What is in the Palliative Care Syringe?

Pay attention! (image only tangentially related to the post, thanks wikimedia)

Remember the landmark trial at MGH by Jennifer Temel that demonstrated palliative care for patients with early stage lung cancer not only improves quality of life, but prolongs survival? The major question we were left with, as Jennifer says quoting Diane Meier in the accompanying audio interview, is "what is in the palliative care syringe?" What exactly did they DO to improve quality of life and prolong survival?

Well, now we have some important clues. In a study published online yesterday in JAMA: Internal Medicine (formerly Archives of Internal Medicine), she mentored a junior researcher named Jaclyn Yoon to examine chart notes from palliative care clinic visits during the MGH trail. They also examined chart notes from oncologist for those times when the disease progressed.

They found:

During the first few patient visits, palliative care clinicians focused on building a relationship, treating symptoms, understanding of prognosis, and establishing preferences for information
When the patients disease progressed, both palliative care clinicians and oncologists addressed plans for end of life care, though oncologists tended to focus more on radiographic progression of disease and medical complications, whereas palliative care docs focused on coping.

This represents an important window into outpatient palliative care encounters. As I noted in the commentary, these findings are as surprising for what they include as what they do not. Some might expect that goals of care discussions and hospice would be introduced from the get go - this was not the case.

As the commentary concludes:

The focus of PC is not browbeating patients into accepting hospice and avoiding resuscitation or hospitalization, as some might assume. Palliative care is at its heart a relationship-centered profession. Palliative care clinicians build strong relationships with patients and families in the hopes of finding a way through the symptoms and distress, a way to cope with the illness experience, and a way to make each day as good as it can be. Many patients with serious illness will not have access to an outpatient PC clinician, but they will probably have access to an internist. Patients might benefit if all internists incorporated this approach, seeking supplementary training in PC. And some benefits, like survival, might be surprising.

by: Alex Smith

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers. Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis. This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis. Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?). This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here).

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

Survival from severe sepsis: The infection is cured but all is not well

Severe sepsis is a syndrome marked by a severe infection that results in the failure of at least one major organ system: For example, pneumonia complicated by kidney failure. It is the most common non-cardiac cause of critical illness and is associated with a high mortality rate.

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. …

George Handzo said…

This lesson learned can just as easily guide the practice, not just of physicians, but of all members of the team (nurses, social workers, chaplains,e etc) both in the hospital and in the community.

January 30, 2013 at 12:27 PM

Kilgore Trout said…

It seems odd that the recent JAMA findings (from the original Temel Lung CA study)suggests that communication and relationship building (components of psychosocial care) is a new medical discovery that needs to be integrated and further studied.

JAMA Study Excerpt: "Further research is needed not only to determine the generalizability of the benefits of early integrated PC but also to identify the components of the intervention that might be most effective," the authors write.

We already know the benefits of early integrated palliative care and what components of interventions are most effective!
Hospice/palliative care social workers and chaplains have been providing this expert care for decades. These palliative professionals are skilled in communication and counseling and comprehensively address profound and complex needs when illness and dying befalls patients and their families. Maybe instead of embarking on a new study to study the old study, first consider the expertise of other palliative team professionals, and the quality outcomes that a team approach produces.

January 31, 2013 at 11:19 AM

Values in Healthcare said…

Thank you for your post! Glad to see discussion of the importance of relationships in healthcare, especially with patients and families. Many know this, but others don't. Relationships with compassion, respect, etc should be at the center of all care!

Our dream is to restore human values to healthcare around the world. We’re working to enhance relationships, empathy, and healing in healthcare, and created the International Charter for Human Values in Healthcare, starting with the capacity for compassion.

The mission of the International Charter for Human Values in Healthcare is to restore the human dimensions of care – the universal core values that should be present in every healthcare interaction – to healthcare around the world. http://charterforhealthcarevalues.org

January 31, 2013 at 12:09 PM

Isaac Vielma said…

During my time as a Medical Director of an Inpatient Palliative Care program the physicians were hesitant to refer due to the fear of browbeating patients to choose DNAR/DNI and Hospice Care. As the study showed, we often didn't talk about code status or hospice care. Often times it was about supporting, affirming, relating, listening and being non-judgmental. We would only address those issues at the appropriate time and by the guidance (verbal and non-verbal clues) of the patient. I've long felt that palliative care is very much like a dance. The patient leads and we follow. They dictate the speed, direction and progression of the dance. Our job is to dance along with them through their journey.

February 3, 2013 at 4:15 PM

Alex Smith said…

Hi Isaac- love the dance analogy. So well put.

Reminds me of what Porter Storey has said, "You do your dance and you walk away." His comment was about relinquishing attachment to needing to "reach" every patient or family member.

February 4, 2013 at 10:34 AM

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