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The Big Chill — Inserting the DEA into End-of-Life Care
Abstract
In October, the U.S. Supreme Court heard arguments in Gonzales v. Oregon. Drs. Timothy Quill and Diane Meier write that beneath the surface of this case lies the risk of empowering agents of the Drug Enforcement Agency to evaluate the end-of-life practices of physicians whose patients die while receiving prescribed opioids or barbiturates.
... If practitioners' diagnosis of "addiction" is based solely on the presence of physical dependence (as evidenced by withdrawal when the patient ceases opioid use), they will significantly overestimate the incidence of addiction when patients are treated with opioids. Physicians also are worried that their controlled substances prescribing practices will be investigated by state licensing boards, the U.S. Drug Enforcement Administration (DEA), or even by law enforcement [19][20][21][22]. Such misperceptions can contribute to decreased prescribing and inadequate treatment of pain, especially when a patient's pain is severe and requires Schedule II opioids (e.g., fentanyl, morphine, and oxycodone) [23]. ...
Opioid analgesics are the drugs of choice for the treatment of moderate to severe acute and cancer pain. Although their role in the management of chronic pain not related to cancer is controversial, there is increasing evidence for their benefit in certain patient populations.
A 32-item survey to assess Wisconsin physicians' knowledge, beliefs, and attitudes toward opioid analgesic use was mailed to 600 randomly selected licensed physicians, resulting in a 36% response rate.
Half of the respondents considered diversion a moderate or severe problem in Wisconsin. A majority considered addiction to be a combination of physiological and behavioral characteristics, rather than defining it solely as a behavioral syndrome. Most physicians felt it lawful and acceptable medical practice to prescribe opioids for chronic cancer pain, but only half held this view if the pain was not related to cancer. Fewer physicians considered such prescribing as lawful and generally accepted medical practice if the patient had a history of substance abuse. About two-thirds of physicians were not concerned about being investigated for their opioid prescribing practices, but some admitted that fear of investigation led them to lower the dose prescribed, limit the number of refills, or prescribe a Schedule III or IV rather than a Schedule II opioid.
Wisconsin physicians who responded to this survey held many misconceptions about the prescribing of opioids. Such views, coupled with a lack of knowledge about laws and regulations governing the prescribing of controlled substances, may result in inadequate prescribing of opioids with resultant inadequate management of pain.
... Furthermore, public policies that emphasize an overaggressive enforcement in combating the diversion of licit drugs for illicit purposes without sensitivity to patient needs hamper effective pain management because practitioners alter their prescribing patterns (Edmondson, 2006). Quill and Meier (2006) specifically argued that when federal and state policies either support or do not limit an expanded role for the Drug Enforcement Agency (DEA) to scrutinize physician practice patterns, they emit a ''chilling effect'' on clinicians' willingness to adequately treat patients' terminal symptoms. Indeed, physicians have reported that they limit pain prescriptions out of fear of regulatory scrutiny (Joranson, Gilson, Dahl, & Haddox, 2002). ...
On average, adults aged 60 years or older have 2.2 chronic diseases, contributing to the over 60 million Americans with multiple morbidities. We aimed to understand the financial implications of the most frequent multiple morbidities among older adults.
We analyzed Health and Retirement Study data, determining out-of-pocket medical expenses from 1998 and 2002 separately and examining differences in the impact of multiple-morbidity constellations on these expenses. We paid particular attention to the most common disease constellations - hypertension, arthritis, and heart disease.
An increasing prevalence of multiple morbidity (58% compared with 70% of adults had two or more chronic conditions in 1998 and 2002, respectively) was accompanied by escalating out-of-pocket expenditures (2,164 dollars in 1998, increasing by 104% to 3,748 dollars in 2002). Individuals with two, three, and four chronic conditions had health care expenditure increases of 41%, 85%, and 100%, respectively, over 4 years. Such patterns were particularly noticeable among the oldest old, those with higher educational attainment, and women, although having supplementary health insurance or Medicaid mitigated these expenses. Finally, there were significant differences in out-of-pocket expenditure levels among the multiple-morbidity combinations.
Increasing rates of multiple morbidities in conjunction with escalating health care costs and stable or declining incomes among elders warrant creative attention from providers, researchers, and policy makers. Further understanding how specific multiple-morbidity constellations impact out-of-pocket spending moves us closer to effective interventions to support vulnerable elders.
... Furthermore, public policies that emphasize an overaggressive enforcement in combating the diversion of licit drugs for illicit purposes without sensitivity to patient needs hamper effective pain management because practitioners alter their prescribing patterns (Edmondson, 2006). Quill and Meier (2006) specifically argued that when federal and state policies either support or do not limit an expanded role for the Drug Enforcement Agency (DEA) to scrutinize physician practice patterns, they emit a "chilling effect" on clinicians' willingness to adequately treat patients' terminal symptoms. Indeed, physicians have reported that they limit pain prescriptions out of fear of regulatory scrutiny (Joranson, Gilson, Dahl, & Haddox, 2002). ...
The continued undertreatment of pain at the end of life is a substantive public health problem that has not been resolved through increased public awareness, the issuance of clinical guidance for providers, or expanded organizational commitments. In this forum, we illuminate the role of public policies in promoting pain management. We review federal and state policies and consider empirical evaluations that compared the quality of state policies and the factors that contributed to their formation. We resolve that any organized interest in improving end-of-life care should begin by focusing on the development and expansion of those state policies that support the provision of evidence-based medicine for reducing the amount of pain an individual experiences at the end of life. Although empirical research is needed to determine which particular aspects of state pain policy are most critical and how these policies can be implemented most effectively, any organized effort that advances state medical board activity or another state policy would appear to be making an important step toward making the pain at the end of life go away.
... urteilung nach wie vor einer moralisierenden Wertung -ein Grund dafür ist, dass Abhängigkeit häufig noch immer selbstverschuldet betrachtet wird. Wohin eine politische Entscheidungsfindung aus Uninformiertheit und ideologisch begründeten Ängsten vor Opioiden führt, sieht man seit kurzem am Beispiel USA, wo chronischen SchmerzpatientInnen und Krebskranken eine effiziente Schmerztherapie erschwert wird (Quill & Meier 2006). ...
Wie sich gleichermaßen die pharmakologischen Therapieansätze in sämtlichen Sparten der Medizin verbreitern und verbessern,
hat sich auch die psychopharmakologische Behandlung in der psychiatrischen Erkrankung der Substanzabhängigkeit von Morphinen im letzten Jahrzehnt diversifiziert. Methadon galt seit den späten 80er Jahren als Golden-Standard in der Therapie der Opioidabhängigkeit,
wobei Österreich eines der ersten europäischen Länder war, das diese Behandlung ermöglichte. Nicht zuletzt der frühzeitigen
Einführung von Methadon ist es zu verdanken, dass Österreich eine relativ geringe HIV-Prävalenz in der intravenös heroinapplizierenden
Population aufzuweisen hat. Neue Erkenntnisse der Wissenschaft haben in den letzten Jahren neuere Substanzen vorgestellt,
wobei es an erster Stelle Buprenorphin zu nennen gilt, ein Opioid mit einer gemischten Opioidrezeptoraffinität. Buprenorphin
hat in zahlreichen Vergleichsstudien ein ähnliches Ergebnis hinsichtlich Retentionsrate, Reduzierung des Zusatzkonsumes und
dem Sicherheits- und Effektivitätsprofil wie Methadon erreicht – für beide Medikamente sind natürlich die Erfolge dosierungsabhängig,
wobei höhere Dosierungen bessere Langzeiterfolge erzielen. In einigen europäischen Ländern wird auch die Therapie mit oralen
retardierten Morphinen ermöglicht, zudem ist in wenigen Ländern die kontrollierte medizinische Verordnung von Heroin durchführbar.
