682
Ethical emergencies and ethical consultations SiR,—You identify the need for a way of dealing with ethical emergencies arising in connection with innovative therapy of terminally ill patients (Feb 15, p 349). This is part of a wider issue in clinical practice resulting from striking technical advances, a greater
patient autonomy and public awareness, and a readiness to resort to litigation. In North America some centres have establishedl-3 24-hour ethics consultation services to resolve difficulties for individual patients and to identify areas of worry and dispute during clinical management. The help of trainedprofessional ethicists can be requested by members of the clinical team, or by patients or their representatives. Because no one individual can have all the necessary ethics and clinical skills knowledge, the ethicist is backed by an interdisciplinary ethics committee. The four commonest reasons for initiating ethics consultation are incapacitated patients with no close relatives to give consent for clinical procedures, ethical conflict amongst clinicians, ethical conflict between clinicians and patients, and unusual and complex cases. US clinicians, after initial reserve, are said to be supportive, and it is claimed that disputatious and possibly litigious situations can be resolved with least harm to all concerned if difficulties can be discussed openly, explanations given, and tempers cooled (which is similar to advice given in Britain by medical defence organisations). Apart from in vitro fertilisation, this arrangement has no formal counterpart in Britain. Local research ethics committees do not have responsibility to arbitrate about issues arising during routine clinical practice,5,6 and the training, skills, and responsibilities of consultants have allowed ethical issues to be dealt with as they arise. But are the changes in medical practice, the new ethical issues raised by medical genetics,’ and the greatly increased public awareness so profound as to require new arrangements? You are correct to suggest the need for more discussion. Department of Medical Genetics, St Mary’s Hospital, Manchester M13 0JH, UK
RODNEY HARRIS
1. Pence GF. Classical cases m medical ethics. New York: McGraw-Hill, 1990. 2. Culver CM. Ethics at the bedside. Dartmouth: New England Press, 1990. 3. Fletcher JC, ed. Introduction to clinical ethics and health care law legal commentaries, by Margot L. White. Charlottesville, VA. Ibis Publishing Company, 1991. 4. Schiedermayer JL. Ethics consultation: skills, roles, and training. Ann Int Med 1991; 114: 115-60. 5. Guidelines on the practice of ethics committes m medical research involving human subjects: a report of the Royal College of Physicians, 2nd ed. London: RCP,
January, 1990. Department of Health. Local research ethics committee. Health Service Guidelines: HSG(91)5. Heywood (Lancashire) Department of Health, 1991. 7. Ethical issues in clinical genetics: a report of a working group of the Royal College of Physicians Committees on Ethical Issues m Medicine and Clinical Genetics. 6.
London: RCP, 1991.
SIR,-As the consultant who made the decision to administer methylene blue, as referred to in your editorial of Feb 15,should like to make some comments. Few would take issue with your statement that a one-off trial of an innovative therapy in a critically ill patient is no substitute for a planned study. Nevertheless, in the intensive care unit setting new therapeutic approaches are continually being introduced, often in a situation where formal clinical study may not be feasible. Provided that the effects of such treatments are closely monitored, as should be the case in intensive care units, I believe that well recorded observations are valuable and worthy of reporting. They may in turn lead to the introduction of these new treatments on a regular basis, examples being the introduction of the newer techniques of renal replacement therapy and the re-introduction of noradrenaline for controlled vasoconstrictor therapy in septic shock. The issue of informed consent in the context of sedated or unconscious patients in intensive care is difficult. Your qualms about the validity of consent received from despairing relatives certainly strike a chord, and you are clearly floating the idea of an emergency ethics opinion mechanism. However, clinical research ethics committees seem unwilling to accept responsibility for
care patients’ participation in clinical research. In general they require intensive care clinicians to seek consent from relatives
intensive
who may be in distress, even when the research involves little from standard practice. Furthermore, they usually demand written consent which may be more stressful for relatives than a clear explanation and oral consent in front of a witness. The written information sheet required is also of doubtful value when shown to a distressed relative. I am therefore very uncertain whether an emergency ethics committee consultation would help. I do not think, however, that one should be too negative about the validity of consent obtained from relatives of the critically ill. In the intensive care unit it is essential that all clinical management decisions are discussed fully with patients’ relatives. With continuing dialogue a close rapport can be developed, and most relatives are able to appreciate and understand what we are trying to do and give meaningful consent for special therapy, procedures, clinical research, or indeed organ donation.
