Kerri Wachter

TAMPA — When conflicts over end-of-life care arise, try to understand the conflict and keep the lines of communication open, said three experts in palliative medicine at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“There's no question that conflicts will occur. The question is how to approach them,” said Dr. Kimberly S. Johnson, an attending physician at the Duke University Center for Palliative Care in Durham, N.C.

“The challenge for us is to be able to recognize the conflict and the nature of the conflict,” said Jennifer Gentry, an adult and geriatric nurse practitioner at the center.

Conflicts can arise when there are different views of the expected roles of family members and of the medical team, noted Dr. Toni Cutson, an attending physician at the center.

Physicians should remember that the family could have a history of problems before the medical team enters the picture. “We're not marriage or family counselors,” Dr. Cutson said. “We're certainly not asked to fix these relationships.” In addition, the team doesn't always know all of the facts. Even the “villain” has his own side to the story. In the case of an unsupportive husband, he might be trying to protect his children from their mother's illness and decline.

“When you see conflict, you're going to see emotion,” Ms. Gentry said. In handling emotions that arise in situations of conflict, she recommends remembering the mnemonic acronym NURSE: name the emotion; understand and relate to that emotion; respect everyone's feelings; support the patient; and explore the emotion by asking the patient and family to tell you more.

“Clear communication and transparency are important tools to resolve conflict,” Dr. Johnson said. Take the time to find out what the patient's and family's goals are, and avoid making assumptions, particularly about a patient/family's culture and relationships, Ms. Gentry advised.

When faced with a patient and family members experiencing conflict, Ms. Gentry recommended that physicians do the following:

▸ Try to understand that each family member might be at a different stage in terms of acceptance of a terminal illness.

▸ Realize that prior family conflict could be contributing to the current conflict over care.

▸ Try to define areas of agreement and disagreement to clarify the problem.

▸ Try time-limited trials of therapies to allow the family more time to make decisions.

▸ Have follow-up meetings to discuss concerns about care.

▸ When appropriate, suggest the family consult a psychiatric professional, ethics consultant, or spiritual adviser.

TAMPA — When conflicts over end-of-life care arise, try to understand the conflict and keep the lines of communication open, said three experts in palliative medicine at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“There's no question that conflicts will occur. The question is how to approach them,” said Dr. Kimberly S. Johnson, an attending physician at the Duke University Center for Palliative Care in Durham, N.C.

“The challenge for us is to be able to recognize the conflict and the nature of the conflict,” said Jennifer Gentry, an adult and geriatric nurse practitioner at the center.

Conflicts can arise when there are different views of the expected roles of family members and of the medical team, noted Dr. Toni Cutson, an attending physician at the center.

Physicians should remember that the family could have a history of problems before the medical team enters the picture. “We're not marriage or family counselors,” Dr. Cutson said. “We're certainly not asked to fix these relationships.” In addition, the team doesn't always know all of the facts. Even the “villain” has his own side to the story. In the case of an unsupportive husband, he might be trying to protect his children from their mother's illness and decline.

“When you see conflict, you're going to see emotion,” Ms. Gentry said. In handling emotions that arise in situations of conflict, she recommends remembering the mnemonic acronym NURSE: name the emotion; understand and relate to that emotion; respect everyone's feelings; support the patient; and explore the emotion by asking the patient and family to tell you more.

“Clear communication and transparency are important tools to resolve conflict,” Dr. Johnson said. Take the time to find out what the patient's and family's goals are, and avoid making assumptions, particularly about a patient/family's culture and relationships, Ms. Gentry advised.

When faced with a patient and family members experiencing conflict, Ms. Gentry recommended that physicians do the following:

▸ Try to understand that each family member might be at a different stage in terms of acceptance of a terminal illness.

▸ Realize that prior family conflict could be contributing to the current conflict over care.

▸ Try to define areas of agreement and disagreement to clarify the problem.

▸ Try time-limited trials of therapies to allow the family more time to make decisions.

▸ Have follow-up meetings to discuss concerns about care.

▸ When appropriate, suggest the family consult a psychiatric professional, ethics consultant, or spiritual adviser.

TAMPA — When conflicts over end-of-life care arise, try to understand the conflict and keep the lines of communication open, said three experts in palliative medicine at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“There's no question that conflicts will occur. The question is how to approach them,” said Dr. Kimberly S. Johnson, an attending physician at the Duke University Center for Palliative Care in Durham, N.C.

“The challenge for us is to be able to recognize the conflict and the nature of the conflict,” said Jennifer Gentry, an adult and geriatric nurse practitioner at the center.

Conflicts can arise when there are different views of the expected roles of family members and of the medical team, noted Dr. Toni Cutson, an attending physician at the center.

Physicians should remember that the family could have a history of problems before the medical team enters the picture. “We're not marriage or family counselors,” Dr. Cutson said. “We're certainly not asked to fix these relationships.” In addition, the team doesn't always know all of the facts. Even the “villain” has his own side to the story. In the case of an unsupportive husband, he might be trying to protect his children from their mother's illness and decline.

“When you see conflict, you're going to see emotion,” Ms. Gentry said. In handling emotions that arise in situations of conflict, she recommends remembering the mnemonic acronym NURSE: name the emotion; understand and relate to that emotion; respect everyone's feelings; support the patient; and explore the emotion by asking the patient and family to tell you more.

“Clear communication and transparency are important tools to resolve conflict,” Dr. Johnson said. Take the time to find out what the patient's and family's goals are, and avoid making assumptions, particularly about a patient/family's culture and relationships, Ms. Gentry advised.

When faced with a patient and family members experiencing conflict, Ms. Gentry recommended that physicians do the following:

▸ Try to understand that each family member might be at a different stage in terms of acceptance of a terminal illness.

▸ Realize that prior family conflict could be contributing to the current conflict over care.

▸ Try to define areas of agreement and disagreement to clarify the problem.

▸ Try time-limited trials of therapies to allow the family more time to make decisions.

▸ Have follow-up meetings to discuss concerns about care.

▸ When appropriate, suggest the family consult a psychiatric professional, ethics consultant, or spiritual adviser.

TAMPA — Physicians caring for older adults at the end of life commonly have to treat these patients for urinary incontinence and delirium and often must decide whether the use of feeding tubes would be helpful.

Several experts offered their tips on dealing with these challenges at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Urinary Incontinence

Urinary incontinence is a troubling and common concern among older patients and is an independent predictor of nursing home placement. Urinary incontinence erodes a patient's quality of life through social withdrawal, body image distortion, and depression, said Dr. Lynn Bunch of Mount Sinai Medical Center in New York. This condition also increases caregiver burden because of the need for frequent changes of undergarments and the extra work involved in preventing and treating skin breakdown.

All palliative care patients should routinely be assessed for urinary incontinence, Dr. Bunch said. If the onset is acute, do a medical evaluation to look for a reversible cause, she said. Reversible causes include urinary tract infection, volume overload, stool impaction, hyperglycemia, hypercalcemia, vaginitis, and urethritis. A review of medications also is important, looking in particular for diuretics (which can increase urinary output), sedatives (which impair mobility and cognition), anticholinergics (which decrease bladder contractility), and α-adrenergics (which alter sphincter tone).

Functional incontinence—an inability to reach the toilet in time and/or coordinate the movements necessary to use the toilet—is common in the palliative care setting because many of these patients have functional decline and loss of mobility. Interventions for functional incontinence include physical rehabilitation, use of assistive devices, space planning/furniture rearrangement, use of a bedside commode, assistance with transfers, elimination of chemical/physical restraints, treatment of depression, scheduled voiding times, decreased intake of fluids at night, and discontinuation of or change of dosing time for diuretics.

It's important to talk with families of palliative care patients about functional urinary incontinence, Dr. Bunch said. Advise caregivers that all patients with life-limiting disease, especially those with dementia, will eventually develop functional urinary incontinence. Provide families with support and resources for this eventuality.

Chronic indwelling catheters have the advantages of protecting skin from moisture, making patient care easier, and decreasing the need for linen and clothing changes. However, they may be uncomfortable for patients, and because they limit patient mobility, they may contribute to delirium and agitation, which is a symptom of delirium. The decision to catheterize at the end of life should be individualized, Dr. Bunch said.

Delirium

The mortality rate of hospitalized patients with delirium ranges from 22% to 76%, and the 1-year mortality rate associated with delirium is roughly 35%–40%. The diagnosis of delirium is primarily clinical, and the condition often goes unrecognized. “Often, we fail to do a formal cognitive assessment,” said Dr. Elise C. Carey, an internal medicine physician who specializes in geriatrics at the Mayo Clinic in Rochester, Minn.

When a patient becomes agitated, determine if it represents an acute change in mental status, and perform a cognitive assessment and an evaluation for delirium using a tool like the Confusion Assessment Method. Identify and address any predisposing or precipitating factors. It's important to remember that delirium is often the sole manifestation of underlying disease. “I can't emphasize this enough,” Dr. Carey said.

Evaluate the patient for new or intercurrent illness: Take a history, do a physical exam, run selected lab tests, and get an ECG. Also look for infection, low blood volume, pressure sores, and poor nutrition. Review the patient's medications, looking for potential troublemakers—such as anticholinergic effects, narcotic pain medications, and benzo-diazepines—and replacing them with alternatives that are less likely to cause delirium. Evaluate environmental factors that may be contributing to the patient's agitation—such as recently performed surgery or multiple procedures, a room change, an ICU stay, sleep deprivation, the use of restraints or bladder catheters, and pain. Then take the necessary steps to treat any identified causes, provide supportive care, and prevent complications.

In terms of treating behavioral symptoms, “primarily we're going to try to rely on nonpharmacologic therapies,” Dr. Carey said. Such an approach includes reorienting patients to their surroundings, encouraging family involvement, having people sit with the patient, avoiding the use of indwelling catheters and of restraints, working to maintain the patient's mobility and self-care ability, and normalizing the patient's sleep-wake cycle.

In cases of severe agitation, pharmacologic treatment may be necessary. The first-line therapy is low-dose haloperidol (Haldol), at 0.5–1.0 mg twice daily plus every 4 hours as needed, Dr. Carey said.

Feeding Tubes

Difficulties with eating are a hallmark of end-stage dementia, said Dr. Rachelle E. Bernacki, a hospitalist, geriatrician, and palliative medicine specialist with the University of California San Francisco Medical Center's palliative care service. Approximately one-third of U.S. nursing home residents with advanced dementia are tube fed, but the number of tube-fed dementia patients varies 10-fold across the country.

Tube feeding commonly is used to prevent aspiration pneumonia and provide nutrition in patients who have trouble eating normally. However, no randomized, controlled trials of tube feeding have been published; of the observational studies in the literature, none have shown a reduction in the risk of aspiration and aspiration pneumonia. There is also no evidence of improved nutritional status with the use of feeding tubes, and it does not appear to prolong survival, Dr. Bernacki said.

There are several drawbacks to the use of feeding tubes. The patient does not experience any gustatory pleasure, may experience discomfort, and has diminished social contact.

“As with everything in palliative care, always try to use the goals of therapy as your guide,” Dr. Bernacki said.

TAMPA — Physicians caring for older adults at the end of life commonly have to treat these patients for urinary incontinence and delirium and often must decide whether the use of feeding tubes would be helpful.

Several experts offered their tips on dealing with these challenges at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Urinary Incontinence

Urinary incontinence is a troubling and common concern among older patients and is an independent predictor of nursing home placement. Urinary incontinence erodes a patient's quality of life through social withdrawal, body image distortion, and depression, said Dr. Lynn Bunch of Mount Sinai Medical Center in New York. This condition also increases caregiver burden because of the need for frequent changes of undergarments and the extra work involved in preventing and treating skin breakdown.

All palliative care patients should routinely be assessed for urinary incontinence, Dr. Bunch said. If the onset is acute, do a medical evaluation to look for a reversible cause, she said. Reversible causes include urinary tract infection, volume overload, stool impaction, hyperglycemia, hypercalcemia, vaginitis, and urethritis. A review of medications also is important, looking in particular for diuretics (which can increase urinary output), sedatives (which impair mobility and cognition), anticholinergics (which decrease bladder contractility), and α-adrenergics (which alter sphincter tone).

Functional incontinence—an inability to reach the toilet in time and/or coordinate the movements necessary to use the toilet—is common in the palliative care setting because many of these patients have functional decline and loss of mobility. Interventions for functional incontinence include physical rehabilitation, use of assistive devices, space planning/furniture rearrangement, use of a bedside commode, assistance with transfers, elimination of chemical/physical restraints, treatment of depression, scheduled voiding times, decreased intake of fluids at night, and discontinuation of or change of dosing time for diuretics.

It's important to talk with families of palliative care patients about functional urinary incontinence, Dr. Bunch said. Advise caregivers that all patients with life-limiting disease, especially those with dementia, will eventually develop functional urinary incontinence. Provide families with support and resources for this eventuality.

Chronic indwelling catheters have the advantages of protecting skin from moisture, making patient care easier, and decreasing the need for linen and clothing changes. However, they may be uncomfortable for patients, and because they limit patient mobility, they may contribute to delirium and agitation, which is a symptom of delirium. The decision to catheterize at the end of life should be individualized, Dr. Bunch said.

Delirium

The mortality rate of hospitalized patients with delirium ranges from 22% to 76%, and the 1-year mortality rate associated with delirium is roughly 35%–40%. The diagnosis of delirium is primarily clinical, and the condition often goes unrecognized. “Often, we fail to do a formal cognitive assessment,” said Dr. Elise C. Carey, an internal medicine physician who specializes in geriatrics at the Mayo Clinic in Rochester, Minn.

When a patient becomes agitated, determine if it represents an acute change in mental status, and perform a cognitive assessment and an evaluation for delirium using a tool like the Confusion Assessment Method. Identify and address any predisposing or precipitating factors. It's important to remember that delirium is often the sole manifestation of underlying disease. “I can't emphasize this enough,” Dr. Carey said.

Evaluate the patient for new or intercurrent illness: Take a history, do a physical exam, run selected lab tests, and get an ECG. Also look for infection, low blood volume, pressure sores, and poor nutrition. Review the patient's medications, looking for potential troublemakers—such as anticholinergic effects, narcotic pain medications, and benzo-diazepines—and replacing them with alternatives that are less likely to cause delirium. Evaluate environmental factors that may be contributing to the patient's agitation—such as recently performed surgery or multiple procedures, a room change, an ICU stay, sleep deprivation, the use of restraints or bladder catheters, and pain. Then take the necessary steps to treat any identified causes, provide supportive care, and prevent complications.

In terms of treating behavioral symptoms, “primarily we're going to try to rely on nonpharmacologic therapies,” Dr. Carey said. Such an approach includes reorienting patients to their surroundings, encouraging family involvement, having people sit with the patient, avoiding the use of indwelling catheters and of restraints, working to maintain the patient's mobility and self-care ability, and normalizing the patient's sleep-wake cycle.

In cases of severe agitation, pharmacologic treatment may be necessary. The first-line therapy is low-dose haloperidol (Haldol), at 0.5–1.0 mg twice daily plus every 4 hours as needed, Dr. Carey said.

Feeding Tubes

Difficulties with eating are a hallmark of end-stage dementia, said Dr. Rachelle E. Bernacki, a hospitalist, geriatrician, and palliative medicine specialist with the University of California San Francisco Medical Center's palliative care service. Approximately one-third of U.S. nursing home residents with advanced dementia are tube fed, but the number of tube-fed dementia patients varies 10-fold across the country.

