Tweet

As I mentioned in a recent post I have accumulated a large back-log of articles to discuss, and so am going to do a few weeks worth of quick-n-dirty article commentaries to catch up.

And so here it is, the 2nd Annual Palllimed Autumn Mag Citrate Bonanza (in reverse chronological order going down my pile):

1)
Medical Decision Making has a study exploring patients wanting chemotherapy and hospice at the same time. It is reminiscent of research we discussed here. This study is based on a survey of smokers (not actual lung cancer patients, and who had a median age of 34 years) and asks them a series of hypothetical questions (essentially if you had incurable lung cancer, and these were the options presented to you, which would you prefer). They were given accurate, albeit simplistic, descriptions of ‘supportive care,’ chemotherapy, hospice care, and hypothetical combinations of those. Basically most subjects responded that they’d prefer chemotherapy and hospice at the same time. This should not be surprising since essentially what they were choosing in this research was 'The Most Care/Win Win' option (treatments to prolong their life, to attenuate chemo side effects and cancer symptoms, and added practical/emotional/spiritual support to boot). Sounds pretty good when the alternatives were not having one of those benefits, and I’m not sure extrapolating from this young/healthy population’s choice of More Help over Less Help particularly adds anything to our understanding of barriers to hospice care.

Which is not to say they’re wrong: having to forswear chemotherapy is a barrier, but a complicated one, and doesn’t answer the question as to whether we want hospice per se to be able to do everything for those with short prognoses (see related post link above). That is, I think part of this research seems to be rooted in the idea that as a society/medical system if someone has a short prognosis (less than 6 months) they should be in hospice and it's a major problem that so many aren't. I'm personally not sure that this is the case (hospice is underutilized, majorly, to be sure) - they should be offered hospice, they should be receiving superb palliative care (whether or not from a palliative specialist), and they should not be offered ineffective, burdensome treatments: 'The Problem' is that patients aren't getting this anywhere nearly as often/much as they should be. This is different from them 'needing' hospice, and that the 'fix' is just getting these patients into hospice. If we advocate for a system in which patients can receive ineffective, burdensome treatments plus hospice care to soften the blow - we aren't doing anyone a big favor.

(Thanks to Dr. David Weissman for alerting me to this article.)

2)
NEJM has a tidy review of renal failure in cirrhosis. It discusses, generally, its pathophysiology and treatment, and the role of liver and kidney transplantation in its management. While not - at all - palliative oriented, it does touch on prognosis, as well as provides a concise summary of the approach to this highly mortal situation that is not uncommonly seen by palliative clinicians at hospitals which manage these patients (ie – a nice brush-up article for the teaching file). The prognosis data are dismal: this article argues for a 50% 1 month and 20% 6 month survival for patients with cirrhosis and renal failure (without transplant). Yikes.

3)
On the social media & medicine side of things, JAMA just published a survey of medical school deans asking about concerns/history with inappropriate content posting to social media sites by medical students. It seems it is indeed an emerging problem. While a lot of the problem seems to be students whining and revealing themselves in undignified situations (drunk/suggestive party shots, etc.), there were also problems with posting confidential patient material (an issue more of a concern to medical bloggers and why we have tried to be very strict about this on our blog). Most of the reports to deans about this were from within the medical school (staff, other med students, etc.) and only 4% were from patients/families themselves.

4)
Social Sciences & Medicine has a qualitative study using grounded theory about the desire for hastened death (DHD) – based on extensive 1 on 1 interviews with 27 adults with advanced cancer at a cancer center in Toronto, all of whom endorsed some contemplation of a wish for a hastened death. These were sick patients – 70% died during the course of the study. The themes that emerged are consistent with what I think many of us who work with dying patients hear frequently. They found that DHD clustered around 3 themes: a hypothetical exit strategy if things get rough; an expression of despair, and a more peaceful-or-at-least-resigned, ‘letting go’ meaning. None of these themes and the quotes they give really are consistent with suicidality – these patients who expressed, at times, DHD, were not suicidal, at least in the way we usually think about suicide (that is – really/truly wanting to be dead; instead the patients wanted to feel better or, as they resigned themselves to the inevitable, had times when they wondered to themselves that given this was actually going to happen anyway why wait around).