Als Langzeitziel gilt nach wie vor eine Medikamentenfreiheit, auch von verschriebenen Opioidagonisten, allerdings hat sich
die wissenschaftliche State-of-the-Art Therapie in Richtung einer Langzeiterhaltungstherapie mit begleitender Psychoedukation
etabliert. Besteht eine Freiheit von Zusatzkonsum von anderen nicht verschriebenen Substanzen (sei es legal oder illegal)
in einer überschaubaren Behandlungsepisode, die über mehrere Jahre bzw. Jahrzehnte andauern kann, kann eine schrittweise und
langsame Reduktion des verschriebenen Opioids eingleitet werden. Kurzzeitinterventionen prägen immer wieder die Idealvorstellung
der Betroffenen, allerdings ist bei diesem Behandlungsansatz (Akutdetoxifizierungen) das Ziel der anhaltenden Abstinenz von
Opioiden meist nicht erzielbar, im Gegenteil – er birgt die Gefahr der erhöhten Akutmortalität. Die Opioiderhaltungstherapie
verlangt in Anlehnung an die meisten psychiatrischen Erkrankungen eine dauerhafte psychopharmakologische Behandlung mit optimalerweise
einer begleitenden psychoedukativen Therapie. Neben der Behandlungsoptimierung für Betroffene gilt es allerdings unter dem
Gesichtspunkt der Volksgesundheit klare Richtlinien der Verschreibungs- und Ausfolgemodalitäten der Medikation zu beachten,
wie selbstverständlich die Voraussetzung für eine optimale Behandlung nur nach entsprechender Ausbildung – sowohl in Diagnostik
und Therapie der Substanzabhängigkeit als auch deren Komorbidität – erzielt werden kann.
Pharmacological treatment standards in different fields of medicine are under ongoing development. Pharmaceutical diversity
represents a modern approach in mainstream medicine, a wide range of medications for the therapeutic management of disorders
is available. In the last ten years, diversification of pharmacological treatment has also taken place in the psychiatric
disorder of opioid dependence. Since the late 80ies of the last century, methadone has been the golden standard in the treatment
of opioid dependence. It has to be mentioned that Austria was one of the first European countries that offered this treatment
to opioid dependent patients. The relatively low prevalence of HIV/AIDS in the Austrian i.v. drug abusers is related to this
fact. Published data from clinical research studies introduced new substances for opioid-maintenance pharmacotherapy, such
as buprenorphine, a partial my-opioid agonist and kappa-antagonist. Research data have shown buprenorphine's comparability
to methadone in regard to retention rate, decreased concomitant consumption and safety and efficacy profile. In general, therapeutic
effects of opioid agonists are dependent on dosing, long-term effects seem to be better in higher dose ranges. In some European
countries, oral slow release morphine is available as additional treatment option for opioid dependent patients, only few
European countries provide heroin assisted treatment. There is the aim of being medication-free – also regarding prescribed
opioid agonists – but long-term opioid maintenance therapy in combination with psychoeducation has proven to be the most effective
treatment and state-of-the-art. After an episode of stabilization without concomitant consumption of non-prescribed substances
(licit or illicit), which can take years or even decades, a slow and step by step reduction of prescribed opioid medication
can be indicated. Short-term interventions are often idealized by patients, although this approach (acute detoxification)
does often not reach the aim of maintaining abstinence, in contrast – mortality rates can increase after this kind of intervention.
Comparable to the management of most psychiatric disorders, a stable psychopharmacological treatment in combination with psychoeducation
is highly recommended also for therapy of opioid dependence. In addition to optimizing standards of care for individual patients,
guidelines corresponding with public health issues have to be taken into account: prescription and administration modalities
in regard to opioid medication, as well as adequate graduate and postgraduate education (in regard to diagnostical and therapeutical
issues of substance dependence, as well as to comorbidity) are required for setting up ideal treatment conditions.
... The same is true, though in the reverse, for laws that prohibit medical interventions. The regulations by the Drug Enforcement Agency (DEA) that place stiff penalties on physicians who prescribe, pharmacists who provide narcotics, and nurses who administer in the absence of sound medical evidence justifying those drugs has also contributed to the undertreatment of dying patients who are suffering needlessly, even though the real risk of DEA action may be quite small (Brower 2009; Garrison & Mitty, 2010; Hellman, 2008; Quill & Meier, 2006; Jung & Reidenberg, 2006). But it is also precarious if legal regulations completely abstain from any substantive guidelines, remaining limited to procedures only. ...
Biomedical advances nowadays enable physicians to keep patients hovering at the brink of death for many years. These new technologies have evoked challenging ethical dilemmas that test society's moral resources. But some have been unwilling to patiently search for new moral wisdom, believing a bold stance is required and they are using legal means to achieve their goal. Attempts to legalize physician assisted suicide and euthanasia are one example, and the literature is replete with analyses of these practices. Far less attention has been paid to opposite attempts at legally enforcing life-sustaining medical interventions. In the mid 1990s, a group called "Nebraskans for Humane Care" sought to amend the Nebraska Constitution to require that nutrition and hydration is administered to any person and with any means available. In this article, the history behind and the text of the proposed amendment is critically analyzed, revealing the serious consequences that adoption of such legal regulation of medical treatment can have.
The article explores the individual patient's right to refuse, withdraw, or insist on medical treatment where there is conflict over these issues involving health care personnel or institutions, family members, legal requirements, or third parties concerned with public policy or religious/ideological/political interests. Issues of physician assistance in dying and medical futility are considered. The basis and the current legal status of these rights is examined, and it is concluded that threats to the autonomy of patients, to the privacy of the doctor/patient relationship, and to the quality of medical care should be taken seriously by individuals, medical practitioners, and others concerned with developing and maintaining reasonable, effective, and ethical health care policy.
The present CEIPC Spanish adaptation of the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice 2008. This guide recommends the SCORE model for risk evaluation. The aim is to prevent premature mortality and morbidity due to CVD by means of dealing with its related risk factors in clinical practice. The guide focuses on primary prevention and emphasizes the role of the nurses and primary care doctors in promoting a healthy life style, based on increasing physical activity, changing dietary habits, and not smoking. The therapeutic goal is to achieve a Blood Pressure<140/90mmHg, but in patients with diabetes, chronic kidney disease, or definite CVD, the objective is<130/80mmHg. Serum cholesterol should be<200mg/dl and cLDL<130mg/dl, although in patients with CVD or diabetes, the objective is<100mg/dl (80mg/dl if feasible in very high-risk patients). Patients with type 2 diabetes and those with metabolic syndrome must lose weight and increase their physical activity, and drugs must be administered whenever applicable, with the objective guided by body mass index and waist circumference. In diabetic type 2 patients, the objective is glycated haemoglobin<7%. Allowing people to know the guides and developing implementation programs, identifying barriers and seeking solutions for them, are priorities for the CEIPC in order to put the recommendations into practice.
