Friday, January 11, 2019

A Randomized Controlled Trial for Fan Therapy in Dyspnea

by Bob Arnold (@rabob)

Winter suits me just fine since I do not like heat. I have a lot of sympathy for patients with chronic obstructive lung disease who do not have an air conditioner during the summer. I am told that there is nothing worse than sitting in hot, humid weather and not being able to breathe.

As a palliative care physician, I love fans. When my patients are short of breath and opiates do not work (1,2) I send their families down to the local ACE hardware store to buy a hand-held fan. Therefore, I was excited to see an article in the Journal of Pain and Symptom Management on fan therapy being effective in treating dyspnea in patients with terminal cancer. (3) The previous data for fans (4) has been meager so I have always been a bit hesitant to recommend fans in my academic hospital for fear that the other doctors would think I was goofier. I was hopeful that this article could make a difference in how they thought about me (a bar that might be too high for any single article).

Briefly, this was a randomized controlled trial of 40 palliative care unit patients with advanced cancer in Japan. The patients all had dyspnea at rest with a score of at least 3 points on a 0-10 numeric grading scale, oxygen saturations greater than 90%, and an ECOG Score of 3-4. The only patients who were excluded were those with a fever, anemia, or a disease or treatment affecting the trigeminal nerve (the purported mechanism for the action of fans). The intervention was a fan blowing across one side of the patient’s face for five minutes. The control group was not blinded but did have air flow directed onto the patient’s exposed legs for five minutes. The outcome measure was a change in the patient’s dyspnea score.

The two groups were similar in characteristics and causes of dyspnea. Importantly, there was no difference in the oral morphine equivalent doses at baseline (although the patients who got leg fans had slightly higher doses; the investigators tried to control for this by having a washout period before initiating therapy). The patient’s cause of dyspnea and their performance status also did not differ

What did differ were the results. People who had fans to the face had a greater change in their dyspnea score (-1.35; range of -1.86 to -.84 versus -0.1; range -0.53 to 0.33). More importantly, 80%of patients who had a 1 point reduction in their dyspnea rating and 35% had a reduction of two or more points versus 25% and 5% in the fan to the leg group.

Was the study valid?

They had to screen a lot of patients to enroll 40. This makes me worry whether this is a very select group of patients that may not be representative of the general patients I see. On the other hand, they were palliative care unit patients with advanced cancer who sound like my patients. The assignment of patients to the two groups was evenly randomized; all the patients were accounted for at the conclusion and there was complete follow-up. The study was not blinded, and I could not tell if the people who were collecting the data knew which groups the patients were in as that might be a problem if they assessed the symptom differently.

Were the results clinically important?

Well this is a bit of a problem. When you try to decide what counts as clinically significant on a dyspnea scale, there is a fair amount of variation depending on the scale. However, in my very quick search of the literature regarding visual analogue scales it seems like a clinically important change is between 10-20 on a 0-100 scale (this would translate to one or two points on the scale used in this study - more on Minimally Clinically Importnat Difference here). So, the difference in this study may be clinically important.



Might other factors have resulted in this difference?

I think the investigators did quite a good job in trying to control for other medications that the patients received that might have increased or decreased dyspnea. I was particularly impressed with how they handled and reported on opiates.

Does this change my practice?

This is a little bit like the aromatherapy article that I reviewed. There is almost no risk and my experience, like the study, is largely positive, so it did not really change my practice because I was doing it anyway. Though an article might help me to lead to a more educated and intellectual discussion with my residents and fellows – the answer to that is yes and that is always a good thing. (I am currently trying to figure out if folks think I am less goofy).

More Pallimed posts from Bob Arnold can be found here.
More Pallimed journal article reviews can be found here.
More Pallimed posts on dyspnea can be found here.


Robert Arnold MD is a palliative care doctor at the University of Pittsburgh and a co-founder of VitalTalk. He loves both high and low brow comedy (The Good Place and Nanette), pop culture (the National Enquirer and Pop Culture Happy hour) and music of all kinds (not opera tho!)

References

1 Clemens K E,, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care Cancer 2009;17:367–77

2 Kamal AH, Maguire JM, Wheeler JL, et al. Dyspnea review for the palliative care professional: treatment goals and therapeutic options. J Palliat Med. 2012. 15, 106-14.

3 Kako J, Morita T, Yamaguchi T, et al. Fan Therapy Is Effective in Relieving Dyspnea in Patients With Terminally Ill Cancer: A Parallel-Arm, Randomized Controlled Trial. JPSM. 2018. Vol 56, 493-500.

4 Bausewein C, Booth S, Gysels M, et al. Effectiveness of a hand-held fan for breathlessness: a randomised phase II trial. BMC Palliat Care. 2010; 9: 22.