It’s a fascinating read, if nothing for the quotes from patients and to hear what they go through (and the things that others put them through):

“I've experienced such incredible pain over the last little while and more in the last week. Such incredible pain that it made me think that death is preferable to this…I'll sit there for 2 hours in terrible pain. Such pain where I can't yawn even, and I get only half a yawn and my whole insides turn and waiting for the medication to start to work…I'd love to have 48 hours let's say, I'd love to have this weekend where I could plan to have a nice weekend and have no pain. I'd love to do that and it doesn't happen, and the pain affects everything. It makes you tired. It affects how you can eat. It affects your mood. It affects other people, and the fact is that even if you try to hide it, you can't… So that's hard…and I know it's gonna get worse, so that's hard too. It's great to be alive, and pain takes that life out of you, and to sit there for 2 hours with a blanket around you just shivering, with no solution, is really hard.”

“I find it difficult. The two extremes, where the people who tell me that I'm not going to die because God is good, and that God will save me in a miracle, and I say ‘God is good and sometimes He will save people in miracles. But if it was something that would happen to me – it would have happened already. So we have to accept the fact that there is no miracle here…that my time is over.’ And I also find it very hard, the other side, where I ‘love’ the people who constantly say there's nothing wrong with me, everything will be fine, because there is something wrong with me and everything will not be fine."

5)
PLoS Medicine has a study about ‘prolonged grief disorder’ (aka ‘complicated grief’) which tries to validate proposed diagnostic criteria for PGD for the DSM V. The data come from the Yale Bereavement Study (which also generated this controversial and misunderstood JAMA paper about the stages of grief) and involved interviewing bereaved adults (~300, mean age 61 years, interviewed on average 6, 11, and 20-months post-loss).

This is a complicated, statistics-heavy paper (involving how they developed and validated the diagnostic criteria for PGD based on their data set) and I’ll freely admit it broke my brain reading it; this is to say that I can’t comment personally about how persuasive, or not, their proposed criteria are (an accompanying editorial is supportive however of the findings). It's a revealing insight for the uninitiated into how these new diagnoses get established.

The proposed criteria call for diagnosing PGD after 6 months post-loss, and the symptom criteria (you can read in the paper – Table 3) include yearning and the following other symptoms (and in usual DSM style, noting that these cause significant impairments, are not better explained by another disorder, etc. etc.).

1. Confusion about one’s role in life or diminished sense of self (i.e., feeling that a part of oneself has died).
2. Difficulty accepting the loss.
3. Avoidance of reminders of the reality of the loss.
4. Inability to trust others since the loss.
5. Bitterness or anger related to the loss.
6. Difficulty moving on with life (e.g., making new friends, pursuing interests).
7. Numbness (absence of emotion) since the loss.
8. Feeling that life is unfulfilling, empty, or meaningless since the loss.
9. Feeling stunned, dazed or shocked by the loss.
   

Tweet

Tweet

Thank goodness I get The Pain Medicine News.  I used to think of it as a throwaway industry newspaper but lately it has been a great source of information about the FDA's plans toward the future of opioid prescribing and the Risk Evaluation and Mitigation Strategy (REMS) plans that are coming down the pipeline.  This week's issue discusses the Pain Medicine communities trepidation towards the REMS for Onsolis. (article behind membership wall)

Some background first: If you have not heard about Onsolis yet, it is a film containing fentanyl applied to the buccal (inside cheek) surface to dissolve for immediate pain relief.  If you are thinking "Haven't I heard of something like that before?" you may be recalling it with:

Fentora - Fentanyl buccal tablet made by Cephalon
Actiq - Oral transmucosal fentanyl citrate (on a stick but don't call it a lollipop!) made by Cephalon

Onsolis is made by BDSI and in the Summer of 2009 received FDA approval.  And it got a parting gift from the FDA, the first opioid to be subject to REMS.  I won't spend this post talking about the relative merits or risks of prescribing Onsolis but instead will focus on the REMS as it has a huge potential to affect good pain relief.

