Mastodon 07_06 ~ Pallimed

Tuesday, June 26, 2007

Paging Dr. TMI; The Poppy Trade

TMI is "Too Much Information" if you needed to know
1) Many news outlets (WSJ and USA Today (read the comments there) and others) are noting an article in the Archives of Internal Medicine regarding physician self-disclosure during clinic visits. The study involved standardized patients secretly recording physician visits which were then later analyzed for "personal emotions and experiences, families and/or relationships, professional descriptions, and personal experiences with the patient’s diagnosis." They even managed to account for one of my favorite errors in research, the Hawthorne Effect (non-Wikipedia link!), by using unannounced, unrecognized SP's, so that the MD's would not alter their behavior. The article includes many interesting snips of conversation from the study. 73 self-disclosures were identified in 34% (38/113) of the visits. The authors even noted if the disclosure was deemed helpful, neutral or disruptive.

This study was well-designed and executed and the discussion section is a great read. It provides insight in how to look at the blurry lines among empathy and disclosure and boundaries and strengthening the clinician-patient relationship. I think these issues are very important for palliative care practitioners since it is so easy to make a quick connection with people by sharing any of your own losses, but ultimately it does turn the focus to us, and not to the patient or family. One technique if you are sharing something of your own experience, is you can always depersonalize it and mention "A patient/family that was in a similar situation thought this was important..." or whatever segue works best.

But I guess that is sharing a little too much about myself!

2)Nature is reporting a release of a innovative proposal to help fight the "war on terror" and the "war on drugs" at the same time. The program is called Poppies for Medicine (P4M) and it is being proposed by the Senlis Council, a European-based think tank dealing with health, counter-narcotics and grass roots improvement in Afghanistan. Some of the basic tenets of the plan include:

  • Afghan farmers preferring a reliable, legal means of income
  • A better price (US$140/kg) for farmers compared to illegal markets (US$92/kg)
  • A worldwide shortage of inexpensive pharmaceutical grade opioids (A very interesting read)
  • Manufacturing on a local level to provide stable jobs in rural areas
  • Close oversight for quality control
This ideas does not sound too crazy, especially since the United States backed a similar plan in Turkey in the 1960's to curb the illegal poppy/heroin trade. There is a great FAQ and a full report at the Senlis Council website if you want to read more about it. Maybe an international vote of support from hospice and palliative care programs for improved access to appropriate medical use of opioids is in order? Anyone from the IAHPC read this? Can anyone imagine morphine bottles labeled "Made in Afghanistan?" I wonder what that would do for the American opioid stigma.

The image of the button at right is courtesy of user violinsoldier. The button is supposed to signify the poppy's firm grip on the country and people of Afghanistan. The writing has been translated as "Save your country from the occupation of drugs" in two languages.

Other tidbits:
The Virginian teen who was initially denied alternative (CAM) treatments, Abraham Cherrix, had to go in for more radiation. Two bloggers (Respectful Insolence and The Cheerful Oncologist)at ScienceBlogs comment on the report. Both are good writers with some interesting insight, so I will not try and outdo them.

Freakonomics (a good non-medicine blog and book) interviews Atul Gawande, author of Better: A Surgeon's Notes on Performance. He makes a comment that we could do better with chronic pain. (I agree!) Then states that we can cure 70% of cancers. (huh?). Despite that last statement needing some 'qualifiers', I have heard great things about his book. Any Pallimed readers get to it? If so you want to write a book review for Pallimed on how it may apply to our field?

Tuesday, June 26, 2007 by Christian Sinclair ·

Monday, June 25, 2007

Geographic variations in EOL care; Early palliative integration into lung cancer; Dying homeless

Medical Care has an interesting article about geographic variations in end of life care. It looks at the phenomenon of wide geographic disparities in end of life spending (last 6 months of life - apparently $8300 in Grand Junction, CO & >$21,000 in McAllen, TX) in Medicare beneficiaries and tries to see if these differences can be explained by patient preferences. The researchers essentially compared end of life preference survey results with regional variations in end of life spending (adjusted to age, sex, and race). The survey proposed to the subjects (all Medicare beneficiaries) a hypothetical terminal illness situation in which they were likely to live less than a year & looked at things like desired location of terminal care/death; whether people would want to be vented if it would extend their life by only a week or a month; if they'd want drugs for comfort even if it meant their lives might be shorter, etc. ~2500 people were surveyed (this was a disappointing but typical response rate of 65%); average age 76; 85% white. Of note: 87% of these subjects would not want ventilation for a week of life gained; 77% wouldn't want it even for a month of life gained. Anyway, when they divided patients up by quintiles of EOL spending & controlled for age, race, and other demographic information there were no differences. That is - the EOL preferences of those in the highest EOL spending regions were the same as those in the lowest spending regions. This of course raises the question of why there is such a disparity in spending and local medical culture is certainly one possibility & is certainly the possibility I'd be most interested in hearing more about (the obvious follow-up study is to mail surveys to physicians about end of life care practices and see if they vary by regional spending). That said, and one of the more annoying things about this study, is that it is well recognized that medical/Medicare spending in general has wide regional variations and it's certainly possible that these differences are explained by those larger/regional forces and not local medical culture. This is unaddressed by the study.

A recent Journal of Clinical Oncology has a couple notable articles. First and briefly was one finding that depressive symptoms are a poor prognostic sign in patients with newly diagnosed hepatobiliary cancer.

Second and less briefly was a study describing a project to integrate palliative care into the care of advanced non-small cell lung cancer patients from the time of diagnosis. The project, which took place at Dana-Farber, involved patients newly diagnosed with Stage IIIb or IV NSCLCa and good performance statuses (presumably all patients with this diagnosis were approached for the study although this is unclear). This paper presents the "phase II" feasibility part of the project: their goal was for the palliative care team to meet with the patients monthly from the time of diagnosis and for at least 6 months & they defined their (feasibility) success as an at least 50% patient 'compliance' rate with the monthly PC visits - basically asking is this even do-able?.

