Annals of Internal Medicine is published by the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), an organization of more than 115,000 physicians trained in internal medicine. The following highlights are not intended to substitute for articles as sources of information. For an embargoed fax of an article, call 1-800-523-1546, ext. 2656 or 215-351-2656. Full content of the March 7, 2000, Annals issue will be available on the Internet at www.acponline.org on March 7, 2000.
Dizziness in the Elderly Has Many Causes, But Is it a Geriatric Syndrome?
An epidemiologic study of a large number of elderly people living in the community found that 24 percent had episodes of dizziness that recurred for at least one month and that seven factors, such as anxiety, depression, impaired balance, and taking five or more medications, were associated with the dizziness (Article, p. 337). The authors suggest that, since dizziness is such a common condition with multifactorial causes, it might be considered a "geriatric syndrome," as are falling, delirium and urinary incontinence. An editorial says that the article rightly calls attention to the many possible of causes of dizziness but cautions against the conclusion that dizziness is "just another undiagnosable, untreatable" sign of old age (Editorial, p. 403).
Last Resort at End of Life: Terminal Sedation, Refusal of Food and Fluids
Some Antihistamines Impair Driving as Much as Alcohol
A study comparing the effects of a first- and a second-generation antihistamine, a dose of alcohol and a placebo on driving performance in a driving simulator found that people who took the first-generation antihistamine had the worst driving performance, followed by those who had the alcoholic drink (Article, p. 354). Those who took the second-generation antihistamine and those taking a dummy pill had similar, good performance. An editorial points out the difficulties of assessing actual driving performance using experimental settings and mentions conflicting evidence about the causes of real-life traffic accidents (Editorial, p. 406).
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CONTACT: Susan Anderson, 215-351-2653 or 800-523-1546, ext. 2653
Terminal Sedation and Refusal of Food and Fluids at End of LifeLast-Resort Responses to Intolerable Suffering
Despite excellent care at the end of life, a few patients still experience extreme and intolerable suffering. A new paper by the End-of-Life Care Consensus Panel of the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) explores two options that physicians and patients sometimes consider in these exceptional cases: terminal sedation and voluntary refusal of food and fluids.
The paper defines the practices, distinguishes them from standard palliative care and from physician-assisted suicide, gives guidance on the conditions under which they can be considered, and shows how to make decisions in these cases. It explores the moral and legal status of the practices and stresses the requirement that the suffering cannot be relieved by other means.
The paper concludes that "terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options. Patients and their families who fear that physicians will not respond to extreme suffering will be reassured when such options are predictably made available."
The paper was written by Timothy E. Quill, MD, associate chief of medicine at Genesee Hospital in Rochester, N.Y., and Ira R. Byock, MD, director of the Palliative Care Service in Missoula, Mont. for the ACP-ASIM End-of-Life Care Consensus Panel. ACP-ASIM convened this panel of experts on end-of-life care in 1997 to develop ethical, policy and clinical recommendations that, if adopted, will lead to demonstrably better care at the end of life. The papers provide guidance to physicians caring for dying patients and are also useful for patients and families. To date, four other papers have been published and are available on the ACP-ASIM Web site -- www.acponline.org/ethics/papers.htm
NOTE TO EDITORS: For copies of the paper, "Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids," please call Penny Fuller at 1-215-351-2656 or 1-800-523-1546, ext. 2656. For an interview with Dr. Byock, please call Susan Anderson at 1-215-351-2653 or 1-800-523-1546, ext. 2653.