Ethical framework for medication discontinuation in nursing home residents with limited life expectancy

A recent editorial by health economist Victor Fuchs summarized the current challenges with health care delivery in this way: “Most physicians want to deliver ‘appropriate’ care. Most want to practice ‘ethically’, but it is difficult to know what is ‘appropriate’ and what is ‘ethical’. This characterization is particularly true for medication use and deprescribing in elderly NH residents with limited life expectancy. Medical ethics sets 4 key principles (beneficence, nonmaleficence, patient autonomy, and justice) to guide practice. However, decisional conflicts will continue between providers and patients, and physicians will continue to struggle with the dilemma of balancing the primacy of patient welfare, values, and beliefs against the desire for promising, but often minimally beneficial and harmful, medications that threaten limited clinical resources. Despite these challenges, physicians should be able to perform systematic medication reviews and monitor discontinuation trials in their NH patients for whom this is consistent with their goals of care.     

Patient priorities of care in rheumatology outpatient clinics: a qualitative study

Objective: To provide more understanding of what rheumatoid arthritis (RA) patients want and need from an outpatient visit. Methods: 25 patients who experienced care in a nurse practitioner clinic (n = 10), junior doctor clinic (n = 9) or consultant clinic (n = 6) in a large teaching hospital in West Yorkshire were interviewed about their perceptions and experiences of care. Interviews were approximately 1¹/₂ hours in duration and were carried out in a neutral environment by a research nurse. Interview data were subjected to atheoretical content analysis, which resulted in the identification of emergent themes. Results: Five main themes emerged from the analysis of interview data: 1) patients want to be communicated to clearly and effectively and value positive relationships with practitioners. These help to give patients confidence in the care they are receiving; 2) patients want to feel in control of their condition and tend to refuse interventions as a way of gaining control; 3) patients want to be given clear explanations during consultations, and want information in oral and written forms; 4) patients want to be able to access practitioners between scheduled appointments as a way of gaining reassurance; and 5) patients want to feel valued by society through having their difficulties appreciated and understood by others. Conclusion: This research adds to the body of evidence on what patients want from their rheumatology care, and each theme has clear implications for future practice. Copyright © 2007 John Wiley & Sons, Ltd.     

Irritable Bowel Syndrome: What Do Patients Really Want?

Knowing what patients with irritable bowel syndrome (IBS) want or expect from their medical care is critical in helping them manage the symptoms of this common, chronic gastrointestinal condition. Failure to identify patient expectations can lead to patient dissatisfaction with care, lack of compliance with prescribed treatments, and the inappropriate use of medical resources. Surprisingly little is known about what patients with IBS really want. Several studies suggest that IBS patients value the relational aspects of medical care as highly as technical skills and knowledge. There seems to be a significant communication gap between health care providers and patients regarding IBS care. This article reviews what is known about IBS patients’ expectations and needs.     

Metabolic Syndrome Associated with Schizophrenia and Atypical Antipsychotics

Patients with schizophrenia are at increased risk for developing the metabolic syndrome or its individual components due to their lifestyle, suspected genetic predisposition, and exposure to antipsychotic medications that can cause weight gain and other metabolic side effects. Despite the availability of clinical guidelines, screening for and monitoring of metabolic problems in this patient population continue to be suboptimal. We provide an overview specifically addressing 1) why patients with schizophrenia are at increased risk for metabolic problems; 2) how commonly used antipsychotic medications vary in terms of their metabolic liability; 3) how to effectively screen for and monitor metabolic problems in patients receiving antipsychotic medications; 4) what interventions can prevent, limit, or reverse the metabolic side effects of antipsychotic drug treatment; and 5) what are the barriers to the care of these patients.     

The Glycemic Effects of Antihypertensive Medications

Older antihypertensive medications are believed to be associated with metabolic disturbances, especially raised glucose levels. Owing to this, many physicians shun their use. Newer antihypertensive medications are metabolically neutral or metabolically favorable; therefore, they are looked upon favorably and are chosen as primary medications for the treatment of hypertension. Here we review the literature on the glucose effects of older and newer antihypertensive medications. We also consider what, if any, impact these metabolic effects have on cardiovascular disease outcomes. We show that the diabetogenic effects of thiazide diuretics and beta blockers are small relative to the glucose effects of angiotensin-converting enzyme inhibitors (ACEIs) and calcium channel blockers, and that over time, the glucose differences between older and newer medications diminish. Importantly, we show that the diabetogenic effects of older antihypertensive medications do not translate into increased cardiovascular disease risk.     

