Biometric Measures of Pain and Self Reporting of Side Effects

A few days ago, I blogged about the dificulty of self-reporting side effects.  The AP has just run a story on how it may be becoming possible to measure pain bio-metrically.

The National Institutes of Health is pushing for development of what its director, Dr. Francis Collins, has called a “pain-o-meter.” Spurred by the opioid crisis , the goal isn’t just to signal how much pain someone’s in. It’s also to determine what kind it is and what drug might be the most effective.

“We’re not creating a lie detector for pain,” stressed David Thomas of NIH’s National Institute on Drug Abuse, who oversees the research. “We do not want to lose the patient voice.”

Around the country, NIH-funded scientists have begun studies of brain scans, pupil reactions and other possible markers of pain in hopes of finally “seeing” the ouch so they can better treat it. It’s early-stage research, and it’s not clear how soon any of the attempts might pan out.

“There won’t be a single signature of pain,” Thomas predicted. “My vision is that someday we’ll pull these different metrics together for something of a fingerprint of pain.”

Obviously, there is still huge amounts to be leaned not only about the measures, but critically their relationship to how we as patients actually experience them.  I was very encouraged to see the quote from David Thomas “We’re not creating a lie detector for pain.  We do not want to lose the patient voice.

Obviously, this will require full involvement from patients in the research design, as well as making sure that those who are trained to use the new measures are fully informed of the relationship of patient experience to the numbers.  Its not hard getting researchers to understand, but less clear that harried caregivers will not be attracted to shortcuts.  In fact, quite apart from research into the reliability of the numbers, we will need research into what happens in the field –“first do no harm.”  I see this new ata ass potentially strengthening the patient partnerhsip, not weakening.

As some who has sat as a patient voice on numerous health care working groups, I have complete trust in the intent of the professional participants, but I have also seen how powerful that unified professional voice can be, unless we understand the full dynamics.

I hope that my caution does not undercut what I see as very good news here.

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More on Identifying Side Effects

Yesterday, I blogged about how hard it can be for patients with co-morbidities to accurately report on side effects.Imuch appreciate the suggestions and ideas I got in response.

Here are some more ways to think about solving this problem:

Keeping a journal over time

Developing a neurological scan that shows nerve responses in real time

Developing brain scans and algorithms to identify side effect-related brain activity

Using medical staff with co-morbidities to do the side effects interviews

Asking families what patterns they are seeing

Including sensitivity to these issues in medical training and rounding

More suggestions and comments always welcome

 

On Identifying Side Effects for Patients with Co-Morbidities

As a patient with lots going wrong, I have found that when I try to answer a question about side effects from a new drug, I often get confused.  I think the reason is I already have so many of the side effects that appear on every drug list, that is it hard to calibrate an increase in side effects.

I suspect that treatment decisions have therefore been made for me based on what are really guesses on my part.  Its good to have my self-reporting taken seriously, but maybe I need some training on listening to my body better.

Remember that most providers are healthy, so that are not used to getting the constant alert messages that us perpetual patients are.  They have not developed the suppression and filtering tools that we have.

So, the question is what can we do?

Maybe patients should be trained in mindfulness on this.

Maybe we should test whether patients under hypnosis report more accurately on side effects.

Maybe providers should talk about this, and develop training protocols.

Maybe our research protocols should be improved to be sensitive to these issues.

Obviously, the last think I want is for providers to ignore patients, but true partnering requires careful listening.  Thanks to all those who listen to me with care and respect.

 

The Gut Feeling, Medical Intervention, and Partnering

A fascinating article in the New York Times about nurses’
“gut feelings,”makes the argument that:

Every nurse likely knows the feeling. The patient’s vital signs are just a little off, she seems not quite herself, her breathing is slightly more labored. But on paper she looks stable, so it’s hard to get a doctor to listen, much less act.

In such situations nurses invoke “gut feelings,” but they actually aren’t feelings at all — they are agglomerations of observations and experiences that over time have turned into finely tuned clinical judgment. The idea is that working at the bedside has honed nurses’ perceptions to be especially alert to brewing trouble.

The article goes on to describe software that aggregates data to help predict problems and support the intuitions described above:

Together the Rothman brothers came up with the Rothman Index, a commercial product that uses data from standard electronic health records — including lab values, vital signs, cardiac rhythms and key aspects of nursing assessments — to monitor hospital patients. It tracks their status as a graph that falls into a blue, yellow or red zone, based on whether they are at low, medium or high risk of an acute event.

While this sounds like a great idea, lets not also lose touch with the value of the intuition — and extend the exploration and valuing to family members and indeed the patient themselves.  I suspect that we could “train” patients and families to be much more mindful about patient monitoring, including how to trust their instincts and how to communicate their feelings to the medical personal.  This, of course, should be accompanied by training of medical staff on how to take the most advantage of, and how to solicit such communications.  It is not hard to construct model ways of doing so.

I suspect that just like the nurse who wrote the article felt badly about a situation in which they had failed to communicate their instincts about a patients decline, many family members worry for the rest of their lives that if they had shared their own intuitions, there might have been a better outcome.  (Actually, that’s not a hard question to survey — self-reporting would be meaningful in itself.)

 

 

 

Advance Directives Look Completely Different to Patients and Treatment Actors – So Partner in the Design

I have come to realize that patients and actual treatment providers may be thinking very differently about advance directives, and that therefore it is particularly critical that these documents — or rather the templates that are used, be designed in close partnership. between patients and providers

For the providers, the question they face is usually very treatment specific — typically something like: “do I turn off this machine now?”

