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1) This last Monday I gave a talk to our palliative medicine fellowship program about topical and transdermal medication in palliative care. While I am generally not a big fan of topical/compounded medications (because of a general lack of efficacy research or basic science studies for many), I did come across a case series of 4 patients who received topical methadone for open wound pain management. I have worked with morphine gel before with mixed success, but never tried a different opioid. In 2005, Romayne Gallagher, MD, CCFP and colleagues mixed methadone and Stomadhesive powder and sprinkled it in the wound. 3 patients had dementia, and the patients could not use pain scales, so the staff rated their pain. (Obviously a weak part of the study) Now this was not successful in all cases which I give credit to the authors for admitting/publishing the 'negative' findings, as this is as important as positive 'findings' in research. But it may be something to try (and publish) for patients with bad wound pain and too much sedation from systemic opioids. If any of our readers have had luck with topical opioids feel free to post in the comments.

While we are on the topical/transdermal issue, I have one key point to make that is often confused....

• Topical medications have a local effect without significant systemic absorption
• Transdermal medications are systemic by nature of their absorption into the blood stream and effect at a location separate from the location of application

For example, scopolamine is transdermal (systemic), but the instructions (for no clear reason) state you must apply it to the retro-auricular area. Marketing, placebo effect (it is near your 'balance centers in your ear')? I am not sure. I wouldn't change your practices on this fact, because everyone is going to look behind the ear for the Scop patch not on their lower back if you put it there to prove my point.

2)PRI's The World had a 5 minute radio spot on hospice acceptance in Hispanic communities last week. They quoted some NHPCO statistics from 2005 noting 14% of the US population was Hispanic but only 4% of hospice patients. They do a good media review of the components of hospice, and the barriers to accessing hospice within the Hispanic community.

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In no particular order:

1)
Critical Care Clinics has an ethical review of discontinuation of mechanical ventilation at the end of life. It’s actually a rather free-wheeling review of the U.S. legal and ethical framework for withdrawal of life-prolonging treatments in the dying. It’s a good one for the teaching file.

The same issue has a review of noninvasive ventilation (such as BiPap) which references its use in dying patients.

“For the terminally ill patient, dyspnea is one of the most distressing and common symptoms. The most widely used treatment for this has been narcotics and anxiolytic medications. These medications are effective in relieving dyspnea, but they also have adverse effects. Noninvasive ventilation presents as an alternative measure to treat dyspnea; it can be used as both treatment and symptomatically. Dyspnea at the end of life is a very common and upsetting symptom for the patient and family. Very few data are available regarding the use of noninvasive ventilation. Hill evaluated the efficacy of nocturnal noninvasive ventilation in symptom relief of patients with terminal illness. Devices were used for 1 week and routinely at night for sleep disorder breathing. These patients noted improvement in fatigue. The patients who had terminally ill cancer noticed improvement in fatigue and reported fewer headaches, less sleepiness, and improved energy.”

I am glad the author mentions the lack of data. In my experience unless the patient has actually both accommodated to noninvasive ventilation and identifies it as something that makes them feel better it is not helpful at all.

2)
The current Lancet presents an observational study of the safety of talc pleurodesis for malignant pleural effusions. There have been concerns with talc pleurodesis causing acute respiratory failure and ARDS which this study tries to answer. It was a multicenter, European study of over 500 people who received thoroscopic talc poudrage. Basically the pleurodesis was very safe: no episodes of ARDS and very few serious immediate complications. The authors conclude it is safe.

Poudrage, from some free online dictionary:

The surgical application of powder, such as the dusting of opposing pleural surfaces with a slightly irritating powder in order to secure adhesion.

3)
Community Oncology has a review on the evaluation and management of insomnia in cancer patients (CO articles are always free). The article makes its management sound so easy, which it never is for me. The same issue has a supplement with an update on current guidelines for chemotherapy related nausea and vomiting. The supplement doesn’t seem to be available online however…?

4)
The current NEJM has a review on the superior vena cava syndrome, one of the least welcome consequences of thoracic cancers. It’s pretty straightforward and has some of the most colorful appearing PET images I’ve seen for a while.

