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by Lyle Fettig

When debriefing after a difficult communication encounter led by a fellow or resident, I’ll often start by asking the trainee, “how do you think it went?” There are times when I thought the encounter went very well, yet the trainee leaves the room with a worried look. Perhaps the trainee clearly explained the medical facts, demonstrated ample empathy, and carefully talked about the next steps, so I’ll be a bit surprised when the trainee says, “It went horrible.” I’ll ask why, and I’ll get a bemused look in response. “Because I made the patient cry,” the trainee might say. Usually, when this happens, the trainee knows that it was the serious news that made the patient cry: A change in condition, a revelation about prognosis, etc. Deliberate reflection on skillful communication requires some understanding that while patients may respond differently to various communication techniques, we are ultimately not responsible for the patient’s emotional response to serious information. Even if giving the information was the ethical and pragmatic way to proceed, the physician is at risk for experiencing strong emotions that mirror those of the patient’s. The response of the patient and the physician’s experience of observing the response might make some second guess whether they have approached the conversation skillfully, even when they have.

“Attending: Medicine, Mindfulness, and Humanity” by Dr. Ronald Epstein, professor of family medicine and palliative care at the University of Rochester, is all about how physicians cognitively and emotionally process not only moments like this one, but also the more routine moment to moment emotional roller coaster of the practice of medicine. It’s a practice that is rich with cognitive complexity but always mingling with emotional intensity: Anxiety over making correct diagnoses or missing something. Frustration about electronic medical record systems. Helplessness when faced with symptoms we cannot explain, or sometimes cannot alleviate adequately.

We all experience these thoughts and emotions in our own way, and all develop methods (sometimes adaptive, sometimes not so adaptive) to respond to our inner experience. Dr. Epstein blends a mix of his own experience (which he describes with vulnerable humility), the experience of colleagues, and a description of some of his own research (example here) as well as related research in neuroscience, decision-science, and resiliency. The result is a readable, thought-provoking, useful, and comforting book that I’d recommend to any physician, or for that matter, any health care professional.

The book starts with a chapter on mindfulness in the practice of medicine and then a chapter on the related concept of “Attending” which describes our human ability to attend to a limited number of stimuli at once, leading to inattentional blindness (which none of us are immune to), and why this contributes to the challenges of medical diagnosis and management as well as why it may be so hard for us to recognize the experience of the patient at times. Even for people who are highly empathic, there’s still a risk of losing sight of the other person’s perspective when you’re lost in clinical reasoning, etc. He then further expands the discussion to the topic of uncertainty, and how we in medicine are certainty junkies, which brings with it a risk for crowding out curiosity. And that has negative implications.

Palliative care clinicians will especially appreciate his reflections on the concept of “presence” or “bonded resonance” in which two people are in touch and in tune with each other. Quoting philosopher Ralph Harper, he talks about the important role of presence in “boundary situations,” times of vulnerability and uncertainty. Philosophers and scientists alike have explored this resonance, and he describes two seemingly competing, but perhaps complementary, theories for how this happens. The first is “theory of mind,” where it’s thought that we theorize what might be going on in other’s minds, and might occasionally verify in communication if we understand their thoughts and feelings. The other theory is “embodied simulation” which posits that we “relive in our own bodies and minds the actions and presumed intentions of the other. He states that the current body of research comes to an intuitive conclusion: our cognitive and emotional lives are shared psychologically and neurobiologically, and boundaries between those sharing in presence are blurred.

This is a wonderment, and it reframes the feeling of dread that often goes along with breaking bad news. Yes, it's the information that makes the patient cry. It's information that the physician shares from his or her own mind to the patient's, who reciprocates with sharing emotion back to the physician. Although the physician has not "caused" the bad news, perhaps the feeling of responsibility for the patient's emotions stems from the blurring of boundaries?

I eagerly read the chapters on “Responding to Suffering” and “The Shaky State of Compassion” and agree with his supposition that while training in empathy is important, it only goes so far and there’s a real risk of emotional contagion- taking on the patient’s distress. Describing research about compassion, he describes “exquisite empathy” or compassionate action that may relieve the patient’s suffering and in concert, release the emotional tension that the clinician experiences.  (I would include plans that come about after careful goals of care discussions as "compassionate actions", and even the process itself, that involves a lot of sitting with patients and grappling.) The good news is that there is growing data that compassion can be cultivated through practices such as loving-kindness meditation.

The book closes with chapters on resiliency in both the individual clinician and in the healthcare system with compassionate suggestions for his colleagues that don’t aim to “fix” the problems of our broken healthcare system, but do aim to help us build capacity to respond to it. Everything he writes about complements, integrates with, and bolsters important communication skills commonly taught by palliative care clinicians.

You’ll have to read the book to see some of his suggestions, but I’ll leave this review on a personal note. I personally am not immune to burnout and anxiety, as well as occasional dysthymia and rarely, depression. I remember when I was just starting, our team’s chaplain asked me to notice my breathing in the middle of a visit with a very anxious man who was in pain as well. To my surprise, I was holding my breath, perhaps an embodied simulation of what I witnessed. I think of the multitude of simulations we process each day, with patients, their families…and with colleagues, and this is a timely book for our field and for medicine in general.

I think this book offers a framework to consider how we might become more resilient, yet I recognize that someone out there might be reading this right now in the midst of a personal crisis. If that's the case, I could imagine that hope might not come as easily as you would want.

So, I have one last heartfelt note for everyone, but especially for my physician colleagues. It comes from the experience in the past couple of years of losing a physician colleague to suicide.

Recent research indicates that burnout in HPM physicians is something we should pay attention to carefully.  It's an issue in medicine more broadly. Physicians have higher rates of burnout, depressive symptoms, and suicide risk than the general population. An estimated 300–400 physicians die by suicide in the U.S. per year.  Don't wait until a crisis point, it's ok to think of it as a quality of life issue!  Seek help if you are suffering. You may feel shame, but that's part of having depression and not because of who you are.

There are likely resources available to you locally at your own institution or in your community. If you are in crisis, you can also call the National Suicide Prevention Lifeline at 1-800-273-8255. There is no shame at all in reaching out- we need you in this world.

