Police are to hold a murder inquiry into the case of a doctor MP who mentioned during a parliamentary debate that he had withdrawn treatment from a 2 year old boy with leukaemia at the parents’ request to save him any more distress.

Peter Brand, Liberal Democrat MP for the Isle of Wight and a GP, said that if the Medical Treatment (Prevention of Euthanasia) Bill had been law when he qualified as a doctor in 1971, he would by now be a “multimurderer”. He made his comments during the second reading debate on the bill, sponsored by the right-wing Conservative MP Ann Winterton, who came top in the ballot for private members’ bills.

Under the bill it would be unlawful for doctors to withhold or stop treatment or sustenance if one of the purposes was to hasten or cause the death of the patient. It would make it unlawful for artificial nutrition and hydration to be withdrawn in the case of patients in a persistent vegetative state, as happened to Tony Bland, a victim of the Hillsborough disaster in 1989.

Hampshire police said that they would investigate after receiving a complaint from a woman in Weybridge, Surrey, who heard Dr Brand interviewed on the radio about the issue. The incident he referred to during the debate happened in 1973 when he was a house officer specialising in paediatrics. The police admitted, however, that they had not read the record of the debate in Hansard.

There is substantial parliamentary support for the principle behind Mrs Winterton’s bill. Twelve of the 16 members of the committee considering the bill are in favour, said Dr Brand

The bill would not allow people to refuse treatment through advance directives. The only circumstance in which treatment could be withheld or withdrawn was if a patient who was in a position to refuse actively did so.

It also dashes with government plans for legislation to allow people to appoint a friend or family member to take treatment decisions for them should they become incapacitated.

Under the current law, parents may refuse treatment for their children if the treatment would not be in the child’s best interests–for example, if it would cause suffering–even if death results.

Dr Brand, who had not been questioned by police as the BMJ went to press, said, “I didn’t do anything other than describe past and current accepted practice.”

WAY BACK WHEN we walked uphill both ways in the snow to nursing school, we were taught team nursing. I did my clinical in a county teaching hospital on a medical floor staffed with RNs, LPNs, CNAs, and lots of medical interns and residents. It fascinated me how knowledgeable and assertive the nurses were. I dreamt that one day I too would be giving information to doctors. The RNs cared for their patients with the help and collaboration of the other members of their team, which consisted of LPNs and CNAs, radiology techs, respiratory techs, and other unlicensed assistive personnel. Their synchronicity in delivering patient care was a wonder to behold.

After a year as an RN in this setting, I began nursing at a private psychiatric hospital where once again we were involved in team nursing. This time my team consisted of mental health workers I, II, and IIIs, and an LPN who gave medications to the entire floor of 27 adolescent psychiatric patients. Although I was a relatively new nurse, I was hired as a supervising RN and I was accountable to nursing administration, medical staff, and of course, most importantly, the patients for all that transpired on my unit during my three, 12-hour shifts per week. All that I had learned in nursing school was put to the test in the supervision and delegation of the care provided to our patients. In this setting, it was crucial that we as staff were of one accord, the proverbial “surrogate parents” who could and would not be split.

In 1993, I moved to Nevada. I spent the first two years finishing my masters in nursing and working as the Director of Clinical Services at a well-known residential center for adolescents and children. Again, we strove to provide a culture of collaboration, utilizing each staff member-licensed and unlicensed-based on his or her scope of practice, skill level, competence, and expertise.

The President. Thank you all for coming. Thank you all for being here. Go ahead and have a seat. Thank you. Nice to be in the part of the world where the cowboy hats outnumber the ties. Thanks for coming. Gosh, it’s wonderful to be back in Montana. What a fabulous State, full of really decent, honorable people.

Conrad, thanks for introducing me. I’m glad you didn’t auction me off. [Laughter] Doing a fine job in the United States Senate, and I’m proud to call you friend. Thank you very much, sir.