departure
Intensive Therapy Unit, Western General Hospital,
Edinburgh EH4 2XU, UK
IAN S. GRANT
Ethics and clinical research in anaesthesia SiR,—Your Feb 8 editorial made several useful points. I was, however, concerned by the third paragraph, in which you imply that research in clinical anaesthesia does not (and presumably cannot) offer therapeutic benefit to the patient, and that other doctors may judge anaesthesia research of minor importance. Do you really believe that the change from ether to propofol-with the ability to have day-case surgery under anaesthesia--or the
introduction of dantrolene for malignant hyperpyrexia offer no benefit to the patient? With respect to your second point, of course other specialties may not see the need for some anaesthetic research; I do not see the need for some of theirs, but I tend to assume that this is a lack of understanding on my part about a project agreed by their local ethical and scientific committees. If other specialties do still consider anaesthesia an unimportant branch of medicine, I feel sure that most of their patients do not. Department of Anaesthetics, Royal Postgraduate Medical School, Hammersmith Hospital, London W12 0NN, UK
D. N. F. HARRIS
Insurance and HIV antibody testing SiR,—A recent report’ showed that 67% of AIDS specialists rated difficulty in getting life insurance as a major disadvantage for individuals who undergo HIV antibody testing. Furthermore, 88% of specialists felt that this discouraged people from being tested. By contrast, only 3 of 1400 adults interviewed believed that this would be a deterrent to HIV antibody testing. Thus, there is an important discrepancy between the views of health professionals and those of potential candidates for HIV tests. Counselling texts have included statements such as "in some cases even a negative result can lead to insurance companies asking further questions; whether this will influence the terms of insurance cover is likely to depend on the insurance company and how satisfied they are with the answers they receive".2 Life insurance might be withheld or higher premiums charged for people who have had a negative HIV antibody test,3 To clarify this issue we approached the Association of British Insurers (ABI) who agreed to produce a poster and leaflet outlining their guidelines for people undergoing HIV antibody testing. The leaflet says, "People should be reassured that if they have an HIV antibody test and the result is negative they will face no difficulty in obtaining future life insurance because of having the test. Existing life insurance policies will not be affected whatever the test result". It also set out the questions about HIV and AIDS that are asked on the proposal forms. Between July and November, 1991, we assessed the effects of the availability of this information on patients considering HIV testing in our clinics. These patients are seen by a health adviser, who administers a simple questionnaire to assess the effects of the posters and leaflets on the patients’ likelihood of
undergoing a test.
