Abstract
Seale C: Hastening death in end-of-life care: A survey of doctors. Soc Sci Med 2009;69:1659–1666.
The medical care of people near the end of life involves many decisions: to provide care, to withhold or withdraw care, or in some areas of the world (including Oregon and Washington in the United States), assisted dying. In this study, the author attempted to estimate the prevalence of end-of-life decisions that doctors expect or at least partly intend to hasten death, and to establish how this varies across different care settings, medical specialties, and patient groups; to examine the role of religious beliefs and attitudes toward legislation of assisted dying are associated with readiness to take decisions doctors expect or at least partly intend to end life; to assess the degree to which requests for a hastened death from patients, relatives, or others are associated with the incidence of decisions involving an expectation or some intention to end life, and the extent to which such decisions are discussed with patients, relatives, or others; and to assess whether such decisions occur disproportionately in groups of patients considered vulnerable. Three thousand seven hundred thirty-three United Kingdom physicians reporting on the care of 2923 people who had died under their care was reported. Results demonstrated that there was no time to make an “end-of-life” decision (i.e., provide care, withhold or withdraw care) for 8.5% of those reporting death. A further 55.2% reported decisions that they estimated would not hasten death, while 28.9% reported decisions they had expected to hasten death, with a further 7.4% reporting deaths where they had to some degree intended to hasten death. Where patients or someone else had made a request to hasten death, physicians were more likely to report expecting or at least partly intending to hasten death. Intensivists were particularly likely to report a degree of intention to hasten death as well as having more patients lacking the capacity to discuss these decisions. Palliative medicine physicians were the least likely to report decisions that they expected or at least partly intended to hasten death, in spite of reporting a high incidence of such requests from patients. Physicians with strong religious beliefs or those who opposed the legalization of assisted dying were unlikely to report such decisions. The author concludes that the study suggests that concerns about the sanctity of life, as well as estimates of the quality of life, enter clinical decision making.
Jeffrey E, Jeffrey D: Vex not his ghost: King Lear and end-of-life care. J R Coll Physicians Edinb 2009;39:15–19.
King Lear, one of Shakespeare's darkest and most cruel of all of his tragedies, was supposedly performed at the court of King James I on December 26, 1606. Shakespeare's original narrative explored grief, loss, and suffering, insights that can be applied to contemporary end-of-life care. In this article, the authors investigate how elements of Shakespeare's King Lear might enrich our understanding of the tensions, challenges, and opportunities of end-of-life care, particularly as it celebrates the human spirit in the face of persistent adversity.
De la Cruz M, Hui D, Parson HA, Bruera E: Placebo and nocebo effects in randomized double-blind clinical trials of agents for the therapy for fatigue in patients with advanced cancer. Cancer (in press).
Cancer-related fatigue significantly reduces the quality of life for patients with advanced cancer. Many treatments for fatigue have been tried, with a significant response to placebo in randomized controlled trials. In this article, the authors report the findings from a retrospective study conducted to determine the frequency and predictors of response to placebo effect and nocebo effects in patients with cancer-related fatigue treated in those trials. The records of 105 patients who received placebo in two previous randomized clinical trials were reviewed. The proportion of patients demonstrating clinical response to fatigue (using the Functional Assessment of Chronic Illness Therapy–Fatigue Score), and the proportion of patients with a nocebo effect (defined as those reporting fewer than two side effects) were determined. In addition, baseline patient characteristics and symptoms were recorded and analyzed using the Edmonton Symptom Assessment Scale (ESAS) to determine their association with placebo and nocebo effects. Results demonstrated that 59 patients (56%) had a placebo response, with worse baseline anxiety and well-being subscale score (univariate) and well-being (multivariate) were significantly associated with placebo response. Commonly reported side effects were insomnia, anorexia, nausea, and restlessness. Multivariate analysis indicated that worse baseline (ESAS) sleep, appetite, and nausea were associated with increased reporting of the corresponding side effects. The authors conclude that greater than half of patients with advanced cancer with fatigue enrolled in trials had a placebo response, with worse baseline physical score associated with placebo response. Patients reporting specific symptoms at baseline were more likely to report these side effects of the medication.
Bonezzi C, Allegri M, Demartini L, Buonocore M: The pharmacological treatment of neuropathic pain. Eur J Pain Suppl 2009;3:85–88.
Neuropathic pain can reduce quality of life, and occurs secondary to many common diseases, injuries, and interventions. In the peripheral and central nervous system. In this brief review article, the authors discuss pain mechanisms and a strategy to treat neuropathic pain, including patient evaluation and commonly used drugs (i.e., antidepressants, anticonvulsants, opioids, etc.).
Cherny NI, Radbruch L; The Board of the European Association for Palliative Care: European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009;23:581–593.
Palliative sedation has been increasingly utilized to manage refractory symptoms at the end of life. The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy in the care of selected palliative care patients, but acknowledges that prudent application of sedation requires due caution and good clinical practice. As noted by the EAPC, procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care, and convey the important message to staff, patients, and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. Thus, the EAPC's recommendations and procedural guidelines for the use of sedation in this well-written and informative article. The authors discuss why procedural guidelines are important, a framework for procedural guidelines, and three valuable appendices. This is an excellent article that is recommended reading for all clinicians in palliative care.
Loggers ET, Maciejewski PK, Paulk E, DeSanto-Madeya S, Nilsson M, Viswanath K, Wright AA, Balboni TA, Temel J, Stieglitz H, Block S, Prigerson HG: Racial differences in predictors of intensive end-of-life care in patients with advanced cancer. J Clin Oncol 2009;27:5559–5564.
Although the majority of American state that they want to die at home, there is a segment that instead prefers intensive, life-prolonging care at the end of life. Frequently included in this latter group are black patients who prefer and receive intensive end of life care at higher rates than white patients. In this study, the authors examined predictors of intensive end of life care for black and white patients with advanced cancer. Three hundred two self-reported black (n = 68) and white (n = 234) patients with stage IV cancer and their caregivers participated in a U.S. multisite, prospective, interview-based cohort study from September 2002 to August 2008. Participants were observed until death, or a median of 116 days from baseline. Patient-reported baseline predictors included end of life care preference, physician trust, end-of-life discussion, completion of a do-not-resuscitate (DNR) order, and religious coping. Results demonstrated that black patients were three times more likely than white patients to receive intensive end-of-life care, while white patients with a preference for this care were approximately three times more likely to receive it than black patients with the same preference. White patients who reported an end-of-life discussion or DNR order did not receive intensive end-of-life care—similar reports were not protective for black patients. The authors conclude that white patients with advanced cancer are more likely than black patients with advanced cancer to receive the end-of-life care they initially prefer; in addition, end-of-life discussions and DNR orders are not associated with care for black patients, highlighting a need to improve communication between black patients and their clinicians.