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Sometimes a lot of good stuff comes our way here at Pallimed but we just don't have time to get to a full commentary but we want to bring what we feel is important issues to the readers. Here are a few digest items from the past week, that I just need to get out of my to do box:

1) Washington Post writer Rob Stein wrote an insightful article on race and end of life issues. Catch it on Washington Post while it is free (a few more days I believe). Some of the highlights of the article:

"I think we need to be very attentive to attending to suffering in our patients and do everything we can to help minimize and ameliorate it," said Richard Payne, who runs Duke University's Institute on Care at the End of Life. "African Americans and other minorities are at greater risk of not dying well."

The article brought forward a point that Drew has made a few times here lately. Death is not pretty. It is a hard, transformative experience for all of those around it because of the difficult nature of the beast. This point about what is a 'good death,' highlights that we need to be patient adovcates in this field, as much as we are patient educators. A militant hospice philosophy is bound to end of being unsuccessful because it imposes the health care professionals values on another.

2) The New York Times (now available free to anyone with a .edu email! Not me.) has yet another pro-hospice article, this time focusing on pediatric/perinatal programs.

And if I really wanted to get on a box about shortages, I would begin to complain about the shortages of pediatric palliativists (that word grows on me everytime I use it). As an adult HPM doctor, I see the pediatric patients at home for our pediatric hospice program because they deserve access and need assistance just as much. And as much as people say 'kids are different, kids are more emotionally difficult, kids are not little adults' I have to disagree. They have much more in common with adults then we ever give them credit for, and palliative care principles apply just as well in the pediatric field. Not to say there is not more to learn, but if you are afraid of dealing with children and dying, but not adults and dying, is this ageism? (Another topic for another day, and besides not the point of the great piece by the NYT.)

If you have 7 minutes (you do, trust me) watch the video on the NYT website on perinatal hospices and the families that work with them.

Thanks to Tom Q, for the tip on this one and the next one.

3) On the pediatric front, CMAJ has a personal article by a nurse about her role in helping be present with infants and children at the end of life. Very short, very poignant.

4) the impact of Terri Schivao's care is still reverberating in the run up to the '08 Presedential Election. Mitt Romney has said the government should not have intervened as they did in Florida. The article on Lifenews.com is an interesting read, given the multiple references to euthanasia, again further making this complex issue even more difficult to understand with terms used in completely different situations then understood by classic medical ethics.

More in the next day or two, my twins are calling/screaming for me.

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The US media has been hot on the article out of the Journal of Oncology Practice by Erikson yesterday about the forecasted shortage of oncologists. The study was well done and should be replicated by many disciplines, including hospice and palliative medicine, but since I don't have the time to write that article I will do a hastily written, poorly designed, non-blinded, utterly biased, uncontrolled case report of my opinion.

First looking at the JOP study (available free, so you don't have to rely on NBC news or USA Today to get your facts.), they looked at the following numbers*:

Existing Oncologists: 10,000
Annual Graduation of Fellows: 500 from 250 programs
2005 Capacity of Oncology Visits: 42 million
2020 Expected Demand of Oncology Visits: 65 million
2020 Expected Capacity of Oncology Visits: 47 million

They attribute much of the rapidly increasing demand to increased survivorship and increased incidence of cancer in a graying baby boomer population.

Well, in the hospice & palliative medicine world we already have a shortage of MD-patient interaction, but lets look closer at the numbers:

My hospice has this many doctors that do clinical visits with patients: 4
We see (optimistically and approximately) 20% of patients admitted to our hospice.
Hospices see roughly 30% of all patients who die (2.2mil non-traumatic) in the US.

So if all hospices had a single board certified physicians (they don't)
And that MD made home visits (very rare) or rounded at an inpatient hospice (kinda rare):

So we don't need to forecast a shortage, we already have one. Also with over 4,000 hospices nationwide, and with only 2,000+ board certified HPM docs, you have a pretty good chance your doctor running your hospice is not board certified.

Limitations of this crummy study include that I did not say a thing about hospital based Palliative Medicine, and a lot of people die in hospitals. Well, hopefully those docs are referring those patients to hospice so I did not want to double dip, and if they are seen by a HPM doc in the hospital and never make it to hospice that does not really bump that number up to high.

