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Pallimed: a Hospice & Palliative Medicine Blog
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February 23, 2009
11:00 PM
835 views

The Terrible Choice

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

JCO has a provocatively titled research paper (see blog post title) comparing patients' need for hospice services with their willingness to sign-on to hospice care. It's related to this paper I blogged on earlier (scroll down to #4; both are written by the same group and appear to be based on the same data set).The study involves interviews with 300 patients (mean age 58 years; 27% African American) with advanced cancer, all receiving some sort of anti-cancer treatment, and all of whom had to have a 'likely less than 6 months' prognosis (if they didn't receive any further cancer-focused life-prolonging treatments): ie these were patients who were potentially hospice-eligible. No patients were receiving home services at the time. They were asked, among other things, to rank the importance of/their perceived need for certain core hospice services (nurse visits, chaplain, home health aide, counselor, respite care - these were not labeled as hospice services) as well as asked about treatment preferences.One key point - when they looked at who were the people who reported the most perceived need for hospice services, they looked at who were eligible for hospice care based on treatment preferences. They defined these patients (again, all of whom had less than 6 month prognoses without further treatment) as those who said they would NOT want any anti-cancer treatment even if it meant that it would guarantee them an 'almost 100%' chance of surviving 6 months. Ie - those who would reject all life-prolonging treatment and are therefore eligible for hospice care based on goals (as well as prognosis based on the study's inclusion criteria). Notably, 13% of these patients (all of whom were receiving anti-cancer treatments) said they would not want any treatments even if it meant a guaranteed 6 month survival. This suggests that these 13% were receiving treatments they didn't actually want, thought they were receiving curative treatments, didn't understand the research questions, or some combination thereof. (I'll also add that they asked patients if they'd want anti-cancer treatments even if it wouldn't change the fact that they'd have an 'almost 0%' chance of 6 month survival - I'm curious as to whether anyone said yes to that. Ok well I know people said yes to that question, but I'm curious as to whether enough of them said yes to warrant an analysis of who these patients were and how they did).Anyway, they found 1) perceived need for hospice services had no relation to eligibility for hospice, as defined above, 2) the group who ended up dying during 6 months of follow up (15%) actually did report increased need for hospice services, 3) African Americans, patients with poorer social support, and patients with worse psychological symptoms all reported increased need for hospice services, and - likely related to #2 and #3 - 4) patients with activities of daily living dependencies reported increased need for hospice servies (as did their family members).In short: hospice eligibility and perceived need for hospice services don't seem to line up very well, and instead being sicker and more debilitated with less social support identifies patients who want hospice services (if not hospice care itself). Part of the authors' discussion of this centers around questions of justice related to the Medicare hospice benefit: patients are excluded from hospice services not due to a lack of need for them but due to ineligibilty due to treatment goals/preferences. Thus, the 'terrible choice' of the title. Need, they argue, should be the criteria for benefits, especially since there is no Medicare-defined equivalent treatment 'package' alternative for patients ineligible due to goals.Fair enough, but compare this to the previous publication from this study that I linked to above, in which it turns out this same set of patients actually ranked, overall, the hospice-type services as pretty low, as compared to non-hospice services like dependent care support, help with transportation, and family care-type programs (financial support for family members to care for them)! Given that, I'm not so sure that the Medicare-defined hospice benefit is the problem per se (it has problems to be sure, but I don't think it needs to meet all the supportive care needs of all patients even with short prognoses), but that there is not any coherent, national 'package' or program of care and assistance to patients with advanced illnesses who are not yet in the final stages of life (the homebound, weeks to few months stages). And given that in the US the simple act of a Presidental candidate mentioning that it might not be the worse thing in the world to tax the rich a little more in order to help the poor was a media event involving a mad screaming chorus of Socialist! I have a hard time imagining unfortunately that we are about to embrace such 'welfare state' programs like family members getting financial support to care for a loved one at home....D. J. Casarett, J. M. Fishman, H. L. Lu, P. J. O'Dwyer, F. K. Barg, M. D. Naylor, D. A. Asch (2009). The Terrible Choice: Re-Evaluating Hospice Eligibility Criteria for Cancer Journal of Clinical Oncology, 27 (6), 953-959 DOI: 10.1200/JCO.2008.17.8079... Read more »

D. J. Casarett, J. M. Fishman, H. L. Lu, P. J. O'Dwyer, F. K. Barg, M. D. Naylor, & D. A. Asch. (2009) The Terrible Choice: Re-Evaluating Hospice Eligibility Criteria for Cancer. Journal of Clinical Oncology, 27(6), 953-959. DOI: 10.1200/JCO.2008.17.8079

February 13, 2009
05:55 PM
1,154 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

February 6, 2009
09:10 AM
1,295 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

