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Press releases Saturday 22 March 2008

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(1) Study highlights increasing use of continuous deep sedation in the Netherlands
(2) Are dual cord blood banks the answer to increasing stem cell demand?
(3) New commissioning policy is neglecting patients, warn doctors
(4) What should the Darzi review recommend?

(1) Study highlights increasing use of continuous deep sedation in the Netherlands
(Continuous deep sedation for patients nearing death in the Netherlands: descriptive study)
http://www.bmj.com/cgi/content/short/bmj.39504.531505.25v2
(Editorial: Continuous deep sedation in patients nearing deathe)
http://www.bmj.com/cgi/content/short/bmj.39511.514051.80v2

The use of continuous deep sedation for patients nearing death in the Netherlands is increasing, while cases of euthanasia have declined, according to a study published on bmj.com today.

Although the exact cause of this trend is unclear, there are indications that continuous deep sedation may in some cases be being used as a substitute for euthanasia.

Patients nearing death often experience distressing symptoms and sedating drugs can be used as an option of last resort. Sedation can be used intermittently or continuously until death, and the depth of sedation can vary from a lowered state of consciousness to unconsciousness.

The most extreme use of sedation is continuous deep sedation until death, but there is a lack of large scale research on its use.

In 2001, a large study in six European countries showed that continuous deep sedation was used in up to 8.5% of all deaths, among patients with cancer and other diseases, and provided in as well as outside hospital.

In 2005, researchers repeated this study using a random sample of over 6,500 deaths that occurred in the Netherlands between August and November 2005. Physicians were surveyed about their medical decisions for the non-sudden deaths.

The use of continuous deep sedation increased from 5.6% of deaths in 2001 to 7.1% in 2005 (an increase of 1800 cases). The increase occurred mostly in patients with cancer who were treated by a general practitioner. In contrast, the use of euthanasia decreased from 2.6% of all deaths in 2001 to 1.7% of all deaths in 2005 (a decrease of 1200 cases).

In about four out of five of cases, sedation was induced by benzodiazepines, and in 94% patients were sedated for less than one week until death. Only 9% of physicians consulted a palliative expert.

About one in ten patients who received continuous deep sedation had previously requested euthanasia or assisted suicide but it had not been granted.

Possible explanations for these trends include increased knowledge and media attention about continuous deep sedation, say the authors. Their findings suggest that continuous deep sedation is increasingly considered part of regular medical practice in the Netherlands.

They call for future research to focus on the underlying reasons for the use of continuous deep sedation.

This study provides some insight into end of life management of patients with intractable suffering, say researchers in an accompanying editorial.

They believe that further research must incorporate the perspectives of patients and families, as well as professionals from health care, spiritual care, social services, law and ethics. And they call for informed public debate about ethical and effective ways to alleviate persistent suffering at the end of life.

Contacts:
Judith Rietjens, Postdoctoral Researcher, Department of Public Health, Erasmus University Medical Center Rotterdam, Netherlands
Email: d.drexhage@erasmusmc.nl
Editorial: Ira Byock, Director of Palliative Medicine, Dartmouth Medical School, USA
Email: IByock@aol.com

(2) Are dual cord blood banks the answer to increasing stem cell demand?
(Public-private partnership in cord blood banking)
http://www.bmj.com/cgi/content/short/336/7645/642

Demand for stem cells from cord blood is greater than supply. In this week's BMJ, two senior doctors, Professors Nicholas Fisk and Rifat Atun, analyse the UK's growing cord blood banking industry and the potential impact of a new bank that provides blood for both personal and public use.

Umbilical cord blood is rich in stem cells that can be used in a way similar to bone marrow to treat diseases such as childhood leukaemia. In future, it might also be used to repair damaged tissues in a range of diseases such as strokes, heart attacks, kidney failure, and diabetes.

Cord blood banks generally fall into two groups. Public banks collect cord blood which has been altruistically donated at birth and the blood is available to everyone. The value of public banks is now well established, but currently only a handful of UK hospitals collect cord blood for the public bank and coverage is insufficient to meet demand.

In contrast, commercial (private) banks offer parents the chance to store their child's cord blood as biological insurance, in case it is needed to treat some future disease in the child or close family member. Customers typically pay £1500 for a 20-25 year service, but the chances of the blood being used are very small and these banks have been opposed by numerous medical bodies.

Private banks also raise serious resource issues for the NHS and are at risk of corporate failure.

Virgin recently introduced the concept of dual public-private banking. Virgin Health Bank stores 20% of the sample for private use and 80% for public use and uses some of the proceeds to support stem cell research.