For patients, the issue presents very differently focused on particular anticipated circumstances: “what do I want done when I can not eat?”

So, look, for example,  at this question from the Maryland MOLST document.

molst

While some of us may think this second way, I think most of us come at it rather from the direction of, “what do I do when then the pain becomes too much?”, or “how do I guarantee that I am not left unable to say that enough is enough?”

I totally understand that given that the role of the MOLST is to ensure that specific decisions are made in accordance with the patient wishes, that often those decisions are made under time and emotional pressure by first responders with limited training, such treatment specific instructions are needed.  Otherwise treatment will tend to continue, regardless of what the patient wants.

But, if you have ever tried filling out the MOLST, or I suspect equivalent documents in other states, you will find that you are constantly fighting its categories, and wanting to add more and more detail, when allowed.

Given these differences in perspective between patients and providers, let me suggest that we need software that walks a patient though questions, and based on those answers, generates the directive.

However, the questions must be structured the way the patient thinks, laying out circumstances, and offering choices.  The software then restructures those into a set of formal directions that are treatment specific, like in the MOLST. Obviously then the patient reads and signs thee derived directives document.

I hope it is obvious that such software needs, and accompanying materials, need to be developed in close partnership between providers and patients.

 

 

 

 

Nyt article on “Not The Good Death We Were Promised”

A wonderful piece in the New York Times, under above heading, draws timely attention to the inadequacies of the current delivery of hospice service.

When a doctor said my father had about six months to live, I invited a hospice representative to my parents’ kitchen table. She went over their Medicare-funded services, including weekly check-ins from a nurse and 24/7 emergency oversight by a doctor. Most comfortingly, she told us if a final “crisis” came, such as severe pain or agitation, a registered nurse would stay in his room around the clock to treat him.

But:

But at the very end, confronted by a sudden deterioration in my father’s condition, hospice did not fulfill its promise to my family — not for lack of good intentions but for lack of staff and foresight.

At 7 p.m. on the night before my father’s last day of life, his abdominal pain spiked. Since his nurse turned off her phone at 5, I called the hospice switchboard. To my surprise, no doctor was available, and it took the receptionist an hour to reach a nurse by phone. She told us we should double his dose of oxycodone, but that made no difference. We needed a house call.

The only on-call nurse was helping another family two hours away. So my sister and I experimented with Ativan and more oxycodone, then fumbled through administering a dose of morphine that my mother found in a cabinet, left over from a past hospital visit. That was lucky, because when the nurse arrived at midnight, she brought no painkillers.

After the nurse left, my father’s pain broke through the morphine. I called the switchboard again, and it took three hours for a new nurse to come. She was surprised he hadn’t been set up with a pump for a more effective painkiller. She agreed that this constituted a crisis and should trigger the promised round-the-clock care. She made a phone call and told us the crisis nurse would arrive by 8 a.m.

 

The nurse did not come at 8 a.m. Or 9 a.m. When his case worker was back on duty, she told us — apologetically — that the nurse on that shift had come down with strep throat. Her supervisor stopped by, showed us the proper way to deliver morphine (we’d been doing it wrong) and told us a pain pump and a crisis nurse should arrive by noon.

Noon passed, then 1 p.m., 2 p.m. No nurse, no pump.

By this time, my father had slipped into a coma without our noticing; we were thankful his pain was over but heartbroken he wouldn’t hear our goodbyes. Finally, at 4 p.m., the nurse arrived — a kind, energetic woman from Poland. But there was little left to do. My father died an hour later.

The thought terrifies all of us facing end of life.  I still believe that such an end is utterly unnecessary, and that it occurs points to multiple failures in the system.  And, this is even scarier:

Kaiser Health News discovered there had been 3,200 complaints against hospice agencies across the country in the past five years. Few led to any recourse. In a Medicare-sponsored survey, fewer than 80 percent of people reported “getting timely care” from hospice providers, and only 75 percent reported “getting help for symptoms.”

Without getting into the specifics of pain relief, or the complex incentives in the capitation payment system, let me suggest that the earlier the partnering team discusses all the options, and the more patient, family, and team, make affirmative choices between hospices, based in part on this government data, on whether certain steps were followed, the pressures for quality to increase.  I would go further and say that any hospice for which this data is not available, for whatever reason, is just off the list.

There were also some great letters in response to the article.

 

 

Using Tools Like Election Prediction Visualizations to Empower Patient Discussions

On a great day last week, one little bit of good news, the icing on the cake, was the New York Times Election Needle, a visual display that showed not only the most likely outcome, but the confidence level in the outcome.

needle

Imagine a medical staffer being able to discuss a similar graphic showing anticipated outcomes for no treatment, for particular treatments, etc., and the confidence level shown being of an appropriate measure of certainty.

The point is that this display of data is the beginning of the discussion, not the end.  Right now the discussion is largely non-statistical, often adding to the fear.  Remember too, that more and more people are acquiring the confidence to talk about numbers in this way, if on by reading the ever more popular fivethirtyeight.com..

To do this would require aggregation of outcome and treatment data — insurance companies already get most of this, its just a political problem of organizing it, and he obvious place to start is Medicare.

 

p.s. On twitter, one reader became so ense watching the changes update, that they tweeted that on their gravestone, it should read:  “He’s here because of the New York Times election needle.”