So here is the REMS process for Onsolis called FOCUS:

• Each patient, prescriber, distributor, and pharmacy enrolls in FOCUS
• Prescriber faxes the initial prescription information to FOCUS
• Prescriber sends the original, hardcopy prescription to a FOCUS pharmacy via courier using the supplied shipping label
• Patient receives a counseling call
  
• While the hardcopy prescription is in transit the FOCUS pharmacy confirms that the patient and prescriber are active in the FOCUS Program database, the patient counseling call has been successfully completed and schedules Onsolis delivery to the patient.
• Upon receipt of the original, hardcopy prescription, the FOCUS pharmacy dispenses Onsolis and delivers the medication directly to the patient via a secure, traceable courier (with adult signature required) (Apparently within 24 hours, and at most 5 business days)
  

So we can now add bureaucracy to the possible barriers to prescribing opioids.  I am not sure how these steps reduce any risk with opioids with overdose and diversion being the two big ones I would assume the FDA is trying to reduce.  I think the goal is laudable and one I think the hospice and palliative care community has not given the full attention I think it deserves, but the method to me just seems to add red tape without effect.  Has the FDA tested this in opioids in a RCT to see if it reduces any risks?  It would be nice to see an evidence based approach to this important problem.  Thank goodness the law that gave the FDA this power also stipulates review of the REMS program for each drug at 18 months, 3 years and 7 years.

But if the FDA trials it with one drug, I doubt anyone is going to prescribe it when there are viable non-REMS options for immediate relief pain control.  The Pain Medicine News article quotes BDSI staff diminishing the REMS effect on sales, but I think the REMS provide a really tough barrier to prescribing unless you have really run out of other options.  The American Pain Society president wrote the FDA a letter stating they were "surprised and disappointed" the Onsolis REMS were "in stark contrast to many of the stakeholder suggestions made."  The article also highlighted the special needs of the hospice and palliative medicine community although I do not know if anyone in our community was directly involved in any of these discussions.


The FDA has a pretty detailed FAQ on the Onsolis FOCUS REMS program here.  The FDA does not expect the Onsolis REMS will be the REMS for long acting opioids. Here is a list of opioids they expect to fall under REMS in the future.  The InVivo Blog has some more info on the FDA's strategy towards REMS.  And here is BDSI's slide deck about Onsolis which I may tease apart more in the future.

And the cost of the medication is unknown at this time.  I knew you were thinking that.  Are you planning on enrolling in the FOCUS program?  I will ask to enroll if only to tell you all about it.

Tweet

Pallimed will be the host for Grand Rounds the weekly round up of the entire medical blogosphere.  Just as a clarification this Grand Rounds is not the same as Palliative Care Grand Rounds, which is published monthly and focuses on a slightly more specific area. (And is really a swell blog carnival if you have not read it!) 

The topic for Pallimed's edition of Grand Rounds will be the 'Art of Medicine/Nursing' which may be interpreted as you like, kind of like art.

So if you read any great blog posts please email me at ctsinclair@gmail.com with "Grand Rounds" in the subject header and if you would be so kind to add the following:

URL:
Author:
Why this highlights the "Art of Medicine/Nursing":

Special consideration will be given to those who submit blog posts that are not their own blog post.  And fair warning I won't be posting every single link that is sent to avoid an endless post of links.

Looking forward to seeing your submissions!

Tweet

I am looking forward to seeing AAHPM President Gail Austin Cooney in Chicago this week to give her a pat on the back for all of her recent publications in high profile media publications.  I think this demonstrates an important function of the AAHPM leadership to engage the public in conversations about palliative medicine and hospice.

This weekend she blogged at The Huffington Post about how the health care reform debate twisted counseling patients about advanced care planning into something more sinister.  She also wrote a Letter to the Editor in the New York Times in August regarding the Palliative Care series.  She was recently interviewed on an internet radio show.  And she is one of the more active hospice and palliative care docs on Twitter (@gcooneymd).  I just wanted to highlight what a great job she is doing.

