“A Request for Abortion”

Allan Templeton, M.D., and David A. Grimes, M.D.

N Engl J Med 2011; 365:2198-2204December 8, 2011DOI: 10.1056/NEJMcp1103639

 

“A 22-year-old student presents to her primary care physician with an unintended pregnancy at 9 weeks of gestation and requests an abortion. She is aware of both medical (drug-induced) and surgical methods of terminating a pregnancy and wants to know which approach would be recommended. She also asks whether either method will affect her future reproductive health. What would you advise?”

 

THE CLINICAL PROBLEM

Induced abortion is one of the most common medical interventions. In the United States, approximately 1.2 million abortions were performed in 2008.1 In the United Kingdom, more than 200,000 abortions are recorded annually.2,3 About one of three women will have had an induced abortion by the time she reaches menopause.

Approximately 90% of abortions are performed in the first trimester because the pregnancy is unintended or unwanted. A small but important proportion (1 to 2%) of abortions are performed later because of a fetal abnormality (e.g., anencephaly, trisomy, or myelomeningocele)4 or serious illness (e.g., cancer or pulmonary hypertension) in the woman.

Until recently, the main method of abortion was surgical, but since 1992 in the United Kingdom and since 2000 in the United States, medical abortion has become increasingly available. Medical abortion involves the combined use of the progesterone antagonist RU-486 (now known as mifepristone), which initiates the abortion, and a prostaglandin, which causes uterine contractions and empties the uterus.5 Of all abortions, medical abortions account for approximately 10% in the United States, 40% in England, and 70% in Scotland 

Easy access to safe, legal abortion services is important to the general health of women and their families.6 Women will seek abortion whether it is legal or not, and the morbidity and mortality associated with illegal abortion remain high. This review article does not address the debate over abortion or the adverse health effects associated with restricting access to abortion services, but it assumes a woman’s right to have her pregnancy terminated if the relevant legal requirements are met.

STRATEGIES AND EVIDENCE

Medical Abortion

Medical abortion has evolved considerably since mifepristone was first licensed for use in Europe in the early 1990s. Whereas initial results with mifepristone alone were disappointing, effectiveness improved dramatically when a prostaglandin or prostaglandin analogue was administered 1 or 2 days after mifepristone.5 Today, the most commonly used prostaglandin is the prostaglandin E analogue misoprostol; its advantages include stability at room temperature (which facilitates short-term storage), possible administration by several routes (vaginal, buccal, sublingual, and oral), and low cost. Misoprostol (and other prostaglandin analogues) can be used alone as abortifacients but are less effective than mifepristone plus misoprostol.7 Similarly, in areas where mifepristone is still unavailable, such as Canada, methotrexate followed by misoprostol can be used, although this regimen is not as effective as the mifepristone–misoprostol regimen.

Initially, misoprostol at a dose of 400 μg was administered orally, and this continues to be the preferred route of administration in France, although in the United Kingdom and United States, vaginal administration of misoprostol at a dose of 400 to 800 μg was shown to be more effective, particularly at gestational ages of more than 7 weeks.8 If needed, the administration of a second dose of misoprostol, either vaginally or orally according to the amount of vaginal bleeding, further increased the likelihood of complete abortion.9 Alternative routes of misoprostol administration, including sublingual10 and buccal,11 have been shown to be as effective as vaginal administration, although side effects of prostaglandin, which are mainly gastrointestinal, are more frequent.12However, many women prefer the convenience of these approaches, which do not involve vaginal administration of tablets.

The Food and Drug Administration–approved dose of mifepristone is 600 mg, but in a randomized trial, the effectiveness of a 200-mg dose was similar to that of a 600-mg dose for medical abortion at all gestational ages.13 An initial vaginal dose of 800 μg of misoprostol is widely used; although a lower dose may be sufficient in many women and is associated with fewer side effects, there is no effective way to predict which women will require the higher dose.

Some studies have indicated that the interval between administration of these two medications can be reduced to 24 hours or less, but most clinics wait 24 to 48 hours after mifepristone administration to administer misoprostol. Once medications have been administered, abortion can be completed at home. The safety and efficacy of medical abortion completed at home are similar to the safety and efficacy of medical abortion in the clinic,14 although ready access to emergency facilities is still required. This is now the usual approach to medical abortion in the United States and is increasingly common in Europe.15

Surgical Approaches

Since the 1970s, suction curettage, also known as vacuum aspiration, has been the standard method of abortion in the United States, where more than 80% of abortions in the first trimester are performed surgically (Figure 1). Vacuum aspiration is a safe procedure that is associated with low rates (<1%) of serious complications (e.g., uterine perforation) and of retained products of conception. Preparation with misoprostol is an effective means of softening and dilating the cervix.16Whether this approach reduces morbidity is not yet established, although the use of osmotic dilators (Laminaria digitata or L. japonica) has been associated with significantly lower rates of uterine perforation17 and cervical injury, as compared with no cervical preparation. Given the rarity of these complications, cervical preparation is not routinely performed before vacuum aspiration, although a recently updated guideline recommends such preparation in all women who are undergoing abortion.18

Local anesthesia (usually with lidocaine) is customary for vacuum aspiration in the United States, since large case series suggest that hemorrhage, cervical injury, and uterine perforation occur more frequently when general anesthesia is used.19 Either electric or manual vacuum aspiration can be used, the latter with the use of a syringe with a valve and plunger that lock when the vacuum is created. The two techniques appear to have similar effectiveness and acceptability,20 although manual vacuum aspiration is preferentially used at earlier gestational ages, since the bulkier uterine contents after 9 weeks limit its efficacy. The uterine contents are aspirated with either a rigid or a flexible plastic cannula; the two types of cannulae have similar efficacy. Although a sharp metal curette has been used to check the completeness of the operation, there are no data to provide support for this practice. The aspirated tissue should be immediately inspected to confirm the presence of the trophoblast and to minimize the chance of an undetected ectopic pregnancy.

