Robert Milch

Effects of Methylphenidate on Fatigue and Depression: A Randomized, Double-Blind, Placebo-Controlled Trial

CONTEXTnFatigue is highly prevalent in populations with advanced illness and is often associated with depressed mood. The role of psychostimulant therapy in the treatment of these conditions remains ill defined.nnnOBJECTIVESnTo evaluate the response of fatigue and depression in patients with advanced illness to titrated doses of methylphenidate (MP) as compared with placebo.nnnMETHODSnIn a randomized, double-blind, placebo-controlled trial, 30 hospice patients, both inpatients and outpatients, who had fatigue scores of at least four on a scale of zero to 10 (0=no fatigue and 10=worst fatigue), were randomly assigned to receive either 5mg of MP at 8 am and 1 pm or placebo. Doses of MP were titrated every three days according to response and adverse effects. Home care patients were monitored daily by telephone and visited by a research nurse on Study Days 0 (baseline), 3, 7, and 14. Fatigue was assessed using the Piper Fatigue Scale as the primary outcome measure and validated by the Visual Analogue Scale for Fatigue and the Edmonton Symptom Assessment Scale (ESAS) fatigue score. Subjects in inpatient facilities were interviewed or assessed by staff on an identical schedule. Depressive symptoms were assessed by the Beck Depression Inventory-II, Center for Epidemiologic Studies Depression Scale, and the ESAS depression score. Primary statistical analysis was conducted using repeated-measures multivariate analysis of the variance.nnnRESULTSnBoth MP- and placebo-treated groups had similar measures of fatigue at baseline. Patients taking MP were found to have significantly lower fatigue scores (Piper Fatigue Scale, Visual Analogue Scale for Fatigue, and ESAS) at Day 14 compared with baseline. The improvement in fatigue with MP treatment was dose-dependent; the mean average effective dose was 10mg on Day 3 and 20mg on Day 14 (dose range of 10-40 mg). Placebo-treated individuals showed no significant improvement in fatigue. For patients with clinically significant depression on Day 0, treatment with MP was associated with a significant reduction in all test indices for depressed mood. For the placebo group, the changes in measures of depression were less than observed in the treatment group but were inconsistent between assessment tools. No significant toxicities were observed.nnnCONCLUSIONnMP reduced symptoms of fatigue and depression when compared with placebo. The effect of MP on fatigue was dose-dependent and sustained over the duration of the study.

Palliative care by the surgeon: how to do it

Geoffrey P Dunn, MD, FACS: This is a symposium, Palliative Care by the Surgeon: How To Do It. This symposium is actually the continuation of an idea that has been evolving in the course of several consecutive symposia held by the American College of Surgeons. The shot across the bow for this ongoing discussion and for this symposium came back in 1997 when the College held a general symposium on the subject of physicianassisted suicide. Many of us took this as a huge red flag or a sign of great distress that surgeons were wrestling with this question. There was controversy within the surgical community with people taking positions pro and con. One thing that was agreed on by everybody at that symposium was the utility, the lasting value, and the moral imperative of good palliative care. Everybody also agreed that in many ways, although we may be temperamentally very committed to the idea, and might have had personal experiences in our practices and also in our families that drove home the point of the value of good compassionate care for people with advanced illness, many of us felt very unprepared to do the basic work, the day-to-day activity at the bedside, to know which kinds of medication to order or how to engage in difficult discussion. That led to a series of initiatives with ongoing and increasing cooperation, interest, and support by the American College of Surgeons. Last year we had a symposium on the subject where we got more at the level of the surgeon identifying and finding a place in palliative care. At the very heart of that discussion was this almost palpable struggle: Is a surgeon really temperamentally suited to do this kind of thing or would it be best left to be done by others? At that point we believed that was a choice that every surgeon would make personally. What we can do is offer the tools, the nuts and bolts, and from that point carry forward; that is the purpose of the symposium today: to provide some basic practical concepts that would be helpful at the bedside. The panelists are members of a newly formed Workgroup for Surgical Palliative Care. This is a Robert Wood Johnsonfunded initiative. The group members were selected because of their demonstrated and proactive interest in these areas. The Workgroup recognizes that many important areas of surgery are not yet represented in this work. The purpose of the Workgroup is to facilitate introduction of the precepts and techniques of palliative care to surgical practice and education in the United States and Canada. The Workgroup will do this by bringing together surgeons with demonstrated interest in palliative care to share resources, strategies, and expertise, and in so doing act as a catalyst for a change. There are a number of definitions of palliative care and that term will be used frequently. This is the very orthodox teaching in any current textbook or article about palliative care. You will see that the World Health Organization definition goes back to 1990 (Table 1). This was specifically applied to oncology but was rapidly accepted as applicable to all areas of palliative care. I find it a very cumbersome and dry definition, and when people ask Presented at the American College of Surgeons 87th Annual Clinical Congress, New Orleans, LA, October 2001. Moderator: Geoffrey P Dunn, MD, FACS, Department of Surgery, Hamot Medical Center, Erie, PA. Panelists: Robert A Milch, MD, FACS, The Center for Hospice and Palliative Care, Buffalo, NY; Anne C Mosenthal, MD, FACS, New Jersey Medical School, Department of Surgery, Newark, NJ; K Francis Lee, MD, FACS, Baystate Medical Center, Springfield, MA; Alexandra M Easson, MD, Princess Margaret Hospital, Toronto, ON; Joan L Huffman, MD, FACS, Crozer-Chester Medical Center, Upland, PA.

