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A blog about recent hospice and palliative medicine research, publications, and news, aimed at health care professionals.
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- August 1, 2008
- 03:00 PM
- 1,313 views
Predicting in-hospital mortality from CHF
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
Journal of the American College of Cardiology has a look at predictors of in-hospital mortality for patients hospitalized with heart failure. The study uses data from the OPTIMIZE-HF registry which was a large, US-based quality improvement study/program (i.e. getting patients hospitalized with CHF on more evidence-based therapies, discharged on beta-blockers, etc. - see here) involving 259 hospitals (both academic and community) and 48,000 patients (mean age 73 years, both patients with systolic dysfunction and preserved systolic function were included). The database included ~50 variables: demographics, comorbidities, laboratory (hemoglobin, serum Na, etc.), drug categories (on diuretics, digoxin, etc.), and things like weight, vital signs, etc. In-hospital mortality was 3.8% (about 1800 patients) for the entire cohort.Using the database, they derived a multivariate prediction model of in-hospital mortality which contained 18 variables. The strongest univarite predictors were serum creatinine (in-hospital mortality increased by 18% for every 0.3mg/dl increase in creatinine), age, and blood pressure (higher being more protective).They then derived a relatively simple point-system based on the factors which most powerfully predicted mortality (the above 3 plus heart rate, serum sodium, presence or absence of systolic dysfunction, and whether or not CHF was the primary reason for hospitalization) and created a mortality risk nomogram based on that point system (available here - click on the prediction nomogram pdf). (Of note, the model only included patients with complete data so this was based on ~40,000 patients/~1300 deaths.) The model was validated with a within-cohort sample, as well as with data from other large CHF registries, with pretty good results (C-statistics greater than 0.7). As an example, an 85 year old with a pulse of 110, systolic BP of 90, serum Na of 120, serum creatinine of 2.5, and systolic dysfunction would have a ~40% chance of in-hospital mortality based on this model.To rephrase that, of 100 patients presenting with those characteristics, about 40% would die each hospitalization. I rephrased that to highlight the obvious limits of such models - they can tell us really accurately what will happen to a population of patients but are really limited in telling us what will happen to the patient in front of us. One further caveat about these models is that since it comes from a large QI study there is reason to think that this may overestimate prognosis - patients are likely to do worse outside of such an environment (this is one of the reasons it is helpful to have it validated in outside cohorts, which was done, all of which however were large study registries....). Despite that, they can be used as clinical 'data points' (one of many) in helping us to counsel patients/families as to what to expect. More than this though these are best used as screening tools to identify patients/families with 'acute' palliative care needs (psychosocial/family assessment, prognostic and goals of care conversations, advance care planning, symptom assessment, etc.).HT to Bob Arnold.ABRAHAM, W., FONAROW, G., ALBERT, N., STOUGH, W., GHEORGHIADE, M., GREENBERG, B., OCONNOR, C., SUN, J., YANCY, C., YOUNG, J. (2008). Predictors of In-Hospital Mortality in Patients Hospitalized for Heart FailureInsights From the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Journal of the American College of Cardiology, 52(5), 347-356. DOI: 10.1016/j.jacc.2008.04.028... Read more »
W ABRAHAM, G FONAROW, N ALBERT, W STOUGH, M GHEORGHIADE, B GREENBERG, C OCONNOR, J SUN, C YANCY, & J YOUNG. (2008) Predictors of In-Hospital Mortality in Patients Hospitalized for Heart FailureInsights From the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Journal of the American College of Cardiology, 52(5), 347-356. DOI: 10.1016/j.jacc.2008.04.028
- February 6, 2009
- 09:10 AM
- 1,289 views
Lidocaine patch for cancer surgery pain
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
Supportive Care in Cancer has published a randomized, double-blind, placebo-patch controlled trial of the 5% lidocaine patch for postsurgical incisional pain in cancer patients. It involved an unfortunately small number of patients (28 randomized, 18 completed the trial) who had greater than one month of pain in/near their surgical site (most had breast or lung surgeries), at least 4/10, and with some 'neuropathic features' (had to have burning, paresthesias, or allodynia). They received active (up to 3 at a time, worn 18 hours a day) or placebo patch each for a month, then switched. The study was powered for 50 patients per arm.There were no statistically significant differences in pain between groups at any times (reported worst, least, average, current pain intensity) - and even eye-balling the graphs it's tough to say there were consistent trends. Pain interference was modestly (and statistically significantly) improved with the active patch (e.g. interference with work), but that was it. Unfortunately I don't think we can conclude anything from these data. This seemed to be a well-thought out, well-designed study, with reasonable outcomes, but there just weren't sufficient number of subjects to tell a difference. Even in the best studies on the patch (all involving post-herpetic neuralgia) which showed significant improvement in the active patch subjects - the average improvement was modest (in the ballpark of 1.5 points on a 0-10 pain scale) - and one is never going to show a significant difference with these small numbers.This raises the question - why even pay attention to a symptomatic therapy whose effects are so modest you need 100+ patients to even demonstrate a little