May 2007

PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) provides palliative care clinicians with concise summaries of the most important findings from more than 30 medical and scientific journals. If you have colleagues who would benefit from receiving PC-FACS and earning CME credit, please encourage them to join AAHPM or subscribe to PC-FACS at www.aahpm.org. Comments from readers are welcomed at resources@aahpm.org.

Effective Consultations

Principles of Effective Consultation

Background: In a world of evolving relationships between different medical and surgical disciplines, what are the expectations for effective communication following a requested consultation?

Design and Participants: This multicenter, anonymous survey of surgeons (orthopedics, general, OB/GYN), general internists, and family physicians at 3 tertiary-care medical centers with associated residency programs in 3 states included demographics, physician profile questions, and 11 5-point Likert-type questions regarding the qualities of the consult, preferences for medical interactions, and writing orders on patients. Of 446 surveys distributed, 323 were received (72% response rate). Forty-seven percent of respondents were surgeons and 50% were attending physicians; 33% were from Hawaii, 39% from Oregon, and 28% from Massachusetts.

Results: Nonsurgeons more commonly preferred that the consultations be limited to a specific question (nonsurgeon vs. surgeon, 69% vs. 41%; p < .001), that consultants discuss the consult with the primary team before writing any orders (59% vs. 37%; p < .001), that literature references be cited (41% vs. 18%; p < .001), that recommendations be placed at the beginning of the consult note (54% vs. 41%; p = .02); nonsurgeons also reported that curbside consultations were helpful (83% vs. 53%; p < .001). Surgeons more commonly preferred a comanagement relationship (surgeon vs. nonsurgeon, 59% vs. 24%; p < .001). Both groups, more so surgeons than nonsurgeons, advocated for daily progress notes (78% vs. 67%, p = .03). Both groups indicated that initial recommendations should be discussed verbally (69%-79%) and that consult recommendations should have a description of importance and urgency (69%-78%). Limiting the number of recommendations to 5 was not considered important by either group (21%-22%).

Commentary: For inpatient palliative care consultation to grow, consultants will need to focus not only on excellent patient care but also on customer service to those who initiate consultations. This article describes the needs and expectations of consultation users and finds that medical doctors and surgeons differ in their preferences. For example, nonsurgeons value literature references, whereas surgeons care more about comanagement of patients. Both groups emphasize that upfront interpersonal contact is critical to a good consulting relationship. The article includes a table of values for contemporary consulting practice, which serves as a handy reference for any clinician. The study is further strengthened by being conducted in three states and eliciting a high response rate for physicians. Missing in this report is an analysis of possible differences between academic and community practice.

Bottom Line: Consulting palliative care specialists should focus on good customer service that includes personal contact with referring physicians. In addition to assisting in the care of patients, such interaction provides opportunities for healing of referring clinicians and nurturing of lasting relationships.

Reviewer: Lorraine Sease, MD, Fellow in Geriatrics and Palliative Medicine, Duke University Medical Center, and James Tulsky, MD, Duke University Medical Center.

Source: Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: An update for the 21st century consultant. Arch Int Med. 2007 Feb 12;167:271-275. PMID: 17296883. To access the abstract of this article, link to NLM–PubMed here.

Question Prompt List

Question Prompt List for Prognosis and End-of-Life Discussions

Background: A question prompt list (QPL) is a structured list of questions to remind patients what to ask their physicians. A QPL was developed specifically for advanced cancer patients and their caregivers. Can this simple communication tool enhance communication regarding end-of-life care?

Design and Participants: This randomized controlled trial (RCT) involved 174 cancer patients from 9 palliative care services in Australia. Patients were randomized to receive the QPL 20 minutes before an outpatient consultation with a palliative care physician, with a physician prompt to the QPL during the visit (n = 92) versus standard palliative care without the QPL (n = 82). Consultations were audiotaped; follow-up questionnaires were conducted at 1 and 21 days. The primary outcome was number of questions asked during the visit; secondary outcomes included concerns discussed, patient and physician satisfaction, and consultation duration. Mean age of participants was 65 (SD 13); 60% were male, 70%-78% had caregivers present, and 75% had estimated survival >12 weeks.

Results: QPL patients asked 2.31 (95% CI, 1.68-3.18; p < .0001) more questions than control patients; overall, 23% (95% CI, 11%-37%) more items were discussed. Caregivers asked 2.11 (95% CI, 1.40-3.18; p = .0005) more questions. Prognosis, lifestyle concerns, caregiver issues, and end-of-life issues were more frequently discussed with the QPL (p = .003, .03, .001, and .001, respectively); treatment options and physical symptoms were discussed equally among groups. The adjusted mean consultation length was 37.8 minutes for QPL patients and 30.5 minutes for control (ratio 1.24; 95% CI, 1.09-1.41; p = .002). There was no significant difference between groups in patient or physician satisfaction.

Commentary: A QPL is a simple method to encourage patients and caregivers to discuss important end-of-life issues. In this RCT, a QPL provided to patients 20-30 minutes before an outpatient palliative care clinic visit was more effective than standard care at facilitating discussion about prognosis, end-of-life care, caregiver issues, lifestyle, and QOL. Intervention success was directly proportional to the degree of physician endorsement for the QPL; this is consistent with other studies of successful educational interventions in end-of-life care. The study was limited in that physicians were not blinded, a single clinic visit was analyzed, and downstream effects were not assessed (e.g., completing wills, place of death). This QPL proved easy to implement, did not interfere significantly with visit flow, and was well-received; however, visit length was significantly longer.

