David Weissman, M.D.

Myth Buster #4 NHPCO Non-Cancer Guidelines

The NHPCO guidelines for non-cancer diagnoses were published in 1996 as a well intentioned attempt to help hospices and clinicians decide when it was appropriate to refer patients for hospice care based on a prediction of less than six months survival. The committee developing the guidelines used the best medical evidence at the time to establish clinical prognostic indicators.  Hospice programs across the country have adopted these guidelines into admission checklists, to be used at the time of hospice referral to help the core team decide if patients meet admission criteria under the Medicare Hospice Benefit; hospice fiscal intermediaries have similarly adopted most aspects of the guidelines as criteria to use for determining payment eligibility.  Unfortunately, since 1996 good quality research projects looking at the validity of these prognostic criteria have shown that the disease-specific NHPCO guidelines are little better than a flip of the coin in determining whether a patient with end-stage heart or lung disease or dementia will survive more or less than six months.  Two recent Fast Facts and Concepts (#141-COPD; #143-CHF) discuss current research on prognostic factors in end-stage heart and lung disease (go to www.eperc.mcw.edu).

Myth Buster #3 Education changes practice

Everyone agrees that health professionals need more education regarding palliative care. But what can education alone accomplish in terms of changing behavior?  We have over 20 years of experience with cancer pain and palliative care education which has largely demonstrated that education alone does little to improve patient care.  If one looks at the major changes leading to clinician behavioral change, one finds elements of institutional systems change, rather than traditional education.  Systems change, a.k.a insitutional change, includes making pain a 5th vital sign, developing standards, policies and procedures for pain management, starting a palliative care consultation program, changing instutional formularies, etc.  Systems change helps to build a better system of care, which forces clinicians to adopt new ways of providing care in accordance with best practice standards.  In one stroke, a systems change approach (e.g. removing meperidine from a hospital formualary) can help overcome dysfunctional attitudes and poor knowledge.  I am not suggesting that education is useless--quite the contrary--education has a key role in reinforcing best practice standards.  But one should think about education as one part of a larger effort to improve care, an effort which needs to include a critical appraisal of how to change the system in a manner that promotes excellent care.

Myth Buster #2 Lorazepam

Anyone who makes rounds with me know that when the topic of lorazepam (Ativan) as an anti-emetic comes up, I start to twitch.  It was during my oncology fellowship some 20 years ago that I remember the push began to add lorazepam to the various anti-emetic cocktails used as pre-treatment for emetogenic chemotherapy. The rationale was to use an anxiolytic to help reduce the incidence of anticipatory nausea--a not uncommon problem in those days when the available anti-emetics worked rather poorly.  Lo and behold, rather quickly lorazepam use metastatsized to treatment of post-chemotherapy nausea, and then, making the final evolutionary leap, to being used throughout hospitals and hospices for nausea of any etiology.  As best as I can find in the literature:  a) lorazepam is a very weak anti-emetic--the current edition of a major cancer textbook says "lorazepam has little efficacy as single agent in carefully conducted trials." (1)  b) lorazepam is effective at reducing anxiety--thus its efficacy in reducing chemotherapy-inducing anticipatory nausea or potentially for anxiety-induced nausea.  c) lorazepam is a sedative--as such, will put people to sleep and/or can induce delirium.  There just isn't the data to support the use of lorazepam as a major anti-emetic for non-anxiety nausea, and there is data on the potential harm of delirium or excessive sedation. For more on this topic, see Jim Hallenbeck's excellent Fast Fact #5 (www.eperc.mcw.edu)

1. Berger AM and Clark-Snow RA. Adverse effects of treatment. in DeVita  VT, et al. Cancer: Principles and practice of Oncology, 7th Edition. Lippincott Williams and WIlkins, 2005.

Myth Buster #1 Fentanyl

I freely admit I'm a Myth Buster junkie--for those who don't know what I'm talking about, Myth Busters is a cable TV show where two guys go about proving or disproving myths from movies and everday life.    As the hospice and palliative care movement is moving toward speciality status, it is important to scrutinize our clinical practice for our own myths.  Over the next few weeks and months I will post some of my favorite pet peeves that permeate the world of end-of-life care.  Now, if anyone has any hard data to prove that these myths are true--by all means come forward.

