Eric Widera

I just got my hands on a copy of a fabulous new book by Drs Goldstein and Morrison and felt compelled to write a quick review about it.  The title of the book is “Evidence-Based Practice of Palliative Medicine” and it’s 528 pages is chock-full of useful palliative care topics.

The most interesting aspect of the new book is the chapter format. The editors put together what can be best described as a detailed FAQs (Frequently Asked Questions) on palliative medicine. There are 81 questions that are addressed in depth in the corresponding chapters.  Some of my favorite questions from the book include:

Symptom Management Section:

• How should patient-controlled analgesia be used in patients with serious illness and those experiencing post-op pain?
• Which opioids are safest and most effective in renal failure? 
• How should methadone be started and titrated in opioid-naïve and opioid-tolerant patients? 
• When should corticosteroids be used to manage pain? 
• When should radiopharmaceuticals be considered for pain management? 
• What nonopioid treatments should be used to manage dyspnea associated with COPD? 
• What interventions are effective for relieving acute bowel obstruction in cancer and other conditions? 
• What treatments are effective for anxiety in patients with serious illness?

Communication Section: 

• What is a useful strategy for estimating survival for persons with advanced non-cancer related illness in palliative care settings? 
• What do palliative care clinicians need to know about teaching communication?

Disease Specific Topics

• What special considerations are needed for treatments patients with chronic liver disease? 
• What special considerations are needs for individuals with ALS, MS, or Parkinson Disease? 
• How is the patients who stops dialysis best managed? 
• Which patients with end-stage renal disease should not be started on dialysis?

Special Topics 

• What techniques can be used in the hospital or home setting to best manage uncontrolled bleeding? 
• What can be done to improve outcomes for caregivers of patients with serious illness? 
• How can palliative care be integrated into home-based primary care programs?

The other nice thing about this book is that it is pretty easy to access all the chapters online via the publishers web-portal www.expertconsult.com.

If you want to take a closer look at the book, you can find it on Amazon and Barnes & Noble.

By: Eric Widera (@ewidera)

Disclosure: I was an author on 2 chapters in this book, but I have not received, nor will receive, any royalties except for a copy of the book (I have though requested it be autographed by Sean and Nate).  

It is better to die dry than wet. At least that is the gist of traditional thinking in hospice and palliative care, where parenteral (IV or subcutaneous) fluids are often avoided at the very end of life to prevent fluid buildup in the lungs and other organs.

The problem is that delirium often complicates end of life care as well. It is one of the four most common emergency calls for individuals receiving palliative care in the home and a common reason for admissions into inpatient hospice units. Reduced oral intake, a part of the natural dying process, may result in dehydration in some but not all individuals at the end of life, and may be a factor in the development delirium. Studies in the geriatric literature suggest that early recognition of dehydration and volume repletion is an important component of delirium prevention.

So, how do we reconcile our desire to avoid the unintended consequences of IV hydration in those at the end of life with that of treating dehydration to prevent delirium?  Some argue for a greater use of parenteral fluids in these patients to improve quality of life, at the very least for those with some evidence of dehydration.  However, the question remains, does IV hydration improve quality of life and decrease incidence of delirium, or will it just worsen symptoms at the end of life?

Dr. Eduardo Bruera and colleagues from MD Anderson add some evidence to how best to manage fluids at the end of life thanks to a study recently published in the Journal of Clinical Oncology. The authors randomized 129 individuals with advanced cancer from 6 hospices to either parenteral subcutaneous hydration of 1 L per day of normal saline or placebo.  In order to maintain blinding for both patients and staff, the placebo was a 100ml a day of saline injected over a similar 4 hour period per day as the fluids in the intervention group.

Inclusion criteria included advanced cancer, reduced oral intake of fluids with evidence of mild or moderate dehydration, at least mild symptoms of fatigue, hallucinations, sedation, and myoclonus, a life expectancy of less than 1 week, , and a Memorial Delirium Assessment Scale (MDAS) score less than 13 (i.e not severe delirium). Those with severe dehydration were excluded as were individuals with renal failure, congestive heart failure, or a history or clinical evidence of bleeding disorders.

The primary outcome was change from baseline to day 4 for the sum of four dehydration symptoms (fatigue, myoclonus, sedation and hallucinations). They also included a rather complete amount of secondary outcomes including:

• Individual items on a symptom assessment scale – the Edmonton Symptom Assessment Scale (ESAS)
• Two dementia scales – the Memorial Delirium Assessment Scale (MDAS) and Nursing Delirium Screening Scale (NuDESC) – and one agitation scale
• A quality of life scale – the Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F)
• Dehydration assessment scale (the Dehydration Assessment Scale)
• Labs including creatinine, urea, and electolytes
• Overall survival.