So why do I bring this up. Because I just got back from the AAHPM-led Fellowship Director's conference and it was very inspiring to be with such a great group of people who are going to teach all the future specialists in our field. I would encourage any of you who read Pallimed, and are not affiliated with any HPM Fellowship Training Program, to find your local one and ask them what you can do to help, time wise or money wise. Trust me they can use the support from and individual or your organization.

Post-script:

Also, I have nothing against oncologists. I am not trying to say their cause is frivolous, it is just that we already have a shortage and no one is making a big deal out of it. Besides some of my best friends are oncologists! Also, I am not advocating that everyone needs to see me or someone like me before they die, but we (HPM docs) should at least be available.

And if you decide to do this study in a decent way, feel free to give me some original idea credit!

*all numbers are rough for ease of understanding, look at the original article for exact numbers

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1)
The latest Clinical Pharmacology & Therapeutics has an article on the pharmcogenetics of opioids (related Pallimed post here). I have to admit my excitement for this article waned as I read it: it's incredibly basic-science heavy and difficult for the average clinician (at least me) to read (another article in this issue about methylphenidate and alcohol caught my eye although I realized I couldn't even make it through its abstract before going cross-eyed). In retrospect I don't know what I was expecting. I find the topic interesting, I guess, because it offers a promise of "hard" answers to many of the vagaries and seemingly-random hazards of my clinical practice; this, however, is currently wishful thinking on my part.... Anyway, for those of you who share my curiosity about this topic this review is an exhaustive, albeit exhausting, reference. The authors' penultimate words summed things up nicely:

"Many of the studies described in this review have increased our knowledge and understanding of how pharmacogenomics can influence the response (efficacy, toxicity, pharmacokinetics, metabolism, transport) of the opioid drugs and contribute to intersubject and interpatient variability. It is another matter for this to be translated into clinical practice."

2)
A recent Cancer had an article on insurance, religiosity, and palliative care in urban African-American and Latino patients. This was an incredibly complex (for me, too complex) study involving patients receiving community-based palliative care which looked at an interesting outcome: pain medication "stress." That is--not access to pain meds or happiness with pain control but levels of 'stress' and 'hope' surrounding their pain (meds). How they actually measured this--what this really meant--remained obscure to me after reading the article--perhaps explaining my initial reaction above. One of their major findings is that a lack of insurance predicted less 'stress' about pain meds. Huh? I'm coming off a week-long illness and perhaps my brain remains addled, but I remain perplexed. Perhaps I need a guide.

3)
BMJ, in an article related to one I recently blogged, has a nice piece about providing appropriate/timely services for those with advanced/chronic or terminal illnesses. It's mostly a concise and incredibly valuable summary of what I (lazily and unfairly to all those others who have helped develop it) call the Joanne Lynn model. What's nice is to see this discussion in a widely read general journal like BMJ. What is discussed is true, society-wide "advance care planning." Some choicer quotes:

"Most people believe their lives will be relatively healthy, punctuated by episodes of illness that last no more than a few weeks. On the rare occasions that we think about dying, we imagine short and overwhelming illness in old age. Healthcare systems are designed as if disability and ill health were aberrations, rather than a phase that lasts months or years near the end of our lives, despite the contrary evidence all around us."

"Although hospice programmes have been an important and instructive initial response, they do not meet the needs of most patients who are sick enough to die. A minority of people who die with chronic conditions use hospices, and then only for an average of a few weeks. In the US, enrolling in a hospice requires acknowledging a prognosis of "less than six months" and forgoing "curative" treatments. The inability of doctors to prognosticate with precision and the reticence of patients and doctors to accept these conditions restrict the use of hospice services. This has led to the conclusion, in the US and in the United Kingdom, that "end of life care" should encompass all people sick enough to die soon, even though some will live in fragile health for some years."

They go on to describe programs developed to care for people, in ways that focuses on quality of life, staying at home, etc., who are experiencing different illness trajectories nearing the end of life.