Tube feeding commonly is used to prevent aspiration pneumonia and provide nutrition in patients who have trouble eating normally. However, no randomized, controlled trials of tube feeding have been published; of the observational studies in the literature, none have shown a reduction in the risk of aspiration and aspiration pneumonia. There is also no evidence of improved nutritional status with the use of feeding tubes, and it does not appear to prolong survival, Dr. Bernacki said.

There are several drawbacks to the use of feeding tubes. The patient does not experience any gustatory pleasure, may experience discomfort, and has diminished social contact.

“As with everything in palliative care, always try to use the goals of therapy as your guide,” Dr. Bernacki said.

TAMPA — Physicians caring for older adults at the end of life commonly have to treat these patients for urinary incontinence and delirium and often must decide whether the use of feeding tubes would be helpful.

Several experts offered their tips on dealing with these challenges at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

Urinary Incontinence

Urinary incontinence is a troubling and common concern among older patients and is an independent predictor of nursing home placement. Urinary incontinence erodes a patient's quality of life through social withdrawal, body image distortion, and depression, said Dr. Lynn Bunch of Mount Sinai Medical Center in New York. This condition also increases caregiver burden because of the need for frequent changes of undergarments and the extra work involved in preventing and treating skin breakdown.

All palliative care patients should routinely be assessed for urinary incontinence, Dr. Bunch said. If the onset is acute, do a medical evaluation to look for a reversible cause, she said. Reversible causes include urinary tract infection, volume overload, stool impaction, hyperglycemia, hypercalcemia, vaginitis, and urethritis. A review of medications also is important, looking in particular for diuretics (which can increase urinary output), sedatives (which impair mobility and cognition), anticholinergics (which decrease bladder contractility), and α-adrenergics (which alter sphincter tone).

Functional incontinence—an inability to reach the toilet in time and/or coordinate the movements necessary to use the toilet—is common in the palliative care setting because many of these patients have functional decline and loss of mobility. Interventions for functional incontinence include physical rehabilitation, use of assistive devices, space planning/furniture rearrangement, use of a bedside commode, assistance with transfers, elimination of chemical/physical restraints, treatment of depression, scheduled voiding times, decreased intake of fluids at night, and discontinuation of or change of dosing time for diuretics.

It's important to talk with families of palliative care patients about functional urinary incontinence, Dr. Bunch said. Advise caregivers that all patients with life-limiting disease, especially those with dementia, will eventually develop functional urinary incontinence. Provide families with support and resources for this eventuality.

Chronic indwelling catheters have the advantages of protecting skin from moisture, making patient care easier, and decreasing the need for linen and clothing changes. However, they may be uncomfortable for patients, and because they limit patient mobility, they may contribute to delirium and agitation, which is a symptom of delirium. The decision to catheterize at the end of life should be individualized, Dr. Bunch said.

Delirium

The mortality rate of hospitalized patients with delirium ranges from 22% to 76%, and the 1-year mortality rate associated with delirium is roughly 35%–40%. The diagnosis of delirium is primarily clinical, and the condition often goes unrecognized. “Often, we fail to do a formal cognitive assessment,” said Dr. Elise C. Carey, an internal medicine physician who specializes in geriatrics at the Mayo Clinic in Rochester, Minn.

When a patient becomes agitated, determine if it represents an acute change in mental status, and perform a cognitive assessment and an evaluation for delirium using a tool like the Confusion Assessment Method. Identify and address any predisposing or precipitating factors. It's important to remember that delirium is often the sole manifestation of underlying disease. “I can't emphasize this enough,” Dr. Carey said.

Evaluate the patient for new or intercurrent illness: Take a history, do a physical exam, run selected lab tests, and get an ECG. Also look for infection, low blood volume, pressure sores, and poor nutrition. Review the patient's medications, looking for potential troublemakers—such as anticholinergic effects, narcotic pain medications, and benzo-diazepines—and replacing them with alternatives that are less likely to cause delirium. Evaluate environmental factors that may be contributing to the patient's agitation—such as recently performed surgery or multiple procedures, a room change, an ICU stay, sleep deprivation, the use of restraints or bladder catheters, and pain. Then take the necessary steps to treat any identified causes, provide supportive care, and prevent complications.

In terms of treating behavioral symptoms, “primarily we're going to try to rely on nonpharmacologic therapies,” Dr. Carey said. Such an approach includes reorienting patients to their surroundings, encouraging family involvement, having people sit with the patient, avoiding the use of indwelling catheters and of restraints, working to maintain the patient's mobility and self-care ability, and normalizing the patient's sleep-wake cycle.

In cases of severe agitation, pharmacologic treatment may be necessary. The first-line therapy is low-dose haloperidol (Haldol), at 0.5–1.0 mg twice daily plus every 4 hours as needed, Dr. Carey said.

Feeding Tubes

Difficulties with eating are a hallmark of end-stage dementia, said Dr. Rachelle E. Bernacki, a hospitalist, geriatrician, and palliative medicine specialist with the University of California San Francisco Medical Center's palliative care service. Approximately one-third of U.S. nursing home residents with advanced dementia are tube fed, but the number of tube-fed dementia patients varies 10-fold across the country.

Tube feeding commonly is used to prevent aspiration pneumonia and provide nutrition in patients who have trouble eating normally. However, no randomized, controlled trials of tube feeding have been published; of the observational studies in the literature, none have shown a reduction in the risk of aspiration and aspiration pneumonia. There is also no evidence of improved nutritional status with the use of feeding tubes, and it does not appear to prolong survival, Dr. Bernacki said.

There are several drawbacks to the use of feeding tubes. The patient does not experience any gustatory pleasure, may experience discomfort, and has diminished social contact.

“As with everything in palliative care, always try to use the goals of therapy as your guide,” Dr. Bernacki said.

Patients with obstructive sleep apnea hypopnea had a greater rate of motor vehicle crashes than did matched controls, and they were three times more likely to be involved in crashes involving personal injury, according to researchers in British Columbia.

“Our data indicate that the increased risk of motor vehicle crash occurs at all levels of OSAH severity,” Dr. Alan T. Mulgrew, of the University of British Columbia, Vancouver, and his colleagues wrote (Thorax 2008 Jan. 30 [Epub doi:10.1136/thx.2007.085464]).

The study involved 783 adult patients who were referred for overnight polysomnography for suspected sleep-disordered breathing. Patients were excluded if they had symptoms of another sleep disorder known to cause daytime sleepiness (periodic limb movement disorder), or if they had another serious medical condition or overt psychiatric disease. They were also excluded if they were already being treated for OSAH.

Overnight polysomnography was performed using conventional instrumentation, and analysis was performed according to the American Academy of Sleep Medicine's recommendations on syndrome definition and measurement techniques. Patients completed a number of surveys on the night of their polysomnography study. Daytime sleepiness was assessed using the Epworth Sleepiness Scale.

All motorists in British Columbia are insured by a single insurance corporation: the Insurance Corporation of British Columbia (ICBC). Objective crash data for patients–including crash severity type–was obtained for 3 years prior to the sleep study.

All patients were matched with an individual control from the ICBC database based on age, gender, type of license, driving experience, and postal region, Dr. Mulgrew said.

Patients were categorized by OSAH severity based on the apnea hypopnea index (AHI): normal polysomnography (AHI of 5 or fewer events per hour), mild OSAH (AHI greater than 5 and up to 15), moderate OSAH (AHI greater than 15 but less than 30), and severe OSAH (AHI of 30 or more per hour).

Most patients (71%) were men, and the average patient age was 50 years. The average AHI was 22.6 events per hour, and the average Epworth Sleepiness Scale score was 10. The mean body mass index (BMI) was 31.8 kg/m

In terms of OSAH severity, 18% of patients had normal polysomnography, 30% had mild OSAH, 26% had moderate OSAH, and 26% had severe OSAH.

In all, there were 374 crashes, of which 251 (67%) happened to patients. In the patient group, 94 of 251 crashes caused minor property damage, 83 crashes caused major property damage, and 74 crashes caused injuries. This compared with 48, 52, and 23 in the control group.

When compared with controls, patients with OSAH had a significantly increased rate of motor vehicle crashes, with relative risks ranging from 1.9 to 2.6. In comparison, patients without OSAH (AHI 0–5 events per hour) were at lower risk of motor vehicle crashes than were patients with OSAH.

The presence of OSAH was linked with a 3.0- to 4.8-fold increase in the rate of more severe motor vehicle crashes.

Within the patient group, there appeared to be a dose-response relationship between OSAH severity and the rate of motor vehicle crashes involving personal injury.

In patients with an AHI of 0–5, motor vehicle crashes involving personal injury accounted for 9% of crashes, compared with 37% in those with an AHI greater than 30.

Compared with patients with an AHI of 0–5, patients with severe OSAH were 6.1 times more likely to be in a crash involving personal injury, the researchers reported.

Patients with obstructive sleep apnea hypopnea had a greater rate of motor vehicle crashes than did matched controls, and they were three times more likely to be involved in crashes involving personal injury, according to researchers in British Columbia.

“Our data indicate that the increased risk of motor vehicle crash occurs at all levels of OSAH severity,” Dr. Alan T. Mulgrew, of the University of British Columbia, Vancouver, and his colleagues wrote (Thorax 2008 Jan. 30 [Epub doi:10.1136/thx.2007.085464]).

The study involved 783 adult patients who were referred for overnight polysomnography for suspected sleep-disordered breathing. Patients were excluded if they had symptoms of another sleep disorder known to cause daytime sleepiness (periodic limb movement disorder), or if they had another serious medical condition or overt psychiatric disease. They were also excluded if they were already being treated for OSAH.

Overnight polysomnography was performed using conventional instrumentation, and analysis was performed according to the American Academy of Sleep Medicine's recommendations on syndrome definition and measurement techniques. Patients completed a number of surveys on the night of their polysomnography study. Daytime sleepiness was assessed using the Epworth Sleepiness Scale.

All motorists in British Columbia are insured by a single insurance corporation: the Insurance Corporation of British Columbia (ICBC). Objective crash data for patients–including crash severity type–was obtained for 3 years prior to the sleep study.

All patients were matched with an individual control from the ICBC database based on age, gender, type of license, driving experience, and postal region, Dr. Mulgrew said.

Patients were categorized by OSAH severity based on the apnea hypopnea index (AHI): normal polysomnography (AHI of 5 or fewer events per hour), mild OSAH (AHI greater than 5 and up to 15), moderate OSAH (AHI greater than 15 but less than 30), and severe OSAH (AHI of 30 or more per hour).

Most patients (71%) were men, and the average patient age was 50 years. The average AHI was 22.6 events per hour, and the average Epworth Sleepiness Scale score was 10. The mean body mass index (BMI) was 31.8 kg/m

In terms of OSAH severity, 18% of patients had normal polysomnography, 30% had mild OSAH, 26% had moderate OSAH, and 26% had severe OSAH.

In all, there were 374 crashes, of which 251 (67%) happened to patients. In the patient group, 94 of 251 crashes caused minor property damage, 83 crashes caused major property damage, and 74 crashes caused injuries. This compared with 48, 52, and 23 in the control group.

When compared with controls, patients with OSAH had a significantly increased rate of motor vehicle crashes, with relative risks ranging from 1.9 to 2.6. In comparison, patients without OSAH (AHI 0–5 events per hour) were at lower risk of motor vehicle crashes than were patients with OSAH.

The presence of OSAH was linked with a 3.0- to 4.8-fold increase in the rate of more severe motor vehicle crashes.

Within the patient group, there appeared to be a dose-response relationship between OSAH severity and the rate of motor vehicle crashes involving personal injury.

In patients with an AHI of 0–5, motor vehicle crashes involving personal injury accounted for 9% of crashes, compared with 37% in those with an AHI greater than 30.

Compared with patients with an AHI of 0–5, patients with severe OSAH were 6.1 times more likely to be in a crash involving personal injury, the researchers reported.

Patients with obstructive sleep apnea hypopnea had a greater rate of motor vehicle crashes than did matched controls, and they were three times more likely to be involved in crashes involving personal injury, according to researchers in British Columbia.

“Our data indicate that the increased risk of motor vehicle crash occurs at all levels of OSAH severity,” Dr. Alan T. Mulgrew, of the University of British Columbia, Vancouver, and his colleagues wrote (Thorax 2008 Jan. 30 [Epub doi:10.1136/thx.2007.085464]).

The study involved 783 adult patients who were referred for overnight polysomnography for suspected sleep-disordered breathing. Patients were excluded if they had symptoms of another sleep disorder known to cause daytime sleepiness (periodic limb movement disorder), or if they had another serious medical condition or overt psychiatric disease. They were also excluded if they were already being treated for OSAH.

Overnight polysomnography was performed using conventional instrumentation, and analysis was performed according to the American Academy of Sleep Medicine's recommendations on syndrome definition and measurement techniques. Patients completed a number of surveys on the night of their polysomnography study. Daytime sleepiness was assessed using the Epworth Sleepiness Scale.

All motorists in British Columbia are insured by a single insurance corporation: the Insurance Corporation of British Columbia (ICBC). Objective crash data for patients–including crash severity type–was obtained for 3 years prior to the sleep study.

All patients were matched with an individual control from the ICBC database based on age, gender, type of license, driving experience, and postal region, Dr. Mulgrew said.

Patients were categorized by OSAH severity based on the apnea hypopnea index (AHI): normal polysomnography (AHI of 5 or fewer events per hour), mild OSAH (AHI greater than 5 and up to 15), moderate OSAH (AHI greater than 15 but less than 30), and severe OSAH (AHI of 30 or more per hour).

Most patients (71%) were men, and the average patient age was 50 years. The average AHI was 22.6 events per hour, and the average Epworth Sleepiness Scale score was 10. The mean body mass index (BMI) was 31.8 kg/m

In terms of OSAH severity, 18% of patients had normal polysomnography, 30% had mild OSAH, 26% had moderate OSAH, and 26% had severe OSAH.

In all, there were 374 crashes, of which 251 (67%) happened to patients. In the patient group, 94 of 251 crashes caused minor property damage, 83 crashes caused major property damage, and 74 crashes caused injuries. This compared with 48, 52, and 23 in the control group.

When compared with controls, patients with OSAH had a significantly increased rate of motor vehicle crashes, with relative risks ranging from 1.9 to 2.6. In comparison, patients without OSAH (AHI 0–5 events per hour) were at lower risk of motor vehicle crashes than were patients with OSAH.

The presence of OSAH was linked with a 3.0- to 4.8-fold increase in the rate of more severe motor vehicle crashes.

Within the patient group, there appeared to be a dose-response relationship between OSAH severity and the rate of motor vehicle crashes involving personal injury.

In patients with an AHI of 0–5, motor vehicle crashes involving personal injury accounted for 9% of crashes, compared with 37% in those with an AHI greater than 30.

Compared with patients with an AHI of 0–5, patients with severe OSAH were 6.1 times more likely to be in a crash involving personal injury, the researchers reported.

BALTIMORE – Children with greater body mass indexes appear to be more responsive to external food cues and less responsive to internal satiety signals, a study involving almost 11,000 children shows.

The findings, presented at the annual meeting of the American Psychosomatic Society, suggest that variation in responsiveness to internal and external cues could contribute to variation in adiposity, said Jane Wardle, Ph.D., who is the director of the Health Behaviour Research Centre at University College London.

It's long been speculated that obese individuals have an overresponsive meal-initiation system (high food responsiveness) and/or inability to end a meal (low satiety sensitivity).

For this study, the researchers looked at two samples: a preschool group of 572 children (aged 3–5 years) and an older group of 10,364 twins (aged 8–11 years). The twins are part of the larger Twins Early Development Study (TEDS), which involves more than 16,000 families whose twins were born between 1994 and 1996.

