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Thursday, January 28, 2010

'First is the widespread and deeply held desire not to be dead...'

It looks like JAMA has closed their series 'Perspectives on Care at the Close of Life,' which we covered extensively the last year, and started a new one 'Care of the Aging Patient.' There have already been two so far, but in addition this week's issue has a 'Clinician's Corner' piece about a patient with cardiac cachexia and hospice care. Thus, a JAMA update today.

First, the Clinician's Corner piece. The case begins succinctly: Mrs H is an 86-year-old retired health care professional and grandmother with severe cardiac cachexia. She is considering the best way to have her life end. The case goes on to describe a patient with advanced heart failure, slowly progressive functional decline, and multiple comorbidities, who considers her current quality of life marginal (ok now, but very worried it will be intolerable if things get any worse), and is making statements about wanting her life to end (although is not overtly suicidal). With the brief case discussion, which includes quotes from the patient herself, you really get to know and feel for this patient:

I’m still doing things and I still enjoy life, but I’m taking so many medicines, and each year I’m a little worse. I’m very afraid that I’m going to be incapable of doing anything—I had a grandfather who used to say, "Why doesn't God take me?" Well, my feeling is "Why doesn't my heart stop beating because it's in such bad shape?" I used to think when I got depressed that I could go and throw myself off the top of the building. Now I couldn't even get there.
I talked with my doctor about the fact that I was interested in the end of life and that I was thinking about discontinuing all my food and liquids and all my medicines, including my insulin. She told me that if I stopped taking insulin I might have a very high blood glucose. My experience with high blood glucose was that I got very, very thirsty. And when I thought about it, I thought, "Well, that means I would die of thirst." I realized that didn't appeal to me.
Her physician recommends a hospice referral. The following wide-ranging discussion is about US end of life demographics and hospice utilization, prognostication in CHF, causes and epidemiology of requests for hastened death, and how palliative care consultation and hospice care could potentially help this patient. Voluntary cessation of eating and drinking is also discussed. Overall it's a balanced, realistic look at the issues, including a description of how hospice and palliative care services can help patients like this, and the article would make a good one for the teaching file, particularly for med students and residents.

The first 'Aging Patient' piece is a look at care in the last years of life, and presents an approach to care for aging patients with potentially years to live - health maintenance, prevention, care coordination, etc. The 2nd 'Aging Patient' review is about falls, a problem very relevant for our field. Good reviews both: for those of us who didn't do geriatrics training, a nice refresher.

And finally, a recent issue had an editorial about advance care planning, 'death panels,' and why ACP just is not finding widespread acceptance by the public. Good editorial, but what really made my night was its citation of a 1999 editorial about a SUPPORT study analysis which discusses in terms which are equally valid now as then as to why this is so difficult. I'm showing my age (youth) here by never having read this before, but it's worth reading, and probably should go into the must-read file for fellows. Most of the editorial unpacks the ideas in this paragraph:
For most patients, 2 fundamental facts ensure that the transition to death will remain difficult. First is the widespread and deeply held desire not to be dead. This is not only existential angst, or the dread of ultimate insignificance, it is also the struggle to avoid annihilation. Second is medicine's inability to predict the future, and to give patients a precise, reliable prognosis about when death will come. When death is the alternative, many patients who have only a small amount of hope will pay a high price to continue the struggle. Several other factors, such as certain societal values or family dynamics, also may make it difficult for a patient to make the transition to dying.

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