Deep sedation (with the use of a tranquilizer, narcotic, or both) or general anesthesia is used less often for first-trimester procedures than for second-trimester procedures. Oral analgesics, such as nonsteroidal antiinflammatory drugs, are commonly administered before the procedure. A paracervical block is widely used. Data are lacking to provide support for this practice, although less pain is reported with a paracervical block that is combined with intravenous sedation than with intravenous sedation alone.21 A supportive environment, including frequent explanation and reassurance by the medical and nursing staff, is known to decrease the perception of pain and the need for analgesia.22

Comparison of Medical and Surgical Abortion

Most abortion providers offer both medical and surgical options for abortion at up to 9 weeks of gestation. Few randomized trials have compared the two approaches.23 Trials in the United States24 and the United Kingdom25 (involving abortions at up to 13 weeks of gestation) showed that women found medical abortion less acceptable than surgical abortion. An earlier trial in Scotland showed equal rates of acceptability for medical and surgical abortion at up to 50 days of gestation, with a lower rate of acceptability for medical abortion at 50 to 63 days of gestation.26 A subsequent randomized trial comparing the two procedures late in the first trimester showed that women undergoing medical abortion were significantly, albeit modestly, less likely to say they would opt for the same method again (70% vs. 79%).27

These results may be explained by the observations that in the trials comparing medical with surgical abortion, medical abortion resulted in more pain, more prolonged bleeding (up to 2 weeks after administration of misoprostol), and a slightly higher failure rate. At approximately 9 weeks of gestation, 2 to 5% of women undergoing medical abortion will require a repeat procedure to complete emptying of the uterus, as compared with 1% of women undergoing surgical evacuation. A registry-based study from Finland involving more than 4000 women likewise indicated that bleeding and incomplete abortion were more common with medical than with surgical abortion, although it also showed higher rates of rare complications requiring major surgery after surgical approaches;rates of infection and other serious complications were similar.28 Hemorrhage requiring blood transfusion is rare (occurring in 0.1% of women) after both medical and surgical abortion.18

Although women value having a choice in the method of abortion, the factors that determine an individual woman’s decision are not always clear. Some women prefer surgical methods that are simple, quick, and associated with a low risk of complications or failure. Others may favor medical methods because they do not involve surgical instrumentation and may appear to be more natural (i.e., more like a miscarriage).

Assessment before Abortion

Once the woman’s choice to proceed with an abortion has been clearly established and written informed consent has been obtained, there is no need for further delay, which may only increase the risk of complications. Counseling should be offered only if the woman requests it or there is a perceived need for it.18 The blood-group rhesus type should be determined and Rh immune globulin should be administered in Rh-negative women. Cytologic screening of the cervix and screening for sexually transmitted diseases should be offered as appropriate. Ultrasonographic examination of the uterus is common, but it is not required routinely before a first-trimester abortion is performed. 29

Prevention of Infection

Antibiotic prophylaxis at the time of abortion significantly reduces the likelihood of infection after vacuum aspiration.30 A randomized, controlled trial showed that prophylaxis was more effective and less expensive than a screen-and-treat approach for chlamydia, gonorrhea, and bacterial vaginosis.31 Doxycycline is widely used, and the best evidence provides support for only a single dose for 24 hours of coverage, although some clinicians prefer presumptive treatment of chlamydia with doxycycline (usually at a dose of 200 mg daily for 7 days); a single 1-g dose of azithromycin can be used instead, but it is more expensive. In the United Kingdom, metronidazole is administered in addition to doxycycline or azithromycin at the time of either medical or surgical abortion, but there are no data to provide support for this routine practice.

Data from randomized, controlled trials of antibiotic prophylaxis with medical abortion are lacking. However, a large before-and-after study of clinics providing medical abortion showed a marked decline (93%) in the rate of serious infections after implementation of routine antibiotic prophylaxis and a change in the route of misoprostol administration from vaginal to buccal.32 It is increasingly common for antibiotic prophylaxis to be used at the time of abortion, whether medical or surgical.

Subsequent Health and Reproductive Risks

Few long-term sequelae are evident after abortion, and the morbidity and mortality are lower with induced abortion (either medical or surgical) than with pregnancy carried to term.33

Induced abortion is not associated with an increased subsequent risk of ectopic pregnancy, placenta previa, infertility, or miscarriage.18 An association between induced abortion and a subsequent risk of preterm birth, which increases with the number of abortions, has been reported18; however, data from prospective cohort studies have not confirmed this finding. There are no data to suggest that medical abortion differs from surgical abortion with respect to these risks.

Two further putative risks warrant mention because they are a source of concern to people who are opposed to the availability of abortion. One is that abortion might be associated with an increased risk of breast cancer. In 2003, the National Cancer Institute reviewed the published data and reported that induced abortion is not associated with an increase in breast cancer risk. The Collaborative Group on Hormonal Factors in Breast Cancer34 later published a reanalysis of 53 studies from 16 countries involving 83,000 women with breast cancer and concluded that pregnancies that end in spontaneous or induced abortion do not increase the risk of breast cancer. This group also observed that the retrospective recording of abortion tended to yield misleading results that supported an association between abortion and breast cancer. Subsequently, two large cohort studies, one in Europe35 and the other in the United States,36 showed no increase in the risk of breast cancer among women who had undergone one or more abortions, regardless of the age of the women, gestational age at the time of abortion, or the number of abortions.

A second putative risk is that induced abortion may have adverse effects on women’s mental health. Most women will find it difficult to make the decision to have an abortion, and many will find the experience stressful and unpleasant. However, the most common emotional response after abortion is a profound sense of relief, although some women have lingering feelings of sadness and regret.18The main predictor of mental health problems after abortion is mental health difficulties preceding the pregnancy. Systematic reviews of observational studies37-39 and a more recent large, population-based, cohort study using linked Danish registries40 concluded that there was no increased risk of mental disorders after an induced abortion in the first trimester. Few studies have compared medical abortion and surgical abortion with respect to subsequent mental health problems, although one trial showed that women’s psychological health at 2 years did not differ according to the type of abortion.41

The prevention of a subsequent unintended pregnancy and of the need for repeated abortion is important. In this respect, the insertion of an intrauterine device (IUD) immediately after abortion, which is safe and acceptable to women,42 has been shown in observational studies from three continents43-45 to be associated with significantly fewer repeated abortions than the use of other methods of contraception. Furthermore, a recent randomized trial comparing immediate with delayed IUD insertion after uterine evacuation showed that immediate insertion resulted in higher rates of IUD use at 6 months.46 Although the evidence at this stage relates to surgical abortion, the same approach should be considered after medical abortion.18

 

COMMENTARY

This is a very young patient with an unwanted pregnancy. As physicians, our duty is to advise and not talk about whether abortion is right or wrong. When a patient has made a decision about her health, we must advise but never force her to do what we consider to be correct.