Eating behavior of the twins and preschoolers was assessed when the children were between 8 and 11 years of age using parent reporting on the Child Eating Behaviour Questionnaire. The researchers were particularly interested in satiety sensitivity (as measured by the satiety responsiveness scale) and food responsiveness (as measured by the enjoyment of food subscale). The researchers determined the height and weight of the preschool group, while the parents measured the height, weight, and waist circumference of the twin group.

Satiety responsiveness was negatively correlated with BMI (adjusted for age and sex) in both groups and also was negatively correlated with waist circumference in the twin group. So children with greater BMIs responded poorly to satiety signals. Food responsiveness was positively correlated with BMI (adjusted for age and sex) in both groups and with waist circumference in the twin group. In terms of satiety responsiveness and food responsiveness, “it's not just a difference between the obese and everybody else. It's a quantitative variation across the distribution,” Dr. Wardle said.

Dr. Wardle suggested that people with higher-risk eating behavior traits–less sensitivity to satiety signals and greater response to external food cues–are more responsive to the modern obesogenic environment, in which eating opportunities are everywhere.

BALTIMORE – Children with greater body mass indexes appear to be more responsive to external food cues and less responsive to internal satiety signals, a study involving almost 11,000 children shows.

The findings, presented at the annual meeting of the American Psychosomatic Society, suggest that variation in responsiveness to internal and external cues could contribute to variation in adiposity, said Jane Wardle, Ph.D., who is the director of the Health Behaviour Research Centre at University College London.

It's long been speculated that obese individuals have an overresponsive meal-initiation system (high food responsiveness) and/or inability to end a meal (low satiety sensitivity).

For this study, the researchers looked at two samples: a preschool group of 572 children (aged 3–5 years) and an older group of 10,364 twins (aged 8–11 years). The twins are part of the larger Twins Early Development Study (TEDS), which involves more than 16,000 families whose twins were born between 1994 and 1996.

Eating behavior of the twins and preschoolers was assessed when the children were between 8 and 11 years of age using parent reporting on the Child Eating Behaviour Questionnaire. The researchers were particularly interested in satiety sensitivity (as measured by the satiety responsiveness scale) and food responsiveness (as measured by the enjoyment of food subscale). The researchers determined the height and weight of the preschool group, while the parents measured the height, weight, and waist circumference of the twin group.

Satiety responsiveness was negatively correlated with BMI (adjusted for age and sex) in both groups and also was negatively correlated with waist circumference in the twin group. So children with greater BMIs responded poorly to satiety signals. Food responsiveness was positively correlated with BMI (adjusted for age and sex) in both groups and with waist circumference in the twin group. In terms of satiety responsiveness and food responsiveness, “it's not just a difference between the obese and everybody else. It's a quantitative variation across the distribution,” Dr. Wardle said.

Dr. Wardle suggested that people with higher-risk eating behavior traits–less sensitivity to satiety signals and greater response to external food cues–are more responsive to the modern obesogenic environment, in which eating opportunities are everywhere.

BALTIMORE – Children with greater body mass indexes appear to be more responsive to external food cues and less responsive to internal satiety signals, a study involving almost 11,000 children shows.

The findings, presented at the annual meeting of the American Psychosomatic Society, suggest that variation in responsiveness to internal and external cues could contribute to variation in adiposity, said Jane Wardle, Ph.D., who is the director of the Health Behaviour Research Centre at University College London.

It's long been speculated that obese individuals have an overresponsive meal-initiation system (high food responsiveness) and/or inability to end a meal (low satiety sensitivity).

For this study, the researchers looked at two samples: a preschool group of 572 children (aged 3–5 years) and an older group of 10,364 twins (aged 8–11 years). The twins are part of the larger Twins Early Development Study (TEDS), which involves more than 16,000 families whose twins were born between 1994 and 1996.

Eating behavior of the twins and preschoolers was assessed when the children were between 8 and 11 years of age using parent reporting on the Child Eating Behaviour Questionnaire. The researchers were particularly interested in satiety sensitivity (as measured by the satiety responsiveness scale) and food responsiveness (as measured by the enjoyment of food subscale). The researchers determined the height and weight of the preschool group, while the parents measured the height, weight, and waist circumference of the twin group.

Satiety responsiveness was negatively correlated with BMI (adjusted for age and sex) in both groups and also was negatively correlated with waist circumference in the twin group. So children with greater BMIs responded poorly to satiety signals. Food responsiveness was positively correlated with BMI (adjusted for age and sex) in both groups and with waist circumference in the twin group. In terms of satiety responsiveness and food responsiveness, “it's not just a difference between the obese and everybody else. It's a quantitative variation across the distribution,” Dr. Wardle said.

Dr. Wardle suggested that people with higher-risk eating behavior traits–less sensitivity to satiety signals and greater response to external food cues–are more responsive to the modern obesogenic environment, in which eating opportunities are everywhere.

TAMPA — A patient's request for a hastened death—either an explicit request or a hint—should be considered a clinical emergency that offers an important therapeutic opportunity.

“When you're in the office and somebody asks, 'Doctor, will you help me die? I just want to end it all,' that is a true clinical emergency,” Dr. Ira R. Byock said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“It's as if somebody develops crushing chest pain or fibrillates and codes in your office. Somebody's life is at risk here. That person may have a progressive illness, but that doesn't mean that [his or her] life is at any less risk or that it's any less of an emergency,” said Dr. Byock, who is director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Such a request is “a remarkable therapeutic opportunity,” he said. “The very fact that the patient has shared this with you … opens up a therapeutic window.”

Occasional thoughts of suicide or a desire for death are fairly common among people living with a serious illness.

In Oregon—where physician-assisted suicide is legal in certain circumstances—65 prescriptions for lethal medications were written in 2006, and 46 people died by lethal prescription that year (out of a total of roughly 31,000 deaths in the state). The 1997 Death with Dignity Act allows terminally ill Oregonians to end their lives through the voluntary self-administration of lethal medications, prescribed by a physician expressly for that purpose.

“Certain diagnoses are particularly associated with a request for assisted suicide and receipt of a lethal prescription,” Dr. Byock said. Based on data through 2006 in Oregon, patients who have amyotrophic lateral sclerosis are about 35 times as likely to use physician-assisted suicide or to ask for a lethal prescription as are patients with chronic obstructive pulmonary disease, he said. HIV/AIDS and cancer also are particularly associated with a request for assisted suicide and receipt of a lethal prescription.

Research also has shown that many terminally ill patients meet the diagnostic criteria for major depression, which is an important risk factor for a request for suicide. “In treating depression, I think we often just reach for the SSRI or the psychostimulant, all of which can be valuable,” Dr. Byock said. But don't forget to look for other causes of the depression, such as hypothyroidism, adrenal dysfunction, or the side effects of other medications.

And because many of the somatic symptoms of depression—including fatigue, anorexia, loss of energy, sleep disturbance, and mild confusion—are common in terminal illness, the psychological symptoms are more useful in identifying depression in these patients. Look for hopelessness, helplessness, guilt, worthlessness, loss of meaning, and preoccupation with death and suicide.

When a patient with advanced illness asks for help dying, it's important for physicians to recognize their own emotional responses to such requests. At the same time that a physician is moved by the patient's suffering, “at times, to a physician's ear, the expression of a wish to die can sound to us like a condemnation of our care,” Dr. Byock observed. Acknowledging this is part of the therapeutic challenge.

The fact that the patient makes such a vulnerable statement is testament to the patient's trust in his or her physician. The most important thing a physician can do in these situations simply is to listen—an act that has therapeutic value in itself. The act of listening “helps people feel acknowledged and helps them feel like you're accompanying them on this difficult journey.

“Even if one is deeply, morally opposed to assisting a patient in suicide, it is possible and essential to be able to listen to the requests and accept the patient's feelings in a nonjudgmental manner,” Dr. Byock said.

Expressing empathy—with comments such as “I can't imagine how hard this must be for you”—can also help to strengthen the therapeutic relationship, “which is itself a powerful tool for treatment,” he said.

It's important to clarify a request for death, as many patients are confused about end-of-life care. Some assume that by not accepting every possible treatment—antibiotics and dialysis, for example—they are essentially committing suicide. “We can often alleviate their anxiety and help them distinguish between actively shortening their lives and simply not using medical treatments that aren't consistent with their preferences and desires,” Dr. Byock said.

Even simply informing patients that they can decline medically administered nutrition and hydration to allow a “natural” death can satisfy their concerns.

Sometimes patients will hint or make provocative statements. One of Dr. Byock's patients told him that, “they should dig a hole and just shoot me.” Statements like these are valuable openings because they express the patient's fears and feelings, he said. They are also a way for patients to test their physician. “If we respond 'oh, don't talk like that,' we've given a strong message,” he said.

Patients also may use provocative statements like, “I hope you'll help me die when it's time” as a way of assessing their physician's commitment to not letting them suffer. What sounds like a request for death may “simply [be a desire] to be assured of a way of escaping suffering if it becomes unbearable,” he said. “It's important to understand whether they're referring to assisted suicide/euthanasia or just adequate analgesia.”

In treating pain in this patient group, Dr. Byock recommends making it explicit to the patient, in the chart, and to medical colleagues that there needs to be a detailed pain management plan in place in case pain gets out of control.

This means taking a multimodal, layered approach using patient-controlled analgesia and scheduled, as-necessary, and crisis medications. It's also important for patients to have specific telephone numbers to call after hours to get a prompt response.

“We pursue symptom-directed treatments even when patients are seriously ill,” Dr. Byock said. These patients may benefit from regional blocks, axial analgesia, or neurolytic procedures.

It's also a good idea to get a formal consultation with palliative care or pain services. Dr. Byock tells his patients that there always is the option of palliative sedation if no other options are working and pain is unbearable. “This is not only ethically acceptable, I would assert that it's ethically required, if nothing else is working,” he said.

Many patients with advanced illness worry about being a burden on their families or caregivers. Dr. Byock tells his patients that although they can't take away the burden, their behavior and attitude can influence how their family responds to it. “The way people die stays in the minds and hearts of those they leave behind,” he said.

There is some evidence that by committing suicide, a person is putting first-degree relatives at greater risk of suicide themselves. “I rarely say that, but there are some times when it's worth sharing,” he said.

Patients who have children can provide a model for their children and grandchildren of living with dignity to the very end of life. A patient can be reassured that this “has value in and of itself,” Dr. Byock said.

A patient's request for a hastened death is both a clinical emergency and “a remarkable therapeutic opportunity,” Dr. Ira R. Byock said. Mark Washburn/Dartmouth-Hitchcock Medical Center

Responding to a Request for Death

One of Dr. Byock's patients, Mr. B, was a 68-year-old man with colon cancer that had metastasized to the liver, lungs, and bone. He presented with increasing, severe left hip pain after a minor injury. He was on hydrocodone/acetaminophen (Vicodin) every 4 hours for pain relief.

He was very anxious, and at times seemed unable to understand the information given to him, Dr. Byock said.

Mr. B had retired after a career in industry. “He was a gentle, well-mannered man. His passions included walking in the wilderness and gardening, interests that he shared with his wife of 22 years,” Dr. Byock recounted.

According to Dr. Byock, Mr. B volunteered that he had been thinking about “ending it all.” He spoke of a neighbor who had committed suicide by gunshot to the head because of severe cancer pain.

“I don't want to end up like that. I hope you will help me die before I get to that point,” Mr. B told his physician.

While hospitalized for the hip pain resulting from the minor injury, he was treated with long-acting morphine, an NSAID, and lorazepam for his anxiety.

A geriatric psychiatrist on the hospital staff was consulted about Mr. B's desire to die.

Mr. B told the psychiatrist that he was feeling fine at the moment but he was in fear of being in constant, uncontrollable pain.

He added that he knew his wife would be devastated if he committed suicide.

When Dr. Byock learned that the real problem was fear of pain, he was able to reassure Mr. B that he could achieve sufficient pain control to live a high-quality life at home.

Mr. B was started on mirtazapine for depression, and his anxiety decreased during the course of his hospital stay. The medication also helped his sleep and appetite.

Before he went home, he was counseled about his pain management plan and assured that there was no circumstance in which he would suffer for more than a very short time.

Mr. B still talked about suicide when asked by a member of his palliative care team, but he no longer brought up the subject.

He said that his feelings hadn't changed but that he felt more confident that he wouldn't have to turn to suicide, Dr. Byock said.

He died at home in hospice care several months after he was discharged.

TAMPA — A patient's request for a hastened death—either an explicit request or a hint—should be considered a clinical emergency that offers an important therapeutic opportunity.

“When you're in the office and somebody asks, 'Doctor, will you help me die? I just want to end it all,' that is a true clinical emergency,” Dr. Ira R. Byock said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“It's as if somebody develops crushing chest pain or fibrillates and codes in your office. Somebody's life is at risk here. That person may have a progressive illness, but that doesn't mean that [his or her] life is at any less risk or that it's any less of an emergency,” said Dr. Byock, who is director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Such a request is “a remarkable therapeutic opportunity,” he said. “The very fact that the patient has shared this with you … opens up a therapeutic window.”

Occasional thoughts of suicide or a desire for death are fairly common among people living with a serious illness.

In Oregon—where physician-assisted suicide is legal in certain circumstances—65 prescriptions for lethal medications were written in 2006, and 46 people died by lethal prescription that year (out of a total of roughly 31,000 deaths in the state). The 1997 Death with Dignity Act allows terminally ill Oregonians to end their lives through the voluntary self-administration of lethal medications, prescribed by a physician expressly for that purpose.

“Certain diagnoses are particularly associated with a request for assisted suicide and receipt of a lethal prescription,” Dr. Byock said. Based on data through 2006 in Oregon, patients who have amyotrophic lateral sclerosis are about 35 times as likely to use physician-assisted suicide or to ask for a lethal prescription as are patients with chronic obstructive pulmonary disease, he said. HIV/AIDS and cancer also are particularly associated with a request for assisted suicide and receipt of a lethal prescription.

Research also has shown that many terminally ill patients meet the diagnostic criteria for major depression, which is an important risk factor for a request for suicide. “In treating depression, I think we often just reach for the SSRI or the psychostimulant, all of which can be valuable,” Dr. Byock said. But don't forget to look for other causes of the depression, such as hypothyroidism, adrenal dysfunction, or the side effects of other medications.

And because many of the somatic symptoms of depression—including fatigue, anorexia, loss of energy, sleep disturbance, and mild confusion—are common in terminal illness, the psychological symptoms are more useful in identifying depression in these patients. Look for hopelessness, helplessness, guilt, worthlessness, loss of meaning, and preoccupation with death and suicide.

When a patient with advanced illness asks for help dying, it's important for physicians to recognize their own emotional responses to such requests. At the same time that a physician is moved by the patient's suffering, “at times, to a physician's ear, the expression of a wish to die can sound to us like a condemnation of our care,” Dr. Byock observed. Acknowledging this is part of the therapeutic challenge.

The fact that the patient makes such a vulnerable statement is testament to the patient's trust in his or her physician. The most important thing a physician can do in these situations simply is to listen—an act that has therapeutic value in itself. The act of listening “helps people feel acknowledged and helps them feel like you're accompanying them on this difficult journey.

“Even if one is deeply, morally opposed to assisting a patient in suicide, it is possible and essential to be able to listen to the requests and accept the patient's feelings in a nonjudgmental manner,” Dr. Byock said.