If you see any other opportunities for Gail or the AAHPM to make an impact email Gail or let me know and I will pass it on at the upcoming board meeting.

Tweet

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

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

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

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

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

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

Here is why I find HPCF-USA so useful:

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

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

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

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

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

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

Tweet

I am traveling to Chicago next week to attend the AAHPM Fall Board Meeting and I wanted to take this opportunity to hear from the Pallimed community if there are any issues you would like voiced at the meeting.  Just trying to do my part in transparency and access so the community represented by the Board of Directors is heard. 

I always knew I could email anyone on the board but it felt intimidating if I did not know them well.  So here is your open invitation, we may not know each other well, but if you read Pallimed you probably know me well enough.  I probably would not have been elected to the board without support from Pallimed readers so if there are any issues/concerns/praise/comments you would like discussed at a higher administrative level I will be willing to listen and pass it on.

You can always email me if you would like it to be private/confidential at ctsinclair@gmail.com or you may want to consider posting it as a comment on this post so the community can also chime in and give supporting or opposing views.

AAHPM Election
Also, just a reminder to all members of the AAHPM that it is election season and you should have received your ballots if you are a full-dues paying member. They must be post-marked October 2nd.  Here is the pdf of the profiles of the candidates.  (Behind membership wall)

Tweet

We don't do a lot of first person narrative commenting here at Pallimed so I wanted to direct you to two fantastic pieces from the previous week.


GeriPal contributor Anne Johnson is a social worker who works with geriatric and palliative care teams (and in fact identifies herself as a GeriPal SW - a first?) who unfortunately had a very difficult time navigating the system to get a palliative care consult for her 93 year old father-in-law.


A couple of quotes to get you interested so you can finish the whole story at GeriPal:

"In other words, I wanted a "goals of care discussion." And that's why I was leaning over the gurney in the ER and shouting (because he's deaf), Joe, do you want to focus on being comfortable? No, he said, I want to wear pants. I took that as a metaphor. I was going to make this hospitalization different."

"I gave him a couple bites of a forbidden scone and jumped guiltily when the nurse came in, feeling like I'd snuck in a crack pipe."

Don't forget to read the comments on the piece as well and leave one yourself for Anne.


Also, Dana Jennings has an excellent piece in the New York Times health section today focusing on the pain that one cannot describe.

"If you can tell an E.M.T., a nurse or a doctor where it hurts and how much, that is generally a good sign. But what interests me even more is the pain that can’t be articulated. Fortunately, I’ve experienced this only twice."

The author goes on to discuss the meaning of severe humbling pain that prevents you from communicating and concludes there is no meaning. "It just is." Another good read from the New York Palliative Medicine Times Textbook. (If anyone wants to compile some of the articles based on some of the links here at Pallimed and some further searching, please let us know. It would be great to categorize some of these articles in a more organized fashion.)

Tweet

Annals has a review of 'last resort' palliative sedation techniques (this makes two Tim Quill papers in a month in Annals). It begins with an apparently true story of a home hospice patient who was denied 'total sedation' despite refractory symptoms and requesting it (patient had to fire the hospice, and a previous palliative care consultant physician managed deep sedation for him over the phone: crazy).

The paper attempts 3 things: first, it tries to clarify the language used to describe sedating practices at life's end; second, it discusses ethical controversies about sedation; and third, it makes some practical suggestions that palliative sedation should be practiced by organizations only with explicit policies, procedures, and quality control.

