Letters To The Editor

"IT IS TIME FOR HPV VACCINATION TO BE CONSIDERED PART OF ROUTINE PREVENTIVE HEALTH CARE"

BARBARA S. LEVY, MD (MARCH 2017)

Nurse practitioner urges advocacy for HPV vaccination

I could not agree more with Dr. Levy's view on human papillomavirus (HPV) vaccination. I am a Doctor of Nursing Practice student and improving HPV vaccination rates in adolescents is the focus of my research project for the next year. Based on the current literature, the most significant factors for increasing vaccination rates are patient education and provider recommendation. As the article mentions, "special" attention should not be given to the HPV vaccine, because this raises questions with families presenting to the office for routine well-child care. There have been many missed opportunities for vaccination of our young people over the past 10 years. As a result, we will continue to see increases in HPV-related cancers. We have a vaccine that has the potential to significantly decrease these cases, but it is underutilized. The recent recommendation of a 2-dose series (before the age of 15) should make completing the series easier. I urge all providers to be better advocates for their patients and make appropriate changes to their current practice in order to reduce the significant burden this disease carries.

Tiffany Edwards, MSN, APRN, FNP-BC
Seaford, Delaware

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

"IT IS TIME FOR HPV VACCINATION TO BE CONSIDERED PART OF ROUTINE PREVENTIVE HEALTH CARE"

BARBARA S. LEVY, MD (MARCH 2017)

Nurse practitioner urges advocacy for HPV vaccination

I could not agree more with Dr. Levy's view on human papillomavirus (HPV) vaccination. I am a Doctor of Nursing Practice student and improving HPV vaccination rates in adolescents is the focus of my research project for the next year. Based on the current literature, the most significant factors for increasing vaccination rates are patient education and provider recommendation. As the article mentions, "special" attention should not be given to the HPV vaccine, because this raises questions with families presenting to the office for routine well-child care. There have been many missed opportunities for vaccination of our young people over the past 10 years. As a result, we will continue to see increases in HPV-related cancers. We have a vaccine that has the potential to significantly decrease these cases, but it is underutilized. The recent recommendation of a 2-dose series (before the age of 15) should make completing the series easier. I urge all providers to be better advocates for their patients and make appropriate changes to their current practice in order to reduce the significant burden this disease carries.

Tiffany Edwards, MSN, APRN, FNP-BC
Seaford, Delaware

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

"IT IS TIME FOR HPV VACCINATION TO BE CONSIDERED PART OF ROUTINE PREVENTIVE HEALTH CARE"

BARBARA S. LEVY, MD (MARCH 2017)

Nurse practitioner urges advocacy for HPV vaccination

I could not agree more with Dr. Levy's view on human papillomavirus (HPV) vaccination. I am a Doctor of Nursing Practice student and improving HPV vaccination rates in adolescents is the focus of my research project for the next year. Based on the current literature, the most significant factors for increasing vaccination rates are patient education and provider recommendation. As the article mentions, "special" attention should not be given to the HPV vaccine, because this raises questions with families presenting to the office for routine well-child care. There have been many missed opportunities for vaccination of our young people over the past 10 years. As a result, we will continue to see increases in HPV-related cancers. We have a vaccine that has the potential to significantly decrease these cases, but it is underutilized. The recent recommendation of a 2-dose series (before the age of 15) should make completing the series easier. I urge all providers to be better advocates for their patients and make appropriate changes to their current practice in order to reduce the significant burden this disease carries.

Tiffany Edwards, MSN, APRN, FNP-BC
Seaford, Delaware

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

"SHOULD YOU ADOPT THE PRACTICE OF VAGINAL CLEANSING WITH POVIDONE-IODINE PRIOR TO CESAREAN DELIVERY?"

ROBERT L. BARBIERI, MD (EDITORIAL; JANUARY 2016)

"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"

KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)

Prepping the vagina before cesarean delivery

I enjoyed your review of the topic. I am interested in using vaginal preparation prior to cesarean in the settings of active-phase and second-stage arrest. This should be most valuable since we anticipate possible prolonged attempt at head delivery. There may be a need for head elevation as well. Of course, we have become enthusiastic about using reverse breech extraction in difficult cases since your article a few years ago. I have yet to do a Patwardhan maneuver. That seems to rely on rotating the spine anteriorly to get the second arm out. With the head impaction, there is limited range for neck rotation. With vaginal preparation, is there any concern about fetal exposure to iodine?  

Kimberly Harney, MD
Stanford, California
 

Dr. Barbieri responds

Dr. Harney raises the important issue of the potential adverse effects of povidone-iodine surgical preparation when used on a pregnant woman with ruptured membranes. There is very little direct evidence of a toxic effect of povidone-iodine on the fetus, but studies on women report that there is a transient increase in circulating iodine and iodine excretion following a vaginal povidone-iodine preparation.¹ The American College of Obstetricians and Gynecologists has suggested that chlorhexidine might be a superior vaginal disinfectant than povidone-iodine,² but chlorhexidine is not approved by the US Food and Drug Administration for use in the vagina, and many surgical nursing directors favor the use of povidone-iodine in the vagina.³

"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"

KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)

Another way to prevent post-cesarean delivery infections  

After 40 years in ObGyn practice (I am now retired), I find it interesting that experts have ignored a major potential source of infection--the operation team. Back in the day of Phisohex (hexachlorophene) use, we scrubbed our hands, arms, and fingers for a finite time--10 minutes--systematically and religiously. Our infection rates increased only when house staff rather than surgical assistants "helped" us. When scrubbing, I was always amazed that the house staff appeared at the sink long after I did and left before I had completed my presurgical ritual. (This was not true of non-MD assistants.) And my private practice postoperative infection rate reflected the difference. So perhaps the evidence is skewed away from this source of infection, which I submit may well be the major one!

Steve Melkin, MD
Phoenix, Arizona

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

"SHOULD YOU ADOPT THE PRACTICE OF VAGINAL CLEANSING WITH POVIDONE-IODINE PRIOR TO CESAREAN DELIVERY?"

