Letters COMMENTS

AND

Annals of Internal Medicine RESPONSES

Guns, Suicide, and Homicide TO THE EDITOR: In Hemenway’s editorial (1), he correctly suggests that our systematic review and meta-analysis (2) “provides too conservative an estimate of the relationship among guns and suicide and homicide at a societal level” (1). Although we agree that our methods have probably underestimated the true relationship between guns and suicide or homicide victimization, our inclusion of only studies that assessed the individual’s personal firearm experience does provide an estimate of the minimum likely risk. The narrative around studies of firearm ownership and harms usually discredits causality assumptions, and causal inference is particularly problematic in ecologic studies. Critics are quick to point out conflicting “evidence” from various sources of rates and their interpretations. In fact, a commonly cited review of ecologic data by Kates and Mauser (3) only adds fodder to the ongoing debate. We purposefully excluded ecologic data, in part, to obviate this common critique regarding the interpretability of population-level data. Hemenway also correctly points out that most individuals commit suicide with a firearm from their own home, thus potentially justifying the use of aggregate population-level data to determine suicide outcomes. Unfortunately, this would probably not be enough to convince doubters that rate data can be used to assert correlations between firearm access and suicide. More important, we had 2 primary outcomes of interest in our review: suicide and homicide victimization. Although we can make a reasonable assumption that the firearms used in suicides were obtained from the home (albeit still an assumption that we wanted to avoid), we cannot reasonably make that same assumption about the firearms used in homicides. Hemenway even writes “most perpetrators [of homicides] do not use a gun from the victim’s home” (1). We feel that using different inclusion criteria for different outcomes would not have been prudent (that is, including ecologic data for suicide outcomes and not for homicide outcomes) because the focus of our review was access to firearms among cases, not among perpetrators, and the result focuses on the home. Moreover, our results may help households understand the risks of keeping a firearm in the home, particularly if there is a household member who is depressed or a violent relationship; results from ecologic studies may be better for evaluating policies. Notwithstanding our review, ecologic studies are a good source of data for establishing trends and positing relationships. We agree that a potential future methodological review could compare the summary estimates we obtained from individual-level data with those that would have been obtained if ecologic data been included. Operationally, of course, a reviewer would need to consider many issues: the rates of ownership to use (such as regional rates, state rates, or city rates), the time frame (that is, the most recent or most reliable data), and the types of suicide (for example, should only firearm-related suicides be included?). For these reasons, among others, ecologic data are seldom seen in meta-analyses of individual-level data. Assuming that the reviewer was able to overcome the operational obstacles of disparate rates over disparate regions describing dissimilar outcomes, he or she would have to ensure that the interpretation of the results from such a review are truly reflective of

aggregated population-level data and not of individual-level data. Of course, there are conceptual steps to calculate ecologic relative risk estimates so that conclusions about individual-level behavior can be inferred, although there are inherent assumptions (4). The reviewer could pool these new “individual-level” relative risk estimates to get a pooled rate from ecologic studies. To compare results from the meta-analysis of ecologic studies with those from the individual-level data we summarize, there are many approaches a reviewer could use. Namely, he or she could pool the results together to get a summary estimate from both ecologic and individual-level data, although combining estimates that were derived from different sources with different assumptions can be problematic. He or she could also perform a sensitivity analysis comparing the pooled estimates with and without ecologic data. Or he or she could perform a subgroup analysis comparing the pooled estimates from ecologic data with those from individual-level data separately. We feel that there are indeed benefits from reviewing ecologic data, and Hemenway’s suggestion for future research will complement our current review nicely. The 2 reviews together could provide a more nuanced understanding of the true relationship between access to firearms and harms outcomes. Andrew Anglemyer, PhD University of California, San Francisco San Francisco, California Disclosures: Authors have disclosed no conflicts of interest. Forms can

be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽L14-0158. References 1. Hemenway D. Guns, suicide, and homicide: individual-level versus population-level studies [Editorial]. Ann Intern Med. 2014;160:134-5. [PMID: 24592499]. 2. Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med. 2014;160:101-10. [PMID: 24592495] 3. Kates DB, Mauser G. Would banning firearms reduce murder and suicide? A review of international and some domestic evidence. Harv J Law Public Policy. 2007;30:64994. 4. Schuessler AA. Ecological inference. Proc Natl Acad Sci U S A. 1999;96:10578-81. [PMID: 10485866]

