Tuesday, April 5, 2016
by Susan Thrane, RN, PhD
modalities have been called by many names:
- complementary and alternative medicine (CAM),
- integrative,
- supportive,
- adjuvant,
- placebo and
- hooey just to name a few.
- What are your thoughts on the use of complementary modalities in pediatric palliative care?
- Do you think there is benefit or harm to any of these modalities?
- Does your facility use any formal complementary modalities? What about informal modalities such as crafts, coloring or listening to music through headphones?
- Are there any you would like to try in your setting?
- Have you tried any of the modalities listed for self-care?
- What do you think about passive (massage, energy therapies, aromatherapy) versus active (yoga, guided imagery, meditation) modalities?
Join us for a lively discussion of complementary therapy use in pediatric palliative care!
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Tuesday, April 5, 2016
Saturday, June 20, 2009
The LA Times has a piece that describes a Zen Buddhism chaplaincy program at Beth Israel Medical Center in New York. Through this program, more than 20 Buddhist chaplains or chaplains in training provide spiritual care to the hospital (including patients, families, and employees). The article starts with a familiar scenario-- a man with lung cancer and cirrhosis who wishes to remain a full code. The authors use this scenario to dive into a main theme of the article: the tension between "alternative therapies" and traditional medicine. The Zen chaplain expresses a wish to disclose his past battle with alcoholism to the patient with hopes that this might lead to conversation that helps the man prepare for his death. A physician hints that this might not be appropriate to do. A psychologist indicates that this disclosure might not be appropriate for some providers, but perhaps okay for the chaplain to do.The article further describes the tension between allopathic medicine and the program. One of the chaplains talks of "culture change" they hope to bring to medicine but later also discusses his hope that their methods might lend to the endpoints with which physicians are concerned (e.g. one suggests that alternative therapies may improve adherence to a diabetic regimen rather than providing a competitive alternative that detracts from the regimen's benefit). A physician who cares for the patient remains unconvinced.
Certainly, I could envision some of the tension described in the article, especially if there are circumstances when chaplains might recommend to non-compliant patients to pursue alternative "disease modifying" therapies versus medically proven treatments. I suspect the level of conflict between physicians and the chaplaincy program is overplayed for the sake of good storytelling, though.
I'd guess that physicians at Beth Israel have mixed feelings that are not adequately represented by this article. For instance, I'm ecstatic this program exists to explore and support the spiritual needs of patients from a unique perspective, ambivalent about the method of self-disclosure that the chaplain proposes in the case of the patient with lung cancer, and a little concerned that someone might recommend seeing an herbalist for poorly controlled diabetes. (The article only infers what the chaplain might be suggesting, and I'd like to hear more about how he thinks a referral to this clinic might support patient adherence.) I'd guess many physicians would respond to this type of program with indifference. What do you think?
The tension described in the article is a familiar one to palliative care providers. Even within the profession of medicine, philosophies and approaches of providers may conflict. One of the main challenges for palliative care providers is to champion the principles of our profession while at the same time helping other providers to see that those principles are not always in conflict with other important principles of medicine. There is a similar struggle described in this article.
Regarding self-disclosure, I'm certainly willing to entertain the psychologist's proposition that it may be okay for chaplains to self-disclose, realizing that there are risks of doing this (for example, the risk of transforming the encounter into a self-therapy session that detracts from the patient's therapy). Pallimed covered physician self-disclosure in 2007. I am curious to hear from chaplains of any denomination about the topic of self-disclosure, and wonder if there is something in particular about the Buddhist mindset that makes self-disclosure less risky and more rewarding for the patient. The author of this article seems suggests that the chaplain who wishes to apply this method "operates under different rules," but it's not described how this relates to Buddhism per se.
While the program is a general chaplaincy program not strictly focused on a palliative care population, it appears to have the support of at least one member of the palliative care team:
Supporters of the Zen chaplains program say the monks' presence brings a calming influence to the often frenetic hospital floors, and that patients, for the most part, are open to them. "I think a lot of it has to do with the fact that a lot of our patients don't really know what a Buddhist monk does," said Terry Altilio, a social worker in Beth Israel's palliative-care department, which focuses on relieving suffering of seriously ill patients. "For a lot of patients, there's a curiosity and an openness you don't necessarily see with rabbis, priests, etc."This certainly rings a cord with my experience. Our team has a "spiritual adviser" rather than a chaplain, which does seem to help some suspicious patients keep an open mind about her role in their care (a role that is from a non-denominational, non-proselytizing stance). Speaking of non-Buddhist chaplains, some will take issue (rightfully) with the portrayal of "typical" hospital chaplains as somewhat feckless when it comes to difficult issues such as confronting death. As with any discipline, you'll find that some chaplains are more comfortable with these topics than others.