When we have a patient with self doubt we must act and give our medical opinion from the medical point of view without mixing too personal.

 In this specific case it is important for the patient to be familiarized with all the

methods available to carry out the abortion. We must take into account the patient’s medical history, age, past illnesses and a good scan to recommend the best treatment available to her.

 It is very important that the patient understands the risks of abortion. Therefore it is very important to sign the consent where she says she wants to perform this procedure. It is also important that the patient knows the prevention of a subsequent unintended pregnancy and of the need for repeated abortion is important. In this respect, the insertion of an intrauterine device (IUD) immediately after abortion is safe and acceptable to women. This has been shown in observational studies from three continents associated with repeated abortions. Significantly fewer than the use of other methods of contraception. Furthermore, a recent randomized trial comparing immediate with delayed IUD insertion after uterine evacuation immediate insertion Showed That Resulted in higher rates of IUD use at 6 months. Although the evidence at this stage relates to surgical abortion, the same approach should be considered after medical abortion.

Few randomized trials have compared short- and long-term outcomes of medical and surgical abortion; the very low rate of serious complications with either type of early abortion means that very large samples would be needed to detect clinically important differences. Data are lacking from large multinational studies comparing the cost-effectiveness and acceptability in different clinical settings of medical and surgical approaches according to standard protocols (mifepristone–misoprostol and vacuum aspiration). The most cost-effective antibiotic regimens for both medical and surgical abortion remain unknown. Whether routine rather than selective cervical preparation before surgical abortion significantly reduces morbidity has not yet been established, although a randomized trial to assess this question is under way (World Health Organization). More study is needed to resolve the question of whether an increase in the risk of preterm birth is associated with a history of either medical or surgical abortion.

Guidelines for first-trimester abortion have been published by the WHO, the National Abortion Federation, the Society of Family Planning, and the Royal College of Obstetricians and Gynaecologists. The recommendations in this article are generally concordant with these guidelines.

The patient described in the vignette, with a pregnancy at 9 weeks of gestation, should be offered the choice of a medical or surgical abortion. Both are safe with respect to short- and long-term sequelae. Medical abortion is associated with more pain and bleeding and a higher risk of incomplete abortion, whereas the risk of rare complications requiring major surgery is higher after surgical approaches. Antibiotic prophylaxis has well-established benefits in suction curettage and may also be useful in medical abortion, although this is less certain. The patient can be reassured that the best evidence indicates no long-term psychological harm, impairment of future fertility, or increased risk of breast cancer associated with abortion. The insertion of an IUD at the time of the abortion should be recommended to prevent another unintended pregnancy.

 

Article found in “The New England Journal of Medicine”

http://www.nejm.org/medical-articles/clinical-cases#qs=%3Fcategory%3Dclinicalcases%26page%3D7

 

CAROLINA PÉREZ BENITO

Publicado en Uncategorized | Deja un comentario

Physician-Assisted Suicide

I have chosen this article in which is exposed a clinical case of a patient who has a terminal cancer of pancreas. The patient suffers very much because of the disease and wants to finish with his life using drugs, so he consults his doctor on the options that he has. This is what we all know as Euthanasia.

There are two opposing options about the Euthanasia in this case.  After reading it, what do you think about the topic? Do you believe that the patients should have right to decide if they want to finish with his life?

 

 

 

Physician-Assisted Suicide

N Engl J Med 2013; 368:1450-1452April 11, 2013DOI: 10.1056/NEJMclde1302615

 CASE VIGNETTE

John Wallace is a 72-year-old man with metastatic pancreatic cancer. At time of diagnosis, the cancer was metastatic to his regional lymph nodes and liver. He was treated with palliative chemotherapy, but the disease continued to progress. Recently he has become jaundiced, and he has very little appetite. He has been seeing a palliative care physician and a social worker on an ongoing basis. His abdominal pain is now well controlled with high-dose narcotics, but the narcotics have caused constipation. In addition to seeing the social worker, he has also been seeing a psychologist to help him to cope with his illness.

Mr. Wallace has been married to his wife, Joyce, for 51 years, and they have three children and six grandchildren. He and his wife have lived in Salem, Oregon, for the past 23 years, and most of his family lives nearby. He understands the prognosis of the disease, and he does not wish to spend his last days suffering or in an unresponsive state. He discusses his desire for euthanasia with his wife and family members, and they offer him their support. The next day, he calls his physician and asks for information about physician-assisted suicide.

 

TREATMENT OPTIONS

Do you believe that Mr. Wallace should be able to receive life-terminating drugs from his physician? Which one of the following approaches to the broader issue do you find appropriate?

 

OPTION 1

Physician-Assisted Suicide Should Not Be Permitted

J. Donald Boudreau, M.D., Margaret A. Somerville, A.u.A. (pharm.), D.C.L.

We recognize that a patient in Mr. Wallace’s situation is in a state of grief. We appreciate his desire to be of sound mind at the end of his life and not to have to suffer as death approaches. We also recognize the obligations of physicians to respect a patient’s refusal of treatment, to relieve pain and suffering, and to provide palliative care. However, we believe that the art of healing should always remain at the core of medical practice, and the role of healer involves providing patients with hope and renewed aspirations, however tenuous and temporary. Within the realm of palliative care, there exists a well-recognized paradox that one can die healed.Physicians have a duty to uphold the sacred healing space — not destroy it. Therefore, physicians must hear Mr. Wallace’s request for death but never carry it out.