5 Riles AL. Minimally Clinically Important Difference for the UCSD Shortness of Breath Questionnaire, Borg Scale, and Visual Analog Scale." COPD. 2005. Vol 2, 105-110.

Fan Therapy Is Effective in Relieving Dyspnea in Patients With Terminally Ill Cancer: A Parallel-Arm, Randomized Controlled Trial.

Friday, January 11, 2019 by Pallimed Editor ·

Tuesday, January 8, 2019

Grieving with Mr. Pickles: Thoughts on Showtime’s ‘Kidding’

by Christine Bridges

“I don’t think I could stand to be around that much death. All that sadness!” When I announced my career change and plan for a Hospice and Palliative Medicine (HPM) fellowship the reaction of most, in healthcare or not, was concern for my emotional wellbeing. Internally my initial response was: 1. Why do people think that death is reserved for HPM alone? and 2. Death and grief are all around, they are a part of life.

Perhaps it is my current vocation, but it seems that modern media agrees. Death and grief are showing up in unexpected formats. Most recently the new ‘dramedy’ on Showtime, ‘Kidding,’ starring a shockingly sedate Jim Carrey. In the pilot episode, we see our central character Mr. Pickles, a pseudo- Mr. Rogers, waiting to be interviewed on Conan Obrien’s talk show. We learn quickly that this famous man recently lost his son. The episode draws us into his life and the way his son’s death has ricocheted through his family. We see him turn to his work to cope with his grief. Mr. Pickles is planning a show where he will openly address his son’s death. Quickly the old anthems come, “People don’t want to hear about death.”



I imagine myself and my HPM colleagues nearly jumping from our chairs, arms waving, “But people do want to talk about death, they do!” We have learned this the hard way, stepping into complex family meetings and hearing that no one has talked about death or the dying process. Now at the very last inescapable moment, there it is, death on the doorstep. 10 years ago Holly Prigerson's research group published a study showing that earlier discussions around end-of-life care lead to lower rates of caregiver depression. When patients and families are surveyed about preferences regarding the outcomes they are seeking for the end of life they list ‘knowing a doctor is comfortable talking about the end of life,’ and ‘clear decision making, preparation for death.’ A decade later the average length of stay in hospice remains a minuscule 2 weeks. Fourteen days is a tiny window to get to know a patient, their family, their goals, and manage their most difficult symptoms. With that small time to prepare, families are confronted with death more suddenly than they expect.

This was the most commonly repeated experience in a recent spousal-loss support group that I attended. So many of the remarkable people who filled that room echoed each other’s frustrations that the medical community had not told or prepared them for death. At the end of life their own doctor seemed to indicate this outcome had been inevitable. The doctor knew Ms. Jones or Mr. Smith was dying, but the patient and family did not. The spouses mentioned the legal and practical concerns of managing shared assets, but they also mentioned the missed chance for one last vacation, or one last day at home together. Doctors can talk about death, or we can avoid the topic Death comes anyway, and it leaves grief behind as its last gift.

I have a slightly unique perspective, losing my father unexpectedly when I was 20 years old. The other day in lecture the organ and tissue donation organization shared about their work in our community. They showed a picture of the medal they give donor families. That same medal sits next to our brown leather family Bible because my father was also a tissue donor. I felt lost, for just a few breaths and it becomes clear that my work of grief may never be done. Even though we are healers, we as medical providers have all experienced loss. How does our past loss affect our future work? How do we carry our personal and professional losses with us and allow them to be transformed into healing? The opportunity exists for us to help our patients and family begin their journey with grief together, to start that difficult journey through grief hand in hand.

Mr. Pickles compares grief to losing an object that you can never find again. He sings about feelings, letting us know that there are no right or wrong emotions. He argues with producers who do not think children can handle talking about death as if children do not grieve. Perhaps parents, much like providers, can feel out of control, torn free of their moorings when the discussion turns to death. Just like a parent, we must help with the transition from death to grief. There are no shortcuts in grief. We are all grieving something, loss of freedom, or youth, or expectation, and often, missing the people we have lost. We in healthcare cannot use our work as a tool to avoid grief, but like Mr. Pickles, use our losses as a way to do better and give back to those around us. Spending a moment in the shoes of those actively grieving is humbling. It is in service to the goals of patients and their loved ones that we must talk about death.

As physicians, we fear causing harm by sharing ‘bad news.’ The idea that we could prevent grief, to keep it at bay by refusing to allow its presence in the same room as our precious patient, may be a dangerous one. If we listen to our patients, listen to the wisdom even in a TV show, we hear the truth: our patients want to know, and their families need to know that death is imminent. It is not always the patient’s death or family’s grief that we dread. We must recognize our own fear of grief, our sense of failure, our frustrations at being left with uncertainty. We as the medical community must conquer the fear of our perceived enemy: death. As my father often said, “We all leave this world sick enough to die.” It is a simple truth that we are all mortal. It is a complex challenge to acknowledge this in the practice of modern medicine.