Lastly, picture #7 associated with the article made me dream about having a scalp massage each day at about noon (and q 3 hours prn afterwards).
Saturday, June 20, 2009
Wednesday, October 15, 2008
We designed the control exposure, simple touch, to control for the time, attention, touch, and healing intent components of the intervention. The control consisted of placement of both hands on the participant for 3 minutes at each of the following locations bilaterally: base of neck, shoulder blades, lower back, calves, heels, clavicles, lower arms, hands, patellae, and feet. Pressure was light and consistent, with no side-to-sidehand movement. Control therapy providers interrupted conscious healing intention by silently counting backward from 100 by 7, reciting nursery rhymes, or planning their day's activities. The control treatments were provided by individuals with no past body or energy work experience.
6)
I've had some correspondence with Dr. Holly Prigerson the PI for the Coping with Cancer study that I recently blogged about. She clarified a few things about the study and promises there are many more analyses and publications forthcoming. I edited some of her comments to me and put them in the comments for that post: click here and scroll to the bottom to read. Thanks Holly.
Wednesday, October 15, 2008
Monday, July 28, 2008
A couple of weeks ago Drew blogged on a short essay/case report in Journal of Clinical 
Oncology that addressed a physician’s struggle in prescribing chemotherapy that he considered to be futile. The same day I got my latest issue of Oncology with an article (with 2 invited responses, here and here) on patient demands for chemotherapy that clinicians feel is futile. I believe this is the inaugural offering in the new feature, “Areas of confusion in oncology.”
The Oncology article is a fairly wide-ranging piece that begins by addressing what is meant by “futile care.” The authors point out that there is no common or consensus definition [I imagine that at least some of this is one of those “I know it when I see it” phenomena]. A recurring theme in this paper is discordance of perceptions and perspectives between patient and physician. Expert panels struggling over guidelines, a physician facing a desperate or resolute patient, children not willing to contemplate “giving up” on Mom, a patient with a religious belief that “everything” must be done, third-party payers—whether private or government, and John Q. Public (i.e., “society”) in the grip of a compelling drama may have varying and conflicting perspectives.
The authors quote a 1993 article in which the reader is advised to distinguish an effect from a benefit. That dovetails nicely with an observation later in the paper that some patients overestimate prognosis because they confuse response with cure.
Not surprisingly, a major cause of the disparate perceptions is assigned to inadequate communication between patient and physician. And not all the blame falls on the physician. When each is waiting for the other to bring up discussions of goals, values, quality of life, prognosis, end-of-life issues, etc., “misalignment of perceptions” can be expected. The physician may even have thought that s/he provided adequate information on prognosis. But if they provide too wide a range of outcomes, don’t periodically come back to the discussion, or don’t check in with the patient to see what was understood, the discrepant perceptions can grow ever wider. “Lack of patient-provider communication regarding prognosis, goals of therapy, and benefits of aggressive symptom management (hospice) all play a role in the delivery of futile chemotherapy.”
There are several interesting tidbits provided that may be helpful to both experienced clinicians and to students or junior clinicians who are trying to get their heads around the issues related to futility dilemmas.
- Over 20% of Medicare patients begin a new chemotherapy regimen within 2 weeks of death
- A recent survey of oncology practices showed a range of 0-34% giving chemotherapy within 2 weeks of death
- At least one study has shown that some patients with previously treated non-small cell lung cancer would accept chemotherapy with a survival benefit of as little as one week, while others would not take it even for a benefit of two years
- Another study showed only a 25% concordance between what patients said their decision-control preferences were and the provider’s perception of the preference.
- Some patients appear to be willing to discuss hospice with a physician other than their oncologist, but not with the oncologist [is it too hard for the patient; does the patient think it will be too hard for or hard on the oncologist?]
- In one study, physicians initiated a hospice discussion 50% of the time, patients or families one-third of the time
- One-quarter of physicians will occasionally administer futile chemotherapy to maintain patient hope.
- The median length of hospice stay is no longer lengthening, but getting shorter (down to 26 days in 2005 vs 29 days in 1995); one-third enroll in the last week of life and 10% on the last day.
An important observation that I have never heard invoked in discussions among clinicians about futility, is that there insufficient information available for patients with advanced disease to access independently. Accurate but vague statements such “current treatments do not cure the cancer” are not helpful for a patient struggling with finding their own process for decision-making. There is very little to be found about the advantages and disadvantages of chemotherapy at this stage, what a patient might reasonably expect, or alternatives such as palliative and hospice care. These points relate to patient questions such as “will I feel better or worse?” (if I take the chemotherapy); “will my cancer shrink [and what does that mean in the short & long term]?;” “how do other people make decisions about these things?”