January 22, 2009
10:43 PM
985 views

Knock! Knock!Hi, It's the Office of Inspector General

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

Imagine a nurse in the ICU raises concerns about possible euthanasia by staff in the ICU. You might think it may first go to the ethics committee, the hospital board, and likely the legal department. Then imagine if the Feds (Office of Inspector General) get involved and conduct a complete investigation into the allegations of hastened death. Really. Just imagine it happening to you.Makes answering, "Hey honey, how was your day?" seem impossible.Now imagine someone in your department says, "You know what we should do? We should publish our experience of being investigated by the OIG in a major medical journal!" Would you not want to throw a drink in that guy's face?Well thank goodness someone did think that was a good idea, because Chest published an important article regarding ICU & Palliative Care ethics this month from the group at VA Palo Alto. They are to be highly commended for shedding some light on this very difficult subject.The paper discusses four cases of alleged euthanasia in detail as well as the investigation and the changes made by the ICU staff to improve communication and standardization of comfort care orders.Briefly here are the four cases (there are many more details in the original article):Man in his late 50's with metastatic lung cancer to the brain, with hemorrhage into his brain, and respiratory failure requiring a ventilator. Family and clinicians agreed to comfort care as the primary goal and the vent was discontinued and the ET tube left in place. Over two days, he received increasing doses of morphine eventually getting 30mg/hr. Another nurse felt this to be excessive and she titrated down to under 10mg/hr. He was extubated 3 days after the vent was stopped and died that morning.Patient in his mid 60's with metastatic lung cancer on a ventilator with pneumonia and ARDS. Goals were changed to comfort care. Vasopressors were stopped and 100% oxygen per vent was decreased to 21%. He was continued on fentanyl (1oomcg/hr) and midazolam (2mg/hr) without titration. He died minutes later.Another man in his mid-60's with metastatic lung cancer with pneumonia and sepsis, renal failure and eventually requiring a ventilator. After 1 week goals were changed to comfort care. His oxygen concentration on the vent was decreased from 100% to 21% and vasopressors were stopped. The ventilator, fentanyl and midazolam were all continued and he died two hours later.Man in his mid-50's with metastatic colon cancer with neutropenia, respiratory failure and sepsis. Placed on a ventilator, vasopressors and antibiotics. He required paralyzation and sedation (fentanyl 200mcg/hr & versed 6mg/hr). After 36 hours family requested comfort care, the paralytic, pressors, and ventilation were stopped. No titration of the fentanyl and versed. He died within minutes.Of particular note the last three deaths happened on the same day, which brings to mind the impact of death acuity. So many deaths in such a short time can be very shocking to staff and in other situations unusual grouping of deaths in medical settings has been a tip off for identifying health care professionals who are killing patients.Another significant issue was the concern that the deaths were hastened to possibly open up ICU beds for other patients. This allegation was not supported by the OIG's investigation.The results of the OIG inspection are online and basically found no substantial evidence for intentionally hastened death but did find there was significant variations with the interpretation of appropriate end of life management in the ICU, and recommended the establishment of new guidelines.The ICU department developed an ICU comfort care QI project, comfort care guidelines, a physician template note for comfort care, and a comfort care order set. The VA Palo Alto ICU group responded in a constructive fashion to potentially severe allegations and demonstrated a willingness to share with the health care community a very difficult situation. This transparency is leading to better care for patients there and with the publication may improve the care for other patients dying in ICU's.W. G. Kuschner, D. A. Gruenewald, N. Clum, A. Beal, S. C. Ezeji-Okoye (2009). Implementation of ICU Palliative Care Guidelines and Procedures: A Quality Improvement Initiative Following an Investigation of Alleged Euthanasia Chest, 135 (1), 26-32 DOI: 10.1378/chest.08-1685... Read more »

W. G. Kuschner, D. A. Gruenewald, N. Clum, A. Beal, & S. C. Ezeji-Okoye. (2009) Implementation of ICU Palliative Care Guidelines and Procedures: A Quality Improvement Initiative Following an Investigation of Alleged Euthanasia. Chest, 135(1), 26-32. DOI: 10.1378/chest.08-1685

January 9, 2009
10:10 PM
654 views

Changing treatment preferences in CHF

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

Journal of the American College of Cardiology has a paper looking at changing treatment preferences for survival after a hospitalization for heart failure. The data come from a prospective trial of hospitalized heart failure patients (N=404, mean age in upper 50s) in which treatment preferences for quality (actually health status) vs. quantity of life were measured using 'time-trade off' methods. Their description of TTO is below - basically ranged from scores from 0 (completely values quality of quantity) to 1 (quantity over quality):The TTO instrument was administered verbally by the study nurse at 1, 2, 3, and 6 months. Whenever possible, this instrument and written questions were administered in the absence of family. After a scripted introduction, the initial question was “Would you prefer living 2 years in your current state of health or living 1 day in excellent health?” An answer of 1 day, equated to a utility of 1/730 (0), would end the script. An answer of 2 years would be followed by the next choice, between living “2 years in your current state of health or living 1 year 11 months in excellent health.” After sequential choices, the number of months (up to 24 months) in excellent health that the respondent considered to be equivalent in value to 24 months of survival in current health was recorded, and this ratio was the utility (between 0 and 1). The number of months at the indifference point subtracted from 24 yielded the number of months of survival time that the patient would be willing to trade.Complex, yes I know, and there's a good (and historically minded) discussion of this method given in an excellent accompanying editorial.They found a distinct bi-modal distribution of answers: 40% of patients more or less said they'd trade no time, 28% said they'd trade nearly 2 years of time to be in excellent health, with a smattering of the rest in between. Demographics including age and ethnicity didn't predict which group patients belonged to, although functional status did (with those willing to trade 2 years having the worst 6 minute walk test results - 60 meters [which is terrible]). Other interesting findings:Preferences didn't change much over time (on average just by 4% using the TTO 'scale). However those that did change substantially (a minority of patients had relatively large changes), most of those changed with preferences for increased survival time.Changing preferences for increased survival time were associated with improved functional status/decreasing symptoms. (Most patients had improved functional status and decreasing symptoms anyway - as one would expect given that at baseline these patients were hospitalized with heart failure - however those whose preferences changed the most had a more pronounced improvement in symptoms than the others). Preferring quality over time was associated with earlier death: 30% of the patients who died by 180 days preferred quality over time, compared to only 6% of those who survived 180 days. Given that these patients were sicker (as mentioned by functional status) at baseline and that this data come from a trial of using pulmonary artery catheters in CHF management (ie these were patients willing to receive PA catheters and so were likely also receiving/willing to receive 'aggressive' care) these preferences were likely markers of poor prognosis, as opposed to causes of it. I find papers like this interesting academically, although how they inform practice is less clear given that I assume ideal practice involves frequently re-clarifying patient goals for all patients with severe chronic and/or life-limiting diseases. Nevertheless it's always interesting to see how preferences do change, and it's important for us in palliative care to be aware that how a patient feels when s/he is quite ill/symptomatic may change if they feel better. Obviously a substantial minority of hospice patients (particularly non-cancer ones) either 'graduate' or sign-off of hospice care after a time, and one reason for this may very well be the phenomenon measured in this study: goals of care are set/decisions are made often in acute settings (e.g. during an acute illness in a hospitalization) - in those patients who recover, improve a little, their treatment preferences may change as well.L STEVENSON, A HELLKAMP, C LEIER, G SOPKO, T KOELLING, J WARNICA, W ABRAHAM, E KASPER, J ROGERS, R CALIFF (2008). Changing Preferences for Survival After Hospitalization With Advanced Heart Failure Journal of the American College of Cardiology, 52 (21), 1702-1708 DOI: 10.1016/j.jacc.2008.08.028Thanks to Dr. Bob Arnold for this.... Read more »