improvement? Especially one as costly as the lidocaine patch? Cost concerns aside, I continue to use the patch because 1) it's incredibly safe and well tolerated (no drug interactions or really no demonstrable side effects other than skin stuff), and 2) a small minority of my patients who use it report tremendous benefit - solid pain relief, opioid sparing, etc. etc. (a substantial minority in addition report modest improvements with it). It's possible that the #2 phenomenon is largely placebo (especially since there's yet to be any controlled data clearly demonstrating the patch is beneficial outside of postherpetic neuralgia), and in some ways the lidocaine patch seems to be a perfect storm of a placebo: a prescription-only treatment containing a 'numbing medicine' with fancy packaging that you apply right where it hurts. Sounds good to me. #2 is why I keep using it, but I remain agnostic about what I'm actually prescribing, and I'm curious as to what others think of the patch. From a health-systems standpoint I understand why many insurers and hospices won't use it.Andrea L. Cheville, Jeff A. Sloan, Donald W. Northfelt, Anand P. Jillella, Gilbert Y. Wong, James D. Bearden III, Heshan Liu, Paul L. Schaefer, Benjamin T. Marchello, Bradley J. Christensen, Charles L. Loprinzi (2009). Use of a lidocaine patch in the management of postsurgical neuropathic pain in patients with cancer: a phase III double-blind crossover study (N01CB) Supportive Care in Cancer DOI: 10.1007/s00520-008-0542-x... Read more »
Andrea L. Cheville, Jeff A. Sloan, Donald W. Northfelt, Anand P. Jillella, Gilbert Y. Wong, James D. Bearden III, Heshan Liu, Paul L. Schaefer, Benjamin T. Marchello, Bradley J. Christensen.... (2009) Use of a lidocaine patch in the management of postsurgical neuropathic pain in patients with cancer: a phase III double-blind crossover study (N01CB). Supportive Care in Cancer. DOI: 10.1007/s00520-008-0542-x
- February 20, 2008
- 12:00 AM
- 1,279 views
Genetics and morphine toxicity; Prognosis articles
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
A rather academic post: genetics and some prognostically relevant papers.1)Cancer has a study on genetic variations and response to morphine in cancer patients. The data comes from a prospective study of ~220 advanced cancer patients who were receiving morphine for pain. They were treated per a palliative care team's protocol and about 60 of them were rotated off morphine due to inadequate analgesia /- intolerable side effects. This analysis compares rates of certain genetic polymorphisms between patients who 'did well' with morphine with those required rotation (it is un... Read more »
Joy Ross, Julia Riley, Annie B Taegetmeyer, Hiroe Sato, Sophy Gretton, Roland M du Bois, & Kenneth I Welsh. (2008) Genetic variation and response to morphine in cancer patients. Cancer. DOI: 10.1002/cncr.23292
- October 2, 2008
- 10:46 PM
- 1,267 views
Race and end-of-life care in JAGS
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
Two from JAGS on race and end-of-life care (see next post for the second)....First is an attempt to understand why there are long-standing and persistent racial differences regarding advance care planning and hospice utilization in the US. The study involved older (over 65 years) primary care clinic patients from a single center who were asked a variety of questions about values regarding end of life care and beliefs/attitudes about advance directives and hospice care. ~200 subjects in all; unfortunately only a ~third of eligible subjects participated, making one wonder how much that skews the results.Besides measuring advance directive completion, they measured (using a variety of scales) attitudes and beliefs about end of life care including about hospice care, treatment preferences at the end of life, spirituality, health care system mis/trust, and beliefs about advance care planning. Consistent with prior studies, African Americans were less likely than white Americans to have advance directives, more skeptical of hospice care, had somewhat more distrust towards the health care system, and were more likely to endorse life-prolonging therapies in the setting of a terminal illness. Controlling for all these findings, they more or less found that it was the aggregate of these cultural values/beliefs that predicted less advance care planning use and skepticism towards hospice and not race per se.The flip side of that is that African American 'race' in this and prior studies is likely just a proxy for a set of beliefs and values which are more prominent in African Americans than white Americans (although individuals within each group share the full spectrum of those beliefs/values). All fine and good, but what is really interesting about this paper is that in the discussion section the authors deliberately try to move the discussion away from suggesting that it's a 'problem' (as in a health care system/racism/policy/etc. problem) that African Americans as a group use advance directives and hospice care less - that that's more the product of deep-seated cultural values - and that the challenge to the medical community as a whole is to find more culturally appropriate ways to deliver good end of life care to African Americans. A quote:This work has implications for the development of culturally competent policies and programs that may improve end-of-life care. In this study, African Americans were less comfortable discussing death, more likely to want life-prolonging therapies, and more likely to agree that those who believe in God do not have to plan for end-of-life care; these factors partly explained the relationship between race and possession of an advance directive. Although interventions in church or community settings have increased dialogue about and comfort discussing end-of-life care, many of these programs have not increased the number of African Americans completing advance directives. This is not surprising, because they only partly address potential cultural barriers. Furthermore, given the lack of data supporting the effectiveness of