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1)
Internal Medicine Journal has an article about anger in palliative care. It is a qualitative & narrative article reviewing anger in palliative care and is based at least on part on interviews with palliative care clinicians (docs, nurses). It's an issue which isn't frequently written about specifically--usually conflict in general is addressed--and for those of you who follow these things it might be interesting. It has this quote near the beginning:

In cancer care, despite being considered a normal reaction, anger is often seen as a negative emotion, which is tolerated, as it may presage a future, more constructive response.

I was hoping when I read this that the article was going to thoroughly de-pathologize anger, but it didn't really.

2)
Journal of Clinical Oncology has kept my inbox busy as of late...

First are a couple of articles about complementary and alternative therapies in cancer care. One is a randomized trial of aromatherapy massage (which is exactly what it sounds like) for depression and anxiety in cancer patients. It was a multi-center non-blinded trial in which 288 cancer patients were randomized to four one-hour sessions of AM or 'usual care.' How these patients were identified is unclear, they apparently met 'modified criteria' for 'clinical anxiety/depression' according to DSM-IV criteria. I don't have a DSM in front of me but the last time I checked 'clinical anxiety' or 'clinical depression' weren't diagnoses in the DSM--GAD, major depressive disorder, adjustment disorder etc--but not 'clinical anxiety.' This sort of stuff worries me when I see it in an article. Their primary outcome was depression and anxiety symptoms at 10 weeks post-randomization and intention to treat analysis was used. (After reading the article a couple of times I'm still a little fuzzy on how they actually defined anxiety and depression). They found modest improvements in anxiety and depression 6 weeks post-randomization (2 weeks after the intervention was done) in the AM group; no differences in anxiety/depression between the AM & usual care group at 10 weeks (this was the primary outcomes); and no differences at any times between the groups regarding pain, fatigue, nausea, or global quality of life.

Problems aside (and, frankly, supportive cancer/symptom trials tend not to be of the highest quality in most instances), this was the best designed and executed CAM trials I've seen for a while, and I commend the authors for publishing its severely underwhelming findings. In their discussion they noted some of the difficulties in undertaking the trial--typical stuff about patients getting sick etc.--but they also mentioned how none of the study sites actually had infrastructure supporting research into supportive cancer research which was a problem for them. This is the real story here.

3)
Second is another CAM study. This one looked at the use of complementary and alternative therapies in cancer patients starting phase I trials. About 200 patients were interviewed at the University of Chicago as they were enrolling in phase I trials about their CAM use. Their most interesting findings, although not surprising I guess, is that CAM use seemed to increase with decreasing quality of life and increasing certainty of death (it was much more common in patients who thought they were likely to die within the year).

4)
Third in JCO is a study looking at advanced cancer patients' religiousness & spiritual support & how it relates to quality of life and end of life treatment preferences. This was another interesting article to come out of the Coping with Cancer Study (a multi-institutional U.S. study of advanced cancer patients and their caregivers). 230 patients were interviewed about spirituality, religion, and sundry other things. Not surprisingly most patients felt like the medical system provided inadequate spiritual support; more surprising was that almost half of patients reported their own religious communities provided inadequate support. This finding was attenuated for African-Americans & Hispanics. Spiritual support was associated with improved quality of life (this finding survived multivariate analysis). In multivariate analysis increased religiousness was associated with wanting all possible measures to extend life 'even if you were going to die in a few days' but not decreased rates of advance directive completion. Being 'non-white' was associated with decreased completion of advance directives and a DNR order (being in the Northeast was also associated with not having a DNR order--no comment on that). Most of these findings are consistent with previous ones. What was striking to me was how, it seems, patients felt like their spiritual needs were not being met by either the medical system or their own religious communities--perhaps part of the progressive isolation many patients undergo as they become increasingly disabled?

(Supporting editorial by Betty Ferrell here.)