Expressing empathy—with comments such as “I can't imagine how hard this must be for you”—can also help to strengthen the therapeutic relationship, “which is itself a powerful tool for treatment,” he said.

It's important to clarify a request for death, as many patients are confused about end-of-life care. Some assume that by not accepting every possible treatment—antibiotics and dialysis, for example—they are essentially committing suicide. “We can often alleviate their anxiety and help them distinguish between actively shortening their lives and simply not using medical treatments that aren't consistent with their preferences and desires,” Dr. Byock said.

Even simply informing patients that they can decline medically administered nutrition and hydration to allow a “natural” death can satisfy their concerns.

Sometimes patients will hint or make provocative statements. One of Dr. Byock's patients told him that, “they should dig a hole and just shoot me.” Statements like these are valuable openings because they express the patient's fears and feelings, he said. They are also a way for patients to test their physician. “If we respond 'oh, don't talk like that,' we've given a strong message,” he said.

Patients also may use provocative statements like, “I hope you'll help me die when it's time” as a way of assessing their physician's commitment to not letting them suffer. What sounds like a request for death may “simply [be a desire] to be assured of a way of escaping suffering if it becomes unbearable,” he said. “It's important to understand whether they're referring to assisted suicide/euthanasia or just adequate analgesia.”

In treating pain in this patient group, Dr. Byock recommends making it explicit to the patient, in the chart, and to medical colleagues that there needs to be a detailed pain management plan in place in case pain gets out of control.

This means taking a multimodal, layered approach using patient-controlled analgesia and scheduled, as-necessary, and crisis medications. It's also important for patients to have specific telephone numbers to call after hours to get a prompt response.

“We pursue symptom-directed treatments even when patients are seriously ill,” Dr. Byock said. These patients may benefit from regional blocks, axial analgesia, or neurolytic procedures.

It's also a good idea to get a formal consultation with palliative care or pain services. Dr. Byock tells his patients that there always is the option of palliative sedation if no other options are working and pain is unbearable. “This is not only ethically acceptable, I would assert that it's ethically required, if nothing else is working,” he said.

Many patients with advanced illness worry about being a burden on their families or caregivers. Dr. Byock tells his patients that although they can't take away the burden, their behavior and attitude can influence how their family responds to it. “The way people die stays in the minds and hearts of those they leave behind,” he said.

There is some evidence that by committing suicide, a person is putting first-degree relatives at greater risk of suicide themselves. “I rarely say that, but there are some times when it's worth sharing,” he said.

Patients who have children can provide a model for their children and grandchildren of living with dignity to the very end of life. A patient can be reassured that this “has value in and of itself,” Dr. Byock said.

A patient's request for a hastened death is both a clinical emergency and “a remarkable therapeutic opportunity,” Dr. Ira R. Byock said. Mark Washburn/Dartmouth-Hitchcock Medical Center

Responding to a Request for Death

One of Dr. Byock's patients, Mr. B, was a 68-year-old man with colon cancer that had metastasized to the liver, lungs, and bone. He presented with increasing, severe left hip pain after a minor injury. He was on hydrocodone/acetaminophen (Vicodin) every 4 hours for pain relief.

He was very anxious, and at times seemed unable to understand the information given to him, Dr. Byock said.

Mr. B had retired after a career in industry. “He was a gentle, well-mannered man. His passions included walking in the wilderness and gardening, interests that he shared with his wife of 22 years,” Dr. Byock recounted.

According to Dr. Byock, Mr. B volunteered that he had been thinking about “ending it all.” He spoke of a neighbor who had committed suicide by gunshot to the head because of severe cancer pain.

“I don't want to end up like that. I hope you will help me die before I get to that point,” Mr. B told his physician.

While hospitalized for the hip pain resulting from the minor injury, he was treated with long-acting morphine, an NSAID, and lorazepam for his anxiety.

A geriatric psychiatrist on the hospital staff was consulted about Mr. B's desire to die.

Mr. B told the psychiatrist that he was feeling fine at the moment but he was in fear of being in constant, uncontrollable pain.

He added that he knew his wife would be devastated if he committed suicide.

When Dr. Byock learned that the real problem was fear of pain, he was able to reassure Mr. B that he could achieve sufficient pain control to live a high-quality life at home.

Mr. B was started on mirtazapine for depression, and his anxiety decreased during the course of his hospital stay. The medication also helped his sleep and appetite.

Before he went home, he was counseled about his pain management plan and assured that there was no circumstance in which he would suffer for more than a very short time.

Mr. B still talked about suicide when asked by a member of his palliative care team, but he no longer brought up the subject.

He said that his feelings hadn't changed but that he felt more confident that he wouldn't have to turn to suicide, Dr. Byock said.

He died at home in hospice care several months after he was discharged.

TAMPA — A patient's request for a hastened death—either an explicit request or a hint—should be considered a clinical emergency that offers an important therapeutic opportunity.

“When you're in the office and somebody asks, 'Doctor, will you help me die? I just want to end it all,' that is a true clinical emergency,” Dr. Ira R. Byock said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“It's as if somebody develops crushing chest pain or fibrillates and codes in your office. Somebody's life is at risk here. That person may have a progressive illness, but that doesn't mean that [his or her] life is at any less risk or that it's any less of an emergency,” said Dr. Byock, who is director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Such a request is “a remarkable therapeutic opportunity,” he said. “The very fact that the patient has shared this with you … opens up a therapeutic window.”

Occasional thoughts of suicide or a desire for death are fairly common among people living with a serious illness.

In Oregon—where physician-assisted suicide is legal in certain circumstances—65 prescriptions for lethal medications were written in 2006, and 46 people died by lethal prescription that year (out of a total of roughly 31,000 deaths in the state). The 1997 Death with Dignity Act allows terminally ill Oregonians to end their lives through the voluntary self-administration of lethal medications, prescribed by a physician expressly for that purpose.

“Certain diagnoses are particularly associated with a request for assisted suicide and receipt of a lethal prescription,” Dr. Byock said. Based on data through 2006 in Oregon, patients who have amyotrophic lateral sclerosis are about 35 times as likely to use physician-assisted suicide or to ask for a lethal prescription as are patients with chronic obstructive pulmonary disease, he said. HIV/AIDS and cancer also are particularly associated with a request for assisted suicide and receipt of a lethal prescription.

Research also has shown that many terminally ill patients meet the diagnostic criteria for major depression, which is an important risk factor for a request for suicide. “In treating depression, I think we often just reach for the SSRI or the psychostimulant, all of which can be valuable,” Dr. Byock said. But don't forget to look for other causes of the depression, such as hypothyroidism, adrenal dysfunction, or the side effects of other medications.

And because many of the somatic symptoms of depression—including fatigue, anorexia, loss of energy, sleep disturbance, and mild confusion—are common in terminal illness, the psychological symptoms are more useful in identifying depression in these patients. Look for hopelessness, helplessness, guilt, worthlessness, loss of meaning, and preoccupation with death and suicide.

When a patient with advanced illness asks for help dying, it's important for physicians to recognize their own emotional responses to such requests. At the same time that a physician is moved by the patient's suffering, “at times, to a physician's ear, the expression of a wish to die can sound to us like a condemnation of our care,” Dr. Byock observed. Acknowledging this is part of the therapeutic challenge.

The fact that the patient makes such a vulnerable statement is testament to the patient's trust in his or her physician. The most important thing a physician can do in these situations simply is to listen—an act that has therapeutic value in itself. The act of listening “helps people feel acknowledged and helps them feel like you're accompanying them on this difficult journey.

“Even if one is deeply, morally opposed to assisting a patient in suicide, it is possible and essential to be able to listen to the requests and accept the patient's feelings in a nonjudgmental manner,” Dr. Byock said.

Expressing empathy—with comments such as “I can't imagine how hard this must be for you”—can also help to strengthen the therapeutic relationship, “which is itself a powerful tool for treatment,” he said.

It's important to clarify a request for death, as many patients are confused about end-of-life care. Some assume that by not accepting every possible treatment—antibiotics and dialysis, for example—they are essentially committing suicide. “We can often alleviate their anxiety and help them distinguish between actively shortening their lives and simply not using medical treatments that aren't consistent with their preferences and desires,” Dr. Byock said.

Even simply informing patients that they can decline medically administered nutrition and hydration to allow a “natural” death can satisfy their concerns.

Sometimes patients will hint or make provocative statements. One of Dr. Byock's patients told him that, “they should dig a hole and just shoot me.” Statements like these are valuable openings because they express the patient's fears and feelings, he said. They are also a way for patients to test their physician. “If we respond 'oh, don't talk like that,' we've given a strong message,” he said.

Patients also may use provocative statements like, “I hope you'll help me die when it's time” as a way of assessing their physician's commitment to not letting them suffer. What sounds like a request for death may “simply [be a desire] to be assured of a way of escaping suffering if it becomes unbearable,” he said. “It's important to understand whether they're referring to assisted suicide/euthanasia or just adequate analgesia.”

In treating pain in this patient group, Dr. Byock recommends making it explicit to the patient, in the chart, and to medical colleagues that there needs to be a detailed pain management plan in place in case pain gets out of control.

This means taking a multimodal, layered approach using patient-controlled analgesia and scheduled, as-necessary, and crisis medications. It's also important for patients to have specific telephone numbers to call after hours to get a prompt response.

“We pursue symptom-directed treatments even when patients are seriously ill,” Dr. Byock said. These patients may benefit from regional blocks, axial analgesia, or neurolytic procedures.

It's also a good idea to get a formal consultation with palliative care or pain services. Dr. Byock tells his patients that there always is the option of palliative sedation if no other options are working and pain is unbearable. “This is not only ethically acceptable, I would assert that it's ethically required, if nothing else is working,” he said.

Many patients with advanced illness worry about being a burden on their families or caregivers. Dr. Byock tells his patients that although they can't take away the burden, their behavior and attitude can influence how their family responds to it. “The way people die stays in the minds and hearts of those they leave behind,” he said.

There is some evidence that by committing suicide, a person is putting first-degree relatives at greater risk of suicide themselves. “I rarely say that, but there are some times when it's worth sharing,” he said.

Patients who have children can provide a model for their children and grandchildren of living with dignity to the very end of life. A patient can be reassured that this “has value in and of itself,” Dr. Byock said.

A patient's request for a hastened death is both a clinical emergency and “a remarkable therapeutic opportunity,” Dr. Ira R. Byock said. Mark Washburn/Dartmouth-Hitchcock Medical Center

Responding to a Request for Death

One of Dr. Byock's patients, Mr. B, was a 68-year-old man with colon cancer that had metastasized to the liver, lungs, and bone. He presented with increasing, severe left hip pain after a minor injury. He was on hydrocodone/acetaminophen (Vicodin) every 4 hours for pain relief.

He was very anxious, and at times seemed unable to understand the information given to him, Dr. Byock said.

Mr. B had retired after a career in industry. “He was a gentle, well-mannered man. His passions included walking in the wilderness and gardening, interests that he shared with his wife of 22 years,” Dr. Byock recounted.

According to Dr. Byock, Mr. B volunteered that he had been thinking about “ending it all.” He spoke of a neighbor who had committed suicide by gunshot to the head because of severe cancer pain.

“I don't want to end up like that. I hope you will help me die before I get to that point,” Mr. B told his physician.

While hospitalized for the hip pain resulting from the minor injury, he was treated with long-acting morphine, an NSAID, and lorazepam for his anxiety.

A geriatric psychiatrist on the hospital staff was consulted about Mr. B's desire to die.

Mr. B told the psychiatrist that he was feeling fine at the moment but he was in fear of being in constant, uncontrollable pain.

He added that he knew his wife would be devastated if he committed suicide.

When Dr. Byock learned that the real problem was fear of pain, he was able to reassure Mr. B that he could achieve sufficient pain control to live a high-quality life at home.

Mr. B was started on mirtazapine for depression, and his anxiety decreased during the course of his hospital stay. The medication also helped his sleep and appetite.

Before he went home, he was counseled about his pain management plan and assured that there was no circumstance in which he would suffer for more than a very short time.

Mr. B still talked about suicide when asked by a member of his palliative care team, but he no longer brought up the subject.

He said that his feelings hadn't changed but that he felt more confident that he wouldn't have to turn to suicide, Dr. Byock said.

He died at home in hospice care several months after he was discharged.

Susceptibility-weighted imaging (SWI) is a T2* MRI technique that takes advantage of both magnitude and phase to enhance contrast. The signal changes result from disturbances in a homogeneous magnetic field caused by paramagnetic, ferromagnetic, or diamagnetic substances, said E. Mark Haacke, Ph.D., professor of radiology at Wayne State University, Detroit, and director of the Magnetic Resonance Imaging Institute for Biomedical Research in Detroit.

Application of a magnetic field to the brain generates an induced field that depends on the applied magnetic field and the magnetic susceptibility of molecules within the brain. Signal intensity changes are dependent on several factors, including hematocrit, deoxyhemoglobin concentration, and the presence of hemosiderin and other paramagnetic or diamagnetic substances. The technique is very sensitive in detecting intravascular venous deoxygenated blood and extravascular blood products. Most blood products are paramagnetic (deoxyhemoglobin, intracellular methemoglobin, and hemosiderin), letting SWI take advantage of magnetic susceptibility effects.

In brain trauma, the identification of smaller hemorrhages and their locations provides useful data about the mechanism of injury and potential clinical outcome. In this case, SWI showed several bleeds, including shearing of the confluence of the medullary veins into the septal vein. The bleeds appear as black areas, visibile because of the iron in hemosiderin, which accumulated postbleeding.

The join between veins and venules tends to be an area of weakness susceptible to bleeding in brain trauma. In fact, for this patient, “almost all of these bleeds were on the venous side,” said Dr. Haacke. “It's well known biomechanically that the veins are weaker than the arteries, but usually you end up seeing tearing and shearing of both arteries and veins when you have bad trauma.” One of the veins running to the front of the brain—to nerve-containing tissue—also seems to have bled, which could account for this man's headaches.

Iron deposited from bleeding tends to stay in the brain. “Odds are that if we imaged 5 years later, we'd probably still see the major bleeding,” said Dr. Haacke.

The long-term goal is to correlate the imaging with motor and cognitive effects of trauma. “If you could eventually come up with a treatment that helped resolve some of the bleeding, for example, then you would potentially be able to watch and see with MRI if the person is getting better,” said Dr. Haacke.

Conventional MRI (left) hints at a possible bleed in the left front brain. SWI (right) reveals several bleeds from trauma. Photos courtesy Zahid Latif/Detroit Medical Center/Wayne State University

Susceptibility-weighted imaging (SWI) is a T2* MRI technique that takes advantage of both magnitude and phase to enhance contrast. The signal changes result from disturbances in a homogeneous magnetic field caused by paramagnetic, ferromagnetic, or diamagnetic substances, said E. Mark Haacke, Ph.D., professor of radiology at Wayne State University, Detroit, and director of the Magnetic Resonance Imaging Institute for Biomedical Research in Detroit.

Application of a magnetic field to the brain generates an induced field that depends on the applied magnetic field and the magnetic susceptibility of molecules within the brain. Signal intensity changes are dependent on several factors, including hematocrit, deoxyhemoglobin concentration, and the presence of hemosiderin and other paramagnetic or diamagnetic substances. The technique is very sensitive in detecting intravascular venous deoxygenated blood and extravascular blood products. Most blood products are paramagnetic (deoxyhemoglobin, intracellular methemoglobin, and hemosiderin), letting SWI take advantage of magnetic susceptibility effects.