Findings: median survival was 9 months, 1-year survival was 36%, symptoms were very common, and 'compliance' with palliative care visits/symptom assessments was good (overall 86%). The authors note they are now doing a randomized trial comparing early/integrated palliative care with usual care in these patients which will presumably look at symptom improvement, patient & physician acceptability, etc. This is an exciting project & I'm looking forward to the coming results (& hoping they're positive!). The mantra has long been that palliative care should be integrated into cancer care early on, long before the terminal phase. This is easier said than done of course, and there are lots of barriers to doing this (including legitimate questions about whether this really benefits patients - does an entire population 'at risk' benefit from seeing specialized palliative care or are we best "reserved" for the tougher cases and how would you define those tougher cases and make sure they get to palliative care etc. etc.). The only way of knowing for sure is of course studying it, and then you won't know for sure anyway, but it's something - and if it does show a benefit to patients (or health systems in reduced utilization/costs) then it helps us politically in expanding our presence, for instance, in the cancer clinic.

Journal of General Internal Medicine recently had a couple of articles about end of life care & the chronically homeless. They are both based on qualitative research done with homeless people in Minnesota . The first is about homeless persons' attitudes towards death & dying and the second is about end of life concerns/preferences (both available in free full-text). My favorite quote:

'For some participants advance care planning meant discussion with significant others and/or appointment of a proxy; however, the most cited forms of advance care planning included written documentation of wishes or contact information, personal identification, or written directive or other advance care planning document. One participant voiced a typical strategy to dictate circumstances of his death: "In my wallet, I have a card with my sister's name and a phone number. Do I want to be buried in Minnesota? Hell no!"'

Monday, June 25, 2007 by Drew Rosielle MD ·

Wednesday, June 20, 2007

Opioids, opioids, opioids, cadavers

Anesthesia and Analgesia has an article urging medicine to conceptualize pain relief as a fundamental human right, and several editorials in response (one on improving access to analgesics worldwide; one on legal aspects of pain management; a general supporting editorial ; and a cautionary editorial warning of overuse of opioids to control chronic and postoperative pain). The main article is a comprehensive review at how and why pain is undertreated and the health and societal costs of this, and focuses a lot on international (WHO, etc.) efforts to improve pain relief. One sobering tidbit: 6 nations use 79% of the world's supply of morphine and 120 countries use virtually zero. (One assumes that in most of these countries the strong opioid of choice is nothing, and not Actiq or OxyContin.) The most interesting aspect of the article was its relatively lengthy summary of legislative and judicial efforts in 'developed' countries to define pain relief as a right, a medical standard, and inadequate pain relief grounds for civil liability.

While the position that pain relief is good/important is rather uncontroversial, the counter editorial reveals that decades into the pain control movement the issue remains very polarized, and polarized specifically around the use of opioids. One side is the opioids are safe and effective and the best we've got camp, the other is the opioids aren't safe, aren't effective, and not worth it camp, and in between the great mass of medical professionals remain afraid to treat pain, and ignorant of how to do it even if they wanted to. It's like a yelling match between one group saying WE ARE NOT TREATING PAIN DOCTORS ARE OPIOPHOBIC PATIENTS ARE SUFFERING and the other WE ARE OVERTREATING PAIN OPIOIDS KILL WE ARE CREATING ADDICTS. And like I've blogged before there's a sense out there that there's a backlash growing against opioids for chronic non-malignant pain and this editorial quite effectively spells out the issues at hand. They note, and I can't argue with them, that there are a lack of quality, long term data supporting the safety and efficacy of opioids for chronic non-malignant pain (however see this post for how research findings can be twisted). While true, there is evidence that a substantial minority of people really benefit, although (and this is my grand gloss on the entire field) - across a population of patients with chronic non-malignant pain a majority of them won't benefit from long-term opioids (and in many studies people just stop using them after a while because the toxicity seems to outweigh the benefit they're getting). Taking this as true it seems like the reasonable public policy should be to, in fact, through clinician education and training, make sure physicians know how to treat pain and effectively use opioids, and, per the 'pro-opioid' camp, make sure the regulatory environment is such that physicians who prescribe opioids for legitimate purposes don't have to worry about 30 year prison terms.

Along these lines Annals of Internal Medicine has a short piece about strategies to stop abuse of prescription opioids . It reviews some of the evidence but is mostly based on interviews with experts. A worthwhile, quick read.

The May Harper's, in the Readings section, had an amazing excerpt from remarks from the undertaker Thomas Lynch made to the President's Council on Bioethics about the treatment of cadavers (these were from hearings about organ transplantation). (Looks like the full transcript of his remarks is here...scroll down a little). Read this.

Some choicer quotes (sorry about the length of this but it's in the public domain, & he does ramble a little, and I can't help myself):

"And there is a difference, as one of your panel pointed out, between the notion of medical death, metabolic death and the notion of social death and spiritual death and actual death as far as your family is concerned, and those are the things this council must wrestle with when you seek to set forth useful policy. I might know, for example, that at the end of a process with cremation, we end up with say 14 pounds of bone fragment and dessicated tissue that we can put in a box and hand to the family. But when you see the elderly sister come to claim the ashes of a sister whose own children couldn't come and get her, when she bears that box like Viaticum, when she walks out the door, flips the button to open the trunk and then reconsiders and goes to the back door and opens it up and then thinks better of it and closes it again, when she goes to the passenger — front seat passenger door, opens it up, places the box on the front seat and then clicks a seatbelt around it, you can see that whether we are remnant or icon or relic is not up to you or me. It's up to the living that bear us in their memory and in fact, that bear our mortality because we are mortals, we are humans. We are tied to this humus, this layer of earth from which our monuments and our homes and our histories rise out of."