5)
Fourth and finally is a randomized controlled trial to help advanced cancer patients ask their physicians about prognosis. Basically a bunch of cancer patients were given a booklet with potential questions to ask their physician about, among other things, prognosis, what to expect in the future, support services, etc. The booklet intervention did seem to raise the number of questions patients asked and topics discussed, although in the long run it's not clear it significantly improved the amount or quality of info patients got. The physicians didn't seem to mind the intervention too much, although I did find this quote notable:

However, five of 13 physicians stated they had some reservations; namely, fear that the patient may not be ready to discuss end-of-life issues, and concern that it may put the onus on the patient to ask questions rather than on the physician to respond to patients' cues.

Because, as we all well know, physicians are the ones who should be deciding when it's time to discuss end of life concerns, and are famous for our ability to pick up on patients' cues, particularly when it comes to discussing uncomfortable information.

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1) Did anyone else miss the Pope talking about palliative care last weekend (Feb. 11)? Where was I?

I work at a Catholic hospital, so any pronouncement about health care by the Pope usually draws some attention. For those of you who also work with Catholic health care systems, you may want to read some of this and tie it in to your palliative care education. Maybe it will help with the administration supporting your efforts? I give you a few choice quotes from the article:

“There is a need to promote policies which create conditions where human beings can bear even incurable illnesses and death in a dignified manner,” he said, pointing to the need for more palliative care centers.

While the Catholic Church has always sought to follow the “example of the Good Samaritan” in showing “particular concern for the infirm,” the pope urged that Catholic health-care professionals, pastoral ministers, volunteers and family members to continue to “stand alongside the suffering and to attend to the dying striving to preserve their dignity at these significant moments of human existence.”

2) An interesting set of letters to the editor (link may expire) in the LA Times in response to a favorable article about San Diego Hospice:

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Thanks to all of you who said Hi at AAHPM and came to the happy hour. It was a good few days, although I'm ecstatic to be home with my boy. In the interim many articles have been piling up and here they are... (JCO has published a spate of interesting articles in the last 2 weeks and I'll try to get to them by the end of the week.)


1)
Annals of Internal Medicine has a study examining the effects of an educational intervention to patients to help them understand medical risk. Patients were given a booklet/primer explaining medical risk. Basically they found it was helpful and higher socioeconomic status patients did better than lower socioeconomic status patients. Unfortunately you can't actually access the primer online and so you tell if it would be helpful for a palliative care population (one assumes it'll be made commercially available at some point). It's an interesting idea and certainly understanding risk is important for decision making for, say, chemotherapy for advanced cancer.

2)
Medscape is reporting that hydromorphone is a minor metabolite of morphine and can be positive in urine drug tests for people taking morphine only (not hydromorphone). The story is from a presentation from the recent AAPM meeting and cannot be otherwise vetted. (Medscape articles are available for free if you sign-up).

3)
BMJ has a news story about a woman in the UK seeking permission from a court to get enough morphine to relieve her pain which, apparently, will kill her. She's a 30 year old woman with end stage Eisenmenger's syndrome (ineligible for heart-lung transplant) and chronic pain. It's unclear from the article, because it's probably unclear to many involved, whether the woman is asking for terminal sedation (with morphine as the primary agent god help us), or for some sort of assisted death like euthanasia. Or, is she asking for simple pain relief and it just happens that she, apparently, only responds to morphine but unfortunately the amount she would need would, in the estimation of her physician, kill her (sound unlikely? I agree). This last scenario seems to be being invoked by the patient herself although what seems to be being talked about is a terminal sedation scenario. Anyway it's another example of coverage of end of life issues that abut hastened death that is confusing.