683
520 patients were evaluated. Of these, 315 (61 %) said that they had seen a poster or leaflet in the waiting room. Of this sample, 37% of men and 46% of women felt that the information from the ABI had increased their likelihood of having an HIV antibody test; no women and only 7% of men stated that the leaflet had decreased their likelihood of undergoing a test. 144 (28 % ) of all patients stated that they intended to have an HIV antibody test but would not divulge the result to any insurance company during an application. 17% of patients stated that they were attending the genitourinary clinic because they did not wish their general practitioner (GP) to know that they were having a test, or of its result. A further 42 (8%) patients specifically stated that their GP had helped in their decision to be tested, and that insurance was a part of this decision. Our findings indicate that direct communication from the insurance industry is of benefit to both counsellors and patients. The provision of clear facts about this issue has improved the confidence of clinic staff about the advice that they were giving to patients. Nevertheless, over a quarter of patients surveyed were still likely to lie about ever having had a test when they apply for life insurance.’Whether or not this was because of confusion about the questions on proposal forms, as Bor et al4 indicated, or for some other reason was not examined in this study. We were encouraged by the GP advice in 8% of patients for testing to be done at a genitourinary clinic, because trained staff can then provide pretest counselling, the patient can be educated about sexually transmitted diseases, and sexual health can be promoted, as well as offering opportunity for a check up for sexually transmitted diseases. However, we believe that the issue of life insurance is confusing and recommend that the ABI should ensure that GPs receive accurate information and leaflets to display in their surgeries. We hope that the clarification of this contentious issue will reduce the amount of time and importance that counsellors need to allocate to life insurance issues. Departments of HIV and St Stephen’s Clinic, London SW10 9TH, UK 1
Genitourinary Medicine,
NICK HULME SUZANNE SMITH SIMON E. BARTON
Department of Health. AIDS and life insurance. London: HM Stationery Office,
bronchial provocation tests (with aspirin, for example), she was not challenged with the specific chemical that had affected her. Since her exposure she has been totally unable to earn a living. There was no suggestion that the legal action she took was frivolous. The defence case included a draft Royal College of Physicians’ report. The Royal College’s solicitors, Field Fisher Waterhouse, stated in a letter: "The College is very concerned about your proposed use of the report of the Royal College of Physicians of London Committee on Clinical Immunology and Allergy called ’Allergy-Conventional and Alternative Concepts’. The report is still only in draft form and should not be relied upon in submissions. There is still some considerable amount of editorial work to be done on the draft report and discussion of its contents continues." It was requested that references to the draft report be dealt with in camera. The report was therefore not in the public domain before the court case and there was no way in which the plaintiff’s solicitors could obtain advice about it in advance because it was only submitted the weekend before the hearing. As a witness for the plaintiff I was not on trial-yet that may be the impression left by the report in The Lancet. Doctors can do little to combat derogatory remarks made about them by judges but by repeating them, the media can put a doctor on trial without all salient facts of the case being known. Breakspear Hospital.
Methotrexate tablet confusion SIR,-When I prescribed methotrexate for psoriasis in one of my patients I specified, as is my habit, the number of 2-5mg tablets to be taken each week, together with the total dose. By chance I bumped into the patient after his prescription had been dispensed; the pharmacist had told him that the tablets were two shades of yellow because they came from different batches. The tablets were indeed two shades of yellow and some were marked 2-5 and some marked 10. They were otherwise of identical size and shape. In the UK methotrexate tablets and in two strengths:
SiR.—The Medicine and Law item in your issue of Feb
1 its
by a
barrister, Diana Brahams. The firm of Brahams Killen Mark Eisenthal, of which her husband is a partner, act as solicitors for Healthwatch, and Mr and Mrs Brahams are members of its committee. In the court hearing referred to, an expert witness for the defence (I was an expert for the plaintiff) was a member of Healthwatch and sitting in court throughout the proceedings was Caroline Richmond, a founder member of Health watch. It is rare for an expert witness to be attacked in the way in which I was in this case, and it would be important for a just assessment to know some of the facts about the patient. She was affected by a chemical spill in the van that she was driving in 1984. Her employers offered compensation. There was no trade union for the fmn’s employees. The plaintiff did not see me until one year after the exposure. During that year she had seen her doctor almost every week complaining of headaches and eye symptoms, general malaise, fatigue, and joint symptoms. Before the exposure her complaints had been sporadic though she had had some headaches, especially when she had been involved in a divorce. My opinion of her having become chemically sensitised could not have anteceded her visit to me and caused her to have had the wide variety of symptoms of which she complained and for which she had neurological and ophthalmological opinions. I saw her only twice more, in 1989 and 1991, yet it is suggested that I persuaded her to have the gamut of symptoms of which she had been complaining for seven years. I did not treat her but undertook chemical challenges in a chemical booth. In the light of the dangers, even fatalities, of
are
available from three manufacturers
Strength
1991. 2. Green J, McCreaner A. Counselling in HIV infection and AIDS. Oxford: Blackwell, 1989. 3. Bor R, Miller R, Johnson M. A testing time for doctors: counselling patients before an HIV test. Br Med J 1991, 303: 905-07. 4 Bor R, Miller R, Johnson M. Counselling patients before an HIV test. Br Med J 1991; 303: 1478.
