E-Prescriptions Reduce Errors, but Their Adoption Is Slow - NYTimes.com

As e-mail and texting have become our favored means of written communication, handwriting has almost disappeared. Penmanship is becoming a modern form of hieroglyphics, intelligible only to literary scholars.

David Pohl

But one place where handwriting persists is on medical prescriptions, and that's unfortunate. Sloppy writing or inappropriate directions can lead to what doctors delicately refer to as preventable A.D.E.'s, or adverse drug events. These can encompass minor but still avoidable problems, like rashesor diarrhea, and much more serious events like, well, death.

Studies show that errors are much less likely if a doctor clicks to select medications from an onscreen list and sends the prescription data via computer to the pharmacy. Rainu Kaushal, a professor of medical informatics at Weill Cornell Medical College, led a study published in 2010 in which she and four colleagues followed prescriptions issued by a sample of providers in outpatient settings in New York. (Providers included physicians, physician assistants andnurse practitioners.) Some were prescribing electronically for the first time, and some continued to use paper.

The researchers found an astonishing 37 errors for every 100 paper prescriptions, versus around 7 per 100 for those who used e-prescribing software.

These errors didn't even include legibility issues, when the pharmacist couldn't read the handwriting with confidence and called the provider to clarify.

Earlier, when the participants who would switch to e-prescribing were still using paper, they had almost 88 legibility errors per 100 prescriptions. (Some prescriptions had more than one error.) An illegible prescription requires time to sort out with the provider. "In the case of an urgent medication," Dr. Kaushal says, "the delay can result in patient harm."

Previous studies of prescriptions in hospital settings have suggested error rates of about 5 per 100 paper prescriptions. Most were not serious, but about 7 percent had potential for harm. The Institute of Medicine has estimated annual costs for preventable A.D.E.'s in hospital settings alone at about $2 billion in the United States.

Yet only about 36 percent of all prescriptions were delivered electronically in the United States in 2011, according to a report to be published in May by Surescripts, which maintains an e-prescribing network.

E-prescribing comes as part of the switch to electronic health records, which can cost a medical practice tens of thousands of dollars. The stimulus package passed in 2009 included provisions that theoretically ease the financial burden for doctors, but the payments are tied to Medicare and Medicaid reimbursements that are spread out over five years. So the upfront costs remain substantial.

In addition to those costs, the other large obstacle to adopting electronic records is their impact on office work flow, Dr. Kaushal says. More hours may have to be added to the workday to enter data. "These systems are far from plug and play," she says.

The number of hospitals using e-prescribing is growing rapidly, but still only about 30 percent have made the switch, says David W. Bates, chief of the division of general internal medicine and primary care at Brigham and Women's Hospital in Boston and a professor at the Harvard Medical School.

Even when they install the technology, hospitals often leave e-prescribing as an option for providers but don't require it. "What one sees often is about two-thirds of prescriptions are generated electronically" at these hospitals, Dr. Bates says, "but it's hard to get that remaining third converted."

In Australia, handwriting has been largely eliminated from prescribing. Johanna I. Westbrook, director of the Center for Health Systems and Safety Research at the University of New South Wales, says that about a decade ago, "the government provided financial incentives for family physicians to introduce computers into the practice." Today, about 90 percent of those practices are computerized, but most pharmacies don't receive prescriptions electronically. So the provider uses a computer and printer to prepare a neat prescription in paper form that the patient drops off at the pharmacy.

Reducing prescription errors can mean more than eliminating handwriting. Software is needed to integrate prescriptions with a patient's electronic health record and to check for adverse interactions. This "decision support" software can have its own issues. It must be vigilant in looking for potential problems, but not overzealous. "Decision support is leading to 'alert fatigue,' " Professor Westbrook says. "The consequence is providers ignore the alerts and the system then can't prevent all of the medication errors that it could."

On balance, though, it's clear that e-prescriptions help prevent errors.

Such prescriptions were not unknown even in the 1990s, so clicks have long seemed to be on the verge of replacing scribbles. Perhaps it won't take another 20 years before the prescription pad is placed next to the jar of leeches as an exhibit in the Museum of Medical Curiosities.

http://www.nytimes.com/2012/04/29/business/e-prescriptions-reduce-errors-but-their-adoption-is-slow.html?_r=1

Physicians turn to exercise prescriptions to prevent and treat chronic condition - Healthzone.ca

There's a powerful medicine gaining favour these days that can't be found in a tablet or on pharmacy shelves.

This potent remedy, which can reduce blood pressure, cholesterol and the risk of heart attack, is good old-fashioned exercise.

A movement is emerging among physicians, researchers and public-health experts who want the medical system to harness its healing and preventive powers — through exercise prescriptions.

At a time when Canadians are fatter, more inactive and facing higher rates of chronic disease than ever before, they say it's time doctors started prescribing brisk walks and strength training the same way they dole out pills for diabetes or hypertension.