The same issue also has letters (free full-text) about the recent article on religion and controversial practices (the original article mentioned terminal sedation but mostly it, and these letters, are about reproductive issues such as contraception and abortion).

5)
Annals of Internal Medicine has an important discussion of the ethics of quality improvement methods. QI work is important across health care and particularly in palliative care as our field (at least in the US) has traditionally been driven by QI efforts (improving cancer pain assessment and management, etc.). One of the more interesting assertions in it, at least to me, was that unlike for research in which patients have no responsibility to participate in (i.e. it should be completely voluntary), the authors argue that patients are obliged to participate in QI projects. “Because QI activities are, and should be, part of normal health care operations patients also have a responsibility to participate in quality improvement, which often requires direct cooperation (for example, permitting collection and use of data about the medical conditions…).” This applies only to QI work has minimal incremental risk to patients of course (e.g. involves data collection). Along these lines they argue that QI, unlike research, “generally aligns with patients’ interests, presents lower risks than continuing with usual care (and certainly less risk than making the same changes without collecting data to monitor its impact).” The article goes on to discuss differentiating between QI work and research, and gives recommendations about ensuring QI work is ethical.

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1) If you have not gone over to see HospiceGuy and his HospiceBlog (www.hospiceblog.org) you are missing out on some great posts. HospiceGuy is on a roll with some insight about the role of the chaplain in hospice, the NHPCO conference, hospice leadership and a quick overview of the Medicare Wage Index for 2008. On the wage index, the NHPCO also has a 5 page announcement (members only) boiled down to the parts that you need to know about.

2) The verdict is in on the case of Dr. Hurwitz and he was found guilty of:

“knowingly and intentionally” distributing drugs “outside the bounds of medical practice” and engaging in drug trafficking “as conventionally understood”? (via NY Times)

Many good overviews below so I will not go into detail here but at least read one of these links because this can impact palliativists in the USA, and you will want to know about it. The frustrating part is noted in John Tierney's NY Times blog (link #2 below):

They (the jurors) said that the jury considered Dr. William Hurwitz to be a doctor dedicated to treating pain who didn’t intentionally prescribe drugs to be resold or abused. They said he didn’t appear to benefit financially from his patients’ drug dealing and that he wasn’t what they considered a conventional drug trafficker.

Hurwitz links:
NY Times
NY Times # 2
Reason Magazine

3) Although the day has passed, apparently April 30th is National Honesty Day. An article written by Shankar Vedantam from the Washington Post about lying and the Libby trial had this interesting conclusion which any HPM provider would say is a familiar situation:

DePaulo once conducted a study in which she asked people to recall the worst lie they had ever told and the worst lie ever told to them. In a reflection of how much our perceptions of lying depend on our particular points of view, the psychologist found that many young people reported that the worst lie ever told to them was by a parent who concealed news that someone they loved was sick or dying. (emphasis mine) By contrast, DePaulo found, parents never thought of such deceptions as particularly serious ethical breaches -- in fact, they saw them as acts of love.

If you look at Bella DePaulo's website, you'll find many studies on deception (she is a social psychologist at UCSB). A study exploring themes of deception among family members, patients, and staff at the end of life would likely find many instances of 'scrupulous lying' in order to protect someone from emotional harm.

4) The NY Times had an article on "chemo brain" showing that the cognitive decline that may accompany chemotherapy is a real phenomena:

“The disparity plays out in all kinds of ways,” said Ellen Coleman, the associate executive director of CancerCare, which provides free support services. “They don’t approach their health care person because they don’t expect help.”

But approaching a doctor does not guarantee help. Susan Mitchell, 48, who does freelance research on economic trends, complained to her oncologist in Jackson, Miss., that her income had been halved since her breast cancer treatment last year because everything took longer for her to accomplish.

She said his reply was a shrug.

“They see their job as keeping us alive, and we appreciate that,” Ms. Mitchell said. “But it’s like everything else is a luxury. These are survivor issues, and they need to get used to the fact that lots of us are surviving.”