advance directives in improving end-of-life care and the cultural beliefs identified in this study and others, emphasis on the process of advance care planning rather than the completion of documents seems more likely to result in the desired outcome—opportunities for those who want to do so to express their preferences for end-of-life care should they become incapacitated. For African Americans, in addition to community and church-based discussions, culturally sensitive advance care planning should consider the importance of family in decision-making and the value of informal ways of expressing preferences, including oral and written instructions or even deferral of decisions to family, and greater emphasis on understanding and respecting preferences for care, whatever they are and however they are expressed in the context of patients' values and goals.Rebecca S. Allen, Jessica Y. Allen, Michelle M. Hilgeman, Jamie DeCoster (2008). End-of-Life Decision-Making, Decisional Conflict, and Enhanced Information: Race Effects Journal of the American Geriatrics Society, 56 (10), 1904-1909 DOI: 10.1111/j.1532-5415.2008.01929.x... Read more »
Rebecca S. Allen, Jessica Y. Allen, Michelle M. Hilgeman, & Jamie DeCoster. (2008) End-of-Life Decision-Making, Decisional Conflict, and Enhanced Information: Race Effects. Journal of the American Geriatrics Society, 56(10), 1904-1909. DOI: 10.1111/j.1532-5415.2008.01929.x
- November 10, 2008
- 11:00 PM
- 1,263 views
Octreotide for radiation-induced diarrhea
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
Journal of Clinical Oncology has a double-blind, placebo-controlled trial of depot octreotide for the prevention of radiation-induced diarrhea. (The context here is that octreotide has some good trial data supporting its use to treat radiation-induced diarrhea.) This study involved 125 patients receiving radiation involving the entire pelvis (for a variety of malignancies); they received 20mg depot octreotide or placebo at enrollment and after 29 days. The study was powered at 85% to detect a 1-grade difference in diarrhea severity between groups.It didn't look very good for octreotide. Diarrhea outcomes were essentially identical (incidence and severity) and the octreotide group had more adverse events (no biliary toxicity, but symptoms of GI cramping and constipation-like symptoms). Incidence of moderate to severe diarrhea was in the 20-30% range overall.This study was done well enough that it's pretty safe to conclude that depot ocreotide is, indeed, worthless to prevent acute radiation associated diarrhea, and has signficant side effects. Given that there are some ok data for short-acting octreotide to treat diarrhea once it starts, I'm unsure whether this is an effect of depot octreotide itself or (more likely) simply a matter that the incidence of acute radiation induced diarrhea is low enough that prophylaxing for it with a drug with significant toxicities is just not worth it. Or both. Severe enteritis from radiation, while relatively rare, can be such a devastating and morbid complication (fecal incontinence, hospitalizations for hypovolemia, disruption in cancer therapy) that it's disappointing this didn't pan out....J. A. Martenson, M. Y. Halyard, J. A. Sloan, G. M. Proulx, R. C. Miller, R. L. Deming, S. J. Dick, H. A. Johnson, T.H. P. Tai, A. W. Zhu, J. Keit, K. J. Stien, P. J. Atherton (2008). Phase III, Double-Blind Study of Depot Octreotide Versus Placebo in the Prevention of Acute Diarrhea in Patients Receiving Pelvic Radiation Therapy: Results of North Central Cancer Treatment Group N00CA Journal of Clinical Oncology, 26 (32), 5248-5253 DOI: 10.1200/JCO.2008.17.1546... Read more »
J. A. Martenson, M. Y. Halyard, J. A. Sloan, G. M. Proulx, R. C. Miller, R. L. Deming, S. J. Dick, H. A. Johnson, T.H. P. Tai, A. W. Zhu.... (2008) Phase III, Double-Blind Study of Depot Octreotide Versus Placebo in the Prevention of Acute Diarrhea in Patients Receiving Pelvic Radiation Therapy: Results of North Central Cancer Treatment Group N00CA. Journal of Clinical Oncology, 26(32), 5248-5253. DOI: 10.1200/JCO.2008.17.1546
- April 2, 2008
- 06:00 PM
- 1,254 views
Leukemia & ICU prognosis; More
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
1)Cancer has a retrospective study looking at prognosis of patients with acute leukemia admitted to the ICU. It looks at all patients with acute leukemia (in any stage of their illness as long as it was pre-transplant) admitted to the ICU at a single institution over a 4 year period - 90 patients in all, mean age ~54 years, almost all had AML. Mortality up to 12 months was measured.Major findings: ICU mortality was ~57% with another 11% dying that hospitalization prior to any treatment for leukemia (out of the ICU). A few percent recovered, were treated, then died. Only ... Read more »
Snehal Thakkar, Alex Z Fu, John W Sweetenham, Zachariah A Mciver, Sanjay R Mohan, Giridharan Ramsingh, Anjali S Advani, Ronald Sobecks, Lisa Rybicki, Matt Kalaycio.... (2008) Survival and predictors of outcome in patients with acute leukemia admitted to the intensive care unit. Cancer. DOI: 10.1002/cncr.23394
- January 17, 2008
- 05:16 PM
- 1,252 views
COPD prognosis; Palliative update in Annals; More
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
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... Read more »
Andrew Briggs. (2008) Development and Validation of a Prognostic Index for Health Outcomes in Chronic Obstructive Pulmonary Disease. Archives of Internal Medicine, 168(1), 71-79. info:PMID/18195198
- April 9, 2009
- 04:02 PM
- 1,220 views
RCT of Kyphoplasty
by Drew Rosielle MD in Pallimed: a Hospice & Palliative Medicine Blog
