog before about how it's confusing to use the term 'palliative' to refer to non-curative but yet disease-modifying (life-prolonging) chemotherapy, but this is the language used in the paper. Along these lines, the same BMJ has a case-report detailing confusion about what level of care was appropriate for a patient - confusion seemingly based in the fact that the patient was labeled as a 'palliative care patient.' In this case the palliative care team advocated for more aggressive life-prolonging/restorative care than was initially considered 'appropriate.' This is a situation I find myself in from time to time - and it was nice to see this discussed in a prominent journal. My clinical team tries to keep on our radar other clinicians' reactions to our involvement as at times people can incorrectly assume we're there because a patient is imminently dying, or that their care goals are 'palliative-only.'

Review of psychological adjustment to chronic illness

Lancet has a narrative review about the psychological adjustment to chronic disease. It covers everything from inflammatory cytokines (they're everywhere), functional status, positive/helpful coping, potential long-term psychological benefits of adjusting to a chronic illness, and more. It's mostly useful as an overview of the topic, with a huge reference list, and would be a good starting point for people looking to do more in-depth review of the topic (teaching file!). I found this discussion interesting:

Prospective studies examining which types of emotion regulation affect adjustment show that, at least in the North American and western European cultures, the regular use of avoidant non-expressive styles of emotion regulation is disadvantageous for psychological adjustment and survival. In less emotionally expressive Asian cultures, non-expressive emotion regulation styles have proven advantageous, suggesting that the congruence between one's general style to handle emotions and the style advocated in one's cultural system determines whether the emotion regulation style is adaptive or maladaptive. Acknowledgment and intense experience of emotions are suggested to be beneficial for adjustment as long as those emotions are expressed and processed; the mere uncontrolled expression of emotions without processing can be maladaptive....

Pall-pourri

1)
Archives of Internal Medicine has a literature review and discussion on relationship building and good communication skills, with a focus on what can be done in brief patient encounters. (It has a specific primary care focus.) To be sure, the literature is sparse, and this paper mostly discusses it in a narrative fashion, making some common-sense recommendations. I'm noting it because, as an educator, I'm constantly telling my residents/fellows/etc. that good communication does not necessarily mean a huge time commitment (and certainly, anecdotally, it can be a huge time saver - I believe this even though I have nothing to back it up), and so it's good to see a paper specifically addressing the time-issues involved in patient-centered communication.

2)
Journal of Pharmacy Practice has a review article on symptom management of non-motor symptoms in Parkinson's disease (GI symptoms, psychosis, pain, dysautonomias, etc.).

3)
JNCI has a commentary warning about the over-selling of epidemiological findings in cancer research. That is - findings that suggest X 'is associated with' Y, even though there is no experimental evidence to suggest there is a causal link (e.g. coffee consumption is associated with lower risk for liver cancer - findings like that). The article is mostly a critical overview of how, why, and when such associations turn out to be 'wrong' (not causal) and is a good one for the EBM teaching file. The topic is important for a variety of reasons, not least because our patients read sensationalistic (or at least over-sold, uncritical) accounts of these findings and they can create false hope or 'false-guilt' (I caused my cancer because I didn't do enough aerobic exercise, etc.).

Pain in dementia pearls

Pain Medicine has a practical, chatty case series plus clinical pearls piece about pain management in hospitalized patients with dementia. It's a good one for the teaching file and highlights many issues I imagine many of us see: patients can't ask for pain meds so never get them; patients placed on PCAs who can't understand what they are; patients unable to report side effects of or response to pain medications. Some practical advice is given. Of course no miracles here.

It does highlight the absolute importance of having well-trained nurses to monitor the patients, use PRNs wisely, record pain responses, etc.

Methadone, methadone, methadone

Three recent methadone-related reviews, two by the same group, are well worth the reading. The first two, on conversion ratios and drug-drug interactions, respectively, are the long-awaited published versions of presentations made at the AAHPM/HPNA conference in Salt Lake City in 2007. They are among the most thorough and well-organized reviews on any topic that I have read in recent years. The third is a consensus guideline on parenteral methadone in palliative care.

Methadone conversion ratios:
The authors reviewed clinical trials, retrospective analyses, case reports, and case series published from 1996 to 2006; reviews were excluded. A total of 41 papers (22 studies, 19 case reports; N = 730) were reviewed. None of the studies were deemed to be of high value. Not surprisingly, they identified the heterogeneity of studies as the biggest challenge in their analysis. Not only were different methods and populations used, as well as different descriptive statistics and outcome definitions, but different conversion values and tables for non-methadone opioids were used. While most suggested conversion procedures recommend converting all opioids to morphine equivalents, some use oral equivalents and some use parenteral equivalents. Rather than just throwing up their hands in frustration, the authors recalculated many of the formulas presented, using consistent values.