The authors’ recommendations:
- Don’t go it alone—use trusted colleagues to share concerns, avoid isolation and burnout
- Ask the patient how much they want to know, how they want to make decisions
- Bring up hospice early as a future possibility; emphasize nonabandonment and aggressive symptom management; avoid euphemisms: use “death” and “dying” [while I personally agree with that philosophy, there are cultural overlays and sensitivities than need to be considered.]
- Use family conference as a way to get the same information simultaneously to multiple people who may be family decision-makers; be prepared to share actual studies to bolster your position that there is little or no benefit to further chemotherapy and that there may be significant burden or harm [is “symptom burden” a useful construct for patients who have been focusing on tumor shrinkage? I think it is.]
Equally valuable as the main article, the reviews provide valuable nuance and perspective. One practical idea is the "differential diagnosis" of a patient request that the oncologist thinks is not in the patient's best interest. What underlies the request--unrealistic expectations? Fear of abandonment? Present hospice as a treatment [reminiscent of Andy Billings' statement that family meeting is one of palliative care's most important procedures]. "A 20-60 minute conversation between an oncologist and a patient . . . is miniscule when weighed against a lifetime of family values, traditions, culturally held beliefs, and deeply entrenched religious beliefs."
Khatcheressian J, Harrington SB, Lyckholm LJ, Smith TJ. 'Futile Care:' What to Do When Your Patient Insists on Chemotherapy That Likely Won’t Help. Oncology 2008;22(8):881-887 (free full text) http://www.cancernetwork.com/cme/article/10165/1168027
Monday, July 28, 2008
Tuesday, June 17, 2008
Several notable pieces from a recent JCO:
1)
First is a study about predicting 2 month survival in hospitalized cancer patients. This was a French study from 2 hospitals (n=~170) which used prospectively gathered data (laboratory, performance status, and disease characteristics such as number of metastatic sites, etc.) to predict mortality in hospitalized advanced cancer patients who weren't 'actively dying.' All patients admitted to the hospital who met the criteria were enrolled in the study (if they agreed) - these were not patients identified by a palliative care referral or anything like that. Mean age was 62 years; the patients had a diverse mix of solid tumors (no hematologic); and median survival in the cohort was 58 days (i.e. despite not being actively dying these were very sick patients).
All the typical prognostic indicators were apparent in univariate analysis (Karnofsky performance score, dyspnea at rest, low albumin, high LDH, leukocytosis, number of metastatic sites, etc.), and 4 of these 'survived' multivariate analysis: KPS, albumin, LDH, and number of mets. These 4 were aggregated into a point-based predictive model which divided the cohort into good, medium, and poor prognostic groups (really poor, worse, & dismal) for 2 month survival. Each prognostic group was well-represented in the cohort, which is welcomed since in many of these models patients with the worst prognoses often have very small representation in the initial model development (e.g. an N of 12 - here it was 63). Patients in the dismal group had a 2 month survival of less than 10%. The prognostic scoring system is quite simple and could be done at the bedside (although it's too long to describe here).
Some thoughts about this: Clearly this needs to be validated in further trials, more patients, different institutions, etc. Beyond this, I have mixed reactions to seeing these indices, of which there are numerous (although this one has some advantages - simple data, and quite a powerfully strong prediction of 2 month mortality...assuming its validity is borne out with further investigation). What do these add to clinical care? Or to a clinician's prediction of survival (which was not tested in this study)? This index could, for instance, be used to identify patients acutely in need of palliative care. However what I'm getting at is how much more help/data do we need to predict which of our advanced cancer patients are going to do poorly? That the issue in patient care is not a lack of a solid scientific basis to prognosticate but a lack of will to actually formulate a prognosis and communicate it to a patient (see previous post). Most of us in medicine are positivists (in the scientific sense) whether we'd like it or not; I'm convinced positivism underlies the EBM movement, and underlies our assumption that more data/better indices/etc. improves patient care - cases like this I'm a little less convinced. I'd welcome any comments here....
2)
Next is one evaluating pain as a poor prognostic factor in prostate cancer. When I went through training I was taught that pain really wasn't a significant prognostic factor in cancer (although from time to time you see in crop up in univariate analyses in papers similar to #1 above). The current study in a post-hoc analysis of data prospectively gathered for a couple prostate cancer treatment trials in the 1990s (~600 men, all with castration refractory prostate cancer and who had ECOGs of 0-2). They used pain interference (from the Brief Pain Inventory) and patients with worse pain interference had a markedly worse survival (~10 months) than those with low pain scores (~17 months). My own, likely arbitrary and wrong, take on this is that it has something specifically to do with prostate cancer - more aggressive disease causing more bone pain, etc.
