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Showing posts from May, 2016

Just ask-tell-ask: Physician-Surrogate discordance about prognosis in the ICU

  by: Alex Smith, @AlexSmithMD I'm sure that all of us have encountered this scenario: the doctor thinks patient's prognosis is not good, but the family thinks it's not so bad.  Why does this happen?  A nice study published yesterday in JAMA  sheds considerable light on the issue.  Doug White and colleagues interviewed 229 surrogates of critically ill ICU patients and their ICU physicians at UCSF.  All patients were on a ventilator (breathing machine) and had been in the ICU 5 days. In 53% of instances, the physicians and surrogates held discordant estimates of the patient's prognosis, defined in this study as at least a 20% difference in likelihood of survival to hospital discharge.  The differences were 4:1 slanted in favor of more optimistic prognostic estimates on the part of surrogates.  One particularly unique feature of this study was the use of qualitative open-ended questions to understand the reasons surrogates were more optimistic. It tu

How We Die: It’s Less about Who You Are and More About Where You Live

by: Eric Widera (@ewidera) Doctors want to believe that they will die differently than the rest of the US. Just look at the 2011 essay written by Dr. Ken Murray, " How Doctors Die ," that went viral when he described that doctors are more likely to die at home with less aggressive care. To back this belief up, studies have surveyed physicians, who state that they would want a nonaggressive, comfort-based approach to care in the face of life-limiting illness. That’s all well and nice, but do they actually die differently, or do they just say they want to die differently? Recently, two articles came out in JAMA ( and nicely summarized by Pallimed ) demonstrating that in reality, doctors don't actually die that differently from others. Today, a new article published by Dan Matlock, Stacy Fischer and colleagues , adds more evidence that our preferences for a different death is unfortunately not well aligned with reality. The Study Using Medicare Part A

SPRINT Trial: Should We Aim for Lower Target Blood Pressures for Older Adults?

by: Meera Sheffrin ( @doctormeera ) The SPRINT trial came out about 6 months ago – it was supposed to revolutionize the way we thought about treating older adults with hypertension. “But adding *more* medicines goes against everything I believe in!” you say. Those are my feelings too, though it’s important to consider what the evidence actually shows. Let’s break down the SPRINT trial to examine what they did, what they found, and whether it applies to the geriatric patients we care for. But wait, don’t we already know the best blood pressure targets? It depends on who you talk to. Let’s look at the data we have so far: the Systolic Hypertension in the Elderly Program (SHEP) and the Hypertension in the Very Elderly Trial (HYVET) showed BP less than 150mg is beneficial. Observational studies show the lower you go, down to 115/75, the more you can prevent cardiovascular outcomes…but the observational studies don’t always show the other side: adverse effects. Really loweri

Thickened Liquid Challenge Strikes Back - #ThickenedLiquidChallenge

by: Eric Widera ( @ewidera ) This week's JAMA IM includes a case of a woman in her 90s with advanced dementia who was started on honey-thickened liquids for aspiration prevention.   She subsequently “refused nearly all food and thickened liquids, turning her head when nurses attempted one-on-one feeding” and was transitioned to inpatient hospice care.   What happened next?  Her diet was changed to regular liquids and she was allowed to eat her favorite foods.  Two months late her weight improved with no clinically apparent aspirations. This is the story of thickened liquids.   As the authors of the article, Drs Wang,  Charlton, and Kohlwes, explain: “thickened liquids have become a part of routine care—some might even argue the standard of care. This has created the perception that thickened liquids are beneficial and safe for patients with dementia.”  Unfortunately, the evidence base to back up its efficacy in dementia is poor and as in this case, places patients at signif