In This Issue of Archives of Internal Medicine FREE

This article introduces a new form of nicotine replacement therapy, a nicotine lozenge, and documents the safety and efficacy. The lozenge comes in 2 doses: 2 mg and 4 mg of nicotine for low- and high-dependence smokers, respectively. In a randomized, placebo-controlled clinical trial with 1818 smokers, the lozenge was highly effective in both low (odds ratio, 2.1) and high-dependence (odds ratio, 3.7) smokers. Efficacy was maintained for 1 year. Patients who used more lozenges experienced stronger treatment effects. Adverse effects were mostly minor and local. The nicotine lozenge is a safe and effective new treatment for smoking cessation.

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Although the fear of legal action against physicians is based in the reality of today's practice of medicine, practicing defensive medicine places physicians at greater risk for being sued. Actual negligence appears not to predict whether a physician will be sued. Rather, the defensive behaviors that physicians and others tend to see as protective may pose the greatest legal risk. What protects physicians from legal liability is practicing patient-centered medicine—the kind that calls for regular and straightforward communication with patients and families, attention to patients' emotional and psychological needs, and thoughtful justification for, and clear documentation of, medical recommendations.

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Back et al report a qualitative study on patients' and family members' interactions with clinicians regarding requests for physician-assisted suicide (PAS). The authors identify 3 themes that describe qualities of clinician-patient interactions about PAS that patients and family members valued. These themes included (1) an openness to discussion about PAS, (2) expertise in dealing with the dying process, and (3) maintenance of a therapeutic patient-clinician relationship, even when the patient and clinician disagree about PAS. Responding to a patient request for PAS is an important and complex clinical skill. The article by Back et al provides results from a unique data set and suggests a set of guidelines that clinicians might use when responding to patient requests for PAS or when teaching communication skills relevant to end-of-life care.

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This multicenter, prospective cohort study defined and validated a simple, clinically usable measure of clinical stability on hospital discharge for patients with community-acquired pneumonia. Unstable factors in the 24 hours prior to discharge were defined as temperature greater than 37.8°C (100°F), heart rate greater than 100/min, respiratory rate greater than 24/min, systolic blood pressure lower than 90 mm Hg, oxygen saturation lower than 90%, inability to maintain oral intake, and abnormal mental status. Among the 680 patients, 19.1% left the hospital with 1 or more instabilities on discharge. By 30 days, 10.5% of patients with no instabilities on discharge died or were readmitted compared with 13.7% of those with 1 instability and 46.2% of those with 2 or more instabilities (P<.003). Instability on discharge (defined as ≥1 unstable factor) was associated with higher risk-adjusted rates of death or readmission (odds ratio, l.6; 95% confidence interval, 1.0-2.8) and failure to return to usual activities (odds ratio, l.5; 95% confidence interval, 1.0-2.4). Patients with 2 or more unstable factors on discharge had dramatically increased risk-adjusted rates of death or readmission (odds ratio, 5.4; 95% confidence interval, 1.6-18.4).

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