Medical witness on trial
JEAN MONRO
Abbots Langley WD5 0PU, UK
Tablet colour,
markings,
Had my patient taken four times the correct dose of methotrexate potentially fatal bone marrow depression might have ensued. Do we really need 10 mg tablets, and ought they not to be significnatly larger than the 25 mg dose and different in colour? 152 Harley Street, London W1N 1HH, UK
MICHAEL KLABER
Prolonged resuscitation efforts SIR,-Should further in-hospital procedures be abandoned when resuscitation outside the hospital is unsuccessful? Some commentators find strong evidence to support the observation that continued resuscitation efforts are not wordlwHe’2 but this evidence tends to be from heterogeneous groups of patients, and the reporting of data on cases of out-of-hospital cardiac arrest is not uniform3 In a prospective study done over three years we analysed 270 consecutive victims of cardiopulmonary arrest before hospital referral on whom cardiopulmonary resuscitation (CPR) was attempted by our medical emergency department. Every patient received advanced cardiac life support from a physician-staffed mobile intensive-care unit serving a radius of 15 km. The mean response time was 7 min. Resuscitation was successful in 43 patients (16%), and in 133 patients (49%) CPR was stopped at the scene. 33 patients (12%) with temporary cardiac output but without spontaneous rhythm and palpable pulse at the scene after 30 min resuscitation were considered eligible for continued efforts in the hospital emergency department. Continued resuscitation was successful in 12 of these, 2
Ethical emergencies and ethical consultations SiR,—You identify the need for a way of dealing with ethical emergencies arising in connection with innovative therapy of terminally ill patients (Feb 15, p 349). This is part of a wider issue in clinical practice resulting from striking technical advances, a greater
patient autonomy and public awareness, and a readiness to resort to litigation. In North America some centres have establishedl-3 24-hour ethics consultation services to resolve difficulties for individual patients and to identify areas of worry and dispute during clinical management. The help of trainedprofessional ethicists can be requested by members of the clinical team, or by patients or their representatives. Because no one individual can have all the necessary ethics and clinical skills knowledge, the ethicist is backed by an interdisciplinary ethics committee. The four commonest reasons for initiating ethics consultation are incapacitated patients with no close relatives to give consent for clinical procedures, ethical conflict amongst clinicians, ethical conflict between clinicians and patients, and unusual and complex cases. US clinicians, after initial reserve, are said to be supportive, and it is claimed that disputatious and possibly litigious situations can be resolved with least harm to all concerned if difficulties can be discussed openly, explanations given, and tempers cooled (which is similar to advice given in Britain by medical defence organisations). Apart from in vitro fertilisation, this arrangement has no formal counterpart in Britain. Local research ethics committees do not have responsibility to arbitrate about issues arising during routine clinical practice,5,6 and the training, skills, and responsibilities of consultants have allowed ethical issues to be dealt with as they arise. But are the changes in medical practice, the new ethical issues raised by medical genetics,’ and the greatly increased public awareness so profound as to require new arrangements? You are correct to suggest the need for more discussion. Department of Medical Genetics, St Mary’s Hospital, Manchester M13 0JH, UK
RODNEY HARRIS
1. Pence GF. Classical cases m medical ethics. New York: McGraw-Hill, 1990. 2. Culver CM. Ethics at the bedside. Dartmouth: New England Press, 1990. 3. Fletcher JC, ed. Introduction to clinical ethics and health care law legal commentaries, by Margot L. White. Charlottesville, VA. Ibis Publishing Company, 1991. 4. Schiedermayer JL. Ethics consultation: skills, roles, and training. Ann Int Med 1991; 114: 115-60. 5. Guidelines on the practice of ethics committes m medical research involving human subjects: a report of the Royal College of Physicians, 2nd ed. London: RCP,
January, 1990. Department of Health. Local research ethics committee. Health Service Guidelines: HSG(91)5. Heywood (Lancashire) Department of Health, 1991. 7. Ethical issues in clinical genetics: a report of a working group of the Royal College of Physicians Committees on Ethical Issues m Medicine and Clinical Genetics. 6.
