State of the Science

This informative talk by Drs. Goldstein and Anderson was a well-paced informative synopsis of 8 important peer-reviewed articles and how the findings can be applied to our patients. I will refrain from citing the actual articles and authors as those can be easily found in the downloaded handouts. I will summarize take home point and offer and few thoughts.

• Telephone follow-up for newly diagnosed advanced cancer patients with monthly group shared appointments resulted in higher QOL, lower reports of depressed mood and a trend towards lower symptom intensity.
• Many patients with a poor prognosis report minimal or no support from the medical system of spiritual/religious needs and no pastoral care from hospital or clinic. Those who report good support are much more likely to use hospice and have better QOL at end of life. Spiritual care is a QUALITY STANDARD for palliative care.
• Terminally ill children whose parents planned location of death were more likely to die at home, and if they did die in the hospital were less likely to die in the ICU or be intubated during last day of life. Planning may also improve parents’ experience of the death.
• “Being a good parent” is a key factor in making decisions for terminally ill children and there are several common themes to define what “being a good parent” means. These include doing right by child, being there for child, conveying love, being an advocate for child, and being a good life example. Clinicians can support parents in “being a good parent”.
• Functional status of elderly nursing home residents declined after the initiation of dialysis and mortality was high. 24% had died at 3 months, 41% at 6 months, and 58% at 12 months. Only 1 in 8 maintained functional status and none improved.
• NH residents with advanced dementia with severe functional impairment, were less likely to receive potentially burdensome interventions if proxies understood that they had prognosis of 6 months or less. Pneumonia, febrile episode, and feeding problems all herald a poor prognosis. Distressing symptoms are common in this population; in this study sample referrals to hospice was only 22%.
• Subcutaneous atropine, scopolamine and hyoscine were equally effective in treating the “death rattle”. 95% of patients in this study had cancer and exclusion criteria included respiratory infection, aspiration and pulmonary edema.
• A small group of primary care physicians who participated in a mindfulness education program were found to have significant increase in mindfulness as well as improvement in burnout, empathy and personal well-being. It sounds like only a small number of physicians actually completed the full program.

Here are some of my random thoughts as an adult inpatient palliative care physician and I’d love to hear yours:

• As a whole, we are really missing the mark with the provision of spiritual care.
• I think planning location of death is important not only for children but for adults as well.
• When caring for debilitated elderly patients facing possible dialysis, I will try to help patients/families understand prognosis with regards to functional status and mortality.
• When caring for patients with advanced dementia, I will not assume that family members understand the natural history of the disease process, as this understanding is likely to reduce burdensome interventions.
• I’d like to know how the death rattly study truly excluded actively dying patients if they had a respiratory infection, aspiration of pulmonary edema. How did they know for sure?
• Completing some type of formal mindfulness training is one of my goals for 2011.

I’d welcome your thoughts…..