"Right between the inhale and exhale of the bone-wracking sob such hurts produce, some frightened and well-meaning ignoramus is bound to give out with, "It's okay, it's not her. That's just a shell." I once saw an Episcopalian deacon nearly decked by the swift slap of a mother of a teenager dead of leukemia to whom he had tendered this counsel. "I'll tell you when it's just a shell," the woman said. "For now and until I tell you otherwise,
she's my daughter." The woman was asserting the longstanding right of the living to declare the dead, dead. Just as we declare the living alive through baptisms and lovers in love by nuptials, funerals are the way we close the gap between the death that happens and the death that matters. It's how we assign meaning to our little remarkable histories. And the rituals we devise to conduct the living and the beloved and the dead from one status to another have less to do with performance than they do with meaning."

Wednesday, June 20, 2007 by Drew Rosielle MD ·

Tuesday, June 19, 2007

Appetite & Pain & Traumatic Memories in the Media

In reading the newspaper and news magazines, and watching evening news show or listening to talk radio or NPR, I enjoy finding the parallels between palliative medicine and the news I'm learning about. Sometimes it takes a little creativity, such as when I am reading a Wall Street Journal article about business strategies an try to apply it to how a hospice team functions or how we market our unique services to others. Other times it is very easy to connect the dots.

The first obvious one was a cover article early in June about new pain research in Newsweek. It led to me discover Ionsys, an new trandermal fentanyl delivery device utilizing self-contained ionopheresis. Apparently it is designed for post-op patients. The device, called a E-Trans, and developed by ALZA, looks like a spaceship (watch the video on the site to get more of the spaceship feel. They even make it glow!). I have not seen any cost statements on it, but I am all for more options when it comes to opioids, but more than a new device I would like to see more medication options. Other than that, the article basic point is that people are starting to recognize pain (especially chronic pain) as a big enough gorilla that addressing it proactively may be the best option. But I can't recommend you read this article, because it hit on some of my palliative medicine pet peeves in the media.

1) Overstating facts/Hyperbole

The author bashed the 10-point visual analog scale as "absurdly imprecise." Absurd? As in logically contradictory; nonsensical; ridiculous? I think that is a bit much. The VAS is not perfect but it does help track pain in one patient over time. It does not help you to say, "Ah you have a pain of 7, well 50 mcg of fentanyl for you!" The article did go on to state the flaws of the VAS, but some of these flaws are also strengths, such as "inability to compare" between patients (i.e. one person's 5 to another person's 5).

Here is another example:

Morphine, also given to Jackson and many others in the Civil War, is still the Army's most commonly used painkilling drug. It works, but compared with more-modern options, it's one step above chloroform and two above biting the bullet. (emphasis mine)

So what are the label for the axis for this particular sc
ale? Comfort? Sedation potential? Historical? Reverse alphabetical? Is it really necessary to compare morphine and demonize and stigmatize it more? It is a powerful medication for sure, but one that can be used effectively and properly when respected and understood to provide effective pain relief without major side effects.

2) Using the word narcotics when referring to opioids


Others pack all the punch of narcotics with less of the specter of addiction.

Narcotic is primarily a legal term referring to controlled substances regulated by the DEA, thus the Narcotics division, the 'narc' informant, etc. Nacrotics, when using the orig
inal definition, really applies to a medications with a effect of sleepiness or stupor. Therefore it is way to broad of a definition to include just opioids. Say 'opioids' when you discuss it in medical terms, say 'narcotics' when you are discussing legal/regulatory issues.

3) Poor use of scientific language

Kadian was referred to a a 'morphine derivative' in the article. The active medication is morphine, and is encapsulated in a different type of delivery system. A good example of a derivative is that codeine (methylmorphine) is a derivative of morphine

The second article was in Time covering the growing (ha!) field of appetite research. And appeared to have a scientific editor review the article more precisely as I did not find as many flaws as in the Newsweek article. The article did not reveal to much in to the world of appetite, anorexia-cachexia in the palliative care population, except to let the public know that appetite is much more complex than:


Speaking of appetite, I was recently tipped off to a 4 day conference on cachexia, which will be held in Tampa this year in December. Check out the schedule, looks like some interesting talks. The logo is pretty clever. Decline, decline, then maybe an improvement! Also check out the font for cachexia. It gets skinnier. I am a sucker for good graphic design. I am really impressed that cachexia research can cover 4 days! Are you?

The last health in the media connection I made recently was 60 Minutes reviewing the use of propranolol in preventing or reducing the severity in post-traumatic stress disorder (transcript and video available). The article had good coverage of the ethical debate in trying to minimize stressful experiences that we may learn from versus traumatic memories preventing people from proper functioning. As I was watching it, I imagined a family member approaching me to ask for propranolol so they could cope better with losing a loved one. Maybe I will discuss this with my team this week and see what the chaplains and social workers say about this? What would you do?

Updated/Added Prognosis Links

I added some prognosis links. Check them out on the Prognosis Links page.

Update on New Orleans Euthanasia Accusation Case

CNN has information that the two nurses accused of euthanasia in post-Katrina New Orleans have received immunity in exchange for their testimony. This is leading to speculation that Dr. Pou will be the main target. But it could also mean that the two nurses now will feel safe to talk openly about the situation without risk of prosecution and it could swing either way.