The notion that cardiovascular disease and other conditions can be prevented and treated with regular aerobic activity is not new.

"The difference we're trying to focus on is to get the authority — the physician — to tell patients 'you need to do this for your health,' " says Brian MacIntosh, kinesiology professor at the University of Calgary and board member of the Canadian Society for Exercise Physiology, which sets national guidelines for physical activity and sedentary time.

Next month, MacIntosh will chair the first meeting of a new group called Exercise is Medicine Canada in Victoria, B.C. Like its U.S. parent, the Canadian chapter wants to make physical activity another "vital sign" that's assessed at every doctor's appointment along with blood pressure and pulse. It is also pushing for physical activity to be at the centre of policy discussions on disease prevention and health.

Other health advocates are also embracing this philosophy. The Canadian Diabetes Association launched its downloadable exercise prescription pad ( http://www.diabetes.ca/documents/for-professionals/Patient_Provider_Prescription_Tool_4.pdf) late last year. It provides doctors with five prescription options, depending on a patient's fitness level and gradually increases in intensity and duration as the patient makes exercise part of their daily routine.

"Just telling someone to be physically active isn't enough," says Jonathon Fowles, kinesiology professor at Acadia University in Wolfville, N.S., and designer of the new pad.

Research has shown that written prescriptions motivate patients to pay attention, retain the information and return for follow-up visits, he says.

Fifty physicians from the Leduc Beaumont Devon Primary Care Network south of Edmonton may be the first in Canada to adopt the practice en masse.

They have handed out 850 exercise prescriptions since launching their initiative in November, and each comes with a free one-month pass to a local recreation facility.

They know doctors' orders have clout. But those orders need to be explicit and in writing, especially for patients who aren't in the habit of exercising.

Take Robert Bradley, 68, of Toronto. After three decades of living with Type 2 diabetes, he takes his prescriptions seriously, carefully following instructions about dosage, frequency and potential side effects.

But general advice to "get more exercise" never had much impact. When his family physician suggested regular walks to make up for sedentary hours at a desk, Bradley would try for a few months. Then he'd gradually slip back to his inactive ways.

"I turned into a couch potato, to be honest, and I wasn't very motivated."

What he needed was an approach that treated exercise as seriously as a bottle of pills.

He finally got one at the Toronto Rehabilitation Institute, which provides assessments, fitness plans and monitoring for people living with chronic health conditions. The program, which treats 1,800 patients a year, is covered by OHIP but requires a physician's referral.

Bradley signed up for a 26-week session last fall, after high blood sugars left him facing the prospect of going on insulin. His first exercise prescription was to walk four laps (800 metres) around the track at the institute's Leaside facility five days a week.

Six months later, he's up to 5.6 kilometres almost every morning on his own treadmill while watching Canada AM (it takes him 64 minutes). He also does resistance training exercises twice a week.

Bradley is 20 pounds lighter, has lost five inches from his waistline and seen his blood sugar levels fall to the normal range. His doctor is delighted.

"Now I look forward to it," says Bradley. "I've had very positive results so I feel a lot better about myself."

His experience underscores the biggest challenges for physicians: making sure patients are consistent; and providing advice tailored to the individual.

"No drug works unless you actually take it, and you have to take it every day and the right dose and at the right time," says Dr. Paul Oh, internist and medical director at Toronto Rehab.

"The analogy to medicine is we would never say 'take some aspirin and good luck.' We would say 'take 81 milligrams each morning, make sure you take it, if you miss a dose, here's what you do. If your stomach is upset, take an antacid or take it with food. If you have bleeding, please call me.' "

Oh has been prescribing exercise for 20 years to improve the outlook for patients with chronic conditions that put them at risk of heart attack and stroke, and to treat those recovering. But he says physicians should make exercise a priority for all patients.

Walking at a brisk pace for half an hour five days a week accompanied by twice-weekly resistance exercises using light weights or elastic can have a huge impact on health. Studies have shown it can improve an array of conditions from osteoporosis to joint pain to anxiety — as long as patients follow through.

"It's as powerful as any medication therapy we might offer," says Oh, also a pharmacologist. "The unfortunate thing is it's vastly underutilized by physicians and patients."

To change the culture, they need to understand exercise isn't just a matter of cosmetics or lifestyle but that "the person over there walking around (the track) actually has a 50 per cent lower chance of dying."

For the past five years, everyone from the World Health Organization to Health Canada and local public health authorities have warned that sedentary behaviour is making society sick.

Exercise guidelines make newscasts, public awareness campaigns blare the "get moving" message on screens and billboards.

But according to Statistics Canada studies that tracked Canadians' activity levels, only 15 per cent of adults get the recommended minimum of 150 minutes a week of moderate to vigorous exercise, while a dismal 7 per cent of kids meet the minimum one hour a day.

Physicians on the front lines are in a unique position to prime the pump, says Dr. Robert Petrella, assistant director at the Lawson Health Research Institute in London, Ont., and a University of Western Ontario professor who holds research chairs in aging and health.