The homocysteine level is considered to be a product of genetic and lifestyle interactions, mainly mutated methylenetetrahydrofolate reductase (MTHFR) and the intake of folate, vitamin B12 and pyridoxine, and their blood levels. Physical activity has been associated with lower homocysteine levels in some population studies, especially among elderly subjects. To further elucidate the observed association between homocysteine and physical activity, while accounting for the effect of the MTHFR C677T genotype, and of plasma levels of folate and B12 vitamins, a cross-sectional study of 620 males and females, aged 70.5 ± 6.8 years, was carried out. Information on lifestyle habits was collected and laboratory examinations of 12-h fasting total plasma homocysteine, folate, and vitamin B12, as well as DNA analysis for MTHFR C677T variant, were performed. Median total homocysteine values were 11.4 μmol/l for males and 9.4 for females; p < 0.001. Smoking and ethnic origin were not found to be associated with homocysteine levels. Physically active subjects had significantly lower total homocysteine levels when adjusted for sex (p = 0.01). Significant inverse correlations were found between body mass index, plasma folate, B12 and homocysteine levels. Homocysteine levels of the CC, CT and TT genotypes were 9.7, 10.6 and 10.2 μmol/l, respectively (p = 0.002, controlling for sex). In a multiple linear regression model, a sedentary lifestyle increased homocysteine levels by 7% as compared to an active one (p = 0.03) controlling for sex, age, body mass index, folate, vitamin B12, and C677T genotype, all of which were also found to be significantly associated with homocysteine levels. Any level of physical activity was found to be independently associated with lower homocysteine levels in an elderly population, controlling for MTHFR genotype, plasma B-vitamins, age, sex, smoking and BMI. This study emphasizes the importance of maintaining a physically active lifestyle in the elderly.
Aspects of trial design, screening and study efficiency can affect recruitment and the findings of the trial itself. A clear understanding of the screening and study inclusion process will assist clinicians in interpreting trial results.
Prospective observational data collection on all patients screened for possible inclusion in a randomized controlled trial of normal vs. augmented renal replacement therapy in critically ill patients (the RENAL Trial).
35 hospitals in Australia and New Zealand.
All patients screened for the RENAL Trial.
We screened 4,551 patients. Of these patients, 767 were ineligible because of lack of inclusion criteria and 2,085 because of exclusion criteria. Of the remaining 1,699, 1,508 (88.7%) were enrolled. The three most common exclusion criteria which prevented recruitment of potentially eligible patients were that the patient had end-stage kidney failure and was already on chronic dialysis (484; 23.2%), the patient's body weight was either <60 or >120 kg (456; 21.8%), and the fact that the patient had already received renal replacement therapy during the index admission. Important modifiable impediments to recruitment were inability to obtain consent in 191 cases, unavailability of research staff in 124 cases, physician objection in 89 cases, and inability to deliver the trial protocol in 78 cases.
The RENAL Trial's enrolment efficiency was high and compared favourably with previous large intensive care units trials and with that of trials in patients with acute renal failure. The high rate of enrolment suggests that the results can be applied with confidence to most patients with de novo acute renal failure. The loss of close to 1.5% of patients due to consent issues highlights a common problem in critical care trials. The low rate of physician objection suggests clinical equipoise.
In January 2006, the Supreme Court ruled that the U.S. attorney general does not have the authority to prohibit Oregon physicians from prescribing medications to assist terminally ill patients who wish to end their lives. In this article, George Annas reviews the Court's decision and discusses its implications.
Atherothrombosis involves the mutually interactive dual mechanistic processes of atherosclerotic plaque progression and thrombus formation. In the setting of acute plaque rupture, resultant thrombus formation precipitates acute ischemic events such as acute coronary syndromes (ACS), stroke, and transient ischemic attack. Peripheral arterial disease is also a manifestation of atherothrombotic disease, and occurs both acutely and as a result of underlying disease progression. Atherothrombotic disease is highly prevalent and imposes a substantial burden on the community. For example, coronary artery disease was the single greatest cause of mortality among men and women in the US and accounted for an estimated US dollars 142.1 billion in health costs in 2005. Activated platelets are the prime mediators of arterial thrombus formation. This review discusses the evidence supporting the use of oral antiplatelet agents with other risk prevention strategies in the long-term secondary prevention of atherothrombotic disease. The most widely used oral antiplatelet agent is aspirin (acetylsalicylic acid), and both aspirin and clopidogrel have proven roles in the management of atherothrombotic disease. Clopidogrel should also be used in combination with aspirin in patients with non-ST-segment elevation ACS and those undergoing percutaneous coronary intervention. Recent data suggest that clopidogrel may have a significant role, with or without fibrinolytic therapy, in the immediate management of ST-segment elevation ACS.
Just as I select my ship as I am about to go on a voyage, so I shall choose my death when I am about to depart from life.—Lucius Annaeus Seneca, c. 4 BC—65 AD
In the OASIS-5 trial, fondaparinux reduced major bleeding with similar short-term efficacy as enoxaparin but lowered death and stroke during long-term follow-up. The mechanism of lower bleeding and improved efficacy with fondaparinux is uncertain.
We compared the anti-Xa concentration (reflecting drug levels), Xa clot time (reflecting anticoagulant effect) and endogenous thrombin potential (ETP; a global test of hemostatic function) in plasma samples collected 6, 24 and 72 h after the first dose of the study drug in 48 patients randomly assigned fondaparinux 2.5 mg day(-1) and 42 patients assigned enoxaparin 1 mg kg(-1) twice daily in the OASIS-5 trial. Patients assigned to fondaparinux compared with enoxaparin had a significantly lower mean anti-Xa level [0.52 IU mL(-1) (SD 0.22 IU mL(-1)) vs. 1.2 IU mL(-1) (SD 0.45 IU mL(-1)), P<0.0001] and Xa clot time [64.9 s (SD 17.7 s) vs. 111.8 s (SD 29.6 s), P<0.0001], and significantly higher ETP area under the curve (AUC) [386.7 mA (SD 51.5 mA) vs. 206.4 mA (SD 90.6 mA), P<0.001] at 6 h, and these differences remained evident at 24 and 72 h. There was significantly less variability of the results of anti-Xa levels, Xa clot time and ETP AUC for fondaparinux compared with enoxaparin at 6 h (P<0.001 for each comparison).
Fondaparinux 2.5 mg day(-1) compared with enoxaparin 1 mg kg(-1) twice daily produces less variable anticoagulant effect and lower mean anticoagulant intensity. These results most likely explain the reduced risk of bleeding seen with fondaparinux compared with enoxaparin in the OASIS-5 trial and suggest that a lower intensity of anticoagulation than used in the past may be sufficient to prevent recurrent ischemic events and death in patients with ACS who are concurrently treated with aspirin and clopidogrel.