First on my hit list is oft repeated idea that transdermal fentanyl (Duragesic) is ineffective in cachectic patients due to the reduced body fat.  Yes, it is true that Transdermal Fentanyl is aborbed across the skin into the fat and the fat serves as a depot for the slow release into the blood stream.  But, I have searched high and low in the medical literature and can find no data that supports the idea that cachexia leads to inadequate pain control with this product.  I found a one sentence statement in a respected palliative care textbook stating this idea as fact, with no supporting reference; I contacted the author who admitted that it was a mistake to include the statement as there was no evidence.  So there it is--if you have evidence or can point me in the right direction, please come forward; otherwise, I will consider the fentanyl-fat connection to be a palliative care myth.

Disclaimer:  I have NO financial or other relationship with Janssen Pharmaceuticals, the maker of Duragesic Transdermal System.

CPR Musings

I'm in the midst of a spirited debate with professional colleagues in SE Wisconsin regarding the role of patient autonomy in CPR decisions.  On the one side are those who belive it is appropriate for patients to indicate their CPR preference on an advance directive form. Question: Do you want CPR if your heart stops? Yes or No.  (Note: The statutory Wisconsin Power of Attorney Health Care document does not include a CPR question, but many health care centers have amended the state form to include this CPR question).  Their argument is that a) patients have a right to voice their opinion which honors their autonomy and 2) having patients state their preference provides their health care professionals important information as to the patient's end-of-life preferences.  I stand firmly on the other side of the debate, arguing that CPR is a medical procedure, with risks/benefits/alternatives.  We don't ask patients to state their future preference to other life saving medical procedures, If you develop liver failure, would you like to receive a liver transplantant?  Yes or No.  I argue that a CPR discussion should only be conducted by a health professional who 1) can present risks/benefits/alternatives; 2) contextualize the use of CPR for the individual patient's medical condition; and 3) is prepared to make a recommendation on the use of CPR as a medical procedure, based on medical knowledge and experience.   From my perspective, the argument boils down to a difference of opinion on the role of patient autonomy vs. professionalism and whether or not you agree that CPR is a medical procedure.  For those interested in reading more, my favorite articles by truly great thinkers/writers are:

Quill TE and Brody H.  Physician recommendations and patient autonomy: Finding a balance between physician power and patient choice. Ann Int Med 1996;125:763-769. 

Tomlinson T and Brody H. Ethics and communication in do-not-resuscitate orders. NEJM 1988; 318:43-46.

Prognostication

Much has been written on the topic of prognostication; in general, physicians do a lousy job both in initiating the conversation and providing any useful information to patients and families.  In the current issue of Newseek(August 22, 2005) there is a poignant article (Page 16) written by the wife of a patient who died following a sudden illness.  She describes her difficulty in tracking down doctors who would give her useful prognostic information; the title says it all, "I shouldnt have had to beg for a prognosis".   I used the article as part of our Palliative Care Grand Rounds this week, distributing copies and taking a few minutes for learners to read and reflect on the article.   Successful models do exist for enhancing information flow in the ICU setting.  Last year I visited a hospital in Connecticut where families were specifically invited to be in the room during rounds in the surgical ICU--by all accounts a positive experience for all involved.  Other hospitals have established routine family conferences for updates or decision making, others have criteria for palliative care or ethics consultations.  The key to improving information seems to be a combination of education and systems change--improving the process of information delivery through a coordinated, systematic process.  Does anyone out in blog land have a successful model to share?

Onco-Industrial Complex

Back in the late 1980s a friend coined the term "lunatic fringe of medical oncology" for a small group of oncologists, myself included, who were advocating improved end-of-life care education and practice within the field of medical oncology.   In the mid 1990s I left the world of medical oncology clinical practice; I resigned my membership in ASCO and removed my name from the NIH PDQ oncology database.  But this information has escaped the marketing geniuses of the pharmaceutical industry. Over the past month I decided to save and sort all the oncology junk mail that came to my home--not my office, but my home--in total, about 20 pounds in one month.  The heaviest category was disease-specific throw-away journals and miscellaneous journals for oncology financial practice, oncology leisure activities, and an oncology guide to the internet.  Next came the  "education" materials--books, CDs, pamphlets--from single pharmaceutical companies, many published by a group called Physicians' Education Resource in Dallas, Texas (no website). 

