Clinical Criteria for Physician Aid in Dying.

More than 20 years ago, even before voters in Oregon had enacted the first aid in dying (AID) statute in the United States, Timothy Quill and colleagues proposed clinical criteria AID. Their proposal was carefully considered and temperate, but there were little data on the practice of AID at the time. (With AID, a physician writes a prescription for life-ending medication for a terminally ill, mentally capacitated adult.) With the passage of time, a substantial body of data on AID has developed from the states of Oregon and Washington. For more than 17 years, physicians in Oregon have been authorized to provide a prescription for AID. Accordingly, we have updated the clinical criteria of Quill, et al., based on the many years of experience with AID. With more jurisdictions authorizing AID, it is critical that physicians can turn to reliable clinical criteria. As with any medical practice, AID must be provided in a safe and effective manner. Physicians need to know (1) how to respond to a patient's inquiry about AID, (2) how to assess patient decision making capacity, and (3) how to address a range of other issues that may arise. To ensure that physicians have the guidance they need, Compassion & Choices convened the Physician Aid-in-Dying Clinical Criteria Committee, in July 2012, to create clinical criteria for physicians who are willing to provide AID to patients who request it. The committee includes experts in medicine, law, bioethics, hospice, nursing, social work, and pharmacy. Using an iterative consensus process, the Committee drafted the criteria over a one-year period.

Estimating the Risk of Cardiac Mortality After Exposure to Conducted Energy Weapons.

BACKGROUND: Conducted energy weapons (CEWs), commonly known as Tasers, are a reputed nonlethal law enforcement weapon. Nevertheless high profile cases have suggested a causal association with cardiac death but the magnitude of any putative risk is unclear. METHODS: An electronic systematic review of all real world, cohort studies of consecutive CEW cases was performed. "Pessimistic" and "optimistic" previous beliefs about CEW mortality were derived from an unbounded internet search, including case series but excluding the previously identified cohort publications. A Bayesian analysis updated these previous beliefs with the published objective cohort data. RESULTS: Pessimistic and optimist previous beliefs with modes of 1/700 and 1/7000, respectively, and upper limits (< 2.5% probability) of 1/100 and 1/1000, respectively, were constructed. Three cohort studies formed the objective data source and their combined mortality was 1 in 2728 cases or 3.67/10,000 (95% confidence interval, 1/107,751 - 1/490). The maximum a posteriori estimated risks of CEW mortality for the pessimistic and optimistic prior distributions were 5.3 and 2.2 deaths per 10,000 exposures, respectively. The upper limits (< 1% probability of occurrence) of the posterior distribution were 1 death per 408 and 982 CEW exposures for the pessimistic and optimistic previous beliefs, respectively. CONCLUSIONS: Limited available evidence can be used to construct approximate boundaries for CEW mortality risk and suggests that the population risk of CEW mortality is likely small but not negligible. More high quality data are required to refine these estimates and extreme caution must be exercised before applying these population risks to individual cases.

Your morality, my mortality: conscientious objection and the standard of care.

Recently the scope of protections afforded those healthcare professionals and institutions that refuse to provide certain interventions on the grounds of conscience have expanded, in some instances insulating providers (institutional and individual) from any liability or sanction for harms that patients experience as a result. With the exponential increase in the penetration of Catholic-affiliated healthcare across the country, physicians and nurses who are not practicing Catholics are nevertheless required to execute documents pledging to conform their patient care to the Ethical and Religious Directives for Health Care Services as a condition of employment or medical staff privileges. In some instances, doing so may result in patient morbidity or mortality or violate professional standards for respecting advance directives or surrogate decisionmaking. This article challenges the ethical propriety of such institutional mandates and argues that legal protections for conscientious refusal must provide redress for patients who are harmed by care that falls below the prevailing clinical standards.

Coronary revascularization in diabetic patients: a systematic review and Bayesian network meta-analysis.

