Abstract
Boyd EA, Lo B, Evans LR, Malvar G, Apatira L, Luce JM, White DB: “It's not just what the doctor tells me:” Factors that influence surrogate decision-makers' perception of prognosis. Crit Care Med 2010;38:1270–1275.
The majority of patients in critical care units are often unable to make their own decisions and depend on surrogate decision-makers to make end-of-life decisions. In this prospective mixed methods study utilizing face-to-face semistructured interviews with surrogate decision makers, the authors attempted to understand what sources of knowledge surrogates rely on when estimating a patient's prognosis. Four intensive care units at the University of California at San Francisco Medical Center were used as study sites. Participants were 179 surrogate decision makers for 142 critically ill patients at high risk for death, and unable to render decisions for themselves. Results demonstrated that less than 2% of surrogates reported that their beliefs about the patients' prognosis hinged exclusively on prognostic information provided by physicians. The majority related other factors in addition to physicians' predictions, including perceptions of the patient's individual strength of character and will to live, the patient's unique history of illness and survival, the surrogate's own observations of the patient's physical appearance, the surrogate's belief that their presence at the bedside could improve prognosis, and the surrogate's optimism, intuition, and faith. Most surrogates endeavored to balance their own knowledge of the patient with the physician's biomedical knowledge. The authors conclude that surrogates use diverse types of knowledge when estimating their loved ones' prognoses, including individualized attributes of the patient. Attention to these considerations may help clinicians identify and overcome disagreements about prognosis.
Raphael J, Ahmedzai S, Hester J, Urch C, Barrie J, Williams J, Farquhar-Smith P, Fallon M, Hoskin P, Robb K, Bennett MI, Haines R, Johnson M, Bhaskar A, Chong S, Duarte R, Sparkes E: Cancer pain: Part 1: Pathophysiology; oncological, pharmacological, and psychological treatments: A perspective from the British Pain Society endorsed by the UK Association of Palliative Medicine and the Royal College of General Practitioners. Pain Med 2010;11:742–764.
Cancer pain management continues to be poorly treated in many institutions and nursing homes, with a clear need for better cancer pain management. In this comprehensive article written from the pain specialist's perspective, the authors provide an excellent overview of pain pathophysiology, as well as oncologic, pharmacologic, and psychologic treatments. The article is suffused with algorithms, illustrations, and tables, and while rather lengthy, it is worth retaining as a reference source.
McCarty CE, Volicer L. Hospice access for individuals with dementia. Am J Alzheimers Dis Other Demen 2009;24:476–485.
Many hospices are enrolling patients with varied diagnoses, including dementia. But despite improved utilization of hospice for demented patients, barriers remain, including problems determining 6-month terminality. In this pilot study of hospice agencies, the authors attempted to determine barriers and characteristics of dementia hospice enrollment. Using a mailed questionnaire and interview, demographics, accessibility, training, referral sources, and marketing were studied. Results demonstrated that hospices with bridge or transition programs had on average 4 times higher numbers of Alzheimer's patients and dementia census than hospices without such programs. The highest rated barriers to hospice use for demented patients were prognosis, education, and finance.
Hajjaj FM, Salek MS, Basra MKA, Finlay AK; Non-clinical influences on clinical decision-making: A major challenge to evidence-based medicine. J R Soc Med 2010;103:178–187.
The authors of this article note that clinical decision-making is the essence of daily clinical practice. This process involves an interaction of application of clinical and biomedical knowledge, problem-solving, weighing of probabilities and various outcomes, and balancing risk-benefit. A vital task is to balance personal experience and prevalent knowledge, something all clinicians do everyday. Evidence-based medicine protocols provide a pathway to physicians that allows them to make sound therapeutic decisions with an element of confidence rather than being based purely on personal experience. Nevertheless, nonclinical influences on clinical decision-making can profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, and physician-related factors such as personal characteristics and interaction with their professional community. This review article brings together the different elements of knowledge concerning nonclinical influences on clinical decision-making. The authors suggest that this aspect of decision-making may be the biggest obstacle to the reality of practicing evidence-based medicine. They conclude that nonclinical influences need to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.
Johnson MJ, Oxberry SJ: The management of dyspnoea in chronic heart failure. Curr Opinion Pall Support Care 2010;4:63–68.
Dyspnea causes a reduced quality of life in chronic heart failure; in addition, its treatment is often neglected by well-meaning clinicians. In this review article, the authors note there is evidence to support exercise training and mindfulness-based programs. They also note that the safety of morphine for breathlessness in acute heart failure has been retrospectively analyzed and seems beneficial, but controlled clinical trials are still required. They further state that sildenafil may be useful for dyspnea in chronic heart failure due to reduction of peripheral muscle signaling, while rolophylline, relaxin, carperitide, nesiritide, and steroids warrant further evaluation. Bronchodilator use for dyspnea in acute heart failure in the absence of chronic obstructive pulmonary disease (COPD) should be used with caution. Finally, a recent Cochrane Review highlights the importance of diuretic therapy for both symptom control and optimizing prognosis. The authors conclude that better standardization of dyspnea outcome measures should help comparison of future trials. Optimization of diuretic therapy and attempted correction of neurohormonal disturbance in congestive heart failure (CHF) remain the therapeutic targets for the underlying cause in dyspnea management.
Kao SCH, Butow P, Bray V, et al. Patient and oncologist estimates of survival in advanced cancer patients. Psychooncology (in press).
Prognostication is an important skill for physicians, particularly in patients with advanced cancer but one fraught with inconsistencies. Studies repeatedly show that physicians err in their prognostic abilities. On the other hand, there is little information about the accuracy of patient perceptions of life expectancy. In this study, the authors compared patient perceptions of life expectancy with their oncologists' estimates of life expectancy to actual survival. Patients with metastatic cancer were recruited for the study. Oncologists were asked to estimate survival as (1) weeks; (2) months; (3) less than 1 year; (4) less than 2 years; and (5) more than 2 years. Patients were asked to estimate their life expectancy on a numerical scale from 1 to 7. Patient and oncologist estimates were then compared with actual survival. Fifty patients were studied, with a median age of 63.5 years; 48% were males, with tumor types colorectal (32%), lung (24%), upper gastrointestinal (10%), and unknown primary (12%). Median survival was 6.8 months. Oncologists were accurate in predicting survival in 32% and overestimated in 42%. The correlation between self-reported patient outlook and survival was modest. The median survival for categories of outlook of 1–3, 4–5, and 6–7 were 4.4, 5.4, and 14.8 months, respectively. The authors conclude that oncologists were relatively poor at predicting survival and tended to be optimistic in their prognostication. The probability of survival significantly decreased with worse self-reported patient outlook.