I'll leave everyone with a loving-kindness meditation:
May you be filled with loving kindness...
May you be held in loving kindness...
May you feel my love now...
May you accept yourself just as you are...
May you be happy...
May you know the natural joy of being alive...

Dr. Lyle Fettig is an Assistant Professor of Clinical Medicine in the Department of Medicine/Division of General Internal Medicine and Geriatrics. Dr. Fettig directs the IUSM Palliative Medicine Fellowship and works clinically with the Eskenazi Health Palliative Care Program.

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by Sujin Ann-Yi

According to the Caregiving in the US 2015 research report (PDF) conducted by the National Alliance for Caregiving (NAC) and American Association of Retired Persons (AARP), 43.5 million adults in the US have provided uncompensated care to an adult or a child in the past year. The same report found caregivers provide on average 24.4 hours per week of support to their family member. Spouses were found to provide on average 44.6 hours per week and almost 25% of caregivers provide 41 hours per week.

Caregivers refers to family members who provide ongoing continuous care, typically without any compensation, for those with serious health issues such as cancer. Family caregivers provide significant support to patients which includes but is not limited to physical, psychological, spiritual, and emotional support as well as communicating with health providers, treatment monitoring, administering drugs and medical treatments, and advocating for their loved ones (Caregiving in the U.S., 2015).

Caregiver distress results when caregivers have overwhelming demands and unmet needs, coupled with other stressors such as feeling isolated, feeling burdened, financial strains, negative emotions, and work loss. A positive correlation has been reported between cancer patients’ and their respective caregivers’ distress (Hodges, Humphries, Macfarlane, 2005). Caregivers are at risk in developing both depression and anxiety as well as consequences to their own health (Nipp, El-Jawahri, Fishbein, et al., 2016; Palos, Mendoza, Liao, et al., 2011). Caregiver distress is associated with: being female, younger age, being the spouse of patients, lower social economic status, employed, and lacking personal and social support (Kim, Given, 2008).

In the spirit of family centered care, recent attention has focused on directly identifying and providing support for caregivers in addition to patients as part of standard care. Palliative care professionals have improved symptom management and quality of life for patients and have intuitively included patient’s families and caregivers. Palliative care has been associated with improved caregiver well-being, family satisfaction, and physical and psychological symptom management for patients and caregivers. Early palliative care with newly diagnosed lung and GI cancers showed improved depression and quality of life in caregivers (El-Jawahri, Jackson, Greer, et. al., 2016).

Please join me @sujinannyi for our #hpm tweetchat to further discuss how palliative care professionals can play an instrumental role in identifying and addressing caregiver distress.

T1: Do your respective organizations currently either formally or informally assess for caregiver distress? If so, what is the process and what tools do you use if any?
T2: What services or resources are offered for caregivers at your respective organizations?
T3: What are some barriers for providing intervention and support for caregivers in your respective organizations?

What: #hpm (hospice and palliative med/care) chat on Twitter
When: Wed 10/26/2016 - 9p ET/ 6p PT
Host: Sujin Ann-Yi, PhD @sujinannyi

Follow @hpmchat and go to www.hpmchat.org for up to date info.

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using tchat.io for ease of following. You can also check out the new site dedicated to #hpm chat - www.hpmchat.org

For more on past tweetchats, see our archive here.

Sujin Ann-Yi, LMFT, PhD is a palliative clinical psychologist from MD Anderson Cancer Center and is hosting her first #hpm chat.

References

Caregiving in the U.S. 2015 (2015). Retrieved from The National Alliance for Caregiving and the AARP Public Policy Institute websites
http://www.caregiving.org/caregiving2015/
http://www.aarp.org/content/dam/aarp/ppi/2015/caregiving-in-the-united-states-2015-report-revised.pdf

El-Jawahri, A., Jackson, V.A., Greer, J.A., Pirl, W.F., Park, E.R., Back, A., Muzikansky,A., Kamdar, M., Rinadldi, S., Jacobson, J., Fishbein, J., Eusebio, J., VanDusen, H., Nipp, R.D., Ryan, D.P., Temel, J.S. (2016). Effect of early integrated palliative care on family caregivers outcomes for patients with gastrointestinal and lung cancer. Journal of Clinical Oncology, 2016 Palliative Care in Oncology Symposium, 34, 234.

Hodges, L. J., Humphris, G.M., Macfarlane, G. (2005). A meta-analytic investigation of the relationship between the psychological distress of cancer patients and their carers. Social Science & Medicine, 60, 1-12.

Kim, Y. and Given, B.A. (2008). Quality of life of family caregivers of cancer survivors. Cancer, 112, 2556-2568.

Nipp, R.D., El-Jawahri, A., Fishbein, J.N., Gallagher, E.R., Stagl, J.M., Park, E.R., Jackson, V.A., Pirl, W.F., Greer, J.A.,Temel, J.S. (2016). Factors associated with depression and anxiety symptoms in family caregivers of patients with incurable cancer. Annals of Oncology, 27, 1607-1612.

Palos, G.R., Mendoza, T.R., Liao, K.P., Anderson, K.O., Garcia-Gonzalez, A., Hahn, K., Nazario, A., Ramondetta, L.M., Valero, V., Lynch, G.R., Jibaja-Weiss, M.L., Cleeland, C.S. (2011).Caregiver symptom burden: the risk of caring for an underserviced patient with advanced cancer. Cancer, 117, 1070-1079.

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by Shannon Haliko

Case:
Mr. K is a 58-year-old male with diabetes and ischemic cardiomyopathy which contributed to end-stage heart failure necessitating circulatory support with a left ventricular assist device (LVAD) implanted one year ago. His post-operative course has been complicated with multiple admissions for infection resulting in several operative revisions and kidney injury. He was admitted with a similar presentation prompting a moment of reflection by his primary team.

Over the last year, Mr. K had declining involvement in his own care, which included poor attention to his medications and wound dressings. It was clear that Mr. K’s lack of involvement was contributing to his frequent admissions, but the root of Mr. K’s suspected apathy was unclear. The Palliative Care team was consulted to assess the patient’s goals of care.

