Abstract
Warmenhoven F, van Rijswijk E, van Hoogstraten E, et al. How family physicians address diagnosis and management of depression in palliative care patients. Ann Fam Med 2012;10:330–336.
Depression is highly prevalent in palliative care patients, and in clinical practice, there is concern about both insufficient and excessive diagnosis and treatment of depression. In the Netherlands, family physicians have a central role in delivering palliative care. In this study the authors explored variation in family physicians' opinions regarding the recognition, diagnosis, and management of depression in palliative care patients. The authors conducted a focus group study in a sample of family physicians with varied practice locations and varying expertise in palliative care. Transcripts were analyzed independently by two researchers using constant comparative analysis in ATLAS.ti. Results demonstrated that in four focus group discussions with 22 family physicians, the physicians described the diagnostic and therapeutic process for depression in palliative care patients as a continuous and overlapping process. Differentiating between normal and abnormal sadness was viewed as challenging. The physicians did not strictly apply criteria of depressive disorder but rather relied on their clinical judgment and strongly considered patients' context and background factors. They indicated that managing depression in palliative care patients is mainly supportive and nonspecific, and noted that antidepressant drugs were seldom prescribed. The physicians described difficulties in diagnosing and treating depression in palliative care, and gave suggestions to improve management of depression in palliative care patients in primary care. The authors conclude that family physicians perceive the diagnosis and management of depression in palliative care patients as challenging. They rely on open communication and a long-standing physician-patient relationship in which the patient's context is of great importance. This approach fits with the patient-centered care that is promoted in primary care.
Feudtner C, Morrison W. The darkening veil of “do everything.” Arch Pediatr Adoles Med 2012;166:694–695.
This brief article was viral on the internet and in medically related blogs, but it is so important, a brief mention of it is necessary. How many times have most physicians heard the mantra “Do everything” when a loved one is seriously ill. How many times have we all heard a physician mention “doing everything” when discussing options with patients and/or their families. In this important commentary, the authors bring this important topic to the table. The authors rightfully ask, What do the words “do everything” mean? As they state in their piece,
Ours is not an argument for confronting daunting choices bluntly—or, worse, brusquely—relying chiefly on medical facts and clinical logic to grapple with frightfully difficult situations. Rather, we argue for taking the time in these conversations to explore the choices that could be made. When confronted with requests or demands to ‘do everything,’ we view this as a starting point for a discussion, not an ending point. The discussion should not so much debate the pros and cons of particular interventions but rather focus on and elaborate specific commitments.
I agree with their thoughts, but their final paragraph says it all. The bottom line is simple: saying that we are going to “do everything” is dangerous nonsense. If we really don't mean it, then we really must not say it. A moratorium is warranted, halting all medical personnel from further casual utterances of “do everything.” This is an excellent and brief read that is recommended for all physicians, students, and trainees.
Widera EW, Block SD. Managing grief and depression at the end of life. Am Fam Physician 2012;86:259–264.
Psychological distress is common in terminally ill persons and can be a source of great suffering. Grief is an adaptive, universal, and highly personalized response to the multiple losses that occur at the end of life. This response may be intense early on after a loss manifesting itself physically, emotionally, cognitively, behaviorally, and spiritually; however, the impact of grief on daily life generally decreases with time. Although pharmacologic interventions are not warranted for uncomplicated grief, physicians are encouraged to support patients by acknowledging their grief and encouraging the open expression of emotions. It is important for the physician to distinguish uncomplicated grief reactions from more disabling psychiatric disorders such as major depression. The symptoms of grief may overlap with those of major depression or a terminal illness or its treatment; however, grief is a distinct entity. Feelings of pervasive hopelessness, helplessness, worthlessness, guilt, lack of pleasure, and suicidal ideation are present in patients with depression, but not in those experiencing grief. Psychotherapy and antidepressant medications reduce symptoms of distress and improve quality of life for patients with depression. Physicians may consider psychostimulants, such as methylphenidate, for patients who have depression with a life expectancy of only days to weeks.
Varma A, Shah KB, Hess ML. Phosphodiesterase inhibitors, congestive heart failure, and sudden death: Time for re-evaluation. Congest Heart Fail 2012;18:229–233.
In this case-based article, a 42-year-old diabetic man was admitted with systolic heart failure and pulmonary hypertension after being treated with sildenafil for the previous year. With an increase in creatinine, he experienced three episodes of ventricular tachycardia and ventricular fibrillation. Withdrawal of the phosphodiesterase (PDE) inhibitor resulted in no further episodes of dysrhythmias. The basic pharmacology of PDE inhibitors is presented and the use of PDE-3 inhibitors for the treatment of heart failure causing an increase in sudden death is also reviewed. There have been several cases of sudden death associated with sildenafil use and with its increasing use in patients with severe pulmonary hypertension and decompensated heart failure. The authors reviewed the electrophysiologic effects of PDE-5 inhibitors associated with their use. The crossover between PDE-3 and PDE-5 inhibitors is also discussed and caution is urged when contemplating the use of PDE-5 inhibitors in patients with systolic heart failure and pulmonary hypertension.
