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Press releases Saturday 24 February 2007

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(1) Using morphine to hasten death is a myth, says doctor
(2) Insulating houses improves health and wellbeing
(3) Risk of birth complications varies between racial groups
(4) Study sheds light on risks of being a second twin

(1) Using morphine to hasten death is a myth, says doctor
(Letter: Double effect is a myth leading a double life)
http://www.bmj.com/cgi/content/full/334/7590/413

Using morphine to end a person±s life is a myth, argues a senior doctor in a letter to this week±s BMJ.

It follows the case of Kelly Taylor, a terminally ill woman who went to court earlier this month for the right to be sedated into unconsciousness by morphine, even though it will hasten her death.

Mrs Taylor±s request to use morphine to make her unconscious under the principle of double effect is a puzzling choice, writes Claud Regnard, a consultant in palliative care medicine. The principle of double effect allows a doctor to administer treatment that hastens death, providing the intention is to relieve pain rather than to kill.

Evidence over the past 20 years has repeatedly shown that, used correctly, morphine is well tolerated and does not shorten life or hasten death, he explains. Its sedative effects wear off quickly (making it useless if you want to stay unconscious), toxic doses can cause distressing agitation (which is why such doses are never used in palliative care), and it has a wide therapeutic range (making death unlikely).

The Dutch know this and hardly ever use morphine for euthanasia, he writes.

Palliative care specialists are not faced with the dilemma of controlling severe pain at the risk of killing the patient - they manage pain with drugs and doses adjusted to each individual patient, while at the same time helping fear, depression and spiritual distress, he adds.

And he warns that doctors who act precipitously with high, often intravenous, doses of opioids are being misled into bad practice by the continuing promotion of double effect as a real and essential phenomenon in end of life care.

Using double effect as a justification for patient assisted suicide and euthanasia is not tenable in evidence-based medicine, he says. In end of life care, double effect is a myth leading a double life.

Contacts:
Claud Regnard, Consultant in Palliative Care Medicine, St Oswald±s Hospice, Newcastle upon Tyne, UK
Email: claudregnard@stoswaldsuk.org

(2) Insulating houses improves health and wellbeing
(Effect of insulating existing houses on health inequality: cluster, randomised study in the community)
http://www.bmj.com/cgi/content/full/334/7590/398
(Editorial: Housing and health)
http://www.bmj.com/cgi/content/full/334/7590/399

Insulating houses can significantly improve health and reduce days off work and school, according to a new study in this week's BMJ. The state of housing has a real impact on health; cold houses place more physiological stress on people, and are more likely to be damp - leading to respiratory problems. Despite the fact we spend about three-quarters of our lives inside, little is known about the specific health effects of the indoor environment. So researchers at the University of Otago in Wellington, New Zealand, identified 1350 uninsulated households, all from low-income communities. The properties were split into two groups. The first did not have insulation installed, whilst properties in the second group were fitted with a standard insulation package, which included ceiling insulation and draught stopping around doors and windows. The researchers then used interviews, questionnaires, occupants± self-reported experience, energy usage, house temperature and other environmental characteristics to measure the effects. Insulation led to a significant increase in indoor temperature and a drop in relative humidity. People in the insulated properties reported that their houses felt significantly less damp and mouldy, were less likely to suffer from wheezing or colds, and spent less on heating their houses. Adults and children in insulated houses were half as likely to take days off work or school than those in houses without insulation. The authors conclude that ±interventions of this kind which focus on low-income communities and poorer quality housing have the potential to reduce health inequalities. Retrofitting insulation is a cost-effective intervention for improving health and well-being.± This new trial emphasises the benefits of investing in housing, which are not limited to health, say researchers in an accompanying editorial. This evidence, and emerging evidence from other housing studies, should inform policies linking housing investment to impacts on health, they conclude.

