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July 16, 2013 Issue

Clinical Practice Points

Alternate-Day, Low-Dose Aspirin and Cancer Risk: Long-Term Observational Follow-up of a Randomized Trial

This observational follow-up of the Women’s Health Study found that long-term use of alternate-day, low-dose (100-mg) aspirin was associated with reduced risk for colorectal cancer; increased risk for gastrointestinal bleeding and peptic ulcers; and no association with risk for total, breast, or lung cancer.

Use this study to:

  • Ask your residents if they think they should recommend aspirin to prevent colorectal cancer. The study authors address this question in the last paragraph of the paper.
  • Ask how self-report of gastrointestinal side effects might have affected the results? How about the lack of extended follow-up for some study participants?

Effect of Electronic Health Records on Health Care Costs: Longitudinal Comparative Evidence From Community Practices

Although electronic health records (EHRs) have been hypothesized to lower health care costs, evidence to support this is lacking. This analysis of EHR implementation by 806 ambulatory care clinicians in 3 Massachusetts communities did not identify statistically significant cost savings but suggests that EHRs may slow the increase in costs in community-based practices.

Use this study to:

  • Discuss the ways in which EHRs might be expected to lower health care costs.
  • Which ones are savings to a health care provider (e.g., dictation costs) and which ones are savings to society (e.g., fewer tests)? In what ways do EHRs generate income for a provider? Do these interests conflict?
  • Do your residents think EHRs are a good thing? How do they know?

Update in Hospital Medicine: Evidence Published in 2012

These concise summaries address studies of perioperative myocardial infarction, transfusion thresholds, the relationship between length of stay and readmissions, leaving against medical advice, and more.

Use this review to:

  • Identify good teaching "pearls" for use on the medical consult service. There are several you could use, for example, when seeing pre- or perioperative consults.
  • Plan a series of subspecialty reviews to quickly cover a few important papers from each subspecialty. We’ve collected the reviews for you.

ACP Journal Club

This monthly feature provides expert reviews and critiques of recent articles published in any of hundreds of journals, each article chosen for its clinical importance.

Use this feature to:

  • Identify a good paper for discussion at a journal club. The authors of each summary help with critiques of the methods and the results’ meaning.
  • Encourage your residents to sign up for ACP JournalWise—where they can personalize alerts of reviewed articles according to their interest.

Humanism and Professionalism

On Not Being Her Doctor

Read, or play an audio recording of, this issue’s On Being a Doctor. In this powerful essay, our colleague, Dr. Bascom Migeon, describes her feelings in honoring her patient’s request for assistance in dying.

Use this essay to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Ask your residents if they would assist a patient to die if requested.
  • Ask what the "double effect" is in reference to the potential side effect of palliative sedation in hastening death. The concept is reviewed in a recent In the Clinic on Palliative Care. Download the teaching slide that accompanies Table 3 and discuss the legal and ethical differences among withholding and withdrawing life-sustaining treatment, palliative sedation, physician-assisted suicide, and euthanasia.
  • Earn CME for yourself—you’ve gone through the In the Clinic on Palliative Care, so take a minute and answer the CME questions.

mksap16

A 54-year-old man is evaluated for a long-standing history of COPD. Although he had previously done well, his lung function has progressively declined over the past year. He is oxygen dependent and is unable to perform even minor physical activity without severe dyspnea. He is not a transplant candidate and is unhappy with his quality of life and prognosis. He requests a prescription that he can take that will cause him to die at the time of his choosing.

Which of the following is the most appropriate next step in management of this patient's request?

A. Assess the adequacy of his current treatment
B. Consult legal counsel about state law in such cases
C. Decline the request
D. Prescribe sedating medication that could ensure a comfortable death

Answer: A. Assess the adequacy of his current treatment

Key Point: When approached with a request for assistance in dying, it is best to respond to the request with empathy and compassion, and assess whether or not the patient is receiving adequate palliative care.

Educational Objective: Manage a request for physician-assisted suicide.

When approached with a request for assistance in dying, it is best to respond to the request with empathy and compassion, and assess whether or not the patient is receiving adequate palliative interventions. Optimizing care interventions focused on maintaining or improving the quality of life may not always occur in the context of treating the underlying disease process; thus, reviewing the patient's overall care to address comfort and functional issues in severe illness is essential to appropriate management. Involving physicians trained specifically in palliative care medicine may also be helpful in such situations.

Physician-assisted suicide is a controversial area of ethics. Most ethicists agree that it is acceptable to consider interventions that may hasten the death of a terminally ill patient if the primary intent is therapeutic (the principle of "double effect"). However, physician-assisted suicide using prescriptions or interventions with the specific intent to kill the patient is illegal in most states. The American Medical Association and the American College of Physicians have both taken positions against the practice.

Seeking legal counsel may be advisable if one intends to provide the patient assistance in dying, as states in which it is legal have specific protocols that must be followed. However, this step would not be appropriate until alternatives such as improved palliative care were assessed. Categorically refusing to discuss a request for physician-assisted suicide can close the door to a discussion of why the patient is making the request and may jeopardize the therapeutic relationship with the patient.

Writing a prescription for medication to assist a patient in dying without a detailed assessment of the patient's situation and motives would be irresponsible.

Bibliography
Snyder L, Sulmasy DP; Ethics and Human Rights Committee, American College of Physicians-American Society of Internal Medicine. Physician-assisted suicide. Ann Intern Med. 2001;135(3):209-216.

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Erin Ney, MD, FACP Assistant Residency Program Director, Department of Internal Medicine, Thomas Jefferson University.

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