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Since there is so much going on at the American Academy of Hospice & Palliative Medicine and the Hospice and Palliative Nurses Association Annual Assembly I will just cover some of the highlights of each day. How I determine what is a highlight is a secret highly objective mathematical formula, but if you want to bring notice to one of your own sessions please feel free to post a comment.

Previous posts for 2008 Annual Assembly:
AAHPM Pre-Conferences Wed Jan 30th
HPNA Pre-Conferences Wed Jan 30th

Thursday, January 31

8-9:45a

Cancer is a Word, Not a Sentence
by Robert Buckman, MD

Author of the book by the same name (and 15 others), Dr. Buckman will be speaking about how to deal with the fear of being diagnosed with cancer. He is a medical oncologist and teaches at the University of Toronto. You can find out more information about him on his personal website. I would guess the talk will be based loosely on his book, but refined for the medical professional as opposed to the patient. He is the author of some great articles as well, notably a series of letters published in BMJ between him and a homeopath practitioner. He has been practicing since 1972 so should have a lot of experience do draw from. I would like to know how he found the time to write 16 books and numerous other articles. But I won't be there to ask the question, so if anyone else can let me know what he says.

10-11a

Slatkin and Rhiner (City of Hope) will tackle topical approaches to pain originating from the skin and from mucositis. I hope they make sure to highlight the difference between systemic (transdermal) and local (topical) applications of medications, since there seems to be a cognitive dissonance with some palliativists as to how these medication routes work. Patrick Clary, MD (Exeter Hospital) has an intriguing session titled Dying for Beginners: A Palliative Physician/Poet's Stories from the Bedside. This is another session that originates from a book. For those who have argued the AAHPM has become to clinically/research oriented this is the one for you. And for the program development folks, you have the cleverly titled "Don't Ask, Don't Receive" which covers physician involvement in development and philanthropy from two esteemed speakers Rodney Tucker (UAB) and Diane Meier (Mt. Sinai).

And probably the most intriguing concurrent session for this time slot: "Can Clinicians Who Care for Adults Also Care for Children with Life-Threatening Conditions?" by 5 different speakers (in only one hour? - maybe this should be a pre-conference next year?) Hopefully all Pallimed readers know the answer is YES!, Absolutely YES! we do not have enough pediatric palliative care providers to shirk the duty of caring for pediatric patients. And while many many pediatricians will tell you that kids are not little adults, I would argue that, "Yes in fact they are!" The communication and symptom control skills once mastered can be dutifully applied to this underserved population. Until we get enough pediatric palliative care practitioners, we should all be willing to step up to help our pediatric colleagues.

11:30a-12:30p

One of the talks during this session is titled State of the Science for Palliative Care for Dialysis Patients by Moss (WVU). Is this an official designation a la the State of the Science lecture given by Fischberg and Goldstein every year at the end, or is the title the submitted one and an appeal to authority? I am not sure but the topic is a good one for expansion of palliative care to a underserved population. Lyckholm (VCU), and Morrison (Baylor) review Developing a Curriculum for Rotating Trainees, which would be nice for many programs to have, except it is hard to find a one size fits all approach for this, but I expect Laurie and Laura will have some good pointers.

Ending Prevention: When and How to Stop the Statin, Ignore the Blood Pressure, and Give the Patient a Cookie covers a topic that needs much more exploration in our field since there are very few research studies on withdrawal of medications and potential harm or benefit. While deciding what to stop may appear simple on the surface it requires a deft blend of medical and psychosocial knowledge to achieve well. Professional Boundaries is covered by Vig (U. Wash), Foglia (NCEHC) and Puchalski (GWU) and is an area we need to help each other in as good teams do. Cross-culturalism, Billing, and Psych meds round out the session, not all in one talk though.

2:15-3:15p

My pick in this session will probably be the very popular Memento Mori in Film and Visual Arts by Matzo and Nedeljkovich (U. Oklahoma). I find these lectures that blend pop culture and medicine typically do well for many reasons: As a break for potentially monotonous speaker via likely inclusion of multimedia, applicability to use back home with colleagues, likely stimulating for discussion with peers. If I was going on Thursday, this is where you would find me.

