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Making health care decisions for patients who cannot is emotionally wrenching for families and poses an ethical dilemma for physicians. In a medical system that puts a premium on individual autonomy, what is to be done when patients lose the capacity to decide on care?

For more than two decades, the answer has been to avoid ever getting to that point. Patients are encouraged to spell out in writing what kinds of life-sustaining care they would find acceptable. Living wills, also known as substantive or instructional advance directives, are intended to give patients prospective autonomy over decisions such as whether to be resuscitated, intubated or artificially hydrated.

But according to a growing body of research, there are serious shortcomings with this type of directive.

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The long-simmering concern about how physicians’ financial relationships with industry could compromise medical research and education has led two prominent academic medical centers to declare they will shine a light on these ties. But some doctors wonder whether access to this kind of information is something that matters to patients.

Physicians and biomedical researchers affiliated with the Cleveland Clinic and the University of Pennsylvania will have their industry ties publicly disclosed, the organizations announced in December 2008.

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Despite intense focus on improving care and keeping patients safe from harm, American health care quality is only about 2% better this decade than last, according to the U.S. Agency for Healthcare Research and Quality. That is just not good enough, say leaders of a major new initiative aimed at coordinating quality improvement and patient safety efforts among physicians, hospitals, accreditation and certification bodies, health plans, payers and patients.

The initiative is known as the National Priorities Partnership (www.nationalprioritiespartnership.org). It was launched in November by the National Quality Forum, a voluntary standards-setting body that convened 28 national organizations to work together to cut unnecessary care and improve quality and patient safety.

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For 10 years, Oregon stood alone as the state with a legal physician-assisted suicide process. But two other states now allow the practice.

Washington voters in November 2008 passed a ballot initiative legalizing aid in dying. Then in December 2008, Montana Judge Dorothy McCarter ruled that state homicide laws unconstitutionally restrict terminally ill patients’ right to dignified deaths.

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A federal appeals court ruling that upheld New Hampshire’s ban on commercial use of prescribing data could clear the way for other states to pursue legislation restricting drugmakers’ access to information they use to tailor marketing pitches to doctors.

The 1st U.S. Circuit Court of Appeals in November found that the 2006 New Hampshire law did not violate the First Amendment, overturning a lower court ruling. The court’s three-judge panel rejected the plaintiffs’ argument that the law prohibited free flow of information.

The judges said the law regulates conduct, not speech, and the state had presented evidence to show that prescribing data was used to fine-tune drug reps’ marketing pitches for higher-cost, brand-name drugs that were not always more efficacious.

“While the plaintiffs lip-synch the mantra of promoting the free flow of information, the lyrics do not fit the tune,” wrote U.S. Court of Appeals Judge Bruce M. Selya in his opinion.

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Doctors know there’s little clinical value in prescribing medications that won’t work. But that doesn’t keep patients from asking for them.

Mitchell Kahn, MD, knows this struggle. The Bellingham, Wash., internist prefers to talk patients through their problems and offer therapeutic reassurance. But the reality is that days are long, time is short and sometimes, he said, patient demands just wear you down.

Dr. Kahn is not alone. Patients who demand antibiotics for the common cold or ask their doctors to recommend vitamins are found frequently in physician exam rooms. They present doctors with an ethical dilemma: When all else fails, is it OK to harness the power of the placebo effect, and what should patients be told?

According to a British Medical Journal study, more than half of American physicians regularly recommend treatments aimed primarily at achieving a placebo effect.

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The lack of access to primary care doctors leads to worse health outcomes and higher costs, according to an American College of Physicians report released in November and aimed at influencing the shape of impending health system reform. As the population ages and demands on health services increase, Americans will find it more difficult to locate primary care physicians to help coordinate care in a fragmented system.

The 63-page ACP white paper reviews more than 100 studies from the last 20 years and concludes that the proportion of primary care doctors in a community is related to population health outcomes and system costs. The number of U.S. medical graduates entering residences in family medicine and internal medicine has dropped by half in the last decade as physicians pursue less time-squeezed and higher-paying specialties, the ACP report said.