ROBERT L. BARBIERI, MD (EDITORIAL; JANUARY 2016)

"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"

KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)

Prepping the vagina before cesarean delivery

I enjoyed your review of the topic. I am interested in using vaginal preparation prior to cesarean in the settings of active-phase and second-stage arrest. This should be most valuable since we anticipate possible prolonged attempt at head delivery. There may be a need for head elevation as well. Of course, we have become enthusiastic about using reverse breech extraction in difficult cases since your article a few years ago. I have yet to do a Patwardhan maneuver. That seems to rely on rotating the spine anteriorly to get the second arm out. With the head impaction, there is limited range for neck rotation. With vaginal preparation, is there any concern about fetal exposure to iodine?  

Kimberly Harney, MD
Stanford, California
 

Dr. Barbieri responds

Dr. Harney raises the important issue of the potential adverse effects of povidone-iodine surgical preparation when used on a pregnant woman with ruptured membranes. There is very little direct evidence of a toxic effect of povidone-iodine on the fetus, but studies on women report that there is a transient increase in circulating iodine and iodine excretion following a vaginal povidone-iodine preparation.¹ The American College of Obstetricians and Gynecologists has suggested that chlorhexidine might be a superior vaginal disinfectant than povidone-iodine,² but chlorhexidine is not approved by the US Food and Drug Administration for use in the vagina, and many surgical nursing directors favor the use of povidone-iodine in the vagina.³

"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"

KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)

Another way to prevent post-cesarean delivery infections  

After 40 years in ObGyn practice (I am now retired), I find it interesting that experts have ignored a major potential source of infection--the operation team. Back in the day of Phisohex (hexachlorophene) use, we scrubbed our hands, arms, and fingers for a finite time--10 minutes--systematically and religiously. Our infection rates increased only when house staff rather than surgical assistants "helped" us. When scrubbing, I was always amazed that the house staff appeared at the sink long after I did and left before I had completed my presurgical ritual. (This was not true of non-MD assistants.) And my private practice postoperative infection rate reflected the difference. So perhaps the evidence is skewed away from this source of infection, which I submit may well be the major one!

Steve Melkin, MD
Phoenix, Arizona

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

"SHOULD YOU ADOPT THE PRACTICE OF VAGINAL CLEANSING WITH POVIDONE-IODINE PRIOR TO CESAREAN DELIVERY?"

ROBERT L. BARBIERI, MD (EDITORIAL; JANUARY 2016)

"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"

KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)

Prepping the vagina before cesarean delivery

I enjoyed your review of the topic. I am interested in using vaginal preparation prior to cesarean in the settings of active-phase and second-stage arrest. This should be most valuable since we anticipate possible prolonged attempt at head delivery. There may be a need for head elevation as well. Of course, we have become enthusiastic about using reverse breech extraction in difficult cases since your article a few years ago. I have yet to do a Patwardhan maneuver. That seems to rely on rotating the spine anteriorly to get the second arm out. With the head impaction, there is limited range for neck rotation. With vaginal preparation, is there any concern about fetal exposure to iodine?  

Kimberly Harney, MD
Stanford, California
 

Dr. Barbieri responds

Dr. Harney raises the important issue of the potential adverse effects of povidone-iodine surgical preparation when used on a pregnant woman with ruptured membranes. There is very little direct evidence of a toxic effect of povidone-iodine on the fetus, but studies on women report that there is a transient increase in circulating iodine and iodine excretion following a vaginal povidone-iodine preparation.¹ The American College of Obstetricians and Gynecologists has suggested that chlorhexidine might be a superior vaginal disinfectant than povidone-iodine,² but chlorhexidine is not approved by the US Food and Drug Administration for use in the vagina, and many surgical nursing directors favor the use of povidone-iodine in the vagina.³

"PREVENTING INFECTION AFTER CESAREAN DELIVERY: 5 MORE EVIDENCE-BASED MEASURES TO CONSIDER"

KATHRYN E. PATRICK, MD; SARA L. DEATSMAN, MD; AND PATRICK DUFF, MD (DECEMBER 2016)

Another way to prevent post-cesarean delivery infections  

After 40 years in ObGyn practice (I am now retired), I find it interesting that experts have ignored a major potential source of infection--the operation team. Back in the day of Phisohex (hexachlorophene) use, we scrubbed our hands, arms, and fingers for a finite time--10 minutes--systematically and religiously. Our infection rates increased only when house staff rather than surgical assistants "helped" us. When scrubbing, I was always amazed that the house staff appeared at the sink long after I did and left before I had completed my presurgical ritual. (This was not true of non-MD assistants.) And my private practice postoperative infection rate reflected the difference. So perhaps the evidence is skewed away from this source of infection, which I submit may well be the major one!

Steve Melkin, MD
Phoenix, Arizona

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

"SHOULD THE LENGTH OF TREATMENT FOR TRICHOMONIASIS IN WOMEN BE RECONSIDERED?"

PATRICK DUFF, MD (MARCH 2017)

Longer metronidazole treatment is better than 1-day dose for women with trichomoniasis

From 37 years of experience as a Women's Healthcare Nurse Practi­tioner, I have found it is always better to prescribe metronidazole 500 mg bid for 7 days rather than 1-day treatment for women. I will prescribe 1-day treatment for men. I have been treating men and women using these regimens in a sexually transmitted diseases clinic for nearly 5 years. Colleagues have used the 1-time dose for women and it rarely works as well as the 7-day dose. However, I am always concerned about men taking the medication for 7 days, because often they are not symptomatic and they may stop taking their medication early if given the 1-week regimen, so I usually prescribe the 1-day dose for men. I wish more prescribers would offer treatment for the male partners, as they may not be symptomatic or may not want to spend the money to visit a provider. In my state, it is legal to prescribe for the partner without seeing him, and the Centers for Disease Control and Prevention suggests doing so. We encourage the men to come in but if the partner says he is unlikely to, we will treat without seeing him.