Length of Survival in Hospice for Cancer Patients Referred From a Comprehensive Cancer Center

This retrospective study examined 180 hospice patients referred from a comprehensive cancer center over 6 months in 2002 to (1) identify the variables associated with shorter length of survival (LOS) in hospice and (2) examine the LOS in hospice for those who previously participated in clinical trials and/or phase I studies. The median LOS in hospice for this cohort was 35 days. In multivariate analysis, low Palliative Performance Score (PPS) at hospice enrollment and male gender were associated with shorter LOS in hospice: males with low PPS had the shortest LOS while females with high PPS had the longest LOS. No correlation was found between the LOS in hospice and prior participation in clinical trials and/or phase I studies.

Introduction and historical background of palliative care: where does the surgeon fit in?1

• Respect the dignity of both patient and caregivers. • Be sensitive to and respectful of the patient’s and family’s wishes. • Use the most appropriate measures that are consistent with the choices of the patient or the patient’s legal surrogate. • Ensure alleviation of pain and management of other physical symptoms. • Recognize, assess, and address psychological, social, and spiritual problems. • Ensure appropriate continuity of care by the patient’s primary and/or specialist physician. • Provide access to therapies that may realistically be expected to improve the patient’s quality of life. • Provide access to appropriate palliative care and hospice care. • Respect the patient’s right to refuse treatment. • Recognize the physician’s responsibility to forego treatments that are futile.

Is this a bad day, or one of the last days?: How to recognize and respond to approaching demise

At the end of a long afternoon case you find a stickynote on the operating room window informing you of a consultation request: “Consult from Staff GI. Room 527. Blair, Robt. Dx: Metastatic ca. of pancreas. Request central line for TPN.” During the walk up you wonder if this is going to be necessary. The chart of this individual yields little history except a scribbled note; “Unfortunate 58 y.o. white male with history of metastatic ca. of pancreas admitted with dehydration and malnutrition. Plan: Hydration/? TPN. Discuss chemorx. options.” The “yes” or “no” box indicating presence of advance directives on the front sheet of the chart is unmarked. On entering Mr. Blair’s room you are greeted from the bed by an alert, sallow-complected, cachectic man who speaks in a whisper and grasps your hand with a surprisingly strong handshake. “I hope you can do something to make me stronger.” His wife, sitting at the bedside, appearing overwhelmed, adds, “I can’t stand to see him like this. He just doesn’t seem to want to eat. He is sleeping all the time and he’s been having nightmares. We both know there’s no cure for this, but at least he shouldn’t starve to death in the meantime! His next chemo appointment is next week. They said they might try something new. I don’t think he can take it unless they put some meat on his bones.” While his wife is speaking you note Mr. Blair gazing in the distance through the window. During the ensuing discussion you learn he had undergone an exploratory laparotomy 2 months previously and had a “double bypass” for his tumor. Subsequently he was treated with what they were told was a fairly new chemotherapy agent with “mild” side effects. Despite the resolution of his jaundice after his operation he continued to lose weight even though he had an initial return of appetite. During the previous 2 weeks, he had shown little interest in food or drink and he seemed to be sleeping more and more of the time. He had been receiving oxycodone (slow release) for his cancer-related back pain, with satisfactory relief and no recent dosage escalations. Earlier that week he had several nightmares about his death. Privately he confided, “I think my wife is more hopeful than I am. I’m just so tired.” After this initial meeting you learn that an abdominal CT done the previous week demonstrated progression in size of his hepatic metastases.

The use of ketamine in severe cases of refractory pain syndromes in the palliative care setting: a case series.