In the past, hypertension has been defined as a systemic arterial blood pressure chronically exceeding certain levels. However, it is now apparent that there is no blood pressure threshold that separates those with increased cardiovascular risk from those with no or low risk. Hypertension is a complex disease that eventually leads to an increase in blood pressure above optimal values for an individual. Moreover, levels of blood pressure, a physical force, need to be evaluated in the context of other cardiovascular risk factors. This definition of hypertension will permit physicians to treat patients with the goal of reducing global risk for myocardial infarction, stroke, and chronic kidney disease.
Colorado's manslaughter law classifies assisted suicide as a felony. Because terminal patients are close to life's end, death while being treated is inevitable, therefore, there was concern among physicians that the fear of prosecution continued to prevent adequate pain relief for terminal patients. A group of physicians and concerned citizens set out to amend Colorado Revised Statutes to reassure doctors and others prescribing or administering palliative care for terminal patients that they would not be indicted under the law prohibiting assisted suicide. The 2006 Assembly passed the amendment (quoted in the text) with virtually no opposition in either house and it was signed into law by the governor, effective July 6, 2006. Note that in addition to allowing appropriate pain management, it specifically emphasizes that it does not permit assisted suicide.
The 2006 term of the United States Supreme Court is now well underway, and the results of the congressional mid-term elections are in. No doubt, decisions will be handed down and national legislation proposed – perhaps even enacted – that will directly or indirectly affect the physician-patient relationship as well as the profession of medicine itself. Of major concern to physicians, patients, and the lay public is the ongoing, rather contentious debate surrounding both patient access to adequate pain control and what constitutes proper physician conduct in treating patients who are experiencing either chronic or end stage disease pain. Those knowledgeable in palliative medicine maintain that an “epidemic of undertreated pain” now exists, and probably has existed for more than a decade. A significant number of patients experience unnecessary pain and suffering, and this disturbing phenomenon is both an individual patient care problem and a public health concern.
Transient ischemic attack (TIA) is a precursor to ischemic stroke. At least half of patients with TIA have a new, small ischemic lesion demonstrable on magnetic resonance imaging using a diffusion weighted sequence. The risk of subsequent major stroke is 10-20% in the next 3 months with much of that risk front-loaded in the first week. Strategies to identify and treat high-risk patients need to be defined. The optimal treatment approach and the timing of interventions, both medical and surgical, remains unknown. In general, aspirin is the first line of treatment to prevent further stroke. Other antiplatelet agents such as clopidogrel alone or in combination with aspirin and the combination aspirin/extended-release dipyridamole may be administered. Endarterectomy or carotid stenting is of great benefit to patients with TIA secondary to stenosis in the extracranial carotid artery.
A survey was performed on behalf of the European Respiratory Society to assess end-of-life practices in patients admitted to European respiratory intermediate care units and high dependency units over a 6-month period. A 33-item questionnaire was sent by e-mail to physicians throughout Europe and the response rate was 28 (29.5%) out of 95. A total of 6,008 patients were admitted and an end-of-life decision was taken in 1,292 (21.5%). The mortality rate in these patients was 68% (884 out of 1,292). The patients received similar proportions of withholding of treatment (298 (23%) out of 1292), do-not-resuscitate or do-not-intubate orders (442 (34%) out of 1,292) and noninvasive mechanical ventilation as the ceiling of ventilatory care (402 (31%) out of 1,292). Withdrawal of therapy was employed in 149 (11%) out of 1,292 patients and euthanasia in one. Do-not-intubate/do-not-resuscitate orders were more frequently used in North compared with South Europe. All of the 473 competent patients directly participated in the decision, whereas, in 722 (56%) out of 1,292 cases, decision-making was reported to be shared with the nurses. In European respiratory intermediate care units and high dependency units, an end-of-life decision is taken for 21.5% of patients admitted. Withholding of treatment, do-not-intubate/do-not-resuscitate orders and noninvasive mechanical ventilation as the ventilatory care ceiling are the most common procedures. Competent patients are often involved, together with nurses.
Unlabelled:
Three national surveys were conducted in 1991, 1997, and 2004 to evaluate state medical board members' knowledge and attitudes about prescribing opioid analgesics for pain management. Topics addressed include perceived legality of prolonged opioid prescribing, characteristics of addiction, prevalence of medication abuse and diversion, and perceived importance and influence of medical board policy. Questions were added in 2004 to determine board members' views about law enforcement involvement in physician investigations and prosecutions. This study assesses medical regulators' current beliefs and compares the 2004 responses with previous responses to determine how knowledge and attitudes about prescribing opioids have changed in recent years. Survey results show that board members have a greater understanding of pain management issues, particularly regarding characteristics of addiction and the legality of prolonged opioid prescribing for chronic noncancer pain. During the last 15 years, there has been substantial regulatory policy development, with medical boards adopting regulations, guidelines, or policy statements to provide guidance to licensees about using opioids to treat pain. However, many board members believe that federal and state law enforcement agencies have increased criminal investigations and prosecutions of physicians. We discuss appropriate regulatory and law enforcement responses to opioid prescribing violations, and suggest crucial next steps.
Perspective:
The authors examine the evolution of state medical board members' knowledge and attitudes about prescribing opioid analgesics to treat chronic pain, demonstrate that medical regulators believe that there have been increased criminal investigations and prosecutions of physicians for their prescribing practices, and suggest ways to avoid unwarranted criminal prosecutions.
Leptospirosis is a public health problem, the severe form of which (Weil's disease) includes acute respiratory distress syndrome, typically accompanied by acute kidney injury (AKI), and is associated with high mortality rates. Recent evidence suggests that dialysis dosage affects outcomes in critically ill patients with sepsis-induced AKI. However, this population varies widely in terms of age, gender, and concomitant conditions, making it difficult to determine the appropriate timing (door-to-dialysis time) and dialysis dosage.
It is logical to assume that increasing the dialysis dosage would minimize uremic complications and improve outcomes in such patients. Patients with Weil's disease constitute a homogeneous population and are typically free of comorbidities, therefore presenting an ideal model in which to test this assumption.
The effects of dialysis dosage were evaluated in this population, with the use of either classic or slow low-efficiency hemodialysis, and two periods/treatment plans were compared: 2002 to 2003/delayed, alternate-day dialysis (DAdD group; n = 15) and 2004 to 2005/prompt and daily dialysis (PaDD group; n = 18). Age, gender, AKI severity, APACHE score, serum urea, and time to recovery of renal function were assessed. All patients received vasoactive drugs (because of hemodynamic instability) and were on mechanical ventilation (because of acute respiratory distress syndrome). Mean serum urea during the dialysis period was significantly lower in the PaDD group than in the DAdD group. Of the PaDD group patients, three (16.7%) died, compared with 10 (66.7%) of the DAdD group patients.
On the basis of this result, it is believed that alternate-day hemodialysis is no longer appropriate for critically ill patients with Weil's disease.