And I want to thank Max Baucus for being here. We have worked a lot together in 4 years. You know, we’ve confronted a lot of things in this country. We’ve confronted a recession and confronted the need to get this economy growing. And Max worked hard with the administration to cut taxes and open up markets. And I appreciate working with you, Max. It’s been a lot of fun. We got more work to do.

We’re here to talk about an issue, after a while, that’s going to remind us we got a lot of work to do if we’re going to do our duties as public servants. But Max, thank you. Denny Rehberg, thank you, friend, for coming. I’m honored you’re here–proud of the United States Congressman from the great State of Montana–and Jan.

The Governor met me at the airport. The Governor is here. Governor, thank you for coming. I’m proud you’re here. One of these days you’re going to join the same club as me and Judy and Marc Racicot–that’s the ex-Governors club. But right now, you may have the best job in America, being the Governor of a great State. So I’m proud you’re here. Lieutenant Governor is with us today. We got a lot of other officials–secretary of State–thanks for coming.

You know, we’re flying over on Air Force One, and guess what Burns and Rehberg–all they wanted to talk about was cattle–[laughter]–Montana beef. And that’s an important subject because it’s part of how to make sure our economy continues to grow. They kept asking, “Are you talking to markets overseas to get the Montana beef into those markets?” I said, “You bet I am.” And we’ll continue to do so.

Several recent studies have examined the consequences of uninsurance in a near-elderly population using data from the longitudinal Health and Retirement Survey (Heeringa and Conner 1995). Baker et al. (2001, 2002) found that those who were continuously or intermittently uninsured, or lost their insurance coverage over a 2-4 year period, experienced greater health declines than those who were continuously insured. McWilliams et al. (2004, 2003) found that lack of insurance was associated with significantly increased mortality, and that previously uninsured near-elderly adults who survived to age 65 increased their use of basic clinical services after they obtained Medicare coverage more than those who had been fully insured.

These research findings raise two important questions. Does lack of insurance prior to age 65 result in people qualifying for Medicare in worse health than if they had been insured? If so, is public insurance spending through Medicare and Medicaid on newly enrolled beneficiaries greater than it would be if people had continuous insurance coverage prior to age 65?

Our analysis extends these previous studies in several ways. As the prior studies were not specifically interested in the question of health status at entry to Medicare, they included changes in health for people as young as 57, as well as people who were older than 65 and had already aged into Medicare coverage. If attaining Medicare coverage improves health (Lichtenberg 2002), then the previous results may understate the impact of lack of insurance on health status at age 65. We also analyze data from the Health and Retirement Survey (HRS), but define our endpoint as health status at the last survey before turning 65.

As this country becomes increasingly Hispanic, a growing number of universities now offer–and sometimes require–Spanish courses geared to health care students. At public and private universities, medical and nursing students are clamoring for classes that better equip them to communicate with patients who speak little or no English. This is occurring even in areas that historically have been primarily White. Educators are responding with classes melding conversational Spanish with medical terms.

“We’re acutely aware of the multicultural world we now live in, and we want to be sensitive to that diverse world,” says Dr. Geraldine Bednash, executive director of the American Association of Colleges and Nursing. “We cannot provide the best medical care without communicating in other languages, especially Spanish.”

In a well-publicized move, the University of Texas at Austin became one of the latest to require its nursing students to enroll in a Spanish course especially designed for health care workers. The move affects this fall semester’s freshman class of 136 students, but they won’t enroll in that Spanish class until fall 2004 to coincide with upper-division clinical courses taught in English, says Dr. Joy Penticuff, UT professor of nursing and former assistant dean for undergraduate nursing programs. Meanwhile, seven upperclassmen chose to enroll in the new three-hour credit course this semester as an elective, she says.

By the end of the course, students should be able to prescribe medication in Spanish and guide patients through basic procedures like drawing blood. They also should be able to translate aloud body parts and basic body functions, Penticuff says. Less emphasis is placed on grammar and the many verb tenses taught in traditional Spanish courses. “We don’t have any delusions that our students will be proficient in discussing every medical procedure in Spanish,” she says. “On the other hand, you cannot give health care today without knowing that you, as a provider, have to reach out and do what’s necessary. It’s not the time to say, `I’m not going to speak to you in Spanish.’”