Interviewing Mr. K was challenging. Though he was pleasant and cooperative, he was distractible. Attempts to elicit his values would take the listener on a long, circumferential and circumstantial path without a clear ending. Despite his confusing stories, he clearly explained a hope to regain his ability to perform tasks on his farm. He also succinctly described the importance of sharing his life with family, including several new grandchildren. While this information helped clarify his values and healthcare goals, the team questioned his cognitive ability. Because we were unable to distinguish between depression, apathy, and cognitive impairment, we asked for a formal psychiatry consult.

Mr. K described his mood as “down in the dumps” for the last two years; he felt his heart failure symptoms prevented him from performing even simple activities on his farm. Unfortunately, he had not noticed any improvement in his energy with LVAD implantation one year ago, but did reflect that he sustained damage to his liver and kidney. Despite prominent feelings related to his illnesses and poor functional status, he remained hopeful that he would recover. Though he provided an accurate general picture of his health state, he gave inconsistent or superficial answers to detailed inquiry about recent complications. He denied feelings of anxiety, hopelessness, guilt or suicidal thoughts and had not noticed any changes in appetite or sleep, or hallucinations. He still found interest in television shows and NASCAR racing.

On exam, he was disheveled and often violated social norms of the interview (interrupting his own storytelling to make an unrelated phone call, commenting on the TV programs currently showing). He had no abnormalities in muscle bulk, tone or movement. There was no dysmetria, tremor or gait disturbance but his Luria test (for executive motor control) was abnormal. His speech was broken into single sentence or phrase fragments with a rare moment of word searching with use of circumlocutions.

His affect was reactive, full and incongruent with his stated mood of depression. His thought content, while future oriented, was indeed impaired as noted by the Palliative Care team, with a particular focus on concrete thought processes. Memory of his own medical history was inconsistent, and his delayed recall of three objects was impaired. His inconsistencies also manifested when discussing insight for his own illness, with a tendency to over-simplify his condition or health consequences.


Discussion:
Mr. K’s exam is consistent with a mild neurocognitive disorder (NCD) with mixed features (concentration, executive function, and mild memory and language impairments). NCD is a new diagnosis found in the update of the DSM-V. This update of psychiatric diagnosis guidelines re-organizes the previous diagnoses of mild cognitive impairment (MCI) and dementia to a neurocognitive disorder (NCD) of either mild or major impairments. NCD is defined as “a change from previous level of function with noted impairment in one of the following domains: complex attention; learning or memory; language; perceptual-motor; social cognition and executive function”¹. The distinction between mild or major impairment is determined by the ability to live independently. Subtypes of NCD can be described by the dementia’s presumed etiology, for example Alzheimer’s type. The definition of NCD yields high inter-rater reliability among clinicians, but the diagnosis is too new to be sure of its prevalence. MCI, the closest approximation of mild NCD, has a prevalence of between 3-42% reported across studies of at-risk inpatients and outpatients.² The prognosis related to NCD is uncertain. Some patients with mild NCD progress to major NCD, but with others the disease is stable or may revert to normal cognition.

There are many hypotheses for the pathophysiology behind neuro-degeneration seen in NCD, including vascular deficits and inflammatory pathways, but no unifying theory has been confirmed. Effective pharmacologic treatment of NCD is currently lacking. Anticholinesterase inhibitors should be utilized only in mild to moderate Alzheimer’s dementia³, but recent guidelines to support this practice are either weak⁴ or discouraging⁵. Promising agents currently include noradrenergic and polyphenolic compounds (ginkgo biloba, wine and some vegetables). Non-pharmacologic therapies (exercise, diet, cognitive stimulation) show variable effects, have poor generalizability, or impermanent results. Other non-pharmacological treatments (cognitive behavioral therapy) have focused on neuropsychiatric symptoms (mood disturbance, apathy, agitation and psychosis) and show improvement in symptoms but not underlying cognitive impairments.⁶ Pharmacologic treatment of the same symptoms has not been found beneficial and may be associated with a more rapid decline⁷.
Mr. K has several risk factors for NCD (heart failure with its metabolic and perfusion derangements, atherosclerosis, bypass surgery and the LVAD itself)⁸. Up to 60% of patients demonstrate some level of cognitive deficit both before and after implantation.⁹ Additionally, depression is present in 20-30% of LVAD patients^10,11, and is often missed, misdiagnosed12 or even confused with cognitive impairment.

Given that depression and NCD often co-occur, it is important to routinely screen patients for both. The PHQ-2, a rapid two question screen for depression that has a sensitively of 97% and specificity of 96%.13 An optimal screening test for NCD remains to be determined, but the mini-Kingston standardized cognitive assessment-revised (mini-KSCAr) yields the highest sensitivity and specificity studied to date. (Detection of mild NCD: sensitivity 81% and specificity 85%; Detection of major NCD: sensitivity 100% specificity 91%. Comparators include Mini-Mental State Examination (MMSE)*, the clock drawing test (CDT), and Montreal Cognitive Assessment (MoCA))14. Identification of complex or concurrent disorders would likely benefit from referral to a specialist for standardized neurocognitive testing and treatment.

*MMSE is copyrighted - see GeriPal for more - Ed.

Case Resolution:
At examination, Mr. K agreed to pursue rehabilitation on discharge in a care facility rather than his home. He clearly described the risk, benefits and alternatives to the choice supporting our assessment of capacity for this decision. However, we expect Mr. K’s capacity will be limited for more complex decisions, and the primary team was alerted that appropriate evaluation of his capacity should be undertaken for each future healthcare decision.

References:
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).; 2013. doi:10.1176/appi.books.9780890425596.744053.

2. Panza F, D’Introno A, Colacicco AM, et al. Current epidemiology of mild cognitive impairment and other predementia syndromes. Am J Geriatr Psychiatry. 2005;13(8):633-644. doi:10.1176/appi.ajgp.13.8.633.