As a fan of semantics, I find the choice of 'chemo brain' troubling. It sounds kind of cute, or minor like 'broken heart' or 'upset tummy.' We don't call Alzheimer's 'fuzzy old brain'? I wonder if this label discouraged attempts to research the syndrome. How about Chemotherapy Associated Cognitive Impairment?

(Don't you think that tree looks like neurons? Photo courtesy of flickr.com user Victoriano)

5) And just in case you needed a picture for your PowerPoint presentation, the Mental_Floss magazine blog has a post on odd street names, such as the following:

I would make sure your hospice offices were not on this street.

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1)
The Clinical Journal of Pain has a study on the long-term use of opioids for chronic non-malignant pain (CNMP). The study looked at 230 patients taking extended release oxycodone after completing short term, controlled trials for CNMP (DJD, low back pain, diabetic neuropathy) - they agreed to be observed for up to 3 years while taking the oxycodone. The patients were 90% white, 57% female, their average pain was 5/10, mean oxycodone dose 30mg a day. The study was terminated early unfortunately due to 'administrative reasons' with the registry database so the data are a little opaque. This study presents almost an overwhelming amount of data but these are some of the more relevant ones to me:

A) 133 patients dropped out prematurely; 30% of these stopped oxycodone due to adverse effects and 14% stopped because of lack of efficacy (the remainder were lost to follow up or were discontinued from the registry for unclear reasons). Most of the patients who had stopped due to adverse effects had done so by 6 months. 64%, 39%, and 18% of the patients took oxycodone for a full 1, 2, and 3 years, respectively (remember some of this data is tainted by the early termination of the registry).
B) 44% of patients increased their oxycodone in the first 4 months; 24% increased it between months 4-6. After that almost no patients who continued on oxycodone needed dose increases (only ~10% a month). Across all time periods the average dose was ~50mg a day.
C) Pain decreased a little in the first few months. There were 17 patients whose oxycodone doses escalated without a concomitant decrease (some even had an increase) in pain.
D) Adverse events were relatively rare (but remember people were dropping out, some of whom were dropping out from adverse events, and data were no longer gathered on them). Interestingly constipation diminished over time. This is counter to other experience which suggests constipation never attenuates. On the other hand it may have been getting better because it was being treated better (there's no way of knowing this) or that those with the worst constipation were dropping out.
E) Worrying behaviors for substance abuse/addiction were very rare--2.6% of patients demonstrated this (these data were collected prospectively as part of the registry data and were based on the investigating physician recording them as part of the routine data collection process).

Given the problems with the early discontinuation of the registry its tough to know how to interpret these findings. They are more or less consistent with the dominant thinking about opioids for CNMP: most patients don't tolerate or find them useful for the long term (years), however the substantial minority that do can use them safely without significant side effects, never-ending dose escalation, or risk of addiction. A major caveat here is that these patients are a relatively select group: they could pass the screening rigors of getting into a controlled clinical trial and there is some reason to believe that this subset of patients is different (among other things, more socioeconomically stable) than the population at large.

After reading this paper, and given the ongoing concerns and controversies about long term opioid use for CNMP, one gets a sense of just how valuable a 'registry' could be for researching this issue and I hope that these researchers or others are able to create a new one.

There are two accompanying editorials/commentaries--here & here. The first in particular is a worthwhile read--it summarizes opioid controversies for a few thousand years and succinctly outlines what we know, what we don't know, and an appropriate research agenda. It also talks about the ongoing epidemic of prescription opioid abuse.

2)
Journal of Clinical Oncology has a study on suffering in patients with advanced cancer. It looked at 380 hospitalized advanced cancer patients (median age 66y, median survival 60 days, all were on palliative care units or had been seen by palliative care teams) in Canada who underwent semi-structured and -quantitative interviews about their experience including if they felt they were suffering, why they were, in what way, and how would they describe it. Half the patients didn't describe themselves as suffering and 25% more described it as mild only. 8% described extreme suffering. This study too presented a lot of data and I've written too much already today. To be brief: younger age and higher socioeconomic status correlated with increased reports of suffering, as did functional status (although time to death was equal in both groups). A lot of the things one would expect predicted suffering did: increased existential and social distress, increased anxiety and depressive symptoms, and increased physical symptoms particularly weakness and pain. In regression analysis physical symptoms retained the most independent predictors of reported suffering.