Supporters of physician-assisted suicide justify their position by placing the value of individual autonomy above all other values and ethical considerations. Giving individual autonomy absolute priority runs roughshod over competing values, protections, and needs and ignores the harmful effects on other people, societal institutions (the medical profession in particular), and the general community.

Permitting physician-assisted suicide creates a slippery slope that unavoidably leads to expanded access to assisted suicide interventions — and abuses. Advocates of euthanasia deny that slippery slopes exist, arguing that legal constraints and administrative safeguards are effective in preventing them. But the evidence is clearly to the contrary, as the High Court of Ireland recently affirmed. In upholding the constitutionality of the prohibition on assisted suicide, the justices wrote, “. . . the fact that the number of LAWER (`life-ending acts without explicit request’) cases remains strikingly high in jurisdictions which have liberalised their law on assisted suicide . . . speaks for itself as to the risks involved.” Vulnerable communities in our societies — persons who are old and frail and those who are disabled or terminally ill — perceive themselves to be threatened. Physicians must not be willfully blind to these serious dangers.

Many aspects of physician-assisted suicide breach physicians’ long-standing ethical norms. For instance, the 2011 annual report on the Death with Dignity Act in Oregon shows that physicians were present at fewer than 10% of “assisted deaths.” Why might they want to disconnect themselves from what they have enabled? Perhaps they have a moral intuition that intentionally facilitating or inflicting death is wrong. Patients expect an empathic presence from their physicians, and authentic healers commit to accompanying patients throughout the illness trajectory.

Referring to physician-assisted suicide as “treatment” is a new rhetorical tool that is used by the advocates of euthanasia. The goal is to make assisted suicide seem less alarming to the public and to promote the idea that legalizing the practice is just another small step along a path already taken and ethically approved. By intentionally confusing physician-assisted suicide with legitimate palliative care, pro-euthanasia advocates hope that the public will conclude that it is a medically and ethically accepted end-of-life treatment.

For palliative care to remain a healing intervention, it cannot include “therapeutic homicide.” Euthanizing and healing are intrinsically incompatible. Involvement of physicians in such interventions is unethical and harms the fundamental role of the doctor as healer.

 

 

 

 

 

 

OPTION 2

Physician-Assisted Suicide Should Be Permitted

Nikola Biller-Andorno, M.D., Ph.D.

To many of us — physicians and nonphysicians alike — death appears as a menace, as something we fear and want to avoid at all cost. At the same time, most of us know someone for whom death has come as a relief. These deaths were sometimes long-awaited or they were actively sought out, prepared for in secrecy, and endured alone. For those persons, the opportunity to ask a competent professional for assistance in ending their lives in a legally and socially accepted way would be a clear improvement. Mr. Wallace is fortunate that this is an option in the state in which he lives and that he can discuss it openly with his family and his physician.

The role of physicians is not simply to preserve life but also to apply expertise and skills to help improve their patients’ health or alleviate their suffering. The latter includes providing comfort and support to dying patients. Such patients may, after careful consideration, come to the conclusion that in their particular situation, asking a physician for assistance in suicide best reflects their interests and preferences. Responding to such a carefully considered request can be compatible with the goals and ethos of medicine, as well as with a trusting patient–physician relationship.

There is broad consensus about the importance and desirability of palliative medicine and hospice care, and physician-assisted suicide is in no way a repudiation of those practices. Yet in some cases, symptoms cannot be sufficiently controlled; in many other instances, what is at stake is a perceived loss of autonomy and dignity. Some patients wish to proactively shape the end of their life; to those patients, taking action to end their life is better than passively waiting for death to occur.

Physician-assisted suicide is now legal in a number of states in the United States, including Oregon and Washington State, as well as in Switzerland and in the Netherlands. The data from these places show that the implementation of physician-assisted suicide, when it is accompanied by certain safeguards (including comprehensive screening and informed consent processes), does not lead to uncontrolled expansion or abuse. In Switzerland, the number of assisted suicides has risen steadily over the past decade, but the total number of suicides has declined. The data from Oregon and Washington show that the majority of persons who request physician-assisted suicide are white, educated men — not a population that would be considered particularly vulnerable. Also, only a minority of persons who inquire about suicide assistance actually complete the process; this indicates that the option is perceived as a choice that can be abandoned.

Even in societies with broad public support for physician-assisted suicide, a certain uneasiness and ambivalence remain, particularly among physicians who have to carry the emotional burden and moral responsibility of having enabled someone to end his or her life. The decision to provide suicide assistance cannot be forced on physicians but needs to be left to their individual conscience. However, if a physician is prepared to respond to a request for assistance in suicide, there are no compelling ethical reasons not to allow that physician to do so. In any case, careful regulation, comprehensive monitoring, and an ongoing critical debate are required to ensure that physician-assisted suicide remains a choice that is based on caring relationships among the patient, the family, and health care professionals.

 

Article found in “The New England Journal of Medicine” : http://www.nejm.org/doi/full/10.1056/NEJMclde1302615#t=cldeOpt1

 

COMMENT

Euthanasia is a very controversial issue worldwide. Many people argue that euthanasia is against the ethics of medicine, because the duty of a doctor is to keep the patient alive. From my point of view, I think that it’s inhuman that a person suffers from a disease that will eventually lead to death. People usually make all the decisions about life: in education, at work, in case of organs donation or what to do after death. It’s evident that the patient also has rights to decide if he must die with dignity. In the same way, must be the family who decides about the death of a patient in a coma, because they are who knows best about the patient’s wishes.

I think that euthanasia should be legalized as long as the person who decides it’s fine psychically and psychologically. It’s important that the patient decides it with the necessary medical information and knowing that there are more options.

We still unknown many things about the death. A lot of people choose to accept the religious beliefs that they had learned since they were kids, and some of them can die in peace with that. But what it happens, can or not, correspond to those beliefs. And because of that, people should know all available information about their lives, always bearing in mind that there are different options and respecting their religious beliefs.

Definitely, I think that a patient should have all freedom to decide about his life, but always under ethical and legal criteria and bearing in mind that he knows all the different options and that no one is pressuring him to decide. 