L STEVENSON, A HELLKAMP, C LEIER, G SOPKO, T KOELLING, J WARNICA, W ABRAHAM, E KASPER, J ROGERS, & R CALIFF. (2008) Changing Preferences for Survival After Hospitalization With Advanced Heart Failure. Journal of the American College of Cardiology, 52(21), 1702-1708. DOI: 10.1016/j.jacc.2008.08.028

December 29, 2008
06:22 PM
712 views

Loss of function and prognosis in older patients

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

These are my final posts for 2009, and likely the last posts for Pallimed as well for the year as we've all been enjoying a lighter holiday posting schedule. Happy 2009 to all, and may it be a better (more peaceful and prosperous) year than 2008! (I'm speaking nationally and internationally here - the blog prospered plenty in 2008 - thank you readers & Christian & Tom & AAHPM - and I'll be happy to simply match it in 09!) On to the articles:Journal of the American Geriatrics Society has a paper hinting at the prognostic significance of a functional decline associated with acute illness and hospitalization in older patients. The data come from a prospective study of ~2300 hospitalized (non-ICU) older patients (mean age ~80 years) at two hospitals in Ohio in which patients' abilities to perform activities of daily living (ADLs) independently were assessed at the time of hospital discharge as well as two weeks prior to hospitalization. Vital and functional status were assessed regularly up to a year after discharge, allowing the researchers to compare survival in patients who 'lost function' during an acute hospitalization with those who didn't.Patients discharge with at least one new ADL disability were older and sicker: had longer hospital stays (8 vs 5 days), more likely to have pre-existing functional impairments at baseline or live in a nursing home, and more likely to have dementia and COPD than those discharged without new disabilities. Not surprisingly the '-ADL' group did much worse: had a ~40% 1 year mortality vs 18% for the stable ADL group. In addition, in looking at how patients do at 1, 3, 6, and 12 months post discharge what seems to happen is that about 1/3 of the -ADL group recovers to baseline in a month. This ~1/3 of patients who return to baseline remains relatively constant for the rest of the year (about 1/3 of the -ADL patient group were at their baseline status at 12 months): the remaining 2/3 either has died or has persistent disabilities at 12 month.The researchers noted that not returning to baseline at 1 month was a bad prognostic indicator for the -ADL group and described the natural history of those patients: only 17% went on to recover baseline function by the end of the year, 44% had died, and 38% had persistent deficits. While most patients' courses seemed to be 'set' at one month there were certainly patients whose status/courses changed after a month as well: of those who recovered to baseline at the end of the year 38% achieved that after one month, 20% of patients who did recover by one month had died by 1 year, etc. Nevertheless the general trends are what are important: loss of function is associated with poor one year survival (40% mortality is worse than the mortality for newly diagnosed metastatic breast cancer in an 80 year old), and the one-month recovery mark seems to have some predictive power as well.The paper's discussion talks mostly about the need for aggressive rehabilitation in these patients, which one can't argue with, but also begs the question of what is causing what? Are the worse outcomes here due to 'inadequate treatment' (in which case patients would indeed benefit from more aggressive/long-lasting rehab) or is loss of function/failure to regain function within a month more of a marker of illness/frailty/something else underlying the poorer prognosis which won't necessarily improve with rehab?Cynthia M. Boyd, C. Seth Landefeld, Steven R. Counsell, Robert M. Palmer, Richard H. Fortinsky, Denise Kresevic, Christopher Burant, Kenneth E. Covinsky (2008). Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness Journal of the American Geriatrics Society, 56 (12), 2171-2179 DOI: 10.1111/j.1532-5415.2008.02023.x... Read more »