The benefits of ketamine in reducing pain are largely based on case reports and small clinical trials. We present a case series describing the application and efficacy of subanesthetic doses of ketamine in the treatment of complex pain syndromes poorly responsive to escalating doses of opioids. The discussion that follows suggests that subanesthetic intravenous ketamine can be used to successfully treat severe pain of different etiologies refractory to opioid dose escalation. Optimal dosing titration, duration of initial treatment, and the role of maintenance ketamine need to be further elucidated. Our case series adds to the extant literature supporting the role of subanesthetic ketamine for refractory pain problems.

The Nature and Timing of Family-Provider Communication in Late-Stage Cancer: A Qualitative Study of Caregivers’ Experiences

CONTEXTnFamily members of people with advanced cancer can experience intensified distress and uncertainty during the final stages of their loved ones illness. Enhanced comprehension about disease progression, symptom management, and options for care can help families adapt, cope, and plan for the future.nnnOBJECTIVESnGuided by concepts from the Sense of Coherence Theory, which illuminates factors that contribute to adaptation in stressful situations, the objective of this study was to explore and describe family caregivers accounts of the nature and timing of communication they had with a loved ones health care provider(s) during the advanced stages of cancer and before hospice enrollment.nnnMETHODSnRetrospective in-depth interviews were conducted with caregivers of 46 people who died of cancer. Interviews were audiotaped, transcribed, and submitted to an iterative process of qualitative data analysis that included 1) systematic coding, 2) the use of data matrices to display summarized results and collapse the codes into themes, 3) and axial coding to characterize the nature of the themes.nnnRESULTSnOverall, communication with providers was found to be either 1)xa0satisfactory or 2) unsatisfactory. Satisfactory communication was 1) compassionate, 2) responsive, and/or 3) dedicated. Unsatisfactory communication was described as 1) sparse, 2) conflicted, 3) contradictory, and/or 4) brink of death.nnnCONCLUSIONnCommunication with health care providers is critical for helping family caregivers understand and manage the changes that accompany a life-limiting illness. Timely communication with information and meaningful discussion about disease progression can help families prepare for the advanced stages of an illness and approaching death.

Robert Wood Johnson Foundation Office of promoting excellence in end-of-life care: Executive summary of the report from the field

I. BACKGROUND AND CONVENING PROCESS In recognition of a growing interest in palliative care by clinicians, patients, and families, the Promoting Excellence in End-of-Life Care national program of The Robert Wood Johnson Foundation, in conjunction with the American College of Surgeons, created a national Peer Workgroup to facilitate introduction of the precepts and techniques of palliative care to surgical practice and education in the United States and Canada. The World Health Organization has defined palliative care as “The active total care of patients whose disease is not responsive to curative treatment.” The Surgeons Palliative Care Workgroup brought together surgeons with demonstrated interest and experience in palliative care to share resources, strategies, and expertise, and in so doing act as a catalyst for change. This is a summary of their analysis of the current state of palliative care in the surgical field and their recommendations. The full report will be released this summer by the Robert Wood Johnson Foundation. The Workgroup met during a 14-month period from September 2001 through November 2002. The initial Workgroup membership of 20 consisted of 17 surgeons representing 6 subspecialties, representatives of the executive and administrative staff of the American College of Surgeons, two recognized leaders in palliative care research and education, and a representative of the National Program Office of the Robert Wood Johnson Foundation. The Workgroup divided into seven subcommittees and conducted its business at four plenary sessions and periodic teleconferences. The Workgroup adopted the American College of Surgeons’ Statement of Principles Guiding Care at End of Life (1998) as its compass in the execution of its charge. After approval by the American College of Surgeons Board of Regents in October 2002, the Workgroup became integrated into the Division of Education of the American College of Surgeons as the Surgical Palliative Care Task Force.

The use of pentobarbital in cases of severe delirium: a case series.

Delirium is a common syndrome present at the end of life and causes significant distress for patients and families. Sleep disruption is a common precipitating factor for delirium and restoration of sleep may be instrumental in attenuating symptoms. In this cases series, we present three patients who were unresponsive to escalating doses of standard delirium medications, but whose delirium resolved once improved sleep was achieved using Pentobarbital. In a fourth patient, delirium was successfully treated where neuroleptics were contraindicated. Pentobarbital has been shown to reduce the time to sleep onset, decrease the number of body movements during sleep and spontaneous awakenings and increase the total sleep time. Pentobarbital may provide an additional treatment option for patients whose delirium is refractory to standard management approaches.