3. Dementia | 1-recommendations | Guidance and guidelines | NICE. http://www.nice.org.uk/guidance/cg42/chapter/1-recommendations#interventions-for-cognitive-symptoms-and-maintenance-of-function-for-people-with-dementia. Accessed June 3, 2015.

4. Doody RS, Stevens JC, Beck C, et al. Practice parameter: Management of dementia (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56(9):1154-1166. doi:10.1212/WNL.56.9.1154.

5. Daviglus ML, Bell CC, Berrettini W, et al. NIH state-of-the-science conference statement: Preventing Alzheimer’s disease and cognitive decline. NIH Consens State Sci Statements. 2010;27(4):1-30. Accessed June 1, 2015.

6. Sachs-Ericsson N, Blazer DG. The new DSM-5 diagnosis of mild neurocognitive disorder and its relation to research in mild cognitive impairment. Aging Ment Health. 2015;19(1):2-12. doi:10.1080/13607863.2014.920303.

7. Rosenberg PB, Mielke MM, Han D, et al. The association of psychotropic medication use with the cognitive, functional, and neuropsychiatric trajectory of Alzheimer’s disease. Int J Geriatr Psychiatry. 2012;27(12):1248-1257. doi:10.1002/gps.3769.

8. Cannon JA, McMurray JJ, Quinn TJ. “Hearts and minds”: association, causation and implication of cognitive impairment in heart failure. Alzheimers Res Ther. 2015;7(1):22. doi:10.1186/s13195-015-0106-5.

9. Petrucci RJ, Truesdell KC, Carter A, et al. Cognitive dysfunction in advanced heart failure and prospective cardiac assist device patients. Ann Thorac Surg. 2006;81(5):1738-1744. doi:10.1016/j.athoracsur.2005.12.010.

10. Baba A, Hirata G, Yokoyama F, et al. Psychiatric problems of heart transplant candidates with left ventricular assist devices. J Artif Organs. 2006;9(4):203-208. doi:10.1007/s10047-006-0353-0.

11. Rutledge T, Reis VA, Linke SE, Greenberg BH, Mills PJ. Depression in heart failure a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes. J Am Coll Cardiol. 2006;48(8):1527-1537. doi:10.1016/j.jacc.2006.06.055.

12. Boland RJ, Diaz S, Lamdan RM, Ramchandani D, McCartney JR. Overdiagnosis of depression in the general hospital. Gen Hosp Psychiatry. 1996;18(1):28-35. doi:10.1016/0163-8343(95)00089-5.

13. Maurer DM. Screening for depression. Am Fam Physician. 2012;85(2):139-144. http://www.ncbi.nlm.nih.gov/pubmed/22335214. Accessed April 22, 2015.

14. Liew TM, Feng L, Gao Q, Ng TP, Yap P. Diagnostic utility of Montreal Cognitive Assessment in the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders: major and mild neurocognitive disorders. J Am Med Dir Assoc. 2015;16(2):144-148. doi:10.1016/j.jamda.2014.07.021.

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by Christian Sinclair

One of the classic benefits touted by any clinician when describing hospice is bereavement support for the family for 12 months after the death*. What bereavement support looks like depends on the hospice agency. Some are large enough to have departments of specially trained bereavement counselors, and some have a social worker who makes it part of their role.  What they offer may range from phone, email or letter correspondence to individual and group therapy sessions depending on the complexity of the case.  What I have always found interesting is this is not considered part of any insurance or Medicare/Medicaid benefit for someone who dies without hospice in a hospital or nursing home. Anyways, back to hospice and bereavement support...

One of the challenges with studying what hospice does is some of the fundamental parts of it are considered standard of care without ever being tested or analyzed**. Prognostication as eligibility criteria? Yeah, that makes sense for a benefit for dying people, except the science of prognosis has not kept up with the demands of the system for ever-increasing accuracy. Interdisciplinary care required? Sure, that makes sense, but how do we know which team members really work best for each patient, we've never tested it to look for improvements. Bereavement support for families - well now we have a study which may help us understand the impact of this lauded benefit.

Ornstein et al published "Association between Hospice Use and Depressive Symptoms in Surviving Spouses" in JAMA Internal Medicine in May 2015 looked at over 1,000 widowed spouses from the Health and Retirement Study (HRS) data set. 30 percent of the patient-spouse dyads had hospice experience for more than 3 days prior to death. They compared depression scale scores between spouses who had hospice experience and those who had none (to be accurate none, or 1-2 days of hospice). 52% of widowed spouses had more depressive symptoms over time no matter the exposure to hospice. In looking at improvement in depression scale scores over time, more widowed spouses had improvement if they had hospice compared to those who did not, although it was not significantly statistic (28% vs 22% (p=.06) of all spouses; 27% vs 21% (p=.10) for spouses identified as the primary caregiver.)

The most favorable finding for hospice use to help depressive symptoms in surviving spouses was not reported in the abstract results. Of the people who were interviewed (as part of the HRS study), 38% of spouses with hospice experience had improved depressive symptoms, a statistically significant (p=.01) improvement over those who had no hospice exposure (26%). For any of you odds ratio fans, that came out to an OR of 2.15!

Most media reports gave pretty favorable headlines to this study, which I think is close enough for public knowledge and understanding. Can you use this research in your hospice 101 presentation? Sure. Can you make some nifty graphics to share online? Sure. Can we use this information to help us better structure interventions for the bereaved family? Maybe.

First, while this is a strong study in terms of numbers, matching interventions with controls, and being somewhat objective to the intervention of hospice***, the study was unable to tell what bereavement interventions occurred and therefore it is difficult to tell what interventions are helpful and which have no effect or potentially harm. So this is not a full ringing endorsement of bereavement services, but rather hospice use.

As mentioned earlier on close examination it is not truly hospice for 3 or more days vs no hospice. The true selection criteria were hospice for 3 or more days vs 0,1,or 2 days of hospice. There isn't a solid explanation in the article for this awkward choice of group selection, and the only place it is mentioned is in the footnotes of Table 4. The authors rightfully note hospice enrollment for even 1 or 2 allows for access to bereavement services, so theoretically we are not testing two different groups.