It should be well known by now that there is not a simple ratio of morphine to methadone that works at all dose levels. Most studies stratified patients according to the pre-rotation morphine-equivalent dose because of the “dynamic inverse potency relationship between methadone and other opioids.” The most common ratios reported were 4:1 and 10:1; the review authors estimate that 30% of all patients were converted using one of these ratios. However, the reported range was 4:1 to 37.5:1.

Using scatter plots, the authors sought to determine the correlation between prerotation morphine dose and the morphine: methadone ratio. They identify a “strong, positive linear relationship between the prerotation morphine dose and the postrotation methadone dose,” but the dose ratio is not constant in relation to the previous morphine dose. When attempting to apply these findings to individual patients, there is confounding due to large interindividual pharmacokinetics with methadone. They emphasize that the “care process” or conversion procedure as well as the calculation of dose ratios varies considerably across studies. “It may be less important to determine an exact opioid ratio . . . than to be sure that the patient is an appropriate candidate for methadone rotation, the switch is carried out over a time period consistent with the therapeutic goals, and that the patient is monitored closely by medical staff throughout the process.” They note that there is no consensus regarding the various published methods of conversion, but that the majority of patients are successfully rotated in all settings regardless of method employed and ratio used.

There is also acknowledgement that conversion ratios are not bidirectional and that there is almost no guidance in the literature for conversion from methadone to another opioid.

Finally, there is a long discussion of the deficits in the research literature and suggestions for the future direction of research.

I’m not sure that anyone already experienced in methadone conversions will change his/her clinical practice because of this paper, but it may well provide rationales for teaching and encouragement for reseach.

Weschules DJ, Bain KT. A Systematic Review of Opioid Conversion Ratios Used with Methadone for the Treatment of Pain. Pain Med. 2008 Jun 18. [Epub ahead of print] DOI:10.1111/j.1526-4637.2006.00289.x


Methadone drug-drug interactions:
This is an advanced primer in the clinical science of managing patients on multiple drugs, especially when one of them is methadone. It should be in everyone’s teaching and reference files. The paper includes:

• Eye-opening dissertation on just how complex methadone metabolism is
• Good description of the cytochrome-P 450 (CYP450) enzyme system in drug metabolism
• Other mechanisms—including some that are pretty esoteric—that can affect how methadone is absorbed, metabolized or eliminated, including the effect of changes in urine pH
• The important effect of the order in which drugs are added—or removed—from a regimen
• Theoretical vs clinically observed interactions
• Class-by-class descriptions of actual or potential interactions
• Limitations of the evidence base
• The fact that pharmacy drug-drug interaction checkers can pick up an interaction when a drug is added but not when it is removed from a regimen

Weschules DJ, Bain KT, Richeimer S. Actual and potential drug interactions associated with methadone. Pain Med. 2008 Apr;9(3):315-44. DOI:10.1111/j.1526-4637.2008.00461.x

Parenteral methadone use:
The consensus panel are almost all very well-known pain and/or palliative care clinicians. They review the very limited literature specific to parenteral methadone, then suggest clinical approaches to optimize it’s use. The paper includes a pretty extensive discussion of the implications for QTc interval changes and the risk of torsades de pointes. This paper doesn’t compare in thoroughness to the other two, but it is a useful review and probably unique in its focus specifically on parenteral methadone.


Shaiova L, Berger A, Blinderman CD, Bruera E, Davis MP, Derby S, Inturrisi C, Kalman J, Mehta D, Pappagallo M, Perlov E. Consensus guideline on parenteral methadone use in pain and palliative care. Palliat Support Care. 2008 Jun;6(2):165-76.

Antipsychotics & death; Hope transitions; Nerve blocks

1)
Continuing the implosion of antipsychotic use for 'behaviors' in patients with dementia, Archives of Internal Medicine published a retrospective cohort analysis about 30 day mortality or hospitalization in patients prescribed antipsychotics (they were higher). All patients were living in nursing homes or at home (none were hospitalized). This is not the greatest study on this topic: increased mortality has been demonstrated in randomized controlled trials of atypicals (i.e. we don't necessarily need retrospective cohort studies). What this one adds is that it looks at both typicals and atypicals and finds that adverse outcomes were higher for both (and a little higher for typicals than atypicals). That is - this supports the idea that this is a class effect of all antipsychotics and not just newer ones (in which the problem was first identified).

2)
Cancer has a discussion addressing hope in the face of a terminal illness. Its focus is that period of time between a patient\family member hearing life-altering news (the cancer is incurable, there are no more treatments that will slow the cancer down, etc.) and them 'accommodating' (that's my language) that news. They describe this time as one in which hope undergoes a transformation (from hope to a cure, etc. to a painless death, or a few good months with the kids before things get bad again, or whatever it is) and which can take quite some time. None of this will likely be news to most readers of the blog, but this was one of the only articles I've read in a long time which focuses on and analyzes specifically that transition - what that transformation actually entails. A good one for the teaching file. I liked this quote about bedside manner:

Here, we focus on the cognitive aspects of hope management, but we also want to emphasize the profound importance of the behavioral and affective components - of the physician recognizing and responding to the patient's emotional condition. When the physician forms an empathic emotional connection with the patient, it conveys an unspoken but important message of caring; the physician's steady presence is an almost physical shelter in the emotional storm that often accompanies impending death.