4)
Annals of Pharmacotherapy has published a review looking at opioid conversions (both PO to IV and between different agents). It's one of the better pieces I've read on the subject and I'd highly recommend it for the teaching file. It is relatively concise, discusses the difficulties of defining rigid conversion ratios, and argues for different ratios depending on which direction you're going ( e.g. morphine to hydromorphone using 3.7:1 vs. hydromorphone to morphine of 1:5). One caveat stems from this paragraph about fentanyl and morphine:

A potential error that is especially dangerous with fentanyl can occur when a conservative ratio for conversion in one direction is reversed, resulting in a liberal conversion in the opposite direction. For example, converting 100 μg of fentanyl to 1 mg of morphine, using a conservative ratio of 100:1, is substantially different from converting 1 mg of morphine to 100 μg of fentanyl.

By my math 100mcg of fentanyl = 0.1mg of fentanyl & by using a 100:1 ratio that would be 10mg of morphine. 1mg of morphine divided by 100 is 0.01mg = 10mcg fentanyl. So
A) I'm not really sure what their point is, and
B) The fact that they made this error in an article about opioid conversions is disquieting. If I'm wrong here, feel free to comment and publicly humiliate me.

Back to their point though--being conservative with these ratios, especially with those we know the least about, is of course prudent, provided the patient has access to sufficient ad lib meds or attentive dose titration, but I'm not sure specifically what their point is here about fentanyl.

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Well the American Academy of Hospice and Palliative Medicine put on another great Assembly this year in Salt Lake City. (Next year it will be in Tampa.) There were some great presentations, and of the four presentations I was involved with they all went pretty well, although I would have loved to see more people at the Professionals-in-Training Case Conference Saturday morning, because honestly the cases presented there touched on some of the great things about our field (educationally, intellectually, socially and more). And nowhere at the Assembly can you really hear about focused cases (you get some of this in the paper sessions but that is more research oriented, and the poster session doesn't have the same feel as a 15 minute case review).

I wanted to comment on the sessions that I really felt were outstanding. The first one being the Heaven & Hell session. Dr. Boal covered the major Eastern and Western Religions view of the afterlife, and made some good points about approaching patients that are having difficulty reconciling issues and concerns about the after life. For a non-chaplain, he did a good job and answered some questions well about the other Christian denominations he did not have time to touch on. A gentleman sitting in front of me at that session, made a fine point afterwards: "If we enter the patients room with a sense of humility and understanding that we DO NOT ALWAYS have to know the answer, we will serve our patients well." (That was paraphrased but fairly close to what he said). (Heaven and Hell: Understanding Your Patient’s View of the Afterlife (304) James Scott Boal, MD, Angela Hospice)

I was interested to find out there is some data from the laboratory that bone pain may have a neuropathic component and that we should consider anti-neuropathic pain medications when treating bone pain. (Cancer Pain: From the Laboratory to the Clinic (313) Pat Mantyh, PhD JD, University of Minnesota)

There was a lot of information at the conference that was important to the continuation of our field, in particular the issues around moving to the ACGME for fellowship training, and moving from the ABHPM to the ABMS. Most of the information you may need can be found on the respective websites, but it was good to hear what is coming down the pipeline from the people who are preparing this transition.

One of the better sessions I went to (although it did run a bit long, because she had so much to cover) was Care of the Dying Infant: Before and After Birth (423) by Jeanne G. Lewandowski, MD FAAHPM, Hospices of Henry Ford. Please see her handout on the CD for more information. Palliative care really has a lot of work to do in the pediatric world. This is really tip of the iceberg stuff.

Other than that, I enjoyed getting to see old friends, work with members of the Professionals in Training Special Interest Group (SIG) and the Fellowship Directors SIG in forming the foundation of education for our field. It was also great getting feedback from all the Pallimed readers and matching up names with some of the people who make comments, like Tom and Marachne (not maraschino). I also found out there are a lot more of you readers out there who don't comment. Please feel free to and if the technology is inhibiting you or the fear of repercussion exists, use an alias or comment anonymously. We can build a great community here that can make an impact on the field through sharing of knowledge, opinions and experience.

