Abstract
Lantos JD, Meadow WL: Should the 'slow code' be resuscitated? Am J Bioeth 2011;11: 8–12.
Most bioethicists and professional medical societies condemn the well-known practice of “slow codes.” The American College of Physicians ethics manual states, “Because it is deceptive, physicians or nurses should not perform half-hearted resuscitation efforts ('slow codes').” A leading textbook and a medical sociologist describe them as crass, dishonest, unethical, deplorable, and inconsistent with established ethical principles.' Nevertheless, the authors of this interesting article believe that slow codes may be appropriate and ethically defensible in situations in which cardiopulmonary resuscitation (CPR) is likely to be ineffective, the family decision makers understand and accept that death is inevitable, but those family members cannot bring themselves to consent or even agree to a do-not-resuscitate (DNR) order. In such cases, the authors argue that physicians may best serve both the patient and the family by having a carefully ambiguous discussion about end-of-life (EOL) options and then providing resuscitation efforts that are less vigorous or prolonged than usual. Clearly, this article will stimulate discussion; I highly recommend its reading.
Akl EA, Vasireddi SR, Gunkula S, et al: Anticoagulation for the initial treatment of venous thromboembolism in patients with cancer. Cochrane Database Syst Rev 2011(4):CD006649
Compared to patients without cancer, patients with cancer who receive anticoagulant treatment for venous thromboembolism (VTE) are more likely to develop recurrent VTE. The objective of this Cochrane Review was to compare the efficacy and safety of three types of parenteral anticoagulants for the initial treatment of VTE in patients with cancer. Randomized clinical trials (RCTs) comparing low molecular weight heparin (LMWH), unfractionated heparin (UFH), and fondaparinux in patients with cancer and objectively confirmed VTE were reviewed. Results demonstrated that of 3986 identified citations, 16 RCTs were eligible: 13 compared LMWH to UFH, two compared fondaparinux to heparin, and one compared dalteparin to tinzaparin. Meta-analysis of 11 studies showed a statistically significant reduction in mortality at three months of follow-up with LMWH compared with UFH. There was little change in the effect estimate after excluding studies of lower methodological quality. A meta-analysis of three studies comparing LMWH with UFH showed no statistically significant reduction in VTE recurrence. The overall quality of evidence was low for LMWH versus UFH due to imprecision and likely publication bias. There were no statistically significant differences between heparin and fondaparinux for the outcomes of death, recurrent VTE, and major or minor bleeding. The one study comparing dalteparin to tinzaparin did not find a statistically significant difference in mortality. The authors conclude that LMWH is possibly superior to UFH in the initial treatment of VTE in patients with cancer, but that additional trials focusing on important patient outcomes will further inform the questions addressed in this review.
Birks T, Krikos D, McGowan C, et al: Is there a need for weekend face-to-face inpatient assessments by hospital specialist palliative care services? Evaluation of an out-of-hours service. Palliat Med 2011;25:278–283
There is an increasing demand for hospital specialist palliative care services to be made more accessible outside of normal working hours, as many palliative care programs provide Monday through Friday coverage. However, it has been argued that extended service provision could be misused and that specialist telephone advisory services are an adequate response to this demand. A 'routine' Saturday face-to-face visiting service was introduced into a hospital palliative care team and the service was evaluated to determine whether it was being utilized appropriately. Review of out-of-hours assessments was undertaken. Anonymous data relating to the nature of the interaction with the palliative care team and the outcome of the consultation were entered into an electronic database. A random sample of routine weekday interactions was also evaluated. A total of 336 Saturday and 93 weekday assessments were analyzed. The authors noted that most of the Saturday assessments resulted in a significant change in management (57%) or were undertaken on patients close to death (10%). There were 39/336 (12%) new referrals assessed on Saturdays. There were few differences between the nature of the Saturday and the weekday service and no evidence of 'inappropriate' referrals. The authors conclude that they found clear evidence of the need for a specialist out-of-hours face-to-face inpatient visiting service for hospital palliative care.
Font C, Farrus B, Vidal L, et al: Incidental versus symptomatic venous thrombosis in cancer: A prospective observational study of 340 consecutive patients. Ann Oncol 2011;22:2101–2106.
