Annals for Educators - 17 October 2017
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2017)

Web Exclusives17 October 2017Annals for Educators - 17 October 2017FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201710170 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsWhat You Can Do to Stop Firearm ViolenceThe author calls upon physicians to educate themselves on how to identify patients at risk for harming themselves or others with firearms. He also asks that we make a personal commitment to ask our patients about firearms, counsel them on safe firearm behaviors, and take further action when an imminent hazard is present.Use this paper to:Ask your learners whether they think firearm-related injuries are a medical issue. Is it appropriate to approach the problem from an epidemiologic and public health perspective?Do your learners think they should talk to patients who they believe are at risk for firearm-related harm about how they can reduce the risks? Use the accompanying editorial to help frame your discussion. The author and editorialists encourage physicians to make a public commitment to talk to patients when they believe risks for firearm-related injuries are present. Do your learners think such declarations are useful or appropriate? Why or why not? Will your learners make such commitments? Will your learners talk to patients they believe are at risk? If so, do they know how? Do they know what they will ask and advise them? Use a recent paper that addresses such issues to help frame your discussion. Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position PaperOregon's Death With Dignity Act: 20 Years of Experience to Inform the DebateThe Slippery Slope of Legalization of Physician-Assisted SuicidePhysician-Assisted Suicide: Finding a Path Forward in a Changing Legal EnvironmentThis series of articles includes a position paper from the American College of Physicians (ACP) on physician-assisted suicide. Another reviews 20 years of experience since Oregon's passage of the Death With Dignity Act, which allows physicians to prescribe medications to be self-administered by terminally ill patients to hasten their death. One of the editorials argues why the ACP position paper should be credited for its clarity and courage, whereas the other warns that the position paper misses an important opportunity to educate clinicians and learn about best practices.Use these papers to:Start a teaching session with a multiple-choice question. We've provided one below.Ask your learners if a patient has ever said that she or he would like to die. How have they responded? What questions should they ask? Have they ever been asked by a patient for help ending his or her life? Do they feel qualified to talk to patients about such issues? If not, what do they need to learn?Do your learners think there are situations where a patient's request for assistance in bringing about death should be honored? Why or why not?What are the laws regarding physician-assisted suicide where you practice? If it is legal, do your learners think all physicians have an obligation to participate? If not, how do we balance the needs and beliefs of the patients and physicians involved?Some health care professional societies oppose participation in physician-assisted suicide, whereas others provide support to physicians who do participate. What do your learners think is the best approach?Do your learners think there is a difference between palliative sedation and/or analgesics that, as a side effect, hasten death versus the provision of sedatives and/or analgesics that are used to bring about death?State Intimate Partner Violence–Related Firearm Laws and Intimate Partner Homicide Rates in the United States, 1991 to 2015Intimate partner violence affects 1 in 3 women. This study examined the relationship between state intimate partner violence–related firearm laws and intimate partner homicides in the United States between 1991 and 2015.Use this study to:Ask your learners who is at risk for intimate partner violence. Do they ask patients whether they have been victims of intimate partner violence or are worried about this issue?Review the U.S. Preventive Services Task Force recommendation statement that recommends screening all women of childbearing age for intimate partner violence. Why have federal laws aimed at protecting women from intimate partner violence been less effective than they might have been?Do your learners think they will be comfortable asking their patients about these issues? Why or why not? How can they overcome any hesitation so as to better protect their patients?What else can physicians do to help reduce the risk for intimate partner violence? Use the accompanying editorial to help frame your discussion. Annals for Hospitalists Inpatient Notes: Diagnostic Excellence Starts With an Incessant WatchThis concise paper discusses how we can improve our diagnostic skills by making better use of feedback on our performance.Use this paper to:Ask your learners whether they have received feedback on how well they have made correct diagnoses in their patients.How do we react when we learn that we have made an incorrect diagnosis or that it took longer than it should have to reach the right diagnosis?How can we improve how we make use of such feedback?Review the paper's table, and ask your learners if together you could adopt some of the suggested “tracking systems” the author proposes in your practices. How will you monitor yourself or each other to see whether this new approach is working? How will you judge success or failure?What does the author mean by “calibration” and “an incessant watch” with regard to improving one's diagnostic skills?Humanism and ProfessionalismOn Being a Doctor: On ContinuityDr. Sinsky recalls how the continuity in her care for her patients, both in and out of the hospital, made enormous differences and meant the world to them (and her). Can such continuity survive as medical practice models evolve?Use this essay to:Listen to an audio recording of the essay, read by Dr. Michael LaCombe.How frequently do physicians at your center follow their outpatients when they are hospitalized? Do your learners go to see their outpatients when they are admitted? Why or why not?What are the barriers to outpatient-based physicians following their patients in the hospital? What pressures have made such practice less common? In what ways has hospital care been improved by its being led by physicians focusing only on inpatient care? What are the tradeoffs?The author wonders whether our profession will continue to develop systems where physicians work in the hospital or in outpatient settings, but not both. She believes that safer and more satisfying models will emerge but that they will be worked out by the next generation of physicians. What do your learners think is best? How should the system work?MKSAP 16 QuestionA 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 treatmentB. Consult legal counsel about state law in such casesC. Decline the requestD. Prescribe sedating medication that could ensure a comfortable deathCorrect AnswerA. Assess the adequacy of his current treatmentEducational ObjectiveManage a request for physician-assisted suicide.CritiqueWhen 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.Key PointWhen 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.BibliographySnyder 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.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 17 October 2017Volume 167, Issue 8Page: ED8KeywordsAnalgesicsFirearm injuriesGraduate medical educationIntimate partner violenceOutpatient clinicsOutpatientsPalliative carePatientsQuality of lifeSuicide ePublished: 17 October 2017 Issue Published: 17 October 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...