Tuesday, June 19, 2007 by Christian Sinclair ·

Saturday, June 16, 2007

"Doctor or drug pusher" in the NY Times

This week's New York Times Sunday Magazine cover story is on criminal prosecutions of pain doctors for prescribing opioids. It is a long article which mostly focuses on a single case of a physician who certainly recklessly prescribed opioids for chronic pain - but for whom there's no evidence that he did it with any sort of intent other than to relieve pain (he wasn't running a prescription mill, conspiring to divert or otherwise distribute opioids, nor was he profiting from people misusing his prescriptions). The journalist more or less accuses the DEA/the Feds of reassuring physicians they won't be prosecuted unless they prescribe with criminal intent - knowingly prescribing opioids to be diverted or abused etc. (and not just recklessly but with analgesic intent which would be a matter for civil litigation/malpractice/etc.); then refusing to define what proper medical prescribing is (because, after all, the DEA shouldn't be telling docs how to practice medicine); then going ahead and prosecuting docs anyway for prescribing recklessly but with analgesic intent.

"But the agency is defining issues of medical practice in dramatic fashion — by jailing doctors who step over the line. It would not seem to be bothering, however, to draw the line first."

"Proper pain management will always take time, but the D.E.A. can at least ensure that honest doctors need not fear prison. It should use the standard it claims to follow: for a criminal prosecution to occur, a doctor must have broken the link between the opioid and the medical condition. If the evidence is of recklessness alone, then it should be a case for a state medical board, the D.E.A.’s registration examiners or a civil malpractice jury."

The article closes with the story of one of the imprisoned pain doc's patients who had been on gram doses of oxycodone daily, apparently doing really well - working, etc. - whose life was dramatically worsened when the doc was arrested and he couldn't find anyone to prescribe him analgesic doses anymore...

'With Ben’s permission I talked to his current doctor, who said Ben was a good patient but had been taking way too much. “I thought Ben made an error,” he said. “He had been taking five or six times the recommended dosage. There are well-recognized levels, and you don’t step across the line. You may have to live with some pain.”'

Recommended dosage? Well-recognized levels? The line? No wonder physicians are being imprisoned if their colleagues (and therefore DA's, judges, and juries) believe this.... While I'm sure our chronic pain colleagues are worried I also wonder if this trend continues if there will be spill-over into the cancer pain world.

Saturday, June 16, 2007 by Drew Rosielle MD ·

Friday, June 15, 2007

Treatment limitations in hemorrhagic stroke; Buccal fentanyl; The Onion

Neurology has an important article looking at prognosis in intracerebral hemmorrhage which finds that early treatment limitations are independently associated with mortality (related editorial here. ) The data come from a large, regional study of ICH outcomes in Texas, and the researchers reviewed charts looking for 'care'-limitations (DNR orders, decisions to not escalate care, withdrawal of life-prolonging treatments) in non-brain dead patients. Long-term mortality was also followed - median length of follow-up was 417 days. They looked at 270 ICH events total: of those, 93 had early (<24h of admission) treatment limitations vs. 177 who did not. Those with early TL's were older (77 vs 70 years), sicker (lower Glasgow Coma Score, larger ICH volume, more likely to come from a NH), and had much higher in-hospital mortality (75% vs 25%). Long-term survival was also very different (~65% survival at 3 years without TL vs 20% survival at 3 years with TL); all the difference in survival however occurred immediately (survival curves are identical - nearly flat - once past the initial event). None of this is surprising - the patients with TL were much sicker. What is notable is that after controlling for age, gender, ethnicity, initial coma score, ICH volume, extent and site of hemorrhage, early treatment limitations were still significantly associated with in-hospital and short & long-term mortality. Implication: the TL patients were in fact considerably sicker (but in a way that wasn't controlled for in the multivariate analysis...for instance medical comorbidity wasn't accounted for at all) or many of the TL patients would have lived much longer without those treatment limitations. Probably both of these are true; withholding or withdrawal of life-prolonging care is just that. The authors conclude: [E]arly predictions of poor prognosis and subsequent reductions in care could result in withholding care from individuals with the potential for meaningful recovery. Physicians may therefore wish to exercise caution prior to recommending limitations in the aggressiveness of care in the initial hours after ICH presentation.

Translation: don't withdraw/limit life-prolonging care immediately because you may be wrong. Those recommendations, then, are the real challenge of the study. What is missing from them though is that while TL may lead to earlier death that may very well be consistent with the patient's values - not have their life prolonged after such an insult if their quality of life afterwards was not going to be acceptable to them. Predicting that is, of course, difficult and weighing out the chances of that happening with a patient's desire not to have potentially burdensome care is the real trick and this research is not designed to speak to that. They mention 'potential for meaningful recovery' but this wasn't measured here - just survival - although if you're dead you don't of course have that 'potential.' To me, it seems like survival is the wrong outcome to measure in these situations. It's an easy outcome to measure to be sure, but what most patients want to know is their likelihood of being restored to health (to an acceptable level of health and function) and not their chances of solely being kept alive. My thinking that that should be the relevant outcome doesn't make it possible to define or measure well or 'operationalize' but one can still think it.

There are some patients who would have recovered well but don't due to treatment limitations, just as there are some who would have not wanted their lives prolonged who nevertheless received full life-prolonging care. Without perfect
knowledge (or even much better knowledge than we have now) these 'mistakes' will be made. But are these 'mistakes'? Is that even the right way of thinking about it? Assuming we will never have perfect knowledge, if we (medical professionals) honestly and with humility talk with patients/families about both the limits of our knowledge to predict and the limits of our ability to heal, earnestly try to understand a patient's values and goals and limits, and then make the best decision possible - that is good medical care and not a 'mistake.' Holding ourselves to perfectly informed decisions is a positivist folly.

So, do treatment limitations in ICH increase your chance of dying? Yes - but that's not the right question.

