This week in the BMJ
Volume 327, Number 7408, Issue of 26 Jul 2003Doctors overestimate survival
Doctors overestimate survival
Doctors know when cancer patients are approaching death, even if their predictions of time till death are inaccurate. Glare and colleagues (p 195) conducted a systematic review and meta-analysis of eight studies that assessed the accuracy of doctors' survival predictions. They found that doctors often overestimate the survival of terminally ill cancer patients and are wrong by more than a month a quarter of the time. Predictions were more accurate closer to death. However, doctors' predictions were reliable, being closely correlated with survival over the next six months. The authors say that doctors need to be aware of their tendency to overestimate survival.
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Caring for dying patients is a source of satisfaction and of distress
The longer a doctor cares for a patient, the more affected he or she is when that patient dies. Redinbaugh and colleagues (p 185) surveyed 188 doctors' emotional reactions to recent deaths of patients in two American teaching hospitals. The patients who died were usually new to the doctors, and most doctors did not feel close to them. Still, most reported moderate levels of emotional distress, and these increased the longer they cared for the patient. Interns (house officers) and female doctors reported the greatest needs for emotional support. Caring for dying patients is part of all doctors' clinical work, but it rarely gets explored. The authors say that further research is needed on how senior doctors might help to support junior doctors after the death of a patient.
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Bereaved people cope better after euthanasia than natural death
Friends and family of cancer patients who died by euthanasia cope better than those of cancer patients who died a natural death. Swarte and colleagues (p 189) conducted a cross sectional study in the Netherlands with the bereaved of patients who had died by euthanasia, comparing them to the bereaved of matched control patients who had died of natural causes in the same hospital during the same time period. The bereaved of patients who died by euthanasia had fewer grief symptoms and post-traumatic stress reactions on standard scales. The opportunity to say goodbye to the patient was an important factor in better coping. The authors say that their results are a plea not for euthanasia but for support for the same level of care and openness for all cancer patients who are terminally ill.
Patients in Uganda prefer to die at home
A good death in developing countries like Uganda, where resources are scarce, occurs when the dying person is being cared for at home, is free from pain and other distressing symptoms, feels no stigma, and is at peace. It is also important that basic needs such as food and school fees for children are met without the patient feeling dependent on others. These are the conclusions of Kikule (p 192), based on her study in Kampala with 173 patients with HIV/AIDS or cancer. The home was the preferred site for care as it was considered a safe place and housed the relationship between the patient and family. The author says that few participants used government health facilities as they were generally poorly equipped and health staff gave priority to patients with curable conditions and did not have time for terminally ill patients.
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Facilitating consent for trials in dying patients
Research in palliative care settings needs novel approaches. As obtaining fully informed consent is usually impossible, research on drugs that could benefit dying patients is particularly difficult. Rees and Hardy (p 198) have developed a novel advance consent process to support a trial comparing two of the drugs commonly used for the control of "death rattle." If generally accepted, this may facilitate the research necessary to advance the care of dying patients.
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