In the intention-to-treat analysis, there were no statistically significant differences between the IV hydration group and the placebo group at either 4 days or 7 days in regards to:

• The sum of the four dehydration symptoms (-3.3 vs -2.8, P=0.77)
• Individual symptom evaluation based on the ESAS
• Overall delirium scores based on the MDAS
• Quality of life scores
• Dehydration assessment scores
• Median survival

The authors did find some differences in some measures such as night-time delirium scores, which was worse in the placebo group. However, given the numerous secondary outcomes (47 of them), I wouldn’t place much weight on this, as by pure chance at least two of these outcomes will be positive using a P of 0.05.

One big limitation of the study was that it was underpowered. The planned sample size was 150 patients, but funding issues required termination of the study after 129 patients. This was likely due to the strict inclusion and exclusion criteria. So, you can argue that the authors didn’t find a difference because they didn’t enroll enough patients (a Type II error). This may be a classic Type II error where no significant difference between groups are reported when in fact such a difference exists.  I would be surprised though if the authors enrolled another 21 patients that a clinically significant result would have materialized for the primary outcome since it didn’t look like a trend was developing (-3.3 vs -2.8, P=0.77).

So in the end, we have some data to suggest that IV hydration of 1 liter is unlikely to provide a meaningful benefit to most hospice patients with advanced cancer with mild to moderate dehydration (but not severe).

by: Eric Widera (@ewidera)

This is a guest post by Dr. Ronald Pies in response to this week’s GeriPal post about the removal of the Bereavement Exclusion from DSM-5.  Dr. Pies is the Editor-in-Chief Emeritus of Psychiatric Times, Professor of Psychiatry and Lecturer on Bioethics & Humanities at SUNY Upstate Medical University, and Clinical Professor of Psychiatry at Tufts USM.

Mr. Smith is a 72-year-old retired businessman whose wife died of cancer 3 weeks ago. He visits his family doctor and says, “I feel down in the dumps and weepy every day, Doc—really lousy! I don’t get any pleasure out of anything anymore, even stuff I used to love, like watching football on TV. I wake up at 4 in the morning almost every day, and I have zero energy. I can’t keep my mind on anything. I barely eat, and I’ve lost 10 pounds since Mary passed away. I hate being around other people. Sometimes I feel like I didn’t really do enough for Mary when she was sick. God, how I miss her! I can still cook for myself, pay the bills, and so on, Doc, but I’m just going through the motions. I don’t enjoy life at all anymore.”

Though it’s still early after his wife’s death—and some clinicians may want to defer a final diagnosis for another week—all clinicians should be very concerned about Mr. Smith. He easily meets DSM-IV (and now, DSM-5) symptom and duration criteria for MDD. (A previous bout of MDD in his history would strengthen the likelihood, as would several other clinical findings I have omitted). And yet, under the present DSM-IV “rules,” Mr. Smith probably would not be diagnosed with a major depressive illness. He would simply be called “bereaved.” Why? Because he is still within the 2-month period that allows for use of the bereavement exclusion; and because Mr. Smith doesn’t have the DSM-IV features that allow the clinician to “override” use of the BE; namely, severe functional impairment, suicidal ideation, psychosis, morbid preoccupation with worthlessness, or extreme guilt. It’s important to note that the DSM-IV exclusion rules did not apply to any other type of loss, such as losing one’s job or becoming homeless. Ironically, if Mr. Smith’s wife had left him for another man, he would meet MDD criteria, using current DSM-IV rules!

Many of us who have specialized in the treatment of mood disorders found the DSM-IV criteria not only illogical, but also inimical to good clinical care. We were concerned that many bereaved patients like Mr. Smith–who meet all symptom and duration criteria for MDD, but who happen to have lost a loved one within the past two months– would be shunted out of the mental health care system. In the view of many (though not all) mood disorder specialists, the risk of overlooking MDD, with its high potential for suicide, far outweighs the less serious risk of “over-calling” MDD—the so-called “false positive” scenario.

The elimination of the bereavement exclusion (BE) by the DSM-5 does not mean that “grief is now a mental disorder,” as some have claimed. Nor does it mean that anyone who is grieving within two weeks of a loved one’s death—i.e., most people!—will be diagnosed with major depressive disorder. (Two weeks is the minimum duration required for MDD, under DSM-IV and DSM-5 criteria). First of all, studies have shown that most bereaved persons will not meet full DSM-5 criteria for MDD. Second: it would be extremely rare, in clinical practice, for a bereaved person to seek psychiatric care within two weeks (or even a month) of the death of a loved one, unless something very unusual or dysfunctional were going on—for example, the bereaved person has developed a psychotic-level disturbance; is severely incapacitated; or has become suicidal–in which cases, the bereavement exclusion would not apply anyway. And, contrary to the strident claims of some, nothing in the diagnosis of MDD will prevent bereaved patients with MDD from receiving the love, support, and solace of family and friends.