TO THE EDITOR: Because public health research predictably guides a

generation of public policy, it is necessary to scrutinize the political science underlying the paired systematic review (1) and editorial (2) on gun control. Challenges are detected to fundamental standards that may compromise an otherwise sound meta-analysis of available literature. The last sentences of each are revelatory. Anglemyer and colleagues’ review finds “restricting [access to a firearm in the home] may effectively prevent injury” (1), and Hemenway’s accompanying editorial concludes that “obtaining a firearm not only endangers those living in the home but also imposes substantial costs on the community” (2). Notwithstanding unaddressed Second Amendment constraints, the authors of both unabashedly campaign to restrict the right to bear arms, thereby ignoring, for example, the human compulsion to manifest reasonable self-defense. The intuitive deduction that the availability of a firearm will increase the risk that momentary depression will yield suicide is consistent with modern lay culture (recalling the 1945 movie Spell-

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Letters bound) and medical scholarship (recalling an essay published last year in Annals [3]). Yet, it is undermined by the editorialist, who has argued that the widespread ownership of firearms in private hands in the United States promotes the spread of the “disease” of gun violence (4). He invoked a generalized reference to his book when claiming, “There is no association between gun ownership levels and suicide by means other than guns. These studies have controlled for . . . depression [and] suicidal ideation.” If true, this assertion would undermine efforts to include scrutiny of mental health data during any mandated background checks; alas, it is untrue, because profiles of psychiatric patients at high risk for suicide have been generated (5). In Anglemyer and colleagues’ review, the study by Brent and colleagues was among the articles cited (reference 26), prompting confusion because it was among 3 articles cited in the online Appendix that purports to show “the disposition of studies excluded after full-text review” along with 2 others (references 32 and 60) “because the study populations were contained in previously published data included in this review” (1). Noting that there are 59 print references and 97 online references, merely counting the number of citations associated with a particular reason for exclusion yields the observation that there is an admixture of articles that were included and articles that were excluded (that is, some were among the references published in print and at least 1 was among those published online only). The authors should have provided a crosswalk pairing of how one set of data was subsuming another set of myriad peer-reviewed studies, precluding concern that any undue selectivity existed. Therefore, author bias—seeking the ability to generate the above preordained outcome— could have clouded how subsidiary observations were drawn regarding, for example, the allegation of enhanced risk for homicide by a household member. Adopting a purely academic approach could have yielded insights as to the type of mental health diagnoses that might predispose to criminal gun use. Indeed, this entire body of work could then have been compared/contrasted with fatal violence committed via nonhousehold unregistered firearms, yielding far more useful insights into which societal interventions might be optimal. Robert B. Sklaroff, MD Nazareth Hospital Philadelphia, Pennsylvania Disclosures: Authors have disclosed no conflicts of interest. Forms can

be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽L14-0159.

5. Brent DA, Perper JA, Moritz G, Baugher M, Schweers J, Roth C. Firearms and adolescent suicide. A community case-control study. Am J Dis Child. 1993;147:106671. [PMID: 8213677]

IN RESPONSE: I disagree with Dr. Sklaroff ’s statements concerning

my editorial. My concluding comment that “obtaining a firearm not only endangers those living in the home but also imposes substantial costs on the community” is a statement concerning my synthesis of the available scientific evidence. It is not a policy statement, and not an “unabashed campaign to restrict the right to bear arms.” Indeed, elsewhere I have suggested policies that could reduce firearm injuries in the United States while keeping nearly all of the recreational and self-defense benefits of firearms (1). Polls have found that the overwhelming majority of Americans and most gun owners are in favor of virtually all such policies (1). Dr. Sklaroff incorrectly claims that I argue that widespread ownership of firearms in private hands in the United States promotes the spread of the “disease” of gun violence. I am not a physician, and I did not use and do not believe I have ever used the metaphorical phrase “disease of gun violence.” Elsewhere, I have reviewed the scientific evidence on guns and homicide (2). All things equal, where there are higher levels of gun ownership and weaker gun laws, there are higher rates of homicide due to higher rates of gun homicide (3). I accurately summarized the evidence from population-based studies: “There is no association between gun ownership levels and suicide by means other than guns. These studies have controlled for such factors as . . . depression, suicidal ideation, and suicide attempts.” On the basis of that statement, Dr. Sklaroff commented that “If true, this assertion would undermine efforts to include scrutiny of mental health data during any mandated background checks.” In fact, I said nothing about the relationship between depression or suicide ideation or suicide attempts and suicide—I only said that they were used as control variables. Furthermore, even if no relationship were found between these control variables and suicide at the ecologic level, it would not mean that there is no relationship at the individual level—that is the ecologic fallacy. For example, if there were no variation in rates of depression across the United States, then depression could not be used as a factor to explain the variation in rates of suicide. But that would not mean that depression was not an individual risk factor for suicide. David Hemenway, PhD Harvard School of Public Health Boston, Massachusetts Disclosures: Authors have disclosed no conflicts of interest. Forms can

References 1. Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: a systematic review and meta-analysis. Ann Intern Med. 2014;160:101-10. [PMID: 24592495] 2. Hemenway D. Guns, suicide, and homicide: individual-level versus population-level studies [Editorial]. Ann Intern Med. 2014;160:134-5. [PMID: 24592499] 3. Fisher CE, Lieberman JA. Getting the facts straight about gun violence and mental illness: putting compassion before fear. Ann Intern Med. 2013;159:423-4. [PMID: 23836046] 4. Wheeler TJ. Book review: Private Guns, Private Health. The Freeman. September 2005.

be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽M13-2657.