While many believe in physical activity for optimum health, the challenge is translating it into practical advice.

His 2007 survey of more than 13,000 family physicians found 85 per cent raised the issue of exercise with patients during routine examinations. While 70 per cent provided verbal counselling, only 16 per cent provided written instructions.

It's that piece of paper that can have the biggest impact among patients accustomed to leaving the office with something in hand. That's where the prescription pad comes in.

There are barriers to getting physicians to make exercise a priority. There is often a lot of ground to cover in limited time during appointments. Many feel they lack the expertise to prescribe exercise.

One solution is expanding health-care teams to include an exercise physiologist trained to design programs for both healthy patients and those with chronic conditions.

Discussing a range of exercise options is also key, says Petrella, whether it's mall-walking, cycling or joining a pickup soccer league. Sending everyone to a fitness centre isn't going to work.

Whatever the exercise of choice, physicians need to be on top of the options in their own communities, including hiking trails, pools and recreation centres, says Petrella.

"And they need to incorporate those into what they're telling patients."

More …

http://www.healthzone.ca/health/articlePrint/1167983

Debt Collectors Take Places Alongside Hospital Staffs - NYTimes.com

Hospital patients waiting in an emergency room or convalescing after surgery are being confronted by an unexpected visitor: a debt collector at bedside.

This and other aggressive tactics by one of the nation's largest collectors of medical debts, Accretive Health, were revealed on Tuesday by the Minnesota attorney general, raising concerns that such practices have become common at hospitals across the country.

The tactics, like embedding debt collectors as employees in emergency rooms and demanding that patients pay before receiving treatment, were outlined in hundreds of company documents released by the attorney general. And they cast a spotlight on the increasingly desperate strategies among hospitals to recoup payments as their unpaid debts mount.

To patients, the debt collectors may look indistinguishable from hospital employees, may demand they pay outstanding bills and may discourage them from seeking emergency care at all, even using scripts like those in collection boiler rooms, according to the documents and employees interviewed by The New York Times.

In some cases, the company's workers had access to health information while persuading patients to pay overdue bills, possibly in violation of federal privacy laws, the documents indicate.

The attorney general, Lori Swanson, also said that Accretive employees may have broken the law by not clearly identifying themselves as debt collectors.

Accretive Health has contracts not only with two hospitals cited in Minnesota but also with some of the largest hospital systems in the country, including Henry Ford Health System in Michigan and Intermountain Healthcare in Utah. Company executives declined to comment on Tuesday.

Although Ms. Swanson did not bring action against the company on Tuesday, she said she was in discussions with state and federal regulators about a coordinated response to Accretive Health's practices across the country. Regulators in Illinois, where Accretive is based, are watching the developments closely, according to Sue Hofer, a spokeswoman with the State Department of Financial and Professional Regulation.

"I have every reason to believe that what they are doing in Minnesota is simply company practice," Ms. Swanson said in an interview, but declined to provide details.

In January, Ms. Swanson filed a civil suit against Accretive after a laptop with patient information was stolen, saying that the company had violated state and federal debt collection laws and patient privacy protections. That action is still pending.

An Accretive spokeswoman declined to comment on whether other states were looking into its practices and issued a brief statement, "We have a great track record of helping hospitals enhance their quality of care." In its annual report, the company said it was cooperating with the attorney general to resolve the issues in Minnesota.

As hospitals struggle under a glut of unpaid bills, they are reaching out to companies like Accretive that specialize in collecting medical bills.

Hospitals have long hired outside collection agencies to pursue patients after they have left hospital facilities. But financial pressures are altering the collection landscape so that they are now letting collection firms in the front door, according to Don May, the policy adviser for the American Hospital Association, a trade group.

To achieve promised savings, hospitals turn over the management of their front-line staffing — like patient registration and scheduling — and their back-office collection activities.

Concerns are mounting that the cozy working relationships will undercut patient care and threaten privacy, said Anthony Wright, executive director of Health Access California, a consumer advocacy coalition. "The mission of these companies is in direct opposition to the supposed mission of these hospitals."

Still, hospitals are in a bind. The more than 5,000 community hospitals in the United States provided $39.3 billion in uncompensated care — predominately unpaid patient debts or charity care — in 2010, up 16 percent from 2007, the hospital association estimated.

Accretive is one of the few companies specializing in hospital debt collection that is publicly traded. Last year, it reported $29.2 million in profit, up 130 percent from a year earlier.

Late last month, Fairview Health Services, a Minnesota hospital group that Accretive provided services to, announced it was canceling its contract with Accretive for back-office debt collection. After Accretive informed investors, its stock plunged 19 percent in a day. On Tuesday, the company's shares closed at $18.49, down 2.7 percent.

Accretive says that it trains its staff to focus on getting payment through "revenue cycle operations." Accretive fostered a pressurized collection environment that included mandatory daily meetings at the hospitals in Minnesota, according to employees and the newly released documents. Employees with high collection tallies were rewarded with gift cards. Those who fell behind were threatened with termination.

