Mastodon 09_01 ~ Pallimed

Thursday, January 29, 2009

African Americans & the US Hospice Model

Cancer has a paper about treatment preferences and hospice enrollment, focusing on African Americans. The data comes from structured interviews with 300 cancer patients at a single cancer center, which included questions about treatment preferences as well as self-reported need/interest in home services. Consonant with other research (for instance this recent paper in JAGS demonstrating higher rates of hospitalization and ICU use at the end of life amongst African Americans), African American patients reported a greater willingness to undergo cancer treatments with a low likelihood of benefit in the last 6 months of life, compared with white Americans. African Americans also reported a greater interest in and assigned higher utility to hospice services (the services weren't described specifically as 'hospice' services, but instead different home services provided by hospice care were described separately), although this difference seemed to be mostly due to economic status (and disappeared when controlling for economic hardship).

The authors conclude that African American cancer patients' needs, at least as described by this study, aren't particularly met by the current US hospice model. They are less likely to be eligible for hospice care (using these treatment preferences as a proxy for eligibility since you technically have to forswear life-prolonging treatments to be eligible for hospice under the Medicare Hospice Benefit), yet have self-reported needs for hospice services which are higher in general than white Americans (even if this is largely due to economic hardship and need). These issues are certainly not unique to African Americans; these data however support the idea that these issues are accentuated for them. They conclude:

For 25 years, hospice services have been restricted to patients in the last 6 months of life who are willing to give up curative treatment. Although this restriction was intended to control costs, it has substantially reduced access to hospice for many patients who have needs for hospice services, and a disproportionate number of these patients are African American. This eligibility criterion should be reconsidered, and needs-based criteria should be considered to make hospice eligibility criteria both fairer and more consistent with eligibility criteria for other health insurance benefits.
Obviously this is what the 'home-palliative care' and 'open-access hospice' models have been trying to address and we'll see how successful these movements are, and given the economic climate (and Medicare floating the idea of paying less for patients with longer stays despite everyone for a long time beating the drum to try to increase hospice lengths of stay) it seems highly unlikely that the needs of sick, symptomatic patients receiving chemotherapy are going to be met by our current and future hospice models. This would be fine if we had another robust system in place, but we don't (at least nationally - the Kaiser home palliative care model and others are available to some in certain areas), and so we muddle along.

Thursday, January 29, 2009 by Drew Rosielle MD ·


The American Journal of Surgery has an interesting read - a qualitative look at medical student 'moral distress.' (Moral distress defined here as 'the negative feelings that arise when an individual believes he or she knows the morally correct response to a situation, but cannot act because of hierarchical or institutional constraints.) It looks at case summaries written by 3rd year medical students and analyzes them for themes surrounding descriptions of moral distress. Issues surrounding death, dying, hope, communication are a distinct part of the discussion. Some of the wisdom of these students is impressive. One wrote, 'But my observation was that more desperately than their need for answers was their need for kindness. And while we may not have had the ability to provide the answer, we certainly had the ability to provide the kindness.'

Thanks to Dr. David Weissman for alerting me to this.

Age and Ageing has a systematic review on the natural history and prognosis of persistent delirium in older hospitalized patients. It adds to the literature on persistent delirium (see related post here) as a major marker of morbidity and early death in older patients. The data here are hampered of course by differences in definitions of delirium, follow-up, etc., and I wouldn't put a huge amount of stock in the actual numbers presented, but the finding that persistent delirium is a poor long-term prognostic sign seems irrefutable. Most interesting to me were the handful of studies which followed patients for multiple months suggesting that many older patients (mean age in these studies was in the early 80s) who are delirious during a hospital stay remain permanently cognitively altered afterwards (the way they define delirium here I hesitate to say they remain 'delirious' as opposed to permanently cognitively impaired, as well as there's a decent amount of variation in the studies between patients who presented delirious vs. those who develop it while hospitalized, as well as the data aren't broken down by who had dementia at baseline). Anyway - a few of the studies which followed patients for 6 months found a substantial minority (~10-30%) remain altered at 6 months. Yikes.

Thanks to Dr. Bob Arnold for alerting me to this.

Pain Treatment Topics (a free, online collection of original publications - often very practical/clinically-oriented papers - along with other resources to do with all things pain), recently published a hard-look at what is known and not-known about the prevalence of opioid-abuse in patients receiving prescribed opioids for chronic pain (free pdf here - page 6), concluding more or less that what research is out there does not support the idea that prescribed opioids cause addiction or that opioid-abuse is inordinately common in these patients. Of course, and unfortunately, none of the research is definitive, but I think this is a good counter to publications such as this one in a highly influential journal: read the abstract (or the full article) which to the casual reader suggests a world of badness and then read my post about what the article actually says about abuse/addiction and chronic opioid therapy. No doubt that abuse/addiction is a problem in patients with chronic pain, but how much of a problem is not yet even well-defined, let alone the role of prescribed opioids in causing/maintaining the problem.

Image is a thumbnail from Pain Treatment Topics 'pain art' page.

There's a new health policy blog out there which has been covering hospice and end of life issues quite well: Health Beat at Check out these recent posts about for-profit hospices and the new MedPac proposals to decrease hospice payments for a patient the longer they are enrolled.

Thanks, again, to David Weissman for letting us know about this.

by Drew Rosielle MD ·

Prognosis of leptomeningeal carcinomatosis

Cancer has a paper looking at the prognosis of leptomeningeal carcinomatosis. It's a single-institution (Spain) case series looking at 70 patients diagnosed with leptomeningeal carcinomatosis (LC), and gives some prognostic data. Mean age was 55 years, ~40% each had breast cancer and lung cancer (the remainder being a smattering of other solid tumors), and about half received specific treatment directed at the LC. The median overall survival was 21 days (although with a range up to 2000+ days). Of those who received intrathecal chemotherapy, median survival was 108 days. Good performance status, higher CSF glucose, and the presense of 'infratentorial' (cranial nerve and spinal symptoms) as opposed to 'supratentorial' symptoms (e.g. seizures, encephalopathy) were associated with improved survival. Apparently cancer type was not associated with survival in this series. Patients who received no chemotherapy were older, with worse performance statuses, etc. and it's impossible to say how much of the survival difference is due to underlying factors vs. treatment effects.

by Drew Rosielle MD ·

Tuesday, January 27, 2009

Abandon All Hope

Journal of Clinical Oncology has an Art of Oncology piece about the role of investigational therapies in patients with refractory cancers - specifically arguing that it is very important not to give up 'hope' too soon and to make sure patients are informed about investigational therapies 'positively.' Two, rather remarkable, case descriptions are included, including one of a man with hairy cell leukemia who apparently was told for over 20 years with each relapse that he 'should receive palliative care,' chose instead investigational treatments, and did really well for a long time.