References 1. Hemenway D. Private Guns, Public Health. Ann Arbor, MI: Univ Michigan Pr; 2006. 2. Hepburn LM, Hemenway D. Firearm availability and homicide: a review of the literature. Aggress Violent Behav. 2004;9:417-40. 3. Fleegler EW, Lee LK, Monuteaux MC, Hemenway D, Mannix R. Firearm legislation and firearm-related fatalities in the United States. JAMA Intern Med. 2013;173: 732-40. [PMID: 23467753]

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17 June 2014 Annals of Internal Medicine Volume 160 • Number 12 877

Letters Futility: Another Way? TO THE EDITOR: Having read Shah’s essay (1), I believe he might do

well to consider a different approach that has often worked well in my interactions with frantic family members. In a situation like the one he described, the physician needs to be clear that adding more interventions is not likely to change the outcome. The additional “treatment” might have changed how Ms. K. died, but it was unlikely to improve her odds (which were not 0% without the added treatment, just very small). The daughter was probably in her 20s or 30s and recently moved nearby with the expectation of becoming friends with her mother, who was suddenly dying. The daughter’s pain certainly needed to be addressed, but I would have recommended working with her to set out the plan for the most likely course—that her mother would die soon. If Ms. K. was able to communicate or at least hear, the daughter could have taken the chance to thank her for being her mother and to say some last words that mattered. She needed the opportunity to say prayers or just sit with her mother and hold her hand. She also needed help in planning for her mother’s death—whom to notify, what sort of memorial and burial to have, and so forth. Even if the daughter couldn’t do those things at the time, the physician’s acknowledgment of them has a remarkable way of making the situation real and approachable rather than something so frightening that the only response is to run. There will be time after her mother’s death, and she will get through it. Perhaps a friend, another family member, chaplain, or sympathetic mature volunteer could help. The daughter was begging for something magical to make the situation different from what it was; the physician probably didn’t help her in the long run by adopting a magician’s role and predictably failing to perform magic. The “treatment” described increased suffering and costs, and a better outcome could have been achieved. Joanne Lynn, MD, MA, MS Altarum Institute Washington, DC

spiritual and emotional support? Did any of the physicians involved receive practical training in addressing grief and bereavement or, for that matter, addressing acute severe emotional distress in a bereaved family? These questions reflect systematic deficiencies in the health care system and in our system of medical education. A long look in the mirror tells us that we have much to do. Steven M. Radwany, MD Summa Health System and Northeast Ohio Medical University Akron, Ohio Disclosures: Authors have disclosed no conflicts of interest. Forms can

be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽L14-0191. Reference 1. Shah SK. Futility. Ann Intern Med. 2014;160:138-9. [PMID: 24592501]

TO THE EDITOR: Shah’s case presentation (1) is an eloquent and poignant example many clinicians may identify with, at least in an analogous manner. Some clinicians might reject such care, on the basis of moral distress, as improper and unnecessary. Although details involve an extreme of surgical intervention at great cost, its specifics do not differ conceptually from a simpler situation, such as maintaining intravenous hydration in a terminally ill patient so that an out-of-state relative may visit. This is often considered and done. Palliative care is a team-based approach directed toward the care of both patient and family. Treatment of futility in this case provided that, albeit by extreme example. On the other hand, many palliative clinicians in this situation may have adopted a nonsurgical course as the sole option while remaining supportive of the family with compassionate resolve. Negating surgery only if it has a 0% chance of success with “absolute certainty” as a possible outcome, is an extreme standard not reasonably supported in our profession. The bereavement of relatives and their psychological closure, with either terminal surgery or intravenous hydration, involve individualized decisions. Thankfully, the art of medicine provides for that when science may have to be set aside.

Disclosures: Authors have disclosed no conflicts of interest. Forms can

be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽L14-0194.