London: RCP, 1991.
SIR,-As the consultant who made the decision to administer methylene blue, as referred to in your editorial of Feb 15,should like to make some comments. Few would take issue with your statement that a one-off trial of an innovative therapy in a critically ill patient is no substitute for a planned study. Nevertheless, in the intensive care unit setting new therapeutic approaches are continually being introduced, often in a situation where formal clinical study may not be feasible. Provided that the effects of such treatments are closely monitored, as should be the case in intensive care units, I believe that well recorded observations are valuable and worthy of reporting. They may in turn lead to the introduction of these new treatments on a regular basis, examples being the introduction of the newer techniques of renal replacement therapy and the re-introduction of noradrenaline for controlled vasoconstrictor therapy in septic shock. The issue of informed consent in the context of sedated or unconscious patients in intensive care is difficult. Your qualms about the validity of consent received from despairing relatives certainly strike a chord, and you are clearly floating the idea of an emergency ethics opinion mechanism. However, clinical research ethics committees seem unwilling to accept responsibility for
care patients’ participation in clinical research. In general they require intensive care clinicians to seek consent from relatives
intensive
who may be in distress, even when the research involves little from standard practice. Furthermore, they usually demand written consent which may be more stressful for relatives than a clear explanation and oral consent in front of a witness. The written information sheet required is also of doubtful value when shown to a distressed relative. I am therefore very uncertain whether an emergency ethics committee consultation would help. I do not think, however, that one should be too negative about the validity of consent obtained from relatives of the critically ill. In the intensive care unit it is essential that all clinical management decisions are discussed fully with patients’ relatives. With continuing dialogue a close rapport can be developed, and most relatives are able to appreciate and understand what we are trying to do and give meaningful consent for special therapy, procedures, clinical research, or indeed organ donation.
departure
Intensive Therapy Unit, Western General Hospital,
Edinburgh EH4 2XU, UK
IAN S. GRANT
Ethics and clinical research in anaesthesia SiR,—Your Feb 8 editorial made several useful points. I was, however, concerned by the third paragraph, in which you imply that research in clinical anaesthesia does not (and presumably cannot) offer therapeutic benefit to the patient, and that other doctors may judge anaesthesia research of minor importance. Do you really believe that the change from ether to propofol-with the ability to have day-case surgery under anaesthesia--or the
introduction of dantrolene for malignant hyperpyrexia offer no benefit to the patient? With respect to your second point, of course other specialties may not see the need for some anaesthetic research; I do not see the need for some of theirs, but I tend to assume that this is a lack of understanding on my part about a project agreed by their local ethical and scientific committees. If other specialties do still consider anaesthesia an unimportant branch of medicine, I feel sure that most of their patients do not. Department of Anaesthetics, Royal Postgraduate Medical School, Hammersmith Hospital, London W12 0NN, UK
D. N. F. HARRIS
Insurance and HIV antibody testing SiR,—A recent report’ showed that 67% of AIDS specialists rated difficulty in getting life insurance as a major disadvantage for individuals who undergo HIV antibody testing. Furthermore, 88% of specialists felt that this discouraged people from being tested. By contrast, only 3 of 1400 adults interviewed believed that this would be a deterrent to HIV antibody testing. Thus, there is an important discrepancy between the views of health professionals and those of potential candidates for HIV tests. Counselling texts have included statements such as "in some cases even a negative result can lead to insurance companies asking further questions; whether this will influence the terms of insurance cover is likely to depend on the insurance company and how satisfied they are with the answers they receive".2 Life insurance might be withheld or higher premiums charged for people who have had a negative HIV antibody test,3 To clarify this issue we approached the Association of British Insurers (ABI) who agreed to produce a poster and leaflet outlining their guidelines for people undergoing HIV antibody testing. The leaflet says, "People should be reassured that if they have an HIV antibody test and the result is negative they will face no difficulty in obtaining future life insurance because of having the test. Existing life insurance policies will not be affected whatever the test result". It also set out the questions about HIV and AIDS that are asked on the proposal forms. Between July and November, 1991, we assessed the effects of the availability of this information on patients considering HIV testing in our clinics. These patients are seen by a health adviser, who administers a simple questionnaire to assess the effects of the posters and leaflets on the patients’ likelihood of
undergoing a test.