 
Carol Glascock, WHNP-BC
Columbia, Missouri

Dr. Duff responds

I appreciate Ms. Glascock's thoughtful comments. I am pleased that her years of clinical experience support the main conclusion reached by Howe and Kissinger that, in general, patients do better when they receive multidose therapy for trichomonas infection.¹ I agree with Ms. Glascock's observation that single-dose therapy still has a role in situations in which patients may not be adherent with multidose therapy, such as the asymptomatic male partner of an infected woman. I also agree wholeheartedly that women will have less likelihood of recurrence when their partner receives adequate antibiotic treatment. I concur that, in states where this practice is legally permissible, we should be willing to offer antibiotic therapy to the partner of our female patient. 

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
 

"SHOULD THE LENGTH OF TREATMENT FOR TRICHOMONIASIS IN WOMEN BE RECONSIDERED?"

PATRICK DUFF, MD (MARCH 2017)

Longer metronidazole treatment is better than 1-day dose for women with trichomoniasis

From 37 years of experience as a Women's Healthcare Nurse Practi­tioner, I have found it is always better to prescribe metronidazole 500 mg bid for 7 days rather than 1-day treatment for women. I will prescribe 1-day treatment for men. I have been treating men and women using these regimens in a sexually transmitted diseases clinic for nearly 5 years. Colleagues have used the 1-time dose for women and it rarely works as well as the 7-day dose. However, I am always concerned about men taking the medication for 7 days, because often they are not symptomatic and they may stop taking their medication early if given the 1-week regimen, so I usually prescribe the 1-day dose for men. I wish more prescribers would offer treatment for the male partners, as they may not be symptomatic or may not want to spend the money to visit a provider. In my state, it is legal to prescribe for the partner without seeing him, and the Centers for Disease Control and Prevention suggests doing so. We encourage the men to come in but if the partner says he is unlikely to, we will treat without seeing him.

 
Carol Glascock, WHNP-BC
Columbia, Missouri

Dr. Duff responds

I appreciate Ms. Glascock's thoughtful comments. I am pleased that her years of clinical experience support the main conclusion reached by Howe and Kissinger that, in general, patients do better when they receive multidose therapy for trichomonas infection.¹ I agree with Ms. Glascock's observation that single-dose therapy still has a role in situations in which patients may not be adherent with multidose therapy, such as the asymptomatic male partner of an infected woman. I also agree wholeheartedly that women will have less likelihood of recurrence when their partner receives adequate antibiotic treatment. I concur that, in states where this practice is legally permissible, we should be willing to offer antibiotic therapy to the partner of our female patient. 

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
 

"SHOULD THE LENGTH OF TREATMENT FOR TRICHOMONIASIS IN WOMEN BE RECONSIDERED?"

PATRICK DUFF, MD (MARCH 2017)

Longer metronidazole treatment is better than 1-day dose for women with trichomoniasis

From 37 years of experience as a Women's Healthcare Nurse Practi­tioner, I have found it is always better to prescribe metronidazole 500 mg bid for 7 days rather than 1-day treatment for women. I will prescribe 1-day treatment for men. I have been treating men and women using these regimens in a sexually transmitted diseases clinic for nearly 5 years. Colleagues have used the 1-time dose for women and it rarely works as well as the 7-day dose. However, I am always concerned about men taking the medication for 7 days, because often they are not symptomatic and they may stop taking their medication early if given the 1-week regimen, so I usually prescribe the 1-day dose for men. I wish more prescribers would offer treatment for the male partners, as they may not be symptomatic or may not want to spend the money to visit a provider. In my state, it is legal to prescribe for the partner without seeing him, and the Centers for Disease Control and Prevention suggests doing so. We encourage the men to come in but if the partner says he is unlikely to, we will treat without seeing him.

 
Carol Glascock, WHNP-BC
Columbia, Missouri

Dr. Duff responds

I appreciate Ms. Glascock's thoughtful comments. I am pleased that her years of clinical experience support the main conclusion reached by Howe and Kissinger that, in general, patients do better when they receive multidose therapy for trichomonas infection.¹ I agree with Ms. Glascock's observation that single-dose therapy still has a role in situations in which patients may not be adherent with multidose therapy, such as the asymptomatic male partner of an infected woman. I also agree wholeheartedly that women will have less likelihood of recurrence when their partner receives adequate antibiotic treatment. I concur that, in states where this practice is legally permissible, we should be willing to offer antibiotic therapy to the partner of our female patient. 

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.
 

I recently read with interest Dr Thomas Strouse’s article written to support physician aid in dying. Within the article he made the following statement: “I have come to view ‘active non-participation’ in legal PAD [physician aid in dying] – that is, decisions by individual physicians and/or health systems not only to not provide, but also not refer patients to possibly willing providers and systems without regard for specific clinical contexts – as a toxic form of patient abandonment.”¹ Within the article, Dr Strouse lays out for us thoughtful precautions in the aid-in-dying laws, attempting to demonstrate that no vulnerable population is abused. Such precautions are important but provide the same result for all participants: the death of a patient. This is the central problem with aid in dying. Certainly there is nothing wrong with dying, and we all will have that opportunity. Though most of us would choose to put that moment off a while, for some, the suffering in this life makes death seem a welcome relief.

What is a physician’s central responsibility in the care of his or her patients near the end of their lives?

As program director for the hematology and oncology fellowship at my institution, I impress upon my fellows the importance of goal-oriented decision-making. I specifically teach them that there are only four goals worth achieving in any therapeutic or diagnostic decision making: to cure the disease; to help patients live longer despite the disease; to maximize the patient’s quality of life, and to prevent impending disasters. I know of no other worthwhile goal in any decision we are to make for our patients. I can point to none of these goals that physician aid in dying achieves. When it comes to physician-assisted suicide, some would argue that selecting an early death is a way of “maximizing quality of life.” And certainly our task is to make life the best it can be for our patients while they live through the dying process, but I am unaware of any published quality of life formula that calculates the end of life as a positive measure.

The question for us is the role of the doctor. Dr Strouse raises two issues with those whom he accuses of toxic abandonment. The first is whether physicians should provide aid in death, and the second is whether physicians should refer for the same service if they believe it is wrong for their patients.

