Dealing with delicate issues in continuous deep sedation. Varying practices among Dutch medical specialists, general practitioners, and nursing home physicians

BACKGROUND: This article examines delicate issues in continuous deep sedation (CDS) from the perspectives of different types of physicians. The following sensitive issues involved in CDS were investigated: artificial hydration, sedation for nonphysical discomfort, the relationship between CDS and euthanasia, and patient involvement in decision making for CDS. METHODS: A structured retrospective questionnaire concerning the most recent case of CDS during the past 12 months was sent to a sample of medical specialists (n = 727), general practitioners (n = 626), and nursing home physicians (n = 111). RESULTS: Response rates were 26.4% for medical specialists, 37.4% for general practitioners, and 59.5% for nursing home physicians. Indications for CDS differed among the types of physicians. General practitioners (25.0%) were most often confronted with a patient request for euthanasia before starting CDS compared with medical specialists (8.9%) and nursing home physicians (6.5%). A decision to forgo artificial hydration in CDS was more often made by nursing home physicians (91.3%) compared with medical specialists (53.7%) and general practitioners (51.2%). Shorter survival was found for patients sedated for nonphysical discomfort (vs other patients) by general practitioners. Among all patients, 74.5% were involved in decision making before the start of CDS. CONCLUSIONS: The present study demonstrates notable differences in CDS practice among various types of physicians. To what extent this is related to different patient populations or to different expertise requires further investigation. The use of CDS for nonphysical discomfort calls for critical examination to avoid ambiguous practice.     

Smoking cessation counseling by resident physicians in internal medicine, family practice, and pediatrics

Residents in primary care specialties care for many patients who smoke cigarettes, but little is known about their smoking cessation counseling (SCC). We surveyed 309 residents (72 family practice, 171 internal medicine, and 66 pediatrics residents) in 13 programs to determine their practices, knowledge, attitudes, and training in SCC. More than 90% thought physicians are responsible for SCC, the majority routinely took smoking histories, and 80% attempted to motivate patients to quit smoking. However, 25% or fewer reported discussing obstacles to quitting, setting a quit date, prescribing nicotine gum, scheduling follow-up visits, or providing self-help materials. Family practice residents used more SCC techniques (1.8) than did internal medicine (0.8) and pediatrics (0.1) residents. Only 54% of residents reported recent SCC training and 13% reported formal SCC training. Recent training correlated with the number of counseling techniques used. Residents in primary care specialties report positive attitudes but inadequate practice and training in SCC.     

社区医师与心内科医师心电图诊断及治疗的差异

目的:比较社区医师与心内科医师对心电图诊断及治疗的差异,了解远程心电图诊断系统安装的必要性。方法:心内科医师对503份心电图重新阅读并书写报告,作出相应的治疗,与社区医师作出的诊断及治疗方案对比,总结其差异性。结果:社区医师心电图诊断完全准确450份(89.5%),误诊53份(10.5%),心内科医师诊断完全准确498份(99.0%),误诊5份(1.0%),两者间比较有统计学差异(P0.01),社区医师诊断需要治疗例数475例(94.4%),不需要治疗28例(0.6%),心内科医师诊断需要治疗病例322例(64.0%),不需要治疗病例181例(36.0%),两者间比较有统计学差异(P0.01)。结论:社区医师对心电图的诊断的正确率显著低于心内科专业医师,而判断治疗需求的患者比例显著高于心内科医师。     

Effect of a GP desktop resource on smoking cessation activities of general practitioners

Objectives To evaluate an intervention aimed at increasing the quantity and quality of brief opportunistic general practitioner (GP) advice to smokers encouraging and supporting quit attempts. Design Randomized controlled trial with two groups: (1) control and (2) GP desktop resource (GDR). Smoking cessation activities of GPs were assessed by an independent postal survey 1 month after distribution of resource. Subjects and setting One hundred and seven GPs in West Dorset. Main outcome measures GPs’ self‐reported rates of advising and counselling smokers on cessation over the previous week. Results The rate of opportunistic advice per week in the GDR group was 4.9 (SD = 4.1), compared with 2.8 (SD = 1.8) in the control group, F = 8.2, p = 0.0025, one‐tailed. The rate of giving counselling was also higher 2.2 (SD = 3.2) in the intervention group versus 1.0 (SD = 1.4) in the control group, F = 4.0, p = 0.025, one‐tailed. The proportion who had recommended or prescribed NRT was greater, although not significantly (54% versus 46%, Fisher’s exact p = 0.1, one‐tailed). Conclusions The findings indicate that the GDR can increase the rate of delivery of opportunistic advice and provision of counselling. Given the importance of this activity, a larger trial appears to be warranted to examine the long‐term effect and the effect on cessation rates in patients.     

Smoking cessation and weight gain

Significant progress has been made in the research on smoking cessation and weight gain since the 1988 Surgeon General's Report, particularly on mechanisms and treatment methods. Smoking cessation results in weight gain in most quitters, primarily due to changes in caloric intake and to a lesser extent from changes in energy expenditure. Thus far, pharmacologic treatments appear more efficacious at preventing the weight gain than behavioral methods. And regarding who should receive treatment, preliminary research suggests that females are more concerned about postcessation weight gain than males, and it is the concern about weight gain-more than the weight gain itself-that appears to play an important role in relapse to smoking. Given the progress that has been made along the spectrum from mechanisms to treatment, those concerned about postcessation weight now have treatment options for preventing weight gain in the critical period immediately after smoking cessation. However, continued research into mechanisms, treatment methods, and individual differences will surely result in new and more effectively tailored treatment options.     