Although there are other good sessions as well, particularly the Cytokines talk by the MD Anderson folks, although the applicability to everyday practice may be lacking, it is good for the field to recognize this type of pioneering basic research to back up our field. Schonwetter and his colleagues at LifePath will be highlighting their efforts to build Community/University Partnerships which will lead to better and more applicable research in hospice organizations. This would be my second pick, as it is something I am working on myself right now. Other talks covered during this session are Evidence Based Care, more Cultural issues, and a focused session on Parkinson's. And of course a congratulations to Russ Portenoy for receiving the PDIA Palliative Medicine Leadership Award. He will also be speaking during this time.
3:30-4:30p

We have our winner for first repetitive use of title: Methadone: The Good, The Bad, and The Ugly. It doesn't happen every year and is of course no fault of the presenters, but hopefully in the future duplicates may get straightened out so all the titles don't become too cliche. Of course if the title is well-integrated into the talk it may be more difficult to change titles so quickly. Picking a title is an important skill in submitting a talk, which I will review more on submissions for talks sometime in the Spring. But seriously, Loitman (Wash U) and Gazelle (Harvard) should do great in helping to learn about the peculiarities of methadone is important, particularly with the recent reports of increasing deaths secondary to methadone.

Interventional Radiology for Symptom Control by Gershon, Ninan, and Singh (MD Anderson) should be good as a primer in the various ways that palliative care can be very helpful but not necessarily cheap. A good argument for not basing the whole financial reason for your service as a a potential cost reducer. Palliative care is not always cheap on the technology or the pocket book. Faith Hospice and Alive Hospice send Dr. Mulder and Dr. Bridges to update our field on the Impact of Open Access Policy on Hospice Length of Stay and Cost per Patient Day. The advocates for Open Access seem to have quieted down from a few years ago, and I wonder if it is because they found a model that works and don't want to share it, or if Open Access is a strategy that cannot be supported under the current (or future) reimbursement mechanisms. I sound too cynical either way, don't ?. I hope they have some good new to report. And my Kansas City colleague Jesse Roberts, MD from NorthCare Hospice & Palliative Care will be presenting data from their 5 year foray into specialized Cardiac Hospice. They have done a good job with it and other hospices will want to see if it is a formula they may be able to emulate in their area. Data Analysis, and Communication topics round out the session as well as another PDIA Leadership Award, this time to Terry Gutgsell, MD from the Cleveland Clinic.

That evening after the Poster Session and Job Fair (Go see Drew!) and the SIG meetings is the AAHPM Music Event. I really had a good time here this year, but I wonder if Cameron Muir or Perry Fine or any other AAHPM royalty will break out the instruments. Good thing this is Thursday night, so you can still attend the Pallimed get together Friday night at Backjack's! I can do a wicked beatbox impression of "I Can't Get No Satisfaction" but that is all the music we have to offer. At least until I can get my new cover band started..."Sinclair & The Opiates."

• University of Tampa sunset photo courtesy of flickr.com user joerosh1675
• Band photo Courtesy of C. Sinclair back when I was in my band "Failure 2 Thrive." Seriously.
  

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Serious toxicities of bisphosphonates, including the oral bisphosphonates indicated for the prevention of osteoporosis, have recently been reported.

Atrial fibrillation
The first was in an article and related letter in NEJM, calling attention to a puzzling association between infusional zoledronic acid (Zometa) (once yearly for prevention of osteoporosis) and atrial fibrillation. A study of alendronate (Fosamax) (oral) was also cited. The FDA followed up with an “Early Communication.”

Severe musculoskeletal pain
More recently—Jan 7, 2008—the FDA issued an “Alert” for health care professionals related to otherwise unexplained severe and “incapacitating” musculoskeletal pain associated with any form of bisphosphonate. In the cases cited, response to stopping the bisphosphonate ranged from immediate cessation of pain to “slow or incomplete resolution.” The FDA Alert points out that the prescribing information for bisphosphonates includes information on this issue in the Precautions section. I have abstracted the pertinent statement from the alendronate package insert (I’m not picking on alendronate; this seems to be a class effect):

Musculoskeletal Pain
In post marketing experience, severe and occasionally incapacitating bone, joint, and/or muscle pain has been reported in patients taking bisphosphonates that are approved for the prevention and treatment of osteoporosis (see ADVERSE REACTIONS). However, such reports have been infrequent. This category of drugs includes FOSAMAX (alendronate). Most of the patients were postmenopausal women. The time to onset of symptoms varied from one day to several months after starting the drug. Most patients had relief of symptoms after stopping. A subset had recurrence of symptoms when rechallenged with the same drug or another bisphosphonate.
In placebo-controlled clinical studies of FOSAMAX, the percentages of patients with these symptoms were similar in the FOSAMAX and placebo groups.

Osteonecrosis of the jaws (and other sites)
Almost all of us (in oncology-related settings, anyway) are aware of the phenomenon of osteonecrosis of the jaws associated with pamidronate (Aredia) and zoledronic acid (Zometa), first reported in 2003. These two bisphosphonates are used to treat bony disease in multiple myeloma and metastatic cancer. However, most of the literature on bisphosphonate-related osteonecrosis of the jaws appears in journals that most of us don’t regularly read.