3)
Finally, there's one looking at sleep disturbances in advanced cancer patients, in which a couple nights' worth of polysomnography was performed on over a hundred cancer patients. There was no control group. Nevertheless the sleep quantify and quality of the subjects was quite disturbed: less nocturnal sleep than normals, more periods of day-time sleep than normal, very low amounts of slow wave sleep (believed to be the essential, restorative element of sleep), etc. Per the authors this was the first large study using PSG on advanced cancer patients and may mark the next phase of cancer-sleep research.
4)
JAMA recently had a 'clinicians' corner' piece about family requests for complementary medicine therapy after a declaration of brain death (based on a case in which just that event occurred). It's really a discussion about futility and a physician's role in providing (or not) 'futile' therapies. Given the patient in question was brain dead, and therefore legally not really a patient but a corpse (the fact that brain dead patients routinely aren't treated like corpses however highlights just how viscerally inadequate the concept of brain death is for many clinicians/families), makes the futility point in this case all the more compelling. On the other hand the traditional medicine that was to be given was in no way going to harm the patient (unless one rejects the concept of brain death), and the piece discusses in length just what physicians can and should do in such situations.
For me, the real question is not whether or not families should be allowed to administer 'futile' alternative or traditional treatments to brain dead patients (or dying ones), but in this case it's one of justice: should scarce and costly medical resources be used on dead people (to maintain brain dead people's cardiopulmonary function) at all (when there is no plan for organ donation)? A quote (I'll note however that the conclusion of the article isn't as strident as these stirring paragraphs):
Physicians generally should not agree to requests for clearly futile treatments, even when cost is not an issue, because doing so undermines medical professionalism and the supportable claims to expert authority of medical science. The physician is not an all-purpose technical extension of the patient's will and interests, but a professional committed to the good of health and the relief of suffering by the application of the medical sciences using sound clinical judgment. The terms of a physician's service are properly regulated by the ideals of medicine, reflectively endorsed and broadly conceived. Although the proper practice of medicine will be subject to lively and creative contestation along various frontiers, a physician with professional integrity is permitted, and sometimes required, to refuse to provide requested service that falls far short of medicine's regulative ideals as currently understood. Respect for the autonomy of the patient requires that a competent patient or her surrogate be allowed to refuse almost all treatments (with some exceptions for refusals that harm others), but such respect does not require the physician to administer all possible treatments. This distinction is underappreciated. ...[P]atients are not entitled to treatment that the treating physician judges to be bad medicine.
Tuesday, June 17, 2008
Tuesday, July 31, 2007
3 disjointed topics this Tuesday:
1)
Two from the latest Journal of Clinical Oncology.
First is one looking at cancer survival trends. It is based on data from the SEER database and presents 5 and 10 year survival estimates for multiple types of cancer. The authors use what is described as a novel and accurate model, "modeled period analysis," to make the survival estimates. Needless to say there is complicated statistical modeling going on here which I don't understand; the authors' claim is that this method provides more accurate information about survival because it is more reflective of recent trends (in this case up to 2003) - if anyone can explain why MPA is good in human-readable language please leave a comment. Why I'm bringing this up though is because it provides the most recent data in long-term cancer mortality for US patients, and presents data stratified by type and stage of cancer, as well as age and sex, giving us a good prognostic 'gestalt' for our patients.
The general findings regarding trends in cancer survival is that for many cancers long term survival has incrementally improved since 1988 (up a few percent). Survival for lung and pancreatic cancers however remains dismal (16% & 7% respectively at 5 years).
The other article is one on survival prediction for patients receiving radiation therapy. This was a prospective German study of 216 people with incurable cancer receiving palliative radiotherapy. The researchers gathered various clinicians' (including their institution's tumor board as a whole) survival predictions and measured a bunch of other variables (performance status, certain symptoms, opioid use, etc.). They found that clinicians' survival estimates weren't great. They asked the clinicians to place people in 3 categories (<1>6 months to live) and they were accurate a little more than half the time. When inaccurate they tended to overestimate survival and were worst at predicting those who would die in a month. I personally think these categories are a little unfair and one wonders if their results would have been different if they were <3mo,>6 months. Nevertheless all of this is in keeping with previous findings (docs aren't great predictors, tend to overestimate survival). Also in keeping with previous findings was that certain objective findings were independently associated with worse survival in their multivariate analysis: brain mets, dyspnea, poor performance status, high LDH, high WBC count. More interesting is that they also found that the use of opioids was an independent predictor of mortality in multivariate analysis (& had about the same magnitude of risk as brain mets). I can't recall opioid use (or pain itself) panning out as an independent risk factor in other similar studies looking at prognosis in advanced cancer. Christian, as our resident prognosis go-to guy, any thoughts? This is all likely a statistical dead-end of course but assuming it's not and assuming opioids weren't the cause of death per se one wonders what opioid use is a marker of here - identification by a doc that they are 'end stage' and strong analgesic use is appropriate? Severe pain itself predictive of mortality?