In brain trauma, the identification of smaller hemorrhages and their locations provides useful data about the mechanism of injury and potential clinical outcome. In this case, SWI showed several bleeds, including shearing of the confluence of the medullary veins into the septal vein. The bleeds appear as black areas, visibile because of the iron in hemosiderin, which accumulated postbleeding.

The join between veins and venules tends to be an area of weakness susceptible to bleeding in brain trauma. In fact, for this patient, “almost all of these bleeds were on the venous side,” said Dr. Haacke. “It's well known biomechanically that the veins are weaker than the arteries, but usually you end up seeing tearing and shearing of both arteries and veins when you have bad trauma.” One of the veins running to the front of the brain—to nerve-containing tissue—also seems to have bled, which could account for this man's headaches.

Iron deposited from bleeding tends to stay in the brain. “Odds are that if we imaged 5 years later, we'd probably still see the major bleeding,” said Dr. Haacke.

The long-term goal is to correlate the imaging with motor and cognitive effects of trauma. “If you could eventually come up with a treatment that helped resolve some of the bleeding, for example, then you would potentially be able to watch and see with MRI if the person is getting better,” said Dr. Haacke.

Conventional MRI (left) hints at a possible bleed in the left front brain. SWI (right) reveals several bleeds from trauma. Photos courtesy Zahid Latif/Detroit Medical Center/Wayne State University

Susceptibility-weighted imaging (SWI) is a T2* MRI technique that takes advantage of both magnitude and phase to enhance contrast. The signal changes result from disturbances in a homogeneous magnetic field caused by paramagnetic, ferromagnetic, or diamagnetic substances, said E. Mark Haacke, Ph.D., professor of radiology at Wayne State University, Detroit, and director of the Magnetic Resonance Imaging Institute for Biomedical Research in Detroit.

Application of a magnetic field to the brain generates an induced field that depends on the applied magnetic field and the magnetic susceptibility of molecules within the brain. Signal intensity changes are dependent on several factors, including hematocrit, deoxyhemoglobin concentration, and the presence of hemosiderin and other paramagnetic or diamagnetic substances. The technique is very sensitive in detecting intravascular venous deoxygenated blood and extravascular blood products. Most blood products are paramagnetic (deoxyhemoglobin, intracellular methemoglobin, and hemosiderin), letting SWI take advantage of magnetic susceptibility effects.

In brain trauma, the identification of smaller hemorrhages and their locations provides useful data about the mechanism of injury and potential clinical outcome. In this case, SWI showed several bleeds, including shearing of the confluence of the medullary veins into the septal vein. The bleeds appear as black areas, visibile because of the iron in hemosiderin, which accumulated postbleeding.

The join between veins and venules tends to be an area of weakness susceptible to bleeding in brain trauma. In fact, for this patient, “almost all of these bleeds were on the venous side,” said Dr. Haacke. “It's well known biomechanically that the veins are weaker than the arteries, but usually you end up seeing tearing and shearing of both arteries and veins when you have bad trauma.” One of the veins running to the front of the brain—to nerve-containing tissue—also seems to have bled, which could account for this man's headaches.

Iron deposited from bleeding tends to stay in the brain. “Odds are that if we imaged 5 years later, we'd probably still see the major bleeding,” said Dr. Haacke.

The long-term goal is to correlate the imaging with motor and cognitive effects of trauma. “If you could eventually come up with a treatment that helped resolve some of the bleeding, for example, then you would potentially be able to watch and see with MRI if the person is getting better,” said Dr. Haacke.

Conventional MRI (left) hints at a possible bleed in the left front brain. SWI (right) reveals several bleeds from trauma. Photos courtesy Zahid Latif/Detroit Medical Center/Wayne State University

TAMPA – A patient's request for a hastened death–either an explicit request or a hint–should be considered a clinical emergency that offers an important therapeutic opportunity.

“When you're in the office and somebody asks, 'Doctor, will you help me die? I just want to end it all,' that is a true clinical emergency,” Dr. Ira R. Byock said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“It's as if somebody develops crushing chest pain or fibrillates and codes in your office. Somebody's life is at risk here. That person may have a progressive illness, but that doesn't mean that [his or her] life is at any less risk or that it's any less of an emergency,” said Dr. Byock, who is director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Such a request is “a remarkable therapeutic opportunity,” he said. “The very fact that the patient has shared this with you … opens up a therapeutic window.”

Occasional thoughts of suicide or a desire for death are fairly common among people living with a serious illness.

In Oregon–where physician-assisted suicide is legal in certain circumstances–65 prescriptions for lethal medications were written in 2006, and 46 people died by lethal prescription that year (out of a total of roughly 31,000 deaths in the state). The 1997 Death with Dignity Act allows terminally ill Oregonians to end their lives through the voluntary self-administration of lethal medications, prescribed by a physician expressly for that purpose.

“Certain diagnoses are particularly associated with a request for assisted suicide and receipt of a lethal prescription,” Dr. Byock said. Based on data through 2006 in Oregon, patients who have amyotrophic lateral sclerosis are about 35 times as likely to use physician-assisted suicide or to ask for a lethal prescription as are patients with chronic obstructive pulmonary disease, he said. HIV/AIDS and cancer also are particularly associated with a request for assisted suicide and receipt of a lethal prescription.

Research also has shown that many terminally ill patients meet the diagnostic criteria for major depression, which is an important risk factor for a request for suicide. “In treating depression, I think we often just reach for the SSRI [selective serotonin reuptake inhibitor] or the psychostimulant, all of which can be valuable,” Dr. Byock said. But don't forget to look for other causes of the depression, such as hypothyroidism, adrenal dysfunction, or the side effects of other medications.

And because many of the somatic symptoms of depression–including fatigue, anorexia, loss of energy, sleep disturbance, and mild confusion–are common in terminal illness, the psychological symptoms are more useful in identifying depression in these patients. Look for hopelessness, helplessness, guilt, worthlessness, loss of meaning, and preoccupation with death and suicide.

Beyond that, the feeling of hopelessness has been shown to be more highly correlated with suicidal ideation in these patients than is depression. Think about recommending or providing counseling to help patients address issues of hopelessness and helplessness.

When a patient with advanced illness asks for help in dying, it also is important for physicians to recognize their own emotional responses to such requests. At the same time that a physician is moved by the patient's suffering, “at times, to a physician's ear, the expression of a wish to die can sound to us like a condemnation of our care,” Dr. Byock observed.

Acknowledging this is part of the therapeutic challenge.

The fact that the patient makes such a vulnerable statement is testament to the patient's trust in his or her physician. The most important thing a physician can do in these situations simply is to listen–an act that has therapeutic value in itself. The act of listening “helps people feel acknowledged and helps them feel like you're accompanying them on this difficult journey.

“Even if one is deeply, morally opposed to assisting a patient in suicide, it is possible and essential to be able to listen to the requests and accept the patient's feelings in a nonjudgmental manner,” Dr. Byock said.

Expressing empathy–with comments such as “I can't imagine how hard this must be for you”–can also help to strengthen the therapeutic relationship, “which is itself a powerful tool for treatment,” he said.

It's important to clarify a request for death, as many patients are confused about end-of-life care. Some assume that by not accepting every possible treatment–antibiotics and dialysis, for example–they are essentially committing suicide.

“We can often alleviate their anxiety and help them distinguish between actively shortening their lives and simply not using medical treatments that aren't consistent with their preferences and desires,” Dr. Byock said.

Even simply informing patients that they can decline medically administered nutrition and hydration to allow a “natural” death can satisfy their concerns.

Sometimes patients won't directly express a desire for death but will hint at it or make deliberately provocative statements. One of Dr. Byock's patients told him that “they should dig a hole and just shoot me.” Statements like these are valuable openings because they express the patient's fears and feelings, he said. They are also a way for patients to test their physician. “If we respond 'oh, don't talk like that,' we've given a strong message,” he said.

Patients also may use provocative statements like, “I hope you'll help me die when it's time” as a way of assessing their physician's commitment to not letting them suffer. What sounds like a request for death may “simply [be a desire] to be assured of a way of escaping suffering if it becomes unbearable,” Dr. Byock said.

“It's important to understand whether they're referring to assisted suicide/euthanasia or just adequate analgesia,” he said.

In treating pain in this patient group, Dr. Byock recommends making it explicit to the patient, in the chart, and to medical colleagues that a detailed pain management plan needs to be put in place, with lots of contingencies, in case pain gets out of control. This means taking a multimodal, layered approach using patient-controlled analgesia and scheduled, as-necessary, and crisis medications. It's also important for patients to have specific telephone numbers to call after hours to get a prompt response.

“We pursue symptom-directed treatments even when patients are seriously ill,” Dr. Byock said. These patients may benefit from regional blocks, axial analgesia, or neurolytic procedures.

In addition, it's a good idea to get a formal consultation with palliative care or pain services. Dr. Byock tells his patients that there always is the option of palliative sedation if no other options are working and pain is unbearable. “This is not only ethically acceptable; I would assert that it's ethically required, if nothing else is working,” he said.

Another issue for many patients with advanced illness is the worry about being a burden on their families or caregivers. Dr. Byock tells his patients that although they can't take away the burden, their behavior and attitude can influence how their family responds to it. “The way people die stays in the minds and hearts of those they leave behind,” he said.

Some evidence suggests that by committing suicide, a person is putting first-degree relatives at greater risk of suicide themselves. “I rarely say that, but there are some times when it's worth sharing,” he said. Patients who have children can provide a model for their children and grandchildren of living with dignity to the very end of life. A patient can be reassured that this “has value in and of itself,” Dr. Byock said.

Dr. Ira R. Byock tells patients that their behavior and attitude can influence the way families respond to the burden of care. Mark Washburn/Dartmouth-Hitchcock Medical Center

How One Patient Found Some Solace

One of Dr. Byock's patients, Mr. B, was a 68-year-old man with colon cancer that had metastasized to the liver, lungs, and bone. He presented with increasing, severe left hip pain after a minor injury. He was on hydrocodone/acetaminophen (Vicodin) every 4 hours for pain relief. He was very anxious, and at times seemed unable to understand the information given to him, Dr. Byock said.

Mr. B had retired after a career in industry. “He was a gentle, well-mannered man. His passions included walking in the wilderness and gardening, interests that he shared with his wife of 22 years,” Dr. Byock recounted.

According to Dr. Byock, Mr. B volunteered that he had been thinking about “ending it all.” He spoke of a neighbor who had committed suicide by gunshot to the head because of severe cancer pain. “I don't want to end up like that. I hope you will help me die before I get to that point,” Mr. B told his physician.

While hospitalized for the hip pain resulting from the minor injury, he was treated with long-acting morphine, an NSAID, and lorazepam for his anxiety. A geriatric psychiatrist on the hospital staff was consulted about Mr. B's desire to die. Mr. B told the psychiatrist that he was feeling fine at the moment but he was in fear of being in constant, uncontrollable pain. He added that he knew his wife would be devastated if he committed suicide. When Dr. Byock learned that the real problem was fear of pain, he was able to reassure Mr. B that he could achieve sufficient pain control to live a high-quality life at home.

Mr. B was started on mirtazapine for depression, and his anxiety decreased during the course of his hospital stay. The medication also helped his sleep and appetite.

Before he went home, he was counseled about his pain management plan and assured that there was no circumstance in which he would suffer for more than a very short time.

Mr. B still talked about suicide when asked by a member of his palliative care team, but he no longer brought up the subject. He said that his feelings hadn't changed but that he felt more confident that he wouldn't have to turn to suicide, Dr. Byock said. He died at home in hospice care several months after he was discharged.

TAMPA – A patient's request for a hastened death–either an explicit request or a hint–should be considered a clinical emergency that offers an important therapeutic opportunity.

“When you're in the office and somebody asks, 'Doctor, will you help me die? I just want to end it all,' that is a true clinical emergency,” Dr. Ira R. Byock said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“It's as if somebody develops crushing chest pain or fibrillates and codes in your office. Somebody's life is at risk here. That person may have a progressive illness, but that doesn't mean that [his or her] life is at any less risk or that it's any less of an emergency,” said Dr. Byock, who is director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Such a request is “a remarkable therapeutic opportunity,” he said. “The very fact that the patient has shared this with you … opens up a therapeutic window.”

Occasional thoughts of suicide or a desire for death are fairly common among people living with a serious illness.

In Oregon–where physician-assisted suicide is legal in certain circumstances–65 prescriptions for lethal medications were written in 2006, and 46 people died by lethal prescription that year (out of a total of roughly 31,000 deaths in the state). The 1997 Death with Dignity Act allows terminally ill Oregonians to end their lives through the voluntary self-administration of lethal medications, prescribed by a physician expressly for that purpose.

“Certain diagnoses are particularly associated with a request for assisted suicide and receipt of a lethal prescription,” Dr. Byock said. Based on data through 2006 in Oregon, patients who have amyotrophic lateral sclerosis are about 35 times as likely to use physician-assisted suicide or to ask for a lethal prescription as are patients with chronic obstructive pulmonary disease, he said. HIV/AIDS and cancer also are particularly associated with a request for assisted suicide and receipt of a lethal prescription.

Research also has shown that many terminally ill patients meet the diagnostic criteria for major depression, which is an important risk factor for a request for suicide. “In treating depression, I think we often just reach for the SSRI [selective serotonin reuptake inhibitor] or the psychostimulant, all of which can be valuable,” Dr. Byock said. But don't forget to look for other causes of the depression, such as hypothyroidism, adrenal dysfunction, or the side effects of other medications.

And because many of the somatic symptoms of depression–including fatigue, anorexia, loss of energy, sleep disturbance, and mild confusion–are common in terminal illness, the psychological symptoms are more useful in identifying depression in these patients. Look for hopelessness, helplessness, guilt, worthlessness, loss of meaning, and preoccupation with death and suicide.

Beyond that, the feeling of hopelessness has been shown to be more highly correlated with suicidal ideation in these patients than is depression. Think about recommending or providing counseling to help patients address issues of hopelessness and helplessness.

When a patient with advanced illness asks for help in dying, it also is important for physicians to recognize their own emotional responses to such requests. At the same time that a physician is moved by the patient's suffering, “at times, to a physician's ear, the expression of a wish to die can sound to us like a condemnation of our care,” Dr. Byock observed.

Acknowledging this is part of the therapeutic challenge.

The fact that the patient makes such a vulnerable statement is testament to the patient's trust in his or her physician. The most important thing a physician can do in these situations simply is to listen–an act that has therapeutic value in itself. The act of listening “helps people feel acknowledged and helps them feel like you're accompanying them on this difficult journey.

“Even if one is deeply, morally opposed to assisting a patient in suicide, it is possible and essential to be able to listen to the requests and accept the patient's feelings in a nonjudgmental manner,” Dr. Byock said.

Expressing empathy–with comments such as “I can't imagine how hard this must be for you”–can also help to strengthen the therapeutic relationship, “which is itself a powerful tool for treatment,” he said.

It's important to clarify a request for death, as many patients are confused about end-of-life care. Some assume that by not accepting every possible treatment–antibiotics and dialysis, for example–they are essentially committing suicide.

“We can often alleviate their anxiety and help them distinguish between actively shortening their lives and simply not using medical treatments that aren't consistent with their preferences and desires,” Dr. Byock said.

Even simply informing patients that they can decline medically administered nutrition and hydration to allow a “natural” death can satisfy their concerns.

Sometimes patients won't directly express a desire for death but will hint at it or make deliberately provocative statements. One of Dr. Byock's patients told him that “they should dig a hole and just shoot me.” Statements like these are valuable openings because they express the patient's fears and feelings, he said. They are also a way for patients to test their physician. “If we respond 'oh, don't talk like that,' we've given a strong message,” he said.

