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The current issue of The Gerontologist has several articles about end of life care. There's a not-so-shocking article surveying bereaved family members on end of life care in nursing homes finding it globally wanting (not enough staff, physicians inaccessible, hospice referrals late, etc.), a qualitative study interviewing nursing home residents about how they make decisions about advanced directives, and a narrative review on the current research about end of life care preferences amongst different racial & ethnic groups.
Most interesting to me was a nursing home study of people with advanced dementia (average MMSE of 4!) and agitation. The article is based on data from a trial of a psychosocial intervention for agitation & so the data about levels of agitation etc. were carefully & prospectively gathered. The current paper looks at the 32 people who died during the study and compares them to 32 survivors (apparently chosen to be matched for age and level of cognitive impairment). They found that those who died were more verbally agitated, spent less time verbally interacting with nursing staff, and were restrained more; there were no differences in deterioration of cognitive status (although an MMSE of 4 doesn't leave much room), perceived pain, or analgesic use; neuroleptic use was higher in the surviving group. Clearly not a huge amount can be taken from this--I can't quite decide if the comparison group is completely or just mostly bogus. This is a difficult group to prognosticate in so anything that's helpful is of interest; however no one's going to go amending the NHPCO hospice guidelines based on this.

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Well it's over--concluding with a humanist perspective, & unfortunately it's the worst of the lot. Perhaps some of you who watched cable access television in the US growing up remember a show called "Atheism Today" (or something similar) which was a forum for atheist leaders to self-righteously pity the foolish believing public, humorlessly discuss slights against atheists, and devise a way to re-brand themselves "Brights" without seeming like they are the sort of people who, in trying to find a way to describe themselves in contradistinction to the rest of the world, chose the term "bright." Well these same people wrote the current piece & it shows--it is full of meaningless platitudes and gripes against hospital chaplains.

Some nuggets: "Fear and sensitivity are not alien to the humanist psyche." "...every humanist is an individual forging his or her own meaning in the world...."

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The current NEJM has a brief perspectives piece (free full text) by Susan Block & Andrew Billings about their class at Harvard Medical School that links up medical students with dying patients.  Mostly the piece is a call to improve end of life training & concludes with this:
"But students and physicians, throughout their years of training, need appropriate learning opportunities and practice to address death, dying, and the human experience of medical practice. Unfortunately, the "hidden curriculum" of contemporary medicine — especially the hurried, disease-centered, impersonal, high-throughput clinical years — still tends to undermine the best intentions of students and faculty members and the best interests of patients and families. Medical schools, residencies, and continuing medical education programs can help learners and their patients by investing in expanded training in palliative care and by hiring and training faculty members who, at all stages of medical training, can model and teach these fundamental skills."
Well said.  There's also an 8 minute interview with a medical student and Susan Block about the course which is worth listening to.

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This week's J of Clinical Oncology has a few articles to note. First is a randomized & placebo controlled trial of 10 or 20mg of paroxetine to treat hot flashes (many, but not all, of whom had had breast cancer). It employed what seems to be a needlessly complicated double cross over design which lead to phenomenally complicated figures such as the one below. Edward Tufte would not approve. If anyone understands why they chose this study design let me know.

Nevertheless hot flashes did decrease in the paroxetine groups by ~40-50% & the difference was apparent within the first couple of weeks. Interestingly there were no real differences on quality of life (using several scales) between groups--people did sleep a little better with paroxetine though. 10mg was overall better tolerated (markedly less nausea than the 20mg) & preferred by the patients.
I'll also point out that besides the good folks at GlaxoSmithKline, a grant from the "Fashion Footwear Foundation/QVC Presents Shoes on Sale" people funded this study.

There's also piece about mental health problems amongst caregivers of patients with cancer. Briefly--13% of those studied probably met DSM-IV criteria for a psychiatric condition & 25% had sought some help for mental health reasons. However only 65% of those caregivers contacted participated in the study & there's no real comparison group. Also the cancer patients had to be able to give consent so presumably the caregivers of many of the sickest patients were excluded. What was most disturbing in some ways was that of those with psychiatric disorders only half of those who had sought care for their problem prior to their loved-one's cancer diagnosis had sought care after the diagnosis was made suggesting perhaps this is an easy time for these people to fall through the cracks.

Finally there was a review of acupuncture for chemo-related nausea, and a fascinating piece about presenting quality of life data to people in different graphical formats (lines vs. graphs etc.) that's a fine read.

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October's American J of Medicine has a brief report of a small blinded trial comparing IV lidocaine to placebo for cholestatic pruritis. 12 patients received 100mg IV lidocaine over 5 minutes (6 received placebo) & visual analogue scale recordings of pruritis were recorded for 7 days afterwards. Basically, there was a significant difference in itching on the 100mm scale (70mm before to 40mm afterwards on average) on days 2 and 3. There was essentially zero change in the placebo patients. Clearly the IV lidocaine had a salutary affect on itching--whether it is feasible (are people going to get q4day dosing of iv lido?), whether the magnitude of the effect is worth the cost/risk, & whether alternative agents (mexilitine) are worthwhile remain to be seen.