4)
The NIH & Robert Wood Johnson Foundation (& affiliated organizations) are releasing a variety of media & publications (including an HBO documentary) on addiction with an eye, it seems, to improving public awareness and rates of treatment. The tone of the project seems to be, very much, one of "addiction is a brain disease that can be treated" (a quote from the promotional material). True--although that may imply to the casual observer that it can be easily & successfully treated & while that's better than suggesting those with addiction problems are moral failures it may end up implying that those who get 'brain treatment' and still aren't 'cured' are nevertheless in some way failures. News releases here (NIH), here (RWJF), and here (NIDA/NIH).

Thanks as always to Tom Quinn for letting us know about this.

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Neurology has a randomized, placebo-controlled, double-blind trial of smoked marijuana/cannabis for painful HIV-associated peripheral neuropathy. The study involved 50 people with HIV who had at least 3/10 pain from their neuropathy. They were randomized to a standardized marijuana cigarette or a placebo joint (marijuana with the THC extracted out): for those of you who follow these things the cigarettes were an average of 0.9oz and each contained 3.56% delta-9-tetrahydrocannabinol (delta-9-THC)--I think they were provided by the US government. Subjects smoked one cigarette three times daily for 5 days in an inpatient research setting; they were subject to the usual pain research tortures ("long thermal stimulation" etc.). Thankfully though the primary outcome was straightforward: subjects' rating of average pain for the preceding 24h on a 0-100mm visual analog scale. Intention to treat analysis was not used, but there were equal drop-outs in each group after randomization (2 each; 50 people completed the study).

Average age was ~50, most were male, ~35% were African-American, baseline pain scores were ~5/10, and almost all subjects were current cannabis users (they were requested to abstain prior to the research). The study's primary outcome favored marijuana: 52% of marijuana subjects vs. 24% of placebo subjects had at least a 30% reduction in mean pain scores (median reduction was 34% in the marijuana group vs. 17% in the placebo group). The number-needed-to-treat for a 30% pain reduction was 3.6. If 30% doesn't sound like much to you this is actually a really good, positive finding in the world of pharmacologic treatments for neuropathic pain: most trials that show any benefit show in at roughly this magnitude. Cannabis looked good in the experimental pain model part of the trial as well.

So this is some good, real-patient evidence furthering the finding that cannabis/THC is an effective analgesic. The trial was short unfortunately, but in order to control everything this was perhaps necessary (the researchers actually weighed the cigarettes after they were smoked to, I guess, ensure that the subject actually got the THC). The big problem with this is its generalizability. These patients were regular marijuana smokers--they were self-selected to 1) be able to tolerate the side effects, and 2) to perceive benefit--of whatever nature--from marijuana's CNS effects. Even with prescription forms of THC, the CNS/psychotomimetic side effects are often dose-limiting, particularly for older, frail patients. The next study should be using similar quantities of prescription THC for people over 50 years old with painful diabetic peripheral neuropathy who don't smoke marijuana at baseline--good results from that might be practice changing.

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Slate's Medical Examiner column has a recent post on "Why doctors are bad at mortality" by Kent Sepkowitz (a physician) (Slate articles are available for free). It's a provocative essay and worth a read. (It's is somewhat of a book review of the books Final Exam by Pauline Chen, and The Lonely Patient by Michael Stein.)

Sepkowitz's major thesis seems to be that doctors are bad at death because it's human nature and therefore it's ok to flee from the deathbed. He makes some remarkable claims:

"In fact, doctors aren't bad at handling the details of dying. We know how to ease pain, promote comfort, and arrange the medical particulars. But we are disasters when it comes to death itself, just like the rest of the human species.... I admire Chen's and Stein's pep-club optimism, but they might have integrated Ernest Becker's seminal Denial of Death into their discussions. Becker's basic point is that all of human behavior can be traced to our inability to accept our own mortality. Cowards that we are, we not only refuse to consider our own inevitable death, but our patients', too: We duck the tough discussions, flinch and flutter and order another test, and finally leave it to a (usually much younger) colleague to sit down with the family. We don't slink away because we are bad people; we slink away because we are people."

I choked on my bagel when I read the first two sentences which seem patently false, based on decades of good documentation of bad pain & comfort mangement at the end of life in the US. That aside, he uses this premise to make this closing argument:

"I agree with Nuland that doctors' failure to deal well with their patients' deaths is not a bad habit that can be corrected by medical-school remediation. Doctors and patients would be better served if we stopped sophomorically pursuing the "good death" reassuringly reducing the end of life to another commodity subject to adjustment and negotiation. Instead, we should do what we can to make the dying and those who survive a tiny bit more comfortable when the time comes."