Patients also may use provocative statements like, “I hope you'll help me die when it's time” as a way of assessing their physician's commitment to not letting them suffer. What sounds like a request for death may “simply [be a desire] to be assured of a way of escaping suffering if it becomes unbearable,” Dr. Byock said.

“It's important to understand whether they're referring to assisted suicide/euthanasia or just adequate analgesia,” he said.

In treating pain in this patient group, Dr. Byock recommends making it explicit to the patient, in the chart, and to medical colleagues that a detailed pain management plan needs to be put in place, with lots of contingencies, in case pain gets out of control. This means taking a multimodal, layered approach using patient-controlled analgesia and scheduled, as-necessary, and crisis medications. It's also important for patients to have specific telephone numbers to call after hours to get a prompt response.

“We pursue symptom-directed treatments even when patients are seriously ill,” Dr. Byock said. These patients may benefit from regional blocks, axial analgesia, or neurolytic procedures.

In addition, it's a good idea to get a formal consultation with palliative care or pain services. Dr. Byock tells his patients that there always is the option of palliative sedation if no other options are working and pain is unbearable. “This is not only ethically acceptable; I would assert that it's ethically required, if nothing else is working,” he said.

Another issue for many patients with advanced illness is the worry about being a burden on their families or caregivers. Dr. Byock tells his patients that although they can't take away the burden, their behavior and attitude can influence how their family responds to it. “The way people die stays in the minds and hearts of those they leave behind,” he said.

Some evidence suggests that by committing suicide, a person is putting first-degree relatives at greater risk of suicide themselves. “I rarely say that, but there are some times when it's worth sharing,” he said. Patients who have children can provide a model for their children and grandchildren of living with dignity to the very end of life. A patient can be reassured that this “has value in and of itself,” Dr. Byock said.

Dr. Ira R. Byock tells patients that their behavior and attitude can influence the way families respond to the burden of care. Mark Washburn/Dartmouth-Hitchcock Medical Center

How One Patient Found Some Solace

One of Dr. Byock's patients, Mr. B, was a 68-year-old man with colon cancer that had metastasized to the liver, lungs, and bone. He presented with increasing, severe left hip pain after a minor injury. He was on hydrocodone/acetaminophen (Vicodin) every 4 hours for pain relief. He was very anxious, and at times seemed unable to understand the information given to him, Dr. Byock said.

Mr. B had retired after a career in industry. “He was a gentle, well-mannered man. His passions included walking in the wilderness and gardening, interests that he shared with his wife of 22 years,” Dr. Byock recounted.

According to Dr. Byock, Mr. B volunteered that he had been thinking about “ending it all.” He spoke of a neighbor who had committed suicide by gunshot to the head because of severe cancer pain. “I don't want to end up like that. I hope you will help me die before I get to that point,” Mr. B told his physician.

While hospitalized for the hip pain resulting from the minor injury, he was treated with long-acting morphine, an NSAID, and lorazepam for his anxiety. A geriatric psychiatrist on the hospital staff was consulted about Mr. B's desire to die. Mr. B told the psychiatrist that he was feeling fine at the moment but he was in fear of being in constant, uncontrollable pain. He added that he knew his wife would be devastated if he committed suicide. When Dr. Byock learned that the real problem was fear of pain, he was able to reassure Mr. B that he could achieve sufficient pain control to live a high-quality life at home.

Mr. B was started on mirtazapine for depression, and his anxiety decreased during the course of his hospital stay. The medication also helped his sleep and appetite.

Before he went home, he was counseled about his pain management plan and assured that there was no circumstance in which he would suffer for more than a very short time.

Mr. B still talked about suicide when asked by a member of his palliative care team, but he no longer brought up the subject. He said that his feelings hadn't changed but that he felt more confident that he wouldn't have to turn to suicide, Dr. Byock said. He died at home in hospice care several months after he was discharged.

TAMPA – A patient's request for a hastened death–either an explicit request or a hint–should be considered a clinical emergency that offers an important therapeutic opportunity.

“When you're in the office and somebody asks, 'Doctor, will you help me die? I just want to end it all,' that is a true clinical emergency,” Dr. Ira R. Byock said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.

“It's as if somebody develops crushing chest pain or fibrillates and codes in your office. Somebody's life is at risk here. That person may have a progressive illness, but that doesn't mean that [his or her] life is at any less risk or that it's any less of an emergency,” said Dr. Byock, who is director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Such a request is “a remarkable therapeutic opportunity,” he said. “The very fact that the patient has shared this with you … opens up a therapeutic window.”

Occasional thoughts of suicide or a desire for death are fairly common among people living with a serious illness.

In Oregon–where physician-assisted suicide is legal in certain circumstances–65 prescriptions for lethal medications were written in 2006, and 46 people died by lethal prescription that year (out of a total of roughly 31,000 deaths in the state). The 1997 Death with Dignity Act allows terminally ill Oregonians to end their lives through the voluntary self-administration of lethal medications, prescribed by a physician expressly for that purpose.

“Certain diagnoses are particularly associated with a request for assisted suicide and receipt of a lethal prescription,” Dr. Byock said. Based on data through 2006 in Oregon, patients who have amyotrophic lateral sclerosis are about 35 times as likely to use physician-assisted suicide or to ask for a lethal prescription as are patients with chronic obstructive pulmonary disease, he said. HIV/AIDS and cancer also are particularly associated with a request for assisted suicide and receipt of a lethal prescription.

Research also has shown that many terminally ill patients meet the diagnostic criteria for major depression, which is an important risk factor for a request for suicide. “In treating depression, I think we often just reach for the SSRI [selective serotonin reuptake inhibitor] or the psychostimulant, all of which can be valuable,” Dr. Byock said. But don't forget to look for other causes of the depression, such as hypothyroidism, adrenal dysfunction, or the side effects of other medications.

And because many of the somatic symptoms of depression–including fatigue, anorexia, loss of energy, sleep disturbance, and mild confusion–are common in terminal illness, the psychological symptoms are more useful in identifying depression in these patients. Look for hopelessness, helplessness, guilt, worthlessness, loss of meaning, and preoccupation with death and suicide.

Beyond that, the feeling of hopelessness has been shown to be more highly correlated with suicidal ideation in these patients than is depression. Think about recommending or providing counseling to help patients address issues of hopelessness and helplessness.

When a patient with advanced illness asks for help in dying, it also is important for physicians to recognize their own emotional responses to such requests. At the same time that a physician is moved by the patient's suffering, “at times, to a physician's ear, the expression of a wish to die can sound to us like a condemnation of our care,” Dr. Byock observed.

Acknowledging this is part of the therapeutic challenge.

The fact that the patient makes such a vulnerable statement is testament to the patient's trust in his or her physician. The most important thing a physician can do in these situations simply is to listen–an act that has therapeutic value in itself. The act of listening “helps people feel acknowledged and helps them feel like you're accompanying them on this difficult journey.

“Even if one is deeply, morally opposed to assisting a patient in suicide, it is possible and essential to be able to listen to the requests and accept the patient's feelings in a nonjudgmental manner,” Dr. Byock said.

Expressing empathy–with comments such as “I can't imagine how hard this must be for you”–can also help to strengthen the therapeutic relationship, “which is itself a powerful tool for treatment,” he said.

It's important to clarify a request for death, as many patients are confused about end-of-life care. Some assume that by not accepting every possible treatment–antibiotics and dialysis, for example–they are essentially committing suicide.

“We can often alleviate their anxiety and help them distinguish between actively shortening their lives and simply not using medical treatments that aren't consistent with their preferences and desires,” Dr. Byock said.

Even simply informing patients that they can decline medically administered nutrition and hydration to allow a “natural” death can satisfy their concerns.

Sometimes patients won't directly express a desire for death but will hint at it or make deliberately provocative statements. One of Dr. Byock's patients told him that “they should dig a hole and just shoot me.” Statements like these are valuable openings because they express the patient's fears and feelings, he said. They are also a way for patients to test their physician. “If we respond 'oh, don't talk like that,' we've given a strong message,” he said.

Patients also may use provocative statements like, “I hope you'll help me die when it's time” as a way of assessing their physician's commitment to not letting them suffer. What sounds like a request for death may “simply [be a desire] to be assured of a way of escaping suffering if it becomes unbearable,” Dr. Byock said.

“It's important to understand whether they're referring to assisted suicide/euthanasia or just adequate analgesia,” he said.

In treating pain in this patient group, Dr. Byock recommends making it explicit to the patient, in the chart, and to medical colleagues that a detailed pain management plan needs to be put in place, with lots of contingencies, in case pain gets out of control. This means taking a multimodal, layered approach using patient-controlled analgesia and scheduled, as-necessary, and crisis medications. It's also important for patients to have specific telephone numbers to call after hours to get a prompt response.

“We pursue symptom-directed treatments even when patients are seriously ill,” Dr. Byock said. These patients may benefit from regional blocks, axial analgesia, or neurolytic procedures.

In addition, it's a good idea to get a formal consultation with palliative care or pain services. Dr. Byock tells his patients that there always is the option of palliative sedation if no other options are working and pain is unbearable. “This is not only ethically acceptable; I would assert that it's ethically required, if nothing else is working,” he said.

Another issue for many patients with advanced illness is the worry about being a burden on their families or caregivers. Dr. Byock tells his patients that although they can't take away the burden, their behavior and attitude can influence how their family responds to it. “The way people die stays in the minds and hearts of those they leave behind,” he said.

Some evidence suggests that by committing suicide, a person is putting first-degree relatives at greater risk of suicide themselves. “I rarely say that, but there are some times when it's worth sharing,” he said. Patients who have children can provide a model for their children and grandchildren of living with dignity to the very end of life. A patient can be reassured that this “has value in and of itself,” Dr. Byock said.

Dr. Ira R. Byock tells patients that their behavior and attitude can influence the way families respond to the burden of care. Mark Washburn/Dartmouth-Hitchcock Medical Center

How One Patient Found Some Solace

One of Dr. Byock's patients, Mr. B, was a 68-year-old man with colon cancer that had metastasized to the liver, lungs, and bone. He presented with increasing, severe left hip pain after a minor injury. He was on hydrocodone/acetaminophen (Vicodin) every 4 hours for pain relief. He was very anxious, and at times seemed unable to understand the information given to him, Dr. Byock said.

Mr. B had retired after a career in industry. “He was a gentle, well-mannered man. His passions included walking in the wilderness and gardening, interests that he shared with his wife of 22 years,” Dr. Byock recounted.

According to Dr. Byock, Mr. B volunteered that he had been thinking about “ending it all.” He spoke of a neighbor who had committed suicide by gunshot to the head because of severe cancer pain. “I don't want to end up like that. I hope you will help me die before I get to that point,” Mr. B told his physician.

While hospitalized for the hip pain resulting from the minor injury, he was treated with long-acting morphine, an NSAID, and lorazepam for his anxiety. A geriatric psychiatrist on the hospital staff was consulted about Mr. B's desire to die. Mr. B told the psychiatrist that he was feeling fine at the moment but he was in fear of being in constant, uncontrollable pain. He added that he knew his wife would be devastated if he committed suicide. When Dr. Byock learned that the real problem was fear of pain, he was able to reassure Mr. B that he could achieve sufficient pain control to live a high-quality life at home.

Mr. B was started on mirtazapine for depression, and his anxiety decreased during the course of his hospital stay. The medication also helped his sleep and appetite.

Before he went home, he was counseled about his pain management plan and assured that there was no circumstance in which he would suffer for more than a very short time.

Mr. B still talked about suicide when asked by a member of his palliative care team, but he no longer brought up the subject. He said that his feelings hadn't changed but that he felt more confident that he wouldn't have to turn to suicide, Dr. Byock said. He died at home in hospice care several months after he was discharged.

WASHINGTON– The combination of optimized acute medication, preventive medication, and behavioral therapy significantly reduced migraine activity, according to study results presented at the annual meeting of the American Pain Society.

In a study of 232 patients with frequent, disabling migraine, Kenneth A. Holroyd, Ph.D., distinguished professor of psychology at Ohio University in Athens, and his colleagues assessed the effectiveness of optimal acute therapy (OAT); OAT plus preventive medications; OAT plus behavioral migraine management; or OAT plus a combination of preventive medications and behavioral migraine management.

All treatments reduced the number of migraine episodes. However, neither preventive medication nor behavioral management in combination with acute medication made a significant difference. But the combination of all three–preventive medication, behavioral therapy, and acute medication–caused a significant improvement in outcome, Dr. Holroyd said.

Potential participants met the International Headache Society criteria for migraine. They had to have a minimum of three migraines per month with significant migraine-related disability. Individuals with medication overuse complications were excluded. Patients who met these criteria completed a 5-week run-in period of acute therapy (triptans, NSAIDs, antiemetics, and rescue medications as needed).

Most of the participants were women (79%). The average age was 38 years and most patients were white (84%). Patients had an average of 5.5 migraine episodes per 30 days and 8.5 migraine days per month.

The patients were randomized to one of four treatment groups. Triptan dose and route of administration were adjusted to achieve optimal acute therapy. Use of antiemetic and rescue medications was adjusted for optimal effect. The primary preventive medication was propranolol-LA (up to 240 mg/day). However, if the drug was ineffective or intolerable, nadolol (up to 120 mg/day) was used. OAT and preventive medication doses were adjusted over a 4-month period to optimize efficacy. During this period, patients had monthly clinic visits and received two phone calls from study staff.

For behavioral migraine management, patients were taught a variety of skills that have been shown to be effective. Patients learned about identifying warning signs and triggers, effective use of medication, reducing the impact of migraine, and biofeedback. Instruction involved clinic visits, telephone calls, home workbooks, and audio tapes.

All patients had five clinic visits (baseline and four monthly visits), which primarily involved medication monitoring, dose adjustment, and quality of life assessment. Quality of life was assessed using the Headache Disability Inventory and the Migraine-Specific Quality of Life Questionnaire. Migraine activity and medication compliance were evaluated using a computer-based diary.

In terms of migraine activity, 80% of those who used both preventive medication and behavioral migraine management along with OAT had at least a 50% improvement in both episodes per month and migraine days per month. OAT alone, OAT with preventive medication, and OAT with behavioral management resulted in less than half of patients experiencing at least a 50% reduction in migraine activity. Looking at quality of life, both the OAT/preventive medication approach and the OAT/behavioral management approach produced improvements over OAT alone.

It is hypothesized that migraines tend to occur in clusters because there is progressive sensitization during the course of a migraine that can persist for up to 96 hours, leaving the sufferer vulnerable to subsequent episodes.

“It's possible that if you completely abort the first migraine before it becomes severe, subsequent migraine clusters won't occur,” Dr. Holroyd said.

WASHINGTON– The combination of optimized acute medication, preventive medication, and behavioral therapy significantly reduced migraine activity, according to study results presented at the annual meeting of the American Pain Society.

In a study of 232 patients with frequent, disabling migraine, Kenneth A. Holroyd, Ph.D., distinguished professor of psychology at Ohio University in Athens, and his colleagues assessed the effectiveness of optimal acute therapy (OAT); OAT plus preventive medications; OAT plus behavioral migraine management; or OAT plus a combination of preventive medications and behavioral migraine management.

All treatments reduced the number of migraine episodes. However, neither preventive medication nor behavioral management in combination with acute medication made a significant difference. But the combination of all three–preventive medication, behavioral therapy, and acute medication–caused a significant improvement in outcome, Dr. Holroyd said.