I’m going to report on a new article, an excellent review of bisphosphonate-related osteonecrosis of the jaws (BRONJ) (the preferred terminology adopted last year in a position statement by the American Association of Oral and Maxillofacial Surgeons). The review begins with a discussion of the actions of bisphosphonates that make them so valuable in cancer therapy and supportive/palliative care: they treat/prevent pain & hypercalcemia, and “skeletal-related events” such as pathologic fractures, are tumoricidal, and may also be antiangiogenic. Bisphosphonates are cytotoxic to osteoclasts, resulting in reduction of bone resorption. Amazingly, the half-life of bisphosphonates is 10 years.

Incidence and prevalence data are weak, but certainly in the single digits for intravenous bisphosphonates, and ranges from 1 in 100,000 patient years to 1 in 2260-8470 patients for oral bisphosphonates. More and more case reports are being published, however. Sites are generally in the mandible or maxilla, probably because the thin mucosa and bacteria-rich environment predispose to injury and infection. There is a long discussion, with plenty of pictures and radiographs, of diagnosis and clinical presentation. Pain may be a presenting symptom, usually because of infection/inflammation, but exposed necrotic bone may be asymptomatic. History and oral examination lead to the diagnosis. A staging system has been proposed, but is yet to be extensively tested.

Proposed risk factors

1. Zoledronic acid has a much higher incidence than pamidronate. A single patient who took only an oral bisphosphonate has been reported to have BRONJ.
2. Cumulative dose of bisphosphonate. Cancer patients receive significantly higher doses than patients treated for prevention of osteoporosis and constitute the preponderance of cases.
3. Risk of developing BRONJ increases significantly with length of time treated.
4. Tooth extraction or other oral surgery
5. Oral trauma

Guidelines for management tend to be conservative, because early experience suggests surgical intervention makes things worse. Goals of therapy are to preserve/improve quality of life by treating pain, preventing infection, and preventing new areas of necrosis. Prevention includes instruction to patients on good oral hygiene, increased frequency of professional oral exams, instruction on the risks of developing BRONJ, and informed consent prior to oral procedures. Whenever possible, dental exams and necessary procedures should be completed prior to commencement of bisphosphonate therapy, especially intravenously. Weighing risks and benefits of alternative, less invasive procedures, should be considered. Optimizing oral health through exemplary self care and professional prophylaxis is emphasized.

Management of later stage BRONJ is not well defined, and prospective trials have not been completed. In addition to surgery, interventions under consideration include hyperbaric oxygen, topical application of autologous platelet rich plasma, laser biostimulation, and systemic administration of teriparatide, a synthetic parathormone.

A major patient-level question, of course, is whether bisphosphonates should be discontinued. This paper recommends consultation between the treating oncologist and treating dental specialist, with risk and benefits thoroughly explored and discussed with the patient. There is general acceptance of the major therapeutic benefits of bisphosphonates. I am unaware of any systematic approaches to adjusting current dose or scheduling of bisphosphonates in an attempt to ameliorate risk. Without a new round of clinical trials with long-term follow up, any changes in current practice will be a shot in the dark and could expose patients to increased risk of the very conditions that bisphosphonate therapy is intended to prevent.

I should also point out that this month alone there are several articles in various journals, mostly from the dental literature, on various facets this topic. An example is a first-of-its kind study of aseptic osteonecrosis (of any site) as a potential adverse outcome of oral bisphosphonates. This was done as a retrospective case control study of a large group of elders in a Quebec data base. The results showed an overall incidence of avascular osteonecrosis (AON) (sites undefined) of approximately 2.7/10,000. Ten matched controls were identified for each AON case. The adjusted rate ratio for oral bisphosphonate users was 2.87. Prior corticosteroid use may have been a risk factor.

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Dear Pallimed Readers,

Thanks so much for joining us here at Pallimed. Drew, Tom and I appreciate your feedback very much. We have received some great emails throughout the past 3 years, but we have never done a more formal sampling of our readers. For the next week, we would like you to complete a short survey to better understand our audience. We also would like to know how you make the best use of Pallimed and what you would like to see us do (or NOT do) in the future.

Please complete it only once. We will not sell your information. We pledge not to bombard you with survey pop-ups, or separate emails asking you to finish this. It is a voluntary survey. But with over 600 regular readers we are hopeful for a good turnout.

We are expecting to provide our readers with some feedback from the survey by mid-February.

Thanks,

Christian Sinclair (on behalf of Drew, Tom and Pallimed)

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The American Academy of Hospice & Palliative Medicine and the Hospice and Palliative Nurses Association Annual Assembly is coming up next week. I started doing the preview because one of my favorite things about conferences is talking to other people to see what they are interested in, so feel free to tell us what you are going to and why. If you are giving any of these talks, I encourage you to leave some comments to get more people aware of your talk. I am not as familiar with some of the HPNA speakers and their experience so please feel free to leave comments.