The British Journal of Cancer has an article comparing buccal fentanyl with IV morphine in a prospective, randomized, non-blinded trial for breakthrough pain in cancer. Despite involving only 25 patients (inpatients in a palliative unit) this was an astonishing complicated trial & results and I'm not quite sure what to make of them. I'm more mentioning this for those of you with a particular interest in transmucosal fentanyl. The major question it is addressed is whether it's safe to start buccal fentanyl in a patient using a dose which is a percentage of their overall opioid dose (many of us choose a starting breakthrough dose of ~10% of the daily opioid dose) as opposed to using the lowest buccal fentanyl dose and titrating up (this latter practice has been proposed because in other trials of buccal fentanyl the effective breakthrough dose seemed to have no relation to the prior opioid dose). In this study they chose 200mcg of fentanyl per 60mg of oral morphine equivalents daily dose as their breakthrough dose and it seemed to work and be safe and effective. That is, for someone on 180mg of oral morphine equivalents daily their data suggest 600mcg is a safe breakthrough dose of buccal fentanyl.

And finally, courtesy of alert reader Dr. Steve Rommelfanger, The Onion once again has an offensive and funny 'end of life' related piece: " I've got some bad news, and I've got some hilarious news." Also note this fake headline from 2002 .

Friday, June 15, 2007 by Drew Rosielle MD ·

Wednesday, June 13, 2007

Surrogates & Hand Shakes; Sedation Guidelines

The recent issue of Archives of Internal Medicine has a number of articles with special significance to the palliative medicine field.

The Physician-Surrogate Relationship by Dr. Torke is probably the first article I have seen that specifically addresses just the important role the surrogate plays in medical decision making. Nothing groundbreaking in the actual content of the article but it is groundbreaking in the fact that it addresses the issue of MD-surrogate relations at all. It lays out the relationship based on 4 key issues:

  • Relationship Building
  • Decision Making Roles
  • Experience of the Surrogate
  • Multiple Surrogates
One thing that I did not find highlighted were the few studies out there that demonstrate surrogate decision making accuracy is not as high as society would hope for the amount of trust we put in surrogates to accurately convey the wishes of the patient.

Also is an article about prescribing practices in the Netherlands with regards to palliative sedation. Despite a poor response rate to the survey, it basically found that voluntary guidelines are not generally adhered too for a number of reasons. Some of the difficulties pointed out in the article include the multiple definitions associated with palliative sedation and that the guidelines did not have an effective implementation policy, therefore not a lot of people knew about them possibly. Of note about 17% of the patients received palliative sedation for existential suffering.

And finally an article on how to greet patients in an evidence-based fashion.
I never thought of greeting in an evidence based fashion, but the authors make some good points:
  1. Shake hands
  2. Say the patients name (first, last or both)
  3. Say your full name
Somehow this seems obvious but the compared what patients said they wanted with what was observed in a video sample of physician-patient interactions and basically we failed on point number 2, and have room for improvement on number 3. I am glad this study was published and the discussion part of the paper makes for great reading and a good summary of points for all health care professionals on the evaluation of the greeting and the importance in setting the tone for the current and future encounters. Didn't say anything in the article about remembering surrogates names, but this is probably important for obvious reasons. The article did not make much mention of accurately pronouncing patients names, except for this small encounter:
There was only 1 instance in which a physician asked how the patient wanted to be addressed, and it seemed to stem from confusion over several names in the chart:
Physician: You have a lot of names here [looking at chart]. What should I call you?
Patient: Dora is my first name.
Physician: What can I do for you?
For anyone that has worked with me, they will know this is a sticking point with me occasionally. Given all the aspects of a person's life we are privy to and the powerful impact we may be having on their life by giving medications and doing surgery and caring for them, the least we could do is know how to pronounce their name correctly. I don't care how difficult it is. Don't laugh it off and shorten it, or call them Mr. Z, unless they ask you to do so. We should all make an effort. For Pete's sake we got through anatomy didn't we? Ask the patient is the 'G is silent' and pronounce their name correctly. It shows respect. [Stepping off my box now!]

Two other brief findings from searching the web:

1) I missed the news report about the death of the 19 month old toddler with Leigh's disease in Texas. He died on May 19th. I blogged about his case earlier this year. Life support was never withdrawn in accordance with the mother's request. It still leaves a contentious issue somewhat unresolved, because in this case a judge temporarily blocked any withdrawal of life support measures. So I imagine if this comes up again in Texas we may see the whole drama played out again.

2) I stumbled across a law school professors blog who used a hospice scenario as a final examination. I always find it interesting how other disciplines learn, and how the methods compare and contrast with my formal medical education.

Here is an excerpt of the testimony from 'Caring Caretaker:'
I work at Hopeful Hospice. I first saw Sam Sidekick there on June 15, 2006. He was in pretty bad shape. I was assigned to be his main caretaker. Of course, all the people who come to Hopeful Hospice are in a bad way; they’re there precisely because they’re dying. But Sam was in a bad way psychically as well as physically, and something other than the prospect of death was troubling his soul.
Flickr photo courtesy of user 8ran

Wednesday, June 13, 2007 by Christian Sinclair ·

Monday, June 11, 2007

Atypical antipsychotics & dementia; Placebo effect; Dementia diagnosis; Prognosis post-arrest

Some quickies:

Annals of Internal Medicine has published another paper suggesting atypical antipsychotics increase mortality in elderly demented patients. This one is a large retrospective study from Ontario using administrative database data comparing demented patients who received antipsychotics to those who didn't (patients with comorbid mental illnesses like schizophrenia or who were receiving palliative care services were excluded). I'm not going to belabor their findings because they're similar to other ones: atypical antipsychotic use is associated with higher mortality (albeit a tiny increase) - in this study it was ~1% increase and evident by as little as 30 days (this is consistent with prospective data). What this study adds is that it also compares risk of death from conventional vs. atypical antipsychotics and finds that the risk of death with conventional antipsychotics is significantly higher (significant in that it is a statistically sound conclusion - actual magnitude of increase is ~2.6%...tiny). The problem with this is that this is all uncontrolled data & doesn't exclude the possibility, or even likelihood, of confounding, although I personally believe that if atypicals increase one's risk of mortality why wouldn't conventional ones? Frankly if these agents were wonderfully effective for behaviors in dementia I'd be arguing, & I think most people would too, that a few percentage increase in mortality is acceptable given the high mortality anyway of this population, quality of life considerations, etc. However they aren't particularly effective, so... I have this vivid memory from a geriatrics rotation in my residency in which the geriatrician was liberally prescribing Geodon & Valproate to his demented patients with behaviors and proudly noted to me how he was on the cutting edge of things. I've always wondered how his practice changed in the subsequent years.