Potential participants met the International Headache Society criteria for migraine. They had to have a minimum of three migraines per month with significant migraine-related disability. Individuals with medication overuse complications were excluded. Patients who met these criteria completed a 5-week run-in period of acute therapy (triptans, NSAIDs, antiemetics, and rescue medications as needed).

Most of the participants were women (79%). The average age was 38 years and most patients were white (84%). Patients had an average of 5.5 migraine episodes per 30 days and 8.5 migraine days per month.

The patients were randomized to one of four treatment groups. Triptan dose and route of administration were adjusted to achieve optimal acute therapy. Use of antiemetic and rescue medications was adjusted for optimal effect. The primary preventive medication was propranolol-LA (up to 240 mg/day). However, if the drug was ineffective or intolerable, nadolol (up to 120 mg/day) was used. OAT and preventive medication doses were adjusted over a 4-month period to optimize efficacy. During this period, patients had monthly clinic visits and received two phone calls from study staff.

For behavioral migraine management, patients were taught a variety of skills that have been shown to be effective. Patients learned about identifying warning signs and triggers, effective use of medication, reducing the impact of migraine, and biofeedback. Instruction involved clinic visits, telephone calls, home workbooks, and audio tapes.

All patients had five clinic visits (baseline and four monthly visits), which primarily involved medication monitoring, dose adjustment, and quality of life assessment. Quality of life was assessed using the Headache Disability Inventory and the Migraine-Specific Quality of Life Questionnaire. Migraine activity and medication compliance were evaluated using a computer-based diary.

In terms of migraine activity, 80% of those who used both preventive medication and behavioral migraine management along with OAT had at least a 50% improvement in both episodes per month and migraine days per month. OAT alone, OAT with preventive medication, and OAT with behavioral management resulted in less than half of patients experiencing at least a 50% reduction in migraine activity. Looking at quality of life, both the OAT/preventive medication approach and the OAT/behavioral management approach produced improvements over OAT alone.

It is hypothesized that migraines tend to occur in clusters because there is progressive sensitization during the course of a migraine that can persist for up to 96 hours, leaving the sufferer vulnerable to subsequent episodes.

“It's possible that if you completely abort the first migraine before it becomes severe, subsequent migraine clusters won't occur,” Dr. Holroyd said.

WASHINGTON– The combination of optimized acute medication, preventive medication, and behavioral therapy significantly reduced migraine activity, according to study results presented at the annual meeting of the American Pain Society.

In a study of 232 patients with frequent, disabling migraine, Kenneth A. Holroyd, Ph.D., distinguished professor of psychology at Ohio University in Athens, and his colleagues assessed the effectiveness of optimal acute therapy (OAT); OAT plus preventive medications; OAT plus behavioral migraine management; or OAT plus a combination of preventive medications and behavioral migraine management.

All treatments reduced the number of migraine episodes. However, neither preventive medication nor behavioral management in combination with acute medication made a significant difference. But the combination of all three–preventive medication, behavioral therapy, and acute medication–caused a significant improvement in outcome, Dr. Holroyd said.

Potential participants met the International Headache Society criteria for migraine. They had to have a minimum of three migraines per month with significant migraine-related disability. Individuals with medication overuse complications were excluded. Patients who met these criteria completed a 5-week run-in period of acute therapy (triptans, NSAIDs, antiemetics, and rescue medications as needed).

Most of the participants were women (79%). The average age was 38 years and most patients were white (84%). Patients had an average of 5.5 migraine episodes per 30 days and 8.5 migraine days per month.

The patients were randomized to one of four treatment groups. Triptan dose and route of administration were adjusted to achieve optimal acute therapy. Use of antiemetic and rescue medications was adjusted for optimal effect. The primary preventive medication was propranolol-LA (up to 240 mg/day). However, if the drug was ineffective or intolerable, nadolol (up to 120 mg/day) was used. OAT and preventive medication doses were adjusted over a 4-month period to optimize efficacy. During this period, patients had monthly clinic visits and received two phone calls from study staff.

For behavioral migraine management, patients were taught a variety of skills that have been shown to be effective. Patients learned about identifying warning signs and triggers, effective use of medication, reducing the impact of migraine, and biofeedback. Instruction involved clinic visits, telephone calls, home workbooks, and audio tapes.

All patients had five clinic visits (baseline and four monthly visits), which primarily involved medication monitoring, dose adjustment, and quality of life assessment. Quality of life was assessed using the Headache Disability Inventory and the Migraine-Specific Quality of Life Questionnaire. Migraine activity and medication compliance were evaluated using a computer-based diary.

In terms of migraine activity, 80% of those who used both preventive medication and behavioral migraine management along with OAT had at least a 50% improvement in both episodes per month and migraine days per month. OAT alone, OAT with preventive medication, and OAT with behavioral management resulted in less than half of patients experiencing at least a 50% reduction in migraine activity. Looking at quality of life, both the OAT/preventive medication approach and the OAT/behavioral management approach produced improvements over OAT alone.

It is hypothesized that migraines tend to occur in clusters because there is progressive sensitization during the course of a migraine that can persist for up to 96 hours, leaving the sufferer vulnerable to subsequent episodes.

“It's possible that if you completely abort the first migraine before it becomes severe, subsequent migraine clusters won't occur,” Dr. Holroyd said.

WASHINGTON — Many of the strategies held to prevent adverse events and promote patient safety “actually are quite speculative. There isn't really a lot of evidence that supports them,” according to Dr. Scott A. Flanders, director of the hospitalist program at the University of Michigan Medical Center in Ann Arbor.

In a presentation at the annual meeting of the American College of Physicians, Dr. Flanders outlined an organized framework for considering and implementing patient safety interventions in the hospital.

Balancing the urgent need to act against the need for good evidence “is a little more complicated than just rolling up your sleeves and running in to begin tackling a problem,” he said. Some interventions are easy to implement, but don't have strong evidence to support them. Others have the evidence, but are difficult to undertake.

Safety interventions also can introduce risks for new errors or complications. And there has been little assessment of the cost-effectiveness of specific interventions, Dr. Flanders said.

Further, the evidence backing patient safety measures can change. Many of the 75 patient safety practices that received high ratings in the Agency for Healthcare Research and Quality's influential 2001 report, “Making Health Care Safer: A Critical Analysis of Patient Safety Practices,” are now being seriously questioned, including the use of β-blockers to prevent perioperative cardiac complications, rapid response teams to avoid failure to rescue, pharmacologic prophylaxis to prevent venous thromboembolism, and surveillance to minimize methicillin-resistant Staphylococcus aureus infections.

“At a minimum, you need to run through the following list of considerations before you get started,” he said.

First consider the scope of the problem being targeted and whether a solution can reasonably be accomplished. Next, evaluate the evidence for the effectiveness of the intervention. Assess the complexity and the possible costs of implementation. Evaluate whether a course of action can cause new errors or other collateral effects. And look for momentum—synergy with other existing or planned efforts at your facility, said Dr. Flanders, who is also an associate professor of medicine at the University of Michigan.

His recommendations for implementing patient safety programs are based on the “balanced diet” approaches suggested in a recent article (Med. Clin. N. Am. 2008;92:275–93):

▸ “Low-hanging fruit.” These are easy-to-implement interventions supported by strong evidence. Examples include the use of ultrasound guidance for central line insertion, guidelines for reducing central line infections, and guidelines for reducing catheter-related urinary tract infections.

▸ “Slightly higher fruit.” Interventions for improved provider communication, for example, are supported by weaker evidence but are easy to implement.

Alternatively, methods of improving care transitions are supported by strong evidence but are somewhat difficult to implement.

Computerized/structured sign-out systems can reduce adverse events and the number of patients missed on resident rounds. Postdischarge adverse events can be reduced by following up with patients within 48–72 hours and using structured discharge summaries that list medications at discharge, changes in medications since admission, current problems, and pending laboratory tests.

Phone communication with providers can be improved by having referring physicians read back important information about critical lab results, requests to bring patients for procedures, and verbal orders.

▸ Projects that will generate momentum. Executive walk rounds can jump-start problem solving, according to Dr. Flanders. On executive walk rounds, senior hospital executives join physician and nurse leaders in conducting periodic visits to different areas within the hospital. This provides opportunities for informal discussions about troubling events, the system issues that led to these events, and suggested solutions.

Planned follow-up is crucial to the success of this approach.

Rapid response teams (RRTs) appear to substantially improve staff morale, especially for nurses, Dr. Flanders said, although the teams haven't been clearly shown to decrease mortality.

▸ Planning for bigger projects down the road. Good examples of long-term solutions that require planning and a team approach include implementation of computerized physician order entry and electronic medical records.

“Computerization is going to happen,” Dr. Flanders said, although there is no evidence that technologic solutions lead to harm reduction.

Dr. Flanders reported that he had no relevant financial relationships.

Postdischarge adverse events can be reduced by following up with patients, Dr. Scott A. Flanders said. Martin Vloet/University of Michigan Photo Services

Evidence Is Mixed for Several Commonly Used Safety Interventions

Dr. Flanders described several examples of patient safety strategies that have not been confirmed by data:

▸ Preventing perioperative cardiac complications. The recommendation to use β-blockers to reduce cardiac complications of noncardiac surgery—based on five randomized trials with a total of about 600 patients—received the second-highest evidence rating in the Agency for Healthcare Research and Quality's 2001 report, “Making Health Care Safer: A Critical Analysis of Patient Safety Practices.”

The overall benefit of this recommendation is now unclear, said Dr. Flanders, citing a 2005 meta-analysis of 22 clinical trials (BMJ 2005;331:313–21). In those trials, the use of perioperative β-blockers appeared to increase the risk of bradycardia and hypotension.

▸ Avoiding failure to rescue. Patients who experience cardiac arrest in the hospital often have preceding signs of clinical deterioration. Rapid response teams (RRTs) or medical emergency teams (METs) have been organized to react quickly and try to prevent deaths.

Two observational studies and one randomized study found a reduced risk of death associated with RRTs. But researchers in Australia found that METs had no substantial effect on the incidence of cardiac arrest, unplanned ICU admission, or unexpected death (Lancet 2005;365:2091–7).

▸ Preventing venous thromboembolism. Half of the estimated 2 million cases of venous thromboembolism (VTE) that occur each year develop in the hospital or within 30 days of discharge. Between 10% and 25% of inpatients may develop VTE, resulting in additional costs of up to $20,000 per episode.

Several meta-analyses have shown inconsistent evidence that pharmacologic prophylaxis can reduce the risk of VTE. “No study has ever shown a mortality benefit, including the meta-analyses that combined thousands of patients,” Dr. Flanders said, and studies have shown a roughly 50% increased risk of minor bleeding.

▸ Preventing methicillin-resistant Staphylococcus aureus (MRSA) infections. Prevention strategies aimed at limiting the spread of MRSA include hand hygiene, environmental decontamination, screening to identify colonized individuals, and the use of contact barriers to isolate colonized/infected patients.

Two large studies recently evaluated MRSA surveillance and decolonization. In an observational study involving three hospitals, polymerase chain reaction (PCR) was used to screen nasal specimens from more than 150,000 patients. Patients who tested positive for MRSA were put in contact isolation and decolonized with nasal mupirocin and chlorhexidine body washes. The baseline MRSA infection rate was about 9 per 10,000 patient days. The rate fell to about 7.5 per 10,000 after surveillance was implemented in the ICU only, and to about 4 per 10,000 after implementation of hospital-wide surveillance (Ann. Intern. Med. 2008;148:409–18).

But an interventional cohort study that involved almost 22,000 surgical patients failed to show a benefit. With use of a crossover design, PCR screening for MRSA on admission plus standard infection control measures was compared with standard infection control alone. There was no difference between the two approaches in the number of infections per 1,000 patient days (JAMA 2008;299:1149–57).

WASHINGTON — Many of the strategies held to prevent adverse events and promote patient safety “actually are quite speculative. There isn't really a lot of evidence that supports them,” according to Dr. Scott A. Flanders, director of the hospitalist program at the University of Michigan Medical Center in Ann Arbor.

In a presentation at the annual meeting of the American College of Physicians, Dr. Flanders outlined an organized framework for considering and implementing patient safety interventions in the hospital.

Balancing the urgent need to act against the need for good evidence “is a little more complicated than just rolling up your sleeves and running in to begin tackling a problem,” he said. Some interventions are easy to implement, but don't have strong evidence to support them. Others have the evidence, but are difficult to undertake.

Safety interventions also can introduce risks for new errors or complications. And there has been little assessment of the cost-effectiveness of specific interventions, Dr. Flanders said.

Further, the evidence backing patient safety measures can change. Many of the 75 patient safety practices that received high ratings in the Agency for Healthcare Research and Quality's influential 2001 report, “Making Health Care Safer: A Critical Analysis of Patient Safety Practices,” are now being seriously questioned, including the use of β-blockers to prevent perioperative cardiac complications, rapid response teams to avoid failure to rescue, pharmacologic prophylaxis to prevent venous thromboembolism, and surveillance to minimize methicillin-resistant Staphylococcus aureus infections.

“At a minimum, you need to run through the following list of considerations before you get started,” he said.

First consider the scope of the problem being targeted and whether a solution can reasonably be accomplished. Next, evaluate the evidence for the effectiveness of the intervention. Assess the complexity and the possible costs of implementation. Evaluate whether a course of action can cause new errors or other collateral effects. And look for momentum—synergy with other existing or planned efforts at your facility, said Dr. Flanders, who is also an associate professor of medicine at the University of Michigan.

His recommendations for implementing patient safety programs are based on the “balanced diet” approaches suggested in a recent article (Med. Clin. N. Am. 2008;92:275–93):

▸ “Low-hanging fruit.” These are easy-to-implement interventions supported by strong evidence. Examples include the use of ultrasound guidance for central line insertion, guidelines for reducing central line infections, and guidelines for reducing catheter-related urinary tract infections.

▸ “Slightly higher fruit.” Interventions for improved provider communication, for example, are supported by weaker evidence but are easy to implement.

Alternatively, methods of improving care transitions are supported by strong evidence but are somewhat difficult to implement.

Computerized/structured sign-out systems can reduce adverse events and the number of patients missed on resident rounds. Postdischarge adverse events can be reduced by following up with patients within 48–72 hours and using structured discharge summaries that list medications at discharge, changes in medications since admission, current problems, and pending laboratory tests.

Phone communication with providers can be improved by having referring physicians read back important information about critical lab results, requests to bring patients for procedures, and verbal orders.

▸ Projects that will generate momentum. Executive walk rounds can jump-start problem solving, according to Dr. Flanders. On executive walk rounds, senior hospital executives join physician and nurse leaders in conducting periodic visits to different areas within the hospital. This provides opportunities for informal discussions about troubling events, the system issues that led to these events, and suggested solutions.

Planned follow-up is crucial to the success of this approach.

Rapid response teams (RRTs) appear to substantially improve staff morale, especially for nurses, Dr. Flanders said, although the teams haven't been clearly shown to decrease mortality.

▸ Planning for bigger projects down the road. Good examples of long-term solutions that require planning and a team approach include implementation of computerized physician order entry and electronic medical records.

“Computerization is going to happen,” Dr. Flanders said, although there is no evidence that technologic solutions lead to harm reduction.

Dr. Flanders reported that he had no relevant financial relationships.