2)
BMJ has a piece by Chochinov on dignity conserving care for all patients. It is a general piece, directed at a broad range of clinicians, and (perhaps mimicking BMJ's ongoing "The A,B,C's of..." series) presents the A,B,C,D's (attitude, behaviors, compassion, dialogue) of dignity in routine patient care. I never know whether I should despair or rejoice when I see pieces like this. Rejoice because they are being published in widely read and prestigious journals. Despair because I am reminded that we (physicians) do in fact really need to be reminded of Chochinov's very basic assumptions and recommendations (basic but of course accurate/important): patients want/need to be cared for as whole people, we should talk to our patients about their lives and strive to understand how their illnesses affect them.
"Treating a patient's severe arthritis and not knowing their core identity as a musician; providing care to a woman with metastatic breast cancer and not knowing she is the sole carer for two young children; attempting to support a dying patient and not knowing he or she is devoutly religious—each of these scenarios is equivalent to attempting to operate in the dark."
To amplify his point (...without this we'd be operating in the dark...): there is nothing special or squishy or superfluous about this, it's just good medical care.
3)
And finally, Pain Medicine presents a randomized, placebo controlled (sham therapy) trial of therapeutic touch for reducing pain and anxiety during stereotactic breast biopsies. They describe sham TT as:
"Sham TT employed the approach of Quinn—practitioners having no conscious intent to help and counting backward by "serial 7s" silently during "treatment"—was administered by providers neither trained nor experienced in actual TT delivery but who completed two 3-hour training sessions instructing them only on hand movements simulating TT. In this way, variables such as support from another person not involved with the procedure and patient distraction during SCB can be controlled for."
No differences were found between the real TT group and the sham group in any of the outcomes, suggesting any benefits from TT are from caregiver attention or other similar mechanism. There has been ongoing concern about publication bias in CAM studies (negative studies not being published) so I'm glad to see decent, controlled trials like this getting published. On the other hand, this isn't the first controlled trial out there showing TT to not work (or its fundamental assumptions to be flawed), and one could argue why bother doing more studies?
Tuesday, July 31, 2007
Tuesday, June 26, 2007
TMI is "Too Much Information" if you needed to know
1) Many news outlets (WSJ and USA Today (read the comments there) and others) are noting an article in the Archives of Internal Medicine regarding physician self-disclosure during clinic visits. The study involved standardized patients secretly recording physician visits which were then later analyzed for "personal emotions and experiences, families and/or relationships, professional descriptions, and personal experiences with the patient’s diagnosis." They even managed to account for one of my favorite errors in research, the Hawthorne Effect (non-Wikipedia link!), by using unannounced, unrecognized SP's, so that the MD's would not alter their behavior. The article includes many interesting snips of conversation from the study. 73 self-disclosures were identified in 34% (38/113) of the visits. The authors even noted if the disclosure was deemed helpful, neutral or disruptive.
This study was well-designed and executed and the discussion section is a great read. It provides insight in how to look at the blurry lines among empathy and disclosure and boundaries and strengthening the clinician-patient relationship. I think these issues are very important for palliative care practitioners since it is so easy to make a quick connection with people by sharing any of your own losses, but ultimately it does turn the focus to us, and not to the patient or family. One technique if you are sharing something of your own experience, is you can always depersonalize it and mention "A patient/family that was in a similar situation thought this was important..." or whatever segue works best.
But I guess that is sharing a little too much about myself!
2)
Nature is reporting a release of a innovative proposal to help fight the "war on terror" and the "war on drugs" at the same time. The program is called Poppies for Medicine (P4M) and it is being proposed by the Senlis Council, a European-based think tank dealing with health, counter-narcotics and grass roots improvement in Afghanistan. Some of the basic tenets of the plan include:
- Afghan farmers preferring a reliable, legal means of income
- A better price (US$140/kg) for farmers compared to illegal markets (US$92/kg)
- A worldwide shortage of inexpensive pharmaceutical grade opioids (A very interesting read)
- Manufacturing on a local level to provide stable jobs in rural areas
- Close oversight for quality control
The image of the button at right is courtesy of flickr.com user violinsoldier. The button is supposed to signify the poppy's firm grip on the country and people of Afghanistan. The writing has been translated as "Save your country from the occupation of drugs" in two languages.