I've blogged before about my disdain for the (at least rhetorical) consumerization of dying and death ("It's all about choice!") that accompanies some discussions of dying & palliative care, but he is using this to claim essentially 1) physician behavior around death is somehow inate, not learned, and therefore not subject to improvement/education ("medical-school remediation"), and 2) we can't really do anything to ease the suffering and dislocation of death anyway (other than make people a tiny more comfortable which apparently is super-easy for most doctors). This seems to be shaky ground on which to excuse what is essentially physician abandonment of the dying (which he describes in the first quote). Death, pretty much by definition, sucks--full of anguish in even the best of circumstances--for patients, families, and frequently clinicians. To pretend otherwise is naive (& I doubt that is what Chen & Stein claim), but to pretend that we can't train future generations of physicians to care for dying patients and families in better and better ways just because we can't fix the existential finality of death is dead wrong and a little weird. Anyway, I guess I'll throw those books onto the "to read" pile.

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Some of you may have seen an email circulating from the Wisconsin Pain & Policy Study Group (PPSG) about an article from last summer's Pharmacoepidemiology and Drug Safety. The email highlights an article and two commentaries regarding a causal association between increasing opioid prescriptions and increasing deaths from opioid 'poisoning*.'

The conclusion of the article is that we have entered a national epidemic of drug poisoning deaths, around the same time as increases in prescription opioid dispensing, and these may be related (inadvertently). Of the increase in unintentional deaths from poisoning, the opiate group had one of the largest % changes (+91%). In 2002, prescription opioids were implicated in more poisoning deaths (5528) than heroin (1937) or cocaine (3909). (For comparison, I have listed some CDC mortality data from 2002, so you can see the relative impact.)

Some interesting data from this study and others found that the demographics of those dying from opioid poisoning match the demographics of those dying from heroin and cocaine, mostly middle-aged males. And that most did not have a prescription for the opioid.

Well, as you can probably guess, a study like this can be intimidating to those who advocate for fair and appropriate prescribing of opioids. But as we all know:

Or 'Correlation does not imply causation.' But it does not mean we should ignore or dismiss this data. We need to read the paper and understand what it may show us. Luckily the journal that published this study included two excellent commentaries to fit along side this piece, but for those who are not keenly interested in this, I presume the abstract with the conclusion will be the only thing read which is a lazy and dangerous step. Scott Fishman, MD provides a good history of law and pain control, as well as a good summary of the problems of 'correlation equals causation.'

Joranson and Gilson provide a critical review of why this database association is difficult to translate into action, and how too much publicity of this article could cause harm:

Unwittingly, publicity about simple associations can exacerbate fears of appropriate medical use of prescription drugs among pain patients and the public, trigger more drug control, and increase fears of regulatory scrutiny among legitimate prescribers and dispensers. All of these can lead to further under-treatment of pain.

But both commentaries do address that the increase in deaths is concerning, but that we need open funding for well-designed studies that look into the complexity of drug diversion, the reasons for abuse, and not necessarily the breakdown of the prescriber-patient dyad that allows for the appropriate treatment pf pain.

For those of us in palliative care and hospice this should be an issue that you talk with your colleagues about, because as a new field we risk being defined by others, and this is not how I envision our field. Better to partner with future studies and make efforts to help address any of these problems of diversion where we are able.

*Poisoning is referred to in the article as: 'the damaging effects of ingestion, inhalation, or other exposure to solids, liquids or gases'

2) Two quickies here that I have been meaning to get off my to do list for Pallimed:

Annals of Internal Medicine had an article by Kurella looking at 80 and 90 year-old patients on hemodialysis. The number of octogenarians and nonagenarians has been increasing steadily with almost 14,000 receiving dialysis in 2003!! 1-year mortality was an impressive (impressively good I thought) 46%.