Cynthia M. Boyd, C. Seth Landefeld, Steven R. Counsell, Robert M. Palmer, Richard H. Fortinsky, Denise Kresevic, Christopher Burant, & Kenneth E. Covinsky. (2008) Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness. Journal of the American Geriatrics Society, 56(12), 2171-2179. DOI: 10.1111/j.1532-5415.2008.02023.x

December 19, 2008
12:20 AM
697 views

Geeking out on PC Research

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

Journal of Clinical Oncology has a paper looking at the changes in the quantity and quality of palliative care and hospice research over the last 100 years. Indeed. The paper looks at the quantity and type of palliative care articles indexed by Medline, comparing those published before 1970 with each 5 year period after 1970 through to 2005 . They essentially looked for papers with the terms 'palliative,' 'hospice,' or 'terminal care' in their citation (they allowed for truncated/variable versions of those terms, and used an all fields search meaning title, abstract, and subject headings were all included). What they found was that yes, palliative care publications have increased greatly in number, as well as percent of total publications, over the last few years: for instance in raw numbers there were ~4000 papers which met their search criteria at 1975, ~28000 at 1995, ~41,000 at 2000, and ~57,000 at 2005. To clarify this: 57000 total articles were found in the database in 2005 - this is a total/cumulative number not ones added in that period - but one can assume that well over 10,000 articles were published between 2000 and 2005 which met the search criteria. Medline does 'back-tag' articles with newly developed subject headings, and so some of the increase between 2000 and 2005 is due to older articles being newly tagged as 'palliative' ones, but likely the vast majority of that increase represents freshly published papers. In addition, they found the fraction of published papers which met their criteria increased over that time period ('palliaitve' articles rose from .08% to .38% of all the total Medline database), that the fraction of 'palliative' papers which represented original research rose dramatically (.96% to 7.2%) and that this increase outpaced the increase for medicine (Medline) overall (.45% to 5%). They give some interesting data about where all these articles are being published - a lot of different journals of course - but you can look at where most were.A few things here. First, looking at the journal list, while there are many that are obvious (JPSM, JCO, JPM, etc.) there are some which aren't, including Gastrointestinal Endoscopy, which highlights the problem with looking at publications this way - the word 'palliative' is used widely particularly in surgical and 'proceduralist' journals in a specific way which is accurate to be sure (basically means non-curative as in a 'palliative gastrojejunostomy' etc.) but doesn't necessarily make it palliative care-relevant (at least to me and people I know who practice it). This is a real-life issue for me because one of the many ways I screen articles for the blog is by using a filtered Medline search which includes everything labeled with a 'palliative care' label/subject heading (along with a whole bunch else). This means my inbox is flooded with technical research about pediatric cardiac surgery (many 'palliative' procedures there), as well as a good amount of endoscopy research, all of it 'palliative' but little of 'drew-palliative.' Actually, my search strategies are completely based on ones the group who published this paper have developed over the years (check out their website) - they are quite good, and suit the function of screening for the blog very well. Then there's the reality that much (most? nearly half?) of research which is relevant to my day-to-day practice isn't caught by a strategy using 'palliative care,' 'hospice,' 'terminal care' etc. subject headings. E.g. pain trials which aren't specifically in a palliative care setting but still would inform my practice, papers about prognosis in brain injuries, etc. 'Palliative care relevant' but not 'palliative care specific' research. Given that, there's every reason to believe then that the fraction of palliative care-relevant research is even higher.Does the exact percentage, or how we do '% clinical research-wise' make any difference? Not at all of course, but the point of the article is well-taken and almost certainly valid: palliative care publications and research are growing rapidly, and we do pretty well research-wise compared to medicine as a whole. Given that this is a big part of my life (on the blog) it kind of gets me going. A quote from the conclusion:The challenge raised by these findings is that clinicians providing hospice or palliative care as part of their practice have no simple way of identifying the evolving evidence base. Effective retrieval would require a comprehensive strategy actively searching general and specialist clinical and research literature. The challenge of not having one set of subspecialist journals on which to rely is magnified given a rate of growth for palliative care clinical trials of 1.4 times the general clinical trials literature over the last 35 years.I think this is a major problem. It's not unique to palliative care, although it might be accentuated in our community. It's tough to actually find our research base, and you can't rely on a few major journals. I'm curious as to whether this will change over the next few years - if the research will consolidate so it'll be easier to find. Probably not, however, given that many of these issues are critically important to other specialist communities (critical care, oncology, trauma surgery, nephrology, etc. etc.) and so will remain sprinkled among dozens of subspecialty journals. J. Tieman, R. Sladek, D. Currow (2008). Changes in the Quantity and Level of Evidence of Palliative and Hospice Care Literature: The Last Century Journal of Clinical Oncology, 26 (35), 5679-5683 DOI: 10.1200/JCO.2008.17.6230... Read more »

J. Tieman, R. Sladek, & D. Currow. (2008) Changes in the Quantity and Level of Evidence of Palliative and Hospice Care Literature: The Last Century. Journal of Clinical Oncology, 26(35), 5679-5683. DOI: 10.1200/JCO.2008.17.6230