Other tidbits:
The Virginian teen who was initially denied alternative (CAM) treatments, Abraham Cherrix, had to go in for more radiation. Two bloggers (Respectful Insolence and The Cheerful Oncologist)at ScienceBlogs comment on the report. Both are good writers with some interesting insight, so I will not try and outdo them.
Freakonomics (a good non-medicine blog and book) interviews Atul Gawande, author of Better: A Surgeon's Notes on Performance. He makes a comment that we could do better with chronic pain. (I agree!) Then states that we can cure 70% of cancers. (huh?). Despite that last statement needing some 'qualifiers', I have heard great things about his book. Any Pallimed readers get to it? If so you want to write a book review for Pallimed on how it may apply to our field?
Tuesday, June 26, 2007
Tuesday, June 5, 2007
Thanks to everyone at the CSPCP conference last week for being so friendly - particularly the Nova Scotian crew (DH & family, RH, PM) for your hospitality and generosity. Halifax, for those of you who are curious, is as lovely as billed (but watch out for hurricanes). I'm still re-orienting myself and so this is going to be a post of 'quickies.'
1)
ASCO occurred last week & Medscape reported on a session on new research on cancer-related fatigue. It's of course impossible to really get a sense for the quality of this research based on a reporter's summary of a conference session but the research presented suggested 1) ginseng may be helpful, 2) modafinil may be effective for chemobrain, 3) donepezil is not effective for fatigue.
(Medscape articles usually require you to sign-up - it's free however.)
2)
On the chronic pain front NEJM this week presents two trials of surgery for chronic back pain (one for severe sciatica lasting at least 6 weeks, the other for spinal stenosis from spondylolisthesis). Both trials were randomized & controlled (surgery vs. conservative treatment) but not blinded (for obvious reasons) and both suffered from a lot of cross-overs. In the spinal stenosis trial almost half the patients assigned to non-surgical care had received surgery by the end of the first year, and - not surprisingly - there were no differences between groups by intention-to-treat analysis. By as-treated analysis (comparing those who actually got surgery to those who didn't - this is essentially non-controlled observational data) surgery came out better (decreased pain, better function). The sciatica trial had some similar troubles (39% of the conservative group patients received surgery) and the 1-year outcomes were similar in both groups. The surgery group had distinctly faster time to pain relief and functional recovery however. Despite the different ways the studies were presented (sciatica as a 'negative' study and spinal stenosis as a 'positive' one) my interpretation is that early surgery for severe sciatica makes sense (speedier functional recovery and decreased pain) despite the similarity of both groups at 1 year; 'early' surgery for spinal stenosis however cannot be endorsed given the lack of benefit in the intention to treat analysis. All of this really highlights the difficulty of doing research like this - can't be blinded, patients (& who can blame them in the absense of no evidence one way or the other) can pull themselves 'off-protocol' which may be the right thing for them but makes interpreting the studies so much harder.
(Image from Wikipedia's laminectomy article which I'm not otherwise endorsing).
3)
The NY Times has an editorial today triggered by Jack Kevorkian's release urging passage of physician assisted suicide legislation (legalizing/creating a mechanism for it). Their take: legislation is needed not because what Dr. Kevorkian did was right but because what he did and how he did it was so reckless and wrong. It gives a nod to 'aggressive' palliative care:
'The fundamental flaw in Dr. Kevorkian’s crusade was his cavalier, indeed reckless, approach. He was happy to hook up patients without long-term knowledge of their cases or any corroborating medical judgment that they were terminally ill or suffering beyond hope of relief with aggressive palliative care. This was hardly “doing it right” as Dr. Kevorkian likes to believe.
By contrast, Oregon, which has the only law allowing terminally ill adults to request a lethal dose of drugs from a physician, requires two physicians to agree that the patient is of sound mind and has less than six months to live. Now California is about to vote on a similarly careful measure. One of its sponsors cites Dr. Kevorkian as “the perfect reason we need this law in California. We don’t want there to be more Dr. Kevorkians.”'