Previous entries:
Preview of AAHPM Pre-Conferences - Part I

Train the Trainer sessions are an essential part of spreading information in a consistent manner. they usually follow a script to some degree as a means to ensure the consistency. Usually they are taught by a few experts in the field. Nancy Grandovic is the director of education for the HPNA, so that is a pretty good qualification. While the course is $200, you do get quite a few resources for the price. Might be a good resource for getting more certified Hospice & palliative Care RN's.

8a-Noon

As anyone who has started to work through billing issues with advanced practice nurses knows there is a lot of variation from state to state, and things that seem clear end up being pretty cloudy. For anyone who has an advanced practice nurse working in your hospice or palliative care program, this one is a must to make sure that you are optimizing a great resource. Tom, any comments on how nurses can make the acronyms less confusing or what the origins for all the different levels are? (APRN, APN, APNP, CNS, etc, etc.)



Covering an important area in hospice care, Betty Morgan delves into PTSD, substance abuse, and other complex psychiatic co-morbities as they relate to patients and families. From the abstract it sounds like it will cover more then just depression and anxiety for sure.


While not an area that many small palliative care programs and hospices may be able to enter, this is a subject that has not been covered much in recent conferences. I am glad to see policy programs such as this. One interesting thing that came up in a recent discussion of future avenues for expanding hospice programs was for individual programs to collaborate for local and regional legislative initiatives. Given some of the very competitive markets for hospice this would be a nice area to see some collaboration.

1-5p


This session would be very helpful for nurses in the field since they act as eyes and ears fro all things clinical in programs that do not have the luxury of physicians that make home visits. Even when you do have more active physician involvement in the home, the level of nurse-MD collaboration seems to increase necessitating better H&P skills for the nurse.


For most palliative care practitioners, family dynamics are really on-the-job training. Having a MSW (Stellrecht) as part of this session may be an important piece to setting up a systematic way to address family conflicts. Interestingly it is listed as a workshop but there is no mention of role-play, maybe because that usually scares people away because of fear of participation?


This description of this session starts out by describing pacemakers and defibrillators, but the rest goes on to only address ICD's and the withholding of ICD therapy when near the end-of-life. I have noticed the general opposition to ICD reprogramming at EOL has been much less recently, but the issue of whether or not to withdraw/withhold pacemaker therapy seems to be more controversial in the cardiac field. I hope they go into more discussion about pacemakers as well since they have 4 hours.

Look for the rest of the conference this week. There are a lot of sessions so expect a few posts.

Photo by Flickr.com user Damgaard

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(Editor's note: this post was originally published Thursday Jan 18 but was never picked up via the email update feed so I reposted it on Saturday for those who rely on the email for Pallimed updates. Thanks/Sorry.)

1)
Archives of Internal Medicine has an article about the development of a prognostic index for COPD. The data came from 12 randomized drug trials for COPD involving ~8800 patients; this analysis extracted data from those trials (mortality, hospitalizations, etc.) and created several prognostic indices from them (they used the first 2/3 of patients temporally enrolled in each trial as the derivation group, with the final 1/3 as the validation group). The methods are quite complicated but essentially were: they identified significant patient characteristics in the trials which predicted death, hospitalization, or COPD exacerbations (e.g. body mass index, FEV1, age, health related quality of life); they made 3 separate indices to predict those outcomes as well as a composite index of all 3 indices; then validated these indices separately for the individual outcomes, as well as the composite index for the individual outcomes. With some tweaking they more or less found that the composite index was pretty decent at predicting all 3 outcomes and the final index they present gives likelihood - at 3 years - of death, hospitalization, as well as expected number of exacerbations.

How useful this is going to be for palliative medicine professionals is unclear. The final index contains mostly readily available information (age, BMI, FEV1, history of cardiovascular disease, gender, history of ED visits) but also needs quality of life data from one of two quality of life indices (they provide a web-based calculator for the index, albeit one that is not currently functional, and it's unclear if the calculator will assume one has access to the QOL indices or not). (The other recent COPD prognotic index - the BODE index - also contains a less than routinely available element - the 6 minute walk test.) Also, similar to the BODE index, this one is unable to predict short term mortality (and, in fact, the highest possible score on the index predicts 'only' a 31% 3 year mortality). I don't want to sniff at a 1/3 3 year mortality, but I think we are all hoping for a reasonably accurate way of identifying patients likely to die within one year, and this is not it. I've done some philosophical pondering about COPD in the past on this blog, although I can't find the post currently, but I have long wondered if COPD is a sufficiently inherently unpredictable disease and it might be a positivistic folly to think we can systematically do better than this (for individual patients, at times of course, we certainly can).