December 12, 2008
11:00 AM
814 views

Cancer survival prediction model

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

Journal of Clincial Oncology has a paper discussing the development of a survival-prediction model for cancer patients. The paper actually looks at the development and validation of two models (based on the same data sets). The data mostly come from Canadian patients referred to a radiotherapy center for palliative radiotherapy (this is a large, prospectively gathered data set which includes cancer type, performance status, types of metastases, etc.). One of the models used a point system (based on type of cancer, performance status, and presence of non-bone metastases), the other model was a simple 1, 2, 3 stratification of patients based on if they had 1, 2, or 3 poor prognostic risk factors: cancer other than breast, Karnofsky score less than or equal to 60 or ECOG greater than or equal to 2, and non-bone metastases.Those who had all 3 risk factors had a median survial of 9 weeks, with 3, 6, and 12 month survival of 35-45%, 14-27%, and 3-11% respectively (the range there is due to differences between the derivation and validation sets). Those with 2 risk factors had a median survival ~25 weeks with the 3/6/12 spread of 68-76%/45-52%/23-26%. There's a lot of extra data here - comparing the two scoring systems with each other and a previous one, etc: they all ended up having similar prognostic power.They don't give enough information in the paper to determine how this would match up to simple time prediction based on one factor (ie performance status), nor is one ever certain how to generalize these sorts of data, particularly as this is based on patient characteristics at the time of referral for palliative radiotherapy. That said, in total over 1000 patients were included in the analyses in this paper, which is a lot for this type of research, and it probably is as good of a representative sample as anything out there. What is particularly helpful clinically, at least for me, is that it presents both median survival data, as well as, e.g., 6 month survival - getting a sense of that spread is always welcomed.E. Chow, M. Abdolell, T. Panzarella, K. Harris, A. Bezjak, P. Warde, I. Tannock (2008). Predictive Model for Survival in Patients With Advanced Cancer Journal of Clinical Oncology DOI: 10.1200/JCO.2008.17.1363... Read more »

E. Chow, M. Abdolell, T. Panzarella, K. Harris, A. Bezjak, P. Warde, & I. Tannock. (2008) Predictive Model for Survival in Patients With Advanced Cancer. Journal of Clinical Oncology. DOI: 10.1200/JCO.2008.17.1363

November 10, 2008
11:00 PM
1,267 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

October 27, 2008
08:00 PM
950 views

'Stuttered' treatment withdrawal in the ICU

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

American Journal of Respiratory and Critical Care Medicine has a paper looking at the duration of life-support withdrawal and family satisfaction. The data come from a multicenter trial in Washington State which looked at various aspects of end-of-life care in the ICU. This analysis looks at ~584 family member surveys of patients who died after some withdrawal of life-sustaining therapies (WLST): patients died in an ICU or within 24 hours of transfer out. (There were 2000 ICU deaths in the study period, and only 820 family surveys completed, and then a couple hundred exclusions based on incomplete data and deaths occuring without WLST.) LSTs here were defined as laboratory testing (?), mechanical ventilation, renal replacement therapy, tube feeds, vasopressors, and IV hydration. (Why lab testing and not antibiotics I'm not sure.) Mean patient age was 72 years, 90% white, mean hospital length of stay was 6 days, 82% were ventilated at some point, and ~50% received vasopressors. The paper has tons of data in it, both simply descriptive about what happened to who when, as well as some analysis looking at patient characteristics which predicted all-at-once or 'stuttered' WLST and family satisfaction.The key findings were that for about half the patients LSTs were withdrawn sequentially over time (greater than a day) - the other half had all LSTs stopped the same day. Across the cohort, ventilation tended to be withdrawn last (a little over 1 day prior to death), with other therapies withdrawn sooner. Renal replacement therapy was stopped more than two days, on average, before death (although only 10% of the subjects ever received RRT). The longer a patient was in the ICU, as well as the more LSTs they were receiving, the more stuttered the WLST was (youth, non-cancer diagnoses particuarly trauma, and more family members involved in decision making also predicted a more stuttered WLST process). Family satisfaction was interesting. The shorter a patient's overall ICU stay was (less then 3 days), stuttered WLST was associated with worse family satisfaction. For longer ICU stays, stuttered WLST was associated with better family satisfaction. Intubation in the last week of life was not associated with family satisfaction (either way), however, for intubated patients, being extubated before death was strongly associated with family satisfaction. The use of non-invasive postitive pressure ventilation (ie 'bipap') was negatively (although not statistically significantly) associated with satisfaction. There are many caveats with interpreting all this, not least being selection bias given the low response rate to the family survey. That said, these seem to be supporting data that stuttered WLST - something I imagine that those of you who see patients in the ICU see done all the time - is common and not necessarily a bad thing for many families. The authors state their original hypothesis was that stuttered WLST would be associated with worse family satisfaction and generate some hypotheses as to why they were wrong. The one most consistent with my own observations is that the process of limiting and withdrawing potentially LST in ICU patients expected to die is often a days' (or weeks') long process, which evolves with the patients' changing clinical course and response to therapy, and while the vast majority of times families agree with withdrawal of some/many/all LST before a patient dies, many require/benefit from time (at least days) to accomodate a patient's changing condition/terrible prognosis and to make decisions accordingly even if the physicians lead-off with straight-forward recommendations for WLST. The observation that increasing number of family decision makers 'prolongs' things seems to support this reality.... E. Gerstel, R. A. Engelberg, T. Koepsell, J. R. Curtis (2008). Duration of Withdrawal of Life Support in the Intensive Care Unit and Association with Family Satisfaction American Journal of Respiratory and Critical Care Medicine, 178 (8), 798-804 DOI: 10.1164/rccm.200711-1617OC... Read more »

