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Discussing Goals of Care with Very Ill Patients Words Matter

More Seniors Living Beyond 90

1.9 million Americans have reached the age of at least 90 years according to a recent report by the National Institute on Aging and the US Census Bureau. This comprises nearly 4.7% of the entire population. Over the last 30 years, the size of this age group has tripled, creating changes in the landscape of elder housing and elder care. Nearly 20% of those 90 and older live in nursing homes. Senior living facilities are home not only to older, but sicker, residents now. “Traditionally, the cutoff age for what is considered the ‘oldest old’ has been age 85,” Census Bureau demographer Wan He said. “But increasingly people are living longer and the older population itself is getting older. Given its rapid growth, the 90-and-older population merits a closer look.” The complete report can be found at: http://www.census. gov/prod/2011pubs/acs-17. pdf.

Issue No. 22

Linda Conti, RN, Certified Hospice & Palliative Nurse Pathways Director of Community Relations “Words matter. What clinicians say and how they say it hugely affect patients. Communicating about emotionally and medically complex topics such as advance care planning, preferences for care, prognosis, and death and dying is challenging,” Steve Pantilat, MD, Professor of Clinical Medicine and Director of the Palliative Care Unit at UCSF wrote in a 2009 JAMA article.

Pantilat recently spoke to an audience of more than 100 physicians and other health care professionals at a Nov. 29 ethics conference held at El Camino Hospital in Mountain View on “Better Words to Say: Communicating with the Very Ill Patient.” “It’s not about the patient’s willingness to have this kind of conversation, but about [physicians’] willingness to have the conversation,” said Pantilat. Discussing end-of-life issues with patients is not associated with depression, sadness, terror or worry according to research done by Wright and published in JAMA. In fact, this sort of conversation leads to better quality of life, fewer invasive interventions and better outcomes for caregivers. But how do we go about having the conversation? Here are some of the highlights of that talk and some useful approaches Steve Pantilat has learned over the years. Ask open-ended questions to establish what the patient and family know. Examples of questions he asks are: “When you think about what lies ahead, what worries you the most?” and “When you think about the future, what do you hope for?”

The answers to these questions may be very different than you anticipated and may guide care decisions. For instance, if a patient says he wants to have chemotherapy and visit his home town, the physician may recognize that the visit may not be feasible after chemotherapy, and that if it will not significantly change the outcome of the disease, perhaps the patient should take the trip first. Listen and sit down. Pantilat referred to a well known study done in the 1970s that demonstrated that patients perceived their physicians’ visits to be much longer than they continued on page 2 Discussing Goals Inside this Issue ▪ Yogurt & Colorectal Cancer ▪ Coffee May Help Depression ▪ Vitamin & Supplement Risks ▪ CT Scans in Lung CA Screening


continued from page 1 Discussing Goals

Pantilat suggests that physicians listen for at least two minutes before talking (which he admits may seem interminable at the time). He emphasizes the value of not interrupting since most important things don’t come out at the very beginning of a conversation. Avoid jargon, use simple language and check understanding.

Discuss death explicitly. Talking about death can be a great relief, says Pantilat. He suggests practicing difficult conversations and in this setting suggests phrasing such as, “Many patients with lung cancer tell me they think about the possibility of dying. They have questions about this. How about you?” Remain sensitive to the patient’s culture.

Pantilat cautioned about assuming all persons of a particular culture Patients will often nod as though have similar beliefs and suggests they understand although they are the solution lies in asking, “In your clueless to the meaning of what you family how do you make medical are saying. Pantilat says that the answer is usually “No” to the question decisions?” His experience has told “Do you have any questions?” But he him that patients often know much has noticed a distinct difference when more than physicians or families he subtly rewords the question to say realize. Although they may never have been spoken to directly about “What questions do you have?” their disease, the visits to a cancer “Accuracy is not critical,” said Pantilat. center, increasing treatment, arrival of Patients and families don’t need to family members from afar and a host know an exact prognosis, but they do of other clues tell them about their need a realistic frame of reference. condition. He suggests using ranges such as Pantilat does caution that we should “hours to days,” “days to weeks,” or “weeks to months.” One person may always ask how much the patient wants to know, regardless of what the interpret “not long” as days while family has said. To be sensitive he another may think it refers to a year. often asks, “I have information about your condition. Some patients want to know the details, others prefer to have me talk to someone else. How do you feel?” Use better words.