"We've started firing people that aren't getting with the program," a member of Accretive's staff wrote in an e-mail to his bosses in September 2010.

Collection activities extended from obstetrics to the emergency room. In July 2010, an Accretive manager told staff members at Fairview that they should "get cracking on labor and delivery," since there is a "good chunk to be collected there," according to company e-mails.

Employees were told to stall patients entering the emergency room until they had agreed to pay a previous balance, according to the documents. Employees in the emergency room, for example, were told to ask incoming patients first for a credit card payment. If that failed, employees were told to say, "If you have your checkbook in your car I will be happy to wait for you," internal documents show.

Employees at Accretive's client hospitals ask patients to make "point of service" payments before they receive treatment. Until she went to Fairview for her son Maxx's ear tube surgery in November, Marcia Newton, a stay-at-home mother in Corcoran, Minn., said she had never been asked to pay for care before receiving it. "They were really aggressive about getting that money upfront," she said in an interview.

Ms. Newton was shocked to learn that the employees were debt collectors. "You really feel hoodwinked," she said.

While hospital collections at Fairview increased, patient care suffered, the employees said. "Patients are harassed mercilessly," a hospital employee told Ms. Swanson.

Patients with outstanding balances were closely tracked by Accretive staff members, who listed them on "stop lists," internal documents show. In March 2011, doctors at Fairview complained that such strong-arm tactics were discouraging patients from seeking lifesaving treatments, but Accretive officials dismissed the complaints as "country club talk," the documents show.

Ms. Swanson said that the hounding of patients violated the Emergency Medical Treatment and Active Labor Act, a federal law requiring hospitals to provide emergency health care regardless of citizenship, legal status or ability to pay.

In the January lawsuit, Ms. Swanson said that by giving its collectors access to health records, Accretive violated the Health Insurance Portability and Accountability Act, known as Hipaa (pronounced HIP-ah). For example, an Accretive collection employee had access to records that showed a patient had bipolar disorder, Parkinson's disease and a host of other conditions.

In addition, she said, the company broke state collections laws by failing to identify themselves as debt collectors when dealing with patients.

Late Tuesday afternoon, Accretive announced it won a contract to provide "revenue cycle operations" for Catholic Health East, which has hospitals in 11 states.

http://www.nytimes.com/2012/04/25/business/debt-collector-is-faulted-for-tough-tactics-in-hospitals.html?

Older Men Still Being Screened for Prostate Cancer - NYTimes.com

Many men 75 years and older, who are far more likely to be harmed than helped by prostate cancer screening, continue to be tested for the disease, despite federal guidelines strongly advising against the practice.

The debate about screening older men for prostate cancer was reignited last week after reports that the billionaire investor Warren Buffett, who is 81, said he received a diagnosis of early-stage prostate cancer after a routine blood test for prostate specific antigen, or P.S.A.

In 2008, the United States Preventive Services Task Force recommended that men 75 and older no longer be given a routine P.S.A. test. The test is notoriously unreliable in older men, who often have elevated P.S.A. scores as a result of natural aging or an enlarged prostate. And even when cancer is found as a result of a P.S.A. test in older men, it typically is so slow-growing that it will never cause harm.

Continued testing of men 75 and older, the task force concluded, was far more likely to result in significant harm, including unnecessary treatment that could cause pain, incontinence and impotence, among other risks.

But very few men and their doctors have heeded the task force advice, according to new research published in The Journal of the American Medical Association.

Researchers from the University of Chicago and the University of California, Los Angeles, studied data collected from the National Health Interview Survey, which every five years includes 13 questions about P.S.A. testing. Among the 5,332 men surveyed in 2005 and the 4,640 men queried in 2010, two years after the new guidelines were issued, the researchers found no difference in the rate of P.S.A. testing among older men. In both cohorts, about 43 percent of men 75 or older were being screened.

In fact, in 2010, P.S.A. screening was more common in men 75 or older than in men in their 40s and 50s. Experts continue to debate the relative benefits of P.S.A. testing at all ages, but most agree that younger men may have the most to gain from screening.

"To our disturbing surprise, the men most likely to benefit were being screened at about half the rate of men in their 70s or 80s, who are the men least likely to benefit," said Dr. Scott Eggener, co-director of the urological oncology fellowship program at the University of Chicago Medical Center and senior author of the study.

Not every medical group opposes P.S.A. testing of older men. The American Cancer Society and the American Urological Association discourage screening for men whose life expectancy is 10 years or less, but suggest that a man who is expected to live 10 years or longer discuss the risks and benefits of testing with his doctor.

Mr. Buffett has disclosed that he will undergo radiation treatment for the cancer, but he has not shared further details that would illuminate his risk, such as the Gleason score indicating how aggressive the cancer may be. Although his life expectancy, based on actuarial data, is an additional seven to eight years, he appears to be in robust health, and his doctors may feel that a life expectancy of 10 years or more is a strong possibility based on his health and family history.