While there's tons of interesting stuff here, what's most interesting to me is the finding that 3/4 of the patients reported no or mild suffering only--these were people 2 months from death. Why is this? I don't know. It seems low to me and may be due to patient selection (these were patients who felt well enough to participate in a lengthy interview among other things). It does have a certain consonance with the recent bereavement study in which acceptance was the most common, immediate reaction to a loved one's death.

(The same issue also has a systematic review of pain management of hospitalized cancer patients--looking at trials of interventions to improve pain management. You can easily guess the results.)

3)
And finally--palliative care was mentioned recently in USA Today. It's a very positive, and only a little muddled, article. USA Today--I guess this means we really are going mainstream in the US. (Thanks to David Weissman for letting me know about this.)

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Sorry about the sparse posting last week, I've got a stack of items piling up that I'll try to get thru this week.

1)
The current Journal of Public Health Policy has a special section on palliative care in developing countries (free full-text is available). The articles are mostly short and descriptive, or calls for more palliative care. The shocking (at least to naive me) lack of availability of opioids in many countries is frequently cited. I assumed there would be discussion of the debate over increasing resources for palliative care in areas where many people die of treatable--if not curable--diseases (e.g. HIV, many cancers) but this is completely absent from the issue. In resource-poor environments--where should the resources go? I'd love to say that, for instance, improving access to antiretrovirals and palliative care should occur simultaneously. Acknowledging this isn't going to be the case I personally am not sure how those precious resources should be divided. The fact that this is a zero-sum game is itself the problem of course; identifying it as such however does not bring one any closer to a solution. I'll nevertheless proffer one though in the spirit of Christian's recent US political speculations: the US goes single-payer, sends the money it saves abroad to improve the health care of developing countries, including palliative care.

2)
Qualitative Health Research has an interesting article about dying cancer patients' 'talk' on CPR and DNR orders. As the journal's name would imply, this is qualitative research, involving a single researcher interviewing 28 dying Australian cancer patients about CPR and DNR orders (most, but not all, subjects had DNR orders). The paper itself involves a 'discourse analysis' of the subjects' talk on CPR, looking at themes that emerge. I'm in no way qualified to critique the paper, and so I won't. I will say it's an interesting look into a world (talking with patients about CPR and code status) most of are are probably familiar with, and there's much there that I recognized. I was particularly struck by this (it is describing a patient):

...[H]e drew on some concept of quality of life ("the way I feel today ...I've got tomorrow to look forward to") to justify a current preference for resuscitation, construing his assessment of his life as the pivotal issue. Invocation of these factors works to reaffirm the primacy of patient autonomy in these decisions, as well as prioritizing subjective judgments about the value of life: having something to live for justifies resuscitation. One consequence of this is that the mere assertion by the patient that some aspect of their life holds worth will suffice to stymie moves to establish DNR orders....

3)
Lancet Oncology has a lovely review of palliative care's history in oncology. It opens with this:

In only four decades, the care of patients with advanced malignant disease and the management of their symptoms during the trajectory of illness has moved from the margins of oncological practice to the very centre of modern cancer care.

While that seems a little grand to me, the remainder of the article is really interesting and actually quite a whirlwind summary of palliative care's history and the current scope of palliative care services and programs worldwide, complete with full-color pictures.

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1)
Archives of Internal Medicine has a couple notable articles. First is an intriguing one on using instructional videos in advance care planning for patients with dementia. 120 adult outpatients (median age 58, 70% women, over half non-white) who didn’t have family members with advanced dementia were given verbal information about advanced dementia and asked, essentially, if you were in this state would you want full, aggressive life prolonging care, less aggressive life prolonging care (hospitalization, antibiotics, etc. but no CPR, vent, or ICU level care), or comfort-only care? Then they were shown a video of a patient with advanced dementia being cared for (you can watch the clip here) and then were asked the same thing.