Contacts:
Paper: Philippa Howden-Chapman, Director Housing and Health Research Programme, University of Otago, Wellington, New Zealand
Email: howdenc@wnmeds.ac.nz

Editorial: Hilary Thomson, Senior Scientific Officer, MRC Social and Public Health Sciences Unit, Glasgow, Scotland, via Medical Research Council Press Office
Email: press.office@headoffice.mrc.ac.uk

Babies born to South Asian women are at a higher risk of perinatal mortality (death before, during or shortly after birth) than babies born to black or white women, concludes a study published online by the BMJ today.

The World Health Organization defines post-term pregnancy as beyond 41 completed weeks from the first day of the last menstrual period. Post-term pregnancy is associated with increased perinatal mortality, and induction of labour at 41 weeks is often used to help avoid this risk.

However, evidence shows that the average length of gestation varies between racial groups. For example, it is shorter in South Asian and black women, suggesting that complications may occur before the 41 week induction point in these women.

Researchers from London and Bristol tested this theory by studying whether the risks of post-term birth complications increased earlier during pregnancy in South Asian and black women compared with white women.

Their study involved over 197,000 white, South Asian and black women who were expecting their first child and who delivered a single baby weighing at least 500 grams at 24 to 43 weeks.

They found that the perinatal mortality patterns differed significantly with racial group. At every stage of gestation, perinatal mortality was highest in South Asian women, and from term onwards, the upswing in risk occurred earliest and steepest in South Asian women, then black women, followed by white women.

The authors say their findings indicate that there are genetic variations in gestational length and argue that increased foetal surveillance and growth monitoring from 40, rather than 41, weeks± gestation is needed for South Asian and black women.

Contact:
Imelda Balchin, Clinical Research Fellow, Academic Department of Obstetrics and Gynaecology, Imperial College Faculty of Medicine, Chelsea and Westminster Hospital, London, UK
Email: balchin@doctors.org.uk

(4) Study sheds light on risks of being a second twin
(Birth order of twins and risk of perinatal death related to delivery in England, Northern Ireland and Wales, 1994 ± 2003: retrospective cohort)
http://www.bmj.com/onlinefirst_date.dtl

For twins born preterm (before 36 weeks), there was no difference in overall death rates between the first and second. This is because the background rate of death is already high for both, due to the effects of prematurity.

However, the researchers found that second twins born at or after the full term of pregnancy (36 weeks and over) were twice as likely to die during labour or shortly after birth. This excess risk appeared to be due to complications arising from the birth process.

Vaginal delivery of the second twin is widely accepted as a time of high risk, but previous research into the impact of birth order on twin morbidity has produced an array of inconsistent findings. A number of studies have suggested that second born twins have significantly elevated levels of mortality compared to their elder siblings, while other surveys have concluded that birth order has no discernable impact on either twin±s chance of survival.

In order to clarify this important area, British researchers conducted an analysis of all twin pregnancies with one death during or shortly after the delivery stage in England, Northern Ireland and Wales between 1994 and 2003.

Data were obtained from a combination of official sources that have recorded twin deaths since the early 1990s, including the Confidential Enquiry into Maternal and Child Health (CEMACH), the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) and Office for National Statistics (ONS). To prevent any distortion of the analysis, each case was screened to remove instances where the fatality was caused by factors not related directly to the delivery process, including where the twin suffered from an inherent abnormality or when therapeutic abortions were performed.

In total, 1377 twin pregnancies were highlighted as meeting these strict criteria and all were analysed to identify the association between birth order and the risk of death. Additional factors were also analysed to assess whether they influenced the relationship between birth order and the risk of death, such as the length of gestation, different methods of delivery and the mother±s age and ethnicity.

The results of this study showed that there was no association between birth order and the overall risk of death among preterm twins. The mother±s age and ethnic group also had no discernable impact on twin mortality.

However, the analysis demonstrated that second twins born at term had a greater than twofold chance of death during or shortly after the delivery phase as a result of complications caused by the birth process. Moreover, the excess risk to the second twin at term was lower if a caesarean section was performed.

The authors caution though that further research needs to be conducted to prove conclusively that caesareans provide a protective effect for second born twins born at term.

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