Thursday, May 27, 2010
In my free time I've been perusing the archives of the New Yorker for interesting articles, and thought I'd mention one I really enjoyed: it's from 2001 and discusses the history, science, ethics, and philosophical meaning of 'brain death' and organ donation. It's thought provoking, and one of the better summaries of the issues I've seen outside of the medical literature. And, like all good reporting, it discusses the issues through the lens of how it impacts real people/families. Good stuff.
Thursday, May 27, 2010
Tuesday, May 11, 2010
Researchers in Melbourne, Australia conducted a single institution prospective randomized controlled trial to investigate the impact of this advance care planning (ACP) intervention, (Respecting Patient Choices) on end of life care in older patients. BMJ publishes the results.
The intervention was delivered in a hospital setting primarily by a nurse or allied health worker who conducted a conversation to evoke the patient's goals, values, and beliefs, and to discuss and document their future choices about health care. Family members, especially potential surrogates, were encouraged to participate. The creation of advance directive documents was encouraged. In this study, the discussions lasted a median of 60 minutes spanning 1-3 visits. The intervention appears similar to POLST programs in the United States.
The participants included 309 medical inpatients aged 80 or more who were followed for six months or until the time of death. Of the 871 patients screened, reasons for ineligibility included a lack of decision making capacity (n=368), expected death during the hospitalization, previous advance care planning, no relative, non-English speaking patients, and the six patients who refused to participate.
At the time of enrollment, intervention and control groups were similar with respect to age (median 84-85), reason for hospital admission, code status, presence of appointed surrogate, and overall preference for life prolonging treatment. There seemed to be a trend towards having more males in the intervention group (54% vs 41%), but p values aren't reported.
Of the 154 patients assigned to the intervention group, the ACP intervention was delivered to 125 (81%). Of those receiving the intervention, 70 completed a written document and 38 expressed wishes verbally (which were then recorded by the facilitator for chart documentation).
The primary outcome examined was the proportion of patients who died at six months and whose end of life wishes were known and respected by their doctors. Compliance was determined by review of patients' charts after death to identify any documentation of patients' wishes, what type of care patients received, and how the patient's wishes impacted medical decisions. It was determined that of 25/29 patients who died in the intervention group, wishes were documented and followed versus 8/27 in the control group (p<0.001).
Yes, six month mortality was...ahem... no different between the two groups.
Even with attempts at blinding to intervention, it was probably evident upon chart review which patients had received the intervention. Whether this is problematic becomes irrelevant in my mind after reviewing some of the secondary outcomes:
- Reduced risk of PTSD in survivors as evidenced by a reduced Impact of Events Scale scores in intervention group family members (including 0% vs 15% who had scores >30, which places them at higher risk of developing post-traumatic stress disorder, p 0.03)
- Reduced Hospital Anxiety and Depression Scale scores (including 0% in intervention group having a depression or anxiety score >8, which indicates clinically significant depression or anxiety, vs. 30% and 20%, respectively, in the control group).
- No patients died in ICU in intervention group vs. four patients in control group. Otherwise, the intervention didn't significantly impact place of death (hospital vs. home vs. palliative care/hospice setting).
- Family members reported greater satisfaction in a survey regarding the patient's "quality of death" (83% very satisfied in the intervention group vs. 48% in control group).
The secondary outcomes are quite reminiscent of the French ICU study on physician-family communication in the ICU that showed a reduction in risk of PTSD, anxiety, and depression in family members in the intervention group. (See Drew's commentary on that study here.) When combined with the many recent Coping with Cancer study results and the fact that results are now coming in from a variety of countries (US, France, now Australia), we should be confident in these secondary outcomes.
The fact that this is not a physician-led intervention should be highlighted. Physicians were drawn into the discussions to help clarify diagnosis, treatment options, and prognosis, but they were not central to the process. This is an important consideration as we confront workforce issues in palliative care and is an example of a "disruptive innovation" in medicine. By no means does this diminish physician involvement in expert palliative care teams nor does it relieve other physicians of their duty to be mindful of advance care planning.
Also notable is that this is not a primary care, office based intervention. It makes sense in some ways that the hospital would be the locus for this type of intervention rather than an office. Patients are captive in terms of having time to spend thinking about this and they are also more likely to see the importance of it (ie in an office, "why are you bothering me with this now? I'm just here for a cold.") Family members are more likely to be around in the hospital. Patients who are most likely to benefit from the intervention are "batched" in the hospital making it easier for those applying the intervention.
Only about 1/6 of patients had died by the six month mark. I'd be quite interested to know if the results hold as a greater proportion of patients die. If so, it only strengthens the above conclusions in my mind. If not, it would be interesting to know why (patient preferences changed? conversations need to be reiterated periodically?)