After hearing a description of dementia, about half said they’d want comfort care and 21% said they’d want ‘full’ life-prolonging care. After the video 90% said they’d want comfort care and none said they’d want ‘full’ life-prolonging care. Before the video, somewhat more Latino and African-American subjects said they’d want full life-prolonging care; this was also true of the more religious and less educated subjects. After watching the videos there were no differences between any groups (ethnic, religious, education-level) regarding preferences.

These are quite dramatic findings, and quite exciting. Not only were the outcomes quite pronounced, they also were strong enough to nullify religious/class/racial differences in treatment preferences which are frequently identified in the advance care planning/treatment preferences research literature. I’m excited to see where people take this. One has to be somewhat cautious. You can look at the video yourself and decide how accurate or frightening it was—to me it seemed a rather accurate and straightforward depiction of someone with far advanced dementia—but one wonders if there was something about this particular video to generate such dramatic outcomes. You’d like to see these findings repeated with different videos, as well as with different disease categories. Of course this sort of intervention lends itself well to dementia; I’m trying to think of other terminal illnesses for which it may be amenable. It would be tough to depict in this way CHF or COPD or cancer for that matter…. It could be done with CPR itself though but the problem there is a focus on the intervention and not its outcome….

The other article is about the development of a “drug-burden index” in the elderly. It involved analyzing the drug use of >3000 elderly (average age 73) community-dwelling adults along with their functional status. Interestingly, these subjects had to have pretty good function in order to be included in the study; they had to be able to walk a quarter mile and be independent in their ADL’s. Anyway the authors found that function (both physical and cognitive) declined in this group in the patients on a higher number of drugs, but that this association was all caused by sedative and anticholinergic drugs—once they removed these from the mix the actual number of drugs didn’t predict functional status. Comorbid illness didn’t have any effect either independent of anticholinergic or sedative drugs. The take-home point is a well-established one: anticholinergic and sedating drugs cause problems in the elderly. Taking a skeptical stance, however, you could argue that this research simply establishes an association between these agents and poorer functioning—causality is not established—and you could argue that, perhaps, maybe the poorer functioning adults were that way because of pain and because of their pain they took more sedating/anticholinergic meds.

2)
The NY Times has an article on the Hurwitz trial & some of the testimony recently given about his practice. It’s quite dramatic and includes the story of a patient that was treated both by Dr. Hurwitz and by one of the prosecutor’s expert witnesses (another pain doc). The two doctor’s treatment approaches are starkly contrasted; it’s pretty damning of one of them (I’ll let you read the article to find out who).

(NY Times articles are available free online for about a week.)

(I was sure we had blogged about this trial before although for the life of me I can’t find it—he is a pain doctor who was criminally convicted of conspiring to distribute opioids etc etc whose conviction has recently been overturned and is going through a re-trial. An overview is here.)

3)
Continuing the last post’s thread about death and its place in our society, the Guardian recently published two editorials about death, mourning, and the media (triggered by last week’s mass murders in Iraq and Virginia). Paul McIntyre, who let me know about these, pointed out that they have a rant-like quality—written from a sense that something is deeply broken with our culture & death. Given that, it is interesting to see palliative care mentioned in the midst of these (not necessarily inaccurate) rants....

“Attitudes to death and mourning grow odder the rarer dying young becomes. There is less sense of proportion about the risks of dying, or about the inevitability of death itself, even when people die in old age. The temptation is to regard every death as avoidable, deny any accident is ever accidental, always find someone to blame, and hunt down that doctor in charge. …At the same time, the public dare not face up to the reality of the prolonged agony modern medicine imposes on the dying. Until it happens to them or their parents, people fondly imagine morphine or palliative care will always ease the end. That fallacy means many will enter the grave via the torture chamber, for failure to demand the legal right to die at a time of our own choosing. People no longer know how to approach death and its rituals….”

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A brief summary of several notable pieces from the most recent BMJ and Lancet. And a note that one should not look at the photos linked to from Christian's post unless one is in a position where it is safe to cry for 10 minutes, as I did sitting at my computer at work this morning. Luckily the palliative care offices here are (kind of) a safe place to sit and cry at one's computer, but I realize not everyone's offices are. Thank you, Christian, for letting us know about the photo series.