(Related posts here, here.)

For you public radio fans out there: WNYC's Radio Lab recently aired a show about the placebo effect. It is an interesting listen and addresses, amongst many things, pain physiology and bedside manner. Radio Lab is quite an interesting show - hour long looks at a variety of topics - all science-related - but usually told through stories (of patients, researchers, etc.) instead of typical reportage. Think of it as what This American Life would be like if it was about science/the natural world. The show goes straight for the Big Ideas - space, time, morality, identity, etc. (You can download or stream the show from the website. Podcast also available through iTunes).

Back to the dementia theme: JAMA has a review on diagnosing dementia as part of their "rational (i.e. evidence-based) clinical exam" series. EBM aside this is actually a nice review of dementia & its symptoms & real-life manifestations - a good one for the teaching file. Its conclusion: there are a variety of brief, validated tools to diagnose (or at least accurately screen) for dementia at the bedside, etc. etc. They didn't however mention the palliative care method: simply asking the patient, "Are you demented?"

And finally, for you arrest-prognosis buffs out there, American Heart Journal has an article about long-term prognosis after in-hospital cardiac arrest. It is a retrospective study from a single US veterans' hospital looking at >700 consecutive in-house arrests from 1995-2004. The point of the study was to look at what was associated with long term survival for those who actually survived an arrest. 6.6% of patients actually survived to discharge. 1- and 3-year survival rates were 68% & 41% for those who survived to discharge (making the overall 1- and 3- year survival rates for in-house arrest 5% & 3%). They note that during this time the hospital had a QI project to improve their response to in-house arrests which increased their immediate survival from CPR by 2.6 times. This, however, had zero effect on long-term survival. (The authors go on to look at things like receiving an ICD and long-term survival but, frankly, there were only 9 patients who both survived to discharge and received an ICD and it's not clear to me that any conclusions can be drawn from so few patients.) For me, the most interesting aspect of the article was the notice given to the fact that the QI project to improve in-house survival didn't affect long-term survival. It corroborates what we tell patients with whom we are discussing code status - even if it temporarily restores life--a beating heart--it will not restore one to health/ameliorate the underlying condition causing the arrest (patients with isolated ventricular arrhythmias aside).

Monday, June 11, 2007 by Drew Rosielle MD ·

Friday, June 8, 2007

2 year anniversary; Medical blogging; Palliative consultation decreases ICU LOS

Well this is the 2 year anniversary of Pallimed and the 360ish post (my God that means we've posted nearly every other day for 2 years). Hooray. I want to thank all the readers and commenters on the blog and all the people over the last 2 years who have given Christian and me encouraging feedback on Pallimed.

Not wanting to wallow in self-congratulation too much here...but I'd also like to thank Christian for his contributions to Pallimed - for the reformat to be sure - but also his unique voice and perspective.

It's not the happiest time to be a medical blogger. There have been several bloggers who have recently packed up shop - frequently due to fear of liability (professionally or legally) - this is particularly true of anonymous bloggers. Most notably for us - Hospice Guy at Hospice Blog seems to be bidding adieu due to concerns for being outed and damaging his own organization or others. Frankly I don't really understand how this could be the case - his blog is so mild mannered & well-reasoned &, well, wise - but that, I guess, doesn't make one immune. I'm not sure if I'm naive or not to think that we are immune from such consequences at Pallimed. The blog, however, has never been anonymous, we don't post about patients or really any personal stuff, the tone has (almost) always been civil and constructive, and probably the most controversial things I've said are that I have ethical queasiness about assisted suicide (although firmly believing it shouldn't be criminal) and that I'm an irreligious & well-left-of-center-politically sort of guy, but this isn't anything I'd hide from my patients (if it ever came up), employers, or a court. If this gets me into trouble, then, well, may god have mercy on us all. Hospice Guy - so long and good luck. I guess I'll add that if lawyers or my employers are reading this, I'll refer you to the disclaimer at the very bottom of the Pallimed homepage.

Back to the blogging - an important article for the profession (thanks to Dr. Dana Lustbader for letting me know about this paper). It's a study in the current Critical Care Medicine about the impact of a proactive palliative care consultation project in an MICU . The study was a project at the University of Rochester and involved 'automatic' palliative care consultation in the ICU if patients met certain criteria: "a) ICU admission following a current hospital stay of >=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g.; end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest (usually with other serious co-morbid conditions); or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation." The project involved a 4 month baseline in which patients were screened but received usual care (this group of 65 patients was the control group) and then a 7.5 month phase in which those patients who screened 'positive' were automatically seen by the hospital's palliative care team. (Well, almost - the patient's chart was reviewed and symptom management, goals of care, psychosocial/family issues were discussed with the MICU team but the MICU attending could elect to not actually have the PC team meet the patient/family. This is an interesting aspect of the project; one which makes the final outcome that much more impressive as well as would make similar projects more politically acceptable to many ICU teams.)

In a pattern that will be recognizable to many-a palliative care clinician, in the baseline phase 65 patients screened 'positive,' only 5 of these were referred to PC for consultation, and the average consultation occurred on ICU day 14. That rings true to experience. Some interesting prognostic data: in-hospital mortality rate was similar in the baseline and intervention groups (55-60%) as was the in-ICU mortality (~37%). Regarding their screening criteria, in-hospital mortality was 54% for patients hospitalized >10 days prior to ICU admission; 55% for the >80 year olds; 63% for the cancer patients; 74% for the arrest patients; 54% for the ICH patients.