So, overall this study (despite the confounding selection choice) does help demonstrate hospice use possibly leads to better depressive symptoms, but we need to look to other studies for a more accurate depiction of the impact of bereavement services on spousal and family coping over time. This is an area of study which would benefit from a good mix of qualitative and quantitative research,

Christian Sinclair, MD, FAAHPM is a palliative care doctor at University of Kansas Medical Center, and has been a hospice medical director for 11 years. He has witnessed the good works of bereavement counselors. 

*The regulations say up to a year, but nearly every hospice offers about 13 months of support to get people past the anniversary of the death.

** You know what else became standard of care without being tested or analyzed? PEG tubes in advanced cognitive impairment. It just 'made sense.' Only recently have we started to get the evidence published that it does more harm than good.

***  The depression scale was part of routine screening, not some asking you to enroll in a study of how hospice affects depressive symptoms in surviving spouses.

Ornstein KA, Aldridge MD, Garrido MM, Gorges R, Meier DE, & Kelley AS (2015). Association Between Hospice Use and Depressive Symptoms in Surviving Spouses. JAMA Internal Medicine PMID: 26009859

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by Kristina Newport, MD

As we care for patients with serious illness, we frequently encounter depressed mood. Multiple studies have shown depression independently contributes to morbidity and mortality, and yet most of us do not systematically screen for it. This is again illustrated in Lloyd-Williams’ et. al recent study of 629 patients with advanced cancer attending palliative care day centers in England. Patients in this study identified as moderately to severely depressed on the PHQ-9 died three weeks sooner than those with no or only mild depression. A similar result was identified in patients who reported consideration of self-harm. Notably, in the majority of cases, involved health care providers did not know of their patient’s self-harm thoughts.

I don’t think this is unique to palliative care centers in England. The complexity of differentiating depression from symptoms of serious illness interferes with diagnosis. (See Fast Fact #7 - Depression in Advanced Cancer ). We, as a field, have not yet decided upon a simple tool that can be used to screen for depression or standardization of when it should be completed. (Although some helpful suggestions are found on Fast Fact 146 - Screening for Depression in Palliative Care ). Also, it can be a helpless feeling to identify a depressed patient when their treatment options for the depression may be very limited due to short prognosis and multiple, irreversible, contributing factors.

So while there is no simple answer to this challenge, I tend to think that we can do better with our current tools. Any effort is better than no effort, right?

In our community cancer institute, we recently began standard administration of the NCCN Distress Thermometer with all new patients. Any patients who had a score of 4 or greater were referred to appropriate support services. Like the Lloyd-Williams’ study, we uncovered distress which the health care team had not previously identified, resulting in a 47% increase in referrals to support services, the majority of which were related to “emotional problems”. While studies to validate the NCCN Distress Thermometer as a depression screening tool have had conflicting results, I can’t help but think that the 745 more people who were referred for increased assessment and assistance would not care about sensitivity and specificity. I can’t prove it yet, but maybe some of them had improvement in their mood and maybe they even lived a day or two longer as a result. I’m just glad that there is a tool out there that is palatable to oncology practices so they are willing to use it, in a standardized way.

Our next steps are to identify what to do with the information we find. What happens when we do refer patients? Do depressed patients live longer if they get treatment? With estimates of 15-50% of palliative care patients experiencing depression, we should figure this out.

But first, we have to ask them about it.

Kristina Newport MD (@kbnewport) practices Hospice and Palliative Medicine in Lancaster, PA where she also spends time running after her children, 4 and 6.

Lloyd-Williams M, Payne S, Reeve J, Dona RK (2014). Thoughts of self-harm and depression as prognostic factors in palliative care patients. Journal of Affective Disorders, 166, 324-9 PMID: 25012448



Image credit: "Depression Ahead" by Christian Sinclair for Pallimed, Photo Credit: "Sad Eggs" by Christian Sinclair

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In addition to my prior post, a handful of additional articles from recent Journal of Clinical Oncology issues:

1.
JCO has a paper on video-assisted advance care planning for cancer patients (see here for a prior post; see here for lots more). This study involved outpatients with aggressive brain cancers (n=50, mean age in 50s, over 3/4 rated their current health status as good or better, about 50% reported they would not want CPR at baseline) who were randomly assigned to either a verbal description of advanced cancer and different treatment options or that plus a short video showing the different treatment options in real life. Advanced cancer "was defined to participants as being "very sick" in a situation where they may or may not be able to speak for themselves" (as far as I can tell no discussion of time-based prognosis or inevitability of death). The treatment options given were 'comfort care,' 'basic medical care' (essentially life-prolonging treatments short of ICU-level care), and 'life-prolonging care' (everything including ICU level care, CPR, mechanical ventilation, etc.).

The video (no sample available unfortunately**) is described as the following:

In the video, life-prolonging care images included: an intensive care unit with a ventilated patient being tended to by respiratory therapists; a simulated code with clinicians illustrating CPR and intubation; and various intravenous medications including vasopressors administered through a venous catheter. Visual images to depict basic medical care included: a patient getting antibiotics via a peripheral intravenous catheter; scenes from a typical medical ward service; and a patient wearing a nasal cannula. The video depiction of comfort care included: a patient on home hospice care receiving pain medications; a patient with a nasal cannula comfortable on oxygen at home; and a medical attendant assisting a patient with self-care.

There were marked differences in levels of care that the patients said they'd wish for themselves: for the verbal-only patients 22% said they'd prefer comfort care, 52% basic care, and 26% full life prolonging care. For the video patients, 91% said they'd prefer comfort care, 4% basic, and one uncertain. More patients changed their mind about CPR in the video group as well (48% declined it at baseline, wheras 91% declined it after the video). (Yes this means the patient who wanted basic care also said, presumably, they wanted CPR.)

**Angelo Volandes, the senior author of the article, has a website with his videos, but they are behind what I think is a paywall. I've seen one of his early videos on advanced dementia and it is very reasonable and well-balanced.