When Roe v. Wade was decided, many constitutional scholars viewed it as a unique event, an aberrant invocation of unenumerated rights forged under the twin pressures of an occluded legislative process and women's urgent demands for reproductive autonomy. Three decades later, this critique is a less persuasive reading of the constitutional landscape. A generation of constitutional development and a broader view of the sweep of constitutional history situates Roe as part of a pattern of decisions protecting the bodies of "we the people" against the violence and control of the state. The pattern does not appear clearly in most constitutional law casebooks, for it has been woven of parallel developments in several rubrics. Rights of prisoners under the Eighth Amendment, rights of the victims of police abuse under the Fourth Amendment and the due process clauses, and rights of bodily autonomy in medical contexts have combined to form a coherent constitutional practice. Notwithstanding the absence of a canonical theory, federal judges in the last generation have substantively confronted both brutal bureaucrats and callous legislators. In the course of those confrontations, they have elaborated an extratextual constitutional doctrine of moral minimalism that denies the state-even in pursuit of legitimate public ends-"uncontrolled authority over the bodies" of those who are subject to its power.This Essay traces the development of this constitutional practice, and the norms, history and tradition that undergird it.
Background
Some patients do not receive adequate pain and symptom relief at the end of life, causing distress to patients, families and healthcare professionals. It is unclear whether undertreatment of symptoms occurs, in part, because of nurses’ concerns about legal and/or disciplinary repercussions if the patient dies after medication is administered.
Aim
The aim was to explore nurses’ experiences and knowledge of the law relating to the provision of end-of-life pain and symptom relief.
Design
Semi-structured interviews with nurses were assessed using a six-stage hybrid thematic analysis technique.
Setting/participants
Four face-to-face and 21 telephone interviews were conducted with nurses who routinely prescribed and/or administered pain and symptom relief to patients approaching the end of their lives in Queensland and New South Wales, Australia.
Results
While many nurses had no personal experiences with legal or professional repercussions after a patient had died, the fear of hastening death and being held accountable was frequently discussed and regarded as relevant to the provision of inadequate pain and symptom relief. Concerns included potential civil or criminal liability and losing one’s job, registration or reputation. Two-thirds of participants believed that pain relief was sometimes withheld because of these legal concerns. Less than half of the interviewed nurses demonstrated knowledge of the doctrine of double effect, the legal protection for health professionals who provide end-of-life pain and symptom relief.
Conclusion
Education is urgently required to strengthen nurses’ knowledge of the legal protections supporting the provision of appropriate palliative medication, thereby improving their clinical practice with end-of-life patients.
People with prehypertension undoubtedly have an increased risk of cardiovascular and other complications. The vast majority have low absolute risk and whether drug treatment would be beneficial is uncertain. While pharmacotherapy has attractions from a public health prospective, clinicians and crucially those with prehypertension require robust evidence that drug treatment will lead to short-term as well as long-term gains. Any changes in recommendations should await adequately powered outcome studies, which provide solid evidence of the magnitude of absolute risk reduction in treating prehyper-tension and assessment of the cost-effectiveness.
Betrachtet man den chronischen Charakter der Opioidabhängigkeit und die enttäuschenden Behandlungsergebnisse bei kurzfristigen Interventionen wie schnellem Herabdosieren der Erhaltungsmedikation oder Detoxifikationsbehandlungen, so stellt die orale Erhaltungstherapie mit synthetischen Opioiden bei opioidabhängigen Patientinnen und Patienten das Behandlungsregime mit dem besten Therapie-Outcome dar. So wie in allen Bereichen der Medizin, kam es auch in der psychopharmakologischen Behandlung im Rahmen der Diagnose Substanzabhängigkeit vom Morphintyp in den letzten Jahren zu einer Diversifikation. Galt Methadon früher als alleinige State-of-the-Art-Therapie für opioidabhängige Patientinnen und Patienten, so gibt es heute eine größere Auswahl an Medikamenten, die für die Behandlung dieser Patientinnen- und Patientenpopulation geeignet und zugelassen sind. Beispielsweise werden in Österreich orale retardierte Morphine seit dem Jahre 1998 zur Behandlung der Opioidabhängigkeit verwendet – 1999 kam in weiterer Folge auch die Zulassung für Buprenorphin, einem synthetischen Opioid mit gemischter Rezeptoraffinität, hinzu. Obwohl nur in wenigen Ländern orale retardierte Morphine in dieser Indikation zugelassen sind, nicht zuletzt durch das Nicht-Vorliegen umfassender multizentrischer Studien und die Gefahr des erhöhten intravenösen Missbrauchspotenzials, hat sich diese Therapieoption bei begleitender psychosozialer Unterstützung als gute Alternative zur Behandlung mit Methadon oder Buprenorphin etabliert. Hervorgehoben muss allerdings werden, dass diese Medikamente einer gleichermaßen sorgfältigen ärztlichen Verschreibung bedürfen und weitere konfirmative Forschungsergebnisse notwendig sind.
It is not always possible to perform clinical interventions that benefit a patient without also triggering some degree of harm. The double effect (DE) is both a moral and pragmatic principle to determine whether the good outcome resulting from an action outweighs any detrimental secondary effects. The principle’s underpinnings are lodged in medieval, theological thought, and the continuing clinical significance of DE to a diverse, technological society is the subject of much debate among scientists and philosophers. In the scientific literature, DE is most often invoked to address questions of what is moral and ethical in end-of-life care.
The Joint Commission (TJC) accredits and certifies more than 19,000 health care organizations in the United States, including hospitals, nursing homes, and home care agencies. Each organization must have a standing health care ethics committee to maintain its status. These interdisciplinary committees are composed of physicians, nurses, attorneys, ethicists, administrators, and interested citizens. Their main function is to review and provide resolutions for specific, individual patient care problems. Many of these committees are well meaning but may lack the information, experience, skills, and formal background in bioethics needed to adequately negotiate the complex ethical issues that arise in clinical and organizational settings. Handbook for Health Care Ethics Committees was the first book of its kind to address the myriad responsibilities faced by ethics committees, including education, case consultation, and policy development. Adopting an accessible tone and using a case study format, the authors explore serious issues involving informed consent and refusal, decision making and decisional capacity, truth telling, the end of life, palliative care, justice in and access to health care services, and organizational ethics. The authors have thoroughly updated the content and expanded their focus in the second edition to include ethics committees in other clinical settings, such as long-term care facilities, small community hospitals, rehabilitation centers, and hospices. They have added three new chapters that address reproduction, disability, and the special needs of the elder population, and they provide additional specialized policies and procedures on the book’s website. This guide is an essential resource for all health care ethics committee members. © 2007, 2015 Johns Hopkins University Press. All rights reserved.