Community Oncology has a brief communication on using pregabalin (Lyrica) for vasomotor instability or 'hot flashes' for menopause, breast cancer and prostate cancer patients, and those on hormonal chemo. They gave pregabalin (open-label) to 12 patients and had some pretty impressive treatment scores with 75% of people reducing their hot flash severity by 50% or more. Although some people did experience unwanted side effects, namely sedation and altered mentation, this may be another tool to consider.

And if you have never checked out Community Oncology or the sister journal Supportive Oncology, you are missing out on some great free journals that have well-written informative accessible articles that are available online...FREE!! Go sign up. Well. Go.

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A few quickies before the weekend...

1)
The American Heart Association is releasing guidelines on pain management in patients with coronary artery disease which places opioids in front on NSAIDs & COX-2 inhibitors as preferred agents (Guidelines here--both BMJ & Medscape have good news articles about them). (Medscape articles are available with a free registration.) The Medscape one has a good discussion of the already rough-and-tumble fight that is breaking out due to the prominence opioids get. From BMJ:

"First line drug choices include paracetamol (acetaminophen), aspirin, tramadol, and short term use of other narcotic analgesics. If these fail to achieve adequate pain control, the next option is non-acetylated salicylates, such as naproxen."

First line. As you can imagine there is going to be general freaking-out about this. The fight is going to be, it seems, over whether naproxen should be considered before or after "narcotic analgesics." Anyway I welcome this--it is another event main-streaming opioids as effective analgesics with relatively well-defined risk:benefit profiles, and whose risk:benefit profiles happen to be, per the AHA, more favorable than NSAIDs and COX-2's for most heart disease patients.

2)
BMJ also has a qualitative article on research barriers to studying the quality of terminal care. It's based on focus groups with end of life researchers & clinicians and covers most of the usual suspects: trouble identifying dying patients; perceptions that researching dying patients does them harm; informed consent issues, etc.

3)
There's also a letter about the case I mentioned a while back about the woman going to court in order to receive...something...which sort of sounds like assisted death. Anyway the letter is about one of my favorite topics: the myth (or at least the overselling) of morphine and hastened death.

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Early this week I was getting really bummed because I was thinking I had nothing to write about for Pallimed, and then BOOM! it all came at me at once. Enjoy!

1) The NOLA case against a physician (Dr. Anna Pou) and 2 nurses (Lori Budo and Cheri Landry) being charged with murder/euthanasia is currently getting ready to go to the Grand Jury investigation. The jury was selected but the trial was delayed by Mardi Gras. (Seriously.)

Interestingly the coroner submitted the deaths as 'undetermined' early in February, and said there was not enough evidence for homicide after consulting with leading forensics experts. Apparently this has not deterred the District Attorney, and the Grand Jury will proceed.

One connection to a previous Pallimed post was that there was an outcry by supporters of Pou, Budo, and Landry before the airing of the Boston Legal episode. They felt that since the doctor to be found guilty (based on leaked information, sorry to give the ending away), and the trial had not started yet, that it would unfairly influence the public.

Wish I could show you some key scenes from the show, but all I could find was this promo clip. I had it on DVR but it got erased somehow, so now I cannot invite all of you to my house.

2) KPBS in San Diego headlined an article with:

Leading Hospice Organization Drops Opposition to Doctor-Assisted Suicide.

Pretty shocking headline. Let's read a little bit further. What the AAHPM (the organization) did was take a position of neutrality. Which is technically 'dropping opposition', but basically the statement moves to at least support health care providers in states where physician-assisted death* is legal (Oregon only, although multiple other states have tried and failed). With headlines like this, and knowing that few people actually read the article, I wonder how this play when it hits more papers, and talk show radio? I encourage all members of the field to read the AAHPM statements as they are well written and have been re-vamped in the past few weeks.

*the AAHPM's choice of terms for more neutrality...although it does make the distinction between euthanasia and physician assisted suicide more murky, a point we have belabored here before. And interestingly the link to the physician-assisted death position statement is to 'suicide.html' (I feel like such a sleuth!)

3) I get some pretty interesting searches when I look for materials for the blog, but business and economics hits for 'hospice' are pretty rare. But I found this very interesting stock market analysis of Chemed the parent company of VITAS and Rotorooter** (thus the Chem I presume?). No plan to debate the for-profit versus non-for-profit here, but it does make for interesting reading.