2.
There is an updated clinical practice guideline on chemotherapy for stage IV non-small cell lung cancer (free full-text here). It's an interesting read for, in particular, beginning fellows who need some sort of introduction to the anti-neoplastic approach to this cancer we see all too-commonly in palliative care practice settings. Note that this is a CPB about chemotherapy for NSCLC, and basically ignores other aspects of care. It does represent a concise summary of the benefits (such as they are) of newer, targeted agents (erlotinib, etc.). On the ASCO website there is an unabridged version of the recommendations (pdf here) which ends with a few pages on discussion chemotherapy with patients, including how to discuss risks and benefits, which also specifically mentions the problems with discussing median survival data (using the infamous bevacizumab example - which is basically that most patients got no benefit, but the percent who did got a lot of benefit/life-prolongation, meaning that the median survival for the study population increased by 2 months but that is an incredibly poor way of actually communicating to patients what they can expect).

Although most clinical trials report the median survival time of the control arm and the experimental arm, it is the consensus of the Update Committee that quoting comparative median survival times to a patient can be misleading. For example, a patient who is considering whether to take bevacizumab with carboplatin/paclitaxel may learn that bevacizumab improves median survival by 2 months (from 10.3 to 12.3 months). A common misconception of an individual patient is that taking bevacizumab will allow him or her to live 2 months longer. On the contrary, some patients experience treatment- related death related to bevacizumab, whereas other patients may live many months longer as a result of the beneficial effects of the drug. Patients who request statistics must be reminded that these numbers are based on the experience of thousands of patients, with median survival time representing the experience of the majority of patients. Physicians can explain what median survival time means—that is, half of the patients live longer, and half die sooner. However, there are patients who live much longer or much shorter than the median survival time.

3.
There's a review of depression screening/diagnosis instruments in geriatric cancer patients. Believe it or not, 'there are insufficient data to...' etc. etc. It's a tidy overview however of many of the most common scales, and how they've been evaluated. Anyone out there using a specific scale for older cancer patients?

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There's a look at emotional distress experienced by bereaved family members of patients who died in Japanese palliative care units. There's an interesting finding that overhearing conversations between medical staff outside the room at the time of the patient's death was one of the strongest predictors of 'high level distress' in bereaved family members. I'm curious as to why they chose to even ask that question (they describe how their questionnaire was created but it's not clear where individual questions came from).

5.
There is an exploratory study of parents of children with cancer who were likely to die and nearing death (the parents had made a decision for either enrollment in a phase I study, a DNR order, and or initiated a plan for end of life care) - looking into how these parents conceptualized being a 'good parent' as they made these decisions.

6.
And finally, a few supportive care articles I'll mention in passing: one on case management (and related) programs for symptom surveillance (didn't do much); another on a home nursing program to monitor symptoms for patients on oral chemotherapy which seemed to be helpful; and another on the frequency of insomnia in cancer patients on therapy.

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We don't typically endorse products, webinars, conferences, job listings or much of anything else here at Pallimed, but when we do know about a resource that can impact your everyday palliative care work we want you to know about it.

Such is the case with the Hospice and Palliative Care Formulary USA ($75/$65 for AAHPM members) now being published in the 2nd edition from the founders of PalliativeDrugs.com, Robert Twycross and Andrew Wilcox.  I wanted to write in more detail about why I access this book more often than any other palliative care book since I just ordered 6 of them for the teams I work with.

The first edition was printed in 2006 and my copy is dog-eared from carrying it around, showing it to hospice team members, lending out to fellows, residents, nurse case managers, copying a page for a pharmacist, referencing it for numerous presentations, etc.

Any other medication reference book (nursing or medical) has so many warnings/misinformation about the medications we commonly prescribe and administer in palliative care settings that general pharmaceutical reference books are essentially useless.  I often find nurses and physician trainees who read some of those freebie/cheap Nursing/Medical Drug Guides begin to contradict basic palliative care understanding.

For some poor examples from referencing other drug guides...

"We can't give more than 5mg of morphine...the book says she might have respiratory depression."
"Octreotide? I don't see anything about small bowel obstruction but it does treat a VIPoma."
"Constipation? How about we try more fiber?"

Here is why I find HPCF-USA so useful:

• Detailed palliative care oriented medication information
• Extremely well referenced drug monographs - Awesome for talks
  
• FDA Approved indications clearly listed as well as likely palliative care uses
• Cost information (in actual dollars not some crappy $-$$$$ scale)
• Candid discussion about alternate route dosing/administration for many medications
• Detailed pharmacologic information in tables to compare different meds within a class
• A treatment monograph on 'Oxygen'  - When was the last time you read 4 detailed pages about the ins and outs of oxygen therapy? Wonderful!
• Monographs on related but not primary palliative care meds - A whole section on antifibrinolytic drugs! Bronchodilators! Diabetes meds! Potassium! Magnesium!  You get the point.
  
• Super helpful chapters covering meds in a meta-approach - Opioids and Fitness to Drive; Continuous Subcutaneous Infusions; Drugs Administered via Enteral Tubes
• Designed for use in the USA (as opposed to the UK version with UK only meds like diamorphine)

Here are the things I wish were included/changed/fixed:

• Better binding - it seems to be fragile after a lot of use, and my book gets used
• Not much info on fentanyl IV compared to transdermal and buccal routes
• The 2nd edition cover is a little boring compared to the Red, White and Poppy motif on the 1st edition.
  

If you are an AAHPM member you can get a 20% discount via the AAHPM website.  Also you could access it online via PalliativeDrugs.com but I find the book very useful and a rapid access to have at my desk.  And now with the extra copies I purchased it will be at almost all of my clinical sites.

Do you use HPCF-USA?  Tell me what you like best about it.

Disclaimer: No kickbacks given to any Pallimed author because of this post.  We did give away a HPCF-USA free edition back in 2007 for our winter contest.  And it was pretty cool when I met Robert Twycross in Austin and he recognized my name from Pallimed and told me he was a big fan of Pallimed.  But that is not why I wrote this.  Obviously I think this is a super awesome book.