Bottom Line: A QPL can help patients and caregivers remember discussion points during palliative care outpatient visits.

Reviewer: Kimberly Johnson, MD, Geriatrics and Palliative Medicine, Duke University Medical Center, Durham, NC, and Laura Hanson, MD, University of North Carolina at Chapel Hill, NC.

Source: Clayton JM, Butow PN, Tattersall MHN, et aI. Randomized controlled trial of a prompt list to help advanced cancer patients and their caregivers to ask questions about prognosis and end-of-life care. J Clin Oncol. 2007 Feb 20;25(6):715-722. PMID: 17308275. To access the abstract of this article, link to NLM–PubMed here.

IL10 and Pain

IL10 and Neuropathic Pain

Background: Proinflammatory cytokines are known to play a role in promoting neuropathic pain. Antiinflammatory cytokines, including IL10, may therefore represent a way of modulating this pain. Do repeated intrathecal (IT) injections of plasmid DNA encoding IL10 result in relief of neuropathic pain?

Design and Participants: Adult male, pathogen-free Sprague-Dawley rats were used in all experiments. Experimental plasmids encoded either human or rat IL10; control plasmids were identical with the IL10-encoding DNA replaced by that of a reporter gene, green fluorescent protein (GFP). Prior to injection, it was verified that all IL10 constructs produced IL10 at sufficient levels. Chronic constriction injury (“injury”) was produced by ligating the sciatic nerve. In sham-operated animals, the nerve was exposed but not ligated. All animals received repeated IT injections of plasmid DNA encoding rat IL10, human IL10, and/or GFP. Blinded behavioral testing was performed, and the response pattern was used to determine the 50% paw withdrawal threshold. Assessments were performed at baseline, 3 and 10 days after injury, and after IT injections.

Results: IT IL10 administered 10, 15, 24, and 65 days after injury transiently decreased injury-induced allodynia in Sprague-Dawley rats. The duration of the therapeutic effect was longer after each successive injection, with reversal lasting approximately 4 weeks following the third injection. IT IL10 also had an effect on rats with chronic injury-induced allodynia; a transient reversal was seen after one IT injection, and a prolonged (~35 day) reversal was seen after a second injection 3 days later.

Commentary: Treatment of neuropathic pain is difficult and oftentimes inadequate. The skill to balance the benefits and burdens of “rational polypharmacy” using currently available palliative drugs, or interventional techniques, is requisite for clinicians treating these patients. In the face of such debilitating and oftentimes demoralizing syndromes, it is important for us and our patients to know that progress is being made.

The putative role of microglia and certain cytokines as a common feature in the pathogenesis of various chronic pain syndromes is becoming increasingly evident. In this rat model, repeated IT injections of plasmid DNA encoding IL10 relieved neuropathic pain. Through a very clever experimental model, this research provides the opportunity to glean insight into mechanisms behind the neurobiology of persistent pain, a novel and cutting edge basic science approach toward remediation of neuropathic pain using in vivo methodology, and a foreshadowing of what may become a tenable prophylactic or treatment strategy for human patients at risk for or suffering from neuropathic pain. Although it may be years before clinicians can capitalize on this or similar technology, we may at long last be witnessing a ray of light at the end of the tunnel.

Bottom Line: In a rat model, IT administration of the antiinflammatory cytokine IL10 relieved neuropathic pain, foreshadowing potential future therapeutic strategies.

Reviewer: Perry G. Fine, MD, University of Utah and the National Hospice and Palliative Care Organization.

Source: Milligan ED, Sloane EM, Langer SJ, et al. Repeated intrathecal injections of plasmid DNA encoding interleukin-10 produce prolonged reversal of neuropathic pain. Pain. 2006 Dec 15;126(1-3):294-308. Epub 2006 Sep 1. PMID: 16949747. To access the abstract of this article, link to NLM–PubMed here.

PC-FACS Feedback

We appreciate your feedback. Send your comments to Amy Abernethy, MD, Editor, at amy.abernethy@duke.edu.

PC-FACS is edited by Amy Abernethy, MD, of Duke University Medical Center. AAHPM thanks the following Associate Editors for their review of the critical summaries and preparation of the commentaries:

Robert M Arnold, MD
Stephen Bekanich, MD
Janet Bull, MD
Ira Robert Byock, MD
Ronald J Crossno, MD CMD FAAHPM
Mellar P Davis, MD FCCP
Betty Ferrell, PhD RN FAAN
Perry G Fine, MD
Daniel Fischberg MD PhD
Gail Gazelle, MD FACP FAAHPM
Laura Hanson, MD MPH
John F Manfredonia, DO
Gregory J Miller, MD
Alan Nixon, MD
David Nowels, MD
John Peppin, DO FACP
Brad Stuart, MD
James A Tulsky, MD
Joanne Wolfe, MD
Donna S Zhukovsky, MD FACP

© 2007, American Academy of Hospice and Palliative Medicine. All rights reserved. No part of this publication may be reproduced without the express written permission of AAHPM.

The views expressed herein are those of the individual authors and are not necessarily those of the Academy. Information included herein is not medical advice and is not intended to replace the judgment of a practitioner with respect to particular patients, procedures, or practices. To the extent permissible under applicable laws, the Academy disclaims responsibility for any injury and/or damage to persons or property as a result of any actual or alleged libelous statements, infringement of intellectual property or other proprietary or privacy rights, or from use or operation of any ideas, instructions, procedures, products or methods contained in this publication.