683
520 patients were evaluated. Of these, 315 (61 %) said that they had seen a poster or leaflet in the waiting room. Of this sample, 37% of men and 46% of women felt that the information from the ABI had increased their likelihood of having an HIV antibody test; no women and only 7% of men stated that the leaflet had decreased their likelihood of undergoing a test. 144 (28 % ) of all patients stated that they intended to have an HIV antibody test but would not divulge the result to any insurance company during an application. 17% of patients stated that they were attending the genitourinary clinic because they did not wish their general practitioner (GP) to know that they were having a test, or of its result. A further 42 (8%) patients specifically stated that their GP had helped in their decision to be tested, and that insurance was a part of this decision. Our findings indicate that direct communication from the insurance industry is of benefit to both counsellors and patients. The provision of clear facts about this issue has improved the confidence of clinic staff about the advice that they were giving to patients. Nevertheless, over a quarter of patients surveyed were still likely to lie about ever having had a test when they apply for life insurance.’Whether or not this was because of confusion about the questions on proposal forms, as Bor et al4 indicated, or for some other reason was not examined in this study. We were encouraged by the GP advice in 8% of patients for testing to be done at a genitourinary clinic, because trained staff can then provide pretest counselling, the patient can be educated about sexually transmitted diseases, and sexual health can be promoted, as well as offering opportunity for a check up for sexually transmitted diseases. However, we believe that the issue of life insurance is confusing and recommend that the ABI should ensure that GPs receive accurate information and leaflets to display in their surgeries. We hope that the clarification of this contentious issue will reduce the amount of time and importance that counsellors need to allocate to life insurance issues. Departments of HIV and St Stephen’s Clinic, London SW10 9TH, UK 1
Genitourinary Medicine,
NICK HULME SUZANNE SMITH SIMON E. BARTON
Department of Health. AIDS and life insurance. London: HM Stationery Office,
bronchial provocation tests (with aspirin, for example), she was not challenged with the specific chemical that had affected her. Since her exposure she has been totally unable to earn a living. There was no suggestion that the legal action she took was frivolous. The defence case included a draft Royal College of Physicians’ report. The Royal College’s solicitors, Field Fisher Waterhouse, stated in a letter: "The College is very concerned about your proposed use of the report of the Royal College of Physicians of London Committee on Clinical Immunology and Allergy called ’Allergy-Conventional and Alternative Concepts’. The report is still only in draft form and should not be relied upon in submissions. There is still some considerable amount of editorial work to be done on the draft report and discussion of its contents continues." It was requested that references to the draft report be dealt with in camera. The report was therefore not in the public domain before the court case and there was no way in which the plaintiff’s solicitors could obtain advice about it in advance because it was only submitted the weekend before the hearing. As a witness for the plaintiff I was not on trial-yet that may be the impression left by the report in The Lancet. Doctors can do little to combat derogatory remarks made about them by judges but by repeating them, the media can put a doctor on trial without all salient facts of the case being known. Breakspear Hospital.