And to all our first time readers or those that have rediscovered us, WELCOME! (You may want to look at this beginners guide to Pallimed post.)

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I likely won't be posting again until next week after AAHPM. A lighter topic until then....

Archives of Internal Medicine has released a study about a subject near and dear to many of us: the role of the consultant. They posit the study as an update of the famous 1983 article about the 10 commandments of consultation.

The current study is from a survey of academic internists, family medicine docs, & general, orthopedic, and ob-gyn surgeons about what they want from consultants. The findings are illustrative but not, I guess, surprising. In general: surgeons (particularly orthopedic surgeons) were much more likely than family docs/internists to want a "co-management" model from their consultants--much more likely to say that it was ok for the consultants to write orders and to not restrict themselves to a narrowly defined question. 60% of surgeons wanted co-management whereas less than a quarter of non-surgeons did. Everyone wanted verbal communication from the consultant about her/his recs.

They go on to update the 1983 commandments. E.g. "thou shalt not covet thy neighbors turf" has been modified to "thou may negotiate joint title to thy neighbor's turf. The first commandment, which I strongly endorse and am glad they kept it as the first (although the wording is a little weird) is "determine your customer." That is, know thy consultee. This is much more important than the differences between orthopods and internists. Everyone wants something different from you....

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This is the sixth and final post in a series previewing the sessions at the American Academy of Hospice & Palliative Medicine's Annual Assembly.

You can see all the posts in the series below:
2/14 - Pre-conferences
2/15 - AM Sessions
2/15 - PM Sessions
2/16 - AM Sessions
2/16 - PM Sessions
2/17 - AM & PM Sessions

Click here for the AAHPM Annual Assembly Brochure 2007 (pdf)

Register soon if you have not already!

Saturday, February 17th - AM Sessions

7-7:45am - SIG meetings
Pick one that you are interested in and go. These are great ways to meet peers who share your concerns and get involved with the AAHPM. I will plan on being at the PIT-SIG meeting as I think this will be my last year actively supporting the PIT-SIG as it is time to pass the torch to the next batch of upstarts who want to get some recognition for fellow within the Academy and field.

8-9am & 9:15-10:15am
Now if you are a reader of this blog, I sincerely hope that you come to the Professionals in Training Case Conference - Part 1 and Part 2. This will be the third year in a row for the case conference which has allowed palliative medicine fellows to present at the national meeting. Typically in a year long fellowship, you have no chance to submit a talk to the national meeting because the submission deadlines are not friendly to the academic year. If you do present it is likely as a generous tag along with a senior faculty member as I did my first year at the AAHPM. I learned so much from presenting at the AAHPM in 2004. I gave a talk on methadone to over 500 people. Ever since then talking in front of people has not been difficult at all, although the Harvard PCEP course did help as I mentioned before. So I and a rotating group of faculty have made an agreement with the AAHPM to allow this case conference to have later deadlines so fellows can submit. This case conference does not get much publicity because it misses a lot of printing deadlines, no one knows what the PIT Case Conference is, or what the PIT-SIG is, or what cases will be presented.

But this case conference is critical to ongoing involvement of the next generation of leaders of the AAHPM. Please come out and support them and see their cases, and ask great questions. Especially if you know them or are part of their program. (Ahem Fellowship Directors!)

Here are the cases for Part 1 & Part 2 (And Drew will be there as well, facilitating):

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Professionals-in-Training Case Conference - Part 1
8-9am

Choreoathetosis in a frail elderly female hospice patient taking low dose trazodone: a case report
Charina Gayomali, MD
Summa Health System
Akron, OH

Communication challenges in a Puerto Rican gentleman with oropharyngeal cancer
Winnie Suen, MD, MSc
Massachusetts General Hospital
Boston, MA

Communication challenges in a patient with multiple myeloma and developmental delay
Cindy Lien, MD
Dana Farber Cancer Institute
Boston, MA