Fine. The cringe-inducing problem here is with their rhetoric around the term 'palliative care' as exemplified best by this palliative care = abandoning hope paragraph:

The distinction between palliative care and participating in investigational therapeutic protocols is the issue of hope. A move to palliative care requires that the individual accept a state of hopelessness. Many patients turn to unproven remedies to restore hope. In the case of investigational therapeutics, the patient is willing to participate in a process that offers not only hope for the patient as an individual, but makes a substantial contribution to the body of knowledge that will benefit patients in the future. Therefore, though there may be a point at which continuing therapy is unrealistic, or when the comfort offered from palliative care is preferable, it is crucial to acknowledge how difficult it is for anyone to know when a patient reaches this point. Breakthroughs, by definition, imply successful treatment in a situation that was previously considered hopeless.
Obviously, this is not what one wants to read in the pages of JCO. To play devil's advocate (with myself I guess), it is important to realize that we really do have a problem in palliative care with terminology which is confusing all around, and we haven't been able to fix this (yet). The problem is that there are many (overlapping) flavors of meaning of 'palliative' and 'palliative care':
  1. A descriptive term which describes the non-disease-modifying-but-hopefully-quality-of-life-improving-ie-symptom-alleviating aspects of medical care (delivered in whatever settings by whomever and without any implication one way or the other if disease-modifying/life-prolonging care is being concurrently given). Similar to, but often used a little distinctively, from 'supportive care.' Not necessarily given by 'palliative care' clinicians.
  2. A descriptive term to describe a global approach to the medical care of a patient (given by whomever) which is solely symptom-alleviating without any disease-modifying aspects (in certain circumstances such as when a patient is receiving this care near to death some people call this 'comfort-care' or 'comfort-only care'). Not necessarily given by 'palliative care' clinicians.
  3. Care given by specialist-level palliative care clinicians and teams (which depending on the situation always involves attempts at 'quality of life improving care' but may or may not involve giving or advocating for life-prolonging interventions and under no circumstances should imply one way or the other if disease-modifying care is being concurrently provided or not)
  4. Heck it's also used for disease-modifying but non-curative interventions as well ('palliative chemotherapy' to refer to life-prolonging but non-curative chemo, a whole range of 'palliative' surgeries)
  5. I'm sure there are other flavors as well.
The authors here are using palliative care in the #2 sense, whereas most of us in the field today I assume think of the term in the #1 and #3 senses. I don't think this is quibbling over subtleties of language, and that these distinctions are important, for a variety of reasons, including but not limited to the fact that those who think of 'palliative care' in only the 2nd sense 1) limit access of patients to palliative care specialist services for needy patients still receiving disease-modifying care (which is most of them), 2) frightens patients, 3) creates situations in which other providers make inaccurate assumptions about a patient's prognosis and goals due to the fact that a palliative care team is involved in a patient's care for some reason.

An excellent editorial touches on those issues, and goes into much more detail about how the piece is perhaps a wee bit off target, albeit in a polite and less wheezy manner than me above. There is sort of a 'phuleeze' quality to the editorial (as in it's not exactly fair to only use examples about hairy cell leukemia - a disease with fantastic and remarkable treatment breakthroughs in the last decades unlike most solid tumors - as well as suggesting maybe perhaps there is more of a problem nationally with poor quality end of life care (etc. etc.) and not so much with patients being inappropriately railroaded into 'palliative care'?). Maybe? Perhaps?

Tuesday, January 27, 2009 by Drew Rosielle MD ·

Care coordination and quality...

Health Affairs has an article from the Dartmouth Atlas people looking at inpatient care intensity and patients' rating of their hospital experiences. Like much of the DA research it looks at administrative Medicare data (specifically regional variations on spending, intensity of care such as hospitalizations, physician utilization, etc.), and using a mortality-follow back design (patients selected for the study had already died). This paper looks at how patient satisfaction ratings compare with that and finds, consistent with other DA research, that more is not better. Patients in the highest utilization regions (for some reason there is a huge spike in the Kansas City region, and given how Christian is talking lately on the blog about how he loves to reverse DNR orders I figure it's got to be due to him**) had the lowest satisfaction (regarding aspects of their hospital care like physician and nurse communication, pain control, etc.).

Hospice use at the end of life did not differ regionally (30%) however no data is presented about length of hospice enrollment. By itself these sort of data don't mean much - maybe there are regional variations in how whiny and dissatisfied patients are and how demanding they are of medical care (or other regional confounders). However this is part of a larger pattern that has emerged (from the work of the DA people and others) that more (more expensive, more intense, more hospital-focused) care for the sickest patients is plainly worse care, however you measure it: mortality outcomes, quality measures, and patient satisfaction. And hell if 'more care' doesn't do any of those things then what are we doing? Interestingly the authors speculate at the end that the 'causal pathway' in these high-utilization regions leading to worse outcomes is due to lack of 'care coordination'...

...Which brings us to the next paper suggesting this phenomenon in a specific circumstance. It's from Archives of Internal Medicine and looks at continuity of care in cancer patients and how it affects ICU use at the end of life. It's a retrospective study using administrative data (the SEER database and Medicare data) to look at associations with care continuity and ICU usage in ~28000 advanced lung cancer patients who died in the US between 1992 and 2002, and who were hospitalized in the last 6 months of life. The key aspect they looked at was if their 'usual care provider' (essentially a physician who saw the patient at least 3 times in the year prior to the index hospitalization) actually saw the patient in the hospital (they looked at the patients' final hospital stay prior to death), and if that was associated with differences in ICU use.

Across the 10 years of the study out- to in-patient continuity declined (the usual care provider seeing the patient in the hospital) from ~60% to ~50%. Many of the usual suspects in care discontinuity were found to be associated with an ICU stay: academic hospital, large metro areas, non-White race. Specifically looking at care continuity they found that it was, in fact, 'protective' against an ICU stay in the final hospitalization (19% vs. 23% of patients without continuity - in the multivariate analysis odds of ICU stay were reduced by 25% with continuity). Really interesting was the very strong association of being cared for by a hospitalist (defined in the study as a doc with over 50% of their billings being inpatient based) with having an ICU stay. The authors speculate that this association was explained by lack of care continuity.

All of this has me speculating about the role of palliative care teams in this. While this is somewhat of a free-association based on my own observations of what I frequently do on the inpatient consultation service, it seems that what we often are doing (or trying to do) is essentially a 'work-around' for this lack of continuity by providing lots of care coordination (how many of you frequently do consults in which your major intervention was getting everyone to talk to everyone at the same time?) as well as trying to provide some of the more ephemeral aspects of care that continuity is supposed to provide (trust, patient-centered care based in a patient's values and goals, etc.).

**This is a joke. Christian, I'm sure, does wantonly waste medical resources but probably not in this way. Kansas City is in the middle; Newark, LA, Miami, Manhattan, and Chicago are at the top.

Thanks to Drs. David Weissman for the Health Affairs piece.

by Drew Rosielle MD ·

ACGME Accreditation of HPM Fellowships

Well while we're all pacing nervously awaiting the results of the first ABMS-sanctioned Hospice & Palliative Medicine board exam, the ACGME is announcing this week the accreditation decisions for the first lot of HPM Fellowships to seek its accreditation. 40-some programs have been accredited (list here - you have to do a search as I cannot link directly to the full list - and as of the time I'm posting this I'm not sure if all programs accredited this cycle have actually been loaded into the database). My institution's program was accredited, which we're pretty happy about, and if you're reading this and looking for a decent fellowship for 2010 drop me a line.