Lancet has the results of a multi-national randomized controlled trial of balloon kyphoplasty for vertebral compression fractures. This was an industry-funded trial of ~300 patients with 1-3 acute or subacute (less than 3 months old - mean was 6 weeks old), painful (4/10 or greater) VCFs who were randomized to KP or medical management/routine supportive care (meds, braces, therapy, etc.). They followed patients for 12 months, although the primary outcome was changes in the SF-36 quality of life scale at 30 days. Intention to treat analysis was used; as far as I can tell no one (not even the researchers administering the follow up surveys) was blinded.Health-related quality of life was improved at 1 month (statistically and likely clinically significant) in the KP group; this had mostly attenuated by a year (although remained statistically significant). Pain improved markedly in the KP group in the short term: from (median) 7/10 before the procedure to ~3.5/10 immediately afterwards. By one month the difference was about 2/10 points between groups (3.5/10 vs. 5.5/10); this gap slowly closed over the year and was about 1/10 points at 12 months (3/10 vs. 4/10). At one month 65% of control group patients were taking opioids vs. 45% in the KP group; this difference was gone by 1 year (both ~30%).There was one serious procedure related adverse event (hematoma); 27% had cement extravasation (all aysmptomatic). Overall, rates of adverse events were similar. Cancer/myeloma-related VCF patients were included in the study although only 1% of the subjects had these so one cannot draw any conclusions specifically about cancer-related VCFs.These is the best study done on KP and the results are supportive of KP: rapid and marked pain relief that endures for a year although over months, as presumably the non-KP patients' fractures heal, the benefits attenuate. The benefits in overall health-related QOL are less pronounced, but they're there at least for a few months. It is also reassuring that patients well over a month out from their fractures appear to get good benefit, although they did not present any analysis of whether time-from-fracture was related to the magnitude of the benefit. The biggest concern for me was the lack of blinding; not even in those administering the survey instruments. Patient-blinding is difficult with interventions like these (although it has been done, e.g. at Mayo in the use of sham-procedures in their controlled trial of celiac plexus blocks) of course, but blinding of those doing the analyses and data collection is ideal. In addition, this does not answer the question of whether simple vertebroplasty (which doesn't use balloons) is as efficacious as the more-expensive KP.Wardlaw, D., Cummings, S., Van Meirhaeghe, J., Bastian, L., Tillman, J., Ranstam, J., Eastell, R., Shabe, P., Talmadge, K., & Boonen, S. (2009). Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial The Lancet, 373 (9668), 1016-1024 DOI: 10.1016/S0140-6736(09)60010-6... Read more »
Wardlaw, D., Cummings, S., Van Meirhaeghe, J., Bastian, L., Tillman, J., Ranstam, J., Eastell, R., Shabe, P., Talmadge, K., & Boonen, S. (2009) Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. The Lancet, 373(9668), 1016-1024. DOI: 10.1016/S0140-6736(09)60010-6
- March 11, 2009
- 09:00 PM
- 1,184 views
Supportive vs palliative care: What's in a name?
by Thomas Quinn, APRN, CHPN in Pallimed: a Hospice & Palliative Medicine Blog
A new study just published online in Cancer by the MD Anderson palliative care group asked this question of medical oncologists, nurse practitioners, and physician assistants at their institution in an anonymous web-based survey. Interestingly, there was a 70% response rate to the questionnaire among the 200 practitioners to whom it was sent.The impetus for this study was apparently an observation that palliative care service referrals continue to be made late in the illness trajectory, despite efforts to encourage clinicians to use PC services earlier. The authors cite 2 studies, one in Japan (patients, families, physicians, and nurses) and one among US pediatricians and parents. These studies found that the name "palliative care" had a negative image and was a barrier to referrals (Japan) and evoked negative emotions and was less favored than "supportive care" (US). The authors decided to conduct a similar study in a large US cancer center with a well-established Palliative Care Service.The study was web-based. The subjects were randomly selected medical oncologists and mid-level providers (NP's & PA's); 100 of each group were invited by e-mail to participate. The questionnaire was short & straightforward, first asking clinicians if they were more inclined to refer patients for symptom control to a service named Palliative Care vs Supportive Care when patients were in the following groups: newly diagnosed with cancer; undergoing primary treatment for cancer; in remission; receiving active treatment for advanced cancer; advanced cancer no longer receiving active treatment or in transition to end of life. A service named "Supportive Care" was the clear choice of preferred name in all patient categories except the last, which was close to a tie.When asked what term they preferred using when discussing the referral with patients and families, only 19% preferred 'palliative.'When asked about perceptions associated with each name, 'palliative care' was considered a barrier to referral; well over 50% said that 'palliative care' is synonymous with hospice; a large percent felt that the term 'palliative' decreases hope in patients and families. 