Offer a prognosis. “False hope is not hope because it is not based in reality,” said Pantilat, reminding his audience of the research published in the NEJM that found that TV patients had a 79% rate of survival with quality life after CPR, whereas in real life the numbers are far grimmer. The problem is that the public gets its information from television.

There is never a time when it is appropriate to say, “There is nothing more we can do.” Pantilat suggests instead, “There is no more we can do to cure your disease.” And rather than arguing with family members about the futility of treatments, Pantilat likes to put himself on their side by saying, “I wish there was something we could do to make your cancer go away.” Ask helpful questions. Questions such as, “Would you like us to do everything possible?” are not helpful and will always be answered “Yes.” However, “everything” may mean all possible curative medical treatments to the physician, while the family interprets it to mean all

possible efforts aimed at keeping their loved one comfortable. Pantilat finds it clarifying in this situation to ask, “How were you hoping we could help?” Be aware of your non-verbal communication. Asking someone if they have any other questions while your hand is on the door sends a loud message and the answer will usually be, “No.” Pantilat concluded by acknowledging that this process is usually more than one conversation and that physicians should share the responsibility with others such as the palliative care team, social workers, and chaplains. Discussions about goals of care are good for patients and families.

Possible Prevention

actually were when the physician sat down to talk with them.

Yogurt & Colorectal Cancer Yogurt may confer some degree of protection against colorectal cancer (CRC) according to a prospective study done in Italy. Yogurt intake was found to be inversely associated with CRC risk.

More than 45,000 volunteers participated by completing dietary questionnaires that included specific questions about yogurt intake. In the following 12 years 289 participants were diagnosed with CRC. High yogurt intake was significantly associated with decreased CRC risk, suggesting that yogurt should be part of a diet to prevent the disease. The protective effect of yogurt was evident in the entire cohort, but was stronger in the 14,178 men in the study.

PA T H WA Y S The study, done at Fondazione IRCSS Istituto Nazionale Tumori, Milano, Italy, was published in the International Journal of Cancer. 2011; 129(11):2712-9 (ISSN: 1097-0215)


You may have read about the benefits of one or two cups of coffee a day: reduced risk of type 2 diabetes, Parkinson’s disease and dementia. Now it looks as though a little java may also decrease the risk for depression.

“There is certainly much more good news than bad news, in terms of coffee and health,” says Frank Hu, MD, MPH, PhD, nutrition and epidemiology

professor at the Harvard School of Public Health. New research published after a 10-year study of more than 50,000 older women suggest that the risk for depression may decrease as coffee consumption increases. Those who drank 2-3 cups a day had a 15% decreased risk of depression compared to women who drank one cup a day or less. “People have often worried that drinking caffeinated coffee might have a bad effect on their health, but there is more and more literature, including this study, showing that caffeine may not have the detrimental effect previously thought,” according to lead author Michel Lucas, PhD, RD, epidemiologist/nutritionist at Harvard School of Public Health in Boston.

High Risk Patients

The study is published in the September 26, 2011 issue of the Archives of Internal Medicine.

Increased Death Rate

Another Benefit

Coffee May Help Depression

Vitamin and Supplement Risks Contrary to what many might believe, vitamins and minerals may be risky. Risks associated with the use of common dietary vitamin and mineral supplements in older women may include higher mortality rates.