All of the “journals” and “education” materials were subsidized overtly, or through advertising, by the pharmaceutical industry and all the “education materials” dealt solely with new, expensive chemotherapeutic agents or oncology support drugs. I also received a total of $100 in pre-paid checks from different marketing firms wanting me to complete mail-in surveys regarding my chemotherapy practice.  Lets do the math ...there are 20,000 members of Amer Assoc of Clinical Oncology (ASCO), that comes to 400,000 pounds of junk mail each month and $2,000,000 in marketing checks per month!  Oh, I almost forgot, there were half a dozen letters from head hunters looking for oncologists—including one letter guaranteeing a starting salary of …. $511,223.  In case you didn’t know, oncologists make the bulk of their income from chemotherapy sales.   The Onco-Industrial complex is alive and well. 

Inpatient Units

I receive frequent questions about the role of inpatient units for palliative care or hospice in acute care hospitals.   There are a variety of opinions on the subject and just as many variations of unit design and structure.  In my hospital, Froedtert Hospital, the main teaching facility for the Medical College of Wisconsin, we started a "Virtual" inpatient unit six years ago to complement our consultation service.  The unit is a 24 bed general medicine ward for which Palliative Care has first call of beds; that is, whenever we need a bed, if the unit is filled, a non-palliative care patient is bumped to another unit.  We are not limited to a set number of beds.  All nurses on the unit have received palliative care training, several have received board certification.  The unit offers special amenties for palliative care patients and families in terms of space and services and there an interdisciplinary team approach with twice-weekly team meeting.  As part of the teaching mission, patients who come to the unit stay on the medical team of origin, but the Palliative Care Service has order writing priviliges and coordinates care.  The Virtual aspect of the unit gives us flexibility  in care options, but does not impose the burdens of needing to "fill beds" or manage the nursing and staffing logistics as in a fixed-bed palliative care/hospice unit.  This Virtual unit fits our needs quite well and has been used successfully at other teaching and community hospitals.  However, it is not necessarily the best fit for all hospitals.  If you would like more information or to discuss your own hospital's needs, visit my website, www.palliativecareeducation.com, or e-mail me, [email protected].

Fast Facts FAQ

I receive many questions about Palliative Care Fast Facts and Concepts (www.eperc.mcw.edu); here is a FAQ of common issues:

1. Who may author a Fast Fact?  Anyone; I welcome submissions from new authors. Contact me with your idea of a topic before writing a first draft. [email protected]

2. What is the review process?  I will do the first review/edit then return to the author for approval. Once we have agreed on text, I will send out for Peer Review.  I have a ten person review board who review and approve all submissions. The reviewers include individuals from Internal Medicine, Surgery, Neurology, Nursing, Hospice and Palliative Care, and Psychiatry.  I use special reviewers for topics that the panel is not equipped to review.  Note: since this is a peer-reviewed publication, those in academic medicine can include their work on a CV towards promotion.

3. What happens after the review?  The time from acceptance to publication is 6-12 weeks; a new Fast Fact is released every other week.

4. Are Fast Facts updated?  The first 50 Fast Facts are in the process of being reviewed and updated; they will be released in Fall 2005.

Introduction

Greetings to everyone in Blog-Land; this is my first Blog, so be kind!  Many of you know me from my work in Palliative Medicine and Pain Management for the past 20 years.  I am Professor of Internal Medicine and Director of Palliative Care at the Medical College of Wisconsin/Froedtert Hospital (www.mcw.edu/pallmed).  I was the founding editor of the Journal of Palliative Medicine, which I turned over last year to the able hands of Charles von Gunten, MD.  I am the co-founder of EPERC (www.eperc.mcw.edu) and continue to edit Fast Facts and Concepts.  From 1997-2004 I coordinated the National Residency End-of-Life Education Project, working to integrate palliative care curriculum into over 400 residency programs in IM, FP, Surgery and Neurology.  Together with Bruce Himmlestein, MD, my pediatric colleague at MCW, we coordinate one of the six Palliative Care Leadership Centers sponsored by the Center to Improve Palliative Care; www.capc.org.   I look forward to using the Blog format to share thoughts about palliative care clinical issues, health professional education, and health policy and welcome feedback from readers.

Disclaimer: I am employed by the Medical College of Wisconsin (MCW); the writings on this blog are mine alone and do not represent those of MCW or other members of the MCW Palliative Care program staff.