It certainly has not been well established that physician-assisted suicide is a good thing rather than a tragic thing. A 2012 statement from the Ethics, Professionalism and Human Rights Committee of the American College of Physicians suggests otherwise: “After much consideration, the College concluded that making physician-assisted suicide legal raised serious ethical, clinical and social concerns and that the practice might undermine patient trust; distract from reform in end-of-life care; and be used in vulnerable patients, including those who are poor, are disabled, or are unable to speak for themselves or minority groups who have experienced discrimination.”² The disability rights group, Not Dead Yet, has agreed with the ACP: “It cannot be seriously maintained that assisted suicide laws can or do limit assisted suicide to people who are imminently dying, and voluntarily request and consume a lethal dose, free of inappropriate pressures from family or society. Rather, assisted suicide laws ensure legal immunity for physicians who already devalue the lives of older and disabled people and have significant economic incentives to at least agree with their suicides, if not encourage them, or worse.”³

Such statements sound prophetic within both our present cost containment health care culture and in the real world of personal family economic pressures that can lead a patient toward the understanding that a right to die is actually a “duty to die.”

As society is driving physicians to be technicians to carry out their bidding, physicians should be clinging tightly to their role as trusted advocates for their patients. Certainly our patients have fears and pain that would at times lead them to prefer death to living, but a patient’s move to nonexistence is not the task of the physician. Our task as physicians was well described recently by Yang and Curlin: “Many patients with terminal illnesses fear unbearable pain or other symptoms. The physician’s role is to care for them in their illness so as to relieve pain or otherwise help them bear up under the symptoms they endure. Many patients loathe the prospect of abject debility. The physician’s role is to maintain solidarity with those whose health is diminished, not to not to imply that debility renders a patient’s life not worth living.”⁴

Statements such as these by reasoned people suggest we, as a country, have no consensus for the question whether aid in dying is possibly good or seriously bad for our patients. So it is quite reasonable for compassionate physicians to refuse to administer lethal medicines to their patients in order to “do no harm.”

The second question Dr Strouse explores is whether physicians who disapprove of physician-assisted suicide are abandoning their patients because they do not refer them to a provider who will provide such services. Dr Edmund Pelligrino, a well-respected medical ethicist, in his discussion of moral absolutes in medicine establishes the moral absolute, “Do not kill” and then addresses the ethical problem of complicity in killing. “Formal cooperation is absolutely and always, forbidden. This is the case when the physician shares the evil intent, partakes directly and freely, or in any way facilitates an intrinsically evil act like abortion or assisted suicide.”⁵ Though personally I would not use the word, “evil,” as he does, since evil implies motive; I would substitute the word “harm” and suggest that we should never be complicit in an act that we feel brings the harm of death to our patients. I would suggest that the expectation that physicians referring for aid in dying is analogous with the patient who comes to me demanding a chemotherapy that I know would cause her harm. I would refuse to give it to her and refuse to send her to a doctor who would be willing to give to her. Referral to produce harm is complicity with causing the harm itself. Our society should never go there. Our society should never ask a physician to cross the boundary line of conscience that is the ultimate protection for vulnerable patients.

I know what it is like to watch our patients suffer. I know what it is like to watch our loved ones suffer. I pushed the morphine at my father’s bedside until he quit screaming in pain. But I did not kill him. I cared for him. Such is the physician’s role. If society decides to allow patients the autonomy to end their lives early and wishes to provide skilled technical help in doing so, let it do so at their peril. But let it choose and train technicians to do it. Do not compromise the one person whom our patients should trust totally to never do them harm.

Alva B Weir, III, MD, FACP ([email protected])
West Cancer Center, Memphis, Tennessee

I recently read with interest Dr Thomas Strouse’s article written to support physician aid in dying. Within the article he made the following statement: “I have come to view ‘active non-participation’ in legal PAD [physician aid in dying] – that is, decisions by individual physicians and/or health systems not only to not provide, but also not refer patients to possibly willing providers and systems without regard for specific clinical contexts – as a toxic form of patient abandonment.”¹ Within the article, Dr Strouse lays out for us thoughtful precautions in the aid-in-dying laws, attempting to demonstrate that no vulnerable population is abused. Such precautions are important but provide the same result for all participants: the death of a patient. This is the central problem with aid in dying. Certainly there is nothing wrong with dying, and we all will have that opportunity. Though most of us would choose to put that moment off a while, for some, the suffering in this life makes death seem a welcome relief.

What is a physician’s central responsibility in the care of his or her patients near the end of their lives?

As program director for the hematology and oncology fellowship at my institution, I impress upon my fellows the importance of goal-oriented decision-making. I specifically teach them that there are only four goals worth achieving in any therapeutic or diagnostic decision making: to cure the disease; to help patients live longer despite the disease; to maximize the patient’s quality of life, and to prevent impending disasters. I know of no other worthwhile goal in any decision we are to make for our patients. I can point to none of these goals that physician aid in dying achieves. When it comes to physician-assisted suicide, some would argue that selecting an early death is a way of “maximizing quality of life.” And certainly our task is to make life the best it can be for our patients while they live through the dying process, but I am unaware of any published quality of life formula that calculates the end of life as a positive measure.

The question for us is the role of the doctor. Dr Strouse raises two issues with those whom he accuses of toxic abandonment. The first is whether physicians should provide aid in death, and the second is whether physicians should refer for the same service if they believe it is wrong for their patients.

It certainly has not been well established that physician-assisted suicide is a good thing rather than a tragic thing. A 2012 statement from the Ethics, Professionalism and Human Rights Committee of the American College of Physicians suggests otherwise: “After much consideration, the College concluded that making physician-assisted suicide legal raised serious ethical, clinical and social concerns and that the practice might undermine patient trust; distract from reform in end-of-life care; and be used in vulnerable patients, including those who are poor, are disabled, or are unable to speak for themselves or minority groups who have experienced discrimination.”² The disability rights group, Not Dead Yet, has agreed with the ACP: “It cannot be seriously maintained that assisted suicide laws can or do limit assisted suicide to people who are imminently dying, and voluntarily request and consume a lethal dose, free of inappropriate pressures from family or society. Rather, assisted suicide laws ensure legal immunity for physicians who already devalue the lives of older and disabled people and have significant economic incentives to at least agree with their suicides, if not encourage them, or worse.”³

Such statements sound prophetic within both our present cost containment health care culture and in the real world of personal family economic pressures that can lead a patient toward the understanding that a right to die is actually a “duty to die.”