However, many older men have health problems, such as diabetes or heart disease, that would shorten their life expectancy, and most experts agree they should not be tested.

Dr. Otis Webb Brawley, chief medical officer for the American Cancer Society, said that many doctors continue to test anyway, because they don't want to have a conversation with their patients about life expectancy.

"If you decide not to do the P.S.A., then you've got to have this conversation you really don't want to have with the patient," Dr. Brawley said. "For doctors to do that, it is emotionally challenging. Talking to someone else about their mortality is really uncomfortable for doctors."

http://well.blogs.nytimes.com/2012/04/24/older-men-still-being-screened-for-prostate-cancer/?nl=todaysheadlines&emc=edit_th_20120425

Melinda Gates: Let's put birth control back on the agenda | Video on TED.com

Contraception. The topic has become controversial in recent years. But should it be? Melinda Gates believes that many of the world's social change issues depend on ensuring that women are able to control their rate of having kids. In this significant talk, she makes the case for the world to re-examine an issue she intends to lend her voice to for the next decade.

http://www.ted.com/talks/melinda_gates_let_s_put_birth_control_back_on_the_agenda.html?

Ethics in the ER: Ottawa emergency makes room for bigger questions | National Post

The patient arrived at the Ottawa Hospital emergency department with "cataclysmic" medical problems and a perplexing dilemma for the doctors. The physicians were confident they could fix the person's potentially fatal ailment, but an "advance directive" document prepared earlier to guide health-care staff in such situations called simply for the patient to be sent back home - without receiving any life-saving treatment.

At that point, medical staff did something almost unheard of in emergency medicine: they slowed the frantic pace of treatment and called in the hospital's bioethicist to help them decide what to do.

It was part of a fledgling project, seemingly unprecedented in North America, to routinely involve ethics professionals in the moral conundrums of the emergency ward, health care's most hectic, time-crunched environment.

"A lot of what we do is very, very immediate. It's very action-based rather than reflection based," said Dr. Jacky Parker, emergency specialist and prime mover behind the new initiative. "[The project] is an attempt to take ethics from the subliminal to the explicit, so that we can identify issues early and respond to them early."

Not only is the department routinely calling on Tom Foreman, the hospital's bioethicist, for "consults" - the type of advice sessions usually sought from medical specialists - but doctors now carry around a card with a checklist of possible ethical challenges.

The project also underscores the plethora of moral conflicts that arise in emergency, which doctors and nurses in chronically overcrowded departments usually resolve on the fly, with little chance to ruminate.

There are emotional decisions on when to pull the plug on terminal patients, conflicts between loved ones over how aggressively to treat their relative, and drug studies where the critically ill patient is enrolled in the trial first, and asked for consent later.

The Ottawa experiment also could mark a new role for bioethicists themselves, whom hospitals started to hire in the 1970s after the Karen-Ann Quinlan case called into question the institutions' ability to handle such prickly issues. The 21-year-old New Jersey woman fell into a persistent vegetative state in 1975 after consuming a cocktail of sedatives and alcohol, but her parents had to fight in court for months to get her removed from life support, a dispute that triggered headlines worldwide.

Many ethicists still see their role almost as academic overseers, and get directly involved only with cases in the intensive-care unit (ICU) or other wards where patients linger for days or weeks, leaving plenty of time to ponder the arguments, Mr. Foreman said.

"Some ethicists say, 'I don't do consults by emergency, period ... I'm not going to jump and run,' " Mr. Foreman said. "I take a very different view. I think if we don't do that, by the time that episode is over, the emergency doctor has moved on to the next emergency. So, have they learned anything? Have they been helped by the unwillingness to accommodate their need?"

Dr. Parker, a veteran of the emergency department who also obtained a Master's degree in ethics, surveyed colleagues in her department at the Ottawa Hospital's Civic campus on whether they needed the help. Most said they could recognize an ethical issue if it arose, but only 10% felt they had time to adequately address it.

The wallet card doctors and nurses now carry asks if they are encountering ethical challenges over such issues as the patient's ability to consent to treatment, end-of-life care, confidentiality and the fairness of how resources are being allocated, and suggests calling the ethics office if necessary.

In some of the cases that have cropped up since the project started, patients simply refused treatment for serious conditions such as a heart attack or stroke, creating significant "moral distress" for the medical professionals. Yet with an ethicist guiding the conversation, and the patient fully informed on the consequences of turning down help, some have been simply let go, she said.

In other situations, two family members with power of attorney over a patient incapacitated by dementia or other problems have disagreed on whether to pursue treatment, one asking that everything possible be done, the other insisting "Mom wouldn't want that," she said.

Mr. Foreman said he handles such dilemmas both on the phone and in person if he can get to the department quickly enough.

Emergency physicians elsewhere said they would welcome having access to such expertise, but note there is simply no time for cogitation in some fast-moving situations, or easy solutions to certain ethically questionable situations.

