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(1) Cancer patients are not given enough information (2) Working time regulations are failing doctors and patients (3) The travel industry should inform travellers about malaria, say doctors (4) Doctors must be held accountable for complying with torture
(1) Cancer patients are not given enough information (What oncologists tell patients about survival benefits of palliative chemotherapy and implications for informed consent: qualitative study) http://www.bmj.com/cgi/content/abstract/337/jul31_3/a752 (Editorial: Informed consent and palliative chemotherapy) http://www.bmj.com/cgi/content/extract/337/jul31_3/a868
Two thirds of cancer patients receive little or no information about the survival benefits of having palliative chemotherapy before making a decision about treatment, according to a study published today on bmj.com.
Palliative chemotherapy for patients with advanced cancer has modest survival benefits and there is an expectation in the UK that such patients should be given accurate information so they can give informed consent before starting chemotherapy.
At the advanced stages of cancer, survival gain from palliative chemotherapy treatment tends to be months rather than years.
A study by researchers from the University of Bristol, however, found that in more than two thirds of cases, patients were not given information about the survival benefits of such treatment.
The study, which was funded by Cancer Research UK, was carried out at a large teaching hospital and a district general hospital in the south west of England where 37 patients' cases were considered.
Consultations with oncologists were digitally recorded with each patient, all of whom had advanced forms of cancer. Three common cancers were chosen - colorectal, non-small cell lung, and pancreatic cancer.
The researchers used data from a study of patients' of experiences treatments (ASPECTS) to examine the extent to which survival gain was discussed when patients were offered palliative chemotherapy.
A researcher interviewed each patient before they saw the oncologist, recorded the consultation with the health professional, and then interviewed the patient again within weeks.
During the consultations, there was consistency in informing patients that a cure was not being sought for them, but the amount of information about survival benefit varied considerably.
Information given to patients about survival benefit included: numerical data ("about four weeks"); an idea of timescales ("a few months extra"); vague references ("buy you some time"); or no mention at all.
Only six patients out of 37 were given numerical data about the survival benefits of treatment.
For the majority of consultations observed (26 out of 37), discussion of survival benefit with patients was vague or it was not mentioned at all.
The researchers say there are concerns that the "intrusiveness of unfavourable numbers", in terms of months left to live, can undermine healthcare relationships and destroy hope.
They say: "Giving comprehensible and appropriate information about survival benefit is extremely difficult. In addition, the reluctance to inform patients of the limited survival gain of palliative chemotherapy may be motivated by a desire to 'protect' patients from bad news.
"However, the reluctance to address these difficulties and sensitivities may be hampering patients' ability to make informed decisions about their future treatment."
The researchers say oncologists and cancer teams have to communicate sufficient information to enable patients to make informed decisions based on realistic aspirations, but to do so in a sensitive manner and at the patient's pace.
They also recommend that oncologists receive training in how to communicate relevant information on survival benefits to their patients.
National updated information is needed about the prognosis of advanced cancer and the benefits of palliative chemotherapy as well as decision aids to help patients interpret information, say Daniel Munday and Jane Maher in an accompanying editorial.
Contacts: Jane M Blazeby, Department of Social Medicine, University of Bristol, Bristol, UK Email: j.m.blazeby@bris.ac.uk Jane Maher via Anna Brosnan, Press Office, Macmillan Cancer Support, London, UK Email: abrosnan@macmillan.org.uk
(2) Working time regulations are failing doctors and patients (Editorial: Outcomes of the European Working Time Directive) http://www.bmj.com/cgi/content/extract/337/jul31_3/a942
Recent changes to working regulations in the UK are seriously damaging the working life and education of junior doctors and patients are also suffering, warn senior doctors on BMJ.com today.
The British government must relax the regulations of the European Working Time Directive (EWTD) or it could spell disaster for medicine in the UK, say the authors.
"British medicine is highly respected worldwide because of the training provided and the breadth of experience and clinical expertise of most consultants and GPs", write Hugh Cairns and colleagues from King's College Hospital in London. But the EWTD is threatening this reputation by having a negative effect on medical training and taking doctors away from direct patient care. No amount of teaching can substitute for this practical experience, they add.
Introduced to improve workers' safety and protection, the directive changed the maximum working week to 56 hours in 2007, with a planned further reduction to 48 hours in 2009, and a minimum requirement of 11 hours rest in any 24 hour period.