UT officials are making this such a high priority that they plan on requiting even bilingual nursing students to enroll. “We might eventually change the policy, but we also know that bilingual speakers don’t necessarily know specialized medical terms,” says Penticuff, a 27-year UT veteran.

Our lab is being sold — what to do?

Q A large, national reference laboratory is purchasing the laboratory I work for. We are being told not to worry, and that since both companies are publicly traded, all of the sale/merger information is confidential. We are all worried about our jobs. Can the panel give me any advice about what to look for and anything I can do to help myself?

A According to Larry Crolla, “There is nothing in particular you can do now. It is always a good idea to let people know you support the new regime and you are not opposed to the changes taking place. The adage applies: ‘You are either with me or against me.’ Also, this may be a great opportunity to learn new skills. If they are looking for people to cross-train or work at a nearby facility you may want to consider the opportunity.”

Alton Sturtevant reminds, “The situation of having your company bought by a large laboratory is certainly stressful. While you cannot change the fact that your company is being sold, you can work to control your own future through a process of self-evaluation and controlling your response to the sale. A positive reaction and a ‘can do’ attitude will help you face the change. Change seems to be a constant in many professions, especially in medical-related industries. You can recognize that a change will occur in your current circumstance. How you react to the challenge of the change can have an effect on your future, both professionally and physically. If you worry and are negative about the sale, you could cause yourself to become emotionally stressed and less effective as an employee, and affect the attitudes of your fellow workers as well. This will have an adverse effect on your future.”

What are the options?

Recent findings about the drawbacks to estrogen (ET) and estrogen/progestin therapy (Combined Hormone Therapy - CHT) make it more difficult than ever to make a rational choice.

When menopause is viewed as a deficiency disease or condition, as it is by some medical practitioners, then it follows that some kind of treatment will be viewed as beneficial to all women approaching menopause. If menopause is seen as a natural stage of biological development, however, hormone therapy will be seen as medication useful only for those most seriously affected (that is, those who have had an artificial menopause, those at serious risk of osteoporosis, and those few women who suffer from intolerable hot flashes). Some people feel that drugs were invented to cushion us from discomfort and stress, and that to spurn such relief is silly. Others feel that we swallow too many drugs without thinking of the consequences, and that sound nutrition and other changes in daily routine should be adopted before resorting to drugs. These differing attitudes influence many decisions about hormone therapy.

ET (or CHT) should be prescribed for a woman only after she has had a thorough medical examination, including not only blood pressure, a pelvic exam, and a Pap test, but also measurement of blood lipids, a clinical breast examination (CBE) and mammogram, and, ideally, a bone density scan. Her doctor will usually insist on a checkup in three months, and every six months thereafter. This means that women on ET or CHT are more likely to have regular medical checkups than women not receiving hormones. Because of this consistent surveillance, including endometrial biopsies, Pap tests, and breast exams, if these women do develop signs of a disease, it is more likely to be caught early.

Your magazine says you can only lose body fat by expending more calories than you take in. Can’t you lose body fat and gain muscle at the same time, making a net gain in weight?

“Definitely,” says Will Thompson, medical exercise specialist, certified by the American Academy of Health, Fitness and Rehabilitation Professionals. “But it’s hard work. To lose body weight, essentially you have to burn more calories than you take in. But when you’re losing weight, you may also be losing muscle that you want to keep. Ideally, you want to maintain or increase lean body mass as you reduce body fat, so the result can be a net weight gain.” Here’s how to do it.

* Eat the proper foods. “Eat fairly lean cuts of meat, taking in up to 40 grams of protein per meal,” Thompson says. “Reduce dietary fat, especially from sources high in saturated fats. That will help increase metabolism, helping you build muscle mass and reduce body fat.” Thompson also suggests reducing your intake of starches such as white bread and pasta and increasing vegetable consumption.