 

LUCÍA PÉREZ SILVESTRE

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Pressing Patients to Change Their Minds

 Pressing Patients to Change Their Minds

 By BARRON H. LERNER, M.D

.

When my patient Suzy took herself off the active liver transplant list, she was too embarrassed to tell me. I found out from her liver doctors.

When I confronted her, we discussed her reasoning. I told her I would continue to support and care for her. But as her longtime physician, I had to ask myself a question: Did I have some type of duty to get Suzy to change her mind?

Suzy was first found to have primary biliary cirrhosis, a severe liver disease, in the late 1990s. By 2005, when she became my patient, she had developed partial liver failure with a swollen abdomen. When the liver specialists told her she would eventually need a transplant, she agreed to go on the active list, which would put in her line to receive a donor organ. That would not occur, however, until she was much sicker.

Meanwhile, Suzy was gradually deteriorating. Fluid accumulated in her chest cavity, which caused shortness of breath and required frequent drainage. I was glad a transplant was in her future.

So Suzy’s decision to leave the active transplant list stunned me. The reason, she explained, was religious. Hailing from Mauritius, Suzy was raised a Catholic but had converted to the Pentecostal church, a branch of evangelical Protestantism that emphasizes personal experiences with God.

She had recently had a discussion with the pastor of her church, who told her how God had healed his own illness. He added that he would never submit to surgery.

 

Although the pastor never told Suzy to decline a transplant, she was moved by his story and concluded that if she showed the same type of faith, God would provide a “miracle of healing.” Suzy’s husband, also Pentecostal, supported her decision.

 The liver specialists involved in Suzy’s case were upset. But they told her they would keep her on the “inactive list” in case she changed her mind.

 Meanwhile, they made sure that Suzy understood the medical ramifications of her decision. Her liver would continue to worsen, and at some point she would die without a transplant. Moreover, even if Suzy eventually changed her mind, she might have become too sick by then to be saved by a transplant. The liver doctors were persistent, bringing Suzy back several times to remind her of her dire prognosis. They had her bring her children to an appointment, hoping that they would convince their mother to change her mind.

 I wanted to do even more. Suzy had been my patient for years. I also took care of her mother, her husband and one of her best friends. As someone who teaches bioethics, I wanted to respect her choice and her religious beliefs — but if I was too understanding, I might actually be “doing harm,” something physicians must always avoid. Moreover, I was not convinced that Suzy’s decision reflected her actual wishes.

When I spoke to Dr. Eva Sotil, her liver doctor, she agreed. While Jehovah’s Witness patients consistently reject specific medical interventions, most notably blood transfusions, Pentecostal teachings stress “divine healing” but do not prohibit surgery or transplants, she pointed out.

 I also kept thinking about a former patient of mine with severe liver disease who had come to my office one morning extremely ill with a blood infection. Another patient might have survived, but her liver was too diseased. She died in intensive care. I wanted to avoid a similar situation with Suzy.

 So I decided to apply some pressure. A 2010 article in the journal Annals of Family Medicine argues for “beneficent persuasion” when patients make counterproductive decisions not in their long-term interest. In this spirit, I cajoled Suzy. I brought up the topic at each visit, continually asking why her religious beliefs precluded a transplant. I also asked to speak to her husband and children. I offered to attend her next liver clinic appointment, thinking that a larger group of physicians might be more persuasive.

I even told her at a December clinic visit that the best Christmas present she could give me would be to go back on the active transplant list.

 Ultimately, as her medical condition worsened, Suzy changed her mind. Her children were now arguing for the transplant. And Suzy had asked God for a vision telling her to decline a new liver. When she did not receive one, she decided to return to active status.

 One day the following summer, I got an e-mail from the liver transplant team telling me that Suzy had undergone a successful liver transplant. I was working at a different hospital, but called Suzy right away. She was elated. Her massively swollen body was returning to normal, and she was no longer short of breath.

 I asked her how she reconciled her faith with having the transplant. She told me that she had prayed to God to get a good liver. “He healed me through surgery,” she explained.

 She also had kind words for her doctors. Without us, she said, “I probably would not be here.”

 It had been nagging me whether I might have crossed some line in Suzy’s case, applying undue pressure against her right to choose. Perhaps I had. But hearing the joy in her voice, I felt justified.

Dr. Barron H. Lerner, a professor of medicine at New York University School of Medicine, is the author of “The Breast Cancer Wars” and “When Illness Goes Public.“

Article found in The New York Times, Health news.

http://well.blogs.nytimes.com/2013/05/09/pressing-patients-to-change-their-minds/

 

USEFUL VOCABULARY:

– cajole: persuade

– undue: inappropiate

– hail from: natural of some place

– nag: annoy

 COMMENT

I had chosen this article because I think that it could be interesting. It talks about a very important thing in medicine, that sometimes is more difficult than treat or diagnoses an illness: it talks about the ethic.  I think that in medical practice there are many situations like this one that implies an issue for the doctor and , in my opinion, it´s important to know how to deal with them.

In Spain there is a good iniciative that are the  Ethics Committees . This committees are  a multidisciplinary group of persons of a sanitary institution .They have the task of giving advise to the doctors in their decisions about the ethical  questions that come up in their clinical practice.

It is very useful to help the doctors in some ethical issues  relating to end of life care, abortion, genetic and prenatal testing, organ donation, religious problems… because in many situations it´s not easy  to make a decision.

Related to this case I  agree with the performance of the doctor but  i find complicated  to be sure about how to bring the situation.. On the one hand,  you have to care your patient, and you have to do the best thing for.her. On the other hand , you must respect her  opinion   because  she is capable  to decide.

So, I think that what  I would do is to give her an advise about the things that may pass if she rejects the transplant and try to convince her that it isn´t a good decision, because if she accepts she will live more years . I would  talk with the other doctors  and I don´t know if I ´d talk  with her family because in my opinion  that it is a personal decision  and I think that this can be too much involvement.

In this case, I find  the situation more complicated because the doctor knows this patient for years  and he also has relation with her family. So,  when you have a closely relation is more difficult to know how you have to perform .