Anyway, congratulations to all the programs who were accredited, may all our site visits be routine and full of friendly laughter, and good luck to those working on it for the next cycle.

by Drew Rosielle MD ·

Monday, January 26, 2009

Hospice and Palliative Care Needs to Go Viral

On my 2008 end of year wish list for Pallimed, I pined for the following:

To know someone generous in time and spirit who would want to help make one minute animations in Flash for educational issues in hospice and palliative medicine.
Well someone heard my wish and offered to help out with some Flash animation. We have batted around a few ideas to help get good info out about hospice and palliative medicine. But we need your help. Please email me or write in the comments if you are interested in brainstorming ideas/topics/text for a short (1-2 minute) video.

What I would like to do is a short video that gets people inspired about hospice and palliative care issues. to give you an idea of the tone I am imagining check out this well done kinetic typography video called The Girl Effect.

Now imagine something that powerful for hospice and palliative medicine. What would it say? What would it not say? How would it look? What would be the tenor of music? Hopeful? Somber?

Again if you have ideas and/or want to join in on this project please comment below or email me (ctsinclair @t g-m-a-i-l - d 0 t c 0 m).

Monday, January 26, 2009 by Christian Sinclair ·

HPM Issues 2009:
#4 Getting Palliative Care Into Mainstream Medicine

(This is the second in a series of 5 posts about issues in hospice & palliative medicine I think will be important in the next year. Feel free to disagree!)*

#4 Getting Palliative Care Into Mainstream Medicine
For a new field palliative care has established a lot of buzz among hospitals and more generally in medicine. But this buzz and excitement for palliative medicine has caused many to rush into the game without a lot of uniformity to palliative care. This can lead to confusion about the merits of a good palliative care program. (read this link!)

  • Is it just hospice in the hospital?
  • Is it just good medical care?
  • Do you need a palliative care physician to run a palliative care program or can you get by with a nurse and a part-time social worker?
  • Can you have a palliative care team if it is just a physician and no other disciplines?
All these questions are answered differently depending on where you practice. The faculty at CAPC is working hard towards some standardization of what defines a palliative care team and what metrics are measured. The certification of HPM physicians will also start to establish a level of competency and quality of care allowing people outside the field to get a more defined sense of palliative care.

But there is still work to do to get palliative care mainstream. I often introduce the palliative care team to patients and families as one that has been at the hospital for eight years as some evidence this is not just some new fangled idea. And yet I (and I know some of my peers) still get the consult, followed by the dreaded 'un-consult' because the doctors, patients, floor nurses, or families just are not ready for a palliative care consult. The role of palliative care is still being misunderstood even in established programs. A good palliative care team knows there are times to advocate for a PEG tube, a reversal of a DNR, or a high risk surgery with little expected benefit. Good palliative care meets the patient and family where they are.

Maybe this difficulty in defining the role of palliative care is not so much of a curse. Maybe palliative care could be defined more as a chameleon as the role of the team shifts to meet the needs of the patient and family. The same needs easily overlooked in a hurried, technology driven, curative driven modern healthcare system: comfort, communication, and psychosocial support.

The easiest way to really mainstream palliative care is to highlight when you see good palliative care outside of your team. Make all of medicine realize that palliative care is possible from everyone in health care. Then they will know palliative care when they see it.

(PS This doesn't even get to the issue of outpatient palliative care which has it's own implementation and mainstream issues)
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by Christian Sinclair ·

Thursday, January 22, 2009

Knock! Knock!
Hi, It's the Office of Inspector General

Imagine a nurse in the ICU raises concerns about possible euthanasia by staff in the ICU. You might think it may first go to the ethics committee, the hospital board, and likely the legal department. Then imagine if the Feds (Office of Inspector General) get involved and conduct a complete investigation into the allegations of hastened death. Really. Just imagine it happening to you.

Makes answering, "Hey honey, how was your day?" seem impossible.

Now imagine someone in your department says, "You know what we should do? We should publish our experience of being investigated by the OIG in a major medical journal!" Would you not want to throw a drink in that guy's face?

Well thank goodness someone did think that was a good idea, because Chest published an important article regarding ICU & Palliative Care ethics this month from the group at VA Palo Alto. They are to be highly commended for shedding some light on this very difficult subject.

The paper discusses four cases of alleged euthanasia in detail as well as the investigation and the changes made by the ICU staff to improve communication and standardization of comfort care orders.

Briefly here are the four cases (there are many more details in the original article):

Man in his late 50's with metastatic lung cancer to the brain, with hemorrhage into his brain, and respiratory failure requiring a ventilator. Family and clinicians agreed to comfort care as the primary goal and the vent was discontinued and the ET tube left in place. Over two days, he received increasing doses of morphine eventually getting 30mg/hr. Another nurse felt this to be excessive and she titrated down to under 10mg/hr. He was extubated 3 days after the vent was stopped and died that morning.

Patient in his mid 60's with metastatic lung cancer on a ventilator with pneumonia and ARDS. Goals were changed to comfort care. Vasopressors were stopped and 100% oxygen per vent was decreased to 21%. He was continued on fentanyl (1oomcg/hr) and midazolam (2mg/hr) without titration. He died minutes later.

Another man in his mid-60's with metastatic lung cancer with pneumonia and sepsis, renal failure and eventually requiring a ventilator. After 1 week goals were changed to comfort care. His oxygen concentration on the vent was decreased from 100% to 21% and vasopressors were stopped. The ventilator, fentanyl and midazolam were all continued and he died two hours later.

Man in his mid-50's with metastatic colon cancer with neutropenia, respiratory failure and sepsis. Placed on a ventilator, vasopressors and antibiotics. He required paralyzation and sedation (fentanyl 200mcg/hr & versed 6mg/hr). After 36 hours family requested comfort care, the paralytic, pressors, and ventilation were stopped. No titration of the fentanyl and versed. He died within minutes.

Of particular note the last three deaths happened on the same day, which brings to mind the impact of death acuity. So many deaths in such a short time can be very shocking to staff and in other situations unusual grouping of deaths in medical settings has been a tip off for identifying health care professionals who are killing patients.

Another significant issue was the concern that the deaths were hastened to possibly open up ICU beds for other patients. This allegation was not supported by the OIG's investigation.

The results of the OIG inspection are online
and basically found no substantial evidence for intentionally hastened death but did find there was significant variations with the interpretation of appropriate end of life management in the ICU, and recommended the establishment of new guidelines.

The ICU department developed an ICU comfort care QI project, comfort care guidelines, a physician template note for comfort care, and a comfort care order set. The VA Palo Alto ICU group responded in a constructive fashion to potentially severe allegations and demonstrated a willingness to share with the health care community a very difficult situation. This transparency is leading to better care for patients there and with the publication may improve the care for other patients dying in ICU's.

ResearchBlogging.orgW. G. Kuschner, D. A. Gruenewald, N. Clum, A. Beal, S. C. Ezeji-Okoye (2009). Implementation of ICU Palliative Care Guidelines and Procedures: A Quality Improvement Initiative Following an Investigation of Alleged Euthanasia Chest, 135 (1), 26-32 DOI: 10.1378/chest.08-1685

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Thursday, January 22, 2009 by Christian Sinclair ·

HPM Issues 2009:
#5 Continue Advancing Good Palliative Care Research

(This is the first in a series of 5 posts about issues in hospice & palliative medicine that I think will be important in the next year. Feel free to disagree!)*

#5 Continue Advancing Good Palliative Care Research

Since palliative medicine is such a young field our research base is relatively small but the last few years have produced some excellent research with the potential to impact clinical care, communication methods and policy matters. We have two major journals dedicated to our field in Journal of Palliative Medicine and the Journal of Pain & Symptom Management (soon to be renamed?) that publish relevant clinical articles along with some basic science research. The AAHPM, CAPC, and the National Palliative Care Research Center have organized resources and tools for the established and beginning researcher.

