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Considering A Non-Fatal Patient’s Quality Of Life

Why is it easier to talk about quality of life with patients who are dying? Why don’t we factor these considerations into the decision-making for patients with conditions that aren’t fatal?

The presence of a terminal illness serves to focus everyone’s attentions. Widespread cancer metastases? Concerns about tight blood glucose control fade away. End-stage liver disease? Blood pressure control doesn’t matter so much any more. Bony pain from prostate cancer? Narcotic and sleeping pill addiction doesn’t even occur to anyone. I find it far more problematic to deal with patients with debilitating but non-fatal conditions when treatment options are perceived as limited because of co-existing diseases that produce so-called contraindications to certain medications.

I have a patient in his mid-70s with severe pain from osteoarthritis. Several fractures and a couple of unsuccessful joint replacement surgeries haven’t helped matters. Several years ago he found that a little drug called Vioxx worked extremely well for him, reducing his pain considerably and allowing him to do pretty much watever he wanted. As we all know, however, that drug was pulled from the market because of an unacceptable increased risk of heart attacks and other untoward cardiovascular events. Interestingly, Read more »

*This blog post was originally published at Musings of a Dinosaur*

Elderly Heart Failure Patients Choose Longevity Over Quality Of Life

Don’t assume elderly heart failure patients are assumed to prefer improved quality of life over longevity, study authors noted. The majority of them prefer longevity over quality of life, half expressed a desire for resuscitation if needed, and it was difficult to predict individual preferences.

Researchers looked at patients’ willingness to trade survival time for quality-of-life and the preferences for among 622 heart failure patients aged 60 or older participating in the Trial of Intensified vs. Standard Medical Therapy in Elderly Patients with Congestive Heart Failure.

End-of-life preferences were assessed by using a time trade-off tool and one question concerning CPR preference. To assess time trade-off, patients were asked whether they preferred living 2 years in their current state of health or living 1 year in excellent health. If 1 year in excellent health was chosen, the patients were asked whether they would prefer 2 years in their current state of health or 6 months in perfect health. If 2 years in the current state were chosen, then they were asked whether they would prefer 2 years in their current state of health or 18 months in perfect health. The series continued until the choices were the same. This time point subtracted from 24 months derived the number of months of survival time that the patient would be willing to trade.

End-of-life preferences were assessed at baseline, and at 12 and 18 months. Read more »

*This blog post was originally published at ACP Hospitalist*

Study Looks Into The Added Benefits Of Breast Reduction Surgery

This article (full reference below) on the additional benefits an individual gains from having a reduction mammoplasty (RM) has been published online ahead of print.  The authors performed a systemic review of the literature focusing on functional outcomes after RM with regard to physical and psychological symptom improvement.

The authors performed a systematic review of the English literature using PUBMED for the period between 1977 to 2010. Studies were chosen that addressed the physical and psychological benefits of RM using a validated questionnaire.

The authors note that nearly eighty thousand breast reductions were performed in 2009.  For insurance coverage in the United States a woman seeking breast reduction must have complaints of physical symptoms (i.e., Read more »

*This blog post was originally published at Suture for a Living*

When A Cancer Patient Might Be Better Off Choosing Hospice Care

Cancer is a dreadful disease. Just dreadful.  Make no mistake: I have tremendous respect for the awesome doctors who treat patients afflicted with it day after day. Still, paradoxically, I can’t help but notice that some of them have just as hard a time as do other doctors with caring for patients at the end of their lives. I believe a large part of their difficulty stems from the ridiculously dysfunctional either/or approach to palliative care and hospice we’re stuck with in this benighted country.

The problem is that in order to qualify for hospice, patients must not only have a certified life expectancy of less than six months, but they must also not be undergoing any active treatment for their malignancy. When you stop to think about it, though, this is actually quite discriminatory. We don’t require people on hospice with other diagnoses to discontinue their life sustaining medications. Patients with COPD are allowed to continue their bronchodilators; CHF patients don’t have to stop their ACE inhibitors and digoxin. But if a cancer patient wants to qualify for hospice, they have to forgo curative treatments like chemotherapy.

So what if the oncologists call it “palliative” chemo instead? Read more »

*This blog post was originally published at Musings of a Dinosaur*

Preventing Falls And “Post-Fall Syndrome” In Seniors: A Call For Anticipatory Care

We hear about stories like this all time: An elderly person falls and breaks something — a hip, a wrist, or an arm. Soon what once was a healthy, independent senior begins an inexorable downhill slide. Such is the case of my 89-year-old mother who recently fell and broke her wrist.

Turns out that 30 percent of people age 65 and older fall each year. Predictably, seniors with the following risk factors are more prone to falls:

  • Using sedatives
  • Cognitive impairment
  • Problems walking
  • Urinary tract infection
  • Eye problems
  • Balance issues

Similarly, when a person does fall, a cascading series of predictable clinical events occurs. It even has a name: “Post-fall syndrome.” This syndrome is characterized by things like fear of falling again, increased immobility, loss of muscle and control, lack of sleep, nutritional deficits, and so on. Seniors susceptible to falls also have higher rates of hospitalization and institutionalization.

What strikes me about falls among the elderly is that they are seemingly predictable events. And once a fall does occur, the consequences seem pretty predictable as well — enter post-fall syndrome. So if falls and their consequences are so predictable, why aren’t primary care physicians more proactive in terms of:

  • Preventing falls?
  • Treating post-fall syndrome?

In the case of my mother, her primary care physician and orthopedist were both very diligent at treating her episodic needs (i.e. her pain and broken bones). But little attention, if any, was given to assessing her long-term needs, such as nutrition, inability to do anything with her left hand (she’s left-handed), sensitivity to new medications (she never took drugs because they make her loopy), gait analysis, and depression counseling. Read more »

*This blog post was originally published at Mind The Gap*

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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