Methotrexate tablet confusion SIR,-When I prescribed methotrexate for psoriasis in one of my patients I specified, as is my habit, the number of 2-5mg tablets to be taken each week, together with the total dose. By chance I bumped into the patient after his prescription had been dispensed; the pharmacist had told him that the tablets were two shades of yellow because they came from different batches. The tablets were indeed two shades of yellow and some were marked 2-5 and some marked 10. They were otherwise of identical size and shape. In the UK methotrexate tablets and in two strengths:
SiR.—The Medicine and Law item in your issue of Feb
1 its
by a
barrister, Diana Brahams. The firm of Brahams Killen Mark Eisenthal, of which her husband is a partner, act as solicitors for Healthwatch, and Mr and Mrs Brahams are members of its committee. In the court hearing referred to, an expert witness for the defence (I was an expert for the plaintiff) was a member of Healthwatch and sitting in court throughout the proceedings was Caroline Richmond, a founder member of Health watch. It is rare for an expert witness to be attacked in the way in which I was in this case, and it would be important for a just assessment to know some of the facts about the patient. She was affected by a chemical spill in the van that she was driving in 1984. Her employers offered compensation. There was no trade union for the fmn’s employees. The plaintiff did not see me until one year after the exposure. During that year she had seen her doctor almost every week complaining of headaches and eye symptoms, general malaise, fatigue, and joint symptoms. Before the exposure her complaints had been sporadic though she had had some headaches, especially when she had been involved in a divorce. My opinion of her having become chemically sensitised could not have anteceded her visit to me and caused her to have had the wide variety of symptoms of which she complained and for which she had neurological and ophthalmological opinions. I saw her only twice more, in 1989 and 1991, yet it is suggested that I persuaded her to have the gamut of symptoms of which she had been complaining for seven years. I did not treat her but undertook chemical challenges in a chemical booth. In the light of the dangers, even fatalities, of
are
available from three manufacturers
Strength
1991. 2. Green J, McCreaner A. Counselling in HIV infection and AIDS. Oxford: Blackwell, 1989. 3. Bor R, Miller R, Johnson M. A testing time for doctors: counselling patients before an HIV test. Br Med J 1991, 303: 905-07. 4 Bor R, Miller R, Johnson M. Counselling patients before an HIV test. Br Med J 1991; 303: 1478.
Medical witness on trial
JEAN MONRO
Abbots Langley WD5 0PU, UK
Tablet colour,
markings,
Had my patient taken four times the correct dose of methotrexate potentially fatal bone marrow depression might have ensued. Do we really need 10 mg tablets, and ought they not to be significnatly larger than the 25 mg dose and different in colour? 152 Harley Street, London W1N 1HH, UK
MICHAEL KLABER
Prolonged resuscitation efforts SIR,-Should further in-hospital procedures be abandoned when resuscitation outside the hospital is unsuccessful? Some commentators find strong evidence to support the observation that continued resuscitation efforts are not wordlwHe’2 but this evidence tends to be from heterogeneous groups of patients, and the reporting of data on cases of out-of-hospital cardiac arrest is not uniform3 In a prospective study done over three years we analysed 270 consecutive victims of cardiopulmonary arrest before hospital referral on whom cardiopulmonary resuscitation (CPR) was attempted by our medical emergency department. Every patient received advanced cardiac life support from a physician-staffed mobile intensive-care unit serving a radius of 15 km. The mean response time was 7 min. Resuscitation was successful in 43 patients (16%), and in 133 patients (49%) CPR was stopped at the scene. 33 patients (12%) with temporary cardiac output but without spontaneous rhythm and palpable pulse at the scene after 30 min resuscitation were considered eligible for continued efforts in the hospital emergency department. Continued resuscitation was successful in 12 of these, 2
