Reformation and Counter-Reformation

Those who work in hospice and palliative care are generally motivated to alleviate pain and distress in patients and their families. For most of us, our entry into the field was accompanied by the thrill to learn of the power of medicinal opioids, analgesics, and coanalgesics to manage pain. The desire to spread “the truth” to treat patients and reform standard of practice is one of the drivers for us to coalesce as a subspecialty and to be acknowledged as effective colleagues in hospitals, hospices, nursing homes, and in outpatient and home care settings. The heady zeal of discovering “a new truth” could be analogous to the zeal of the Protestant Reformation in Europe. The reemerging concern that our zeal for medicinal opioids are a scourge upon humanity, and those profligate physicians and their abetting nurses are leading the general public to the moral decay of recreational drug use and death could be analogized to the Roman Catholic Counter-Reformation that arose in response to the Protestant Reformation. The legislators and regulators have a drive analogous to that of the Spanish Inquisition in restoring the moral order. David Weissman first gave me this analogy to help me frame what seems like a distressing erosion of progress and a gross distortion of fact.

It strikes me that this simile also applies to the use of neuroleptic antipsychotics for the management of delirium. Patients with dementia living at home and cared for by their general practitioners are reported to have prescriptions remarkable for the absence of neuroleptic medications; their counterparts in nursing homes do have neuroleptic medications prescribed. ¹ The authors infer that the care of the patients is better in the specialized care units with their specialized teams. Further, a Delphi study of palliative care specialists identified four drugs that anyone, anywhere in the world, should have available for appropriate management, including a neuroleptic antipsychotic. ² Presumably, this is what we would wish for were we on a desert island, or working in a low-resource country. Yet, in the Unted States, the neuroleptic antipsychotics have been identified as tantamount to abuse of patients in nursing homes. Their presence on a patient's medication list is a reason for regulators to investigate the nursing home and potentially revoke its licensure. Is this another situation of Reformation and Counter-Reformation? Should we fear the regulators like those who feared the Spanish Inquisition? I certainly believe the neuroleptics are essential to our practice and can't conceive of an environment where I would be deprived of that tool. Yet, there are nursing homes where this class of drugs has essentially vanished out of fear of the regulators.

Could we be wrong? In a third study, investigators asked palliative care experts what errors they make in practice. ³ Interestingly, the experts don't identify errors in medication management very often. Yet, our recent medical literature frequently finds that treatments “everyone knows to be effective” are found to be ineffective when appropriately studied. How I hate to be forced to say, like Ruth Buzzi's character on television's Laugh-In from the 1970s when confronted with facts that refute her ranting, “Oh….Never mind.” I much prefer the energy of zealotry. As we enter the New Year, each of us should be yearning for the emergence of better science, better evidence that supports our professional zeal, and the willingness to admit to ourselves and our patients when we are wrong, despite our best intent.