E. Gerstel, R. A. Engelberg, T. Koepsell, & J. R. Curtis. (2008) Duration of Withdrawal of Life Support in the Intensive Care Unit and Association with Family Satisfaction. American Journal of Respiratory and Critical Care Medicine, 178(8), 798-804. DOI: 10.1164/rccm.200711-1617OC

October 7, 2008
11:12 PM
721 views

EOL discussions and EOL outcomes

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

JAMA (huzzah) has published what will likely be remembered as the core publication out of the Coping with Cancer Study (CWCS)(see our posts here, here, and here for more). This analysis looks at the association between end-of-life (EOL) discussions and several outcomes including patient mental health and aspects of EOL care. Briefly: the CWCS was a prospective, multi-institutional (several cancer centers in Northeast US and Texas) cohort study of advanced cancer patients (metastatic; 'failed' first line chemotherapy) and their family caregivers. It involved an intensive psychosocial assessment including disease understanding at baseline; patients were followed over time and bereavement outcomes were measured in family members of those who died (most ~6 months post-loss). This paper is based on the ~320 who died by the time the analysis was done (total enrollment was a little over 600): median time from enrollment to death was 4.4 months.This study compared outcomes in those who reported having a discussion about EOL issues at baseline vs those who didn't. The presence of an EOL discussion was defined by patients answering positively to the question: Have you and your doctor discussed any particular wishes you have about the care you would want to receive if you were dying? They used 'propensity score weighted' adjustments to balance differences between groups: I can't say that I understand exactly what this means - it seems to be different from the use of propensity scores I discussed previously in the blog. Their use here seems to be, and I trust any statisticians out there will forgive me for saying this, a propensity-score enhanced regression model to adjust for baseline differences between groups. Short story: they used linear and logistic regression models to try to control for underlying differences in the +EOL conversation group and the -EOL conversation group.37% of these patients (who had a median 4.4 month prognosis!) answered they had EOL discussions at baseline. The differences at baseline, for which they adjusted, were: performance status, symptom burden, survival time, and recruitment site. About recruitment site: rates of EOL conversations varied from 16% to 62% depending on which cancer center you were at. Even if you believe the rest of the results here are bogus that wide variation in patient care (because this is a patient care issue) is astounding and cause for alarm.Anyway - reporting an EOL conversation at baseline was associated with major differences (improvements) in EOL care and bereavement and no significant differences in adverse mental health outcomes. Rates of depressive and anxiety disorders, PTSD, subscale scores looking at depressive and anxiety symptoms, etc. were the same between groups, even after adjustment. And the results keep on getting better: in another analysis in which they adjusted further for baseline treatment preferences, terminal illness acceptance, and self-reported desire for prognostic information, rates of ICU admission/ventilator use/resuscitation prior to death were lower and rates of hospice length of stays over 1 week were higher in the baseline +EOL conversation group. These were pretty substantial differences in the relative rates (e.g. 11 vs 1.6% for ventilator use; 66% vs 45% for longer hospice stays, etc.). Ok, I guess that last one is a pretty good difference in absolute rate as well - 20%.These differences in care at the end of life were associated with substantial changes in bereaved caregivers ratings about patients' quality of life (better in those who had less 'aggressive' interventions and who had longer hospice lengths of stay). Bereaved caregivers of patients with more aggressive interventions reported more depression, regret, and other unwelcome outcomes.Some thoughts:Because I like the outcomes I am trying to be cautious in interpreting them. The two big questions that CWCS is trying to answer is 1) does having these conversations hurt our patients by causing emotional harm, and 2) does having these conversations help our patients and their loved ones by improving the care they receive as they die? And these findings overwhelmingly show that patients who report having these conversations are no worse off than those who don't report such conversations and the care received by these patients as they die is measurably different/better and these differences are associated with improvements in outcomes in loved ones. One could also argue that it's not just having these conversations (because one assumes that most patients had an EOL talk prior to their death if not at baseline) but that it's having these conversations relatively early that made the difference.I think the major caveat here, which is one that can't be overcome without a randomized trial (which will never happen, and this sort of study design will likely be the best level of evidence we'll get on this topic), is of course confounding from unmeasured patient characteristics. Two possible sources immediately come to mind 1) patients who willingly report talking about dying with their docs to a relative stranger (a member of the research team) vs. those who don't (e.g. what is actually being measured is not rates of EOL conversations per se but patients' willingness to talk about those conversations, or something along those lines), and 2) patients who reported EOL conversations were more likely to want to have them in the first place and, again, the 'real' difference between the groups is something along the lines of innate patient characteristics regarding openness to EOL discussions, talking about the future, etc. You could imagine that these 'open' patients were more amenable to less aggressive care as they died, may have had more open/sharing relationships with their caregivers which resulted in better bereavement outcomes, etc. The other issue is that they may be measuring a broader pattern of physician behavior, and this reporting of an EOL discussion (or not) really reflects substantial differences in overall physician care for their patients, being more or less likely to offer/recommend aggressive care, etc. and that "-EOL conversation" is a proxy here for, bluntly, bad end of life care.Reflecting on how concerned I am about confounding, I'm asking myself how would I have responded to this if they found that early EOL conversations had no effect on EOL care (would have believed it, and wondered if the measurable differences were too small to be appreciated with an N of 320) or emotionally 'harmed' patients such as by increasing levels of anxiousness (I think I would have believed that too, although it wouldn't have led me to conclude we shouldn't do it but look more into how it's done, etc.). Given that, the real benefits which seem to be associated with such early conversations, and the disappointing rates of these conversations and disparity across treatment centers, I think that the CWCS has given real backbone to the idea that 'early' EOL discussions should be a standard of care for advanced cancer patients, and that this is not some nice fantasy of self-righteous palliative care people who think that talking about dying is 'just the right thing to do' but something backed by good data.It's not a 'moral' question, but a clinical one of ensuring the best possible outcome for our sickest patients.Alexi A. Wright, Baohui Zhang, Alaka Ray, et al (2008). Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA, 300 (14), 1665-1673... Read more »