As society is driving physicians to be technicians to carry out their bidding, physicians should be clinging tightly to their role as trusted advocates for their patients. Certainly our patients have fears and pain that would at times lead them to prefer death to living, but a patient’s move to nonexistence is not the task of the physician. Our task as physicians was well described recently by Yang and Curlin: “Many patients with terminal illnesses fear unbearable pain or other symptoms. The physician’s role is to care for them in their illness so as to relieve pain or otherwise help them bear up under the symptoms they endure. Many patients loathe the prospect of abject debility. The physician’s role is to maintain solidarity with those whose health is diminished, not to not to imply that debility renders a patient’s life not worth living.”⁴

Statements such as these by reasoned people suggest we, as a country, have no consensus for the question whether aid in dying is possibly good or seriously bad for our patients. So it is quite reasonable for compassionate physicians to refuse to administer lethal medicines to their patients in order to “do no harm.”

The second question Dr Strouse explores is whether physicians who disapprove of physician-assisted suicide are abandoning their patients because they do not refer them to a provider who will provide such services. Dr Edmund Pelligrino, a well-respected medical ethicist, in his discussion of moral absolutes in medicine establishes the moral absolute, “Do not kill” and then addresses the ethical problem of complicity in killing. “Formal cooperation is absolutely and always, forbidden. This is the case when the physician shares the evil intent, partakes directly and freely, or in any way facilitates an intrinsically evil act like abortion or assisted suicide.”⁵ Though personally I would not use the word, “evil,” as he does, since evil implies motive; I would substitute the word “harm” and suggest that we should never be complicit in an act that we feel brings the harm of death to our patients. I would suggest that the expectation that physicians referring for aid in dying is analogous with the patient who comes to me demanding a chemotherapy that I know would cause her harm. I would refuse to give it to her and refuse to send her to a doctor who would be willing to give to her. Referral to produce harm is complicity with causing the harm itself. Our society should never go there. Our society should never ask a physician to cross the boundary line of conscience that is the ultimate protection for vulnerable patients.

I know what it is like to watch our patients suffer. I know what it is like to watch our loved ones suffer. I pushed the morphine at my father’s bedside until he quit screaming in pain. But I did not kill him. I cared for him. Such is the physician’s role. If society decides to allow patients the autonomy to end their lives early and wishes to provide skilled technical help in doing so, let it do so at their peril. But let it choose and train technicians to do it. Do not compromise the one person whom our patients should trust totally to never do them harm.

Alva B Weir, III, MD, FACP ([email protected])
West Cancer Center, Memphis, Tennessee

I recently read with interest Dr Thomas Strouse’s article written to support physician aid in dying. Within the article he made the following statement: “I have come to view ‘active non-participation’ in legal PAD [physician aid in dying] – that is, decisions by individual physicians and/or health systems not only to not provide, but also not refer patients to possibly willing providers and systems without regard for specific clinical contexts – as a toxic form of patient abandonment.”¹ Within the article, Dr Strouse lays out for us thoughtful precautions in the aid-in-dying laws, attempting to demonstrate that no vulnerable population is abused. Such precautions are important but provide the same result for all participants: the death of a patient. This is the central problem with aid in dying. Certainly there is nothing wrong with dying, and we all will have that opportunity. Though most of us would choose to put that moment off a while, for some, the suffering in this life makes death seem a welcome relief.

What is a physician’s central responsibility in the care of his or her patients near the end of their lives?

As program director for the hematology and oncology fellowship at my institution, I impress upon my fellows the importance of goal-oriented decision-making. I specifically teach them that there are only four goals worth achieving in any therapeutic or diagnostic decision making: to cure the disease; to help patients live longer despite the disease; to maximize the patient’s quality of life, and to prevent impending disasters. I know of no other worthwhile goal in any decision we are to make for our patients. I can point to none of these goals that physician aid in dying achieves. When it comes to physician-assisted suicide, some would argue that selecting an early death is a way of “maximizing quality of life.” And certainly our task is to make life the best it can be for our patients while they live through the dying process, but I am unaware of any published quality of life formula that calculates the end of life as a positive measure.

The question for us is the role of the doctor. Dr Strouse raises two issues with those whom he accuses of toxic abandonment. The first is whether physicians should provide aid in death, and the second is whether physicians should refer for the same service if they believe it is wrong for their patients.

It certainly has not been well established that physician-assisted suicide is a good thing rather than a tragic thing. A 2012 statement from the Ethics, Professionalism and Human Rights Committee of the American College of Physicians suggests otherwise: “After much consideration, the College concluded that making physician-assisted suicide legal raised serious ethical, clinical and social concerns and that the practice might undermine patient trust; distract from reform in end-of-life care; and be used in vulnerable patients, including those who are poor, are disabled, or are unable to speak for themselves or minority groups who have experienced discrimination.”² The disability rights group, Not Dead Yet, has agreed with the ACP: “It cannot be seriously maintained that assisted suicide laws can or do limit assisted suicide to people who are imminently dying, and voluntarily request and consume a lethal dose, free of inappropriate pressures from family or society. Rather, assisted suicide laws ensure legal immunity for physicians who already devalue the lives of older and disabled people and have significant economic incentives to at least agree with their suicides, if not encourage them, or worse.”³

Such statements sound prophetic within both our present cost containment health care culture and in the real world of personal family economic pressures that can lead a patient toward the understanding that a right to die is actually a “duty to die.”