Professionals-in-Training Case Conference - Part 2
9:15-10:15am

It’s never too late
Kelly Ryder Letsinger, MD
VCU Medical Center
Richmond, VA

Communication challenges: denial, language and cultural barriers
Sarah E. Harrington, MD
VCU Medical Center
Richmond, VA

ICU as a comfort measure: treating the anxiety of a lung transplant patient who has survived it all
Lise Taylor Barbour, MD
Medical College of Wisconsin
Milwaukee, WI

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No comments on other sessions during this slot although I do admit there are some interesting talks. Especially the one in which my partner Ann Allegre receives an award from the American Academy of Hospice & Palliative Medicine and the Project on Death in America for Palliative Medicine Community Leadership. She really deserves it for what she has accomplished in the Kansas City area with Kansas City Hospice & Palliative Care.

10:45-11:45am
Couple of good talks here. Bruera and Fatigue should be good, although I don't know how much of a sea change there is, unless he is announcing something spectacular. I don't know if we have had a talk solely devoted to updated legal issues, although this one may be good to follow as hospice and palliative medicine becomes more ubiquitous it will be hard to keep up the great press and high expectations because of all the different programs growing out there. Medical futility and religion is a very good topic as this can be a huge barrier/opportunity to finding consensus. No big comments on the speakers although there are some big names in this time slot.

Noon-1:30pm

Now as some longtime readers may know, I am not a huge fan of pharma sponsored activities. I have been underwhelmed with these presentations in the past, and so last year did not sign up for it and was relieved to find that there were many people that I was excited to run into and have lunch with. It allowed for some great networking and catching up. This may be your last chance before the end of the conference to catch up with people.

1:45-2:45pm

Another candidate for intriguing but leave me guessing title is "A Complex Case Awaits Your Input." Picking titles is key to getting your talk accepted, so I hope the abstract was what they focused on, so this might be a gem. But I guess you could say the same thing about the PIT Case Conf being enigmatic as well.

Another talk during this time is about research papers, which is a good sign I hope of trying to improve the caliber of research done in our field. I would love to do some research but it somehow never finds the time to reach my desk and get completed. I have a ton of great questions as I am sure most HPM providers do.

Other than that, not much that thrills me at this time.

3–4:15 pm
Plenary Session
State of the Science
Daniel Fischberg, MD PhD, The Queen’s Medical Center
Nathan E. Goldstein, MD, Mount Sinai School of Medicine

This has been a great talk the last two years I have been to it. Goldstein and Fischberg do an excellent job of going through the key articles in our field with humor and insight. Get to this talk if you do nothing else. That being said, I will miss it. I have to catch a earlier flight home to be there for my twins first birthday. I think Goldstein and Fischberg would understand.

And with that I am done. Leave any thoughts if you would like. ( I decided not to review the paper cases. Not enough time. I got to prepare for my 4 talks!)

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Not going to any of the special interest group meetings at AAHPM? Christian and I will be having a clandestine "Blogging SIG" meeting on Thursday and all are welcome!

To be precise, Christian and I will be talking/drinking/socializing/philosophizing at Kristauf's Martini Bar starting ~6:45ish after Thursday's program is finished. It will be super-informal and casual. If anyone wants to come, talk about Pallimed, medical blogging, how one can try to rationally sip from the apocalyptic deluge of medical information we constantly find ourselves under, or anything else--please stop by. If not CS & I will have a fine time alone. CS, knowing him, will likely be drunk by 6:45pm anyway**, so it promises to be a worthwhile evening.

Map is here (I think it's mere blocks from the conference).
I've changed the photo on my profile temporarily and will invite CS to do the same so you can recognize me/us.

**For the record that was a joke. He'll be tipsy by noon. To (mis)quote Arrested Development, the only thing CS usually has in him is a bottle of vodka and an estrogen pill. This was also a joke.

