Side effects deserve greater emphasis at end of life
http://www.100md.com
《英国医生杂志》
EDITOR—We agree with many of the points made by Stevenson et al on managing comorbidities at the end of life, particularly the emphasis on assessing the overall benefits of treatment kept in perspective through numbers needed to treat or absolute risk reduction, often much smaller than the relative risk reductions more commonly cited.1 2
We believe that side effects deserve greater emphasis. Pharmacokinetics and sensitivities to drugs are often more marked and less predictable in disease, as Stevenson et al say. With this comes an increased risk of doing harm. For example, the risk of oesophageal perforation associated with bisphosphonate treatment is increased because of reduced oesophageal motility and difficulty remaining erect for the requisite half hour.
The authors say that current and emerging evidence can help generate a framework to improve clinical decision making in patients at the end of their life. The patient population discussed is invariably excluded from the trials investigating many of the conditions mentioned. For these patients, the same effects of treatment cannot be assumed, and decisions must be made empirically. This is a situation that we cannot envisage changing.
One recently described approach that may help guide clinicians involves dividing patients into four categories according to the style of care provided—aggressive management, usual, palliative (emphasis on symptom control but no secondary prevention), and terminal care. 3
Adam Harper, acting consultant geriatrician
adamharper@doctors.org.uk, Department of Medicine for Older People, Southampton General Hospital, Southampton SO16 6YD
Jan Ritchie, registrar, Jeremy Rowland, senior house officer, Vladimir Malykh, honorary preregistration house officer
Department of Medicine for Older People, Southampton General Hospital, Southampton SO16 6YD
Competing interests: None declared.
References
Stevenson J, Abernethy AP, Miller C, Currow DC. Managing comorbidities in patients at the end of life. BMJ 2004;329: 909-12. (16 October.)
Bogaty P, Brophy J. Increasing burden of treatment in the acute coronary syndromes: is it justified? Lancet 2003;361: 1813-6.
Vanpee D, Swine C. Scale of levels of care versus DNR orders. J Med Ethics 2004;30: 351-2.
We believe that side effects deserve greater emphasis. Pharmacokinetics and sensitivities to drugs are often more marked and less predictable in disease, as Stevenson et al say. With this comes an increased risk of doing harm. For example, the risk of oesophageal perforation associated with bisphosphonate treatment is increased because of reduced oesophageal motility and difficulty remaining erect for the requisite half hour.
The authors say that current and emerging evidence can help generate a framework to improve clinical decision making in patients at the end of their life. The patient population discussed is invariably excluded from the trials investigating many of the conditions mentioned. For these patients, the same effects of treatment cannot be assumed, and decisions must be made empirically. This is a situation that we cannot envisage changing.
One recently described approach that may help guide clinicians involves dividing patients into four categories according to the style of care provided—aggressive management, usual, palliative (emphasis on symptom control but no secondary prevention), and terminal care. 3
Adam Harper, acting consultant geriatrician
adamharper@doctors.org.uk, Department of Medicine for Older People, Southampton General Hospital, Southampton SO16 6YD
Jan Ritchie, registrar, Jeremy Rowland, senior house officer, Vladimir Malykh, honorary preregistration house officer
Department of Medicine for Older People, Southampton General Hospital, Southampton SO16 6YD
Competing interests: None declared.
References
Stevenson J, Abernethy AP, Miller C, Currow DC. Managing comorbidities in patients at the end of life. BMJ 2004;329: 909-12. (16 October.)
Bogaty P, Brophy J. Increasing burden of treatment in the acute coronary syndromes: is it justified? Lancet 2003;361: 1813-6.
Vanpee D, Swine C. Scale of levels of care versus DNR orders. J Med Ethics 2004;30: 351-2.