Edmonton's emergency wards are so packed, doctors often examine patients in the waiting rooms, sometimes sending them directly from the lounge to the operating room with ailments such as acute appendicitis, Dr. Brian Rowe said, a University of Alberta professor of emergency medicine. In the process, doctor-patient confidentiality all but vanishes. "There's no privacy," he said. "Your neighbour knows about as much about you as the doctor does. I'm asking someone an ethical question like, 'Are you having intercourse with anybody but your wife or husband?' That's not the kind of thing anybody else would hear.... It's the inhumane treatment of patients that really gets at people."

Clinical studies in the emergency department, though crucial to improving care and approved in advance by university ethics committees, also raise issues. Because emergency patients often need immediate help and may be incapacitated, they are sometimes enrolled in studies comparing new treatments with existing ones, but before the usual step of asking their consent, Dr. Rowe said. Patients are randomly assigned to one option or the other, as occurred in a recent U.S. study on whether limiting intravenous fluids could prevent some trauma victims from bleeding to death. "That's a pretty tough trial. You've just been stabbed, so they pull out this envelope [for randomizing research subjects] and it says 'restricted fluids' and the paramedics are going 'What?'" Dr. Rowe said. "That's the kind of trial you would need to do without consent up front.... Even if the person dies, you say, 'Listen, we did everything we could, we put him in a study, can we use the data?' Most people will say 'Yes.' "

Emergency specialists say deciding whom to treat first - even in an era of overcrowding - is made relatively easy by well-defined triage protocols, generally avoiding moral conflicts.

It can still be challenging, however, to consider the needs of patients on life support whose deaths are inevitable, especially in the context of limited resources, said Dr. Merril Pauls, both an emergency physician and ethics director in the University of Manitoba faculty of medicine.

"I'm sitting there and I have 40 patients in the waiting room and I have another 20 in beds," he said. "Someone comes in with an irreversible or untreatable problem and yet the family want to continue some type of resuscitative care.... My resuscitation room is full and I'm trying to have this very challenging conversation with the family."

The principles of ethics dictate that no one should be denied treatment simply because there might be other patients who need the resources more, Dr. Pauls said. Still, emergency doctors are frequently asked if they can discharge patients to make room for others, he said. At the Ottawa Hospital, the ethicist, doctors and family members worked through the dilemma of the sick patient whose directive said to let them go, and in the end the individual received treatment and recovered, Dr. Parker said.

In other instances, however, Mr. Foreman said he has helped doctors come around to a patient's wish to forego medical help.

"For the physician in emerg, their number one priority is to rescue and save," he said.

"When faced with the option of not rescuing and not saving, it can sometimes go against their training and intuition and instincts. Having that independent counsel can help them work through their own confusion."

http://news.nationalpost.com/2012/04/22/ethics-in-the-er-ottawa-emergency-makes-room-for-bigger-questions/

How Psychedelic Drugs Can Help Patients Face Death - NYTimes.com

Pam Sakuda was 55 when she found out she was dying. Shortly after having a tumor removed from her colon, she heard the doctor's dreaded words: Stage 4; metastatic. Sakuda was given 6 to 14 months to live. Determined to slow her disease's insidious course, she ran several miles every day, even during her grueling treatment regimens. By nature upbeat, articulate and dignified, Sakuda — who died in November 2006, outlasting everyone's expectations by living for four years — was alarmed when anxiety and depression came to claim her after she passed the 14-month mark, her days darkening as she grew closer to her biological demise. Norbert Litzinger, Sakuda's husband, explained it this way: "When you pass your own death sentence by, you start to wonder: When? When? It got to the point where we couldn't make even the most mundane plans, because we didn't know if Pam would still be alive at that time — a concert, dinner with friends; would she still be here for that?" When came to claim the couple's life completely, their anxiety building as they waited for the final day.

As her fears intensified, Sakuda learned of a study being conducted by Charles Grob, a psychiatrist and researcher at Harbor-U.C.L.A. Medical Center who was administering psilocybin — an active component of magic mushrooms — to end-stage cancer patients to see if it could reduce their fear of death. Twenty-two months before she died, Sakuda became one of Grob's 12 subjects. When the research was completed in 2008 — (and published in the Archives of General Psychiatry last year) — the results showed that administering psilocybin to terminally ill subjects could be done safely while reducing the subjects' anxiety and depression about their impending deaths.

Grob's interest in the power of psychedelics to mitigate mortality's sting is not just the obsession of one lone researcher. Dr. John Halpern, head of the Laboratory for Integrative Psychiatry at McLean Hospital in Belmont Mass., a psychiatric training hospital for Harvard Medical School, used MDMA — also known as ecstasy — in an effort to ease end-of-life anxieties in two patients with Stage 4 cancer. And there are two ongoing studies using psilocybin with terminal patients, one at New York University's medical school, led by Stephen Ross, and another at Johns Hopkins Bayview Medical Center, where Roland Griffiths has administered psilocybin to 22 cancer patients and is aiming for a sample size of 44. "This research is in its very early stages," Grob told me earlier this month, "but we're getting consistently good results."

