Annals for Educators - 17 October 2017,Annals of Internal Medicine

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Annals for Educators - 17 October 2017
Annals of Internal Medicine ( IF 39.2 ) Pub Date : 2017-10-17 , DOI: 10.7326/afed201710170
Darren B. Taichman

Clinical Practice Points

What You Can Do to Stop Firearm Violence

The 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 Paper

Oregon's Death With Dignity Act: 20 Years of Experience to Inform the Debate

The Slippery Slope of Legalization of Physician-Assisted Suicide

Physician-Assisted Suicide: Finding a Path Forward in a Changing Legal Environment

This 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 2015

Intimate 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 Watch

This 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 Professionalism

On Being a Doctor: On Continuity

Dr. 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 Question

A 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 treatment

B. Consult legal counsel about state law in such cases

C. Decline the request

D. Prescribe sedating medication that could ensure a comfortable death

Correct Answer

A. Assess the adequacy of his current treatment

Educational Objective

Manage a request for physician-assisted suicide.

Critique

When 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 Point

When 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.

Bibliography

Snyder 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.

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中文翻译：

教育家年鉴-2017年10月17日

临床实践要点

您可以采取哪些措施来制止枪支暴力

作者呼吁医生们进行自我教育，以使他们了解如何识别有枪支伤害自己或他人危险的患者。他还要求我们做出个人承诺，向我们的患者询问枪支，就安全的枪支行为向他们提供咨询，并在存在迫在眉睫的危险时采取进一步的措施。

使用本文可以：

询问您的学习者他们是否认为与枪支有关的伤害是医疗问题。从流行病学和公共卫生角度解决问题是否合适？
您的学习者是否认为应该与他们认为有枪支相关伤害风险的患者就如何降低风险进行讨论？使用随附的社论来帮助您进行讨论。
作者和社论作者鼓励医生公开承诺与患者交谈，前提是他们认为存在枪支相关伤害的风险。您的学习者是否认为此类声明有用或适当？为什么或者为什么不？您的学习者会做出这样的承诺吗？
您的学习者是否会与他们认为有危险的患者交谈？如果是这样，他们知道如何吗？他们知道他们会问什么并给他们建议吗？使用针对此类问题的最新论文来帮助您进行讨论。

伦理与医师协助自杀的合法化：美国医师学院立场书

俄勒冈有尊严的死亡法：20年的辩论经验

医生协助自杀合法化的滑坡

医师协助的自杀：在不断变化的法律环境中寻找前进的道路

该系列文章包括美国医师学院（ACP）关于医师协助自杀的立场文件。另一位评论者回顾了俄勒冈州通过《有尊严的死亡法》以来的20年经验，该法允许医生开出由绝症患者自行服用以加快死亡速度的药物。一篇社论认为，为什么应以ACP立场文件的清晰和勇气来赞扬他，而另一篇警告说，立场文件错过了教育临床医生和了解最佳实践的重要机会。

使用这些文件可以：

从选择题开始教学。我们在下面提供了一个。
询问您的学习者，患者是否曾经说过他或他想死。他们如何回应？他们应该问什么问题？病人曾经要求他们提供帮助以终止其生命吗？他们是否有资格与患者讨论此类问题？如果没有，他们需要学习什么？
您的学习者是否认为在某些情况下应该尊重患者的死亡协助请求？为什么或者为什么不？
您在执业医师自杀的法律有哪些？如果合法，您的学习者是否认为所有医生都有参加的义务？如果没有，我们如何平衡所涉患者和医生的需求和信念？
一些卫生保健专业协会反对参加医生协助的自杀，而其他协会则向参加的医生提供支持。您的学习者认为什么是最好的方法？
您的学习者是否认为姑息镇静和/或镇痛药之间有区别，该镇痛和/或镇痛药会加速死亡，而提供镇静剂和/或镇痛药会导致死亡？

1991年至2015年美国州亲密伴侣暴力相关的枪支法和亲密伴侣杀人率

亲密伴侣的暴力行为影响三分之一的女性。这项研究研究了1991年至2015年间，州亲密伴侣暴力相关枪支法与亲密伴侣杀人罪之间的关系。

使用此研究可以：

询问您的学习者谁有遭受亲密伴侣暴力的风险。他们问患者是亲密伴侣暴力的受害者还是担心这个问题？
查看美国预防服务工作队的建议声明，该建议建议对所有育龄妇女进行亲密伴侣暴力检查。
为什么旨在保护妇女免遭亲密伴侣暴力的联邦法律却没有那么有效？
您的学习者认为他们会很乐意向患者询问这些问题吗？为什么或者为什么不？他们如何克服犹豫，从而更好地保护患者？
医师还能做些什么来帮助减少伴侣之间发生亲密暴力的风险？使用随附的社论来帮助您进行讨论。