I look forward to taking the journey with Mr. Pickles and his family. I will try to make death an old friend, and grief a teacher.

Christine Bridges, MD is a hospice and palliative medicine fellow at the University of Louisville Health Science Center. She enjoys baking and watching zombie movies with her husband.

Wright AA et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008 Oct 8; 300(14): 1665–1673.

Steinhauser KE, Christakis NA. Preparing for the End of Life: Preferences of Patients, Families, Physicians, and Other Care Providers. Journal of Pain and Symptom Management. Volume 22, Issue 3, September 2001, Pages 727-737.

Steinhauser KE, Clipp EC. In Search of a Good Death: Observations of Patients, Families, and Providers. Annals of Internal Medicine. 132(10):825-832

Tuesday, January 8, 2019 by Pallimed Editor ·

Tuesday, January 1, 2019

First Ever Medical Humanities Chat (#MedHumChat)



by Christian Sinclair (@ctsinclair)

What started off as a spontaneous tweet by resident Colleen Farrell, MD (@colleenmfarrell) generated a swell of interest from the health care Twitter community and now is being fully realized with the first Medical Humanities chat on Twitter (#MedHumChat) starting tonight January 2, 2019 at 9pm ET.

While not directly focused on our field, we know many hospice and palliative care clinicians have a deep appreciation and connection to the humanities and thought this chat would be of significant interest to the Pallimed online community. We know how hard it is to get Twitter chats started and sustained, and since this chat occupies the same time frame as the old weekly #hpm chats, many of you may be looking for something to fill that gap we left open back in 2017.

Dr. Farrell was kind enough to answer some questions about the chat below.

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CTS: What key reasons make the humanities are important in training of clinicians?

CMF: Oh so many reasons! My organic chemistry professor in college (David Richardson at Williams) urged me to take classes to “understand the human condition.” (I ended up no sticking with my chemistry major as planned and majored in women’s and gender studies with a minor in Spanish.) I think so much of what we do in medicine is trying to understand the human condition, but our ways of doing so in medicine are somewhat limited. For millennia, humans have been telling stories and creating art to make sense of human experience and the mysteries of life and death. We sometimes make the mistake of thinking we only need modern medicine to make sense of life and death but so much mystery remains. I find turning to stories and art helps me make sense of the vastness of what my patients are experiencing and my own experience as a doctor. I think art ultimately raises more questions than it answers, and when it comes to suffering and death, what we need, as doctors, is to recognize the unanswerability of these questions and at the same time the vital necessity of embracing them.

I wrote my senior thesis on the early years of the AIDS epidemic in the US, focusing on the experiences and responses of gay men in particular. (I worked with an incredible US historian Sara Dubow.) I read a lot of patient memoirs, studied the AIDS Quilt and its role in collective memory, and examined artistic representations of Kaposi’s sarcoma. My take away from the project was that illness isn’t fundamentally biomedical with social overlays, but rather a fundamentally social and biological phenomenon. The two simply can’t be separated.

CTS: What Twitter chats have you followed or participated in that might have inspired this?

CMF: I’ve been peripherally following the #womeninmedicine (Sundays 9pm ET) chat. That’s what introduced me to twitter chats. And though I’m not an active participant myself, I’ve seen the sense of community it’s created and how empowering it has been for so many women. The internet gets a bad reputation. A place where people go because they can’t face the real world. But the internet can be a force for good. It creates space to say honest, vulnerable things you maybe can’t share in your normal environment. And it allows connections between people who need each other but are often isolated from each other, whether it’s women in medicine or folks with disabilities.

CTS: What has surprised you most about the response to your initial tweets?

CMF: About the chat? I was so surprised people are so interested! I really just tweeted the initial idea as a whim. I really hadn’t thought it through. But then there was so much interest, I thought maybe I’d touched a nerve, identified some kind of gap in people’s experience with healthcare. Maybe. So I’m taking it on as an experiment. We’ll see how it goes!

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The two pieces of work that will be discussed at the first #MedHumChat will be “Practicing Medicine Can Be Grimm Work” by Valerie Gribben and “Intensive Care” by Jane O. Wayne.



I strongly encourage the online #hpm community to come out and support this first #MedHumChat January 2nd at 9pm ET. You can find out more by following @MedHumChat and @colleenmfarrell)

Christian Sinclair, MD, FAAHPM is the editor-in-chief of Pallimed, co-founder of #hpm chat, and palliative care physician at the University of Kansas Health System. When he isn't writing for Pallimed, you can probably find him updating one of several social media accounts to help advocate for hospice and palliative care.

Tuesday, January 1, 2019 by Pallimed Editor ·

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