Some of the more interesting quotes (I don't read business-ese, but they sound pretty bullish on hospice & palliative medicine, kind of like us here at Pallimed):

While the relatively low absolute capital requirements represent a low barrier to entry, the regulatory complexity associated with establishing a Medicare-licensed hospice location remains a significant barrier.

AND also...

This industry has benefited in the last few years from favorable demographic trends and expanded Medicare reimbursements. There have been several notable disasters in this industry recently (ironically, due to issues with Medicare reimbursements). However, a favorable pricing environment, with tiered benefit plans and double-digit premium increases, coupled with stable inflation, should result in estimated earnings growth of 15% to 20% for the industry over the medium term. Medical care organizations will benefit from continued volume growth, innovative plans designed to moderate cost increases (along with higher consumer co-payments), better claims handling (leading to improved reimbursements from insurers), and expanded Medicare coverage and reimbursements.

I guess no one told them Bush is planning to cut Hospice Medicare Reimbursements.

** Super side note and obscure reference here (thanks Wikipedia!): From the show Futurama, a ad jingle: "Call robo-rooter if you flush a towel. We can also help with that impacted bowel."

4) Some short entries:

Business and HPM again: The folks at the Freakonomics Blog (Very interesting read by the way) actually posted about the JAMA Grief article we just posted about here.

HospiceGuy with some great posts! If you have not been reading HospiceBlog by Hospice Guy, he is making some great posts over there. Especially his very interesting and well written take on different payment levels for home hospice versus nursing home hospice.

Hospice and the lottery. An interesting way to fund hospice programs in the UK. Hope it does not come to that here in the US.

I got a Drew style heavy duty analysis post coming up by the end of this week, for those who read Pallimed for the articles.

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Two from the latest JAGS and one from Journal of Medical Ethics...

1)
First is a mortality follow-back study on advance directives and quality of terminal care. I have expressed skepticism about AD's on this blog before--wondering whether they really improve end of life care etc.--and I'm happy to report that here is a bit of data proving me wrong. The study was a typical, solid Teno mortality follow-back survey of ~1500 bereaved family members. About 70% of patients had AD's before they died; those with AD's were more likely to be older, female, and white. AD's were definitely associated with 'better' terminal care:

"For decedents with written ADs, the last place of care was most likely to be a nursing home. Those with an AD used less life-sustaining treatment in the last month of life, because they were less likely to die in an intensive care unit (11.8% vs 22.0%), to be on a respirator (25.6% vs 36.7%), or to be using a feeding tube (17.3% vs 26.8%) in the last month of life. Family members of decedents with ADs were not more likely to report that the decedent did not receive enough life-sustaining treatment."

In multivariate analysis, having an AD was associated with improved communication with physicians about decision making and better family preparation for death. I would interpret these findings with caution (as do the authors of the article)--they argue that having an AD is associated with 'better' EOL care; this doesn't mean that the AD lead to the better care & in fact in this study those with ADs were significantly different than those without. It could be used, however, as an argument that AD completion is a valid quality marker for EOL care--that debate however is a whole other story....

2)
There's a study looking at pain and how it attenuates recovery from depression in elderly veterans. It does (well, maybe--it's a complicated study which I'm not going to belabor here--it's an interesting read for those of you interested in the topic).

3)
Journal of Medical Ethics has an article proposing a conceptual framework for medical futility. This is a rather erudite treatise which references Hume liberally, as well as has a dash of Schrodinger's cat, and frankly it lost me frequently. That being said its thesis seems to be rather straight-forward: that the futility of a medical intervention can only be evaluated if the goal of the medical intervention is established, but that, you know, there's often disagreement about what a reasonable goal is, and who gets to decide what the goal is anyway...? If there's anything more subtle going on in this paper that I've missed please comment and let me know.

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JAMA published an excellent, ground-breaking study in to the actual testing of the stage theory of grief (apparently this is a full-text free article) this week. You may have seen this brought up in some of the media outlets over the past few days, but we here at Pallimed will break down the study for you in ways those health care reporters cannot.