That aside, there is good reason to believe this index overestimates prognosis for COPD patients, as all subjects involved were healthy enough to participate in a drug trial, and it would be helpful to see further validation (more like re-calibration) studies in more real-life COPD patients, particularly those which HPM professionals tend to see (applying it to a series of patients at the time of hospitalization for a COPD exacerbation, for instance). Despite the relatively good survival of the worst group, they were predicted to have 9 exacerbations in that time: these are patients in need of help, support, and advance care planning.

Briggs, A. (2008). Development and Validation of a Prognostic Index for Health Outcomes in Chronic Obstructive Pulmonary Disease. Archives of Internal Medicine, 168(1), 71-79.

(The same issue also has an interesting discussion of whether participants in phase I cancer studies should be considered 'vulnerable' or not. The authors conclusions are more or less that most phase I patients are white, middle-class, English speakers with good performance statuses and therefore can't be considered vulnerable.)

2)
Annals of Internal Medicine has published an 'Update' in palliative medicine, as well as a couple other palliative care reviews/guidelines.

The update, which is to the best of my knowledge the first one ever published by Annals for palliative medicine, is part of an ongoing series Annals publishes on all the internal medicine subspecialties/disciplines (cardiology one month, hospital medicine the next, etc.). The intended audience is non-palliative care internists/subspecialists, and it is great to see HPM included in the mix. Maybe ACP Journal Club will be next.

The first guideline is one on improving pain, dyspnea, and depression at the end of life. The second is a systematic review of improving palliative care at the end of life. The first is a fine one for the teaching file, although there's likely not much new there most HPM professionals. The second is a good, broad overview of improving care at the end of life, and is well worth a read. I found this paragraph particularly interesting about how we even go about defining 'end of life' care:

"The literature used various approaches to identify patients at the end of life. Some used clinician assessment of "active dying" or "patient readiness," but no precise definitions or performance characteristics of these terms have been published. Many studies used specified clinical characteristics, survival prediction rules, or physician judgment. Although prognostic tools usefully characterize subpopulations (for example, heart failure), many patients with fatal conditions have substantial probabilities for 2- or 6-month survival, even in their last week of life. Patients with metastatic cancer, who have an estimated 10% or greater chance of dying within 6 months, are more likely to prefer to avoid resuscitation, even when survival was much less likely than they acknowledged. Thus, clinicians might define the end of life as having a fatal condition, risking death with the next exacerbation, or beginning to acknowledge the seriousness of the situation. Asking clinicians "Would it be a surprise if this patient were to die within 6 months?" is being used widely but also has had no rigorous testing. The studies emphasize that acknowledging death risk is important for decision making. Waiting for near-certainty would fail to identify most dying people, so palliative approaches need to be regularly incorporated for people living with serious illnesses."

The same issue also has a prospective study on the prevalence and severity of pain in adults with sickle cell disease. Disturbing findings.

3)
American Journal of Medicine has a report on sudden death and methadone use. It's based on an autopsy series comparing findings in patients with sudden death who had methadone in them at the time of death (known overdoses were excluded) with those who weren't taking methadone and found that cardiac abnormalities (e.g. coronary artery disease) was more common in those not taking methadone (suggesting increased rates of death from cardiac arrhythmias in the methadone group). The level of evidence to support this conclusion is weak (based on the study design), but it is still another cautionary study about methadone (there has seemingly been a half dozen or so of these in the last couple years).

4)
A recent Current Heart Failure Reports has a casual article about long-term use of inotropes in 'end of life heart failure care.' It is a general discussion of their use, but also discusses a single institution's experience with home inotrope use specifically in a palliative/end of life context. While the paper doesn't formally present data, it looks like however this program wasn't terribly successful in keeping patients at home: 36 patients, mean survival 3.2 months, 46 hospitalizations (7 for line sepsis), and 42% died in the hospital. (To be fair of course it may not have been the patients' or clinicians' goals to keep the patients out of the hospital, and while I don't have any ready figures I wonder if 42% in-hospital death is relatively low for CHF....).

5)
And in case you missed it here is the info on the Pallimed Happy Hour at AAHPM:

The '2nd Annual Pallimed Happy Hour' will be at Backjack's, Friday February 1st at 7:30PM until at least 8:30PM, but could go longer if anyone hangs around. 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).

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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.

