A recent study from the University of Chicago surveyed 729 medical oncologists on their practice of discussing prognosis with their terminally ill cancer patients (J Clin Oncol 2008 Nov 24, epub). Although 98% of them said they would tell these patients that they will die, 48% of them would only discuss prognosis if the patient brought up the topic. When asked if they routinely communicated an estimate of time as to when death is likely to occur, 43% said they always or usually communicate but 57% said sometimes, rarely or never, when asked by their patients for the time frame. When asked about their training in prognosis communication skills, 73% of the respondents replied that they had no or inadequate training.

Effective communication is an important skill to have in all walks of life. For the doctor, delivering good news is all too easy because the reaction from the patient and relatives is always positive. There are no awkward moments and everyone feels good about it. However, when bad news is delivered, the uncertainty of how the patient and relatives will react to the news can make the doctor feel uneasy. Some may not know how best to handle the situation, especially if they have not been formally taught in medical school.

Discussing prognosis and time frame with the patient is important. This gives the patient time to settle his / her affairs with loved ones and colleagues. It allows them to plan on what they want to accomplish or do in the remaining days. In certain circumstances, the doctor can play a meaningful role by tempering the over ambitious expectations of the patient and relatives in terms of what they can achieve in the time remaining. The doctor can help in prioritizing what to do.

Doctors, like patients, are humans. The prognostication is based on statistics. Hence, when the doctor says 6 months, it is not cast in stone. A patient and his / her relatives must realize that it can be shorter or longer than 6 months. Multiple factors, such as the general starting condition of the patient, nutritional status after the diagnosis, the patient’s frame of mind and response to palliative treatment modalities all play a role in determining the time frame.

I believe in discussing time frame with my patients. However, I always emphasise to my patients that this does not mean they should give up and sit there waiting for the fateful day. While both the patient and I must be realistic in our expectations, we should still try to live and enjoy those days as full and as best we can. The doctor’s roles are to guide the patient in choosing the right management plan for him / her, to ameliorate symptoms and thus improve the quality of life, to offer a sympathetic ear at times of distress and despair and when all has failed, to let the patient know that you are still there.

Treating a patient with terminal illness is like setting out on a journey together. Sometimes you do things and someitmes you just walk in silence. You only leave when your patient asks you to or you have reached the end of the road with your pateint. The journey can be longer or shorter but it does not matter. We should try to make it a smooth journey with a sprinkle of hope.

With changing life styles, more and more individuals are complaining that they need more than 24 hours in a day to accomplish their daily needs - work, play and sleep, in that order! Consequently, sleep bears the brunt of the shortage of time and people end up sleeping less. So, apart from feeling a bit tired does sleeping less really matter?

A report from the University of Pittsburgh examined the relationship between sleep duration and the presence of the metabolic syndrome in 1214 individuals, aged 30 – 54 years, who participated in the University of Pittsburgh’s Adult Health and Behavior (AHAB) registry (Sleep 2008; 31: 635 – 643). There were 4 groups of participants based on sleep duration: < 6 hours (= very short sleepers), 6 – 6.99 hours (= short sleepers), 7 – 8 hours (reference group) and > 8 hours (= long sleepers).  Metabolic syndrome was defined according to the American Heart Association / National Heart Lung and Blood Institute’s (AHA/NHLBI) criteria as the presence of 3 or more of the following: (1) waist circumference > 102 cm in men or > 88 cm in women; (2) fasting serum glucose of ≥ 100 mg / dL or use of oral hypoglycaemic medication; (3) blood pressure of 130 mm Hg systolic, 85 mm Hg diastolic or higher or use of antihypertensive medication; (4) serum triglycerides of ≥ 150 mg /dL or use of hypertriglyceridaemia medication; (5) high-density lipoprotein (HDL) cholesterol of < 40mg / dL in men or < 50 mg / dL in women or use of medication for low HDL cholesterol. Twenty percent of the population was ‘very short sleepers’ and only 8% was ‘long sleepers’. When compared to the reference group, the odds of having the metabolic syndrome in short sleepers and long sleepers were increased between 48 – 83%.

A study from  Korea University looked at 4222 participants in the 2001 Korean National Health and Nutrition Survey and evaluated the relationship between sleep duration and metabolic syndrome [Int J Obes (Lond) 2008; 32: 1091 -1 1097]. The average amount of sleep per night, in hours, was categorized as ≤ 5, 6, 7, 8 and ≥ 9. Those who slept 7 hours per night had the lowest prevalence for metabolic syndrome. Individuals who slept ≤ 5 hours per night had the highest risk for metabolic syndrome, a 74% increased risk. Equally, those who slept ≥ 9 hours per night also exhibited an increased risk for metabolic syndrome. The prevalence of abdominal obesity and hypertension was highest in those who slept ≤ 5 hours per night while the prevalence of hyperglycaemia and hypertriglyceridaemia was highest in those who slept ≥ 9 hours per night.

Researchers from Japan and USA studied the impact of short sleep duration on incident cardiovascular disease (CVD; CVD events include stroke, fatal and non-fatal heart attacks and sudden cardiac deaths) and its possible interaction with nocturnal blood pressure (BP) in 1255 Japanese men and women with a mean age of 70.4 years (Arch Intern Med 2008; 168: 2225 – 2231). Short sleep duration was defined as < 7.5 hours. If the mean night time systolic BP exceeded the day time systolic BP, the individual would be classified as having a riser pattern of BP. Short sleep duration was found to be associated with a 68% increased risk of incident CVD. On comparing individuals with short sleep duration plus a riser pattern of BP to individuals with normal sleep duration plus a non-riser pattern, the risk of incident CVD is increased 4.43 times in those with short sleep duration plus a riser pattern.

Whenever I meet a patient who gives a history of loss of energy and tiredness, I invariably find that they have been burning the candle from both ends – staying awake longer in order to do more! In these cases, you really do not need to see a doctor; what you really need is to listen to your body. Your body is just like a motorcar, abuse it and it will break down quicker, look after it and it will merrily chug along for years.