David H. Wesorick, MD; Vineet Chopra, MD, MSc
Disclosures: Dr. Chopra reports grants from the Agency for Healthcare Research and Quality. Dr. Wesorick has disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1400.
The ACP formally opposes the legalization of physician-assisted suicide.
One editorial suggests that all physicians should firmly decline to participate in physician-assisted suicide, noting that it is simply not the duty of a physician. The author highlights uncertainties of the practice, including the identification of appropriate candidates and the challenges of creating reliable safeguards against misuse. He also argues that a patient's autonomy should not be considered absolute—indeed, physicians do not make decisions based solely on what patients want or request. Rather, medical decision making depends on the weighing of competing values, including the “intrinsic value of human life.”
Another editorial suggests that physicians should not adopt a stance of rigid opposition to physician-assisted death. The authors recognize that most of the public favors legalization of physician-assisted suicide, even though physicians and some professional organizations are divided on the issue. The authors also suggest that now is the time to carefully study physician-assisted suicide, to debate its ethical implications, and to improve related processes and safeguards that serve the patients who choose this “last resort” option.
A wealth of data about physician-assisted suicide is available from states and countries where the practice is legal, including Oregon. Analysis of these data can answer some important questions about the practice.
Most patients cited loss of autonomy or inability to participate in activities that make life enjoyable as reasons for seeking DWDA prescriptions. Financial concerns were not frequently reported as motivating the request.
Patients requesting DWDA prescriptions were only infrequently referred for psychiatric evaluations despite concerns that depression may be prevalent in this population.
The current health care environment may undermine the emphasis on diagnostic reasoning in internal medicine training by demanding efficiency and pressuring trainees to “test (or even treat) first, think later.”
Residents doing shiftwork are often unaware of the ultimate results of the diagnostic process they initiate and lack a clear feedback loop necessary to inform and refine diagnostic reasoning.
The authors suggest that internal medicine training programs should act deliberately to preserve the development of diagnostic reasoning in these trainees. Possible solutions might include a renewed focus on diagnostic reasoning during teaching rounds and training conferences and efforts to ensure that trainees receive feedback about the outcomes of the diagnostic evaluations they initiate. For a related discussion, see this month's Inpatient Notes by Gurpreet Dhaliwal, MD.
Clinicians should not screen for or treat asymptomatic bacteriuria, except in pregnant patients or those undergoing invasive urinary procedures that will induce mucosal bleeding (e.g., transurethral resection of the prostate).
Although UTI can be diagnosed clinically, urine culture should be done in patients in whom the diagnosis is uncertain, in pregnant women, and in men with suspected UTI. Urine culture is also indicated when pyelonephritis or complicated infection is suspected and in cases of relapse or treatment failure.
Antibiotic choice depends on the classification of the disease. Fluoroquinolones should not be used to treat uncomplicated cystitis based on safety and stewardship concerns but may be used to treat pyelonephritis and complicated infections (e.g., structural abnormalities of the urinary tract or immunocompromised host). Resistance is common in many areas.
Wesorick DH, Chopra V. Annals for Hospitalists - 17 October 2017. Ann Intern Med. 2017;167:HO1. doi: https://doi.org/10.7326/AFHO201710170
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Published: Ann Intern Med. 2017;167(8):HO1.
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