Palliative care oriented articles are also being published in core medical journals with robust support from JAMA, Archives of Internal Medicine and Annals of Internal Medicine. I hope to see this trend continue. But even with this growth it is critical to realize palliative medicine interventions have not quite proven themselves on the evidence based medicine stage as this recent call to arms article noted.

On my wish list for this item: A resurgence of the community based hospice research. With all the care being delivered by hospice agencies, we are missing out on lots of observational data because of the barriers to beginning research from non-academic medical institutions. The Population Based Palliative Care Research Network started by Jean Kutner has been the leader in this field, but I have not seen this well integrated into many of the other hospice related organizations. I think PoPCRN is a great idea and I hope to see it stronger and more visible in the next year.

*Thanks to Dr. RW for the idea.

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by Christian Sinclair ·

Palliative Medicine Board Certification Numbers

The American Academy of Hospice and Palliative Medicine and ABIM released the final test taking numbers for the first round of official accredited boards for HPM. Now we are all just waiting on them to release the actual board scores. Some interesting findings from the demographics of the 1,455 test takers.

Internal Medicine -892
Family Medicine - 400
Pediatrics 52
Psychiatry/Neurology -30
Anesthesiology -22
Radiology - 17
Emergency Medicine - 12
Surgery - 12
Obstetrics and Gynecology - 9
Physical Medicine and Rehabilitation - 9

So one big question I have about some of the less represented specialties is: are these mid career changes and these doctors are now doing strictly palliative medicine or are they still practicing radiologists, surgeons, etc and are adding palliative medicine to their repertoire? If you are from psych, neuro, anesthesiology, radiology, EM, surgery, OB/GYN, or PMR please comment and help the rest of palliative medicine understand what drew you to the field. I would like to see a much larger representation across the specialties, but with fellowship becoming the sole pathway to a HPM board certification in the future, the chance to establish foothold in the other fields is diminshing.

Looking at these numbers and comparing to rough estimates of work force can give us an idea of what the saturation of palliative medicine is within each specialty.

The Bureau of Labor and Statistics estimates about 633,000 physicians employed in 2006. Here are the following reordered breakdown of physicians by specialty (approx) with the number of HPM physicians in each. (1 HPM physician out of x specialists)

Internal Medicine (ABIM) - 177,000 - 1 out of 198
Family Medicine (AFP) - 100,000 - 1 out of 250
Physical Medicine and Rehabilitation (AAPMR) - 8,000 - 1 out of 888

Pediatrics (AAP) - 90,000 - 1 out of 1730
Radiology (ACR) 32,000 - 1 out of 1882
Psychiatry/Neurology (ABPN) - 46,000 & 13,000 - 1 out of 1966

Emergency Medicine (ABEM) - 34,000 - 1 out of 2833
Surgery (ABS) - 55,000 - 1 out of 4583
Obstetrics and Gynecology (ACOG) - 52,000 - 1 out of 5777

Anesthesiology (ABA) - unable to access ABA

(Here it is as a spreadsheet if you want to copy the numbers)

What are your thoughts on this distribution?

by Christian Sinclair ·

Monday, January 19, 2009


Patient Impact Assessments: A late entry in the category of Most Intriguing Ideas of 2008: require that the DEA conduct a “Patient Impact Assessment” (PIA), analogous to the Environmental Impact Assessment required prior to major building projects, before issuing new controlled-substance regulations. David Brushwood, a pharmacist and lawyer, has suggested this idea as a way for the DEA to make more informed and balanced decisions. The PIA would do the following:

  • Describe purpose of proposed regulation, including the problem it is intended to address
  • Alternatives that have been considered and found to be inferior to the proposed regulation
  • Describe the patient population affected
  • Describe adverse effects on access, if any, to necessary therapies, and health outcomes that could result from new restrictions
  • Describe strategies to minimize adverse effects, including monitoring of effects
  • Explain challenges of unknown aspects of the situation

    Brushwood DB. Should the DEA conduct a "Patient Impact Assessment" when promulgating new restrictions on controlled substance distribution? J Pain Palliat Care Pharmacother. 2008;22(4):322-326.

WHO Analgesic Ladder Reconsidered: In the ever-interesting guideline vs rule debate, two short essays from a European perspective question the ladder, especially Step 2, the so-called weak opioid step. Both authors credit the ladder with helping to improve cancer pain management over the past 20 years. They point out that the Ladder assumes a gradual progression of pain, starting with mild pain amenable to non-opioid analgesics. The second step has been criticized on a couple of points. Some researchers and clinicians see no advantage to using codeine, tramadol, or propoxyphene rather than low doses of “strong” opioids such as morphine and oxycodone. Codeine & propoxyphene, in particular, may have more problematic side effect profiles than the strong opioids. Neither author addresses the combination products oxycodone or hydrocodone plus acetaminophen, which appear as Step 2 drugs. They also complain that if a patient has rapidly escalating pain, strict adherence to the ladder forces a delay in getting to the strong opioids, because of the belief that the 2nd step must be exhausted before the 3rd step can be entered.

Also pointed out is that there is no provision for either psychological approaches nor invasive approaches at any step.

Personally, I think the ladder is a useful construct that, after all these years, seems so logical and straightforward that is needs little defending, nor should a lot of ink be spent on attacking its perceived inadequacies. It’s a guideline--not a rule. It was promulgated at a time when using opioids was controversial in most places. It remains a useful teaching tool for new clinicians or those new to cancer pain management. As with any other guideline, individual patient needs trump the guideline (because it is not a rule) and adequate measures need to be taken, including skipping steps one or two and using invasive interventions earlier rather than later, if necessary.
That said, I would not object to a major multinational, multidisciplinary study group being tasked with bringing the ladder up to date with the complexities of pain management as we now know it.

See the International Perspectives on Pain & Palliative Care section of J Pain Palliat Care Pharmacother. 2008;22(4):327-330.

Number needed to treat, Number needed to harm: "Number needed to treat" is an interesting construct intended to translate (primarily) pharmaceutical research findings into information that clinicians can use in decision-making about whether to recommend a particular treatment. The lower the NNT, the more likely it is to have the intended effect in patients in the target population. An excellent review of history, interpretation, and appropriate and inappropriate use of this measure is found in the Sept 2008 Canadian Medical Association Journal.

A logical extrapolation is the notion of the "number needed to harm" which followed close on the heels of NNT. An article describing the use of both numbers in clinical decision-making is Sierra (below).A recent appeal to apply NNH to palliative care appears in a short letter to the editor by a hospice medical director (Herbst, below) who wonders if it's application would result in better utilization of resources in large medical systems.

McAlister FA. The "number needed to treat" turns 20--and continues to be used and misused.
CMAJ. 2008 Sep 9;179(6):549-53. (Free full text)

Sierra F. Evidence-Based Medicine (EBM) in practice: applying number needed to treat and number needed to harm. Am J Gastroenterol. 2005 Aug;100(8):1661-3.