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1) Pain has early e-pub'd a randomized, controlled trial of alvimopam for opioid-induced constipation. (Alvimopam is a peripherally acting mu-opioid antagonist - it counteracts opioid effects in the periphery such as constipation without blocking central effects like analgesia or sedation.) This is an industry-funded study. ~520 patients were randomized to placebo or 3 different dosing regimens of alvimopam for 6 weeks (.5mg big, 1mg daily, 1mg bid). These were adult patients, from 9 different countries, all taking opioids for chronic non-malignant pain (mean age ~50 years, almost all were white, mean opioid usage was ~6 years, mean daily oral morphine equivalent doses were in the 200-300mg range, most had chronic back pain & the rest an assortment of other chronic pain syndromes). Subjects had to have 2 or fewer spontaneous (not laxative induced) bowel movements in a two week run in period prior to the study and were 'asked' to discontinue other laxatives during the study but were given rescue bisacodyl. The primary outcome was increase in spontaneous bowel movements (SBMs) through week 3, although they followed patients for 6 weeks.

SBMs increased significantly more in all treatment groups compared with placebo (baseline was ~1/week, placebo increased to ~3/week, alvimopam groups increased to 4-5/week). This difference was despite notably increased use of rescue bisacodyl in the placebo group. There were a bunch of other secondary outcomes looked at - all related to improvements in stool frequency, consistency, and overall constipation symptoms: alvimopam globally did better than placebo, and there weren't much differences between the different alvimopam dosing regimens. Side effects & drop outs were similar between all groups, with a little more abdominal pain and diarrhea in the high dose alvimopam group, although not statistically significant. Pain and opioid use were stable in all groups. The improvements in bowel function were sustained for the full 6 weeks in the treatment groups, without attenuating. Due to similar efficacy and better tolerance, the authors' conclusion is that 0.5mg bid is the recommended dosage.

So, more good evidence that alvimopam is effective for opioid induced constipation, without any causing withdrawal or worsening analgesia. The question really is, is it a better (more effective, better tolerated) agent than the traditional mainstay of opioid induced constipation - stimulant laxatives such as sennasides and bisacodyl? My experience has been that these are quite effective for most patients...although it's a perennial problem educating patients sufficiently in how to effectively use/titrate them. I'm looking forward to using this, and methylnaltrexone, but will likely reserve them for the minority of patients who 'fail' stimulants. (On the other hand, since these will be prescription drugs if approved they may actually be cheaper for patients since high dose over the counter senna & bisacodyl can be really expensive). Anyway, one doubts that Industry is going to be funding such a study anytime soon. Final comment: I have it in the back of my head that alvimopam was encountering regulatory issues in the US regarding its approval due to toxicities (?cardiac) - I can't find my reference on that though - does anyone know or did I hallucinate this?

2)
Briefly, Lancet recently published a blinded, randomized, controlled trial of haloperidol, risperidone, or placebo for aggressive behaviors in patients with intellectual disabilities. Basically all groups improved equally (placebo actually did a little better) in the study and the authors conclude antipsychotics are overused for this indication. A reasonable conclusion, however the doses used were small-ish (mean of less than 2mg for risperidone, 3mg for haloperidol), and there was such a dramatic (and presumably spontaneous) improvement in all groups that it's tough to judge anything. Either way, I'm watching with interest how the research on the use of antipsychotics for 'behaviors' (in dementia or in this case intellectual disabilities) is catching up with practice, and practice doesn't seem all that evidence-based anymore. I don't know what exactly this has to do with palliative care, other than we use these agents frequently (although for different indications), and it's interesting to see this scrutiny of them.

And even more briefly - and this one is really for prognosis 'completists' - Lancet Oncology has a paper about a prognostic nomogram for newly diagnosed glioblastoma. I'm not particularly qualified to judge the merits of this (it was developed using 'recursive partitioning analysis' and other things that I long to understand but know I'll never devote the energy to actually doing it) but it uses routinely available patient characteristics (at least in one of its iterations) to predict median survival and 2 year survival (calculator here).

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There have been a few pieces in the media recently that have caught my eye in regards to how we as a society look at death and dying. The Montreal Gazette published an opinion article with the title "What if we could choose our time to die?" The author, Hugh Anderson, writes the piece in response to letters from his previous piece about growing old. He never makes a strong statement about hastened death, but his title alone is provocative to start a few conversations.

What if we took our current concepts of medical care and instead had a very open approach to time of death, similar, for example, to our medical approach to time of birth. Time of birth used to be wholly a natural event, for better or for worse, but the advancement of modern C-sections, medicines & delivery techniques changed the natural prognosis (expected timing and medical outcomes) for births. What would our current system of hospice, palliative medicine, and intensive care units look like if in 1950 American society determined choosing the time of your own death was an inalienable right? I doubt if we took the quick road to death that the modern hospice movement would have evolved as it did. Would this change our approach to organ transplants as well? What other areas of medicine would be vastly different because of this massive social change? If there are any literary minded Pallimed readers who would be interested in doing some creative writing, we could collaborate on an alternate history of the approach to death in American society. Exploring alternate history is a wonderful tool for insight into current situations and values via taking what we hold as normal and turning it completely around. I think you could take this idea and explore it in various outcomes, from dytopia to utopia. Obviously movies like Soylent Green and books like The Giver explore some of the social ramifications of euthanasia, but a focus solely on our medical culture would be an interesting approach as well. (Disclaimer: Not endorsing hastened death, physician-assisted suicide or euthanasia, just using these examples to explore the deep intricacies of such a profound part of life. Besides, Hugh brought it up, not me. I can't help wanting to share some potentially provocative ideas. Great dinner conversation!)