As far as their major outcomes, 25% of patients received a 'complete' palliative consultation at an average of 5 days after MICU admission. MICU LOS was much shorter (for those who died in the MICU) in the intervention group ( 5.7 vs. 14 days). In addition MICU LOS for all patients was shorter in the intervention group (9 vs 16 days). Hospital LOS was not changed.

The authors' conclusions: 'proactive' PC consultation dramatically decreased MICU LOS in a very sick cohort, did not affect overall hospital LOS, and did not affect mortality (comparing the outcomes of similarly screened groups of patients before-after the intervention). All this despite only 25% of the intervention group actually had full palliative care consultation raising the question of the effect of the 'basic' consultation itself (simply raising symptom and goals of care issues with the MICU team had an effect?). Anyway if anything this underestimates the effects of what PC consultation could do. On the other hand one could argue that the LOS went down dramatically because of a change in practice in the MICU service during the study - e.g. more 'sensitive' to goals of care issues etc. due to the very fact a study was being done. However it's hard to imagine this, itself, would nearly halve a team's average LOS and these results are quite convincing despite the obvious limitations of a study of this kind. In fact one's real wish for this study is that they had gathered more information (symptoms, patient/family satisfaction, bereavement, acceptability to ICU team members, and health care costs although one assumes they were dramatically decreased due to the reduction in ICU LOS) - however this was probably a pragmatic study of a quality improvement project without the means to do such an expensive research endeavor. Which, actually, is part of its strength - it seems very reproducible and they did this without any major research. So I think this will be a very important study - particularly in a political sense - for our profession, insofar as much of our growth in the US has been supported by institutions who believe our services decrease unnecessary health care utilization (see CAPC). It will also seems to be an exemplary example of ICU-PC collaboration that would hopefully acceptable to many ICU services (final decision about full PC consult remains with ICU team; does not seem to lead to more deaths, just faster transfer of patients to presumably a more appropriate level of care - out of the ICU)...a piece of good news to start Pallimed's 3rd year.

Friday, June 8, 2007 by Drew Rosielle MD ·

Tuesday, June 5, 2007

Fatigue-o-rama at ASCO; Surgery for back pain; Kevorkian; Ethics Consults

Thanks to everyone at the CSPCP conference last week for being so friendly - particularly the Nova Scotian crew (DH & family, RH, PM) for your hospitality and generosity. Halifax, for those of you who are curious, is as lovely as billed (but watch out for hurricanes). I'm still re-orienting myself and so this is going to be a post of 'quickies.'

ASCO occurred last week & Medscape reported on a session on new research on cancer-related fatigue. It's of course impossible to really get a sense for the quality of this research based on a reporter's summary of a conference session but the research presented suggested 1) ginseng may be helpful, 2) modafinil may be effective for chemobrain, 3) donepezil is not effective for fatigue.

(Medscape articles usually require you to sign-up - it's free however.)

On the chronic pain front NEJM this week presents two trials of surgery for chronic back pain (one for severe sciatica lasting at least 6 weeks, the other for spinal stenosis from spondylolisthesis). Both trials were randomized & controlled (surgery vs. conservative treatment) but not blinded (for obvious reasons) and both suffered from a lot of cross-overs. In the spinal stenosis trial almost half the patients assigned to non-surgical care had received surgery by the end of the first year, and - not surprisingly - there were no differences between groups by intention-to-treat analysis. By as-treated analysis (comparing those who actually got surgery to those who didn't - this is essentially non-controlled observational data) surgery came out better (decreased pain, better function). The sciatica trial had some similar troubles (39% of the conservative group patients received surgery) and the 1-year outcomes were similar in both groups. The surgery group had distinctly faster time to pain relief and functional recovery however. Despite the different ways the studies were presented (sciatica as a 'negative' study and spinal stenosis as a 'positive' one) my interpretation is that early surgery for severe sciatica makes sense (speedier functional recovery and decreased pain) despite the similarity of both groups at 1 year; 'early' surgery for spinal stenosis however cannot be endorsed given the lack of benefit in the intention to treat analysis. All of this really highlights the difficulty of doing research like this - can't be blinded, patients (& who can blame them in the absense of no evidence one way or the other) can pull themselves 'off-protocol' which may be the right thing for them but makes interpreting the studies so much harder.

(Image from Wikipedia's laminectomy article which I'm not otherwise endorsing).

The NY Times has an editorial today triggered by Jack Kevorkian's release urging passage of physician assisted suicide legislation (legalizing/creating a mechanism for it). Their take: legislation is needed not because what Dr. Kevorkian did was right but because what he did and how he did it was so reckless and wrong. It gives a nod to 'aggressive' palliative care:

'The fundamental flaw in Dr. Kevorkian’s crusade was his cavalier, indeed reckless, approach. He was happy to hook up patients without long-term knowledge of their cases or any corroborating medical judgment that they were terminally ill or suffering beyond hope of relief with aggressive palliative care. This was hardly “doing it right” as Dr. Kevorkian likes to believe.

By contrast, Oregon, which has the only law allowing terminally ill adults to request a lethal dose of drugs from a physician, requires two physicians to agree that the patient is of sound mind and has less than six months to live. Now California is about to vote on a similarly careful measure. One of its sponsors cites Dr. Kevorkian as “the perfect reason we need this law in California. We don’t want there to be more Dr. Kevorkians.”'