'Supportive care,' on the other hand, was significantly associated with treatment for chemotherapy side effects.14% of participants reported that using 'palliative care' actually caused them distress, compared to 6% for 'supportive care.'Despite these findings, participants reported that palliative care services are useful and there was a general willingness to refer, increasing as disease progressed and the patient approached the end of life.The majority of respondents have a different perception of the role of palliative care and where it fits in various parts of the disease trajectory than do most palliative care clinicians, who see a valuable and appropriate complementary role much earlier in the disease. Will concerted efforts to educate clinicians on the definition, benefits, and strategic place of palliative care make a difference in both perceptions and timing of referrals? The authors cite studies suggesting that this might be the case. There has been dramatic growth in the availability of palliative care in the past decade, but that simple visibility & availability is probably insufficient to change perception & practice. Outreach, education, and daily practice will all be needed to expand the prevailing view.It occurs to me that I have seen many studies on the symptom burden of hospice patients and those with advanced disease. It's pretty easy to say that a specialized service might be the most appropriate element in the cancer care structure to address these needs. We also have studies on individual symptoms associated with primary therapy or the disease process, often in the context of intervention studies. But I don't believe that I have seen a study that clearly demonstrates the need for palliative care due to symptom burden in earlier stage disease. "Everyone knows" that patients have symptoms, psycho-emotional distress around diagnosis or decision-making and the like at earlier disease stages, but we probably haven't made the case, backed by data, that a specialty service could/would/should be involved in these earlier phases of the disease.Fadul, N., Elsayem, A., Palmer, J., Del Fabbro, E., Swint, K., Li, Z., Poulter, V., & Bruera, E. (2009). Supportive versus palliative care: What's in a name? Cancer DOI: 10.1002/cncr.24206... Read more »
Fadul, N., Elsayem, A., Palmer, J., Del Fabbro, E., Swint, K., Li, Z., Poulter, V., & Bruera, E. (2009) Supportive versus palliative care: What's in a name?. Cancer. DOI: 10.1002/cncr.24206
- May 8, 2008
- 08:00 AM
- 1,164 views
Peaceful acceptance of cancer; Chemo neuropathy; 'Slow medicine'
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
Two from Cancer:1)First is a paper discussing a scale developed to measure peaceful acceptance of a cancer diagnosis. This comes from the Coping With Cancer Study (previous publication here) and the paper describes the development and some of the validation of their scale ('PEACE') which attempts to measure both 'peaceful acceptance' of an illness (e.g. asks things like To what extent do you feel you have made peace with your illness?) and 'struggle with an illness' (asks about what extent a patient feels their life is over as they now know it, what extent they feel it's unf... Read more »
Jennifer Mack, Matthew Nilsson, Tracy Balboni, Robert J Friedlander, Susan D Block, Elizabeth Trice, & Holly G Prigerson. (2008) Peace, Equanimity, and Acceptance in the cancer experience (PEACE). Cancer. DOI: 10.1002/cncr.23476
- February 13, 2009
- 05:55 PM
- 1,150 views
Cancer pain intensity and analgesic complexity
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
Journal of Clinical Oncology has an intriguing paper on cancer pain intensity and 'complexity' of cancer pain management. The data come from a prospective, Canadian study of ~600 'advanced' cancer patients referred for palliative care consultation (including inpatient and hospice-based settings). 21% reported severe, at least 7/10 pain, at initial assessment. They defined pain control as pain 3/10 or less and 3 or fewer breakthrough doses for at least 3 consecutive days.The findings are interesting on a couple levels. First is the natural history data. Median time to pain control was 4 days for patients reporting mild pain at baseline, compared to 22 days with those reporting severe pain. In fact it looks like (I say 'looks like' because this is me eye-balling a Kaplan-Meier curve) there is a group (~15% of patients with baseline moderate or severe pain) who don't achieve stable pain control (as defined above) even after 90 days. In multivariate analysis having baseline moderate to severe pain, suspected neuropathic pain, and age less than 60 years were independently associated with longer time to pain control. Psychological factors, at least how they measured them, did not predict length of time to pain control in the multivariate analysis. Increased baseline pain also predicted increased use of adjuvant analgesics and higher final opioid dose (a median of 72 vs 12 mg of oral morphine equivalents, compared with baseline mild pain patients).Well, so what? Patients who hurt more need more meds and it takes longer to achieve decent analgesia. On its face that isn't surprising, and could seem to be quite a dull finding. It isn't necessarily however. First off this is supporting data that numeric rating scale reports do tell us something about a group of patients (ie - allow comparisons between groups of patients as opposed to only the strict interpretation of NRS data that they are meaningful only on an individual basis to compare, say, treatment response after initiating a new analgesic in an individual patient). (Yes, this has been a point of some controversy, and the paper's discussion section addresses it further if you're interesting). Second, it's supporting data that for patients who present with severe pain we should not necessarily be 'starting low and going slow' and should in fact be more aggressive. I suspect however that most of us do this anyway because it's, well, the obvious thing to do (much of the time).Finally, however, I am left wondering about this last 15%: the ones that never achieve good control (at least as defined by the criteria above which has the major limitation of not being based in how patients themselves rate their satisfaction with their analgesia: are they happy with their pain relief? Can they do the things they want to do despite having, say, 5/10 pain, etc.?) Most of us who practice in referral cancer pain settings (that is, for example, an oncologist has to refer a patient to me for pain in order for me to see that patient) tend to get referred the patients with the toughest to control pain syndromes (intolerable side effects, lack of efficacy of multiple agents, etc.). This, then, is a patient population near and dear to my heart, and one that hasn't been studied very closely, but is actually quite central to many of us with referral-type palliative practices. Talking with others about this, it