Alexi A. Wright, Baohui Zhang, Alaka Ray, & et al. (2008) Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA, 300(14), 1665-1673. DOI: http://jama.ama-assn.org/cgi/content/abstract/300/14/1665

October 2, 2008
10:46 PM
1,269 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

Medicine

August 4, 2008
10:10 AM
752 views

Aggressiveness of end of life care in lung cancer

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

Cancer has e-pub'd a study looking at the aggressiveness of care in patients dying of non-small cell lung cancer. The data come from a prospective study looking at early specialist palliative care involvement for patients newly diagnosed with advanced (stage IIIb or IV) NSCLC - essentially a 'concurrent care' model in which patients received specialist palliative care alongside routine cancer care/therapy (see here). This study looks at data for 46 patients (mean age 66 years; 100% white) accrued at one of the sites (Massachusettes General Hospital) and examines factors associated with aggressiveness of care (use of anti-neoplastic therapy, emergency department visits, hospitalizations, hospice use, place of death, etc.). The primary framework was looking at elements of care in the last 30 days of life for the 40/46 patients who died during the study - it's kind of like a mortality follow-back design although the patients were enrolled and followed prospectively.The findings generally support the impression of aggressive care in the final days of life: 40% received antineoplastic treatment within 30 days of dying (nearly a quarter within 14 days of dying), and ~50% visited the ED and/or had a hospital admission. 62% died in a hospice setting, although with a mean of only 16 days. One-third of patients spent less than a week in hospice before death; one-third however spent more than a month. Interestingly, in bivariate analysis of predictors of 'aggressive' care elevated baseline anxiety or depression symptoms predicted increased likelihood of anticancer treatment within 14 days of death. They don't mention whether they evaluated for a 'treatment effect' of individual oncologists (i.e. distinct variations in care based on who the oncologist was - such an effect has been observed for aggressiveness of care for dying patients in ICUs - given the intimacy of this study this may not have been an easy thing to do politically, or may just have been outside the scope of this analysis).The discussion at the end of the paper highlights the many, many unanswered questions this study raises, as well as generally cautions against throwing up of arms in the air about this. The big question (at least from a patient-centered perspective) of course is does this seemingly high rate of aggressive care reflect 'bad care' or 'less than ideal care'? On its face it seems that it does, but I'm not convinced that that's necessarily true; if all these patients at the beginning of their last month of life had been told that it was 'highly likely' that they would die in the next 1-2 months (regardless of what care they received), were given all the available options and services (hospice, other types of home care, ongoing anticancer treatment, supportive-only treatment, etc. etc.) - would these outcomes have been any different? We really don't know, and even if they outcomes would be different it's not like the levels of hospitalization/ED visits would go to zero (sometimes the best place for people, even very sick dying people, is the hospital). In addition, chemotherapy (oral or IV) does benefit quality of life in NSCLC (for some patients) - something which the authors address in the paper's discussion - and unless one is really darn sure someone has less than 30 days to live a decision to continue that treatment is not necessarily a bad one, although it eliminates a patient's access to otherwise indicated hospice services.Reflecting on my own experience, I think there are major barriers to good end of life care on both ends (doctors aren't having realistic conversations and advising about appropriate care plans in light of a poor prognosis until way too late; the way US hospice services are set up creates barriers to access except for patients in the final days/few weeks of life due to restrictions [real or imagined] on anticancer treatments, emergency room visits, etc.).Temel, J.S., McCannon, J., Greer, J.A., Jackson, V.A., Ostler, P., Pirl, W.F., Lynch, T.J., Billings, J.A. (2008). Aggressiveness of care in a prospective cohort of patients with advanced NSCLC. Cancer DOI: 10.1002/cncr.23620... Read more »

Jennifer Temel, Jessica McCannon, Joseph A Greer, Vicki A Jackson, Patricia Ostler, William F Pirl, Thomas J Lynch, & J Andrew Billings. (2008) Aggressiveness of care in a prospective cohort of patients with advanced NSCLC. Cancer. DOI: 10.1002/cncr.23620

Medicine

August 1, 2008
03:00 PM
1,316 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