住院医生年鉴住院注意事项：卓越的诊断始于不断的观察

这篇简明的文章讨论了如何通过更好地利用绩效反馈来改善诊断技能。

使用本文可以：

询问您的学习者，他们是否已收到关于他们对患者进行正确诊断的程度的反馈。
当我们得知自己做出了错误的诊断或者花费了比正确的诊断更长的时间时，我们将如何应对？
我们如何改善使用这些反馈的方式？
查看论文表，并询问您的学习者，您是否可以一起采用作者在您的实践中提出的一些建议的“跟踪系统”。您将如何监视自己或彼此，以查看这种新方法是否有效？您将如何判断成功或失败？
作者在提高个人诊断技能方面的“校准”和“不间断观察”是什么意思？

人文主义和专业精神

关于当医生：关于连续性

Sinsky博士回顾了她在医院内外对患者的护理连续性如何产生巨大差异，并为他们（和她）带来了意义。随着医学实践模型的发展，这种连续性能否生存？

通过这篇文章可以：

收听迈克尔·拉康姆（Michael LaCombe）博士朗读的论文录音。
您中心的医师住院时会多久跟进一次门诊病人？您的学习者入院后会去看门诊吗？为什么或者为什么不？
门诊医生跟随病人进入医院的障碍是什么？哪些压力使这种做法变得不那么普遍了？在仅专注于住院治疗的医生的带领下，医院治疗在哪些方面得到了改善？权衡是什么？
作者想知道我们的专业是否会继续发展医生可以在医院或门诊工作的系统，但不能同时开发这两种系统。她认为，将出现更安全，更令人满意的模型，但下一代医师将制定出这些模型。您的学习者认为最好的是什么？系统应如何工作？

MKSAP 16问题

对一名54岁的男性进行了COPD长期病史评估。尽管他以前做得不错，但在过去的一年中，他的肺功能逐渐下降。他是氧气依赖者，如果没有严重的呼吸困难，甚至无法进行轻微的体育锻炼。他不是移植候选人，并且对其生活质量和预后不满意。他要求他可以服用的处方会导致他在选择时死亡。

以下哪项是处理该患者请求中最合适的下一步？

A.评估他目前治疗的适当性

B.在这种情况下，咨询州法律的法律顾问

C.拒绝请求

D.开具镇静药物，以确保舒适的死亡

正确答案

A.评估他目前治疗的适当性

教育目标

处理医生协助下的自杀请求。

批判

当请求死亡协助时，最好以同理心和同情心回应该请求，并评估患者是否正在接受适当的姑息治疗。在治疗潜在疾病的过程中，不一定总是以维持或改善生活质量为目标而优化护理干预措施；因此，对患者的总体护理进行审查以解决严重疾病中的舒适度和功能问题对于适当的管理至关重要。在这种情况下，让接受过姑息治疗医学培训的医生参与进来也可能会有所帮助。

医师协助的自杀是一个有争议的伦理学领域。大多数伦理学家一致认为，如果主要目的是治疗，可以考虑考虑考虑考虑考虑考虑采取可能会加速绝症患者死亡的干预措施（“双重效果”原则）。但是，在大多数州，使用处方或干预手段以杀死病人为特定目的的医生协助自杀是非法的。美国医学会和美国医师学院都采取了反对这种做法的立场。

如果有人打算在死亡过程中为患者提供帮助，则寻求法律顾问是明智的，因为合法的州必须遵循特定的规程。但是，在评估其他方法（如改善姑息治疗）之前，此步骤不适当。

绝对拒绝讨论医生协助自杀的请求可能会导致讨论患者为何提出该请求的大门，并可能危及与患者之间的治疗关系。

在不详细评估患者状况和动机的情况下编写药物处方以帮助患者死亡将是不负责任的。

重点

当请求死亡协助时，最好以同理心和同情心响应该请求，并评估患者是否正在接受适当的姑息治疗。

参考书目

Snyder L，Sulmasy DP；美国内科医师学会-美国内科医师学会伦理与人权委员会。医师协助的自杀。安实习生。2001； 135（3）：209-216。

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更新日期：2017-10-26

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