The use of antirheumatic medication during pregnancy and in the puerperium

Patients with rheumatic diseases will want to take as few medications as possible while they are conceiving, pregnant, or breast feeding. The guidelines above can be used to balance the risk of a drug effect on the fetus or neonate with the effect of provoking a flare in disease activity by ceasing the drug. Where no information on drug concentration in pregnancy or lactation exists, guidelines can be developed from knowledge of the drug's inherent metabolism. In most of the rheumatic diseases, disease activity can be reduced to a minimum using the smallest possible dose of drugs with known behaviors in pregnancy and lactation and thus providing minimal risk to mother and fetus.     

Elderly patients' preferences and experiences with providers in managing their drug costs

OBJECTIVES: To determine whether elderly patients with high drug expenditures want and receive providers' help in managing drug costs.
DESIGN: Cross-sectional survey.
SETTING: A Medicare managed care plan (>400,000 members) in one state in 2002.
PARTICIPANTS: One thousand one hundred six seniors (62% response rate) sampled so that half exceeded caps on their drug benefits the previous year, and all had total drug expenditures in the top quartile of members in their cap level.
MEASUREMENTS: Participants' preferences and experiences with providers discussing costs and participation in choosing medications.
RESULTS: Two-thirds reported difficulty paying for medications, and one-fourth decreased medication use because of cost. Most wanted providers to ask about medication affordability (81%), consider cost (86%), offer choices (70%), and to persuade them or decide for them which medication to use (88%), but few said providers asked about affordability (17%), usually or always discussed prices (19%), or offered choices (45%), although nearly all said providers chose their medications (93%). Sixty-two percent had asked providers for help with drug costs, although 34% who used less medication because of cost or had difficulty paying for medications had not asked for help.
CONCLUSION: Providers should be aware that elderly patients want their help in managing drug costs but do not always receive it or ask for help when they need it. Providers could improve communication by initiating conversations about cost and by asking patients about preferences when prescribing.     

Do-not-resuscitate orders – should the patient be informed?

Objectives. To analyse the ethical implications of informing patients about their do-not-resuscitate status (DNR). Design. Questionnaire. Setting. Nationwide, 6 months after the publication of guidelines on DNR in 1994. Subjects. A 10% random sample of the members of the Swedish Cardiac Society, 104 physicians and 196 nurses. Main outcome measures. To what extent are patients, physicians and nurses involved in decisions about DNR, and how should the ethical conflict involved in informing patients about their DNR status be described and analysed? Results. Of 73% responding, 84% of the physicians and 8% of the nurses had made a DNR decision. The decision was regarded as ethically right and well timed and it was discussed with 33% of the competent patients. Half of the respondents believed that DNR orders should be discussed with the competent patient, but still only one third of the patients are involved. The ethical conflict is analysed using the principles of autonomy and nonmaleficence as value premises. Conclusions. Many physicians are still reluctant to find out what the patient wants. Being ignorant they risk harming the patient. It is recommended that information about DNR status should be given incrementally and that the attitudes of the old and chronically ill in-hospital patients are studied. Do they want to be informed, and if so, how and when do they want it to be done?     

Problems associated with clinical evaluation of antianginal medications

Assessing the efficacy of antianginal medications is not as easy as it might first appear. Many factors, including the protocol, the subjects chosen for study and the physicians conducting the trial, may produce study bias and thereby yield equivocal results. Objectively attempting to quantitate a subjective event such as angina inherently poses many difficulties. The variable nature of anginal episodes makes identification of attacks, or conversely, elimination of such attacks, difficult to assess. In terms of the protocol, it is necessary to determine what indexes will be used as criteria of efficacy, what doses, either standard or maximally tolerated, will be used for study and what measures will be taken to nullify placebo effect. In terms of patient selection, the varying methods of confirming the diagnosis of ischemia and the questions of concurrent illness, compliance and life-style alterations are all factors that can make findings difficult to elucidate. Finally, investigator bias may be introduced into study results because of prestudy prejudice, involvement in data acquisition and interpretation of findings. It is unlikely that any investigator or group of investigators will ever produce a protocol applicable to all types of antianginal medications that will be universally convincing. Conclusions regarding the efficacy of any antianginal medication will undoubtedly continue to be predicated on assessments made by independent investigators using a variety of research protocols, none of which is likely to be perfect.     