During the past forty years, thousands of studies have been carried out on the subject of happiness. Some have explored the levels of happiness or dissatisfaction associated with typical daily activities, such as working, seeing friends, or doing household chores. Others have tried to determine the extent to which income, family, religion, and other factors are associated with the satisfaction people feel about their lives. The Gallup organization has begun conducting global surveys of happiness, and several countries are considering publishing periodic reports on the growth or decline of happiness among their people. One nation, tiny Bhutan, has actually made "Gross National Happiness" the central aim of its domestic policy. How might happiness research affect government policy in the United States--and beyond? In The Politics of Happiness, former Harvard president Derek Bok examines how governments could use the rapidly growing research data on what makes people happy--in a variety of policy areas to increase well-being and improve the quality of life for all their citizens. Bok first describes the principal findings of happiness researchers. He considers how reliable the results appear to be and whether they deserve to be taken into account in devising government policies. Recognizing both the strengths and weaknesses of happiness research, Bok looks at the policy implications for economic growth, equality, retirement, unemployment, health care, mental health, family programs, education, and government quality, among other subjects. Timely and incisive, The Politics of Happiness sheds new light on what makes people happy and how government policy could foster greater satisfaction for all.
This book explores the current debates on global medical issues including national health care, experimental cancer drugs, quality of medicine and patient safety, preparation for a global flu pandemic, and regulating/outlawing cloning and germline genetic alterations. The book addresses national security issues concerning current national policies such as the best response to bioterrorism, force-feeding hunger strikers at Guantanamo, killing civilians in Afghanistan, with an emphasis on the roles played by physicians and lawyers in each.
The development of many electrolyte disturbances in the ICU can be prevented by attention to the use of intravenous fluids and nutrition. Hyponatremia is a relative contraindication to the use of hypotonic intravenous fluids and hypernatremia calls for the administration of water. Formulae have been devised to guide the therapy of severe hyponatremia and hypernatremia. All formulae regard the patient as a closed system, and none takes into account ongoing fluid losses that are highly variable between patients. Thus, therapy of severe hyponatremia and hypernatremia must be closely monitored with serial electrolyte measurements. The significance of hypocalcemia in the critically ill is controversial. Hypokalemia, hypophosphatemia, and hypomagnesemia should be corrected.
La atención médica al final de la vida es una situación a la que se enfrentan, cada vez con más frecuencia, los anestesiólogos. En esas circunstancias es esencial un enfoque médico y ético apropiado, con el fin de garantizar una calidad de muerte adecuada para el paciente y su familia. Se describe un caso de un paciente de 42 años, con cáncer de colon metastático, a quien se le inició sedación paliativa en presencia de síntomas refractarios, tanto físicos como existenciales. La práctica de la sedación como una opción terapéutica válida dentro de un contexto de atención paliativa eficiente, debe llevarse a cabo teniendo en cuenta los principios éticos y médicos relevantes. Así mismo, hay que reconocer las características propias de la formación del anestesiólogo, para que no se limite este tipo de atención en los pacientes al final de su vida. La atención médica al final de la vida es una situación que, cada vez con más frecuencia, enfrentamos los anestesiólogos. La sedación paliativa se establece como una opción terapéutica, basada en importantes criterios éticos y clínicos. En el momento de iniciarla hay que asegurarse del cumplimiento de dichos criterios, que deben evidenciarse frente al paciente, la familia y el grupo de salud.
As antibiotic resistance is increasing worldwide, it is important to prescribe fluoroquinolone (FQ) antibiotics appropriately for a given infection to preserve class efficacy. Clinical studies reveal good efficacy and tolerability of the currently approved FQs (ciprofloxacin, levofloxacin and moxifloxacin) in a wide range of community- and hospital-acquired infections. However, certain features supporting their clinical efficacy suggest a rationale for inclusion of moxifloxacin and ciprofloxacin with complementary clinical benefit on a formulary rather than levofloxacin alone; it may also be more cost effective. Ciprofloxacin has advantages over levofloxacin in the treatment of Gram-negative infections, whilst moxifloxacin has certain efficacy and ease of use advantages over levofloxacin in respiratory tract infections. To preserve the potential of FQs and to minimise the risk of resistance selection, agents with the highest in vitro activity and supportive pharmacokinetic/pharmacodynamic profiles should be used first-line, as appropriate for local guidelines and prescribing information.
Gatifloxacin, a broad-spectrum fluoroquinolone, has recently been voluntarily withdrawn by Bristol-Myers Squibb from the market secondary to dysglycemic events associated with this agent. Risk factors for this adverse event include diabetes and those who are elderly (65 years of age or older), have renal insufficiency, or take glucose altering medications. The mechanism for this adverse reaction is not fully understood. However, it is theorized that there is an association between accumulation of gatifloxacin (particularly in elderly patients or those with renal insufficiency) and dysglycemic events with gatifloxacin. A review of the literature found 13 reported cases of hyperglycemia induced by gatifloxacin and 2 clinical trials evaluating gatifloxacin's association with hyperglycemia. Similarly to other reported cases, the authors' 4 outpatients were initiated on gatifloxacin therapy and subsequently had developed hyperglycemia during gatifloxacin therapy. Prior to the multiple observations of dysglycemias associated with gatifloxacin, this medication was widely used and thought to have an excellent safety profile. Hence, clinicians should be vigilant and exercise caution with newly approved medications.
Objective:
This study aims to assess the cost-effectiveness of rotavirus immunization in Indonesia, taking breastfeeding patterns explicitly into account.
Method:
An age-structured cohort model was developed for the 2011 Indonesia birth cohort. Next, we compared two strategies, the current situation without rotavirus immunization versus the alternative of a national immunization program. The model applies a 5 year time horizon, with 1 monthly analytical cycles for children less than 1 year of age and annually thereafter. Three scenarios were compared to the base case reflecting the actual distribution over the different breastfeeding modes as present in Indonesia; i.e., the population under 2 years old with (i) 100% exclusive breastfeeding, (ii) 100% partial breastfeeding and (iii) 100% no breastfeeding. Monte Carlo simulations were used to examine the economic acceptability and affordability of the rotavirus vaccination.
Results:
Rotavirus immunization would effectively reduce severe cases of rotavirus during the first 5 years of life of a child. Under the market vaccine price the total yearly vaccine cost would amount to US$ 65 million. The incremental cost per quality-adjusted-life-year (QALY) in the base case was US$ 174 from the societal perspective. Obviously, it was much lower than the 2011 Indonesian Gross Domestic Product (GDP) per capita of US$ 3495. Affordability results showed that at the Global Alliance for Vaccines and Immunization (GAVI)-subsidized vaccine price, rotavirus vaccination could be affordable for the Indonesian health system. Increased uptake of breastfeeding might slightly reduce cost-effectiveness results.
Conclusion:
Rotavirus immunization in Indonesia would be a highly cost-effective health intervention even under the market vaccine price. The results illustrate that rotavirus immunization would greatly reduce the burden of disease due to rotavirus infection. Even within increased uptake of breastfeeding, cost-effectiveness remains favorable.
It is not always possible to perform clinical interventions that benefit a patient without also triggering some degree of harm. The double effect (DE) is both a moral and pragmatic principle to determine whether the good outcome resulting from an action outweighs any detrimental secondary effects. The principle’s underpinnings are lodged in medieval, theological thought, and the continuing clinical significance of DE to a diverse, technological society is the subject of much debate among scientists and philosophers. In the scientific literature, DE is most often invoked to address questions of what is moral and ethical in end-of-life care.