there seems to be a bi-modal distribution of patients with cancer pain: the (thankfully vast) majority who do just fine with all our 'usual moves' vs. the (thankfully) few who don't seem to gain particular benefit (whether it's in pain rating, function/mobility, mood/ability to enjoy life) from most things we do, and often with a tremendous amount of suffering tacked on (not least of which are the side effects from the treatments we prescribe). It's these few I'm particularly interested in - who they are, how we can recognize them early, why they respond differently to our 'usual moves' (yes I'm sure it's a combination of genetic, psychiatric, and otherwise neurobiologic reasons but what exactly does that mean anyway), and what we can do about it (because I wonder if they need a distinctly different approach than running them through the toolkit which happens to work for most other patients)....So, sure, that was a rambling presentation of some thoughts that have been meandering through my mind lately, but I am hopeful that as our research base matures these questions will begin to get answered.R. L. Fainsinger, A. Fairchild, C. Nekolaichuk, P. Lawlor, S. Lowe, J. Hanson (2008). Is Pain Intensity a Predictor of the Complexity of Cancer Pain Management? Journal of Clinical Oncology, 27 (4), 585-590 DOI: 10.1200/JCO.2008.17.1660... Read more »
R. L. Fainsinger, A. Fairchild, C. Nekolaichuk, P. Lawlor, S. Lowe, & J. Hanson. (2008) Is Pain Intensity a Predictor of the Complexity of Cancer Pain Management?. Journal of Clinical Oncology, 27(4), 585-590. DOI: 10.1200/JCO.2008.17.1660
- June 30, 2008
- 06:00 PM
- 1,101 views
Prognostic awareness in CHF
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
JAMA has a really interesting article comparing heart failure patients' perceptions of their prognosis with their 'actual' prognosis. 'Actual' in quotes because they looked at their predicted survival with the Seattle Heart Failure Model and not the cohort's actual survival (although they tried to look at that as best they could.) The study involves ~120 patients (median age 61 years) from a single US cardiac center (Duke) with a broad range of heart failure severity (about half NYHA III-IV). They were asked in a couple different ways how long they thought they'd live; this was compared wit... Read more »
L Allen, J E Yager, M J Funk, W C Levy, J A Tulsky, M T Bowers, G C Dodson, C M O'Connor, & G M Felker. (2008) Discordance Between Patient-Predicted and Model-Predicted Life Expectancy Among Ambulatory Patients With Heart Failure. JAMA: The Journal of the American Medical Association, 299(21), 2533-2542. DOI: 10.1001/jama.299.21.2533
- March 18, 2009
- 11:44 PM
- 1,100 views
Religious Coping and Aggressiveness of Medical Care at the End of Life
by Thomas Quinn, APRN, CHPN in Pallimed: a Hospice & Palliative Medicine Blog
I'm expecting a lot of discussion about this study in the current issue of JAMA, "Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer." Religious coping is defined as "how a patient makes use of his or her religious beliefs to understand and adapt to stress." Previous studies have shown that people with high positive religious coping are more likely to have preferences for aggressive life-prolonging treatment and less likely to have advance directives. "Positive" religious coping employs reliance on faith to promote healthy adaptation. "Negative" religious coping tends to see illness as punishment and may indicate existential crisis. Positive and negative religious coping are not mutually exclusive, but negative coping is uncommon. This is the first study to look at actual outcomes in patients with high vs low religious coping.The subjects in this study were enrolled in the Coping with Cancer Study, a multi-institutional, prospective, psychosocial study of patients with advanced cancer. The Coping study is funded by the National Cancer Institute and the National Institute of Mental Health. Data was collected in a 45-minute interview. Both English and Spanish-speaking subjects were enrolled. In addition to patients, caregivers completed separate questionnaires, although caregiver religiousity was not a focus of the current study. Caregivers were approached a few weeks after the patient's death for information about the death (post-mortem chart reviews were also done). The instrument used was the Brief RCOPE, a validated 14-item questionnaire that assesses religious coping. Seven positive and seven negative types of religious coping are included, answered with a 4-point Likert scale. 92% endorsed a least one positive coping scale item, while only 43% endorsed any negative item. Patients were designated as having either high or low religious coping depending on whether they scored above or below the median. In addition, the Structured Interview for DSM IV Axis I to identify patients with panic, anxiety, or posttraumatic stress disorders or depression. Finally patients were asked to characterize their health status and whether their religious/spiritual needs were being met by the medical system.A total of 664 patients participated in the overall study. Data were available on 345 of the 385 patients who had died at the time of the analysis. Death came a median of 122 days after the patient interview. The primary findings were that "a high level of positive religious coping at baseline was significantly associated with receipt of mechanical ventilation compared to patients with a low level;" and with "intensive life prolonging care in the last week of life." Nonsignificant differences were found for CPR received, death in the ICU, and hospice enrollment. In addition, a high level of religious coping, compared to low, was associated with the following: use of negative religious coping, active coping, greater acknowledgement of terminal illness, greater support of spiritual needs, preference for heroic measures, less advance care planning in all forms.The findings persist when adjustment for various psychosocial factors are included. "These results suggest that relying upon religion to cope with