Researchers examined vitamin and mineral supplement use in relation to total mortality in 38,772 older women (mean age 61.6 years at baseline in 1986). Vitamin B6, folic acid, iron, magnesium, zinc, and copper were all associated to some extent with increased risk of mortality when compared with non-use. The association was strongest with supplemental iron, but in contrast to other findings, calcium was associated with decreased risk. For more information, the research is part of the Iowa Women’s Health Study and was reported in the Archives of Internal Medicine, 2011; 171(18):1625-33 (ISSN: 1538-3679)

CT Scans in Lung Cancer Screening New recommendations from the National Comprehensive Cancer Network (NCCN) say that patients determined to be at high risk for lung cancer should have regular screening with low-dose CT scans. The NCCN guidelines define high-risk patients as:

• Age 55-74 plus ≥30 pack-year smoking history plus smoking cessation <15 years or • Age ≥50 and ≥20 pack-year history of smoking and other risk factors besides second-hand smoke A negative scan should be followed by annual low-dose CT scans for three years and then periodically until age 74. If the baseline image reveals one lung nodule, the patient should have close follow up with additional low-dose CT scans, with the scan interval determined by the nodule’s characteristics.

According to the guidelines, a solid or partly solid nodule ≤4 mm requires annual screening with low-dose CT for three years and until age 74. Larger nodules have shorter screening intervals, ranging to follow-up CT in one month for patients with solid endobronchial nodules. Patients who have nodules with a ground-glass appearance require follow-up CT at intervals ranging from three to six months to 12 months, depending on nodule size. Patients with a low or moderate risk for lung cancer do not need routine lung cancer screening. The NCCN defines moderate-risk patients as age ≥50, a smoking history of ≥20 packyears, and no additional risk factors. A low-risk patients is younger than 50 and has less than a 20 pack-year smoking history. “Lung cancer screening with CT should be part of a program of care and should not be performed in isolation as a free-standing test,” accord-

ing to the guidelines available on the NCCN website. “Given the high percentage of falsepositive results and the downstream management that ensues for many patients, the risks and benefits of lung cancer screening should be discussed with the individual before doing a screening low-dose CT. “It is recommended that institutions performing lung cancer screening use a multidisciplinary approach that may include specialties such as radiology, pulmonary medicine, internal medicine, thoracic oncology, and thoracic surgery. Management of downstream testing and follow up of small nodules are imperative and may require establishment of administrative processes to ensure the adequacy of follow up.” The NCCN offers additional guidance for solid and ground-glass nodules, based on specific nodule characteristics. NCCN is a consortium of major US cancer centers.


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Antidepressants in Dementia As many as 20% of patients with dementia may also have depression. The usual treatment is a selective serotonin reuptake inhibitor or a noradrenergic and specific serotonergic antidepressant. But some research has questioned the effectiveness of these treatments.

treatments we use are not proven,” said Dr. Banerjee.

In a study published in The Lancet, (volume 378, Issue 9789, pages 403 - 411, 30 July 2011), Sube Banerjee MD, a London-based expert in old age psychiatry, and his colleagues concluded that because there was an absence of benefit compared with placebo and increased risk of adverse events, the practice of using these antidepressants should be reevaluated.

“I am surprised by just how unequivocal our findings are,” said lead author Banerjee, professor of mental health and aging at King’s College London, Institute of Psychiatry, United Kingdom. “The present practice of use of these antidepressants with usual care for first-line treatment of depression in Alzheimer’s disease should be reconsidered,” write the authors.

“Depression is one of the most important co-morbidities in dementia. It is a source of great distress yet the

“The message is to think before using antidepressants for depression in dementia. It may well be that

In their parallel-group, double-blind, placebo-controlled study of more than 326 patients with Alzheimer’s dementia, decreases in depression scores at 13 and 39 weeks did not differ between 111 controls and 107 participants allocated to receive sertraline (Zoloft) or 108 who received mirtazapine (Remeron).

these symptoms will resolve with the problem-solving and informationgiving that is implicit in good-quality dementia care,” added Dr. Banerjee. The investigators suggest that antidepressants be reserved for “individuals whose depression has not resolved within 3 months of referral, apart from those in whom drug treatment is indicated by risk or extreme severity.” Funding for this study was provided by the UK National Institute of Health Research HTA Programme.


Pathways Physician & Health Professional Bulletin - Issue 22