Speaking of how society feels about death, the Supreme Court heard a potential landmark case (Baze v. Rees, 2008) today noting the 3-drug lethal injection (thiopental, pancuronium, potassium) is unconstitutional because of the potential for severe pain without the ability to identify it (secondary to the paralytic). You can read the transcripts of the oral arguments here for you legal junkies. What is interesting is to read some of the amicus briefs in support, opposition and neutral positions. The American Society of Anesthesiologists weighs in as well as heavyweight medical ethicists/palliativists Robert Truog, Bernard Lo, and Margaret Campbell (with fellow critical care providers and ethicists.) One of the arguments heard today for changing lethal injection is to co-opt the methods for hastened death in the Netherlands or Oregon, by using inordinately large amounts of barbiturates. How would this change the debate on physician assisted suicide if it was a similar clinical approach to capital punishment?

Wired Magazine had a recent article showing us that death is nothing we need to worry about because of some new miracle drugs that focus on our mitochondria. Some great quotes are found in the article from bench researchers:

"They die of natural death ....probably their heart stops to beat!" wrote Fontana of the rodents in his and other studies, which betray little evidence of the histopathological lesions -- tissue and organ damage or abnormality -- mentioned by Bartke. "The animal drops dead and we cannot really know why.... One expanation (sic) is the failure of the electrical conductive system of the heart because of metabolic alterations.... No pain, no suffering, no medical and social cost for society!"

Well this post is already getting too long so I won't comment on the broad assumptions in the last part. Maybe it is because I fear I might lose my job if this comes true. But it did make me chuckle to think of how these little mice will change lifetimes of angst about death.
YouTube clip of Ingmar Bergman's The Seventh Seal - Knight Facing Death in Chess
(wait until about 2 minutes in, there are some great lines here)

• Did not see much press (unfortunately) about Dr. Byock's initiative for Reclaiming the End of Life and discussing this with Presidential candidates at town hall meetings. Since the NH primary should soon be over and the last news report on the website is Sep 2007, we might not see more action from this until the Presidential election in November.
  

• Speaking of politics, political candidates are (sadly) bringing up the unfortunate case of the 17 year old who died while awaiting a liver transplant as a way to point out failures in our current medical system. While most media outlets seemed to pitch the most emotional part of the story ("A girl was denied a life-saving treatment by an evil insurance company"), Maggie Mahar at Health Beat does a great job of highlighting the complex ethical issues in this case that has some good teaching points for palliative care (prognostic accuracy, second opinions, goals of care, etc.) There were not easy answers in this case, and there are many tragedies here as well, which now seems to by devolving into finger pointing.
  

• Feedback on some of the DonorsChoose Projects are included in the comments section. Thanks to all of those who participated on behalf of Pallimed!
  

• Winners of the HPCFUSA BOOK and Coffee Mugs will be contacted soon and later announced.

Pallimed will be represented at AAHPM by Drew and Christian so due to popular demand, we will be having another Pallimed Gathering @ AAHPM in Tampa, FL. We do not have the location yet, but we have planned on Friday night Feb 01, so mark your calendars and bring your friends. We had a great turnout last year, and hope to meet more Pallimed readers this year. Look here for more info soon.

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Happy New Year and welcome to 2008, which is Pallimed's 4th calendar year (we've been around since 2005), which seems like a long time to me, and perhaps should warrant a more festive or at least reflective post that the one I'm composing, but oh well.

1)
Journal of Clinical Oncology has an 'Art of Oncology' piece with the not-too subtle title and message 'Just Say Die.' That is - when you think a patient is in fact dying, or death is nearing, or whatever, to tell them that, D-word and all. It has the cheekiest table I've seen for a while in the article: column 1 contains actual quotes from oncologists to a dying patient (most of them awkward, and wordy), column 2 is labeled 'What the physician meant' (the translation of column 1) and every entry is 'You are dying.'