terminal cancer may contribute to receiving aggressive medical care near death." The authors characterize this as a possible negative outcome for religious copers "because aggressive end-of-life cancer care has been associated with poor quality of death and caregiver bereavement adjustment." This is a problematic statement for me. It seems to contradict a previous statement that these patients see themselves as "collaborating with God to overcome illness and positive transformation through suffering. Sensing a religious purpose to suffering may enable patients to endure more invasive and painful therapy at the end of life." In addition, some patients see prolonging life as an essential acknowledgement of the sacredness of life. It seems to me that the task of spiritual care with this population is to support, to the extent possible, the patient's expressed beliefs and values while maintaining informed decision-making and consent. It is also important for patients who belong to an organized religion to receive adequate teaching and counsel in the teachings of that religion in order to clear up misunderstandings and misconceptions that may impact their decision making.The authors recommend earlier spiritual assessment and support and inclusion of clergy/chaplains in the care team. A follow up research recommendation is to study the "mechanisms by which religious coping might influence end-of-life care preferences, decision making, and ultimate care outcomes."Andrea C. Phelps, Paul K. Maciejewski, Matthew Nilsson, Tracy A. Balboni, Alexi A. Wright, M. Elizabeth Paulk, Elizabeth Trice, Deborah Schrag, John R. Peteet, Susan D. Block, & Holly G. Prigerson (2009). Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients With Advanced Cancer JAMA, 341 (11), 1140-1147... Read more »
Andrea C. Phelps, Paul K. Maciejewski, Matthew Nilsson, Tracy A. Balboni, Alexi A. Wright, M. Elizabeth Paulk, Elizabeth Trice, Deborah Schrag, John R. Peteet, Susan D. Block.... (2009) Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients With Advanced Cancer. JAMA, 341(11), 1140-1147. DOI: http://jama.ama-assn.org/cgi/content/abstract/301/11/1140
- June 22, 2008
- 03:00 PM
- 1,095 views
Identifying CHF patients eligible for hospice care
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
First - a note on format. As you may have noticed with Christian's last two posts, and mine today, we are changing the format a little. Instead of having ~3 long posts a week, each of which (usually) references many articles, we are going to be splitting up the content into separate posts but will still be updating the content approximately 3x a week. The same volume of content will still be there; just in multi-post form (usually a 'major'/long post and one or more 'minor'/shorter posts).We're doing this to make the blog easier to navigate and search - a post's title... Read more »
Bao Huynh, Aleksandr Rovner, & Michael W Rich. (2008) Identification of Older Patients with Heart Failure Who May Be Candidates for Hospice Care: Development of a Simple Four-Item Risk Score. Journal of the American Geriatrics Society, 56(6), 1111-1115. DOI: 10.1111/j.1532-5415.2008.01756.x
- April 11, 2008
- 01:00 AM
- 1,075 views
Specialized Palliative Care is Not Effective...or Is It?
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
(Begin sarcasm)Stop the palliative medicine fellowship accreditation! Stop the first official accredited subspecialty palliative medicine boards this year! Tell JACHO not to include palliative care in their next round of hospital reviews! Find a job in a procedure based specialty! Quick! Hurry before it is too late. In case you have not heard, palliative care doesn't do anything beneficial.(End sarcasm)Now take a deep breath. Do some self-care. Don't over-react.Let's look at the study JAMA published this week on a detailed systematic review on the "Effecti... Read more »
C Zimmermann, R Riechelmann, M Krzyzanowska, G Rodin, & I Tannock. (2008) Effectiveness of Specialized Palliative Care: A Systematic Review. JAMA: The Journal of the American Medical Association, 299(14), 1698-1709. DOI: 10.1001/jama.299.14.1698
- May 5, 2010
- 11:55 PM
- 1,073 views
Hypothermia, SSEPs, and Prognosis
by Drew Rosielle MD in Pallimed: a Hospice & Palliative Medicine Blog
As a follow up for today's top-post, some more floundering about prognosis in brain injuries, and yes this one is for the progno-wonks out there.
Neurology also has an article looking at the prognostic importance of bilateral absence of the N20 response of median nerve somatosensory evoked potentials for patients with hypoxic-ischemic encephalopathy (anoxic brain injury) who have undergone therapeutic hypothermia.
Some background (although this NEJM review is the best place to go for a quick summary) on why I'm even mentioning this. Absence of the N20 response of median nerve SSEPs more than 24 hours after a cardiac arrest has been reported in multiple studies to indicate a uniformly poor neurologic prognosis (comatose patients after cardiac arrest who have these SSEP findings have uniformly poor outcomes), and it's become a well-established marker (among several) to identify patients with essentially no chance of a good neurologic recovery (see today's other post for more about 'good neurologic recovery').
In the last several years therapeutic hypothermia has been widely adopted for patients who survive initial resuscitative efforts after an arrest (essentially patients are cooled to ~32 deg. C for 24 hours - this is thought to attenuate some of the brain damage that occurs during/after an arrest and has been shown to improve neurologic recovery). Most of the research on prognosis for comatose patients after cardiac arrest was done before hypothermia was adopted, so there's some concern that previously established prognostic criteria are no longer valid (or at least not as powerfully predictive). See for instance this study, which attempts to investigate whether absent SSEPs still invariably predicts a poor outcome for patients who undergo hypothermia (it indicates they do).