BACKGROUND: The optimal revascularization technique in diabetic patients is an important unresolved question. PURPOSE: To compare long-term outcomes between the revascularization techniques of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). DATA SOURCES: English-language publications in PubMed, the Cochrane Central Register of Controlled Trials, Ovid, and EMBASE between 1 January 1990 and 1 June 2014. STUDY SELECTION: Two investigators independently reviewed randomized, controlled trials comparing PCI (with drug-eluting or bare-metal stents) with CABG in adults with diabetes with multivessel or left main coronary artery disease. DATA EXTRACTION: Study design, quality, patient characteristics, length of follow-up, and outcomes were extracted. For duplicate publications, outcomes were obtained from the publication with the longest follow-up. DATA SYNTHESIS: 40 studies were combined using a Bayesian network meta-analysis that accounted for the variation in stent choice. The primary outcome, a composite of all-cause mortality, nonfatal myocardial infarction, and stroke, increased with PCI (odds ratio [OR], 1.33 [95% credible interval {CrI}, 1.01 to 1.65]). Percutaneous coronary intervention resulted in increased mortality (OR, 1.44 [CrI, 1.05 to 1.91]), no change in the number of myocardial infarctions (OR, 1.33 [CrI, 0.86 to 1.95]), and fewer strokes (OR, 0.56 [CrI, 0.36 to 0.88]). LIMITATIONS: Study design and length of follow-up were heterogeneous, and results were driven primarily by a single study. Costs and nonvascular complications of the interventions were not examined. CONCLUSION: Coronary artery bypass grafting seems to be the preferred revascularization technique in diabetics, especially if long-term survival is anticipated. However, because of residual uncertainties and increased risk for stroke with CABG, clinical judgment is required when choosing a revascularization technique in patients with diabetes. PRIMARY FUNDING SOURCE: Fonds de recherche du Québec-Santé.

Pathologizing suffering and the pursuit of a peaceful death.

The specialty of psychiatry has a long-standing, virtually monolithic view that a desire to die, even a desire for a hastened death among the terminally ill, is a manifestation of mental illness. Recently, psychiatry has made significant inroads into hospice and palliative care, and in doing so brings with it the conviction that dying patients who seek to end their suffering by asserting control over the time and manner of their inevitable death should be provided with psychotherapeutic measures rather than having their expressed wishes respected as though their desire for an earlier death were the rational choice of someone with decisional capacity. This article reviews and critiques this approach from the perspective of recent clinical data indicating that patients who secure and utilize a lethal prescription are generally exercising an autonomous choice unencumbered by clinical depression or other forms of incapacitating mental illness.

Prognosis terminal: truth-telling in the context of end-of-life care.

Recent contributions to the medical literature have raised yet again the issue of whether the term "terminal" is an intelligible one and whether there is a consensus view of its meaning that is sufficient to justify or even require its use in discussing end-of-life care and treatment options with patients. Following a review of the history and development of informed consent, persistent problems with the communication of prognosis and the breaking of bad news are analyzed. The author argues that candid but compassionate communication between physicians and patients about prognosis is essential to informed decisions about both disease-directed (curative) and palliative therapies.

Prescription opioid forgery: reporting to law enforcement and protection of medical information.

OBJECTIVE: To review confidentiality requirements of prescribers who become aware of a forged prescription. DESIGN: A case is reviewed in which a prescriber believes that a prescription has been forged. RESULTS: The literature and law related to prescription forgery and confidentiality are reviewed. Although prescription forgery is a crime, the prescriber's responsibility for reporting to law enforcement is not clear under current state and federal law. Federal laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA), do not permit prescribers in all circumstances to disclose prescription fraud to law enforcement. CONCLUSIONS: Under common circumstances, HIPAA may prohibit prescribers from reporting prescription forgery to law enforcement. However, collaborating with a dispensing pharmacist may offer a lawful pathway to reporting prescription forgery. State legislature may consider laws that clarify the reporting responsibilities of prescribers in cases of prescription forgery.

Off-label prescribing: in search of a reasonable patient-centered approach.

This commentary relates to an article entitled "Off-Label Prescribing of Medications for Pain: Maintaining Optimal Care at an Intersection of Law, Public Policy, and Ethics," which appears in the same journal issue. Off-label prescribing and off-label marketing of drugs are differentiated. Vulnerability of pain patients with off-label prescribing is noted as is the lack of data on benefits and risks of the practice. The influence of the pharmaceutical industry in off-label prescribing is discussed. A lack of transparency when communicating with patients about off-label drug use is a concern.