The SYNTAX (SYNergy Between PCI With TAXUS and Cardiac Surgery) trial ([1][1]) was designed to determine whether treatment of complex coronary artery disease with percutaneous coronary intervention (PCI) with a drug-eluting stent was noninferior to treatment with coronary bypass surgery (CABG). The
Leptospirosis is an acute septicemic illness that affects humans in all parts of the world. Approximately 10% of patients with leptospirosis develop severe disease, the Weil' syndrome, with ictericia, acute kidney injury (AKI) and pulmonary hemorrhage. Leptospirosis-induced AKI is typically nonoliguric with a high frequency of hypokalemia. Experimental and clinical studies demonstrated that tubular function alterations precede a drop in the glomerular filtration rate and are mainly in the proximal tubule. Studies in humans and animals have demonstrated a decrease in the expression of proximal sodium (NHE3) and water tubular transporter, aquaporin 1 (AQP1) together with higher renal expression of the Na-K-2Cl cotransporter NKCC2. In an experimental model, at the initial phase of the disease the expression of AQP2, the water transport of the collecting duct is decreased, which explains the higher incidence of nonoliguric AKI. During the recovery phase of AKI, AQP2 expression increased in human and animals as a compensatory mechanism. Alveolar hemorrhage, pulmonary edema, ARDS, or a combination of these features may accompanied AKI and is associated with high mortality. Studies with hamsters demonstrated that in leptospirosis, a noncardiogenic pulmonary edema occurs consequently to a decrease in the clearance of alveolar fluid, due to a decrease in sodium transporter in the luminal membrane (ENaC) and an increase in the NKCC1 basolateral membrane transporter. Antibiotic treatment is efficient in the early and late/severe phases and revert all kidney transporters. Early and daily hemodialysis, low daily net fluid intake and lungprotective strategies are recommended for critically ill leptospirosis patients.
Inconsistent local Medicare service coverage policies constitute one of the most prominent barriers encountered by mental health professionals who provide services to older adults. In this study, the authors analyzed the scope and delineation of local Medicare policies for 19 types of psychiatric and psychological services in 2003 and again in 2006. Results indicated policies now exist for all Medicare services in all the states, and many of the local policies provide definitive statements to guide practice. However, some policies lacked delineation and variability persists from one region to the next. While researchers ascertain how local policies can impact service outcomes, providers should form issue networks and resolve current problems such as the inequities surrounding service documentation requirements and the lack of guidance in providing mental health care to older persons with dementia. Given that the Medicare administrative structure will undergo substantive changes in the next five years, there is an exceptional opportunity for providers to address these problems successfully and pave a pathway for providing specialty mental health services to older adults. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The effects of brain AngII (angiotensin II) depend on AT1 receptor (AngII type 1 receptor) stimulation and include regulation of cerebrovascular flow, autonomic and hormonal systems, stress, innate immune response and behaviour. Excessive brain AT1 receptor activity associates with hypertension and heart failure, brain ischaemia, abnormal stress responses, blood–brain barrier breakdown and inflammation. These are risk factors leading to neuronal injury, the incidence and progression of neurodegerative, mood and traumatic brain disorders, and cognitive decline. In rodents, ARBs (AT1 receptor blockers) ameliorate stress-induced disorders, anxiety and depression, protect cerebral blood flow during stroke, decrease brain inflammation and amyloid-β neurotoxicity and reduce traumatic brain injury. Direct anti-inflammatory protective effects, demonstrated in cultured microglia, cerebrovascular endothelial cells, neurons and human circulating monocytes, may result not only in AT1 receptor blockade, but also from PPARγ (peroxisome-proliferator-activated receptor γ) stimulation. Controlled clinical studies indicate that ARBs protect cognition after stroke and during aging, and cohort analyses reveal that these compounds significantly reduce the incidence and progression of Alzheimer's disease. ARBs are commonly used for the therapy of hypertension, diabetes and stroke, but have not been studied in the context of neurodegenerative, mood or traumatic brain disorders, conditions lacking effective therapy. These compounds are well-tolerated pleiotropic neuroprotective agents with additional beneficial cardiovascular and metabolic profiles, and their use in central nervous system disorders offers a novel therapeutic approach of immediate translational value. ARBs should be tested for the prevention and therapy of neurodegenerative disorders, in particular Alzheimer's disease, affective disorders, such as co-morbid cardiovascular disease and depression, and traumatic brain injury.
Palliative care and hospice should be the standards of care for all terminally ill patients. The first place for clinicians to go when responding to a request for assisted death is to ensure the adequacy of palliative interventions. Although such interventions are generally effective, a small percentage of patients will suffer intolerably despite receiving state-of-the-art palliative care, and a few of these patients will request a physician-assisted death. Five potential "last resort" interventions are available under these circumstances: (1) accelerating opioids for pain or dyspnea; (2) stopping potentially life-prolonging therapies; (3) voluntarily stopping eating and drinking; (4) palliative sedation (potentially to unconsciousness); and (5) physician-assisted death. Patient, family, and clinicians should search for the least harmful way to respond to intolerable end-of-life suffering in ways that are effective and also respect the values of the major participants. A system that allows an open response to such cases ultimately protects patients by ensuring a full clinical evaluation and search for alternative responses, while reinforcing the need to be responsive and to not abandon.
Excessive allostatic load as a consequence of deregulated brain inflammation participates in the development and progression of multiple brain diseases, including but not limited to mood and neurodegenerative disorders. Inhibition of the peripheral and brain Renin-Angiotensin System by systemic administration of Angiotensin II AT(1) receptor blockers (ARBs) ameliorates inflammatory stress associated with hypertension, cold-restraint, and bacterial endotoxin administration. The mechanisms involved include: (a) decreased inflammatory factor production in peripheral organs and their release to the circulation; (b) reduced progression of peripherally induced inflammatory cascades in the cerebral vasculature and brain parenchyma; and (c) direct anti-inflammatory effects in cerebrovascular endothelial cells, microglia, and neurons. In addition, ARBs reduce bacterial endotoxin-induced anxiety and depression. Further pre-clinical experiments reveal that ARBs reduce brain inflammation, protect cognition in rodent models of Alzheimer's disease, and diminish brain inflammation associated with genetic hypertension, ischemia, and stroke. The anti-inflammatory effects of ARBs have also been reported in circulating human monocytes. Clinical studies demonstrate that ARBs improve mood, significantly reduce cognitive decline after stroke, and ameliorate the progression of Alzheimer's disease. ARBs are well-tolerated and extensively used to treat cardiovascular and metabolic disorders such as hypertension and diabetes, where inflammation is an integral pathogenic mechanism. We propose that including ARBs in a novel integrated approach for the treatment of brain disorders such as depression and Alzheimer's disease may be of immediate translational relevance.
People with pre-hypertension (high blood pressure but below the conventional threshold for intervention with antihypertensive drugs) undoubtedly have increased risk of cardiovascular and other complications. However, the vast majority has low absolute risk and whether treatment would be beneficial is uncertain. While pharmacotherapy has attractions from a public health perspective, clinicians and crucially those with pre-hypertension require robust evidence that drug treatment will lead to short term as well as long term gains. Any changes in recommendations should await adequately powered outcome studies which provide solid evidence of the magnitude of absolute risk reduction in treating pre-hypertension and assessment of the cost-effectiveness.