1)
First is an editorial about DEA regulation of opioid prescribing in the US, arguing it is onerous and leads to poor pain management, while acknowledging the therapeutic controversies around opioids for chronic non-malignant pain. It mentions the infamous FAQ affair.
"Friction between regulators and medical providers is perhaps inevitable, as they both have noble yet conflicting goals—the one to control diversion, the other to preserve treatment for pain. As drug misuse becomes a greater problem, legislators react by tightening regulations. The American experience teaches that over aggressive regulations that ignore legitimate needs for opiates compromise doctors' ability to treat pain. As the pendulum has swung here between medical underuse and overuse, patients have been harmed. Now that it is becoming clear that the outcome of chronic opioid treatment is often poor, studies are urgently needed to investigate who benefits and under what conditions. The bigger question may be whether regulations have succeeded at all in controlling drug misuse, but the more immediate question for doctors in the US and elsewhere is how they should control their own prescribing so that interference by regulators does not discourage appropriate medical use of opiates."

2)
Second is a brief 'observation' on reintegrating death (culturally) into 'Western' society, focusing on the book A Social History of Dying which seems pretty interesting. Palliative care is mentioned, sort of, as a remedy for our lack of 'integration' of death into our society, which, sort of, makes me nervous. I realize there are people within our community who feel deeply that death & dying are 'broken' in our culture and feel that palliative care is or should be a remedy for that. This seems like an incredible tall order and a set up for failure, not to mention a vast overestimation of the scope and influence of the palliative care movement. Deep cultural, economic, and scientific-technological changes have caused all of this and a scrappy movement to improve the medical care of dying patients seems unlikely to change much. It may be a palliative for this, an anodyne, but likely not much else. Last fall at the Montreal conference there was a distinct current of despair and anger about just how broken death & dying are in our ('Western') culture which was linked to, among other things, secularization. While I don't necessarily disagree with this I was confused as to why it was being laid out at a palliative care conference--how were we going to 'fix' this? Should we be even engaged as a community in trying to 'fix' this? Caring for dying people, as whole, spiritual people, in an interdisciplinary way, including spiritual care, does not mean we are healing the world or the dislocations brought about by several centuries of capitalism, migration, secularization, and technological change. Perhaps a worthwhile project, but not one we should set ourselves up as being a part of in my humble opinion.

3)
There is an 'interim summary' and update about a NHS project in the UK to improve palliative care services in the community via primary care practitioners.

4)
Finally there's a clinical review of delirium in older people. It's a practical review of the topic and doesn't add much to the recent NEJM one (the papers share a common author). It would be a nice addition to one's teaching file though for medical & other students.

5)
Lancet has an editorial about one of my favorite topics: morphine and the myth of hastened death and why it seems to be so persistent in our culture, even the larger medical culture. It's brief, but good fighting words, and I'm glad to see it in the Lancet. There's also a brief bit on the concept of fraility in the elderly, arguing the controversial point that it is a useful concept medically--a discreet medical condition/syndrome with its own evaluation and therapy.

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This is a short post, but an important one. The 2007 Pulitzer Prize for Feature Photography was awarded to Renee C. Byer of the Sacramento Bee for her photojournalism of Derek, a 10 year old boy with cancer and his mother Cyndie.

This set of photos reminded me how important our work is in the field of hospice & palliative medicine.

I am lucky enough to work for a hospice with a strong pediatric program with great pediatric nurses. Even though I am an internal medicine trained physician, I try to make home visits for these pediatric patients and their families, and to support our pediatric team. We need more pediatricians who want to learn more about palliative care.

These photos just reminded me to thank all those who care for pediatric palliative care patients.

(Thanks to Kevin MD for the link via Graham)

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1)
From the chronic pain world....
Annals of Internal Medicine just published a metaanalysis of randomized, controlled trials for chondroitin for osteoarthritis pain (22 trials, over 4000 patients, median dose of chondroitin 1000mg daily, median duration of treatment 25 weeks). Basically they found (surprise!) a lot of heterogeneity between the trials but when they looked at the better quality trials (the larger trials which had intention to treat analysis & good allocation concealment) therapy with chondroitin didn't seem to have much effect. They looked at their data in many ways, and it seems that chondroitin probably has a mild effect compared to placebo, but insofar as this effect diminishes with larger, better designed trials it seems highly probably that this effect is minimal and not anything one would advocate for their patients. Doesn't diminish traditional analgesic use, etc. It's a good example of how small trials can be misleading, particularly for agents that are of marginal benefit.