In my opinion, it´s a hard part of our future work because it´s a thing that you can´t  search in books , and it depends of many factors.  It´s a subjective matter no like treatment or diagnoses.  When you make a decision, people will think you are right and other people  will think that you´re wrong

I think that what you have to do is trying to do the best for your patient, having  arguments to defend your opinion, but always respecting the opinion of the others, specially your patient´s opinion. 

Finally, what do you think about ethics? Do you agree with this  doctor ? What would you do in this case? .

 

 CRISTINA DE LLANO SÁNCHEZ

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Increase potassium and cut salt to reduce stroke risk

Increase potassium and cut salt to reduce stroke risk

Increasing potassium in our diets as well as cutting down on salt will reduce blood pressure levels and the risk of stroke, research in the British Medical Journal suggests.

One study review found that eating an extra two to three servings of fruit or vegetables per day – which are high in potassium – was beneficial. A lower salt intake would increase the benefits further, researchers said. A stroke charity said a healthy diet was key to keeping stroke risk down.

While the increase of potassium in diets was found to have a positive effect on blood pressure, it was also discovered to have no adverse effects on kidney function or hormone levels, the research concluded. As a result, the World Health Organisation has issued its first guidelines on potassium intake, recommending that adults should consume more than 4g of potassium (or 90 to 100mmol) per day.

The BMJ study on the effects of potassium intake, produced by scientists from the UN World Food Programme, Imperial College London and Warwick Medical School, among others, looked at 22 controlled trials and another 11 studies involving more than 128,000 healthy participants. The results showed that increasing potassium in the diet to 3-4g a day reduced blood pressure in adults. This increased level of potassium intake was also linked to a 24% lower risk of stroke in those adults. Researchers said potassium could have benefits for children’s blood pressure too, but more data was needed.

Salt solution

A separate study on salt intake, led by researchers at the Wolfson Institute of Preventive Medicine, Queen Mary, University of London, analysed the results of 34 previous trials involving more than 3,000 people.

 It found that a modest reduction in salt intake for four or more weeks caused significant falls in blood pressure in people with both raised and normal blood pressure. This happened in both men and women, irrespective of ethnic group. Lower blood pressure levels are known to reduce the risk of stroke and heart disease.

Graham MacGregor, professor of cardiovascular medicine at Queen Mary, who led the study, said that the “modest reduction” in salt intake was equivalent to halving the amount of salt we consume each day. “In the UK on average our dietary salt intake is 9.5g, so we are talking about bringing this down to 6g, or if you’re very careful you can get it down to the recommended 5g – but it’s very difficult because of the amount of salt already in the food we buy. “Bread is the biggest source of salt in our diet.”

Long-term target

He added that a further reduction in salt intake to 3g per day would have a greater effect on blood pressure and should become the long-term target for population salt intake. Getting people to eat more fruit and vegetables containing potassium was equally important, he said. “Salt and potassium work in opposing ways. So a combination of lower salt and higher potassium in our diets has a bigger effect than changing just one of those factors alone.”

Clare Walton, research communications officer at the Stroke Association, said high blood pressure was the single biggest risk factor for stroke. “We know that making changes to your diet can go a long way to keeping your blood pressure under control. “This research suggests that reducing your salt intake and eating more potassium-rich foods such as bananas, dates and spinach could reduce blood pressure and keep your risk of stroke down.”

The World Health Organisation recommends that adults should not consume more than 5g of salt a day (about one teaspoon). The UK National Institute for Health and Care Excellence (NICE) recommends that salt intake should be reduced to 3g a day in the UK adult population by 2025.

 

BBC News- Health 5 April 2013

http://www.bbc.co.uk/news/health-22025341

 

 

Useful vocabulary:

Stroke: apoplejía/ derrame cerebral

Charity: organización benéfica

Average: promedio/ media

Target: meta/ propósito

To issue: publicar

To link: enlazar/ unir

Led (to lead): guiado (guiar)

Halving (To halve): reducir a la mitad

 

 

Text commentary:

This is an article found in the BBC News-Health. I found it completely interesting because of the high percentage of people suffering from hypertension in our society at present, which is one of the most important cardiac risk factors and the most dangerous one associated with the risk of having a stroke.

The author of this text, based on the results of different studies, tries to inform that reducing the amount of salt intake and increasing potassium in the diet can lower blood pressure in adults, and it is an essential key not only to prevent people from having a stroke, but also from a heart attack, an angina and a sudden death syndrome.

Potassium is an important mineral that controls the balance of fluids in the body and helps lower blood pressure. It is found in most types of food, but particularly in fruit, such as bananas, vegetables, pulses, nuts and seeds, milk, fish, chicken and bread. It is recommended that adults consume around 4g of potassium a day (or at least 90-100mmol). That is equivalent to five portions of fruit and vegetables a day.

In my opinion, people should be aware of the importance of having a healthy and balanced diet in order to avoid a preventable disease. It is completely easy to eat properly, increasing the amount of this kind of “healthy food” and cutting down on others, like salt and sugar, that are just the opposite of beneficial for our blood pressure. Therefore, we can conclude with it saying that “Prevention is better than cure”.

What do you think about it? I would like you to give your opinion about the necessity of eating in a healthy way in relation to prevent cardiovascular and other important diseases. I think we can debate about this relevant issue, and also if you have another great idea to add! 

Publicado en Uncategorized | 8 comentarios

Medical residents work long hours despite rules

To reduce errors by doctors in training, medical educators have capped how long they can work. But enforcing the limits can be a challenge.

More than 10 years after she was a internal medicine resident, Dr. Vineet Arora still thinks about how her shifts used to end.

She says the best shift change was one that didn’t require her to transfer single patient to the next bunch of residents. “A good sign out was ‘nothing to do,’ ” she recalls. “When I trained, you worked here until your work was done.”

But things have changed a lot since then. Now, Arora is the associate director of the University of Chicago’s internal medicine residency program. And the residents she supervises aren’t allowed to work indefinitely long shifts.

Rules implemented nationally in 2003, and tightened last year, put a hard cap on the length of residents’ shifts: no more than 16 hours for first-year residents or interns, and no more than 28 hours in one shift for others.