Also--I wanted to highlight a wonderful comment on my last post by Lyle Fettig which addressed, among other things, some of my frustration with the Lancet end of life perspectives series this way:
"Perhaps by reading these articles, one develops a broader "differential" regarding the meaning of death in individuals, regardless of their religion or lack thereof."
Click on the comment link below the post to read it in full. Thanks Lyle.

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The current BMJ has several opinion pieces about the current debate over euthanasia & physician assisted suicide (together called "assisted dying" in the BMJ).  The occasion is the recent change in BMA policy no longer opposing assisted dying & a pending debate in the House of Lords about its de-criminalization.  The many pieces in this issue address the history of the BMA and assited dying in the UK, the current debate, and present pro- and anti- opinions.  Everything from most people & doctors in the UK want it therefore we should do it to legalizing euthanasia will endanger our disabled countrymen is present here.  There does seem to be somewhat of a lumping of PAS and euthanasia here which may be appropriate to the debate in the UK although here in the US--at least amongst PAS's proponents--the distinction between the two is kept firm.  Although I can't imagine myself performing PAS I don't think it should be a criminal offence.  And while I can't at all accept the morality of euthanasia, those who argue that true terminal sedation (deliberately knocking someone out & keeping them down until they die to control advanced symptoms) is not that removed from euthanasia make a certain amount of sense, especially for those of us who believe what makes us human is our mind and the ability to relate/interact with other members of our species.  The difference, however,  is that it seems that in both the Dutch euthanasia experience & the Oregon PAS experience, most people seeking assisted dying don't do it as an escape from advanced symptoms but because they are afraid of advanced symptoms, losing control, etc (or they're frankly depressed).  This is, in a sense, a form of existential suffering, & is that then sufficient reason to comply with requests for assisted dying? 

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J of Clinical Oncology recently published a review of the management of brain metastases. It covers whole brain radiation, surgery, stereotactic radiosurgery, radiosensitizers, and future directions. As a non-oncologist I found it nicely informative & it would make good teaching material.
I found the following two sections particularly interesting:
The prognosis for patients with brain metastases is poor. Overall, median survival of brain metastases patients is about 4 months after whole-brain radiation therapy (WBRT), but it varies based on several prognostic variables. For example, in a study of 740 brain metastases patients, the actuarial 2-year survival rate was 8.1%, but it ranged from 1.7% for brain metastases patients with small-cell lung cancer to 23.9% for those with ovarian cancer. Factors that predict for better survival include good performance status, age younger than 65 years, successful control of the primary tumor, absence of extracranial metastases, favorable tumor histology, and presence of a solitary brain metastasis.
Patients with brain metastases exhibit significant neurologic and neurocognitive deficits. In a recent study of 401 brain metastases patients by Meyers et al that included careful neurocognitive testing of memory, verbal fluency, executive function, and fine motor control, 90.5% of patients were impaired in at least one neurocognitive domain at the time of diagnosis. In particular, memory, executive function, and fine motor control were affected. The degree of impairment correlated with tumor volume but not with the number of lesions, and it was an independent predictor of survival. [Here is the reference for the Meyers article: Meyers CA, Smith JA, Bezjak A, et al: Neurocognitive function and progression in patients with brain metastases treated with whole-brain radiation and motexafin gadolinium: Results of a randomized phase III trial. J Clin Oncol 22:157-165, 2004 [Abstract/Free Full Text]

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A couple of recent articles...
July's J of the American Geriatrics Society has a piece about racial differences in the US in end of life care .  It is based on interviews with decedents identified from a US death certificate database & has all the problems associated with post-mortem interviews.  Nevertheless their findings are generally in line with previously described differences between African-Americans and whites w/r/t end of life care and medical care in general.  The decedents of the African-American patients reported more communication and accessibilty problems with physicians, more problems with lack of support of support of the family, less use of advanced directives, more financial burden from the death, and more use of 911 services, respirators, and feeding tubes in the last month of life.  Interestingly, perceived symptom control was similar across groups.  African-Americans were more likely to be cared for by a family member at home in the last month of life. 
The current Lancet continues its series on end of life perspectives from different faiths with the "traditional" Christian view.  We will have to wait for the less-than-traditional Christian view before it's clear what the authors mean by "traditional."  I have to admit I love the idea of this series but am getting a little disappointed with it.  This is supremely unfair & probably stems from my desire to get some good meaty answers to make things all-A-OK when I enter the room of someone from a different culture and faith tradition from me (which is probably most rooms).  This is clearly stupid.  On the other hand, and in contradistinction to the desire expressed above, it seems to me that the differences between patients and families within a culture or tradition are often just as great as the general differences between people from different traditions and, as a palliative care consultant, you have no idea what you're walking into when you enter that patient's room to talk about death.  Anyway, I'll end with a quote from the Lancet article:  We will all need to acknowledge that our culture is rent by profound religious and moral disagreements.