Dev R, Dalal S, Bruera E. Is there a role for parenteral nutrition or hydration at the end of life? Curr Opin Support Palliat Care 2012;6:365–370.
The purpose of this review was to update health care providers on the role of parenteral nutrition/hydration in terminal patients and highlight recent research. Cachexia is felt to be refractory to treatment at the last stages of life, and the majority of patients will derive no benefit from parenteral nutrition with some exceptions including patients with a good functional status and a nonfunctional gastrointestinal tract or a slow growing tumor. Dehydration can potentially be reversible in patients at the end of life. However, recent research examining parenteral hydration reveals no clear clinical benefits on symptom burden or survival for terminally ill cancer patients with the exception of possibly reversing the complication of delirium. The authors conclude that hydration and nutrition are essential for the maintenance of life, but in patients at the end of life, artificial hydration and nutrition pose clinical, ethical, and logistical dilemmas. No strong evidence exists supporting the use of parenteral hydration/nutrition for the majority of terminally ill patients; however, a subset of patients may derive some benefit. Uncertainty about determining prognosis, psychosocial factors, and perceptions of perceived benefits results in artificial nutrition/hydration being initiated in many terminally ill patients. Discontinuation of artificial support can result in distress for patients, family members, and health care providers, and as such, contribute to a complicated grief and bereavement.
Fredheim OMS, Moksnes, K, Borchgrevink PC, Skurtveit S. Opioid switching to methadone: A pharmacoepidemiological study from a national prescription database. Palliat Med 2012;26:804–812.
Opioid switching to methadone is reported frequently to improve pain control in patients with an unacceptable balance between pain control and side effects during treatment with first line opioids, but carries a risk of drug accumulation and respiratory depression. To justify this risk it is required that less risky treatments are tried beforehand and that a sufficiently large proportion of patients experience a long-lasting improvement in pain control. In this longitudinal pharmacoepidemiological study from the complete national Norwegian Prescription Database, the authors attempted to discover how large was the proportion of patients remaining on long-term methadone treatment after a switch from a strong opioid to methadone, and how long had the patients been treated with opioids before the switch to methadone? Results demonstrated that 130 (77%) cancer patients received more than one dispensed prescription of methadone. Forty-nine (40%) chronic nonmalignant pain (CNMP) patients continued to have methadone prescriptions dispensed more than six months after the switch. Of 168 cancer patients, 48 (29%) had tried two strong opioids prior to the switch to methadone, whereas 21 (12.5%) had tried three or more strong opioids. Similar numbers for 124 CNMP patients were 26 (21%) and 34 (27%), respectively. The authors conclude that opioid switching to methadone appears to provide a long-lasting improvement in pain control in a significant proportion of patients. However, the study raises concerns that treatment options with less risk are not being exhausted prior to switching to methadone.
Strada EA, Homel P, Tennstedt S, Billings JA, Portenoy RK. Spiritual well-being in patients with advanced heart and lung disease. Palliat Support Care 2012 (epub ahead of print; DOI 10.1017/S1478951512000065).
The purpose of this prospective, longitudinal study was to evaluate levels of spiritual well-being over time in populations with advanced congestive heart failure (CHF) or chronic obstructive lung disease (COPD). Patients with CHF or COPD (each n=103) were interviewed at baseline and every three months for up to 30 months. At each interview, patients completed the basic faith subscale of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) questionnaire, the Memorial Symptom Assessment Scale (MSAS), the Rand Mental Health Inventory (MHI), the Multidimensional Index of Life Quality (MILQ), the Sickness Impact Profile (SIP), and the Short Portable Mental Health Questionnaire (SPMSQ). Results demonstrated that the mean age was 65 years, 59% were male, 78% were Caucasian, 50% were married, 29% lived alone, and there was no significant cognitive impairment. Baseline median FACIT-Sp score was 10.0 on a scale of 0–16. FACIT-Sp scores did not change over time and multivariate longitudinal analysis revealed higher scores for black patients and lower scores for those with more symptom distress on the MSAS-Global Distress Index (GDI) (both p=0.02). On a separate multivariate longitudinal analysis, MILQ scores were positively associated with the FACIT-Sp and the MHI, and negatively associated with the MSAS-GDI and the SIP (all p-values<0.001). The authors conclude that in advanced CHF and COPD, spiritual well-being remains stable over time, it varies by race and symptom distress, and contributes to quality of life, in combination with symptom distress, mental health, and physical functioning.