The rules came down from the Accreditation Council for Graduate Medical Education, which was responding to a series of front page headlines about overworked residents and interns making life-threatening mistakes. The most famous of these was the Libby Zion case, in which an 18-year-old died at New York Hospital in 1984 while under the care of a first-year resident working a 36-hour shift.

 

 

New Rules On Medical Residents’ Hours Spur Debate

 

While the rules may have changed, the situation inside many hospitals hasn’t budged as much as you might have expected.

A 2008 study of three hospitals found that 87 percent of interns reported working past their shift limits. Two other studies, from 2006 and 2010, found that doctors routinely lie when reporting the number of hours they worked to get around the shift restrictions.

In a commentary in this week’s JAMA, the Journal of the American Medical Association, Arora argues that flouting of the rules can be dangerous.

Working too long without a break and without sleep can lead to more errors, she says. Another study published in this week’s JAMA found that interns who weren’t given a break between shifts of at least five hours slept an average of less than two hours a night. Interns who slept longer were significantly more alert the next day.

Beyond patient safety, Arora says working extra hours on the sly raises ethical issues. “If you lie about your hours, are you more likely to lie about other things?” she tells Shots. “You’ve already engaged in misdocumentation.”

Arora says the reasons why this happens lie deep in hospitals’ work culture. She says some doctors who did their residencies before the new shift rules went into effect look down on new residents — something Arora calls “generation bashing.”

Residents can pick up on this and, as a result, feel the need to work longer hours and fudge their time sheets to impress their more senior colleagues.

“In our program, we let our residents know that we don’t want them to stay,” Arora says. The rules on shift length “are not going away. Engaging in generation bashing is counterproductive.”

Dr. Joanne Conroy, the chief health care officer at the Association of American Medical Colleges, says the new rules on work hours are not at odds with the longstanding principle of medical professionalism. “Nobody would actually want residents to not feel accountable and responsible for their patients,” she says. But “that requires that they be rested and that they be ready.”

 

 

 

Some vocabulary: 

-Bunch: Group, team

-Cap: Cover, plug

-Spur: Stimulate, encourage

-Budge: Move, assign

-Flouting: Disobeying

-On the sly: Secretly

-Bashing: beating, whipping, thrashing

-Fudge: Avoid

 

I consider this article could be interesting for us because in a few years we’ll be residents in a hospital. We know that when we’ll be residents we’ll do too many hours and many shifts, and more or less we accept that because it has been done for ages. But nowadays there have been some changes to improve the quality of life of the residents while they are doing the residence. I think that these changes are necessary because it could provide more efficiency and fewer mistakes. If a resident didn’t sleep a required number of hours or was awake too many hours, there would be more probabilities that the resident could cause some mistakes which could have been avoided.

However, there are some doctors who don’t agree with that because they say that the residence is a period of time where residents learn a lot, and if they do less hours, they will learn less. On the other hand, some doctors say that residents should work in suitable conditions to prescribe the right things, because it is known that many mistakes have been done by residents who were working many hours without any break.

So as you see, there are too many opinions about this item and I’d like to know what you think about that; and also I’d like to know if you think that the system of our country is a good one, and if not, what you would do to improve it.

 

SANDRA SORIANO SÁNCHEZ

Publicado en Uncategorized | 7 comentarios

Neurology Now Magazine

Neurology Now

March/April 2007

 Volume 3(2)

 

When you hear the word epilepsy, what comes to mind? Hollywood usually shows us the convulsions of the grand mal seizure, but the seizures caused by temporal lobe epilepsy are more common, if less obvious.

During a temporal lobe seizure, a person can be overcome by intense emotions, vivid memories-even sensory hallucinations. And accumulating evidence suggests that people with epilepsy are prone to developing depression and other mood disorders, while people with a history of depression develop epilepsy four to seven times more often than average.

Fortunately, the seizures caused by temporal lobe epilepsy can be controlled by an array of medications, many of which also improve mood. If the medications don’t work, and if the brain lesion causing the seizures can be located, it can be surgically removed, often leaving the patient both seizure- and depression-free.

THE SEAT OF EMOTION

The temporal lobes, which ride the brain like saddlebags, each contain an almond-shaped structure called the amygdala that generates an emotional reaction to our sensory perceptions. Presented with the smell of smoke, the amygdala may generate fear, until we realize that the smoke is coming from a neighbor’s grill. Then, at the thought of juicy hamburgers, the amygdala may generate excitement.

When we see or hear something, the amygdala tells us if it’s frightening or sexually arousing or whatever, says David Bear, M.D., a neurologist in the department of psychiatry at the University of Massachusetts. It adds the emotional charge to our experiences. When the amygdala is removed from both hemispheres of an animal’s brain, the animal doesn’t show fear, it doesn’t become aggressive, and it may try to mount animals of both sexes. It doesn’t even do a good job of determining what’s good to eat! A monkey without an amygdala may try to bite a piece of metal.

Temporal lobe epilepsy often creates the opposite situation: the amygdala generates too much emotion, which can result in mood disorders.

EPILEPSY AND PERSONALITY

What did Joan of Arc and Fyodor Dostoyevsky have in common? They both showed signs of Geschwind syndrome, a group of personality traits that seem to result from the epileptic storms that excite the temporal lobes.

The most common traits of Geschwind syndrome-excessive writing or hypergraphia, intense interest in religion, a clingy personality, aggression, and altered sexuality-are not inherently abnormal. What one person considers hyperreligious behavior another might consider admirable piety. A sticky personality can be viewed as devotion to friends. Hypergraphia can propel a writer to literary achievement, as in the case of Dostoyevsky. Aggression can be seen as a sign of intense passion, and loss of interest in sex as high-minded celibacy.

In addition, the intensity of emotion caused by temporal lobe epilepsy can be captivating. For religious leaders such as Joan of Arc, this passion may have deepened their spiritual feelings and attracted followers.

People with temporal lobe epilepsy are like everyone else, only more so, says Eve LaPlante, author ofSeized, a fascinating look at how temporal lobe seizures have affected the lives of the famous, the infamous, and the ordinary.