Postdischarge adverse events can be reduced by following up with patients, Dr. Scott A. Flanders said. Martin Vloet/University of Michigan Photo Services

Evidence Is Mixed for Several Commonly Used Safety Interventions

Dr. Flanders described several examples of patient safety strategies that have not been confirmed by data:

▸ Preventing perioperative cardiac complications. The recommendation to use β-blockers to reduce cardiac complications of noncardiac surgery—based on five randomized trials with a total of about 600 patients—received the second-highest evidence rating in the Agency for Healthcare Research and Quality's 2001 report, “Making Health Care Safer: A Critical Analysis of Patient Safety Practices.”

The overall benefit of this recommendation is now unclear, said Dr. Flanders, citing a 2005 meta-analysis of 22 clinical trials (BMJ 2005;331:313–21). In those trials, the use of perioperative β-blockers appeared to increase the risk of bradycardia and hypotension.

▸ Avoiding failure to rescue. Patients who experience cardiac arrest in the hospital often have preceding signs of clinical deterioration. Rapid response teams (RRTs) or medical emergency teams (METs) have been organized to react quickly and try to prevent deaths.

Two observational studies and one randomized study found a reduced risk of death associated with RRTs. But researchers in Australia found that METs had no substantial effect on the incidence of cardiac arrest, unplanned ICU admission, or unexpected death (Lancet 2005;365:2091–7).

▸ Preventing venous thromboembolism. Half of the estimated 2 million cases of venous thromboembolism (VTE) that occur each year develop in the hospital or within 30 days of discharge. Between 10% and 25% of inpatients may develop VTE, resulting in additional costs of up to $20,000 per episode.

Several meta-analyses have shown inconsistent evidence that pharmacologic prophylaxis can reduce the risk of VTE. “No study has ever shown a mortality benefit, including the meta-analyses that combined thousands of patients,” Dr. Flanders said, and studies have shown a roughly 50% increased risk of minor bleeding.

▸ Preventing methicillin-resistant Staphylococcus aureus (MRSA) infections. Prevention strategies aimed at limiting the spread of MRSA include hand hygiene, environmental decontamination, screening to identify colonized individuals, and the use of contact barriers to isolate colonized/infected patients.

Two large studies recently evaluated MRSA surveillance and decolonization. In an observational study involving three hospitals, polymerase chain reaction (PCR) was used to screen nasal specimens from more than 150,000 patients. Patients who tested positive for MRSA were put in contact isolation and decolonized with nasal mupirocin and chlorhexidine body washes. The baseline MRSA infection rate was about 9 per 10,000 patient days. The rate fell to about 7.5 per 10,000 after surveillance was implemented in the ICU only, and to about 4 per 10,000 after implementation of hospital-wide surveillance (Ann. Intern. Med. 2008;148:409–18).

But an interventional cohort study that involved almost 22,000 surgical patients failed to show a benefit. With use of a crossover design, PCR screening for MRSA on admission plus standard infection control measures was compared with standard infection control alone. There was no difference between the two approaches in the number of infections per 1,000 patient days (JAMA 2008;299:1149–57).

WASHINGTON — Many of the strategies held to prevent adverse events and promote patient safety “actually are quite speculative. There isn't really a lot of evidence that supports them,” according to Dr. Scott A. Flanders, director of the hospitalist program at the University of Michigan Medical Center in Ann Arbor.

In a presentation at the annual meeting of the American College of Physicians, Dr. Flanders outlined an organized framework for considering and implementing patient safety interventions in the hospital.

Balancing the urgent need to act against the need for good evidence “is a little more complicated than just rolling up your sleeves and running in to begin tackling a problem,” he said. Some interventions are easy to implement, but don't have strong evidence to support them. Others have the evidence, but are difficult to undertake.

Safety interventions also can introduce risks for new errors or complications. And there has been little assessment of the cost-effectiveness of specific interventions, Dr. Flanders said.

Further, the evidence backing patient safety measures can change. Many of the 75 patient safety practices that received high ratings in the Agency for Healthcare Research and Quality's influential 2001 report, “Making Health Care Safer: A Critical Analysis of Patient Safety Practices,” are now being seriously questioned, including the use of β-blockers to prevent perioperative cardiac complications, rapid response teams to avoid failure to rescue, pharmacologic prophylaxis to prevent venous thromboembolism, and surveillance to minimize methicillin-resistant Staphylococcus aureus infections.

“At a minimum, you need to run through the following list of considerations before you get started,” he said.

First consider the scope of the problem being targeted and whether a solution can reasonably be accomplished. Next, evaluate the evidence for the effectiveness of the intervention. Assess the complexity and the possible costs of implementation. Evaluate whether a course of action can cause new errors or other collateral effects. And look for momentum—synergy with other existing or planned efforts at your facility, said Dr. Flanders, who is also an associate professor of medicine at the University of Michigan.

His recommendations for implementing patient safety programs are based on the “balanced diet” approaches suggested in a recent article (Med. Clin. N. Am. 2008;92:275–93):

▸ “Low-hanging fruit.” These are easy-to-implement interventions supported by strong evidence. Examples include the use of ultrasound guidance for central line insertion, guidelines for reducing central line infections, and guidelines for reducing catheter-related urinary tract infections.

▸ “Slightly higher fruit.” Interventions for improved provider communication, for example, are supported by weaker evidence but are easy to implement.

Alternatively, methods of improving care transitions are supported by strong evidence but are somewhat difficult to implement.

Computerized/structured sign-out systems can reduce adverse events and the number of patients missed on resident rounds. Postdischarge adverse events can be reduced by following up with patients within 48–72 hours and using structured discharge summaries that list medications at discharge, changes in medications since admission, current problems, and pending laboratory tests.

Phone communication with providers can be improved by having referring physicians read back important information about critical lab results, requests to bring patients for procedures, and verbal orders.

▸ Projects that will generate momentum. Executive walk rounds can jump-start problem solving, according to Dr. Flanders. On executive walk rounds, senior hospital executives join physician and nurse leaders in conducting periodic visits to different areas within the hospital. This provides opportunities for informal discussions about troubling events, the system issues that led to these events, and suggested solutions.

Planned follow-up is crucial to the success of this approach.

Rapid response teams (RRTs) appear to substantially improve staff morale, especially for nurses, Dr. Flanders said, although the teams haven't been clearly shown to decrease mortality.

▸ Planning for bigger projects down the road. Good examples of long-term solutions that require planning and a team approach include implementation of computerized physician order entry and electronic medical records.

“Computerization is going to happen,” Dr. Flanders said, although there is no evidence that technologic solutions lead to harm reduction.

Dr. Flanders reported that he had no relevant financial relationships.

Postdischarge adverse events can be reduced by following up with patients, Dr. Scott A. Flanders said. Martin Vloet/University of Michigan Photo Services

Evidence Is Mixed for Several Commonly Used Safety Interventions

Dr. Flanders described several examples of patient safety strategies that have not been confirmed by data:

▸ Preventing perioperative cardiac complications. The recommendation to use β-blockers to reduce cardiac complications of noncardiac surgery—based on five randomized trials with a total of about 600 patients—received the second-highest evidence rating in the Agency for Healthcare Research and Quality's 2001 report, “Making Health Care Safer: A Critical Analysis of Patient Safety Practices.”

The overall benefit of this recommendation is now unclear, said Dr. Flanders, citing a 2005 meta-analysis of 22 clinical trials (BMJ 2005;331:313–21). In those trials, the use of perioperative β-blockers appeared to increase the risk of bradycardia and hypotension.

▸ Avoiding failure to rescue. Patients who experience cardiac arrest in the hospital often have preceding signs of clinical deterioration. Rapid response teams (RRTs) or medical emergency teams (METs) have been organized to react quickly and try to prevent deaths.

Two observational studies and one randomized study found a reduced risk of death associated with RRTs. But researchers in Australia found that METs had no substantial effect on the incidence of cardiac arrest, unplanned ICU admission, or unexpected death (Lancet 2005;365:2091–7).

▸ Preventing venous thromboembolism. Half of the estimated 2 million cases of venous thromboembolism (VTE) that occur each year develop in the hospital or within 30 days of discharge. Between 10% and 25% of inpatients may develop VTE, resulting in additional costs of up to $20,000 per episode.

Several meta-analyses have shown inconsistent evidence that pharmacologic prophylaxis can reduce the risk of VTE. “No study has ever shown a mortality benefit, including the meta-analyses that combined thousands of patients,” Dr. Flanders said, and studies have shown a roughly 50% increased risk of minor bleeding.

▸ Preventing methicillin-resistant Staphylococcus aureus (MRSA) infections. Prevention strategies aimed at limiting the spread of MRSA include hand hygiene, environmental decontamination, screening to identify colonized individuals, and the use of contact barriers to isolate colonized/infected patients.

Two large studies recently evaluated MRSA surveillance and decolonization. In an observational study involving three hospitals, polymerase chain reaction (PCR) was used to screen nasal specimens from more than 150,000 patients. Patients who tested positive for MRSA were put in contact isolation and decolonized with nasal mupirocin and chlorhexidine body washes. The baseline MRSA infection rate was about 9 per 10,000 patient days. The rate fell to about 7.5 per 10,000 after surveillance was implemented in the ICU only, and to about 4 per 10,000 after implementation of hospital-wide surveillance (Ann. Intern. Med. 2008;148:409–18).

But an interventional cohort study that involved almost 22,000 surgical patients failed to show a benefit. With use of a crossover design, PCR screening for MRSA on admission plus standard infection control measures was compared with standard infection control alone. There was no difference between the two approaches in the number of infections per 1,000 patient days (JAMA 2008;299:1149–57).

Diabetes may significantly increase a woman's risk of developing co-lorectal cancer, according to the findings from a study involving more than 45,000 women across the United States.

“There was about a 50% increased risk of colorectal cancer in women with diabetes,” said Andrew Flood, Ph.D., a professor of epidemiology and community health at the University of Minnesota in Minneapolis.

Dr. Flood presented study findings at a press briefing held in conjunction with the annual international conference of the American Association for Cancer Research.

Dr. Flood and his colleagues prospectively analyzed data from the Breast Cancer Detection Demonstration Project follow-up cohort study.

From 1987 to 1989, 45,519 women without a history of colorectal cancer completed a series of questionnaires that assessed dietary and other health and lifestyle risk factors for colorectal cancer. The average age at the time of the interview was 62 years. On average, the time between the baseline and follow-up was 9 years, during which time 489 women developed colorectal cancer. After the researchers controlled for age, physical activity, energy intake, alcohol consumption, hormone therapy, smoking, multivitamin use, education, ethnicity, NSAID use, calcium supplementation, and calcium intake from diet, women with diabetes at baseline had an adjusted hazard ratio (HR) of 1.50 for developing colorectal cancer.

The researchers hypothesized that the elevated levels of insulin typically seen in people with type 2 diabetes may play a central role. Insulin stimulates the growth of normal colonic and carcinoma cells. Insulin also modulates insulin-like growth factor 1 (IGF-1) and its binding proteins, creating a promitotic environment for colonic epithelial cells. Insulin is chronically elevated in prediabetes and in diabetes until the pancreas becomes unable to keep up with the body's need for insulin.

When the researchers conducted a second analysis that included women who were likely prediabetic at baseline, according to self reports at the 1993-1995 follow-up, the multivariate adjusted HR for developing colorectal cancer was slightly lower (1.36) in this population of women.

Among the prediabetic women, the degree of hyperinsulinemia may not have been of a sufficient magnitude or of a sufficient duration to increase the risk of colorectal cancer, the researchers speculated. Alternatively, there may be some factor related to diabetes, independent of hyperinsulinemia, that is driving the observed increase in colorectal cancer risk among the diabetic women.

Diabetes may significantly increase a woman's risk of developing co-lorectal cancer, according to the findings from a study involving more than 45,000 women across the United States.

“There was about a 50% increased risk of colorectal cancer in women with diabetes,” said Andrew Flood, Ph.D., a professor of epidemiology and community health at the University of Minnesota in Minneapolis.

Dr. Flood presented study findings at a press briefing held in conjunction with the annual international conference of the American Association for Cancer Research.

Dr. Flood and his colleagues prospectively analyzed data from the Breast Cancer Detection Demonstration Project follow-up cohort study.

From 1987 to 1989, 45,519 women without a history of colorectal cancer completed a series of questionnaires that assessed dietary and other health and lifestyle risk factors for colorectal cancer. The average age at the time of the interview was 62 years. On average, the time between the baseline and follow-up was 9 years, during which time 489 women developed colorectal cancer. After the researchers controlled for age, physical activity, energy intake, alcohol consumption, hormone therapy, smoking, multivitamin use, education, ethnicity, NSAID use, calcium supplementation, and calcium intake from diet, women with diabetes at baseline had an adjusted hazard ratio (HR) of 1.50 for developing colorectal cancer.

The researchers hypothesized that the elevated levels of insulin typically seen in people with type 2 diabetes may play a central role. Insulin stimulates the growth of normal colonic and carcinoma cells. Insulin also modulates insulin-like growth factor 1 (IGF-1) and its binding proteins, creating a promitotic environment for colonic epithelial cells. Insulin is chronically elevated in prediabetes and in diabetes until the pancreas becomes unable to keep up with the body's need for insulin.

When the researchers conducted a second analysis that included women who were likely prediabetic at baseline, according to self reports at the 1993-1995 follow-up, the multivariate adjusted HR for developing colorectal cancer was slightly lower (1.36) in this population of women.

Among the prediabetic women, the degree of hyperinsulinemia may not have been of a sufficient magnitude or of a sufficient duration to increase the risk of colorectal cancer, the researchers speculated. Alternatively, there may be some factor related to diabetes, independent of hyperinsulinemia, that is driving the observed increase in colorectal cancer risk among the diabetic women.

Diabetes may significantly increase a woman's risk of developing co-lorectal cancer, according to the findings from a study involving more than 45,000 women across the United States.

“There was about a 50% increased risk of colorectal cancer in women with diabetes,” said Andrew Flood, Ph.D., a professor of epidemiology and community health at the University of Minnesota in Minneapolis.

Dr. Flood presented study findings at a press briefing held in conjunction with the annual international conference of the American Association for Cancer Research.

Dr. Flood and his colleagues prospectively analyzed data from the Breast Cancer Detection Demonstration Project follow-up cohort study.

From 1987 to 1989, 45,519 women without a history of colorectal cancer completed a series of questionnaires that assessed dietary and other health and lifestyle risk factors for colorectal cancer. The average age at the time of the interview was 62 years. On average, the time between the baseline and follow-up was 9 years, during which time 489 women developed colorectal cancer. After the researchers controlled for age, physical activity, energy intake, alcohol consumption, hormone therapy, smoking, multivitamin use, education, ethnicity, NSAID use, calcium supplementation, and calcium intake from diet, women with diabetes at baseline had an adjusted hazard ratio (HR) of 1.50 for developing colorectal cancer.

The researchers hypothesized that the elevated levels of insulin typically seen in people with type 2 diabetes may play a central role. Insulin stimulates the growth of normal colonic and carcinoma cells. Insulin also modulates insulin-like growth factor 1 (IGF-1) and its binding proteins, creating a promitotic environment for colonic epithelial cells. Insulin is chronically elevated in prediabetes and in diabetes until the pancreas becomes unable to keep up with the body's need for insulin.

When the researchers conducted a second analysis that included women who were likely prediabetic at baseline, according to self reports at the 1993-1995 follow-up, the multivariate adjusted HR for developing colorectal cancer was slightly lower (1.36) in this population of women.

Among the prediabetic women, the degree of hyperinsulinemia may not have been of a sufficient magnitude or of a sufficient duration to increase the risk of colorectal cancer, the researchers speculated. Alternatively, there may be some factor related to diabetes, independent of hyperinsulinemia, that is driving the observed increase in colorectal cancer risk among the diabetic women.