Grob and his colleagues are part of a resurgence of scientific interest in the healing power of psychedelics. Michael Mithoefer, for instance, has shown that MDMA is an effective treatment for severeP.T.S.D. Halpern has examined case studies of people with cluster headaches who took LSD and reported their symptoms greatly diminished. And psychedelics have been recently examined as treatment for alcoholism and other addictions.

Despite the promise of these investigations, Grob and other end-of-life researchers are careful about the image they cultivate, distancing themselves as much as possible from the 1960s, when psychedelics were embraced by many and used in a host of controversial studies, most famously the psilocybin project run by Timothy Leary. Grob described the rampant drug use that characterized the '60s as "out of control" and said of his and others' current research, "We are trying to stay under the radar. We want to be anti-Leary." Halpern agreed. "We are serious sober scientists," he told me.

Sakuda's terminal diagnosis, combined with her otherwise perfect health, made her an ideal subject for Grob's study. Beginning in January 2005, Grob and his research team gave Sakuda various psychological tests, including the Beck Depression Inventory and the Stai-Y anxiety scale to establish baseline measures of Sakuda's psychological state and to rule out any severe psychiatric illness. "We wanted psychologically healthy people," Grob says, "people whose depressions and anxieties are not the result of mental illness" but rather, he explained, a response to a devastating disease.

Sakuda would take part in two sessions, one with psilocybin, one with niacin, an active placebo that can cause some flushing in the face. The study was double blind, which meant that neither the researchers nor the subjects knew what was in the capsules being administered. On the day of her first session, Sakuda was led into a room that researchers had transformed with flowing fabrics and fresh flowers to help create a soothing environment in an otherwise cold hospital setting. Sakuda swallowed a capsule and lay back on the bed to wait. Grob had invited her — as researchers do with all their subjects — to bring objects from home that had special significance. "These objects often personalize the session room for the volunteer and often prompt the patient to think about loved ones or important life events," Roland Griffiths, of Johns Hopkins, says.

"I think it's kind of goofy," Halpern says, "but the thinking is that with the aid of the psychedelic, you may come to see the object in a different light. It may help bring back memories; it promotes introspection, it can be a touchstone, it can be grounding."

Sakuda brought a few pictures of loved ones, which, Grob recalled, she clutched in her hands as she lay back on the bed. By her side were Grob and one of his research assistants, both of whom stayed with the subjects for the six-to-seven-hour treatment session. Sakuda knew that there would be time set aside in the days and weeks following when she would meet with Grob and his team to process what would happen in that room. Black eyeshades were draped over Sakuda's face, encouraging her to look inward. She was given headphones. Music was piped in: the sounds of rivers rushing, sweet staccatos, deep drumming. Each hour, Grob and his staff checked in with Sakuda, as they did with every subject, asking if all was O.K. and taking her blood pressure. At one point, Grob observed that Sakuda, with the eyeshades draped over her face, began to cry. Later on, Sakuda would reveal to Grob that the source of her tears was a keen empathetic understanding of what her spouse Norbert would feel when she died.

Grob's setup — the eyeshades, the objects, the mystical music, the floral aromas and flowing fabrics — was drawn from the work of Stanislav Grof, a psychiatrist born in Prague and a father of the study of psychedelic medicine for the dying. In the mid-'60s — before words like "acid" and "bong" and "Deadhead" transformed the American landscape, at a time when psychedelics were not illegal because most people didn't know what they were and thus had no urge to ingest them — Grof began giving the drug to cancer patients at the Spring Grove State Hospital near Baltimore and documenting their effects.

Grof kept careful notes of his many psychedelic sessions, and in his various papers and books derived from those sessions, he described cancer patients clenched with fear who, under the influence of LSD or DPT, experienced relief from the terror of dying — and not just during their psychedelic sessions but for weeks and months afterward. Grof continued his investigations into psychedelics for the dying until the culture caught up with him — the recreational use of drugs and the reaction against them leading to harsh antidrug laws. (Richard Nixon famously called Timothy Leary "the most dangerous man in America.") Financing for psychedelic studies dried up, and Grof turned his attention to developing alternative methods of accessing higher states of consciousness. It is only now, decades later, that Grob and a handful of his fellow scientists feel they can re-examine Grof's methods and outcomes without risking their reputations.

More …

http://www.nytimes.com/2012/04/22/magazine/how-psychedelic-drugs-can-help-patients-face-death.html?&pagewanted=print

In Therapy Forever? Enough Already - NYTimes.com

MY therapist called me the wrong name. I poured out my heart; my doctor looked at his watch. My psychiatrist told me I had to keep seeing him or I would be lost.