4)Mayo Clinic Proceedings has a case series describing 10 years of their institution's ethics consults (255 in total). Despite not being generalizable to other institutions there are many interesting findings. Most compelling to me was that 9 patients had more than one ethics consultation - one can only imagine those situations. Most patients had 'poor' or 'terminal' prognoses (as recorded by the ethics team) and being the subject of an ethics consult, based on this case series, is one of the worst predictors of in-hospital mortality (similar to having 2 ICU stays but not as bad as in-hospital arrest): 40% died (and another 9% died within a month of discharge). Their ethics consultations also sound very similar to my own team's consultations, reflecting the overlapping and differing roles ethics teams and palliative care teams have at different institutions: over half their consultations addressed some combination of withholding/withdrawing treatments, goals/futility, quality of end of life care, and staff or professional conflict (a full 76% of consults involved this). Actually, the most common issue addressed by the team, in over 80% of consults, was patient decisionality.
I particularly appreciated this comment:
"Ethics consultants, while gathering data for the structured questionnaire, interviewed all interested parties, including the patient, the patient’s family, and members of the health care team. This process alone frequently resulted in resolution of ethical dilemmas (eg, discovery of a previously unknown advance directive that articulated a patient’s wishes about life-sustaining treatment during terminal illness). In fact, of the 255 ethics consultations in our series, 179 (70%) were resolved before assembling the full multidisciplinary team to review the case...."
Tuesday, June 5, 2007
Wednesday, April 18, 2007
1)
From the chronic pain world....
Annals of Internal Medicine just published a metaanalysis of randomized, controlled trials for chondroitin for osteoarthritis pain (22 trials, over 4000 patients, median dose of chondroitin 1000mg daily, median duration of treatment 25 weeks). Basically they found (surprise!) a lot of heterogeneity between the trials but when they looked at the better quality trials (the larger trials which had intention to treat analysis & good allocation concealment) therapy with chondroitin didn't seem to have much effect. They looked at their data in many ways, and it seems that chondroitin probably has a mild effect compared to placebo, but insofar as this effect diminishes with larger, better designed trials it seems highly probably that this effect is minimal and not anything one would advocate for their patients. Doesn't diminish traditional analgesic use, etc. It's a good example of how small trials can be misleading, particularly for agents that are of marginal benefit.
Anyway, none of this is very interesting. The metaanalysis is worth reading for other reasons: maybe it's been a while since I read a metaanalysis in Annals but this one was actually a treat to read. The authors describe in language, understandable to non-statisticians (something absent from many a metaanalysis), all the different analyses they did, why, why and how they did exploratory analyses, what they mean for interpreting this large body of heterogeneous data, what the research implications of all of this is, and came up with realistic clinical recommendations based on their findings (much more helpful than the annoying conclusion to many a Cochrane review 'there are insufficient data to support the use of X for Y'). I may not have learned much about chondroitin but did about metaanalyses.
2)
The NEJM has a review on the management of adult fecal incontinence. It spends most of its time on fecal incontinence due to neurologic conditions (strokes, spinal cord injuries) and pelvic muscle weakness but also addresses overflow diarrhea in constipated patients and fecal incontinence from things like radiation proctitis. It's a problem which is thankfully rare in my practice, but devastating for the patient when it occurs; as well as something about which I've had very little training (other than overflow diarrhea).
Wednesday, April 18, 2007
Thursday, February 22, 2007
1)
Internal Medicine Journal has an article about anger in palliative care. It is a qualitative & narrative article reviewing anger in palliative care and is based at least on part on interviews with palliative care clinicians (docs, nurses). It's an issue which isn't frequently written about specifically--usually conflict in general is addressed--and for those of you who follow these things it might be interesting. It has this quote near the beginning:
In cancer care, despite being considered a normal reaction, anger is often seen as a negative emotion, which is tolerated, as it may presage a future, more constructive response.
I was hoping when I read this that the article was going to thoroughly de-pathologize anger, but it didn't really.
2)
Journal of Clinical Oncology has kept my inbox busy as of late...
First are a couple of articles about complementary and alternative therapies in cancer care. One is a randomized trial of aromatherapy massage (which is exactly what it sounds like) for depression and anxiety in cancer patients. It was a multi-center non-blinded trial in which 288 cancer patients were randomized to four one-hour sessions of AM or 'usual care.' How these patients were identified is unclear, they apparently met 'modified criteria' for 'clinical anxiety/depression' according to DSM-IV criteria. I don't have a DSM in front of me but the last time I checked 'clinical anxiety' or 'clinical depression' weren't diagnoses in the DSM--GAD, major depressive disorder, adjustment disorder etc--but not 'clinical anxiety.' This sort of stuff worries me when I see it in an article. Their primary outcome was depression and anxiety symptoms at 10 weeks post-randomization and intention to treat analysis was used. (After reading the article a couple of times I'm still a little fuzzy on how they actually defined anxiety and depression). They found modest improvements in anxiety and depression 6 weeks post-randomization (2 weeks after the intervention was done) in the AM group; no differences in anxiety/depression between the AM & usual care group at 10 weeks (this was the primary outcomes); and no differences at any times between the groups regarding pain, fatigue, nausea, or global quality of life.