Acute respiratory distress syndrome (ARDS) has been shown to increase morbidity but not mortality in trauma patients; however, little is known about the effects of ARDS in nontrauma surgical patients. The purpose of this study is to evaluate the risk factors for and outcomes of ARDS in nontrauma surgical patients.
A prospective observational study was performed in the surgical intensive care unit (ICU) of an academic tertiary care center. From 2000 to 2005, all nontrauma surgical admissions to the surgical ICU were evaluated daily for ARDS based on predefined diagnostic criteria. Logistic regression analysis identified independent predictors for ARDS and ICU mortality.
Of 2,046 patient identified, 125 (6.1%) met criteria for ARDS. The incidence of ARDS declined annually from 12.2% to 2.1% during the study period (p < 0.001). ARDS patients were significantly older (55.4 years vs. 51.8 years, p = 0.014) and more likely to be obese (32% vs. 22%, p = 0.007) than the non-ARDS population. Independent predictors of ARDS included use of pressors (relative risk, RR = 3.30), sepsis (RR = 1.72), and body mass index >or=30 kg/m (RR = 1.57). Independent predictors of ICU mortality included ARDS (RR = 6.88), pressors (RR = 2.85), positive fluid balance (RR = 2.27), Acute Physiology and Chronic Health Evaluation II (RR = 1.04), and age (RR = 1.02).
Unlike trauma patients, ARDS was an independent predictor of ICU mortality in nontrauma surgical patients, independent of age and disease severity. Nontrauma surgical patients who developed ARDS were older, sicker, and had a longer ICU stay. Independent predictors of ARDS included use of pressors, sepsis, and obesity.
Thrombosis is observed in several areas of medicine. Equilibrium between pro- and anticoagulant factors is required for maintaining blood flow. Tissue injury from multiple causes may induce coagulum formation mediated by coagulation pathway activation. Tissue factor (F III) + F VIIa interacts with both platelet and endothelial cell receptors. This coagulation model displays four stages: a) initiation, b) amplification, c) propagation and d) stabilization. Development of thrombosis is associated with either primary or hereditary and acquired factors. Primary thrombophilia is determined genetically by a hypercoagulative state shown by loss of natural anticoagulant activity, such as antithrombin III, C, S protein or procoagulant activity gaining resistance to activated C protein: factor V (Leiden), prothrombin and methylenetetrahydrofolate reductase mutations. Acquired thrombophilia mainly relates to an autoimmune condition such as the presence of anticardiolipin antibodies or lupus anticoagulant. Surgical procedures enhance mechanisms that predispose to thrombosis, e.g., acidosis, hypothermia, plasma expanders, extracorporeal circulation, duration of surgical procedure, and tissue manipulation. Adequate classification of the patient's thrombosis risk and adequate use of primary and secondary prophylactic recommendations in these groups of patients is necessary.
Pain is often inadequately treated. To evaluate a common method of assessing pain and to identify some barriers to improving pain control, 50 hospitalized patients in pain, their nurses, and their physicians were interviewed about the pain experienced by the patients. The patients' "pain behavior" was assessed and literatures was reviewed to identify the risk for developing iatrogenic drug addiction in patients with no prior history of drug abuse. Doctors and nurses tended to assess pain intensity as less than the patients' assessments. The doctor's and nurse's assessment of the same patient correlated poorly (r = 0.21). Pain behavior correlated weakly (rs = 0.36) with patients' pain scores. Twenty-one patients wanted more pain medicine but often staff would not give more. A common reason was fear of addiction, notwithstanding a literature that iatrogenic addiction hardly ever occurs in usual hospitalized patients. Barriers to better pain control in acutely hospitalized patients include: (1) exaggerated fear of iatrogenic addiction, (2) an attitude among staff that patients exaggerate the intensity of their pain, (3) poor correlation between pain behavior and pain intensity that can mislead staff who rely on pain behavior to assess pain intensity, and (4) a lack of agreement between doctor and nurse in estimating the intensity of a patient's pain. A new way of thinking about patients in pain, assessing pain as either present or absent, is proposed for evaluation. If pain is present, one should attempt to ameliorate it in a manner consistent with the desire of the patient and the acceptability of adverse effects.
Presented is a review of the pain management provided to an elderly male patient dying of mesothelioma in an acute care hospital and, subsequently, in a nursing home. Discussed are the medico-legal aspects of the case, including the patient's survivors' efforts to hold the treating physicians, hospital, and nursing home accountable for inadequate pain management through complaints submitted to the state medical board, the state department of health services, and the Center for Medicaid/Medicare Services, and in state court.
Criteria-driven policy analysis resources from the University of Wisconsin Pain and Policy Studies Group (PPSG) evaluated drug control and professional practice policies that can influence use of controlled substances for pain management, and documented changes over a 3-year period. Additional research was needed to determine the extent of change, the types of messages contained in the policies, and what has contributed to changing policy content. Four research aims guided this study: (1) evaluate change between 2000 and 2003 of state policy that can affect pain relief, (2) describe content differences for statutes, regulations, guidelines, and policy statements, (3) evaluate differences between policies specific to pain management and policies governing general healthcare practice, and (4) compare content of policies specific to pain management created by healthcare regulatory boards to those created by state legislatures. Results showed that more current policies, especially policies regulating health professionals, tend to encourage pain management and avoid language that restricts professional decision-making and patient treatment. In addition, pain policies from healthcare regulatory boards were generally less restrictive than statutes or policies that govern general healthcare practice. These findings suggest that the positive policy change results primarily from state medical, pharmacy, and nursing boards adopting policies promoting pain management and the use of opioids, while containing few if any restrictions. Despite this improvement, further progress can be made when states continue to abrogate additional restrictions or clinically obsolete provisions from policies. PPSG policy evaluations provide guidance to lawmakers, healthcare regulators, and clinicians who are striving to achieve balanced policy, an attainable but redoubtable goal, to benefit patient care.
Despite skilled palliative care, some dying patients experience distressing symptoms that cannot be adequately relieved. A patient with metastatic breast cancer, receiving high doses of opioids administered to relieve pain, developed myoclonus. After other approaches proved ineffective, palliative sedation was an option of last resort. The doctrine of double effect, the traditional justification for palliative sedation, permits physicians to provide high doses of opioids and sedatives to relieve suffering, provided that the intention is not to cause the patient's death and that certain other conditions are met. Such high doses are permissible even if the risk of hastening death is foreseen. Because intention plays a key role in this doctrine, clinicians must understand and document which actions are consistent with an intention to relieve symptoms rather than to hasten death. The patient or family should agree with plans for palliative sedation. The attending physician needs to explain to them, as well as to the medical and nursing staff, the details of care and the justification for palliative sedation. Because cases involving palliative sedation are emotionally stressful, the patient, family, and health care workers can all benefit from talking about the complex medical, ethical, and emotional issues they raise.