Herbst L. Number needed to harm. J Palliat Med. 2008 Dec;11(10):1291.

New agents: Two new unrelated agents for pain--tapentadol and milnacipran--use inhibition of reuptake of norepinepherine as the primary mechanism of action. Tapentadol is a cousin of tramadol, and like tramadol is also a weak mu receptor agonist. Milnacipran (trade name Savella) is a serotonin-norepinephrine re-uptake inhibitor (SNRI). As with the two previous SNRI's on the market, duloxetine and venlafaxine, it is approved for fibromyalgia. Unlike the other two (as far as I can tell) it has not been approved for major depression.

Monday, January 19, 2009 by Thomas Quinn, APRN ·

Friday, January 16, 2009

Sometimes Being Sick Helps

We like to keep our personal lives and even our daily professional lives to ourselves instead of filling this blog with soap opera like ramblings. But there are times when the examination of self in response to our work as palliative care professionals becomes poignant. (For the best example read Drew's Old Milwaukee and Art Therapy post from Pallimed: Arts & Humanities*)

This past week I was sick. Very ill. In fact my whole family was ill, but my body faced the brunt of the symptomatic onslaught.

Fevers, chills, sweats while wearing sweats, and then having to get out of my sweats because of the sweat; anorexia (not nervosa) but with plenty of nausea (not vomiting), ageusia (lack of taste (for food not fashion)), odynophagia, dysphonia, insomnia, headaches. Weakness or asthenia, it really is all the same. Cough, ahem, with little production. Apathy and body aches, but nothing really hurt. Xerostomia, why did I once call you my favorite symptom? Forgetful and occasionally mildly confused with no sense of time, I was a living breathing review of systems.

And of course it was not any one symptom individually it was a recording studio soundboard of switches, dials and slides, varying the intensities to torture me all the more. As a movie finally ended and the room became more quiet, my mind attempted to rationalize and explain all my symptoms, and even somewhat delusionally made an appointment for me, the patient Sinclair with my alter ego, the Doctor Sinclair.

Doctor Sinclair: I am a symptomatologist, a palliativist if you will. I help other people feel better even when there is nothing you can do to alter the course of a disease. Do you have pain?

Patient Sinclair: No not really.

Dr: Are you hungry?

Pt: No not really.

Dr: Are you nauseous?

Pt: Not unless a food commercial comes on the tv, or my brain tortures me with thoughts of food.
Dr: Are you hungry?

Pt: No, and that is fine with me.

Dr: Well how can you help you, the other part of me?

Pt: You can just stop talking and leave me be.

Dr: Oh you must be depressed.

Pt: No just leave me alone.

As I processed this internal dialogue it became obvious how many times I have had this conversation before with patients. This revelation of how bad it can feel to be ill or to be dying since dying encompasses many of the same symptom, and feeling impotent, because there is no one symptom that trumps them all; this revelation is powerful to those attempting to heal others. In medicine, It can be helpful (but not neccessary) to feel the loss of your health.

In medical school, I suffered an intense but limited GI virus with plenty of vomiting. I had to skip a couple of my ED shifts, but when I came back and saw my first patient who had also been vomiting, my demeanor changed. No longer were my first thoughts penetrated with a clinician's diagnostic approach: How often? How much? Was there any blood?

I paused and offered a brief, "I'm sorry that happened. That had to be rough." After a smile and nod of validation from the patient, I continued. "May I ask you some questions so we might help you feel better?" From that began a new way of looking at the therapeutic relationship beteween doctor and patient.

So in my recent illness, while I cursed my microscopic enemies, I am also grateful for the occasional (but not too often, OK?) reminder of what it is like to lose your health. Paradoxically, my first day back today was as refreshing to my professional duties as coming back from a vacation.

*There are a lot of other good posts on Pallimed: Arts & Humanities too, so if you have not checked it out recently head on over, you will be pleasantly surprised.
**Per HIPPA law both patient Sinclair, and Dr. Sincair signed a relase form for this post.

Friday, January 16, 2009 by Christian Sinclair ·

Announcing Palliative Care Grand Rounds (A Blog Carnival)

With the growth of palliative medicine and hospice oriented blogs, as well as other blogs most powerful posts being on palliative care and end of life topics, we have reached a level of inertia to robustly support a blog carnival. This won't take the place of occassional links to other good timely posts, but will be a more formal event to help galvanize the palliative care blog community and highlight palliative care on a larger scale than might be done by any one individual blog.

What is a blog carnival?

It is a periodic round up of the best of topic X from blogs. And in the medical blogosphere the king of blog carnivals is Grand Rounds, now in its 5th year and which has been hosted at Pallimed twice.

So here are the details:

Title: Palliative Care Grand Rounds (unless anyone can think of a catchier title?)
Timing: First Wednesday of every month
Hosting: Rotating basis by invitation and/or request
Format: Host selections and submissions from other bloggers, readers, commenters. I am strongly encouraging the host to edit for the highlights of the month and not just every single thing that is emailed to them, as the post should not just be a link farm. I would like to aim to keep it the best posts with a high signal to noise ratio.

The first Palliative Care Grand Rounds will be hosted here on Pallimed on Feb 4th.
Deadline for submissions will be Jan 31st at MN.

There will be a separate blog listing the upcoming hosts and dates as well as archives. This should be set up by the time of the first PCGR. If you read any good blog post on any site feel free to email it to:If anyone would like to host, create a logo, or anything else please email me as well.

by Christian Sinclair ·

Wednesday, January 14, 2009

Families & Prognostic Disclosure & The Hammer

Annals of Internal Medicine recently published a research paper looking at how family members view the interaction of hope and truth-telling regarding critically ill ICU patients. It is based on a prospective cohort study at a single medical center in California, and involved interviews with surrogate decision makers (N=179, mostly close family members of patients, 61% were white, 70% women) of 142 intubated ICU patients. Interviews occurred on between days 3 and 5 of mechanical ventilation. Among other things, family members were asked specifically if they thought physicians should avoid discussing prognosis in order to maintain hope.

Most of the results are qualitative. The major quantitative result is that 93% of family members endorsed the idea that not discussing prognosis was an unacceptable way to maintain hope. This is not to say that they thought that discussing prognosis didn't effect hope (they didn't quantatively assess this) - just that the need for physicians to discuss prognosis with them was so important that hope considerations shouldn't preclude it. The bulk of the article presents a thematic summary of why the family members thought discussing prognosis was important: mostly things one would expect - helps them prepare emotionally and logistically, it's a core physician obligation/helps family members make decisions, doesn't impact 'outside' sources of hope (faith), etc.

All good, but my major question was what about that 7%? Unfortunately we don't learn much about them (which is fine, and what I personally care about reading this paper may not have been what the authors were particularly interested in). About half of that 7% were ambivalent about prognostic disclosures simply because of the emotional impact. The other few seemed to endorse the idea that discussing something will make it happen (discuss prognosis-->people give up-->patient dies). That's about all we learn.

Overall the research is consonant with numerous other studies showing that patients overwhelmingly want to discuss the future with their doctors. (At least when you ask patients in a research setting they say Tell me everything - this study however gives an interesting twist to that finding, suggesting when you push on beyond that simple question some patients are much more ambivalent about exactly how much they want to know). Anyway - this study supports that the vast majority of family members as well seem to say the same thing: tell us, we want to know, concerns about hope don't preclude the need to talk about what to expect.