Anyway, none of this is very interesting. The metaanalysis is worth reading for other reasons: maybe it's been a while since I read a metaanalysis in Annals but this one was actually a treat to read. The authors describe in language, understandable to non-statisticians (something absent from many a metaanalysis), all the different analyses they did, why, why and how they did exploratory analyses, what they mean for interpreting this large body of heterogeneous data, what the research implications of all of this is, and came up with realistic clinical recommendations based on their findings (much more helpful than the annoying conclusion to many a Cochrane review 'there are insufficient data to support the use of X for Y'). I may not have learned much about chondroitin but did about metaanalyses.

2)
The NEJM has a review on the management of adult fecal incontinence. It spends most of its time on fecal incontinence due to neurologic conditions (strokes, spinal cord injuries) and pelvic muscle weakness but also addresses overflow diarrhea in constipated patients and fecal incontinence from things like radiation proctitis. It's a problem which is thankfully rare in my practice, but devastating for the patient when it occurs; as well as something about which I've had very little training (other than overflow diarrhea).

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1)
Medscape is reporting that alvimopan (an investigational drug for opioid-induced constipation) caused a small increase in heart attacks in one of its phase III trials ( 1.1% of patients with placebo vs. 2.6% with alvimopan had cardiovascular events). The FDA is apparently reviewing things. Alvimopan, along with methylnaltrexone, has been one of the much hoped for up & coming agents for opioid constipation (and potentially other side effects), so we'll see where this leads. That magnitude of increase in CV events is similar to many other drugs which have remained on the market (newer antipsychotics come to mind)--the FDA will have to decide if the added benefit of this new drug will be worth the risks....

(Medscape articles are available free if you sign-up.)

2)
Heart has a review of the management of 'end-stage' heart failure patients. It's noteworthy for a couple of reasons. First, it's a well-written overview of the subject and addresses some of the newer trends: devices (ICD's, biventricular pacing), ventricular assist devices, etc. Second, it gives a nod towards palliative-oriented approaches to care and advance care planning in this population (for those of you who've read this blog for a long time you'll remember I use to track major review articles of highly mortal diseases such as mesothelioma and if they mentioned palliative/terminal care). It has a section, 'Palliative Approaches,' which gets just about as much column space as 'Experimental Approaches' which mentions advance care planning, supportive care, treatment limitations, hospice, etc. Included in this is a mention of continuous infusions of inotropes (i.e. dobutamine), a practice many in our field will balk at, although they definitely fit a palliative model (they don't make people live longer...if anything they shorten peoples' lives...but they can make people feel better). I'm curious if anyone has used these or seen them used in 'terminal' settings with palliative-only goals--I haven't yet.

3)
An update on an earlier post:
Marachne alerted me to a provision in the Oregon Death with Dignity Act which explicitly addresses insurance:

127.875 s.3.13. Insurance or annuity policies. The sale, procurement, or issuance of any life, health, or accident insurance or annuity policy or the rate charged for any policy shall not be conditioned upon or affected by the making or rescinding of a request, by a person, for medication to end his or her life in a humane and dignified manner. Neither shall a qualified patient's act of ingesting medication to end his or her life in a humane and dignified manner have an effect upon a life, health, or accident insurance or annuity policy. [1995 c.3 s.3.13]

4)
And to continue in the vein of Christian' s recent media postings, American Radioworks has a radio documentary available online on the hospice movement (you can stream it for free). It's a couple years old, but I just recently discovered it because, despite its age, it's the most recently posted documentary on their podcast list in iTunes (for those of you who use iTunes go to the Podcast directory>American Public Media under 'Featured Providers'>American Radioworks). Worth listening to, particularly if you're a public radio junkie.