The Regulation of Biosimilars in Latin America

This article summarizes the regulatory scenario on biological medications in Latin America focusing on comparability studies, extrapolation of indications, interchangeability and pharmacovigilance issues. In the case of comparability studies, what is being discussed is the possibility of decreasing the clinical trials requirement, but that the molecule should be well characterized in the studies of pharmacokinetics and pharmacodynamics. With the worldwide-level approval of the first monoclonal antibody biosimilar, infliximab, extrapolation of indications are being discussed, since the behavior of the Latin America regulatory agencies has been different with regard to such issue. Another issue discussed by the regulatory agencies is the interchangeability between biological medications and their biosimilars, mainly due to the fact that there is a clear confusion on interchangeability and substitution concepts. Finally, the pharmacovigilance debate, according to what takes place globally, is related to the need for identifying and differentiating the reference biological medication and its biosimilars for traceability purposes.     

Two successful pregnancies in a chronic myeloid leukemia patient treated with imatinib

The number of CML patients in child-bearing age and treated with imatinib is increasing. These women may want to be pregnant or are actually pregnant while on imatinib. Physicians do not know when to stop the treatment and what the risks are for the foetus and the mother. We report a case of a CML patient treated with imatinib who has two children, now 3 years and 10 months of age, in good health. The mother was in complete molecular remission, relapsed during pregnancy and reverted to remission in both cases after delivery.     

The case for treating tobacco dependence as a chronic disease

Smoking remains the leading cause of preventable death in the United States, yet it is still regarded by many as merely a bad habit. Most smokers want to quit but find it difficult. Behavioral counseling and pharmacotherapies are available, safe, and effective in the treatment of tobacco dependence. Nicotine replacement therapy effectively delivers nicotine in safer doses without exposure to the toxins and chemicals in cigarette smoke. The optimal duration of tobacco dependence treatment is unknown, and some smokers may require extended courses. For smokers using long-term cessation medications, health care providers should encourage treatment and insurance carriers should cover it. Both tobacco dependence and such conditions as diabetes are similar in their potential to exacerbate other diseases, their behavioral components of treatment, and their effectiveness of medications. Despite these similarities, treatments for diabetes are well covered by insurance, whereas tobacco dependence treatments are often limited. Tobacco dependence should share the status of other chronic illnesses, with effective treatments given as long as is necessary to achieve successful clinical outcomes.     

Endoscopic therapy of gastroesophageal reflux disease: outcomes of the randomized-controlled trials done to date

Endoscopic therapies to treat gastroesophageal reflux disease have been developed as another option for patients with reflux symptoms who do not want to continue medications indefinitely or are unwilling to undergo surgical intervention. The endoscopic treatments can be divided into those that pleat or plicate the upper stomach, deliver thermal energy into the lower esophageal sphincter, or inject or implant biopolymers into the gastroesophageal junction. Although capable to improve reflux symptoms for the majority of treated patients for a short while, durability has been variable among the various treatments, and there have been safety issues with some of the therapies. Although symptom improvement has been universally shown in short-term follow-up, there has been variable outcome for reduced need of antisecretory medications and pH studies show normalization of the distal esophageal acid exposure for only the minority of treated patients. Patients with significant reflux esophagitis or Barrett esophagus are not typically candidates for this antireflux intervention. Except for the NDO Plicator, in sham-controlled studies, there have been no significant differences between treated and sham-treated individuals for ability to discontinue medications or normalize pH. One issue in interpreting the results of these preliminary studies is the influence of the learning curve of a new technology. Another is that the devices and techniques have not been optimized. Currently, only the Davol/Bard EndoCinch and the NDO Plicator are available for commercial use. There are several newer devices under study or in development, and further testing and experience will demonstrate their capabilities in the treatment of gastroesophageal reflux disease.     

