Wednesday, February 20, 2013

Five Things Physicians and Patients Should Question in Palliative Care and Geriatrics



The American Academy of Hospice and Palliative Medicine (AAHPM) and the American Geriatrics Society have partnered up the American Board of Internal Medicine (ABIM) Foundation in producing two lists of  “Five Things Physicians and Patients Should Question."  These lists just published today provide targeted, evidence-based recommendations to help physicians and patients have conversations about making wise choices about their care in order to avoid interventions that provide little to no benefit.

AAHPM’s Choosing Wisely list of 5 Five Things Physicians and Patients Should Question are the following:
  1. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
  2. Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.
  3. Don’t leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsistent with the patient/family goals of care.
  4. Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.
  5. Don’t use topical lorazepam (Ativan), diphenhydramine (Benadryl), haloperidol (Haldol) (“ABH”) gel for nausea.

Interestingly, AGS’s list of Five Things Physicians and Patients Should Question starts off on a very similar note as AAHPM's list:
  1. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding.
  2. Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
  3. Avoid using medications to achieve hemoglobin A1c less than 7.5 in most adults age 65 and older; moderate control is generally better. 
  4. Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. 
  5. Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. 

I'm a big fan of both lists.  First, I think having both societies give clear recommendations not to recommend percutaneous feeding tubes for individuals with advanced dementia is a bold step in the right direction.

Secondly, there are many things on both lists that I still see used by members of our respective fields.  For instance, ABH and anti-nausea gels are still commonly prescribed in home hospice despite the fact that they aren't absorbed through the skin.

Lastly, there are things on the list that I think we can focus on from a quality improvement standpoint. As an example, fewer than 10% of US hospices have AICD deactivation policies.   Bringing this information back to our teams and asking simple questions like "do we have an AICD policy?" is one way to move this conversation forward.

by: Eric Widera (@ewidera)

6 comments:

achaymon said...

I like the lists too - only I would have set an even higher level on the A1C (at least 8) and i would have liked to see something similar for blood pressure targets (Sbp 140-150). Still, if we save even one person with advanced dementia from a feeding tube, I'll call that a win. Thanks for spreading the word!

Dan Matlock said...

These are just brilliant. I couldn't be happier. The 7.5 doesn't bother me that much because the gist is that less intensive control is better which is really the message, the absolute number should likely be tailored to the patient anyway.

Nice work to both AGS and AAHPM!!

Bruce Scott said...

I like the lists, for the most part. I'm pleasantly surprised by a couple. The single fraction radiation and the glyco target of no less than 7.5 are nice to see.

There are a couple that I would have liked to see on the Geri list that didn't make it (stop doing CTs and EEG on dementia patients with delirium unless you have clear suggestion of stroke or seizure, and stop doing cancer screening on patients with limited life expectancies--especially Alzheimer's patients.)

achaymon commented on wanting to see a change in BP goals too...which I don't think we'll see until we get JNC8. Docs seem reluctant to follow the guidelines of NICE in the UK, which advocate for loosened goals.

I am most happy to see the tube feeding recommendations.

The asymptomatic bacturia one is a battle that we shouldn't have to keep fighting. It's irritating that it should have to be on the list. The fact that my residents and students continue to want to treat it highlights the need for it to be on the list, though.

As a glass-half-empty sort, I'm really unhappy about the claim that antipsychotics should not be first line therapy for BPSD. It's true, if read in a certain way, but misleading. If they had worded it differently, I would have whole-heartedly supported it. If they had talked about making sure to try nonpharm interventions first, and to make sure to treat unmet physical needs, and to make sure to treat other comorbid medical conditions if possibly contributing (including psychiatric ones), and to make sure that the behavior merited treating at all, then I'd be fine. However, once you get to the decision that you should be treating them pharmacologically, then antipsychotics SHOULD be first line. (I tell my fellows that Tylenol is first line, but that is only a way of emphasizing that we treat the unmet physical need of untreated pain.) The wording suggests that some other drug is better. It ain't true.

Eric Widera said...

Great comment Bruce. Just to be clarify the recommendations. They each have a short explanation to further address what couldnt be said in a short sentence. This is what is written for antipsychotics and dementia related behaviors:

"People with dementia often exhibit aggression, resistance to care and other challenging or disruptive behaviors. In such instances, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including strok e and premature death. Use of these drugs should be limited to cases where non-pharmacologic measures have failed and patients pose an imminent threat to themselves or others. Identifying and addressing causes of behavior change can make drug treatment unnecessary.

kathy kastner said...

About the UTIs: I'm not a hcp (just a devotee of geripal and pallimed blogs). my 96 y/o aunt had asymptomatic UTI. Treatmenent: antibiotics. Explanation to her daughter: 'without meds your mother could go toxic and die.'
3 rounds of meds later, UTI persists,and now aunt has a stent and startles when she sits. My question: what does it mean, in QOL terms: go toxic and die. Is one or another a better choice in this complex world of living longer, dying longer.

Bruce Scott, MD said...

If anyone feels short on irritation in their life, they might pop on over to Medscape: http://goo.gl/gZNIc
where Dr. Matthew Mintz entirely misses the point about Choosing Wisely (specifically the AGS position on tight glucose control), attacks a straw man, and provides a case presentation that oozes with apparent conflict of interest. Dr. Mintz, who has AstraZeneca Pharmaceuticals, LP and Bristol-Meyers Squib in his Disclosures list as part of the large number of pharmaceutical companies he's taken money from, gives a case presentation where a robust 70 year old woman managed for 5 years on metformin has a HgbA1C that is slowly creeping up (now 7.5). He recommends switching her to a metformin/DPP4 combination. These are quite expensive. On an unrelated front, AstraZeneca Pharmaceuticals, LP and Bristol-Meyers Squib happen to make a metformin/DPP4 combination.

Their contact page allows you to contact the editor. I've already done so to ask them to remove the opinion piece based on the inescapable appearance of conflict of interest involved with an idiosyncratic recommendation of an expensive medication change (despite the fact that the patient is currently at goal), when the medication change happens to correspond with one made by a company the author has admitted to taking money from.