Smoking cessation and weight gain

Cigarette smoking is the single most important preventable cause of death and illness. Smoking cessation is associated with substantial health benefits. Weight gain is cited as a primary reason for not trying to quit smoking. There is a great variability in the amount of weight gain but younger ages, lower socio‐economic status and heavier smoking are predictors of higher weight gain. Weight change after smoking cessation appears to be influenced by underlying genetic factors. Besides, weight gain after smoking cessation is largely because of increased body fat and some studies suggest that it mostly occurs in the subcutaneous region of the body. The mechanism of weight gain includes increased energy intake, decreased resting metabolic rate, decreased physical activity and increased lipoprotein lipase activity. Although there is convincing evidence for the association between smoking cessation and weight gain, the molecular mechanisms underlying this relationship are not well understood. This review summarizes current information of the effects of nicotine on peptides involved in feeding behaviour. Smoking was shown to impair glucose tolerance and insulin sensitivity and cross‐sectional studies have demonstrated that smokers are insulin‐resistant and hyperinsulinaemic, as compared with non‐smokers. Smoking cessation seems to improve insulin sensitivity in spite of the weight gain. Nicotine replacement – in particular nicotine gum – appears to be effective in delaying post‐cessation weight gain. In a group of women who failed to quit smoking because of weight gain, a dietary intervention (intermittent very‐low‐calorie diet) plus nicotine gum showed to both increase success rate in terms of smoking cessation and prevent weight gain. On the other hand, body weight gain at the end of treatment was significantly lower in the patients receiving bupropion or bupropion plus nicotine patch, compared with placebo. Studies with new drugs available for the treatment of obesity – sibutramine and orlistat – are warranted.     

Smoking cessation strategies and evaluation

The success of smoking cessation interventions appears to be most closely related to the amount of positive reinforcement that the smoker receives for not smoking (unpublished data). The goal of the clinic is to reinforce not smoking over the longest period of time. The program outlined focuses on helping the smoker who wants to stop smoking, it demands a minimal amount of time from the physician and it is self-supporting. If these guidelines are followed, the physician should find that helping the smokers who want help to stop smoking is a productive and rewarding experience.     

Smoking, smoking cessation, and risk of cardiovascular disease

Opinion statement Cigarette smoking increases the risk of atherothrombotic clinical events such as myocardial infarction and the effect is dose dependent for persons who continue to smoke. Reductions in smoking habit and smoking cessation are important ways to improve cardiovascular risk and favorably affect primary and secondary prevention of clinical disease. Therapeutic methods to improve smoking reduction and cessation include nicotine replacement, behavioral interventions, and medications (bupropion, clonidine). Improved cessation rates are under active study and include behavioral methods, targeting smokers immediately after myocardial infarction, consideration of depression in smokers, pharmacogenomics to identify persons who may respond more favorably to specific interventions, and newer medications that affect endocannabinoid receptors.     

Clinical activities and satisfaction of general internists,cardiologists, and ophthalmologists

To define factors that affect the levels of practice satisfaction of different specialities, an observer recorded the activities of 15 physicians in practice (nine general internists, three cardiologists, and three ophthalmologists) as they examined 304 clinic patients. General internists reported less satisfaction with their clinics than did the other physicians and attributed their satisfaction primarily to successful social interaction in 54% of visits, while cardiologists most often derived satisfaction from intellectual stimulation (50%) and ophthalmologists from medical success (81%). The general internists whom the authors observed are less satisfied with clinical encounters than are cardiologists and ophthalmologists and derive satisfaction mostly from social interaction, not biomedical aspects of care. Presented in part at the 14th annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1, 1991.     

Identification of the four conventional cardiovascular disease risk factors by Dutch general practitioners

BACKGROUND: Detecting and managing the four major conventional risk factors, smoking, hypertension, diabetes mellitus, and hypercholesterolemia, is pivotal in the primary and secondary prevention of cardiovascular disease (CVD). OBJECTIVE: To assess the preventive activities of general practitioners (GPs) regarding the four conventional risk factors and the associated measurements for cardiovascular risk factors by GPs in relation to the time of the first clinical presence of CVD. SETTING: Large longitudinal general practice research database (the Integrated Primary Care Information database) in the Netherlands from September 1999 to August 2003. PARTICIPANTS AND METHODS: Patients > 18 year of age with newly diagnosed CVD with a valid history of at least 1 year before and after the first clinical diagnosis of CVD. Details on conventional risk factors and associated measurements for the four cardiovascular risk factors were assessed in relation to the first clinical diagnosis of CVD. RESULTS: In total, 157,716 patients met the study inclusion criteria. Of the 2,594 patients with newly diagnosed CVD, at least one of the four investigated risk factors was observed in 76% of women and 73% of men. In 40% of cases, no risk factor was recorded before the date of the first CVD diagnosis. In 16% of cases, no associated measurements were present before the first CVD diagnosis. CONCLUSION: In daily practice, GPs seem to focus on the secondary prevention of CVD. Intervention strategies that aim to influence GPs' case finding behavior should focus on increasing the awareness of physicians in performing risk factor-associated measurements in patients who are eligible for the primary prevention of CVD. Further research will have to show the feasibility and effectiveness of such intervention strategies.