The language proposed in the paper are three phrases:

1. Ordinary sedation: attempts to relieve a symptom (e.g. anxiety) without trying to alter a patient's level of consciousness. (I don't know why this then would be called 'sedation' as opposed to, e.g., anxiolysis with a medication which can have a sedating side effect, but that's not really important here.)
2. Proportionate Palliative Sedation (from the article): sedating medications (usually benzodiazepines) are progressively increased alongside other symptom-relieving measures, resulting in increasing levels of sedation during both waking and sleeping hours to help relieve suffering. It is usually initiated in response to otherwise intractable physical suffering in imminently dying patients, as in the case described, for example, or for agitated terminal delirium. The end point is relief of suffering that is acceptable to the patient by using the minimum amount of sedation needed to achieve this goal.
3. Palliative Sedation to Unconsciousness: This is what has variously been known as 'terminal sedation,' 'continuous deep sedation,' etc. Deliberately, pharmacologically, inducing a state of unconsciousness in order to relieve otherwise refractory symptoms, and with a plan of maintaining such a state until the patient dies (usually while withholding life-sustaining treatments otherwise such as artificial hydration/nutrition). They mention that this has been proposed, controversially, for existential suffering.

Fair enough; one might note that PPS and PSU in certain instances may, on the ground, appear identical (ie you rapidly sedate someone to unconsciousness for refractory symptoms), although a clinician's intentions might be different (PPS you are trying to control a symptom and 'happen' to need to use deeply sedating doses of a drug to do so; in PSU you've decided there's no way you can control symptoms otherwise, so you intentionally and from the start attempt to induce a pharmacologic coma).

One can appreciate that, in real life, what starts as PPS 'turns into' PSU in those rare occurances when you realize relief of suffering cannot be obtained without induction of unconsciousness, and that clinicians on the ground often don't spend too much time worrying about whether they are doing PPS or PSU. I also wonder that, with these definitions, and by describing PSU as a last resort practice, which it should be and I think by and large is used this way, one should argue that PSU should only be peformed after a trial of PPS, because how else can we be sure it is a last resort option? Which is another indication that trying to distinguish between these practices on the grounds of initial therapeutic goal (adequate sedation vs. coma) can't entirely account for real clinical practice - I think it's fuzzier. That said, there are times in which PSU is attempted from the get-go; for me it's when I conclude suffering is tremendous and death is very imminent (and I don't have hours or a couple days to tinker - or if I did it would be at the expense of ensuring a peaceful death) and you just go straight for deep sedation. Of course, I'd argue this is absolutely 'proportionate' when the alternative is a scenario when an imminently dying patient spends half their remaining hours suffering just so I can be 100% sure that I'm being 'proportionate.'

Which highlights the element of all this which I think they undersell in this paper: the question of imminence. It's actually barely mentioned, at least in frank terms. While they discuss ethical objections to PSU (as potentially death hastening, such as when artificial nutrition and hydration are withheld), such objections, to me, only have merit (which is not to say one has to agree with them) if one concludes that providing PSU is materially death-hastening (by weeks, months let's say). A declining, advanced cancer patient, bedbound, not taking much PO, who is developing altered mental status - this is someone who has days to maybe a couple weeks to live (generally speaking) - PSU without artificial nutritional support is unlikely to be death hastening, and if so by hours or a day or two. And if one is worried about hours or a day or two in dying cancer patients then we should all be debating about whether we should intubate and ventilate these patients to get them those precious days.

These questions have not been rigorously researched (there have been some preliminary attempts), and certainly would be difficult to study (e.g. prognoses of patients who have PSU performed, etc.). Along these lines the authors note that it's very difficult to tell in the palliative sedation literature what exact practice is being studied, due to the lack of agreed upon definitions of these practices. It's possible the authors don't believe imminence, per se, matters - it's less important than the refractory nature of the symptoms and lack of other options. Fair enough, but not foregrounding the importance of prognosis gives fuel to the fire that PSU is PAS-lite, or otherwise ethically suspicious. We all think in terms of risk-benefits; and the risk of a loss of two days vs 2 months, to me, are different.

Leaving my agenda aside here, the paper also gives important recommendations to all hospice and palliative care groups to establish sedation policies, procedures, checks, and quality control to both ensure the best possible care but to also mitigate potential for abuse or misinterpretation of these practices. I think one could also add we, as a community, should agree upon research definitions of these terms, to improve our ability to actually study sedation practices.

(Image is from an August Annals issue.)

Tweet

American Journal of Respiratory and Critical Care Medicine has a paper about the prognostic importance of delirium in ICU patients, and continues the thread of research we've been following recently about delirium and prognosis.