DEPRESSION AND EPILEPSY

Depression affects about 20 to 40 percent of people with temporal lobe epilepsy, compared to 3 to 7 percent in the general population. This depression often yields to the antidepressants known as selective serotonin reuptake inhibitors (SSRIs), which are the first choice of treatment. Anti-epileptic drugs can help too.

The dance between epilepsy and depression is complex: People with epilepsy often can’t drive or hold a job, problems that can interfere with their quality of life and lead to depression. Still, the interplay suggests that a common underlying problem promotes both conditions. Magnetic resonance imaging (MRI) often shows that the hippocampus in the temporal lobe of a depressed person shrinks, along with areas farther forward in the brain. These changes are common in people with temporal lobe epilepsy as well.

You see the same changes in people with primary mood disorders without temporal lobe epilepsy as you see in people with temporal lobe epilepsy, says Andres M. Kanner, M.D., director of the electroencephalography (EEG) lab at the Rush Epilepsy Center in Chicago.

This means that some medications work for both. Antiepileptics such as lamotrigine (Lamictal) and valproic acid (Depakote, Depakene) are also used to treat bipolar disorder in people without epilepsy, says Brien Smith, M.D., medical director of the Comprehensive Epilepsy Program at Henry Ford Hospital in Detroit.

One link between temporal lobe epilepsy and mood disorders is the neurotransmitter serotonin. Seizures can be induced in animals by sending electricity into their brain; subsequent seizures then become much easier to induce due to a process known as kindling. But if these animals receive antidepressants that boost their level of serotonin, the kindling stops, and seizures become much more difficult to induce.

This suggests there’s a serotonin dysfunction in both temporal lobe epilepsy and in mood disorders, says Kanner.

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I believe this reading to very interesting and also very suitable to what our studies are about these days.  We are studying at Psychiatry different mental disorders and we will be studying in a few months the neurological diseases. At this entry we can see how a pathoneurological status can influence in the mental behavior of the person, how the organic sickness of the patient can actually determine the patient personality. In this particular case it is show how epilepsy it is often match to a specific kind of personality which clinicians described as “a positive personality change among patients with chronic temporal lobe epilepsy”. It is the Epilepsy Personality Syndrome or Geschwind Syndrome. Besides the scientific point of view, History has passes us some stories about well-known personalities. There is a general belief in how part of their greatness was due to their supposed epilepsy illness. This is not a medical or scientific fact, but as a curious detail here are some of them: Julius Caesar, Alexander the Great, Napoleon, Vladimir Lenin, Dostoyevsky, Tolstoy,  …
In short just to say that I find, among other also interesting elements of the epilepsy , this subject about a superior-special personality, rather riveting.

 ANA NARBONA DIEZ

Publicado en Uncategorized | 7 comentarios

NHS foreign doctors must speak English, say ministers

By James GallagherHealth and science reporter, BBC News

Dr Daniel Ubani was struck off the UK medical register

 

Foreign doctors wanting to treat NHS patients in England will have to prove they have the necessary English skills, the government has confirmed.

Concerns were raised after a German doctor, Dr Daniel Ubani, gave a patient a fatal overdose on his first and only shift in the UK.

He had earlier been rejected for work because of poor English skills.

From April there will be a legal duty to ensure a doctor’s English is up to scratch before they are employed.

Foreign doctors will have to prove they can speak a “necessary level of English” before they are allowed to treat patients in hospitals or in GP surgeries, the Department of Health said.

Dr Ubani had been refused work by Leeds Primary Care Trust, but was later employed in Cambridgeshire.

From April, there will be a national list of GPs to prevent doctors being rejected in one part of the country and then cropping up somewhere else. GPs will have to prove their language skills before being put on the list.

 

Health minister Dr Dan Poulter said the measures were about protecting patients, who “should be able to understand and be understood by their doctor if we are to give them the best care they deserve”.

“These new checks will ensure that all doctors who want to work in the NHS can speak proficient English and to prevent those who can’t from treating patients,” he said.

New powers for the body which regulates doctors in the UK – the General Medical Council – are also being discussed. A change of law could give it powers to test the communication skills of doctors from within the EU as it already can for non-EU doctors.

Niall Dickson, chief executive of the GMC, said tighter rules would “strengthen patient safety”.

He added: “Our position is clear – patients must be confident that the doctor who treats them has the right communications skills to do the job.

 

“If doctors cannot speak English to a safe standard then the GMC must be able to protect patients by preventing them from practising in the UK.

“At present we can do that for doctors who have qualified outside Europe but we cannot do it for doctors within the European Union.

“We have been working hard for some time to close this loophole in UK legislation which has caused so much concern to patients and their families and we are delighted that the government has decided to act.”

Katherine Murphy, chief executive of the Patients Association, said: “New language checks for doctors are welcome, and long overdue.

“Lessons from the past have served to highlight the tragic consequences of poor language skills.”

Dean Royles, director of the NHS Employers organisation, said foreign doctors had made an “invaluable contribution” but safety needed to be the “top priority”.

 

Some vocabulary:

–          NHS: british national health system

–          To shift: to change

–          To scratch: to cuto r make a mark on something with a sharp thing.

–          GP: general practitioner

–          Loophole: a way of escaping a difficulty.

–          Overdue: late

 

I have chosen this article because I consider it’s quite interesting for us to know that in the future if we want to work abroad, particularly in England, we do have english skills.

I think that getting on with the pacient is more important than diagnose him/her, if we can’t understand what the pacient is telling us, we won’t arrive to a good diagnosis, as it happens in the article.                   

Many diseases don’t have cure, so what the pacient needs is not only someone who tries to cure him but also someone who listens and encourages him, and without a good level of english it won’t be possible.

As a medical student, I think we must practise our english so that we can’t forget it during our degree, because probably we will need it during our career even though we rest here in Spain working.

I would like you to give your opinion about the importance of knowing  languages in our career and about the possibility doctors have to make mistakes in the diagnosis or treatment.

Minientrada | Publicado el por | 9 comentarios