CS Here...Umm...I am not sure how to respond to Drew's allegations of my vices, for he has only been to lunch with me, and I had a club sandwich and a soda. But his post reminds me of what a social worker was telling me about this week. Something about projecting the image of yourself onto others. Something like that. And for the record, I am not planning on drinking heavily. Coming to hang out with us does not have to be about alcohol if that is not your scene. Binge drinking, joke or not, can be dangerous to your health and generally does not impress people, or so Drew has told me.

I have changed my profile pic temporarily. I may or may not have a goatee at the conference.

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I compiled this list of helpful hints from my own experiences and from peers input over the past few years. I think it may be helpful to first timers but also to veterans of national/regional medical meetings like the AAHPM Annual Assembly.

This was originally posted to the AAHPM Professionals-in-Training Special Interest Group email list.

Any updates or additions would be appreciated.

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Christian Sinclair's Handy Hints for a National Meeting
Originally written Jan 2005

* Bring your CV (multiple copies, and UPDATED) and business cards, regardless of whether you are looking for a job. Many people may want to know more about you for networking reasons, not just job offers.
* Talk to people. Don't sit by yourself unless you are the first person in the room. Sit next to someone and then introduce yourself.
* Don't stay in your room too much, you'll miss too many opportunities
* Stay in your room sometimes. Take some time to unwind and be yourself.
* There is a bulletin board in a central place where people post messages: Llook there for any messages regarding you or get-togethers you are interested in.
* The bulletin board is a good place to post a flyer with your picture on it, with a sign that says "Will provide good end-of-life care for food", if you want people to contact you about a job. (Trust me there will be a lot of people there looking for fresh new trainees.)
* When you go out with other people, you do not HAVE to talk about medicine (The people at the table next to you may appreciate that); find out what really makes someone tick (just like talking to patients)
* You should make dinner plans with other people (outside the group you came with, but invite them along too)
* Write down key facts you have learned towards the end of the day. The facts may be about topics you have learned about or people you have met. You may meet so many people it may be difficult to remember everyone and their interests. (The back of the business card is a good start)
* Don't be afraid to introduce yourself to any of the 'hospice celebrities'. Most of the well-known people in hospice and palliative medicine are very friendly and willing to talk, just make sure they are not in a rush for somewhere else. A lot of people would like to have their attention.
* Go to the poster session and talk to the people who made the posters. A lot of hard work went into most of these, and everyone likes to hear when they have done a job well.
* If you are bringing family or a significant other, make sure to spend some time with them.
* Reconnect with old friends.
* After a session, if you talk with a speaker, make your point or ask your question, and then allow others to interact. Nothing is worse, than trying to make a quick point after a session, then the know-it-all who wants to take up all the time of the presenter without regards to other people's interest. If you are presenting and you find this know-it-all who wants all of your time, make sure to set limits, and let others ask you questions.
* Turn in your session evals in a timely manner.
* Thank the coordinators who are organizing the meeting if you find them, they have put a lot of hard work and seldom get recognized.
* Try and get out and see the city you are in, since you never know when you will be back there or if it will be devastated by a major hurricane.
* When you come back to work schedule a educational session with interested parties to share everything you learned there.
* Go to at least one paper session. The concurrent sessions are great but you can find out some interesting up and coming things in the paper sessions. (Same goes for the Professionals-in-Training Case Conferences!)

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NY Times has a positive article about "open-access" model hospices. (For those of you not familiar with this it is a model where hospices provide/pay for costly and even disease-modifying treatments like chemotherapy, hospitalizations, etc.) Most interesting, to me, is that it seems several private insurers are trialling open-access in an effort to increase the number of hospice enrollees and lengthen hospice length of stay (one also hopes they are planning on publishing their findings on enrollment, LOS, cost, and patient/family satisfaction).

Open-access is not without criticism, much of it about cost of course but also about it changing the nature (or at least the flavor) of hospice. Instead of opining on that I think I'll do my taxes instead and let commenters share their thoughts.