Medicine

July 30, 2008
02:43 PM
1,000 views

Changing the culture of EOL care in the trauma ICU

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

The Journal of Trama has an article about changing the culture around end of life care in the trauma ICU. This is a before-and-after comparison of communication and end of life care practices in a single trauma ICU after a structured palliative care program was integrated into this ICU's standard care practices. The program (described in detail here) is summarized as follows:Because trauma patients admitted to an ICU have a significant mortality risk (15–20%), and families have consequent, immediate psychosocial needs, the intervention was designed to apply to all trauma patients and their families regardless of their prognosis. Because of the nature of trauma, its sudden onset and rapid trajectory from well to life-threatening illness, the intervention was designed to begin at admission to the ICU, with early communication and family support. The program consisted of five clinical steps grouped into parts I and II in a timed sequence from admission.... In part I, within 24 hours of admission, each patient had a palliative care assessment by physician and nurse. Each family received psychosocial or bereavement support. The palliative care assessment encompassed prognosis, advance directives, family support, and surrogate decision maker, and pain and symptoms. To assess prognosis, physician and nurse were asked the most likely outcome using a score 1-5 similar to the Glasgow Outcome Score, with 1 = death and 5 = independent functional recovery. In part II, within 72 hours, an interdisciplinary family meeting was held regardless of prognosis; during the meeting, likely outcomes, treatments, and goals of care were discussed. These meetings were assessed subjectively by counselors for discussion of goals of care, family understanding of information, and conflict. When the goals of care transitioned from curative to a completely palliative approach, a palliative care order set was implemented. This paper compares aspects of care between the ~280 admissions in the baseline year with the ~370 in the year after implementation. About 70% of patients completed both steps 1 and 2 of the program.Many outcomes didn't change: total mortality was the same in both years (15%); rates of DNR orders (~43%) and family meetings were similar (~60%) as was the timing of family meetings (nearly all within 72 hours of admission).What did change were: rates of withdrawal of life-prolonging treatments were higher after the program started (37% of deaths vs 24% - again, however, overall mortality was the same); timing of DNR orders and withdrawals of life prolonging treatment were earlier; overall length of stay in the ICU and hospital was shorter in those patients who died after the program was implemented (mean hospital stay went from 14 days to 6.5 days in those who died).Essentially, then, what this intervention did was accelerate the decision-making process between families and ICU staff about transition care goals to comfort in a dying patient - and this happened without any demonstrable effect on overall mortality. What's really interesting here is that even before the intervention this ICU team were having early family meetings at a high rate, suggesting that these were not responsible for the changes in care. Instead one wonders if it was the rapid and structured identification of patients very likely to die along with immediate opening of discussions about prognosis and patient/family values/goals. That, and a general culture shift that attended this formalization of 'palliative care' principles into the care of this population (for instance, the discussion notes that this group also introduced end of life peer review into their morbidity and mortality conference).I think that these formal, deliberate changes in standards of care/expected practice are one of the best ways in improving end of life care in hospitals, and are particularly suitable to ICU situations where mortality rates are very high compared to the rest of the hospital (so the likelihood of measurable impact is so much higher than, say, a general medical ward). One caveat here is that group is clearly one which already had a culture (and presumably leadership) which was open to examining and improving end of life practice - this isn't something which could be foisted onto an unwilling group. Given the changes that are happening with the Joint Commission regarding end of life care in the hospital, it's possible that hospitals in the near future will be 'incentivized' into 'willingness' in the not-too-distant future. We'll see....Mosenthal, A.C., Murphy, P.A., Barker, L.K., Lavery, R., Retano, A., Livingston, D.H. (2008). Changing the Culture Around End-of-Life Care in the Trauma Intensive Care Unit. The Journal of Trauma: Injury, Infection, and Critical Care, 64(6), 1587-1593. DOI: 10.1097/TA.0b013e318174f112... Read more »

Anne Mosenthal, Patricia A Murphy, Lyn K Barker, Robert Lavery, Angela Retano, & David H Livingston. (2008) Changing the Culture Around End-of-Life Care in the Trauma Intensive Care Unit. The Journal of Trauma: Injury, Infection, and Critical Care, 64(6), 1587-1593. DOI: 10.1097/TA.0b013e318174f112

Medicine

July 11, 2008
06:00 PM
684 views

Depression in cancer RCT

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

Lancet this week presents a randomized controlled trial of a nurse-delivered educational intervention for depression in cancer patients. This was a single-center Scottish study involving 200 outpatients (mean age 56 years; expected prognosis had to be greater than 6 months for inclusion; a plurality of subjects had breast cancer) who were randomized to usual care or usual care plus the intervention. Outpatients at this center were screened with the Hospital Anxiety and Depression Scale & if this was positive were diagnosed with depression using DSM-IV criteria (using the DSM structured cli... Read more »

V STRONG, R WATERS, C HIBBERD, G MURRAY, L WALL, J WALKER, G MCHUGH, A WALKER, & M SHARPE. (2008) Management of depression for people with cancer (SMaRT oncology 1): a randomised trial. The Lancet, 372(9632), 40-48. DOI: 10.1016/S0140-6736(08)60991-5

Medicine

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

Medicine

June 22, 2008
03:00 PM
1,096 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

Medicine

June 17, 2008
05:00 PM
616 views

2-month prognosis in hospitalized cancer patients; Much more

by Pallimed Bloggers in Pallimed: a Hospice & Palliative Medicine Blog

Several notable pieces from a recent JCO:1)First is a study about predicting 2 month survival in hospitalized cancer patients. This was a French study from 2 hospitals (n=~170) which used prospectively gathered data (laboratory, performance status, and disease characteristics such as number of metastatic sites, etc.) to predict mortality in hospitalized advanced cancer patients who weren't 'actively dying.' All patients admitted to the hospital who met the criteria were enrolled in the study (if they agreed) - these were not patients identified by a palliative care referral... Read more »

A-C Barbot, P Mussault, P Ingrand, & J-M Tourani. (2008) Assessing 2-Month Clinical Prognosis in Hospitalized Patients With Advanced Solid Tumors. Journal of Clinical Oncology, 26(15), 2538-2543. DOI: 10.1200/JCO.2007.14.9518

Medicine

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