Medication,Behavior and the Elderly:

A large number of elderly reside in what has come to be known as board and care facilities, many of which are operated by non-medical personnel who lack sufficient knowledge of the common medications used by the elderly. In addition, few educational opportunities exist for such providers to increase and expand their knowledge regarding important gerontological issues. Community based educational programs can help increase the knowledge base of board and care operators on critical topics such as medications and their common side effects.     

The changing face of internal medicine: Patient centred care

Patient centred care is now considered the gold standard and there should be ‘no decision about me, without me’. Internists who treat patients with complex multi-morbidities should consider patients' preferred outcomes, following a ‘goal-oriented’ principle. Perhaps the most important barrier to goal-oriented care is that medicine is deeply rooted in a disease-outcome-based paradigm. Rather than asking what patients want, the culture of modern medicine has prioritised optimal disease management according to guidelines and population goals. Doing what is right for the patient should be based on trust. Patients and internists must therefore meet as equals: ‘I’ and ‘you’ should be replaced by ‘we’.     

The evolving role of glycoprotein IIb/IIIa inhibitor therapy in contemporary care of acute coronary syndrome patients

Results from clinical trials of glycoprotein IIb/IIIa(GPIIb/IIIa) inhibitors during the past decade have established their current role in the treatment of non-ST-segment elevation acute coronary syndrome and in percutaneous coronary interventions. However, there are still unanswered questions on optimal use of GPIIb/IIIa inhibitors. Moreover, as new concomitant or alternative medications become available, the role of GPIIb/IIIa inhibitors must be reconsidered. This review discusses, in the light of clinical trials recently presented, what we know, what we are learning, and what we still need to learn.     

How to keep up with the medical literature: VI. How to store and retrieve articles worth keeping

The human mind is not well suited to storing and retrieving large amounts of infrequently used information. An effective personal filing system is needed if good articles that we encounter in our efforts to keep up to date are to be kept handy for future reference. Many options exist for the creation of a personal filing system. In this article, we assist the reader in the development of a tailor-made system that is based on making key decisions that strike a balance between filing needs and the lack of enthusiasm that most of us have for filing. The complexity of the system should match the number of purposes that your file must serve. Important additional considerations include how much time and effort you are willing to spend; where and how you will house your collection; how many articles you want to keep in the file; what standards you will apply in selecting material for your file; what subject headings are most appropriate for your articles; whether you will need to cross-reference; and what access you will have to personal computers.     

Understanding Patient Preference for Integrative Medical Care: Results from Patient Focus Groups

Background Integrative medicine (IM), a combination of conventional and complementary and alternative medicine (CAM), has become a popular source of medical care, yet little is known about its use. Objective To identify the motivations of people who choose IM for their primary care needs. Design Qualitative study from focus group data of regular users of IM. Participants Six focus groups that include a total of 37 regular users of IM who consented to participate in a study of IM use. Approach Focus group meetings were audiotaped and transcribed verbatim. Qualitative analysis using grounded theory was used to derive the motivations for use of IM. Results Participants beliefs include the following: the combination of CAM and conventional medicine is better than either alone; health is a combination of physical, emotional, and spiritual well being; nutrition and lifestyle play a role in wellness; and pharmaceuticals should be avoided except as a last resort. Participants suffer from health problems that are not well treated by conventional medicine. Participants want to discuss CAM with physicians and obtain guidance on its use. Participants want time with their providers, to feel listened to and to have the opportunity for shared decision-making. Conclusion Much of what patients are seeking in integrative medical care is likely universally shared: a strong therapeutic relationship with providers who listen and provide time and knowledgeable advice. Users believe a combined approach of CAM and conventional medicine is better than either alone and want to be able to discuss CAM use with their providers.     

Colon cancer surveillance in inflammatory bowel disease patients: current and emerging practices

Colorectal cancer (CRC) is a feared complication of inflammatory bowel disease (IBD). The cumulative probability of developing this malignancy is significantly higher than in the general population, making IBD the third highest risk condition for CRC. Since CRC is such a concerning complication, it should be no surprise that patients and physicians want to know what the most important risk factors are for its development, as well as potential strategies for reducing these risks. This article reviews the current practice and emerging technologies for detecting and preventing colon cancer in patients with IBD.