Inpatient Notes
In this issue's Inpatient Notes, the author describes a simple yet powerful practice to develop and enhance one's diagnostic performance.
Highlights of Recent Articles From Annals of Internal Medicine
Ann Intern Med. 2017;167:576-578. Published 19 September 2017. doi:10.7326/M17-0938
In this position paper, the American College of Physicians (ACP) states its formal position against the legalization of physician-assisted suicide, citing ethical, legal, and practical concerns. The authors argue that physician-assisted suicide violates the ethical tenets of beneficence and nonmaleficence. In addition, they express concern that physician participation in suicide could erode trust in the physician–patient relationship and fundamentally alter the role of the medical profession in society. Moreover, they recognize that a focus on facilitating death at the end of life might distract physicians from striving for the traditional goals of end-of-life care: relieving suffering and improving access to hospice and palliative care.
Key points for hospitalists include:
The ACP formally opposes the legalization of physician-assisted suicide.
One editorial suggests that all physicians should firmly decline to participate in physician-assisted suicide, noting that it is simply not the duty of a physician. The author highlights uncertainties of the practice, including the identification of appropriate candidates and the challenges of creating reliable safeguards against misuse. He also argues that a patient's autonomy should not be considered absolute—indeed, physicians do not make decisions based solely on what patients want or request. Rather, medical decision making depends on the weighing of competing values, including the “intrinsic value of human life.”
Another editorial suggests that physicians should not adopt a stance of rigid opposition to physician-assisted death. The authors recognize that most of the public favors legalization of physician-assisted suicide, even though physicians and some professional organizations are divided on the issue. The authors also suggest that now is the time to carefully study physician-assisted suicide, to debate its ethical implications, and to improve related processes and safeguards that serve the patients who choose this “last resort” option.
Ann Intern Med. 2017;167:579-583. Published 19 September 2017. doi:10.7326/M17-2300
This article summarizes data from 20 years of experience with Oregon's Death With Dignity Act (DWDA), which allows physicians to legally prescribe lethal medications to terminally ill patients who want to end their own lives. During the past 20 years, 1857 Oregonians received prescriptions and 1179 died from ingesting them. About one third of the patients who obtained the prescriptions never took the medication. Of note, although the annual number of DWDA deaths has gradually increased over 20 years (16 deaths in 1998 vs. 136 deaths in 2016), it represents a small fraction of all deaths in the state. The median age of DWDA patients was 72 years—52% were men, 96% were white, and 72% had some college or higher education. Most DWDA patients had cancer (77%), and most (88%) were enrolled in hospice. During the first decade of implementation, 11% of DWDA patients had a formal psychiatric evaluation, but only 3% had been evaluated since.
Key points for hospitalists include:
A wealth of data about physician-assisted suicide is available from states and countries where the practice is legal, including Oregon. Analysis of these data can answer some important questions about the practice.
Most patients cited loss of autonomy or inability to participate in activities that make life enjoyable as reasons for seeking DWDA prescriptions. Financial concerns were not frequently reported as motivating the request.
Patients requesting DWDA prescriptions were only infrequently referred for psychiatric evaluations despite concerns that depression may be prevalent in this population.
Ann Intern Med. 2017;167:507-508. Published 12 September 2017. doi:10.7326/M17-0163
This Ideas and Opinions article suggests that the current health care environment may pose a threat to the cultivation of diagnostic reasoning skills in internal medicine trainees.
Key points for hospitalists include:
The current health care environment may undermine the emphasis on diagnostic reasoning in internal medicine training by demanding efficiency and pressuring trainees to “test (or even treat) first, think later.”
Residents doing shiftwork are often unaware of the ultimate results of the diagnostic process they initiate and lack a clear feedback loop necessary to inform and refine diagnostic reasoning.
The authors suggest that internal medicine training programs should act deliberately to preserve the development of diagnostic reasoning in these trainees. Possible solutions might include a renewed focus on diagnostic reasoning during teaching rounds and training conferences and efforts to ensure that trainees receive feedback about the outcomes of the diagnostic evaluations they initiate. For a related discussion, see this month's Inpatient Notes by Gurpreet Dhaliwal, MD.
Ann Intern Med. 2017;167:ITC49-ITC64. doi:AITC201710030
This narrative review provides an update of the evidence regarding diagnosis and treatment of urinary tract infections (UTIs).
Key points for hospitalists include:
Clinicians should not screen for or treat asymptomatic bacteriuria, except in pregnant patients or those undergoing invasive urinary procedures that will induce mucosal bleeding (e.g., transurethral resection of the prostate).
Although UTI can be diagnosed clinically, urine culture should be done in patients in whom the diagnosis is uncertain, in pregnant women, and in men with suspected UTI. Urine culture is also indicated when pyelonephritis or complicated infection is suspected and in cases of relapse or treatment failure.
Antibiotic choice depends on the classification of the disease. Fluoroquinolones should not be used to treat uncomplicated cystitis based on safety and stewardship concerns but may be used to treat pyelonephritis and complicated infections (e.g., structural abnormalities of the urinary tract or immunocompromised host). Resistance is common in many areas.
The Latest Highlights From ACP Journal Club
For older patients with chronic disease, do transitional care interventions reduce mortality or readmission rates?
Ann Intern Med. 2017;167:JC32. doi:10.7326/ACPJC-2017-167-6-032
This systematic review is the latest of many demonstrating the benefit of transitional care for older patients after hospital discharge. Transitional care provided care coordination and continuity, preplanned and structured follow-up after discharge, and ≥1 follow-up ≤30 days after discharge. Although the interventions were associated with lower rates of mortality and readmissions, which interventions are most clinically or cost-effective are unclear.
How should high-sensitivity cardiac troponin I (hs-cTnI) levels be used to rule out myocardial infarction (MI) in the emergency department (ED)?
Ann Intern Med. 2017;167:JC34. doi:10.7326/ACPJC-2017-167-6-034
This prospective cohort study evaluated 1218 patients who presented to the ED with suspected acute coronary syndrome who had hs-cTnI testing ordered by the attending clinician. The study compared the European Society of Cardiology (ESC) Pathway (which uses a 6-hour, sex-adjusted troponin cutoff) with the High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome (High-STEACS) Algorithm (which uses a 2-hour, unadjusted troponin cutoff). Both approaches use repeat troponin levels at 3 hours for early presenters. The High-STEACS Algorithm ruled out more MIs at presentation and demonstrated a higher negative predictive value at 3 hours than the ESC Pathway.
Ann Intern Med. 2017;167:JC35. doi:10.7326/ACPJC-2017-167-6-035
This study used data from a prospective cohort of 2828 European patients who presented to the ED with suspected MI. It applied 4 strategies that used hs-cTnI to rule out MI and found that most strategies performed similarly.
Taken together, the 2 aforementioned studies reflect growing interest in understanding how to most effectively use hs-cTnI to rule out MI in the ED. As important assumptions (e.g., that patient-reported symptom timing is accurate, and that all troponin assays are the same) and biases (e.g., incorporation bias and verification bias) within both studies limit conclusions, randomized trials focusing on this important question seem necessary.
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