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Constipation: A Common Problem In End-Of-Life Care

Family physicians who care for terminally ill patients must manage a wide range of bothersome symptoms, including pain, fatigue, dyspnea, delirium, and constipation. According to a Cochrane for Clinicians article in the December 1st issue of American Family Physician, constipation affects up to half of all patients receiving palliative care and nearly 9 in 10 palliative care patients who use opioid medications for pain. Unfortunately, a Cochrane systematic review found limited evidence on the effectiveness of laxatives in these patients, as Dr. William Cayley Jr. comments:

“For patients with constipation, especially those with opioid-induced constipation, there is insufficient evidence to recommend one laxative over another. The choice of laxatives should be based on past patient experience, tolerability, and adverse effects. Methylnaltrexone is a newer agent that may be useful especially for patients with opioid-induced constipation that has not responded to standard laxatives, but there is limited evidence of potential adverse effects. Therefore, judicious use preceded by a discussion with patients about known risks and benefits is warranted.”

The Cochrane Library recently discussed this review in its Journal Club feature, which includes open access to the full text of the review, a podcast by the authors, discussion points, and a Powerpoint slide presentation of the review’s main findings.

Additional resources for physicians and patients on advanced directives, hospice care, and ethical issues are available in the AFP By Topic collection on End-of-Life Care.
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The above post was first published on the AFP Community Blog.

*This blog post was originally published at Common Sense Family Doctor*

Dealing With Cyclic Vomiting Syndrome Given How Little Is Known About The Condition

I have been working as an ER doctor for over a decade, and in that time I have come to recognize that there are certain complaints, and certain patients who bear these complaints, that are very challenging to take care of. I’m trying to be diplomatic here. What I really mean is that there are certain presentations that just make you cringe, drain the life force out of you, and make you wish you’d listened to mother and gone into investment banking instead. Among these, perhaps most prominently, is that of the patient with cyclic vomiting syndrome.

The diagnosis of cyclic vomiting syndrome, or CVS, is something which is only in recent years applied to adult patients.  Previously, it was only described in the pediatric population. It has generally been defined as a disease in which patients will have intermittent severe and prolonged episodes of intractable vomiting separated by asymptomatic intervals, over a period of years, for which no other adequate medical explanation can be found, and for which other causes have been ruled out.

That is not much in the way of good literature about this disease entity, which is surprising, because it is something that I see in the emergency department fairly regularly, and something with which nearly all emergency providers are quite familiar. These patients are familiar to us in part because we see them again and again, in part because they are memorable because they are so challenging to take care of.

Some things about the cyclic vomiting patient that pose particular challenges: Read more »

*This blog post was originally published at Movin' Meat*

CDC Reports Increased Deaths From Prescription Pain Medications: Should We REALLY Blame Doctors For This Trend?

The overdose death rate from prescription opioids, referred to as “narcotics”, has reached “epidemic levels” in the US according to a report just released by the Centers for Disease Control and Prevention (CDC).  The report further states that the intentional misuse and abuse of popular opioids such as OxyContin, Vicodin, methadone and others now cause more deaths than those caused by heroin and cocaine combined.

Dr. Thomas Frieden, CDC Director told reporters that “Narcotics prescribed by physicians kill 40 people a day.” He continued by stating “Prescription painkillers are meant to help people who have severe pain. They are, however, highly addictive.”

The report states that increased prescribing of pain medications by doctors is a significant cause of this growing number of deaths. However, the situation is far more complicated than this report presents. Poor pain management and prescription drug abuse has become Read more »

The Plight Of The Uninsured

This is depressing:

A 24-year-old Cincinnati father died from a tooth infection this week because he couldn’t afford his medication, offering a sobering reminder of the importance of oral health and the number of people without access to dental or health care.

According to NBC affiliate WLWT, Kyle Willis’ wisdom tooth started hurting two weeks ago. When dentists told him it needed to be pulled, he decided to forgo the procedure, because he was unemployed and had no health insurance.

When his face started swelling and his head began to ache, Willis went to the emergency room, where he received prescriptions for antibiotics and pain medications. Willis couldn’t afford both, so he chose the pain medications.

The tooth infection spread, causing his brain to swell. He died Tuesday.

It can’t be denied that his poor decision-making was the proximate cause of this guy’s death (and many times I’ve gotten the maddening call from the pharmacy, “Doctor, the patient only wants the narcotics”). The underlying cause, however, was the fact that he was uninsured. Read more »

*This blog post was originally published at Movin' Meat*

Living With Severe Chronic Pain

Living Beyond Pain

Prepared Patient - When Pain Doesn't End - photo from fotolia.comFor people with severe chronic pain like Kelly Young and Teresa Shaffer—both of whom have become patient advocates—coping with agony is a fact of life.  Young suffers from rheumatoid arthritis while Shaffer’s pain is linked primarily to another degenerative bone disease.

Chronic pain is one of the most difficult—and common—medical conditions.  Estimated to affect 76 million Americans—more than diabetes, cancer and heart disease combined—it accompanies illnesses and injuries ranging from cancer to various forms of arthritis, multiple sclerosis and physical trauma.

Pain is defined as chronic when it persists after an injury or illness has otherwise healed, or when it lasts three months or longer. The experience of pain can vary dramatically, depending in part on whether it is affecting bones, muscles, nerves, joints or skin. Untreated pain can itself become a disease when the brain wrongly signals agony when there is no new injury or discernable other cause. Fibromyalgia—a disease in which pain in joints, muscles and other soft tissues is the primary symptom—is believed to be linked to incorrect signaling in the brain’s pain regions.

Finding a Doctor

The first step to deal with chronic pain is Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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