The report comes amid signs from Capitol Hill that politicians are taking the work force shortage seriously.

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Orlando, Fla. — Most climate scientists say the Earth is getting hotter and that human activity is speeding up the process. At its Interim Meeting in November, the AMA House of Delegates agreed with the scientific consensus.

The house endorsed the findings of the United Nations’ Intergovernmental Panel on Climate Change. Delegates also warned that climate change could have dramatic public health consequences, causing heat waves, drought and flooding, cutting potable water supplies, displacing populations and spreading infectious diseases.

Policymakers should “work to reduce human contributions” to global warming, says the AMA’s new policy, which is based on a report from the Association’s Council on Science and Public Health.

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Orlando, Fla. — Nearly all hospitals have ethics committees to help resolve dilemmas facing physicians, patients and families, especially regarding end-of-life care. Yet surveys have found the typical ethics consultation service handles only three cases a year.

When should ethics services be consulted? Who should sit on ethics committees? Should they tell doctors and patients what to do, or just offer advice?

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Orlando, Fla. — Physicians who refer patients for services at facilities in which they have a financial interest should disclose the conflict to patients, according to ethical guidelines on physician self-referral adopted at the AMA Interim Meeting in November.

The new ethics policy goes beyond restrictions laid out in federal anti-kickback laws and regulations, and declares that physicians must put patients first when making referrals. In addition to disclosing self-referrals, doctors should assure patients that their ongoing care is not in jeopardy if they decide to refuse recommended referrals.

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Orlando, Fla. — A Joint Commission standard on disruptive behavior could lead to “arbitrary and capricious enforcement” against physicians, the AMA House of Delegates warned.

Delegates at the Interim Meeting directed the AMA to seek a one-year moratorium on the new standard, slated to take effect Jan. 1, 2009, to allow organized medical staffs time to change their bylaws to comply with the rule. The house also adopted policy advocating that medical staffs develop their own conduct codes and investigation and appeals procedures.

Delegates directed the AMA to update its 2000 policy on disruptive behavior and work with the commission, the Federation of State Medical Boards and other entities to develop an appeals process for physicians charged with bad behavior. The AMA also will work with these groups to “develop a definition of disruptive behavior by a physician to include the actions that would rise to the level of true abusive behavior.”

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Fourteen years after a slight majority of Oregon voters made their state the first to allow physician-assisted suicide, a Washington ballot initiative nearly identical to Oregon’s law was approved with 58% of the vote.

“It was a resounding win,” said Peg Sandeen, executive director of the Portland-based Death With Dignity National Center, whose political action committee raised more than $615,000 for the ballot fight. “That’s a trouncing any sort of politician would be glad to win anyplace.”

The group’s board plans to meet in November and December to analyze which state to target next.

“We really believe this is a people’s movement,” Sandeen said. “The legislatures are still afraid” of physician-assisted suicide. She predicted it will take two to three years to mount another state ballot drive. Planning for Washington’s physician-assisted suicide ballot measure, Initiative 1000, began in 2005.

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Three of the country’s top-10-selling drugmakers have pledged to publicly disclose their financial relationships with physicians. The move comes ahead of bipartisan congressional legislation, the Physician Payments Sunshine Act, that would mandate such reporting. The bill is widely expected to pass in some form next year.

Eli Lilly and Co. in September said by the second half of 2009 it would report payments to its physician speakers and advisers. By 2011, the Indianapolis-based drugmaker would publicly report all physician compensation that exceeds $500 a year, including food, entertainment, gifts, travel and continuing medical education, as specified in the Sunshine Act.

“Physicians perform some extremely valuable services for not only Lilly but for the entire pharmaceutical industry, and you hate to have that relationship diminished by questions of possible distrust about that relationship,” said Eli Lilly spokesman Ed Sagebiel.

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