The clinical significance of incidental venous thrombosis (IVT) in cancer is uncertain. The objective of this prospective observational study was to compare the clinical characteristics and the outcome of cancer patients with IVT with those of patients with symptomatic venous thrombosis (SVT). Consecutive cancer patients newly diagnosed with venous thromboembolism from May 2006 to April 2009 were enrolled. Diagnosis of IVT was based on vascular filling defects in scheduled computed tomography scans in the absence of clinical symptoms. Anticoagulant therapy was routinely prescribed regardless of SVT or IVT. Results demonstrated that IVT was diagnosed in 94 out of 340 (28%) patients. Patients with IVT were older (63.7 ± 10.5 years versus 60.8 ± 10.5 years), more frequently had metastatic cancer (82% versus 65%), and were less likely to be receiving chemotherapy at the time of the thrombotic event (53% versus 67%). Mean follow-up was 477 days. A lower risk of venous re-thromboses was observed in patients with IVT (log-rank P = 0.043), with no differences in major bleeding and overall survival compared with SVT patients. The authors conclude that a high proportion of venous thrombotic events in cancer patients are diagnosed incidentally during scheduled imaging and that prospective controlled trials evaluating the optimal therapy in this setting are required.
Bruno JJ, Hernandez M, Ghosh S, et al: Critical illness-related corticosteroid insufficiency in cancer patients. Support Care Cancer 2011, published online first.
Critically ill cancer patients with sepsis represent a high-risk subgroup for the development of critical illness-related corticosteroid insufficiency (CIRCI); however, the incidence of CIRCI in this complicated population is unknown. The purpose of this single-center, retrospective, observational study was to determine the incidence of CIRCI in cancer patients with severe sepsis or septic shock. The study was conducted in a 52-bed medical-surgical intensive care unit (ICU) of a National Cancer Institute recognized academic oncology institution. Eighty-six consecutive patients with a diagnosis of severe sepsis or septic shock who received a high-dose 250 μg cosyntropin stimulation test were included. CIRCI was identified by a maximum delta serum cortisol of 9 μg/dL or less post-cosyntropin. Results demonstrated that overall, 59% of cancer patients with severe sepsis or septic shock were determined to have CIRCI. When compared to patients without CIRCI, patients with CIRCI had higher baseline serum cortisol (median, 26.3 versus 14.7 μg/dL; p = 0.002) and lower delta cortisol levels (median, 3.1 versus 12.5 μg/dL; p < 0.001). Mortality did not differ between the two groups. An inverse relationship was identified between baseline serum cortisol and maximum delta cortisol. The authors conclude that the incidence of CIRCI in cancer patients with severe sepsis or septic shock appears high, and that further large-scale prospective trials are needed to confirm these findings.
Pini S, Hugh-Jones S, Gardner PH: What effect does a cancer diagnosis have on the educational engagement and school life of teenagers? A systematic review. Psychooncology 2011, published online first.
A diagnosis of cancer during the teenage years occurs at an important stage of development, where issues of normality, identity, and independence are crucial. Education provides opportunity for peer contact, achievement, and development for teenagers. This systematic review examined the impact of a diagnosis of cancer on the educational engagement and school life of teenagers. The authors searched five electronic databases, returning a total of 3209 articles. Inclusion criteria were broad to allow for the range of literature within this area. Following screening, 22 articles (inclusive of both quantitative and qualitative methodologies) were retained and subjected to independent review and quality assessment. Results demonstrated that key areas involved in the impact of a cancer diagnosis on teenagers' educational engagement included school attendance, reintegration, peer relationships, and long-term effects on education and employment. The authors conclude that school absences are a concern for teenagers, but do not necessarily lead to a reduction in educational and vocational attainment. It is important to involve health care and education professionals as well as parents and teenagers themselves in school reintegration if it is to be successful. Peer groups and body image are two areas that could mediate education engagement for teenagers. Further research needs to be undertaken to determine the overall impact of successfully maintaining education engagement specifically for teenagers, the role that peer groups play in this process, and how education engagement contributes to the overall coping and well-being of teenage cancer patients.