Simon Kassabian, MD VA Hudson Valley Health Care System Montrose, New York

Reference 1. Shah SK. Futility. Ann Intern Med. 2014;160:138-9. [PMID: 24592501]

Disclosures: Authors have disclosed no conflicts of interest. Forms can

TO THE EDITOR: I was touched by Shah’s essay (1). It points to how

be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽L14-0193.

unprepared we are as physicians to address what is essentially an emotional crisis in response to an irreversible medical situation. My read of this story is that a daughter’s grief and sense of isolation were treated with repeated invasive surgical procedures. Please believe that I do not say this to criticize Shah. He was put in an untenable position as a surgical resident to try to address someone in severe emotional distress on first acquaintance, probably without the training or tools needed to help begin to relieve the daughter’s suffering. That we, as a health care system, put a surgical resident in this position at night while on call is sad but all too typical. I was left with many more questions than answers in the end. Was palliative care involved at any time before or after the transfer to the receiving hospital? Was pastoral care or a psychologist involved to provide

Reference 1. Shah SK. Futility. Ann Intern Med. 2014;160:138-9. [PMID: 24592501]

TO THE EDITOR: Shah’s story on futility (1) misleads readers to believe that surrendering to an unreasonable request made by the daughter of a dying patient, under the guise of “giving hope,” is acceptable. He seemed to forget whose physician he was, subjecting a terminally ill patient to extensive surgery, bowel resection, and open abdomen only to have her die a few days later. Shah’s responsibility should have been to help his dying patient and not a family member in desperate need of support that he apparently could not provide. It is also painfully surprising to see that the person communicating

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Letters these complex and difficult decisions with the family was a surgical resident and not an experienced medical or surgical attending physician who could have assisted this desperate daughter toward the appropriate decision for her ailing mother. End-of-life discussions have been the Achilles’ heel of health care in the United States (2). Physicians are not properly trained to handle them; they are discomforting and not good for marketing or for the pocket. Because of this, a practicing physician frequently hides behind terms like “giving hope,” “miracles happen,” and “everybody has a chance” or overestimates prognosis (3) and proceeds with painful, invasive, and expensive treatments. Shah should have called together his favorite palliative care physician and a spiritual member of the hospital to discuss the treatment plan for this patient. The reality is that this decision made Shah feel better about himself while his patient suffered more. The cost was shared among all who pay for health care in the United States, another unfair consequence of such decisions continuously made in our hospitals. I agree that we are pressured by illusions of cure created by our beliefs, the media, and a lack of knowledge, but physicians, who are aware of the futility of these fallacies, should lead this war and not surrender. Keyvan Ravakhah, MD, MBA St. Vincent Charity Center Cleveland, Ohio Disclosures: Authors have disclosed no conflicts of interest. Forms can

be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽L14-0191.

IN RESPONSE: Thanks to Dr. Lynn and Dr. Radwany, who wrote to

offer practical suggestions for the future or to simply share their experiences. I agree wholeheartedly with Dr. Kassabian’s point that a 0% success or survivability rate is not a reasonable criterion that can be endorsed by physicians. It is important to note, however, that this criterion is used by patients and families on occasion, and I have seen it become the source of much conflict between the patient and treating physicians. The corollary issue of uncertainty in medicine, specifically in prognostication, is an important one that is beyond the scope of my comments. Most important, Dr. Ravakhah’s accusation that the surgical team abandoned its responsibility to the patient and the like is typical of the strong emotions that surround end-of-life discussions. Dr. Ravakhah assumed that the surgical resident was the only physician to communicate with the daughter. In fact, in teaching hospitals, residents are typically the first to respond to a situation, but critical decisions occur only with the approval of attending physicians. In this case, the general surgery and cardiac surgery staff both independently discussed the situation with the daughter. Regretably, Dr Ravakhah completely misunderstands the point of the story by writing that it was a defense of surrendering to “an unreasonable request made by the daughter of a dying patient,” and that the treatment decisions made me feel better. This was a situation that was deeply saddening and unsettling to me and to senior surgeons. His solution—to call my “favorite palliative physician”—seems too simplistic for such a complex, nuanced problem. Many physicians know about and have access to palliative care, yet versions of my story occur daily across the United States. There is something deeper and more difficult going on here.

References 1. Shah SK. Futility. Ann Intern Med. 2014;160:138-9. [PMID: 24592501] 2. Clayton JM, Butow PN, Arnold RM, Tattersall MH. Discussing life expectancy with terminally ill cancer patients and their carers: a qualitative study. Support Care Cancer. 2005;13:733-42. [PMID: 15761699] 3. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ. 2000;320:469-72. [PMID: 10678857]

Samir K. Shah, MD Cleveland Clinic Cleveland, Ohio Disclosures: Authors have disclosed no conflicts of interest. Forms can

be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms .do?msNum⫽L14-0190.

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17 June 2014 Annals of Internal Medicine Volume 160 • Number 12 879

Futility: another way?--in response.

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