The current article, which is a retrospective case series from a single German ICU in which they looked at all patients who underwent hypothermia and had SSEP measurement performed, presents data about two patients who suggest this isn't necessarily the case. Of 36 patients with bilateral absent N20 responses, a 43 year old (who had absent N20 responses at day 3 after his arrest) went on to have a normal cognitive recovery (so much so that apparently he went on to resume drinking and they were able to measure SSEPs 18 months later when he was hospitalized and in alcohol withdrawal - a very sad detail they shared - he had recovered N20 responses at that measurement). (They also report on a patient who had abnormal/barely detectable N20 responses who went on to have a normal cognitive recovery).
35 out of 36 patients with absent N20s did not recover, despite hypothermia. (While that makes 97%, one should be cautious; this is a retrospective case series and it's inappropriate to establish event rates from this study design.) One did.
My suspicion is that we will be seeing similar findings for other established 'uniformly bad' prognostic indicators in anoxic injuries. It always seemed, in a perverse way, too good to be true - that there were not just one but several findings which implied, based on all the available research, that if a patient had one or more of them they have essentially no chance of recovery. It will not be that these markers are worthless - they still will be (and this series supports it) - evidence of devastating injury with slim chance of recovery, but not some sort of 100%/clean cut/no questions asked evidence. The world's too messy for that, especially when it comes to brain injuries.
I'm curious as to whether anyone is seeing this used in clinical practice, and having conversations with colleagues about the effect of hypothermia protocols on how and when to examine patients and perform tests (for prognostic purposes), and how and when to talk with families about what we are concluding?
Leithner C, Ploner CJ, Hasper D, & Storm C (2010). Does hypothermia influence the predictive value of bilateral absent N20 after cardiac arrest? Neurology, 74 (12), 965-9 PMID: 20308680
... Read more »
Leithner C, Ploner CJ, Hasper D, & Storm C. (2010) Does hypothermia influence the predictive value of bilateral absent N20 after cardiac arrest?. Neurology, 74(12), 965-9. PMID: 20308680
- February 28, 2008
- 12:00 AM
- 1,061 views
Antibiotics and Treating Infections in the Elderly
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
1)The Archives of Internal Medicine published a significant study regarding antibiotic use in the elderly authored by Dr. D'Agata and Dr. Mitchell from Beth Israel Deaconess. In their article, they review the antibiotic usage in 214 (mostly white, female and over 80yo) nursing home residents with advanced dementia, defined as very severe cognitive impairment, minimal communication, dependent eating/toileting, bowel/bladder incontinence, and inability to walk. This study was part of a larger study called CASCADE (Choices, Attitudes and Strategies for Care of Advanced Dementia at the End... Read more »
E D'Agata, & S Mitchell. (2008) Patterns of Antimicrobial Use Among Nursing Home Residents With Advanced Dementia. Archives of Internal Medicine, 168(4), 357-362. DOI: 10.1001/archinternmed.2007.104
- March 27, 2008
- 10:00 PM
- 1,057 views
DCD & not hastening death with opioids
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
1)The American Journal of Transplantation has an interesting article about predicting rapid death in a donation after cardiac death (DCD) setting.Context: DCD is a technique of obtaining organs for transplantation in non-brain dead patients. In brain dead patients you can obtain presumably well-perfused, healthy organs from a patient while their heart is still beating as they are considered dead once they are determined to be brain-dead. There are some circumstances however - usually in patients with severe brain injuries but who aren't brain dead - in which life support i... Read more »
M DeVita, M M Brooks, & C Zawistowski. (2008) Donors after cardiac death: validation of identification criteria (DVIC) study for predictors of rapid death. American Journal of Transplantation, 432-441. DOI: 10.1111/j.1600-6143.2007.02087.x
- February 5, 2008
- 12:00 AM
- 1,022 views
Race and hospice revocation; COPD; Nabilone for pain; Much more
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
This is my first post for a couple weeks and I have amassed a large backlog so my next few ones will likely focus on a single article and then mention others only in passing.Thanks for everyone who said Hi in Tampa, or who came to the happy hour (M. sorry about the loud music - it's too bad Wham! is not your cup of tea). Tom Q - we missed you.A quick note about the Blogging on Peer-Reviewed Research and Research Blogging system that we have alluded to before. The Research Blogging website is now officially up and running. It is, among other things, an aggregator of ... Read more »
K Johnson. (2008) Racial Differences in Hospice Revocation to Pursue Aggressive Care. Archives of Internal Medicine, 168(2), 218-224. http://archinte.ama-assn.org/cgi/content/abstract/168/2/218
- April 22, 2008
- 10:00 PM
- 1,015 views
Morphine vs fentanyl vs methadone; More
by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog
1)The European Journal of Pain has a randomized trial comparing long acting morphine with transdermal fentanyl or methadone as the initial long-acting drug in cancer patients. This was a prospective, unblinded study of ~100 Italian cancer patients (mean age ~60 years) who had ongoing moderate to severe pain (mean baseline pain scores were 7/10) on weak opioids. (It's unclear what the baseline opioid use was in these subjects - without the paper explicitly saying so one has the impression that the group doing the study used a standard 'WHO Pain Ladder' protocol and these patients were o... Read more »
S MERCADANTE, G PORZIO, P FERRERA, F FULFARO, F AIELLI, L VERNA, P VILLARI, C FICORELLA, V GEBBIA, & S RIINA. (2008) Sustained-release oral morphine versus transdermal fentanyl and oral methadone in cancer pain management. European Journal of Pain. DOI: 10.1016/j.ejpain.2008.01.013
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