As society is driving physicians to be technicians to carry out their bidding, physicians should be clinging tightly to their role as trusted advocates for their patients. Certainly our patients have fears and pain that would at times lead them to prefer death to living, but a patient’s move to nonexistence is not the task of the physician. Our task as physicians was well described recently by Yang and Curlin: “Many patients with terminal illnesses fear unbearable pain or other symptoms. The physician’s role is to care for them in their illness so as to relieve pain or otherwise help them bear up under the symptoms they endure. Many patients loathe the prospect of abject debility. The physician’s role is to maintain solidarity with those whose health is diminished, not to not to imply that debility renders a patient’s life not worth living.”⁴

Statements such as these by reasoned people suggest we, as a country, have no consensus for the question whether aid in dying is possibly good or seriously bad for our patients. So it is quite reasonable for compassionate physicians to refuse to administer lethal medicines to their patients in order to “do no harm.”

The second question Dr Strouse explores is whether physicians who disapprove of physician-assisted suicide are abandoning their patients because they do not refer them to a provider who will provide such services. Dr Edmund Pelligrino, a well-respected medical ethicist, in his discussion of moral absolutes in medicine establishes the moral absolute, “Do not kill” and then addresses the ethical problem of complicity in killing. “Formal cooperation is absolutely and always, forbidden. This is the case when the physician shares the evil intent, partakes directly and freely, or in any way facilitates an intrinsically evil act like abortion or assisted suicide.”⁵ Though personally I would not use the word, “evil,” as he does, since evil implies motive; I would substitute the word “harm” and suggest that we should never be complicit in an act that we feel brings the harm of death to our patients. I would suggest that the expectation that physicians referring for aid in dying is analogous with the patient who comes to me demanding a chemotherapy that I know would cause her harm. I would refuse to give it to her and refuse to send her to a doctor who would be willing to give to her. Referral to produce harm is complicity with causing the harm itself. Our society should never go there. Our society should never ask a physician to cross the boundary line of conscience that is the ultimate protection for vulnerable patients.

I know what it is like to watch our patients suffer. I know what it is like to watch our loved ones suffer. I pushed the morphine at my father’s bedside until he quit screaming in pain. But I did not kill him. I cared for him. Such is the physician’s role. If society decides to allow patients the autonomy to end their lives early and wishes to provide skilled technical help in doing so, let it do so at their peril. But let it choose and train technicians to do it. Do not compromise the one person whom our patients should trust totally to never do them harm.

Alva B Weir, III, MD, FACP ([email protected])
West Cancer Center, Memphis, Tennessee

To the Editor: I enjoyed the article “Serotonin syndrome: Preventing, recognizing, and treating it.”¹ I am a relatively new internal medicine physician, out of residency only 1 year, and sadly I felt that the psychiatric training I received was minimal at best. Therefore, I was very excited to read more about serotonin syndrome since such a large percentage of my patients are on selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors.

Could you speak to the time frame it takes for serotonin syndrome to develop? For instance, if someone is taking an SSRI and develops a terrible yeast infection, would 3 doses of fluconazole be enough to tip the scales? Or as-needed sumatriptan, with some ondansetron for migraine? The problem I have is that patients often require short doses of many medications that can interact, and I routinely sigh, briefly explain the possibility of serotonin syndrome, and then click through the flashing red warning signs on the electronic medical record and send patients out with their meds—though in honesty I do not know the likelihood of developing even mild symptoms of serotonin syndrome with short courses of interacting medications.

To the Editor: I enjoyed the article “Serotonin syndrome: Preventing, recognizing, and treating it.”¹ I am a relatively new internal medicine physician, out of residency only 1 year, and sadly I felt that the psychiatric training I received was minimal at best. Therefore, I was very excited to read more about serotonin syndrome since such a large percentage of my patients are on selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors.

Could you speak to the time frame it takes for serotonin syndrome to develop? For instance, if someone is taking an SSRI and develops a terrible yeast infection, would 3 doses of fluconazole be enough to tip the scales? Or as-needed sumatriptan, with some ondansetron for migraine? The problem I have is that patients often require short doses of many medications that can interact, and I routinely sigh, briefly explain the possibility of serotonin syndrome, and then click through the flashing red warning signs on the electronic medical record and send patients out with their meds—though in honesty I do not know the likelihood of developing even mild symptoms of serotonin syndrome with short courses of interacting medications.

To the Editor: I enjoyed the article “Serotonin syndrome: Preventing, recognizing, and treating it.”¹ I am a relatively new internal medicine physician, out of residency only 1 year, and sadly I felt that the psychiatric training I received was minimal at best. Therefore, I was very excited to read more about serotonin syndrome since such a large percentage of my patients are on selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors.

Could you speak to the time frame it takes for serotonin syndrome to develop? For instance, if someone is taking an SSRI and develops a terrible yeast infection, would 3 doses of fluconazole be enough to tip the scales? Or as-needed sumatriptan, with some ondansetron for migraine? The problem I have is that patients often require short doses of many medications that can interact, and I routinely sigh, briefly explain the possibility of serotonin syndrome, and then click through the flashing red warning signs on the electronic medical record and send patients out with their meds—though in honesty I do not know the likelihood of developing even mild symptoms of serotonin syndrome with short courses of interacting medications.

In Reply: The questions posed by Dr. Rose reflect critical issues primary care physicians encounter when prescribing medications for patients who are taking serotonergic agents. “Switching strategies” have been described for starting or discontinuing serotonergic antidepressants.¹ Options range from conservative exchanges requiring 5 half-lives between discontinuation of 1 antidepressant and initiation of another vs a direct cross-taper exchange. Decisions regarding specific patients should take into account previous adverse effects from serotonergic medications and half-lives of discontinued antidepressants. To our knowledge, switching strategies have not been validated and are based on expert opinion. Scenarios are complicated further if patients have already been prescribed 2 or more antidepressants and 1 medication is exchanged or dose-adjusted while another is added. With this degree of complexity, we recommend referral to a psychiatrist.