This study was a single-center (Yale) prospective cohort study of older (over 60 years) adults in an ICU, in which delirium was prospectively and rigorously assessed (by research nurses, using the CAM-ICU scale); ~300 consecutive eligible admissions were enrolled. They note that they included patients with 'coma/stupor' as delirious; I initiatlly assumed this implied patients who were spontaneously stuporous/comatose (due to a high grade encephalopathy from sepsis, etc.) as opposed to pharmacologically induced sedation/stupor. However as far as I could tell there were no such exclusions and these data apply to patients with delirium/coma from any cause. They basically looked at the number of days a patient was delirious/altered in the ICU, and correlated that with survival.

Patients (mean age 74 years, 31% with a diagnosis of dementia, 54% intubated, 82% received opioids or benzos in the ICU at some point, median ICU LOS 6 days, meidan hospital LOS 11 days, and median days of ICU delirium was 3). 16% of patients died in the ICU and 50% died by 1 year.

Yes, that's 50% 1 year survival for older patients admitted to an ICU, with or without delirium.

They did a mutlivariable Cox regression analysis and found that number of ICU delirium days were independently associated with shorter survival (hazard ratio); age, comorbidities, and severity of ICU illness were also independently associated with worse survival. Eye-balling median and 1-year survivals based on days of ICU delirium (this is me eye-balling a Kaplan Meier curve): median survival for ICU delirium lasting 5 days or longer was about 2 months with 1 year survival being about 35% for those with delirium 5+ days and 45% for those with 3-4 days. Patients without delirium did much better: 1 year survival was 75% (as far as I can tell the number of patients this represents is not shared).

This is further supporting evidence to the now vast pile of data indicating that delirium in multiple settings is a poor prognostic marker. To take these data at face value, being older, in an ICU, and having alterations in your mental status for more than 4 days implies a 50% 2 month mortality and 2/3 1 year mortality (and any ICU stay implies only a 50% chance of surviving a year). It's important to acknowledge that despite the good quality of the data collection for this type of research - prospective, used a validated assessment tool, all-comers were offered enrollment, etc. - it is still from a single institution and the absolute value of these numbers is not easy to generalize. That said, whether it's 2 months or 4 months or whatever: it's bad, and this study is as good as any recently to show that.

What do we do with this? I have always hummed and hahed about how to apply this sort of research at the bedside. We already know if you're 75 years old, and in an ICU, for any reason - it's a marker of high 1 year mortality. Which is not to say that you're likely to die in the ICU, and that going to an ICU isn't going to 'save you.' Most of these people survived the ICU, although most who had rocky ICU stays died within a few months. That, to me, is the real story - we can save you, but often for a relatively short period of time (and who knows what quality of life). Patients want to live, and be 'saved,' and all that good stuff, but we are doing them a disservice if we don't let them know that while we can 'save them,' and all that good stuff, it's usually not going to be for a long and healthy life. It's time to begin planning, and sorting through how you want to spend that time. A wise mentor once told me when talking about The ICU and older patients is that that the big question is not can this patient survive the ICU (most do and we have incredibly sophisticated systems in place to get people out of ICUs alive) but that can they survive it for what? And for how long? And while most patients want to live, knowing that they might be facing going through that again, and with likely little long-term benefit, many will choose not to do it again.

Anyway - the big etiologic question here, which may have a long term impact on how patients are treated, especially as pain and symptom meds do, indeed, cause/worsen/lengthen delirium, is whether the delirium itself causes the worse prognosis, or whether it's a passive marker of poor prognosis. If it's the delirium itself then anything to prevent or shorten it will make people live longer presumably: that will 1) hopefully be an impetus to actually do large/good trials of delirium treatment (in ICU and anywhere else - we need 'em), 2) raise the spectre of withholding symptom meds in hospitalized patients as they could be perceived as causing/worsening/lenghtening delirium and thus worsening long term prognosis?

(Thanks to Dr. Bob Arnold for alerting me to this.)