My favorite quote from the study was towards the end, in which they were discussing how family members want to hear about prognosis, and that most don't want to hear unequivocally bad news, and that iterative approaches (letting it trickle out a little bit) are welcome. A family member is quoted as saying: "I think it's best done through multiple communications. A bomb on 'em not gonna help anybody." In my program, we call the 'bomb' 'The Hammer' and constantly grabble with and discuss as a team When, How Many Times, and How Hard do we 'bring down The Hammer' in having these discussions....

Wednesday, January 14, 2009 by Drew Rosielle MD ·

WaPo On Death in America

Washington Post recently published a commentary, written by a hospitalist, about the modern American way of dying. Well written, with lots of familiar patient scenarios. It tends towards the philosophical side, and seems to place the burden of the problem on patients, the culture at large, etc., as opposed to our medical system and culture. Of course that's a problem, but I don't think it's one that any clinician is going to fix, and the question for us clinicians is how can we impact this within the medical system (as we are not going to revolutionize our overall society's approach to death and dying)? Anyway - worth a read:

Everyone wants to grow old and die in his or her sleep, but the truth is that most of us will die in pieces. Most will be nibbled to death by piranhas, and the piranhas of senescence are wearing some very dull dentures. It can be a torturously slow process, with an undeniable end, and our instinct shouldn't be to prolong it. If you were to walk by a Tilt-A-Whirl loaded with elderly riders and notice that all of them were dizzy to the point of vomiting, wouldn't your instinct be to turn the ride off? Or at the very least slow it down? Mercy calls for it. This isn't about euthanasia. It's not about spiraling health care costs. It's about the gift of life -- and death. It is about living life and death with dignity, and letting go. In the past, the facade of immortality was claimed by Egyptian kings, egomaniacal monarchs and run-of-the mill psychopaths. But democracy and modern medical advances have made the illusion accessible to everyone. We have to rid ourselves of this distinctly Western notion before our nation's obesity epidemic and the surge of aging baby boomers combine to form a tsunami of infirmity that may well topple our hospital system and wash it out to sea.

At some point in life, the only thing worse than dying is being kept alive.

Thanks to Dr. Fred Holm for alerting me to this.

by Drew Rosielle MD ·


Some ramblings on recent papers piling up from JAMA & Journal of Clinical Oncology, following two tenuous threads of 'whopping' and 'modest but measurable.'

JAMA has a brief discussion of allowing terminally ill patients access to experimental drugs (written in the context of the 'Abigail Alliance' ruling see here & multiple posts here). The commentary is not about the Abigail decision(s) per se - about whether patients have the right to obtain experimental drugs - but more a practical discussion of how best to allow patients access - balancing interests, minimizing exploitation, etc.

JAMA also continues its 'perspectives on care at the close of life' series with a review of agitation and delirium at the end of life. Nicely done & good for the teaching file.

Continuing on with JAMA - a randomized trial of deep-brain stimulation vs. best medical therapy for patients with Parkinson's disease has been published. I am in no position to be a good judge of the clinical import of the findings - the major outcome evaluated was time spent in the 'on' state without significant dyskinesias as measured by self-reported patient motor diaries (which seems a somewhat troubling measurement tool particularly given that this was not a blinded study as patients knew whether they had hardware in their brains or not). Patients who received DBS had substantially more 'good motor function' hours a day (4.5 overall) than the best medical therapy patients (which sounds pretty good to me), although at a cost. A whopping 40% had serious adverse events due to the surgery (infections, etc.), and even at 6 months there were some ongoing trade-offs (some increased depression, more falls, mild cognitive decrements) in the DBS patients. I mention the study in large part because interventions like this (up front risky/invasive, costly device therapies/interventions which however may improve either longevity or quality of life in a substantial number of patients - think LVADs) continue to become more common, our patients with highly morbid and/or life-limiting diseases are going to be facing decisions about these interventions more and more (whether to try them, managing complications from them, struggling with considering stopping them), and palliative care folks will be called upon more and more to help patients with those decisions.

JCO recently had a look at the natural history of bisphosphonate associated osteonecrosis of the jaw in multiple myeloma patients. A whopping 26% of patients did not heal over the course of the study (sufficient patients are still enrolled and being followed such that the median follow-up time has not yet been reached: minimum follow-up has been 3.2 years for the cohort).

also has another study looking at the quality of life impact of prophylactic whole brain radiation for patients with extensive stage small cell lung cancer (yes, at least on a time frame of 3 months, it has a modest but measurable impact on health related quality of life for the worse).

Finally, there's a fascinating randomized (routine-care-controlled) study involving giving advanced lung cancer outpatients a quality of life diary (they were asked to fill out a QOL questionnaire once a week and were encouraged to bring concerns to their providers). They found that those who were given the diary had, yes, modest but measurable decrements in their health related quality of life. The diary, if it did anything, seemed to make the patients feel worse. Most diary patients didn't however share their concerns, questionnaire results, etc. with their providers. It's a fascinating study, and if you believe the results a good warning - giving patients these measurement tools without any system for responding to them, any monitoring or routine evaluation of the patients' questionnaire responses, may actually make them feel worse.

It seems we clinicians are stuck in the unfortunate position of having to ask our patients how they are doing.....

by Drew Rosielle MD ·

Friday, January 9, 2009

Changing treatment preferences in CHF

Journal of the American College of Cardiology has a paper looking at changing treatment preferences for survival after a hospitalization for heart failure. The data come from a prospective trial of hospitalized heart failure patients (N=404, mean age in upper 50s) in which treatment preferences for quality (actually health status) vs. quantity of life were measured using 'time-trade off' methods. Their description of TTO is below - basically ranged from scores from 0 (completely values quality of quantity) to 1 (quantity over quality):

The TTO instrument was administered verbally by the study nurse at 1, 2, 3, and 6 months. Whenever possible, this instrument and written questions were administered in the absence of family. After a scripted introduction, the initial question was “Would you prefer living 2 years in your current state of health or living 1 day in excellent health?” An answer of 1 day, equated to a utility of 1/730 (not, vert, similar0), would end the script. An answer of 2 years would be followed by the next choice, between living “2 years in your current state of health or living 1 year 11 months in excellent health.” After sequential choices, the number of months (up to 24 months) in excellent health that the respondent considered to be equivalent in value to 24 months of survival in current health was recorded, and this ratio was the utility (between 0 and 1). The number of months at the indifference point subtracted from 24 yielded the number of months of survival time that the patient would be willing to trade.
Complex, yes I know, and there's a good (and historically minded) discussion of this method given in an excellent accompanying editorial.