(Multiple readers emailed us about the article--thanks!)
(NY Times articles are usually available free for a week.)

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It should be noted that with Christan's flurry of posts the last couple of weeks Pallimed has now exceeded the 300 post mark.

Several things in brief:

1)
BMJ reports that over half of complaints against Britain's NHS regarding hospital care were to do with deaths:

"In many cases, families complained that they had received contradictory or confusing information from different staff caring for a relative. In other cases, relatives felt that they were unprepared for the death or had no time to arrange for family members to be present."

Sound familiar?

2)
BMJ also has an interesting look at the role of NGOs in physician assisted suicide. It examines two organizations in detail (Exit in Switzerland and Compassionate Choices in the US). Both function as patient advocacy groups, assisting people seeking PAS--Exit volunteers will even physically help people fill and administer the lethal prescription. The authors'--whose tone is neutral--take is that these organizations help people overcome the physician obstacles to PAS (the fact that many physicians want nothing to do with it). Oregon aside, the article is most relevant to the UK where there is a very active national debate about 'assisted death.' If you're interested Compassionate Choices website is quite interesting, especially in how it uses a lot of palliative-care type language (although my sense is that most palliative care clinicians in the US are neutral about PAS at best--many, myself included, feel quite negative about it--there are notable exceptions of course). The other interesting thing about CC is its use of consumerist language..."choice" etc. As if one can pick from a buffet of choices about end of life care (leather or vinyl seats?)--something that doesn't reflect the reality of dying at all.

3)
NEJM this week has an article about religion, conscience, and controversial clinical practices (full-text available for free). The article is base on a survey of American physicians and their attitudes towards religion and controversial practices. Most of the context for this is reproductive issues (abortion, contraception) but terminal sedation is also specifically included. Basically they found that most physicians feel it is appropriate to disclose their moral objections to a medical therapy, but that they should still inform their patients of all available medical options, and refer a patient to a physician willing to help the patient (86% and 71% for the last two obligations). The more religious the physician was, however, the less likely they were to endorse an obligation to informing/referring their patient. And those physicians who morally objected to a specific practice were much more likely to say that they had no obligation to inform or refer. (Only 15% of physicians personally objected to terminal sedation compared to ~half for reproductive issues.) It should be noted that only 63% of physicians responded to the survey. The lesson, I guess, is caveat emptor, and particularly regarding reproductive issues one cannot assume that your physician has your best interests in mind/agrees with you about your best interests/or will even engage with you about this.

I wish the authors had asked the physicians if they believed they should promote their own religious beliefs to their patients--my guess is that only a tiny minority of physicians, even the most religious ones, would endorse this. This, to me, raises the question of whether there is an active/passive element at play here--that it is ok for your religious beliefs to "passively" effect your patients (not mentioning to them legal and effective medical therapies based on your religious beliefs) but actively proselytizing is not ok. Of course active/passive distinctions are frequently invoked in palliative care as being morally valid....

4)
In a laterally related article The Hastings Center has just published a report on patient religious belief and medical-decision making capacity (free .pdf here). It is a long argument (that I can't really summarize) that religious beliefs may lead to patients lacking medical decision-making capacity, but that this does not necessarily mean that those patients are incompetent to make decisions. Incompetent in the sense of patients having their (legal and ethical) right to autonomy and to decide what is done to their body taken away from them. Are certain patients due to strongly held religious beliefs incapable of rationally understanding medical information and making decisions on that? Yes. Does this mean their right to make decisions should be forfeited? No (not necessarily). This is the crux of the author's argument. A problem, which is addressed in the article, is that one person's religious beliefs may be another's psychosis, and does cultural sanctioning of religious beliefs ( i.e. there are a lot of believers in X therefore it's ok versus a small fringe-cult's beliefs) make a difference in what is, well, crazy (my words, not the authors) and what is faith?