3)
British Journal of Anesthesia has a review of nerve blocks in advanced cancer patients. It's a casual review of the topic written from an anesthesiologist's perspective and is somewhat interesting for its discussion of the different approach taken in dying patients than, for 'non-dying' patients. Teaching file.

Chemotherapy in Dying Patients

JAMA continues the wonderful series "Perspectives of Care at the Close of Life" with an article from Dr. Harrington and Dr. Smith from VCU about the timing of chemotherapy in patients with advanced cancer who may be dying (sub req'd). This is particularly relevant because of the recent Dartmouth Atlas report on geographic variability in aggressiveness and costs in the last two years of life despite no large differences in outcomes.

A common opinion is that health care spending is higher then it should be in the last two years/year/6 months of life. Taking this position is clearly a sign of superior skills in prognostication or it demonstrates the ability to use a 'retrospectoscope.' Reading the case presented of a gentleman with metastatic non-small cell lung cancer as he progresses through three lines of chemotherapy will sound familiar to many palliativists. But it is not necessarily obvious when he become 'terminal.' Thus the dilemma of when to shift from curative to palliative care as a primary goal.

The two interviewed physicians in the case do well to show respect for the other, but you still get a sense of the tension that can exist between oncologists and palliative doctors. After being consulted the palliative care doctor called the oncologist and clarified the issues at hand, but they did not explicitly share prognosis as this quote from the palliative care doctor shows:

"They were shocked about the prognosis that I offered . . . of days to weeks. They were still expecting more chemotherapy. Here I was, walking into the room and basically saying, “Okay, folks, it’s time for hospice.”

Curiously as much as prognosis plays a role in these decisions it is somewhat glossed over in the article. This quote from the authors somewhat baffled me:

"When the prognosis is predictable, as with Mr L, why do most oncologists not directly address it?"

The answer to the question is that the prognosis is not always so predictable. We need more prospective studies to demonstrate prognostic skill that so greatly influences decision making. The article quotes many studies showing use of new chemotherapy regimens within a few weeks of someone dying. What is not always clear is was it appropriate to be on the chemotherapy. It is easy to imagine the patient with an ECOG of 4 or PPS of 30 as one of those patients who died within a few weeks after the new chemotherapy started. But what if their ECOG was 2 and the PPS 60 or 70% and they still died. Would you consider that use of palliative chemotherapy appropriate?

These prospective studies of clinician and patient prognostication and the impact on clinical decision making is what medicine needs to better determine if we are making the 'right' decisions at the right time. Looking retrospectively only generally informs us of a existing challenge. It does not provide the answer.

The article is a good read with some great references and an excellent one for the teaching file for oncology and palliative medicine. The focus is not really on prognosis as I have made it here, and what it does cover the authors do an exemplary job. The tables are also particularly notable:

• What Patients Know About Their Advanced Cancer and Its Prognosis
• Palliative Chemotherapy for Metastatic Disease for 4 Common Solid Tumors
• Helpful Questions to Consider Asking About Palliative Chemotherapy
• Things to Do or Say (and Not to Do or Say) About Chemotherapy for Advanced Cancer
• Studies of Concurrent Palliative Care With Oncology Care

The lead author of the article was also one of the selected speakers for the Annual Case Conference for Professionals-in-Training in 2006 at the AAHPM. Way to go Sarah! COngrats on the JAMA publication.

The article was highlighted in USA Today this week, and here are a few of the interesting comments from the website article:

Sorry for the long comment, but I have seen people refuse treatment and die because they were afraid of chemo or something as silly as losing their hair. Chemo is not that bad and has the possibility of extending a life significantly.

As a physician, we don't have crystal balls. To say, you have 5 weeks or 5 months is extremely difficult. We can say based on a certain type of cancer or terminal disease, MOST PEOPLE with this disease typically survive "X" amount of time....but to narrow it down to the individual patient is not feasible. There are many variables.

Palliative care is the wave of the future. These highly trained doctors and nurses do outstanding work with patients and the medical team assigned to those patients. Many times, my sister (the nurse practioner) has had to counsel doctors, interns and other nurses on how to talk to the patient and what to say. She herself has worked with scores of terminally ill patients and their families walking them through the journey, talking directly but gently, and helping them to see the full picture. Hopefully as this unique practice grows, most, if not all, hospitals will have palliative units to help everyone with these difficult issues.

Harrington, S.E., Smith, T.J. (2008). The Role of Chemotherapy at the End of Life: "When Is Enough, Enough?". JAMA: The Journal of the American Medical Association, 299(22), 2667-2678. DOI: 10.1001/jama.299.22.2667

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.

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 h