To be sure, physicians and other health care workers need a much better understanding of the key differences between ordinary grief and major depression. For example, bereaved persons with normal grief often experience a mixture of sadness and more pleasant emotions, as they recall memories of the deceased. Anguish and pain are usually experienced in “waves” or “pangs,” rather than continuously, as is usually true in major depression. The grieving individual typically maintains the hope that things will get better. In contrast, the clinically depressed patient’s mood is almost uniformly one of gloom, despair, and hopelessness–nearly all day, nearly every day. The bereaved individual usually maintains a strong emotional connection with friends and family, and often can be consoled by them. The person suffering a severe major depressive disorder is usually too self-focused and emotionally “cut off” to enjoy the company of others. Indeed, Dr. Kay R. Jamison has pointed out that “The capacity to be consoled is a consequential distinction between grief and depression.” My colleagues and I are now developing a screening questionnaire (the PBPI) based on these distinctions. We don’t yet know the final wording of the DSM-5 text, which we hope will emphasize and clarify the distinctions between ordinary grief and major depression.

I would urge readers of GeriPal to take a look at the excellent piece by Dr. J. Sloan Manning, in the September 7, 2012, Psychiatric Times, from which I provide a few excerpts. Dr Manning is Co-director of the Mood Disorders Clinic at the Moses Cone Family Practice Center in Greensboro, NC. Here is what he wrote:

“I write this as one in the midst of bereavement, having lost my dear mother several months ago… During the last year of her life (in rehab facilities and briefly in a nursing home) we were never closer. I still avoid driving by the nursing home. I still wake up at night occasionally tearfully thinking of her. I cook a lot of pot roasts in the old cast iron Dutch oven she made famous. I am converting a home office to a guest bedroom filled with family memories. I am not ill. I am grieving. It doesn’t look like illness. It doesn’t need to be treated like illness. I can’t believe anyone would mistake it for illness, especially an experienced clinician. But if I were ill and grieving, I would expect my health care providers to understand that the two concepts are not mutually exclusive, and I would expect them to offer help for my illness . . .Part of my practice is in a mood disorders clinic in a family practice residency…I cannot remember a single instance in this setting where the [bereavement exclusion] saved the day, preventing the unnecessary use of medication for a non-illness. In situations in which previous ill episodes were absent, symptoms were mild, and cognition and function were preserved, we would always choose the path of supportive and cognitive psychotherapy, and bibliotherapy or other non-pharmacological means as primary interventions. However, in patients with severe symptoms or those with documented histories of Axis I illness, we would never ignore the reality that intact affective control systems are a requirement for successful negotiation of grief.”

In conclusion: eliminating the bereavement exclusion means essentially this: the death of a loved one–a common precipitant of major depression—-will no longer be a “disqualifying” factor in diagnosing MDD, within the first few weeks after bereavement. This emphatically does not mean that we should be starting everyone with bereavement-related MDD on antidepressants! Some depressed and bereaved patients will heal and recover with “tincture of time”; some will benefit from cognitive, supportive or grief-oriented psychotherapies. More severely depressed, grieving patients–those, for example, with melancholic features or pronounced suicidality–may require concurrent medication and psychotherapy.

No, indeed: we must not “medicalize” normal grief. But neither must we “normalize” major depression, simply because it occurs in the context of bereavement.

by: Ronald Pies MD
SUNY Upstate Medical University, Syracuse, NY
Tufts University School of Medicine, Boston

For further reading:

• Pies R. Was the bereavement exclusion originally based on scientific data? World Psychiatry. 2012 Oct;11(3):203.
• Pies R. Bereavement, complicated grief, and the rationale for diagnosis in psychiatry. Dialogues Clin Neurosci. 2012 Jun;14(2):111-3.
• Zisook S, Pies R, Corruble E. When is grief a disease? Lancet. 2012 Apr 28;379(9826):1590.
• Zisook S, Corruble E, Duan N, et al: The bereavement exclusion and DSM-5. Depress Anxiety. 2012 May;29(5):425-43.
• Lamb K, Pies R, Zisook S. The Bereavement Exclusion for the Diagnosis of Major Depression: To be, or not to be. Psychiatry (Edgmont). 2010 Jul;7(7):19-25.
• Zisook S, Simon NM, Reynolds CF 3rd, Pies R, Lebowitz B, Young IT, Madowitz J, Shear MK. Bereavement, complicated grief, and DSM, part 2: complicated grief. J Clin Psychiatry. 2010 Aug;71(8):1097-8.
• Zisook S, Reynolds CF 3rd, Pies R, Simon N, Lebowitz B, Madowitz J, Tal-Young I, Shear MK. Bereavement, complicated grief, and DSM, part 1: depression. J Clin Psychiatry. 2010 Jul;71(7):955-6.
• Pies RW. Depression and the pitfalls of causality: implications for DSM-V. J Affect Disord. 2009 Jul;116(1-2):1-3.
• Pies R: How the Public is Being Misinformed about Grief. Psychcentral. http://psychcentral.com/blog/archives/2012/02/28/how-the-public-is-being-misinformed-about-grief/all/1/
• Manning JS: Debate: Let the Bereavement Exclusion in DSM-5 Die. Psychiatric Times, Sept. 7, 2012. http://www.psychiatrictimes.com/mdd/content/article/10168/2101417?CID=rss  
• Dunlop BW: Debate: Is It Worth Saving the Bereavement Exclusion in DSM-5? Ringing the Bell to Save the Bereavement ExclusionPsychiatric Times, September 7, 2012 http://www.psychiatrictimes.com/mdd/content/article/10168/2101460  
• Pies R: After Bereavement, Is It “Normal Grief” or Major Depression? The PBPI: A Potential Assessment Tool. Psychiatric Times. February 21, 2012. http://www.psychiatrictimes.com/mdd/content/article/10168/2035804  
• Jamison KR: Nothing Was the Same. Knopf, 2009. Also: an excellent video with Dr. Kay R. Jamison explains some of the key differences between grief and depression: http://bigthink.com/ideas/16707  

Acknowledgments: Thanks to Laura Dunn, MD and Sidney Zisook MD, for suggestions on earlier drafts of this blog; however, the views expressed here are my own.

Disclosure statement: Dr. Pies reports no financial or other conflicts of interest with respect to the content of this piece. He has had no official role in the DSM-5 development process, or any formal connection to the DSM-5 committees. He receives no monies from any pharmaceutical companies. A formal disclosure statement may be found at: http://www.psychiatrictimes.com/editorial-board

Have you been tearful and sad after the death of a loved one?  Did you notice changes in appetite, difficulty sleeping, troubles concentrating, and decreased energy for at least two weeks after the loss? Did you think that was a normal, healthy, and adaptive response to a major loss? Well, if you believe the new DSM-5 criteria approved today by The American Psychiatric Association’s (APA) board of trustees, you would be wrong, as your reaction would now fit the criteria for Major Depression.

Under the current DSM-IV criteria, you would have been right, as the bereaved would have not qualified for depression unless symptoms persisted for longer than 2 months or were characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.   It made sense to do this as most individuals successfully cope with the loss of a loved one without medical intervention, even though the first few weeks to months following a loss is associated with significant distress.

Times are changing though.  Even though the final manual is not out yet, the APA Board of Trustees released a statement that noted the newly approved DSM-5 will remove the “bereavement exclusion.”

Now there are some persuasive arguments for this change. Probably strongest is that there is little difference between the development of depression from that of bereavement versus other life stressors, such as being diagnosed with advanced cancer or having gone through a marital breakup.  In other words, if you have an exclusion for bereavement, shouldn’t you also have an exclusion for other significant losses in life?

In addition, grief seen in bereavement is not completely benign.  There are a minority of bereaved individuals (approximately 10-20%) in which grief can become complicated and prolonged. For these individuals, complicated grief has been shown to have a significant detrimental impact on their ability to function and quality of life.  There are also individuals who truly developed profound depressive episodes shortly after the loss of a loved one.  However, the current DSM-IV criteria clearly allows a diagnosis of Major Depression to be made in these instances, although the bar is set higher.

I can’t help but see this as a broad overreach by the APA.  Grief is not a disorder and should be considered normal even if it is accompanied by some of the same symptoms seen in depression.  Yes, uncomplicated grief may cause significant distress, but for the majority of bereaved, it is an adaptive and healthy reaction to the loss of a loved one.   Furthermore, there is no evidence that medical interventions significantly improve outcomes or symptoms in the bereaved, outside of those with prolonged or complicated grief disorders.  Most
bereaved individuals will adjust to a new life without their loved one, but this takes time – certainly longer than 2 weeks.

by: Eric Widera (@ewidera)