The question, at the heart of editorial, is essentially - is important to say die/dying/death to a patient if that's what happening - as opposed to some euphemism ('time might be getting short,' 'this may be entering a terminal phase') - as long as the patient understands what we mean? The author emphatically (although not dogmatically) that the answer is Yes to the above question, and gives several reasons, which go beyond 'it's the right thing to do,' and I'll excerpt my favorite:

"Clearly, the quality of an end-of-life discussion may influence the quality of the relationship we have with a patient. Forthright and clear exchanges will help nurture and develop better relationships while confusing discussions could cause irreparable harm. Death and dying are painful and emotionally charged issues. These words cannot just be thrown into the discussion for clarity's sake; they must be used with care and understanding to let patients know what physicians really mean. As Loprinzi et al suggest, "Such stark and life-changing information needs to be shared sensitively if it is to deepen, rather than injure, trust between patient and physician." Some of the most important talks we have with our patients will be those where we need to discuss their approaching death. These discussions help us understand how they view their future and their prognosis. Oncologists get to know their patients’ personalities well as they care for them, and our conversations (and the words we use in those conversations) are tailored for that individual. Will using the words "death " or "dying" be the right thing for every patient or conversation? No. But used appropriately, these words could help improve our discussions about death with many of our patients."

It's my favorite because it frames the conversation in reverse to how it's often conceived: as a way to build trust/relationship with a patient as opposed to a way of undermining trust (because we've failed them, because we are hurting them by telling them unwelcome information, etc.). It reminds me of times during my training when I was discernibly scared of telling a patient the truth, so much so that on several occasions I was patted on the arm by the patient him/herself and told, in as many words, 'There, there, I know this is tough for you.' Humbling moments, to be sure. Facing decline and death is frightening enough that most patients probably don't benefit from seeing their physicians fumbling for words in talking about it, afraid to name the facts of a situation....

As a perverse aside, I'll also note that when I first saw the title of this article I was instantly reminded of a Simpson's episode when Bart's arch-nemesis Side-Show Bob denied homicidal intent behind his writing of "Die Bart, Die" by claiming he was merely writing in German "The Bart, The."

The same issue also has an article about age as a prognostic factor for patients receiving treatment for non-small cell lung cancer (the data are taken from a couple therapy trials). The conclusion is that comorbidity but not age, per se, was associated with worse prognosis.

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Multiple from the last couple issues of Mayo Clinic Proceedings....

Most welcomed, to me, is a practical/clinical review of urine drug testing. It's readable and thorough, and answers many of the questions that come up (at least in my experience) regarding drug testing - ones that I'm asked a lot (e.g. oxycodone and methadone are not picked up by routine 'opiate' screening, sertraline can cause a positive test for benzos, and poppy seeds can lead to 'false' positives for opiates). As to that last point, they cite one analysis which suggested that a poppy seed bagel can have 1.5mg of morphine in it! Anyway, a good one for the teaching file.

There's also a brief discussion about engaging the 'hostile patient,' a situation familiar to all of us. It provides straight-forward, practical advice, and gives examples of language to use. Most appreciated is the discussion that defusing these situations and forging therapeutic alliances with patients can take just a few minutes. It's a teaching point I try to make again and again to residents when we're talking about communication skills: good communication does not take a long time (usually) - sitting down, pretending you have all the time in the world, asking the patient's understanding of what's going on, and sharing info with them/making recommendations can all be done in a matter of minutes in a lot of cases. Careful communication saves time in the long run. (Ok, I'll admit it, that's a 'talking point,' and one that I can't back up with data, but I believe it with sufficient confidence that I promulgate it. I often show little videos of breaking bad news interactions with patients - the 'bad example' is 2.5 minutes long & the 'good example' is 3.5 minutes long and includes therapeutic silence etc. I often ask residents how long they thought the interactions were, and they tend to substantially overestimate how much time was spent - especially the therapeutic silence - 10 seconds - it seems like 30 when you watch it. Anyway, the 3.5 minute video, which is a great demonstration of compassionate, patient-centered communication in which the clinician gives the sense that he has all the time in the world for the patient, is a great example for the residents that all these good communication skills are not time-consuming.)

And super briefly: there's also articles on hospitalized patients' expectations about interactions with chaplains (what they want out of their visits with them, how frequently they want those visits, etc.); on the content of patients' advance directives (i.e. whether they designate a proxy, whether they empower their proxy to withhold or withdraw treatment, etc.); and a single institution study about the prevalence of advance directive completion amongst health care providers at a cancer center.

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JAMA has an article comparing opioid prescribing in emergency rooms by race - white patients were more likely to receive an opioid for pain than African-Americans, Hispanics, and Asian-Americans, even after adjusting for pain severity and diagnosis (even, for instance, long-bone fractures). An associated editorial surveys global disparities in pain treatment, and doesn't mince any words:

"The overregulation of medicinal opium is an enduring and critical problem that contributes to the global undertreatment of pain."