Mayo Clinic Proceedings has a case series describing 10 years of their institution's ethics consults (255 in total). Despite not being generalizable to other institutions there are many interesting findings. Most compelling to me was that 9 patients had more than one ethics consultation - one can only imagine those situations. Most patients had 'poor' or 'terminal' prognoses (as recorded by the ethics team) and being the subject of an ethics consult, based on this case series, is one of the worst predictors of in-hospital mortality (similar to having 2 ICU stays but not as bad as in-hospital arrest): 40% died (and another 9% died within a month of discharge). Their ethics consultations also sound very similar to my own team's consultations, reflecting the overlapping and differing roles ethics teams and palliative care teams have at different institutions: over half their consultations addressed some combination of withholding/withdrawing treatments, goals/futility, quality of end of life care, and staff or professional conflict (a full 76% of consults involved this). Actually, the most common issue addressed by the team, in over 80% of consults, was patient decisionality.

I particularly appreciated this comment:

"Ethics consultants, while gathering data for the structured questionnaire, interviewed all interested parties, including the patient, the patient’s family, and members of the health care team. This process alone frequently resulted in resolution of ethical dilemmas (eg, discovery of a previously unknown advance directive that articulated a patient’s wishes about life-sustaining treatment during terminal illness). In fact, of the 255 ethics consultations in our series, 179 (70%) were resolved before assembling the full multidisciplinary team to review the case...."

Tuesday, June 5, 2007 by Drew Rosielle MD ·

Saturday, June 2, 2007

AAHPM vs. Other Specialty Meetings: SHM and ASCO

I had the pleasure to give a talk at the Society for Hospital Medicine (SHM) Annual Meeting in Dallas Texas last Friday, and it was very interesting for me because it was the first non-hospice/palliative medicine national meeting I had visited. The SHM is celebrating ten years in business as the group representing hospitalists, a fast emerging field of physicians. Now the AAHPM has been operating since 1988, and so I thought it would be interesting to compare the two groups and see how far they have come.

Members: ?
Founded: 1997
# of practicing Hospitalists (2003): >8000
# of Hospitalists Groups (2003): >1800
Fellowships (non-ACGME): 13 Int Med, 4 Fam Med, 4 Pediatric
Annual Meeting Attendance (est by me): 1500
Estimated Intensity of Pharma Sponsorship at Annual Meeting: Moderate

Members: around 3000
Founded: 1988
# of Board Certified Palliative Medicine Doctors: >2000
# of Practicing Hospice or Palliative Medicine Doctors: maybe 4,000?
# of Hospices: >4100
# of Fellowships (soon to be ACGME Certified): 56 Adult, 3 Pediatric
Annual Meeting Attendance: around 1600 (incl HPNA)
Estimated Intensity of Pharma Sponsorship at Annual Meeting: Minimal

I think this is an interesting comparison because there are some similarities between the fields. Hospitallists and palliativists have been marketed to hospital administrators as 'quality care' and 'efficient, cost-saving' measures. But how many people (public or medical) know what a hospitalist does versus a palliativist? I would guess more people know about hospitalists than palliativists.

Another interesting comparison is the amount of pharma sponsorship at the annual meetings. The booths in the exhibit hall at SHM were full of much larger pharma displays than I recall from the SLC 2007 AAHPM, although those displays were getting larger at AAHPM too. I have not expounded on my particular views about pharma supported education here, but a good synopsis would be: "I hope the field of hospice and palliative medicine does not become anything like endocrinology, oncology, infectious disease or cardiology from what I recall about those rotations and the amount of physician marketing (too much!)" So I find it interesting that on the front page of the AAHPM website listed in the second slot is a link for commercially funded symposia.

So with that I have a few questions for Pallimed readers:

How do the rest of you HPM folks feel about pharma and our field?

Would it help us grow faster like SHM, or would we pay a price in being 'influenced' too much?

Feel free to share your opinions on that or comparing our field and our annual meetings/societies to other ones you are familiar with. W
hat could we do better as a field? What should AAHPM focus on? Or NHPCO? Or HPNA? Talk about it here and if we get some comments I will make sure the right people in those organizations see them.

I will plan on commenting next week (after my vacation!) on the great focus that the SHM annual meeting had on palliative medicine. They had a sole track of lectures dedicated to palliative care! I was impressed with that attention to our field by hospitalists!

Which brings me to my second topic...ASCO! And why don't they have a palliative care track?

The annual meeting is this weekend in Chicago. I did a quick Adobe Reader search for some Pallaitive Care terms in their 80+ page handbook (abstract titles search results in parentheses) for the meeting and this is what I came up with:
  • Cancer - 659 (100+)
  • Pediatric - 24 (11)
  • Survivor - 15 (7)
  • Hospice - 12 (1)
  • Palliative - 12 (9)
  • Pain - 4 (12)
  • Prognosis - 2 (10)
  • Fatigue - 2 (7)
  • Insomnia - 0 (0)
  • Cachexia - 0 (1)
  • Anorexia - 0 (1 - same one as above)
Any other terms to be searched?

When I reviewed ASCO's mission statement to make sure that palliative issues were part of their vision, I came across these two points that seem to highlight palliative care type issues:

  • FOSTERING communication among cancer-related medical subspecialties and the exchange of a wide range of ideas related to cancer, including its biology, prevention, diagnosis, staging, treatment, and psychosocial impact;
  • ASSISTING oncologists in addressing the challenges of the modern-day practice of oncology.
I realize this is a biggie of a meeting, but I guess I would hope for a little more focus on palliative care issues. Any readers out there ever been to ASCO? Please feel free to offer any insight? Since I have not been there I don't have a taste for the nuances that might be discussed, so I do not want to appear to naive.

If any Pallimed readers are going to ASCO and want to do a guest post about the meeting and what HPM practitioners should know about it, feel free to email Drew or I and we will possibly post it here. I know it is late notice but if you are interested let us know.

Hey Drew, maybe if we could get a press pass for Pallimed next year to go to ASCO?

Saturday, June 2, 2007 by Christian Sinclair ·

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