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Tom recently posted on another major publication from the Coping With Cancer Study. Psycho-Oncology, a couple months back, also published a CWC analysis that I overlooked until recently - looking into whether rates of psychological illness increase as cancer patients approach death.

(See prior posts for descriptions of how the CWCS was done). In this analysis of ~280 patients, they compared baseline assessments (of, among other thing, psychiatric symptoms) across groups of patients by time to death (groups were divided into months to death from the initial assessment, ie: 1-2-3-4-5-6-6+ months). This way, for instance, psychiatric morbidity could be compared between those patients who ended up dying within a couple months to those who lived 6 or more. This analysis is cross-sectional: patients weren't followed from the initial assessment with repeated assessments until death to see if mental illness/symptoms increased - instead those who 'happened' to die rapidly were compared with those who didn't.

They found that rates of mental illness (major depression, PTSD, generalized anxiety disorder, panic disorder) were ~10% across all groups, regardless of time-to-death. Existential distress did seem to be increased in those closer to death, along with physical symptoms; but not actual rates of psychiatric illness. They suggest that it is perhaps physical limitations and symptoms which cause the existential distress, although curiously not 'diagnosable' psychiatric illness.

This is good news overall of course, and should lead further support to the idea that depression is not 'normal' in (even advanced) cancer - and should not be accepted as such (as normal and therefore not worthy of intervention). Concluding 'Well I'd be depressed too if this was happening to me' is just wrong: you'd likely have episodes of sadness, grief, loss, longing but not a pervasive disturbance of mood and thought.

Psycho-Oncology also has a review on existential concerns in cancer patients. It's a quick summary of the scope and nature of the research about this; not particularly practical/clinically oriented but an excellent summary/starting point for those interesting in the research (good one for the teaching file, particularly for fellows).

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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.

M. 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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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).

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This is the Journal of Clinical Oncology iteration of Magnesium Citrate.  

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Lancet this week presents a randomized controlled trial of a nurse-delivered educational intervention for depression in cancer patients. This was a single-center Scottish study involving 200 outpatients (mean age 56 years; expected prognosis had to be greater than 6 months for inclusion; a plurality of subjects had breast cancer) who were randomized to usual care or usual care plus the intervention. Outpatients at this center were screened with the Hospital Anxiety and Depression Scale & if this was positive were diagnosed with depression using DSM-IV criteria (using the DSM structured clinical interview materials). The intervention was delivered by 3 study nurses, none of whom had training in psychology, and involved up to 10 one-on-one sessions over 3 months (the mean was 7 sessions). The intervention is described here:

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1)
The Archives of Internal Medicine published a significant study regarding antibiotic use in the elderly authored by Dr. D'Agata and Dr. Mitchell from Beth Israel Deaconess. In their article, they review the antibiotic usage in 214 (mostly white, female and over 80yo) nursing home residents with advanced dementia, defined as very severe cognitive impairment, minimal communication, dependent eating/toileting, bowel/bladder incontinence, and inability to walk. This study was part of a larger study called CASCADE (Choices, Attitudes and Strategies for Care of Advanced Dementia at the End-of-Life). (Take that cardiologists with all your fancy acronyms!)

The mean number of antibiotic courses per resident was 4 (range 1-20!), and about 66% of the 214 received at least one course with the majority of residents receiving a course within the 14 days prior to death, indicating the effectiveness of antibiotics to cure an infection in advanced dementia may be limited. This multi-center prospective cohort is probably the best study to demonstrate the limited efficacy of antibiotics in patients with advanced dementia.

The study did not have data representing success of treatment for each course, which makes hampers clinical relevance. If we had information that indicated say 80% of the UTI's were cured, but only 35% of respiratory infections improved or similar info, we could have more informed discussions with staff and family. Also this article does not have information on symptom improvement, since antibiotics may have improved symptoms (although data in elderly says this is not a major effect), but that would be difficult to get workable objective data from someone who by inclusion criteria cannot communicate.

Despite this information, one cannot conclusively make an across the board declaration that patients with advanced dementia should never get antibiotics. We don't yet know what the outcomes might be for those that had antibiotics withheld. There is a general understanding that fever and likely infections are a common pathway towards death for advanced dementia patients. The optimal strategy is not yet clear, and these issues must be decided on an individual basis with open discussions of goals of care. But this study may help nursing home staff, and hospice and palliative medicine staff make more judicious use of a minimally efficacious treatment, that as a secondary gain could potentially help public health by decreasing antibiotic resistance in the community. I would imagine this second point is a bit more challenging to ethically justify. Autonomy versus Distributive Justice...en garde!

Interestingly the CDC is debating on how to advocate influenza immunization of all school age children to protect the children, but also to decrease influenza deaths/infections in the older community. The CDC are not necessarily advocating we "treat the children to save the elderly." So it is interesting this Archives of Internal Medicine study could be spun as "Don't treat the elderly to save the children." I realize I am making broad generalizations, but it is interesting the eerie similarities between the two circumstances. The editorial for this article is highly recommended as well.

(Thanks to Pallimed reader Maria F for the tip!)

D'Agata, E., Mitchell, S.L. (2008). Patterns of Antimicrobial Use Among Nursing Home Residents With Advanced Dementia. Archives of Internal Medicine, 168(4), 357-362. DOI: 10.1001/archinternmed.2007.104

I have had so many things crossing my desk that I have wanted to share, that I have to clear some of these out.

For our chaplain readers, you may be interested in the recent Religious Landscape Survey by the Pew Forum on Religion and Public Life. The site has some good demographic maps to look at the different faith communities in the US and by states. The full report is here. The media's take on this has been focused on how people change religions more often.

The British Medical Journal recently published a clinical review on treatment of adult depression. Dr. Shock (a blogger) reviews it nicely. Obviously the article is not focused on palliative medicine, but a good general background on current views on depression management (and not just pharmacological management). But before you prescribe that Prozac, a recent study (free pdf) in PLoS Medicine suggests that antidepressants may be no better than placebo. James Hrynyshyn at Island of Doubt has a nice blog post summarizing the study and the drug-placebo controversy.