Maciejeski, Zhang, Block, and Prigerson followed 233 bereaved people up to 24 months post-death of their loved ones. They were interviewed in 3 different periods after their loss (1-6, 6-12, and 12-24 mos). The stages of grief assessed were a combination of Kubler-Ross' (Denial, Anger, Bargaining, Depression, and Acceptance) and Bowlby & Parkes' (Shock-Numbness, Yearning-Searching, Disorganization-Despair, and Reorganization) stages of grief. The study stages were as follows:

Disbelief -> Yearning -> Anger -> Depression -> Acceptance

Now it should be said these items do not have to happen in any particular order, nor does any one stage have to be completed before the other can begin. In fact what is great about this study is that it demonstrated that these various stages do have peaks, and do largely overlap each other. I wish I could post the figure that demonstrates this, but JAMA has some strict terms of use. The article is free so go get it. The graphs would be very helpful in any talk on grief and bereavement. The discussion is very well formed in this article and should be a must read for any SW or counselor dealing with the bereaved or soon to be bereaved.

The ones sentence that really makes the study is this one:

Within each period, acceptance is greater than disbelief, yearning, anger, and
depression; yearning is greater than disbelief, anger and depression; and
depression is greater than anger.

It does give support to the resilience of the human spirit in times of great adversity. I hope to see more studies on grief based off of this one. Maybe ones that track people closer to the time of loss? In this study the mean time to first interview was 6.3 months post-loss. Hopefully with active bereavement groups in hospices this could be started a little earlier. The authors do comment on the difficulty in obtaining IRB for bereavement studies out of fear of causing harm in discussing loss.

It should also be noted that this study excluded those who met criteria for complicated grief and the the majority of participants were white (97%), females (71%) over 65 (54%) who lost their spouse (84%). So your mileage may vary with your population that you see. Obviously A 24yo Laotian father who loses his son may not have the same sort of grief. Which brings up the point to study the stage theory of grief in vastly different populations to see if it is the humanity that gives us a commonality or if our cultures really separate our emotional experiences.

(Thanks to Scott L. for the heads-up)

2) Coming home from the AAHPM, I had a layover in Denver and got to read a whole Newsweek. (Man it has been a long time since I have done that.) The My Turn piece (not yet avail online) was written by a father who lost his son 13 years ago and is still distressed over the junk mail he receives for his son. Graduation pictures, military recruitment ads, etc. I thought it was bad when my dog got a credit card application (Spot Sinclair, c'mon?!), but this has too be very difficult as Gary Weiner writes very well in his editorial. I have already written a letter to the editors to bring light on the UK solution with the bereavement register that we posted here on Pallimed. Do you think the Bereavement Register would work here in the US? Or would direct mailers oppose it fiercely, and funeral home directors balk at more data collection? It might save a lot of heartache...

3) Time magazine has an opinion piece by Scott Haig [link fixed 2/25] (an emergency room doctor I presume, although his credentials are not listed) about the value of the human mind in assessing other people’s pain. The discuss the poor efficacy of the Visual Analog Scale in the ED comparing a stoic man who denies pain to a recent female MVA patient who seems to be embellishing her pain in the desire to get Percocet.

While I agree that the VAS can be of limited usefulness and that patients sometimes rebel against it, or become confused by it, we should not abandon the VAS. It remains a critical tool for assessing impact of therapies in reducing a patient’s pain. All of us have different thresholds for pain and to imagine that we can walk in another shoes and feel their pain is ludicrous. I gave a talk a few months ago about assessing pain, and I asked the audience to assess my pain by looking at me. They all said 'Zero.' Well I rated my pain at a 6 because I just played hockey last night and my back was killing me from a accidental body check in my no-check league (Honestly, I did not see the guy coming. I didn't mean to knock him over.)

The professional skill comes in taking the VAS applying it to the clinical situation and using it as part of a comprehensive examination. Never should a policy say, "for pain of X give a morphine dose of Y." That makes our professional skills take a back seat. So while the general point of the article (our minds are still useful in medicine) was good, I think the gist is that 'people may deceive' and 'the VAS is worthless.' It all depends on how you use the tools provided.

PS for those of you wanting the talks at the AAHPM , check out Rollin' Recordings for the MP3's they have there. I got to talk to Lou at the meeting and he is a great guy. And you can listen to the talks in your car.

-CTS