In the article's conclusion, the authors discuss the fact that advance directives were once much ballyhooed and more recently have been derided as ineffective at changing care at the end of life. They propose reasons why their intervention may be more effective than other previous attempts:
"We specifically focused on a model with five key elements identified by others as crucial to successful advance care planning: trained facilitators, patient centred discussions, involvement of family in discussions, correctly filed documentation, and systematic education of doctors.....Four of these five key elements were absent from the SUPPORT study, a project that relied on a research nurse to relay information verbally to the treating doctor about a patient’s preference for cardiopulmonary resuscitation, but which did not facilitate patient centred discussions, involve the patient’s surrogate, and ensure that the treating doctor was aware of the patient’s advance care plan when end of life decisions were made."Should hospitals implement programs like this? If so, what role should palliative care teams play in developing and implementing such programs? The palliative care team is a natural home for the direction of interventions like this--these conversations are the bread and butter of our daily work, although the patient population we see is generally sicker than the population included in this study. An intervention like this may represent an opportunity for earlier formal palliative care involvement (through triggers) versus an opportunity to insert palliative principles into the patient's care through separate but related programs. Physician and non-physician leaders alike can play an integral role in the development of programs and the training of other health care professionals to conduct these conversations (without needing to insert ourselves into every advance care planning event, which is, of course, impossible). We'll still be needed for the more complex scenarios, no doubt.
A number of possibilities exist to incentivize hospitals/providers to institute interventions like this. For instance, I wonder if there's an opportunity to include this somehow in the "national pilot program on payment bundling" (included in the health care reform bill, PPACA, Sec. 3023). See Dr. Brad Stuart's recent commentary at Geripal on issues related to health care reform and palliative care.
Many locales throughout the United States that have implemented POLST interventions, and I don't practice in one of them. Feel free to leave any ideas you have below, especially if I'm missing some major demonstration or pilot project.
See also Alex Smith's thoughtful commentary on this and a related article at Geripal.
Tuesday, May 11, 2010
Friday, May 7, 2010
Research by The RAND Corporation quantified some of the overuse: 20-40 percent of some surgical procedures are performed on patients who cannot, on scientific grounds, be expected to benefit from them (Leape et al. 1991). - From Don Berwick's Eisenberg lecture, April 2005
According to the American College of Physicians (ACP) 2009 policy paper, Controlling Health Care Costs While Promoting the Best Possible Health Outcomes, the Congressional Budget Office estimates that 5% of the American gross domestic product (roughly $700 billion per year) is spent on medical tests and proceduresthat do not improve health outcomes. (Introduction to interview with Steven Weinberger, MD, FACP - on Medscape)
- One physician pointed to the small improvements each day: the wounds were healing, his face less swollen, cardiac function improving. His honest perspective was that he was getting better, and could continue to improve to leave the hospital. This physician treasured life over all else. In the words of Dr. Epstein's article referred to by Dr. Levy in his blog "Running a hospital:"
"The Role of the Physician in the Preservation of Life." Q J Med 2007; 100:585–589.
That, however, what he missed was meaning of the next part of Dr. Epstein's speech -
We physicians belong to an ancient profession, standing apart from all others in its primary concern and respect for human life and its enmity to death. And in the long run, that attitude of the profession may be as important to society as any miracle that modern technical medicine can perform.The fact is that for all our talk and our science, we do only a little. Life cannot be prolonged indefinitely, and death comes at last. But the little we can do has an importance that transcends the patient, for it carries a message to all our patients and to the world: Human beings are important.
- The other physician saw a very different picture: a young man, an athlete and artist who would never return to his previous vigorous self and should he survive this hospitalization (a big if) would likely remain on life-support for his remaining years would definitely always be completely dependent for all activities of daily living, unable to carry on a conversation. He saw the ongoing aggressive life-sustaining interventions as possible overuse, given the dismal outcome.
Harm from overuse is not merely harm to the patient and family (providing risky or painful procedures that have little to no benefit - principle of beneficence and non-maleficense) society (cost, burden - from the principle of justice), but also may harm staff: physicians, nurses, other caregivers. In some settings: test after test, procedure following procedure in a patient with progressive end-stage disease who remains minimally interactive but winces to the interventions. One physician ordering this, while others are the ones doing it, protesting as they do, questioning the rationale and the harm with perceived little-to-no benefit, as nurses pick up the pieces. Nurses, resident physicians, and attending physicians have spoken to me of their sense of struggle, their inclination to avoid patients to whom they are "forced" to provide care they see as not having benefit but instead harm. For the ordering physician, the drive may indeed be patient preference, or perhaps that personal and professional commitment to valuing life and fighting of its enemy - i.e. death.
One of our roles as the palliative care clinician or team-member, is to navigate in this world of uncertainty. To support families struggling as they see the patient slowly, ever-so-slowly die as more and more is done to prevent or slow down the death per their request, while supporting the healthcare team who struggles with the procedures that seem to have little to offer, while supporting and watching with the physician who is also doing all he or she can to keep this person, their patient alive - as he or she believes we can clinicians are called to do.
