Cutaneous Treatment of Nausea: You Can’t Get There From Here

At the annual assembly of the American Academy of Hospice and Palliative Medicine, Boston

Courtesy flickr user rjcox (CC)

Nausea and vomiting are a common reason for palliative care consultation and admission and are a frequent reason for “hospice failure” admissions, Dr. Thomas Smith of Virginia Commonwealth University said to no surprise to his palliative care colleagues at this meeting. He expressed the keen needs for guidelines for the cutaneous treatment of nausea and vomiting in palliative/hospice care, and bemoaned the fact that the lack of evidence-based therapies all but precludes the writing of such guidelines.

While topical compounds, including lorazepam, diphenhydramine, and haloperidol (ABH gel) with or without metoclopramide (ABHM gel), are routinely used and have anecdotally yielded promising results, “we have no data to show that any of the drugs are absorbed through the skin in therapeutic amounts,” Dr. Smith said.

He shared with the attendees his own failed attempt at getting an efficacy study of ABH gel approved. “I wrote a clinical trial, and since I am an oncologist, I sent it to the [review committee] at the NCI.” Among the comments he received from the review panel were:

• “Poorly structured preliminary data,” despite the fact that the preliminary data were not his and, in fact, were precisely the data that proposed study aimed to improve;
• “Reporting nausea and vomiting by subjective assessment isn’t good enough. There has to be some sort of objective assessment.” Huh?
• “The study is needed, but frankly it’s not going to change clinical practice because people are so wedded to [ABH gel] already.”

Although the study didn’t get approved, Dr. Smith later received notice of a grant to conduct a small pilot study on the absorption of ABH gel, “so in 3-6 months, we will have some actual data about whether the drug is absorbed through the skin,” he said. “That’s a start.”

—Diana Mahoney (@DMPM1 on Twitter)

A Little Goes a Long Way in Palliative Care

From the annual assembly of the American Academy of Hospice and Palliative Medicine, Boston

Courtesy flickr user Rosie O'Beirne (CC)

During the “State of the Science” plenary presentation here, at least two things became abundantly clear about the hospice and palliative care arena: that a little thoughtful effort goes a very long way toward improving the end-of-life experience for terminally ill patients and their families; and that a little thoughtful effort is often absent.

Dr. Nathan Goldstein of Mt. Sinai School of Medicine in New York and Dr. Wendy Gabrielle Anderson of the University of California San Francisco presented a round-up of some of the year’s top peer-reviewed articles, focusing in particular on research that could have an immediate clinical impact in palliative care and hospice settings.

In the “a little thoughtful effort goes a very long way” category, they discussed the findings of the Project ENABLE II randomized controlled trial that were published in August in the JAMA which showed that patients with advanced, life-limiting cancer who participated in a four-session, group psycho-educational intervention with telephone follow up experienced higher quality of life, decreased depression, and a trend toward reduced symptom intensity compared with usual care.  International guidelines and consensus statements recommend the implementation of palliative care interventions concurrent with oncology treatment, and this is the first randomized controlled trial to test the efficacy of doing so, according to the presenters.

Regarding the absence of  “a little thoughtful effort,” a study out of Dana Farber Cancer Institute published in the January 20, 2010 issue of the Journal of Clinical Oncology, looked at the provision of spiritual care to nearly 350 patients with advanced cancer and showed that the majority of the patients (60%) reported their spiritual needs were only minimally supported or were not supported at all, and more than half (54%) had not received pastoral care visits. The findings are somewhat astonishing, and heartbreaking, particularly considering the advanced stage of the patients’ disease (the study sample died a median of 116 days after the baseline interview, according to the authors).

Spiritual care is supposed to be a quality standard for palliative care, yet, as this study illustrates, that the standard is often not being met.

—Diana Mahoney (@DMPM1)