Thomas LeBlanc and Amy Abernathy (of PC-FACS) explore research in hospice patients in an ethics forum for American Medical News. A good conversational review on a desperately needed area.

And finally with the recent movie "The Bucket List" about making a list of things to do before you die comes this very helpful blog post about priorities in life and how to 'manage' your bucket list.

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1)
If you're going to the AAHPM conference in Tampa, the '2nd Annual Pallimed Happy Hour' will be at Backjack's, Friday February 1st at 7:30PM until at least 8:30PM, but longer if someone buys Christian drinks. Map here - note it is just a short, tree-lined bridge south of the convention center (601 S Harbour Island Blvd - Backjack's is the bar associated with a restaruant - Jackson's Bistro). Tom unfortunately can't make it (we'll miss you Tom) but Christian and I will be there. It will be simple, and casual, and done for mostly selfish reasons: we love to meet people who are part of the community reading this blog. If you want to come to give us a piece of your mind - feel free to - but remember, I'm sure whatever we said that annoyed you was written by Christian or Tom, and not me.

I will also be found at the Job Fair Thursday afternoon, recruiting academic palliative care physicians for openings here at the Medical College of Wisconsin. It's a great place to practice and teach palliative medicine, and if you're interested and aren't going to be at the Job Fair feel free to drop me an email. I'll be the one sitting under a banner depicting Milwaukee's most famous architectural landmark, the Calatrava addition to the Milwaukee Art Museum (featured in Futurama). Actually, I probably won't be under such a banner, but I figured I'd use the opportunity to 'reprent the 414' as a place which has more to offer than beer-n-brats, and which is a decent place to live (in addition to being a superb place to practice palliative care).

(Christian and Tom, this earns you one free shameless plug on Pallimed for any local program or project or job opportunity of your choosing.)

2)
The latest JCO presents research about newly diagnosed lung cancer patients' satisfaction with and recall of their doctors' communication about their diagnosis. It involved prospectively interviewing ~70 patients (all Swiss, mean age 68 years, about half with advanced disease at diagnosis whose treatment goals were non-curative) within 3 days of being told they had lung cancer. The study looked at what they recalled about their diagnostic disclosure (type of cancer and stage), what treatment was planned, their understanding of the goal of their treatment (curative vs 'palliative'), and their satisfaction with their discussions with their physicians. The physicians involved were a mix of internists and pulmonologists - nearly half were internal medicine residents.

There was good recall overall for diagnosis (90% had at least partial congruence with their physicians about the diagnosis), and planned treatment (85% had some congruence). However, can you guess what the congruence for treatment goals was? Yes, much worse: 56% of the patients who were being recommended 'palliative' treatment thought it was curative, 42% being offered curative therapy thought it was 'palliative' (this difference didn't achieve statistical significance; there is no mention in the study of any power calculations). Satisfaction with discussions of treatment goal was low (39%) compared with satisfaction with other aspects of communication (~75%) and was not associated with actual treatment goal.

Without further commenting on the remarkable finding that 10% of these patients, fresh from a diagnostic disclosure, were not able to tell the researchers that they have cancer, this is further supportive evidence that many cancer patients are confused about what the point of their treatment is. 56% not understanding is a lot, and thankfully more than the range usually found in cancer patients actually receiving non-curative chemotherapy (often in the 30-40% range), and I wonder if some of this difference is due to half of these patients being just a few days out from an internal medicine resident's disclosure, and had not spoken to a medical oncologist about their care (I say this reflecting on the pallor I've seen in many residents' faces when confronted with a cancer patient's requests for information about the 'big picture'). That said, while satisfaction was associated with having a pulmonologist tell you, they don't mention whether 'goal-congruence' was associated with physician specialty/training; one assumes it wasn't.

As a final note, I quoted 'palliative' treatment goals in the above discussion. This is the language used in the article, but it's language that I find confusing (to patients as well as clinicians) and have stopped using. Cytotoxic chemotherapy, aimed primarily at prolonging life (but not at cure), doesn't seem 'palliative' to me - aimed at improving quality of life/symptoms without necessarily modifying a disease's course. Cancer patients are confused enough by their treatment goals, clearly, and many of them kinda sorta know what 'palliative' means, and describing their emetogenic but life-prolonging cancer treatments 'palliative' just seems needlessly confusing. None of this is to say of course that 'palliative' can't mean life-prolonging, and I don't mean to imply a rigid 'palliative=comfort' standard (which is wrong and needlessly confusing but for other reasons), but why not use clearer terms when they're available? I tend to use terms like 'curative,' 'non-curative,' 'life-prolonging,' etc., and am curious as to what others do.

3)
NEJM has a couple articles to note. First is a review on the pathophysiology underlying depression from the journal's 'mechanisms of disease' series. The article covers the biochemical mechanisms which are thought to underlie depression, and really doesn't cover much else, but it's an interesting read if you like that stuff.

Second is a look-back at the Dr. Pou case (free full-text available). Dr. Pou is the surgeon accused of euthanizing several patients during the Hurricane Katrina disaster (no formal criminal charges were brought, although civil suits are still pending). It's a thorough recounting of the allegations and different accounts of the events, but is most interesting for its more general discussion of disasters and 'reverse triage' (evacuating the healthiest and most likely to survive first) - how does one care for those left behind, and what protections are there for those clinicians left behind who no longer have the means to keep those sickest patients alive and who instead try to make sure they are comfortable? (Previous blog posts on Dr. Pou here).

4)
Chest recently published a retrospective analysis of the use of indwelling pleural cathethers for patients with recurrent, malignant chylothorax. It compares the natural histories of those who received indwelling pleural drainage catheters with those who didn't and, for what it's worth, found that those who received the catheters required fewer subsequent 'pleural interventions.'

5)
The Wisconsin Medical Journal recently published a piece about providing culturally sensitive end of life care for Latinos (free full-text here: scroll about half-way down). It's written by a Latina physician who cares for many Latino patients, and is an idiosyncratic (and I mean that in a good sense) overview of Latino end of life care and culture. There is an appendix at the end which talks about funerals and death rituals and Dia de Muertos.