Problems aside (and, frankly, supportive cancer/symptom trials tend not to be of the highest quality in most instances), this was the best designed and executed CAM trials I've seen for a while, and I commend the authors for publishing its severely underwhelming findings. In their discussion they noted some of the difficulties in undertaking the trial--typical stuff about patients getting sick etc.--but they also mentioned how none of the study sites actually had infrastructure supporting research into supportive cancer research which was a problem for them. This is the real story here.
3)
Second is another CAM study. This one looked at the use of complementary and alternative therapies in cancer patients starting phase I trials. About 200 patients were interviewed at the University of Chicago as they were enrolling in phase I trials about their CAM use. Their most interesting findings, although not surprising I guess, is that CAM use seemed to increase with decreasing quality of life and increasing certainty of death (it was much more common in patients who thought they were likely to die within the year).
4)
Third in JCO is a study looking at advanced cancer patients' religiousness & spiritual support & how it relates to quality of life and end of life treatment preferences. This was another interesting article to come out of the Coping with Cancer Study (a multi-institutional U.S. study of advanced cancer patients and their caregivers). 230 patients were interviewed about spirituality, religion, and sundry other things. Not surprisingly most patients felt like the medical system provided inadequate spiritual support; more surprising was that almost half of patients reported their own religious communities provided inadequate support. This finding was attenuated for African-Americans & Hispanics. Spiritual support was associated with improved quality of life (this finding survived multivariate analysis). In multivariate analysis increased religiousness was associated with wanting all possible measures to extend life 'even if you were going to die in a few days' but not decreased rates of advance directive completion. Being 'non-white' was associated with decreased completion of advance directives and a DNR order (being in the Northeast was also associated with not having a DNR order--no comment on that). Most of these findings are consistent with previous ones. What was striking to me was how, it seems, patients felt like their spiritual needs were not being met by either the medical system or their own religious communities--perhaps part of the progressive isolation many patients undergo as they become increasingly disabled?
(Supporting editorial by Betty Ferrell here.)
5)
Fourth and finally is a randomized controlled trial to help advanced cancer patients ask their physicians about prognosis. Basically a bunch of cancer patients were given a booklet with potential questions to ask their physician about, among other things, prognosis, what to expect in the future, support services, etc. The booklet intervention did seem to raise the number of questions patients asked and topics discussed, although in the long run it's not clear it significantly improved the amount or quality of info patients got. The physicians didn't seem to mind the intervention too much, although I did find this quote notable:
However, five of 13 physicians stated they had some reservations; namely, fear that the patient may not be ready to discuss end-of-life issues, and concern that it may put the onus on the patient to ask questions rather than on the physician to respond to patients' cues.
Because, as we all well know, physicians are the ones who should be deciding when it's time to discuss end of life concerns, and are famous for our ability to pick up on patients' cues, particularly when it comes to discussing uncomfortable information.
Thursday, February 22, 2007
Monday, January 8, 2007
Dateline: New Orleans, LA
Old Pallimed Post #1 Post #2 post #3
Dateline: Chincoteague, VA
Old Pallimed Post
One nice silver lining for a often-maligned discipline, social workers. The same social services that first reported the case for suspicion of neglect (a good thing to at least look into) were also the same social services that came to the mother's aid when she was separated and was having difficulty with her bills and emotional support. Social workers are really great people. They are not baby stealers. (A social worker once told me that and it has stuck with me.)
Dateline: Rome, Italy
Old Pallimed Post
"This must not be mistaken for euthanasia. It is a suspension of therapies;But despite his clarification, the Associated Press still managed to muddy the issue, by contrasting his statements with how long you could be prosecuted for assisted suicide and about how law makers felt about euthanasia. Again, three different issues with very important differences that are often confused for one another.
refusing treatment is a right. Quite frankly, in Italian hospitals
therapies are suspended all the time, and this does not lead to any intervention
from magistrates or to problems of conscience."
When the people took his coffin through the streets, apparently the Roman Catholic Church kept the doors closed denying him a religious ceremony, because he 'sought to end his own life.' there is some explanation of possible investigation and prosecution of the physician involved. Apparently most of the Italian public supported the patients right to withdraw his ventilator.
Monday, January 8, 2007
