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FOR THE PRESS

Annals of Internal Medicine Tip Sheet
September 19, 2017


Below is information about articles being published in Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.


1. First, do no harm: ACP reaffirms opposition to legalization of physician-assisted suicide

Abstract: http://annals.org/aim/article/doi/10.7326/M17-0938
Editorial: http://annals.org/aim/article/doi/10.7326/M17-2160
Editorial: http://annals.org/aim/article/doi/10.7326/M17-2072
Related Review: http://annals.org/aim/article/doi/10.7326/M17-2300

The American College of Physicians (ACP) is reaffirming its opposition to the legalization of physician-assisted suicide and affirming a professional responsibility to improve the care of dying patients. ACP cites ethical arguments and clinical, policy, legal, and other concerns for its positions. ACP’s updated position paper, “Ethics and the Legalization of Physician-Assisted Suicide,” is published in Annals of Internal Medicine, along with two editorials and a related review article.

Despite arguments by proponents, ACP finds ethical and other arguments against physician-assisted suicide to be the most compelling, including that physician-assisted suicide alters the physician’s role as healer and comforter and the medical profession’s role in society, and it affects trust in the patient-physician relationship and the profession. ACP asserts that the focus at the end of life should be on efforts to prevent or ease suffering and on the often unaddressed needs of patients and families. A recent study found 90 percent of US adults do not know what palliative care is; but when told its definition, more than 90 percent said they would want it for themselves or family members if severely ill. ACP stresses the need to improve hospice and palliative care, including awareness and access.

As noted in the paper, medical ethics and the law strongly support a patient’s right to refuse treatment, including life-sustaining treatment. The intent is to avoid or withdraw treatment judged by the patient as unduly burdensome and inconsistent with her health goals and preferences. Death follows naturally after the refusal due to underlying disease. Vigorous management of pain and symptoms such as nausea at the end of life is ethical, even when the risk of shortening life is foreseeable, if the intent is to relieve those symptoms.

ACP advises physicians to thoroughly discuss patient concerns and reasons for requests for physician-assisted suicide. The paper has a list of 12 steps that physicians should follow with all patients nearing the end of life. Requests for physician-assisted suicide are unlikely to persist when compassionate supportive care is provided, ACP says in the paper.

Expert commentary: Exploring both sides of the issue

ACP’s position paper is published along with two editorials looking at both sides of this issue. In “Physician-assisted Suicide: Finding a Path Forward in a Changing Legal Environment,” lead author Timothy E Quill, MD of the University of Rochester Medical Center, expresses support for the steps outlined in the ACP position paper, but writes that ACP’s rigid opposition to physician-assisted suicide could be a missed opportunity to educate clinicians and learn about best practices for terminally ill patients who are suffering. He and his co-authors believe that if requests persist and the unacceptable suffering continues, all legally available last-resort options should be explored.

In the second commentary, “The Slippery Slope of Legalization of Physician-Assisted Suicide,” William G. Kussmaul III, MD gives ACP credit for its clarity and courage regarding physician-assisted suicide. Dr. Kussmaul takes a strong stance against the practice, writing that legalization is a “slippery slope” that could lead to abuse, as has been seen in the Netherlands.

Historical perspective: Oregon’s Death with Dignity Act

In a related review, lead author Katrina Hedberg, MD, MPH of the Oregon Public Health Division, discusses Oregon’s Death with Dignity Act, which was the first to allow physicians to prescribe medications to be self-administered by terminally ill patients to hasten their death. The review summarizes the types and number of patients and providers that have participated in physician-assisted suicide in the 20 years since the Act was passed. The authors found that participation is low compared to all Oregon deaths, and that most participants had at least some college education, which should assuage concerns about patients being uneducated or poor. The authors also found several processes in place to protect patients from abuse.

2. Sudden death and cardiac arrest during triathlon are not rare; men over 40 at highest risk

Abstract: http://annals.org/aim/article/doi/10.7326/M17-0847
Editorial:
http://annals.org/aim/article/doi/10.7326/M17-2031

A survey of more than 9 million triathletes over 30 years found that sudden death, cardiac arrest, and trauma-related death during triathlon are not rare, and occurred most often during the swim segment, which typically occurs in the early portion of the race. The risk associated with participation in a single triathlon was found to exceed the expected annual risk for sudden death for a middle-aged person in the general population, and also exceeds previous estimates for long-distance running races, including marathon. The findings are published in Annals of Internal Medicine.