They found a distinct bi-modal distribution of answers: 40% of patients more or less said they'd trade no time, 28% said they'd trade nearly 2 years of time to be in excellent health, with a smattering of the rest in between. Demographics including age and ethnicity didn't predict which group patients belonged to, although functional status did (with those willing to trade 2 years having the worst 6 minute walk test results - 60 meters [which is terrible]). Other interesting findings:
  1. Preferences didn't change much over time (on average just by 4% using the TTO 'scale). However those that did change substantially (a minority of patients had relatively large changes), most of those changed with preferences for increased survival time.
  2. Changing preferences for increased survival time were associated with improved functional status/decreasing symptoms. (Most patients had improved functional status and decreasing symptoms anyway - as one would expect given that at baseline these patients were hospitalized with heart failure - however those whose preferences changed the most had a more pronounced improvement in symptoms than the others).
  3. Preferring quality over time was associated with earlier death: 30% of the patients who died by 180 days preferred quality over time, compared to only 6% of those who survived 180 days. Given that these patients were sicker (as mentioned by functional status) at baseline and that this data come from a trial of using pulmonary artery catheters in CHF management (ie these were patients willing to receive PA catheters and so were likely also receiving/willing to receive 'aggressive' care) these preferences were likely markers of poor prognosis, as opposed to causes of it.
I find papers like this interesting academically, although how they inform practice is less clear given that I assume ideal practice involves frequently re-clarifying patient goals for all patients with severe chronic and/or life-limiting diseases. Nevertheless it's always interesting to see how preferences do change, and it's important for us in palliative care to be aware that how a patient feels when s/he is quite ill/symptomatic may change if they feel better. Obviously a substantial minority of hospice patients (particularly non-cancer ones) either 'graduate' or sign-off of hospice care after a time, and one reason for this may very well be the phenomenon measured in this study: goals of care are set/decisions are made often in acute settings (e.g. during an acute illness in a hospitalization) - in those patients who recover, improve a little, their treatment preferences may change as well.

ResearchBlogging.orgL STEVENSON, A HELLKAMP, C LEIER, G SOPKO, T KOELLING, J WARNICA, W ABRAHAM, E KASPER, J ROGERS, R CALIFF (2008). Changing Preferences for Survival After Hospitalization With Advanced Heart Failure Journal of the American College of Cardiology, 52 (21), 1702-1708 DOI: 10.1016/j.jacc.2008.08.028

Thanks to Dr. Bob Arnold for this.

Friday, January 9, 2009 by Drew Rosielle MD ·

Aging & Cancer

Cancer recently devoted an entire supplemental issue to cancer & aging. I'll briefly note a few of the papers.

This paper is a good general review of the clinical & research issues in 'geriatric oncology' - clearly the major perspective here is that chronological age is less important than co-morbidities/functional age, etc.

There is a review of end-of-life care planning and its effects on EOL care/decision-making. It talks about advance directives and their well-described limits, as well as offers a chatty, case-based discussion of what actually constitutes EOL planning/discussion. It has a distinctly psychological focus, and says this towards the end about what's needed in the future:

Policies also must require changes in practitioner performance; it is insufficient to frame policies solely for patients and families. These policies will include changes in medical education and updating how practitioners frame their exchanges with patients. Although being nice, respectful, and a good listener are essential, more is required. Practitioners need a framework that allows them to communicate effectively and to explore how the perceptions and beliefs of a patient and their family about disease and treatment affect how they process the information they receive from oncologists and how they interpret and assign meaning to their ongoing experience with disease and treatment. The understanding emerging from these processes affects patients' treatment preferences and decisions. Patients can frame these gains and losses either abstractly, as days and weeks alive, or concretely, in a realistic view of functioning and surviving to experience significant, vivid, worthwhile life events. Policy must call for and implement educational experiences to achieve this goal.
I agree with this, of course, but also note that that's a really tough thing to teach people - some clinicians sort of 'get it' anyway - but those that don't, being taught how to figure out what a patient's understanding is, how they make decisions, their 'narrative' so to speak - that's not a task that can be packaged into a review article or lecture and requires a lot of ongoing time, support, reflection, and mentoring. What I'm saying is that I'd like to know what exact 'policies' the authors have in mind....

The other article is about 'dual process theories' and decision making. It is an incredibly wonkish (written by all PhDs) paper describing psychological research regarding affective (emotional, experiential) decision making and deliberative (cognitive, intellectual) decision making; how age may affect this; and speculating on how this may all affect cancer decision making. If you're interested in this sort of stuff it's a window into the psychological-research world regarding decision making but I can't say it has any easily applicable clinical relevance.

by Drew Rosielle MD ·

Wednesday, January 7, 2009

More Good Blogs to Follow

I have been following Jessica Knapp's blog The Good Death since she came to my attention in some Google Alerts during the run up to the voting on the Washington State I-1000 Medically Assisted Death Initiative. From her About Me Section:
I have always been interested in the way people communicate. In 2004, I earned my MA in communications from Fordham University. Before that, I worked for two years as a research assistant in bioethics, and during that time, I found myself particularly interested in the issues surrounding the way we talk about death and dying. Over the past year, I had a health scare myself, and closely following that, my grandfather died in about the worst possible way you can—in the hospital, hooked up to tubes, with family not completely sure whether they were doing the right thing by letting him go. All of these factors have led me to decide to pursue my PhD in communications with the goal of improving the way we communicate about death. It is something everyone will face, and in America, most of us are afraid to talk about. We need to get better at talking about it so that we can have better deaths. Also, because death can be such a dark and trying subject to deal with, and because I am also a student of media studies, you will see some pop-culture references to death on this site.
Here is a sampling of her posts:

Cybertime - Describing her mother opening an unused email account that her deceased husband had been sending emails to before he died.

Televised Assisted Suicide - About Kevorkian and the recent televising of the act in Britain.

Fantastic Death - An excerpt from a recent book she read.

Another blog I only discovered last week is the only blog I know written by a hospice chaplain. We practically have a hospice team of blogs now! The blog Rainy Nights is written by Ken Bradstock (D. Min.) and combines some personal reflections, some patient stories (names and details changed for HIPPA), and the occasional poem.

Here are some examples of his posts:

How Nice - a poem about the difference between clinical staff and adminsitration.

Book of James
- How do you minister a minister?

And lastly, Confessions of a Young Looking Social Worker should hopefully intrigue you enough to check the blog out. (Yes! Now we have a core hospice/palliative care team) The blog is a mix of personal reflections (i.e. the White Sox) and the occasional fictionalized/altered accounts of interactions with staff and patients. There have not been a lot of hospice related posts lately, but here are a few choice ones:

Cross It Off The List - Taking a patient skydiving? Call your hospice social worker!

- "My favorite patient is dying..."

If you know of any other good hospice & palliative medicine oriented blogs feel free to post them in the comments or email me at ctsinclair - a - t - gmail d0t com.

Hospice & Palliative Medicine Blogs
(in order of age of blog)
**just added**

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Wednesday, January 7, 2009 by Christian Sinclair ·

New Options to Share Pallimed with Others

The posts on the website have a new look on the footer this new year. The multiple buttons to share a post you find interesting on Pallimed have been consolidated into a Share This button. It looks something like this:When you click on it a small window opens to give you the option to bookmark it to several social networking sites (Facebook,, Google Bookmarks, Technorati, etc.), email to a friend, or post on your own blog (similar to the reblog feature). If there are ones you prefer, but do not see them, let me know, and I will add them.