Dr. Rose’s questions on prescribing nonpsychiatric serotonergic drugs concurrently with antidepressants broaches a topic with even less evidence. Some data exist about nonpsychiatric serotonergic drugs given in combination with triptans. Soldin et al² reviewed the US Food and Drug Administration’s Adverse Event Reporting System and discovered 38 cases of serotonin syndrome in patients using triptans. Eleven of these patients were using triptans without concomitant antidepressants. Though definitive evidence is lacking for safe prescribing practice with triptans, the authors noted that most cases of triptan-induced serotonin toxicity occur within hours of triptan ingestion.²

The evidence on the risk of serotonin syndrome with other medications is limited to case reports. In regard to linezolid, a review suggested that when linezolid was administered to a patient on long-term citalopram, a prolonged serotonin syndrome was precipitated, which is not an issue with other antidepressants.³ The World Health Organization has issued warnings for serotonin toxicity with ondansetron and other 5-HT3 receptor antagonists based on case reports.^4,5 No data are available for the appropriate prescribing of 5-HT3 antagonists with antidepressants. A review of cases suggests a link between fluconazole and severe serotonin toxicity in patients taking citalopram; however, no prescribing guidelines have been established for fluconazole either.⁶

Dr. Rose asks important clinical questions, but evidence-based answers are not available.  We can only recommend that patients be advised to report symptoms immediately after starting any medication associated with serotonin syndrome. For patients on multiple antidepressants, psychiatric assistance is advised. An observational cohort study of patients using antidepressants while exposed to other suspect drugs may better delineate effects of several pharmaceuticals on the serotonergic axis. Only then may safe prescribing practices be validated with evidence.

In Reply: The questions posed by Dr. Rose reflect critical issues primary care physicians encounter when prescribing medications for patients who are taking serotonergic agents. “Switching strategies” have been described for starting or discontinuing serotonergic antidepressants.¹ Options range from conservative exchanges requiring 5 half-lives between discontinuation of 1 antidepressant and initiation of another vs a direct cross-taper exchange. Decisions regarding specific patients should take into account previous adverse effects from serotonergic medications and half-lives of discontinued antidepressants. To our knowledge, switching strategies have not been validated and are based on expert opinion. Scenarios are complicated further if patients have already been prescribed 2 or more antidepressants and 1 medication is exchanged or dose-adjusted while another is added. With this degree of complexity, we recommend referral to a psychiatrist.

Dr. Rose’s questions on prescribing nonpsychiatric serotonergic drugs concurrently with antidepressants broaches a topic with even less evidence. Some data exist about nonpsychiatric serotonergic drugs given in combination with triptans. Soldin et al² reviewed the US Food and Drug Administration’s Adverse Event Reporting System and discovered 38 cases of serotonin syndrome in patients using triptans. Eleven of these patients were using triptans without concomitant antidepressants. Though definitive evidence is lacking for safe prescribing practice with triptans, the authors noted that most cases of triptan-induced serotonin toxicity occur within hours of triptan ingestion.²

The evidence on the risk of serotonin syndrome with other medications is limited to case reports. In regard to linezolid, a review suggested that when linezolid was administered to a patient on long-term citalopram, a prolonged serotonin syndrome was precipitated, which is not an issue with other antidepressants.³ The World Health Organization has issued warnings for serotonin toxicity with ondansetron and other 5-HT3 receptor antagonists based on case reports.^4,5 No data are available for the appropriate prescribing of 5-HT3 antagonists with antidepressants. A review of cases suggests a link between fluconazole and severe serotonin toxicity in patients taking citalopram; however, no prescribing guidelines have been established for fluconazole either.⁶

Dr. Rose asks important clinical questions, but evidence-based answers are not available.  We can only recommend that patients be advised to report symptoms immediately after starting any medication associated with serotonin syndrome. For patients on multiple antidepressants, psychiatric assistance is advised. An observational cohort study of patients using antidepressants while exposed to other suspect drugs may better delineate effects of several pharmaceuticals on the serotonergic axis. Only then may safe prescribing practices be validated with evidence.

In Reply: The questions posed by Dr. Rose reflect critical issues primary care physicians encounter when prescribing medications for patients who are taking serotonergic agents. “Switching strategies” have been described for starting or discontinuing serotonergic antidepressants.¹ Options range from conservative exchanges requiring 5 half-lives between discontinuation of 1 antidepressant and initiation of another vs a direct cross-taper exchange. Decisions regarding specific patients should take into account previous adverse effects from serotonergic medications and half-lives of discontinued antidepressants. To our knowledge, switching strategies have not been validated and are based on expert opinion. Scenarios are complicated further if patients have already been prescribed 2 or more antidepressants and 1 medication is exchanged or dose-adjusted while another is added. With this degree of complexity, we recommend referral to a psychiatrist.

Dr. Rose’s questions on prescribing nonpsychiatric serotonergic drugs concurrently with antidepressants broaches a topic with even less evidence. Some data exist about nonpsychiatric serotonergic drugs given in combination with triptans. Soldin et al² reviewed the US Food and Drug Administration’s Adverse Event Reporting System and discovered 38 cases of serotonin syndrome in patients using triptans. Eleven of these patients were using triptans without concomitant antidepressants. Though definitive evidence is lacking for safe prescribing practice with triptans, the authors noted that most cases of triptan-induced serotonin toxicity occur within hours of triptan ingestion.²

The evidence on the risk of serotonin syndrome with other medications is limited to case reports. In regard to linezolid, a review suggested that when linezolid was administered to a patient on long-term citalopram, a prolonged serotonin syndrome was precipitated, which is not an issue with other antidepressants.³ The World Health Organization has issued warnings for serotonin toxicity with ondansetron and other 5-HT3 receptor antagonists based on case reports.^4,5 No data are available for the appropriate prescribing of 5-HT3 antagonists with antidepressants. A review of cases suggests a link between fluconazole and severe serotonin toxicity in patients taking citalopram; however, no prescribing guidelines have been established for fluconazole either.⁶

Dr. Rose asks important clinical questions, but evidence-based answers are not available.  We can only recommend that patients be advised to report symptoms immediately after starting any medication associated with serotonin syndrome. For patients on multiple antidepressants, psychiatric assistance is advised. An observational cohort study of patients using antidepressants while exposed to other suspect drugs may better delineate effects of several pharmaceuticals on the serotonergic axis. Only then may safe prescribing practices be validated with evidence.