Since its origin in the 1970s, the triathlon has become an increasingly popular endurance activity worldwide. According to data from USA Triathlon, more than 3,200 sanctioned adult events involving more than 460,000 participants took place in 2015. However, over the years, the number of race-related fatalities has generated concern regarding athlete safety.

A team of investigators led by researchers at Minneapolis Heart Institute Foundation at Abbott Northwester Hospital studied incidences of sudden death and cardiac arrest during triathlon to define the public health implications of the competition more completely. They found that deaths and cardiac arrests during the triathlon affected 135 athletes, with an incidence of 1.74 per 100,000, which is higher than earlier estimates and exceeding the incidence reported for marathon racing. These events have most often occurred in middle-aged and older men, and death usually occurs during the swim segment of the competition. Autopsy data showed that clinically silent cardiovascular disease was present in an unexpected proportion of decedents, suggesting a need for participants to know their risk before racing. The incidence of cardiovascular events was strikingly lower in female triathletes, 3.5-fold less than in men.

Practical strategies to reduce the risks of triathlon competition largely focus on improving event organization. Future efforts to reduce the number of swim-related fatalities should focus on targeted, robust, coordinated, and practiced safety responses to identify distressed participants promptly. Participants themselves should be aware of the risks and should be adequately trained for the event. They also should be aware of their risk and of possible symptoms of underlying cardiovascular disease.

The author of an accompanying editorial from Thomas Jefferson University Hospital in Philadelphia writes that the findings are an important step toward understanding the causes of death during triathlons. The author also explores some of the reasons why the swim portion of the event may be particularly risky.

3. Gun laws that require domestic abusers to surrender firearms could save lives

Abstract: http://annals.org/aim/article/doi/10.7326/M16-2849

State laws that restrict firearm possession by persons deemed to be at risk for perpetrating intimate partner violence (IPV) may save lives. Laws requiring at-risk persons to surrender firearms already in their possession were associated with lower intimate partner homicide (IPH) rates. The findings are published in Annals of Internal Medicine.

Every year, more than 1,800 persons in the United States are killed by their intimate partners. About half of those homicides are committed with firearms and most (85 percent) of the victims are women. Among many laws enacted in the United States to reduce IPH, the 1994 Violence Against Women Act barred firearm possession by persons subject to permanent IPV-related restraining orders. However, due to a glaring loophole called the “relinquishment gap,” offenders who already had guns in their possession were not required to actually surrender them. Recently, some states have taken steps to enforce their gun restrictions by going beyond federal law. Few studies have assessed the effect of these policies.

A team of investigators led by Boston University School of Public Health and funded by Robert Wood Johnson Foundation sought to determine the association between state IPV-related firearm laws and IPH rates between 1991 and 2015. Using data from the Federal Bureau of Investigation’s Uniform Crime Reports, Supplementary Homicide Reports, the researchers assess homicides committed by intimate partners during the 25-year timeframe. They found that when state laws that prohibit persons subject to IPV-related restraining orders from possessing firearms also required them to relinquish firearms in their possession, IPH rates dropped by 9.7 percent and firearm-specific IPH rates dropped by 14.0 percent compared to states without these laws.

Also in this issue:

Blast Injuries and Cardiopulmonary Symptoms in U.S. Veterans: Analysis of a National Registry

Nisha Jani, MPH; Michael J. Falvo, PhD; Anays Sotolongo, MD; Omowunmi Y. Osinubi, MD, MSc, MBA; Chin-lin Tseng, DrPH
Brief Research Report
Abstract: http://annals.org/aim/article/doi/10.7326/M17-0711

Reimagining Halfway Technologies With Behavioral Science

David A. Asch, MD, MBA, and Kevin G. Volpp, MD, PhD
Ideas and Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M17-1449

Your Money or Your Patient's Life? Ransomware and Electronic Health Records

I. Glenn Cohen, JD; Sharona Hoffman, JD, LLM, SJD; and Eli Y. Adashi, MD, MS
Ideas and Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M17-1312

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