If you use any of the web tools or social networks, we encourage you to tag any Pallimed post you like. By doing so it raises the awareness of palliative medicine issues to the web in general since others may stumble upon the post at the aggregations sites. If you don't use any of them, might I encourage you to consider the following:

RSS reader: Google Reader
Social Bookmarking:
Social Networking: Facebook (has a Pallimed readers group, palliative medicine fellows group and AAHPM group) or LinkedIn (has a AAHPM group)

Here are some quick videos to teach you what they are if you are not familiar with them (email subscribers click the title of the post to view):

RSS Reader

Social Bookmarking

Social Networking

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by Christian Sinclair ·

2008 Medgadget Medical Blog Awards Final Nominations

The final nominees for various categories of best medical blogs have been announced on Medgadget, and alas Pallimed did not get into the finalists for Best Clinical Sciences Blog. Many thanks again to Paul Levy of Running a Hospital for nominating us.

The nominees in this and the other categories are very good blogs and I am particularly happy to see Medical Futility nominated as one of the Best Health Policy/Ethics Blogs. If you are a fan of his blog feel free to head on over to vote for him and peruse the other nominees. (Here you can find the longer list of all blogs intially nominated.)

Good luck to all the nominees! Voting ends January 18th.

by Christian Sinclair ·

Monday, January 5, 2009

Depression in Parkinson's

Neurology has published a randomized controlled comparison of nortriptyline with paroxetine for depression in patients with Parkinson's disease. It's a rare treat to see a decently designed, controlled trial of depression treatment in a palliative-care-relevant population (when was the last time we've seen a controlled drug trial of depression therapy in advanced cancer patients?).

This was an 8 week, NIH-funded, randomized comparison of nortiptyline (starting dose 25 mg), paroxetine CR (starting dose 12.5 mg), and placebo in 52 patients (median age ~63 years) with Parkinson's disease. Patients were seen at 2, 4, and 8 weeks and doses were titrated per the treating physician's discretion (mean doses at the end of the study were ~50 mg of nortriptyline and 30 mg of paroxetine). They used changes in depression symptoms measured by the Hamilton Depression Rating Scale for their primary outcome. No power analysis was done.

Overall, nortriptyline looked better than paroxetine. At 2 and 4 weeks nortriptyline patients had significantly greater decreases in depression symptoms compared to paroxetine; by 8 weeks this was a non-significant trend. Nortriptyline was superior to placebo at all points; paroxetine was not (trended better; not statistically significant). Again - no power analysis was done and so there's a good risk of 'type II' error here in concluding paroxetine is genuinely 'no better' than placebo. In looking at the percent of patients who had a 50% reduction in their HDRS score, nortriptyline again looked much better than paroxetine (~50% of patients vs. 11% with paroxetine being no better than placebo for this outcome). Symptoms/side effects/drop-outs were similar across all groups, including orthostatic hypotension, although the study was certainly not powered to detect any differences.

The authors note in their discussion that the other controlled trials of SSRIs in Parkinson's disease patients did not support their efficacy either. Despite the small size of the study nortriptyline seemed to be consistently, and by different analyses, better than paroxetine, without any obvious differences in side effects, although one wonders if those would have emerged in a larger trial. The authors speculate that norepinephrine (and not serotonin) may have a particular role in the pathophysiology of depression in Parkinson's disease which is why nortriptyline was more effective. Given that, a trial of norepinephrinergic antidepressants (duloxetine, venlafaxine) seems to be in order. Overall I think the findings are pretty compelling.

ResearchBlogging.orgM. Menza, R. DeFronzo Dobkin, H. Marin, M. H. Mark, M. Gara, S. Buyske, K. Bienfait, A. Dicke (2008). A controlled trial of antidepressants in patients with Parkinson disease and depression Neurology DOI: 10.1212/01.wnl.0000336340.89821.b3

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Monday, January 5, 2009 by Drew Rosielle MD ·

'2nd generation' antidepressants in Annals

And more on depression....

Annals of Internal Medicine recently had a couple articles on '2nd generation' antidepressants. (2nd generation here means SSRIs and other/newer antidepressants that have emerged in the last couple decades.) The first is a clinical practice guideline on 2nd generation ADs, and the second is the metaanalysis looking at the comparative efficacy of 2nd gen ADs which is the basis of the practice guideline. These are good ones for the teaching file - compiles a large amount of the comparative research on newer ADs.

The overall finding is that the vast majority of the research data support the idea that all of these agents are similarly effective for treating depression (where they have been compared, they have nearly uniformly shown to have comparable efficacy). What I found most interesting was the comparison of other outcomes, some of which are of particular importance in our patient population: 1) apparently there have been several studies showing that mirtazapine has a faster onset of action (symptom alleviation) than SSRIs, although by 4 weeks this effect is no longer apparent, 2) there is no clear evidence that any newer AD is better/worse than any others regarding alleviating anxiety symptoms associated with depression (with the exception of venlafaxine likely being better than fluoxetine), 3) nausea and vomiting are the most common reason for discontinuation of ADs (in the trials) with venlafaxine probably having more N/V than other ADs, and 4) duloxetine appears to be no better than SSRIs (at least paroxetine) in the treatment of pain associated with major depressive disorder (which is not to say that it's no better for other types of pain).

by Drew Rosielle MD ·

'Between utter despair and essential hope'

Journal of Clinical Oncology has an 'Art of Oncology' piece about denial and hope. It starts as a discussion of 'denial' (framing it as a normal coping mechanism in the initial aftermath of hearing life-altering news):

Patients tend to perceive a diagnosis of cancer as if they were in a movie. Professional experience educates: it is most often of no use to try to drag patients, or their family members, out of this movie. Psychologists and doctors conscientiously have to know that, although the diagnosis and facts may be explained more than once, even then patients often do not accept the facts. Patients with a cognitive escape-avoidance coping were reported to have a longer survival than other patients with localized melanoma. At some time, the patient will get over this state of shock. The time for a first psychic consolidation of reality awareness will come.
It then goes on to discuss patients moving from denial to other stages - using the 'Renz model of maturation' - and describes in somewhat spiritual terms this process:
The third stage consists of nothing less than transformation. What happens is more than just being able to accept. It is a gift of grace beyond human endeavor and power. It is here where the spiritual dimension comes in, so that patients momentarily, or for a while, feel different. There is happiness and well-being in the midst of illness. In the course of the dying process, spiritual experiences of such intensity often happen more than just once. After a shorter or longer struggle, patients reach a new mental state, just as a gift of grace.
Ok, well, not somewhat spiritual terms but explicitly spiritual terms. What struck me about this was not that I don't know what the authors are talking about. We all see amazing things every day in this line of work - life-transformations, patients in unbelievably horrible circumstances coping with truly humbling serenity and generativity, etc. - and I'll be the first to admit that I find this a 'mysterious' process. Why it happens with some patients/families and not others? If clinicians actually have some power over it (to foster it, to help cause these 'positive' transformations, etc.)?

That said, and with all acknowlegments to the critical importance of faith, religion, and/or spirituality in our patients' lives, I still am hesitant for us as a community to use spiritual language to describe such events. "It is a gift of grace beyond human endeavor and power" strikes me as an incredibly therapeutic nihilistic statement: both our patients and us as clinicians are passive witnesses to this, as how could we have an impact on something beyond our power? The fact that the process appears mysterious does not mean it is describable/understandable in spiritual terms alone, and doing so takes it out of the realm of inquiry, understanding, and intervention. I am probably over-reacting, but language is important....

by Drew Rosielle MD ·

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