“TRUST: How to build a support net for ObGyns affected by a medical error”

PATRICE M. WEISS, MD (JANUARY 2017)

Support for ObGyn versus “evidence” for attorney

While every clinician recognizes the need to support the practi- tioner involved in a significant medical error, I found it puzzling that Dr. Weiss’ article did not mention our constant after-the-event associate, the personal injury attorney. How are we to provide the needed relief for the practitioner’s emotional distress without handing ammunition to the plaintiff’s lawyer?

E. Darryl Barnes, MD
Mechanicsville, Virginia

Experienced being the second victim

As Dr. Weiss states in her article, patients and their families, the first victims, are not the only ones affected by medical errors. I was involved in a medication error on a labor and delivery unit more than 20 years ago, and I was the second victim. There were also countless others. You are correct when you state that physicians, and others in medicine, do not support colleagues who have experienced a medical error. I agree with Dr. Wu’s observation that lack of empathy by peers is distressing. Symptoms of depression, burnout, decreased quality of life, and feelings of distress, guilt, and shame can occur in the second victim. I hope more people will get on board to use The Joint Commission toolkit to assist health care organizations in developing a second-victim program.

Carol Permiceo, RN
Long Island, New York

Dr. Weiss responds

I thank Dr. Barnes for his comments. The purpose of this article was mainly to assist people in establishing institutional support systems for providers when medical errors occur. Often we are not aware of litigation until some time well after the event. The TRUST second-victim support program and other programs are for immediate first aid for the provider and the team. Concerning the plaintiff’s ammunition, please remember that the purpose of these support systems, whether immediate or ongoing, is to discuss the emotional impact of the case on the provider, not the clinical details of the case.

I appreciate Ms. Permiceo sharing her story. As you probably have figured out, my interest in this area stems from my own experiences with medical errors (one in particular) and unanticipated outcomes. I hope by talking about it and validating our feelings (we are only human, after all) others will suffer less and come forward.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“TRUST: How to build a support net for ObGyns affected by a medical error”

PATRICE M. WEISS, MD (JANUARY 2017)

Support for ObGyn versus “evidence” for attorney

While every clinician recognizes the need to support the practi- tioner involved in a significant medical error, I found it puzzling that Dr. Weiss’ article did not mention our constant after-the-event associate, the personal injury attorney. How are we to provide the needed relief for the practitioner’s emotional distress without handing ammunition to the plaintiff’s lawyer?

E. Darryl Barnes, MD
Mechanicsville, Virginia

Experienced being the second victim

As Dr. Weiss states in her article, patients and their families, the first victims, are not the only ones affected by medical errors. I was involved in a medication error on a labor and delivery unit more than 20 years ago, and I was the second victim. There were also countless others. You are correct when you state that physicians, and others in medicine, do not support colleagues who have experienced a medical error. I agree with Dr. Wu’s observation that lack of empathy by peers is distressing. Symptoms of depression, burnout, decreased quality of life, and feelings of distress, guilt, and shame can occur in the second victim. I hope more people will get on board to use The Joint Commission toolkit to assist health care organizations in developing a second-victim program.

Carol Permiceo, RN
Long Island, New York

Dr. Weiss responds

I thank Dr. Barnes for his comments. The purpose of this article was mainly to assist people in establishing institutional support systems for providers when medical errors occur. Often we are not aware of litigation until some time well after the event. The TRUST second-victim support program and other programs are for immediate first aid for the provider and the team. Concerning the plaintiff’s ammunition, please remember that the purpose of these support systems, whether immediate or ongoing, is to discuss the emotional impact of the case on the provider, not the clinical details of the case.

I appreciate Ms. Permiceo sharing her story. As you probably have figured out, my interest in this area stems from my own experiences with medical errors (one in particular) and unanticipated outcomes. I hope by talking about it and validating our feelings (we are only human, after all) others will suffer less and come forward.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

“TRUST: How to build a support net for ObGyns affected by a medical error”

PATRICE M. WEISS, MD (JANUARY 2017)

Support for ObGyn versus “evidence” for attorney

While every clinician recognizes the need to support the practi- tioner involved in a significant medical error, I found it puzzling that Dr. Weiss’ article did not mention our constant after-the-event associate, the personal injury attorney. How are we to provide the needed relief for the practitioner’s emotional distress without handing ammunition to the plaintiff’s lawyer?

E. Darryl Barnes, MD
Mechanicsville, Virginia

Experienced being the second victim

As Dr. Weiss states in her article, patients and their families, the first victims, are not the only ones affected by medical errors. I was involved in a medication error on a labor and delivery unit more than 20 years ago, and I was the second victim. There were also countless others. You are correct when you state that physicians, and others in medicine, do not support colleagues who have experienced a medical error. I agree with Dr. Wu’s observation that lack of empathy by peers is distressing. Symptoms of depression, burnout, decreased quality of life, and feelings of distress, guilt, and shame can occur in the second victim. I hope more people will get on board to use The Joint Commission toolkit to assist health care organizations in developing a second-victim program.

Carol Permiceo, RN
Long Island, New York

Dr. Weiss responds

I thank Dr. Barnes for his comments. The purpose of this article was mainly to assist people in establishing institutional support systems for providers when medical errors occur. Often we are not aware of litigation until some time well after the event. The TRUST second-victim support program and other programs are for immediate first aid for the provider and the team. Concerning the plaintiff’s ammunition, please remember that the purpose of these support systems, whether immediate or ongoing, is to discuss the emotional impact of the case on the provider, not the clinical details of the case.

I appreciate Ms. Permiceo sharing her story. As you probably have figured out, my interest in this area stems from my own experiences with medical errors (one in particular) and unanticipated outcomes. I hope by talking about it and validating our feelings (we are only human, after all) others will suffer less and come forward.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.