New patients tell me things like this all the time. And they tell me how former therapists sat, listened, nodded and offered little or no advice, for weeks, months, sometimes years.  A patient recently told me that, after seeing her therapist for several years, she asked if he had any advice for her. The therapist said, "See you next week." 

When I started practicing as a therapist 15 years ago, I thought complaints like this were anomalous. But I have come to a sobering conclusion over the years: ineffective therapy is disturbingly common.

Talk to friends, keep your ears open at a cafe, or read discussion boards online about length of time in therapy. I bet you'll find many people who have remained in therapy long beyond the time they thought it would take to solve their problems. According to a 2010 study published in the American Journal of Psychiatry, 42 percent of people in psychotherapy use 3 to 10 visits for treatment, while 1 in 9 have more than 20 sessions.

For this 11 percent, therapy can become a dead-end relationship. Research shows that, in many cases, the longer therapy lasts the less likely it is to be effective. Still, therapists are often reluctant to admit defeat.

A 2001 study published in the Journal of Counseling Psychology found that patients improved most dramatically between their seventh and tenth sessions. Another study, published in 2006 in the Journal of Consulting and Clinical Psychology, looked at nearly 2,000 people who underwent counseling for 1 to 12 sessions and found that while 88 percent improved after one session, the rate fell to 62 percent after 12. Yet, according to research conducted at the University of Pennsylvania, therapists who practice more traditional psychotherapy treat patients for an average of 22 sessions before concluding that progress isn't being made. Just 12 percent of those therapists choose to refer their stagnant patients to another practitioner. The bottom line: Even though extended therapy is not always beneficial, many therapists persist in leading patients on an open-ended, potentially endless, therapeutic course.

Proponents of long-term therapy have argued that severe psychological disorders require years to manage. That may be true, but it's also true that many therapy patients don't suffer severe disorders. Anxiety and depression are the top predicaments for which patients seek mental health treatment; schizophrenia is at the bottom of the list.

In my experience, most people seek therapeutic help for discrete, treatable issues: they are stuck in unfulfilling jobs or relationships, they can't reach their goals, are fearful of change and depressed as a result. It doesn't take years of therapy to get to the bottom of those kinds of problems. For some of my patients, it doesn't even take a whole session.

Therapy can — and should — focus on goals and outcomes, and people should be able to graduate from it. In my practice, the people who spent years in therapy before coming to me were able to face their fears, calm their anxieties and reach life goals quickly — often within weeks.

Why? I believe it's a matter of approach. Many patients need an aggressive therapist who prods them to face what they find uncomfortable: change. They need a therapist's opinion, advice and structured action plans. They don't need to talk endlessly about how they feel or about childhood memories. A recent study by the National Institute for Health and Welfare in Finland found that "active, engaging and extroverted therapists" helped patients more quickly in the short term than "cautious, nonintrusive therapists."

This approach may not be right for every patient, but the results described in the Finnish study are consistent with my experience.

If a patient comes to me and tells me she's been unhappy with her boyfriend for the past year, I don't ask, as some might, "How do you feel about that?" I already know how she feels about that. She just told me. She's unhappy. When she asks me what I think she should do, I don't respond with a return interrogatory, "What do you think you should do?" If she knew, she wouldn't ask me for my thoughts.

Instead I ask what might be missing from her relationship and sketch out possible ways to fill in relationship gaps or, perhaps, to end it in a healthy way. Rather than dwell on the past and hash out stories from childhood, I encourage patients to find the courage to confront an adversary, take risks and embrace change. My aim is to give patients the skills needed to confront their fear of change, rather than to nod my head and ask how they feel.

In graduate school, my classmates and I were taught to serve as guides, whose job it is to help patients reach their own conclusions. This may work, but it can take a long time. I don't think patients want to take years to feel better. They want to do it in weeks or months.

Popular misconceptions reinforce the belief that therapy is about resting on a couch and talking about one's problems. So that's what patients often do. And just as often this leads to codependence. The therapist, of course, depends on the patient for money, and the patient depends on the therapist for emotional support. And, for many therapy patients, it is satisfying just to have someone listen, and they leave sessions feeling better.

But there's a difference between feeling good and changing your life. Feeling accepted and validated by your therapist doesn't push you to reach your goals. To the contrary, it might even encourage you to stay mired in dysfunction. Therapy sessions can work like spa appointments: they can be relaxing but don't necessarily help solve problems. More than an oasis of kindness or a cozy hour of validation and acceptance, most patients need smart strategies to help them achieve realistic goals.

I'm not against therapy. After all, I practice it. But ask yourself: if your hairstylist keeps giving you bad haircuts, do you keep going back? If a restaurant serves you a lousy meal, do you make another reservation? No, I'm sure you wouldn't, and you shouldn't stay in therapy that isn't helping you, either.

Jonathan Alpert is a New York psychotherapist and the author of "Be Fearless: Change Your Life in 28 Days."

http://www.nytimes.com/2012/04/22/opinion/sunday/in-therapy-forever-enough-already.html?&pagewanted=print