I think physicians fall in all areas of believe around these topics - influenced, of course, by personal values and education. I remember when I was a medical student meeting another med student at a wedding. On his way to the wedding he had seen a massive accident with multiple deaths. He told me that there he met our shared enemy - death. At that moment, I began to believe that there are two general places where people fall - on one end of the extreme: death the enemy, on the other, suffering the enemy. At risk of influencing this readership, I will share that in my mind, I believe that our call as physicians (and nurses, and all in healthcare field) is to prevent premature or preventable death, but the primary role - as Eric Cassell so eloquently wrote in numerous articles, is to alleviate suffering - in all its manifestations.
Friday, May 7, 2010
Wednesday, May 5, 2010
Image from Wikipedia.
Finley Caulfield A, Gabler L, Lansberg MG, Eyngorn I, Mlynash M, Buckwalter MS, Venkatasubramanian C, & Wijman CA (2010). Outcome prediction in mechanically ventilated neurologic patients by junior neurointensivists. Neurology, 74 (14), 1096-101 PMID: 20368630
Wednesday, May 5, 2010
As a follow up for today's top-post, some more floundering about prognosis in brain injuries, and yes this one is for the progno-wonks out there.
Neurology also has an article looking at the prognostic importance of bilateral absence of the N20 response of median nerve somatosensory evoked potentials for patients with hypoxic-ischemic encephalopathy (anoxic brain injury) who have undergone therapeutic hypothermia.
Some background (although this NEJM review is the best place to go for a quick summary) on why I'm even mentioning this. Absence of the N20 response of median nerve SSEPs more than 24 hours after a cardiac arrest has been reported in multiple studies to indicate a uniformly poor neurologic prognosis (comatose patients after cardiac arrest who have these SSEP findings have uniformly poor outcomes), and it's become a well-established marker (among several) to identify patients with essentially no chance of a good neurologic recovery (see today's other post for more about 'good neurologic recovery').
In the last several years therapeutic hypothermia has been widely adopted for patients who survive initial resuscitative efforts after an arrest (essentially patients are cooled to ~32 deg. C for 24 hours - this is thought to attenuate some of the brain damage that occurs during/after an arrest and has been shown to improve neurologic recovery). Most of the research on prognosis for comatose patients after cardiac arrest was done before hypothermia was adopted, so there's some concern that previously established prognostic criteria are no longer valid (or at least not as powerfully predictive). See for instance this study, which attempts to investigate whether absent SSEPs still invariably predicts a poor outcome for patients who undergo hypothermia (it indicates they do).
The current article, which is a retrospective case series from a single German ICU in which they looked at all patients who underwent hypothermia and had SSEP measurement performed, presents data about two patients who suggest this isn't necessarily the case. Of 36 patients with bilateral absent N20 responses, a 43 year old (who had absent N20 responses at day 3 after his arrest) went on to have a normal cognitive recovery (so much so that apparently he went on to resume drinking and they were able to measure SSEPs 18 months later when he was hospitalized and in alcohol withdrawal - a very sad detail they shared - he had recovered N20 responses at that measurement). (They also report on a patient who had abnormal/barely detectable N20 responses who went on to have a normal cognitive recovery).
35 out of 36 patients with absent N20s did not recover, despite hypothermia. (While that makes 97%, one should be cautious; this is a retrospective case series and it's inappropriate to establish event rates from this study design.) One did.
My suspicion is that we will be seeing similar findings for other established 'uniformly bad' prognostic indicators in anoxic injuries. It always seemed, in a perverse way, too good to be true - that there were not just one but several findings which implied, based on all the available research, that if a patient had one or more of them they have essentially no chance of recovery. It will not be that these markers are worthless - they still will be (and this series supports it) - evidence of devastating injury with slim chance of recovery, but not some sort of 100%/clean cut/no questions asked evidence. The world's too messy for that, especially when it comes to brain injuries.
I'm curious as to whether anyone is seeing this used in clinical practice, and having conversations with colleagues about the effect of hypothermia protocols on how and when to examine patients and perform tests (for prognostic purposes), and how and when to talk with families about what we are concluding?
Palliative Care Grand Rounds is up at the greatest blog written by a law professor about medical ethics and decision making with life threatening illness, "Medical Futility" by Thaddeus Pope, J.D., Ph.D. He cranks out a ton of great information on his blog featuring very interesting court cases. His grand rounds post is a classic covering many great hospice and palliative care blogs.
Go comment over at Medical Futility and seek out the other blog posts featured in Grand Rounds. Share it with your friends on Facebook, Twitter and your IDT.
As for Thaddeus' blog, if you EVER give a talk on Medical Futility or Ethics and DON'T reference/highlight his blog, I won't consider you to be an expert who knows what they are talking about. (Redundant last point, but worth it.)