According to the authors, these changes have posed considerable problems for medicine in the UK because of the need for junior medical staff to work long hours to fulfil training requirements and to provide a 24 hour service to patients.
They point out that the EWTD has dramatically changed working patterns in hospitals. Junior doctors are spending an increasing amount of their time "handing over" to incoming staff, reducing the time available to provide patient care. In addition, they say, a large part of junior doctors' working weeks are spent on solitary out-of-hours shifts with "little or no training value", which will only get worse with the introduction of a 48 hour week.
Furthermore, they say, many specialities are having to share junior staff because of insufficient numbers of juniors to provide a legal "rota", resulting in poorer continuity of care, and many patients receiving almost no routine care at night and at weekends.
The directive "is not achieving any of its presumed aims for junior medical staff - quality of life has not improved, training has deteriorated, and, for most patients, medical care is not safer", claim the authors.
They propose that the government abandon the further reduction of the working week from 56 to 48 hours and call for the minimum daily rest to be changed from 11 to eight hours. At the very least, they conclude, hospitals and medical staff should be exempt from the 48 hour limit.
Contact: Hugh Cairns, Consultant Nephrologist, Renal Administration, King’s College Hospital, London, UK Email: hugh.cairns@kch.nhs.uk
(3) The travel industry should inform travellers about malaria, say doctors (Letter: Travel industry should highlight malaria prophylaxis) http://www.bmj.com/cgi/content/full/337/jul31_3/a1027
Tour operators and airlines are wasting an ideal opportunity to warn travellers about the risk of contracting malaria in specific countries, say infectious disease experts on BMJ.com today.
The authors reviewed 27 travel brochures from British tour companies and found that only 12 contained any information about malaria, yet they all featured holidays to African countries where the disease is endemic.
Tour operators are really missing a trick here, say the authors, as this would be an ideal place to target travellers about malaria and the need to take preventative medication.
The authors call on the Association of British Travel Agents (ABTA) and the International Air Transport Association (IATA) to provide guidance on malaria.
Currently IATA advises member airlines on how to disinfect aircraft to remove insects, but offers no health advice to travellers. This means that people travelling independently to visit relatives in countries that have malaria may not receive any information about this potentially life-threatening disease.
"We believe that the travel industry has an obligation to improve the quantity and quality of the malaria advice it provides …. [and] for independent travellers, malaria advice should be provided by the airline, for example on the ticket itself."
Contact: Edward Green, Royal Hallamshire Hospital, Sheffield, UK Email: edward.green@sth.nhs.uk
(4) Doctors must be held accountable for complying with torture (Editorial: Doctors' complicity with torture violates civil society and the ethics of medicine) http://www.bmj.com/cgi/content/extract/337/jul31_3/a1088
Doctors who assist in torture or other forms of cruel, inhuman or degrading treatment should face prosecution and licensing punishments, says an editorial on BMJ.com today.
Steven Miles from the Center for Bioethics at the University of Minnesota, says that more doctors are involved in torturing prisoners than in treating torture survivors. But doctors who assist in torture rarely face professional consequences. He argues that the medical profession must not only dissociate itself from torture but actively investigate and sanction offenders.
More than 100 countries condone the use of torture and up to half of torture survivors report that a doctor was present and oversaw the abuse.
Miles points out that while medical societies are quick to condemn doctors participating in torture abroad, they are not so vocal when it comes to what is taking place in their own country.
In addition, while medical societies support ethical codes that ban doctors from assisting in torture, such as the World Medical Association's Declaration of Tokyo, in practice their policy is to do little, and doctors typically remain exempt from punishment, he writes.
Miles believes that national medical councils and licensing agencies should ensure that doctors who comply with torture can be punished for breaching medical ethics. This has happened in some countries after the torturing regimes have lost power. For example, the Chilean Medical Society expelled six doctors for overseeing torture during Pinochet's rule, and in South Africa two doctors were punished for failing to report or treat Steven Biko for a fatal head injury inflicted by police. But such examples are rare.
Miles calls for all medical societies to state that abetting torture is a punishable breach of professional conduct for which there are no term limits. Such codes would lay the foundation for holding doctors accountable for torture after a torturing regime loses power, he says.
"Governments that practice torture need doctors. The medical accomplices of torture must not rest in the confidence that they can violate civil society and the ethics of medicine with impunity", he concludes.
Contact: Steven Miles, Professor of Medicine, Center for Bioethics, Department of Medicine, University of Minnesota, Minnesota, USA Email: miles001@umn.edu
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