Abstract
Mueller PS, Swetz KM, Freeman MR, et al. Ethical analysis of withdrawing ventricular assist device support. Mayo Clin Proc 2010;85: 791–797.
Approximately 5 million Americans suffer with heart failure, of which 250,000 have end-stage disease. In spite of improvement in therapies for heart failure, the 1-year mortality for severe heart failure is more than 50%. Clearly, heart transplant is an effective treatment for end-stage heart failure, but not enough hearts are available. However, left ventricular assist devices (LVAD), surgically implanted devices that support circulation by pulling blood from the left ventricle and pumping it into the aorta, can support patients waiting for a heart transplant, or can support patients that are not candidates for heart transplant for the rest of their lives. Unfortunately, LVADs are not without complications, including stroke, infection, and multiorgan failure—in these cases, patients or their surrogates may decide that the LVAD is burdensome, and may request withdrawal. In this study, the authors describe a series of patients with LVADs who requested (or their surrogates requested) withdrawal of LVAD support and the legal and ethical issues pertaining to these requests. Medical records from Mayo Clinic (from March 1, 2003 through January 31, 2009) were retrospectively reviewed. Fourteen patients were identified (13 men, 1 woman), with a median age of 57 years—requests were made by 2 patients and 12 surrogates, and none of the patients advance directives mentioned LVADs. For 11 patients, multidisciplinary care conferences were held before withdrawal of LVAD support, and only 1 patient had an ethics consult. All 14 patients died within one day of LVAD withdrawal. The authors conclude that patients have the right to refuse or request the withdrawal of any unwanted treatment, and that that right extends to LVADs. They also argue that the cause of death is the underlying heart disease, and not assisted death or euthanasia, and that patients (or their surrogates) with LVADs may request withdrawal of this treatment in accordance with the principles that apply to withdrawing other life-sustaining treatments.
Mack JW, Paulk ME, Viswanath K, Pirgerson HG. Racial disparities in the outcomes of communication on medical care received near death. Arch Intern Med 2010;170:1533–1540.
Black patients receive more life-prolonging measures and less comfort care at the end of life than white patients (i.e., Hanchate A, et al. Arch Intern Med 2009;169: 493-501). In this multiinstitutional prospective longitudinal cohort study, the authors attempted to evaluate whether differences in patient-physician communication contribute to disparities in end-of-life care between black patients and white patients. Seventy-one black patients and 261 white patients with advanced cancer were studied. Main outcomes measures were differences between black and white patients in relationship among end-of-life discussions and communication goals (terminal illness awareness, treatment preferences, do-not-resuscitate [DNR] orders) and end-of-life care outcomes (life-prolonging care, hospice care, and receipt of end-of-life care consistent with preferences). Results demonstrated that end-of-life discussions between physicians and their white patients were associated with less life-prolonging end-of-life care compared with their black patients (p = .04). despite similar rates of end-of-life discussions, more black patients than white patients received life-prolonging end-of-life care. End-of-life discussions were associated with attainment of some communication goals among black patients including placement of DNR orders, but these communication goals were not consistently associated with end-of-life care received by black patients. The authors conclude that end-of-life discussions and communication goals seem to assist white patients in receiving less life-prolonging care, but black patients do not experience the same benefits of end-of-life discussions. Instead, black patients tend to receive life-prolonging measures at the end of life even when they have DNR orders or state a preference for symptom-directed care.
Ahles TA, Saykin AJ, McDonald BC, et al. Longitudinal assessment of cognitive changes associated with adjuvant treatment for breast cancer: Impact of age and cognitive reserve. J Clin Oncol 2010;28:4434–4440.
Cross-sectional and longitudinal studies have found evidence for chemotherapy-induced cognitive changes in a subgroup of patients with breast cancer, although negative studies have been reported. Studies also have suggested that tamoxifen alone or in combination with chemotherapy contributes to cognitive decline, with less consistent evidence for the cognitive effects of aromatase inhibitors. In this study, the authors attempted to examine the impact of age and cognitive reserve on cognitive functioning in patients with breast cancer who are receiving adjuvant treatments. Patients with breast cancer exposed to chemotherapy (n = 60; mean age, 51.7 years) were evaluated with a battery of neuropsychological and psychological tests before treatment and at 1, 6, and 18 months after treatment. Patients not exposed to chemotherapy (n = 72; mean age, 56.6 years) and healthy controls (n = 45; mean age, 52.9 years) were assessed at matched intervals. Results demonstrated that mixed-effects modeling revealed significant effects for the Processing Speed and Verbal Ability domains. For Processing Speed, a three-way interaction among treatment group, age, and baseline cognitive reserve revealed that older patients with lower baseline cognitive reserve who were exposed to chemotherapy had lower performance on Processing Speed compared with patients not exposed to chemotherapy and controls. A significant group by time interaction for Verbal Ability suggested that the healthy controls and no chemotherapy groups improved over time. The chemotherapy group failed to improve at one month after treatment but improved during the last two follow-up assessments. Exploratory analyses suggested a negative effect of tamoxifen on Processing Speed and Verbal Memory in the no-chemotherapy group. The authors conclude that these data demonstrated that age and pretreatment cognitive reserve were related to posttreatment decline in Processing Speed in women exposed to chemotherapy and that chemotherapy had a short-term impact on Verbal Ability. Exploratory analysis of the impact of tamoxifen suggests that this pattern of results may be due to a combination of chemotherapy and tamoxifen.
Epner DE, Ravi V, Baile WF. When patients and families feel abandoned. Support Care Cancer (published online September 19, 2010).
Patients with serious and life-threatening illnesses develop a sense of security by a bonding that occurs with their physician. However, these relationships can create expectations in patients that are not necessarily shared by their clinicians. Providers often focus on treating disease and emphasize technically excellent, “evidence-based” practice while all-too-often failing to fully appreciate the power of the patient–provider relationship. In contrast, vulnerable patients expect much more than technical competence, including open and clear communication, security, continuity, and access. Patients are often left feeling abandoned when their providers do not meet their expectations, even when their care is technically sound. In this article, the authors describe scenarios that can lead to feelings of abandonment and discuss strategies to avoid and respond to them. These strategies can help maintain healing relationships with patients by maintaining their trust, confidence, and satisfaction. Cultivating relational aspects of medical practice requires an interchange and takes time, and experienced physicians know this and continue to do so because being present and staying with the patient during difficult times is a pillar of moral and ethical training and a fundamental attribute of a good physician.
West RL, Hernandez AF, O'Connor CM, et al. A review of dyspnea in acute heart failure syndromes. Am Heart J 2010;160: 209–214.
In acute heart failure syndrome (AHFS), dyspnea is one of the most common but least understood presenting symptoms for hospitalization. For this reason, dyspnea relief is increasingly becoming a focus in the development of therapies for the treatment of AHFS, and currently stands as an acceptable primary end point for regulatory approval by governmental agencies. This raises the question of how best to measure such a subjective symptom. In this review, the authors describe the basis for dyspnea, provide a detailed description of the strengths and weaknesses of the current best tools used to measure it, and describe future directions for future development of dyspnea measurement in AHFS.