In this way, Virgin has addressed the impasse between parents' desire to store their baby's cord blood and the unmet need for public banks, say the authors. Nevertheless, Virgin's service still has many of the core disadvantages of private banking.

To succeed, Virgin will need to get the support of midwives and obstetricians who collect the blood and advise prospective customers, they write. The logistics of collection must also be streamlined to minimise burden on staff.

The charitable intent and public provision may help overturn entrenched professional opposition to commercial banking, say the authors, but fears about risks of private sector involvement in cord blood banking remain high.

These need allaying through greater transparency, strict regulation of financial practices, and greater accountability to public sector bodies through an appropriate regulatory framework, they conclude.

Contacts:
Nicholas Fisk, Professor of Obstetrics and Fetal Medicine, Institute of Reproductive and Developmental Biology, Imperial College London, UK
Email: nfisk@uq.edu.au
Rifat Atun, Professor of International Health Management, Tanaka Business School, Imperial College London, UK
Email: r.atun@imperial.ac.uk

(3) New commissioning policy is neglecting patients, warn doctors
(Personal View: Do we neglect patients with multiple health problems?)
http://www.bmj.com/cgi/content/short/336/7645/670

The government's new healthcare commissioning policy for England has not only jeopardised the future of many hospitals but has also led to considerable frustration and disappointment among patients, argue senior doctors in this week's BMJ.

Under the new policy, primary care trusts or general practitioners directly commission specialised services and the trusts pay for the treatment of their patients in hospitals. The aim of such commissioning is to save huge sums of money by using hospital services as sparingly as possible.

But Rahij Anwar and colleagues believe that weaknesses in the referral system mean that their patients are not receiving appropriate care.

The worst affected patients, they explain, are those who have more than one condition at the same time because to primary care trusts these are very "expensive" patients, and therefore some of their problems might be "downplayed" to be managed in the community, and referrals to specialists are filtered.

Constant reminders to comply with trusts' policy in relation to clinic times and referrals also mean that patients are often sent back to their GPs if they have a new problem for which a referral has not yet been made.

The crux of the matter is that these patients could well have received better care had they been treated in the traditional system, where there were no "time bound appointments," "designated payment pots," and "referral politics," they argue.

Patients should be given sufficient time and opportunity to discuss their problems properly, so that the problems may be dealt with concurrently, not consecutively, they say. Hospital specialists should also be allowed to generate a fresh "episode of treatment" if a patient develops a condition related to the same specialty while he or she is waiting for an appointment.

This will not only significantly lessen the workload of general practitioners but would also help to reduce waiting times, paperwork, and inconvenience to patients.

Although we all are expected to use the meagre resources of the NHS wisely in these difficult times, we should not forget that our foremost duty is to safeguard the interests of our patients, they write.

We should continue to question all policies that adversely affect the care of patients, and we believe that "one way healthcare commissioning" is one such policy.

Contact:
Rahij Anwar, Specialist Registrar, London, UK
Email: rahijanwar@hotmail.com

(4) What should the Darzi review recommend?
(Editorial: Assessing the options available to Lord Darzi)
http://www.bmj.com/cgi/content/short/336/7645/625

As health minister Lord Darzi undertakes a major review of the NHS, an editorial in this week's BMJ assesses which options are most likely to produce an effective, efficient, and patient centred health service.

The review needs to strengthen primary care, writes Martin Roland, Director of the National Primary Care Research and Development Centre. The UK system of universal registration with a single general practitioner must be retained, even though patients may occasionally consult other practitioners, for example, a doctor near their workplace.

In terms of polyclinics, which provide a range of services under one roof, Roland believes that providing good premises and facilities in highly deprived areas could make a big difference to care. However, he points out that the NHS goal of increased patient choice requires more high quality practices, not the small number of large practices that some polyclinic models suggest.

Some models for polyclinics also include a greater role for specialists working in the community (bringing services "closer to home"), and government policies are already moving specialists out of hospitals and training primary care staff to take on new specialist roles. However, specialists may be less efficient when deployed outside hospitals, warns Roland.

Better support is also needed for patients with long term conditions, and several changes are necessary to improve continuity and coordination of care for patients with multiple conditions, he adds.

Vigorously pursued policies may deliver on their stated goals but have other unintended effects, he argues. For example, strategies designed to reduce waiting times to see general practitioners have made it more difficult for patients to book in advance.

He concludes: Now is the time to look at both the system and the patient as a whole. That is the challenge for the Darzi review.

Contact:
Martin Roland, Director, National Primary Care Research and Development Centre, University of Manchester, UK
Email: m.roland@manchester.ac.uk

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