* Eat frequently. Thompson stresses the importance of the thermic effect of food. “Every time you eat, it kicks up your metabolism,” he says. “So try to eat five or six times a day. If you sit down and eat a pound and a half of steak at the end of the day, taking in all those calories at once will promote body-fat storage. But if you eat eight ounces of that same steak over the course of three meals, you’re much more likely to promote muscle building.”

* Weight-train correctly. “If you’re training properly, your body can absorb more protein, which allows you to build more muscle mass. At the same time, the carbs you’re taking in aren’t going to be sitting around and getting stored as fat.” Thompson says to weight-train for 60 minutes four or five times a week, emphasizing one or two body parts each session.

* Keep cardio moderate. “One mistake people make is doing too much cardio,” Thompson says. “Adding a marginal amount of cardio a day–20 minutes–to your weight training is a much better strategy, as you encourage fat burning at the same time that you increase lean body mass. In turn, this will increase your metabolism, further promoting body-fat burning.”

A recent article published in the New England Journal of Medicine (October 23, 2003) deserves the attention of both policy makers and a public suffocating under the expense of health care. It reports that during the last decade, the Department of Veterans Affairs (VA) undertook a structural reform designed to reduce its emphasis on hospitals in favor of providing medical care through a comprehensive, high-quality primary-care system. The VA oversees the largest health-care system in the United States.

Analyzing the effect of this change in the VA’s medical delivery, researchers found that the number of days spent in the hospital fell by a remarkable 50 percent, and that there was only a moderate increase in outpatient utilization when compared to the period prior to the reform. On top of that, urgent-care services fell by 35 percent, and still more impressive, survival rates were not affected. Those who conducted the study came to the conclusion that the decrease in hospital use did not diminish access to necessary medical care, and that this shift caused no adverse consequences for the health of VA beneficiaries. These findings, coupled with the study’s conclusion that more efficient care does not automatically equate with poorer care, bring to mind related research on how the American health-care system fails to utilize its vast resources properly.

Health economists have long noted variations in healthcare utilization by comparing geographic areas. In 2000, Medicare expenditures (a good measure of the utilization of medical services) were $10,500 per enrollee in Manhattan but only $4,823 per enrollee in Portland, Oregon. This difference, it turns out, was not caused by a greater burden of illness in New York, or even to its higher cost of living. Using statistical methods to control for variables, researchers eliminated possibly misleading comparisons, such as using dissimilar populations and/or variations in the cost of doing business, and they were able to document that the differences were real. They found, for example, that the gap in expenditure persisted even after population characteristics (age, sex, race, and burden of illness) and the price of medical services had been taken into account.

Health administrators, researchers, and policymakers use prediction models to forecast patient outcomes including morbidity, mortality, and health system utilization. Traditionally, administratively derived predictors have been used for such purposes, however, their limitations have led to the development of alternatives (Romano et al. 1993; Iezzoni et al. 1996; Iezzoni 1999; Schneeweiss and Maclure 2000; Schneeweiss et al. 2001, 2003). Measures of self-rated health are robust risk predictors that have gained in popularity as a substitute for administratively derived tools. These self-rated health measures are patient centered and predictive of subsequent health outcomes, even in patients without prior health problems. In several studies, patient self-rated health status has predicted such important patient outcomes as mortality and health system utilization (Miilunpalo et al. 1997; Curtis et al. 2002; Fan et al. 2002a, b; Spertus et al. 2002; Knight et al. 2003). These measures remain consistent predictors of hospitalizations and mortality rates even after adjustment for clinically relevant factors (Clarke and Oxmann 2002; Lowrie et al. 2003).

Routine use of self-rated health measures for health care planning and delivery is partially limited by burdens associated with collection of health status information. Many self-rated health measures are multi-item scales that are often onerous to collect in routine practice settings. Single-item general self-rated health status (GSRH) measures may serve as a reasonable substitute for multi-item measures of self-rated health (Balkrishnan and Anderson 2001). They have the advantage of being less expensive and less burdensome to collect, and could be conceivably collected at the point of care with relative ease. In a health care setting that uses a relational, electronic database, this collection could occur as part of routine intake in the primary care setting.