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Kathryn M. Gores, MD; Gregory A. Schmidt, MD, FCCP
Author and Funding Information

From the Department of Pulmonary and Critical Care Medicine (Dr Gores), University of Michigan Hospital Systems; and the Department of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Carver College of Medicine (Dr Schmidt).

CORRESPONDENCE TO: Kathryn M. Gores, MD, Department of Pulmonary and Critical Care Medicine, University of Michigan Hospital Systems, 1500 E Medical Center Dr, SPC 5360, Ann Arbor, MI 48109; e-mail: kagores@med.umich.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(3):e105-e106. doi:10.1378/chest.14-2859
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To the Editor:

We thank the authors for their interest in our ethical dilemma1 and for giving us another opportunity to emphasize our message. When faced with a patient with hepatic failure following Amanita poisoning, we chose to offer treatment with the investigational drug silibinin.1 In doing so, we sought to balance its risks and benefits, attributes that we found difficult to quantify. The evidence making silibinin the “treatment best supported” relies on animal studies alone. Publications reporting use in patients include only uncontrolled case reports or series in which all subjects were treated with the drug.2-4 This is thin ice, indeed. On balance, we chose to offer the drug but found that we wrestled with our decision.

We have little doubt that many clinicians would, like these authors, see no conundrum. But we were troubled by our inclination to action, knowing that sometimes doing nothing is the best medicine.5,6 When faced with uncertainty, physicians often choose action over inaction, for many psychologic, medicolegal, and other reasons. But “clinical inertia” may serve to protect unwitting patients from our own overzealous attempts to help.7 In their closing paragraph, the authors justify our concern: They “want silibinin.” That is exactly the problem we hoped to illuminate.

References

Gores KM, Hamieh TS, Schmidt GA. Survival following investigational treatment of amanita mushroom poisoning: thistle or shamrock? Chest. 2014;146(4):e126-e129. [CrossRef] [PubMed]
 
Hruby K, Csomos G, Fuhrmann M, Thaler H. Chemotherapy ofAmanita phalloidespoisoning with intravenous silibinin. Hum Toxicol. 1983;2(2):183-195. [CrossRef] [PubMed]
 
Enjalbert F, Rapior S, Nouguier-Soulé J, Guillon S, Amouroux N, Cabot C. Treatment of amatoxin poisoning: 20-year retrospective analysis. J Toxicol Clin Toxicol. 2002;40(6):715-757. [CrossRef] [PubMed]
 
Ganzert M, Felgenhauer N, Schuster T, Eyer F, Gourdin C, Zilker T. Amatoxin poisoning—comparison of silibinin with a combination of silibinin and penicillin [in German]. Dtsch Med Wochenschr. 2008;133(44):2261-2267. [CrossRef] [PubMed]
 
Ofri D. When doing nothing is the best medicine. New York Times. October 20, 2011.
 
Groopman J. How Doctors Think. Boston, MA: Houghton-Mifflin; 2007.
 
Giugliano D, Esposito K. Clinical inertia as a clinical safeguard. JAMA. 2011;305(15):1591-1592. [CrossRef] [PubMed]
 

Figures

Tables

References

Gores KM, Hamieh TS, Schmidt GA. Survival following investigational treatment of amanita mushroom poisoning: thistle or shamrock? Chest. 2014;146(4):e126-e129. [CrossRef] [PubMed]
 
Hruby K, Csomos G, Fuhrmann M, Thaler H. Chemotherapy ofAmanita phalloidespoisoning with intravenous silibinin. Hum Toxicol. 1983;2(2):183-195. [CrossRef] [PubMed]
 
Enjalbert F, Rapior S, Nouguier-Soulé J, Guillon S, Amouroux N, Cabot C. Treatment of amatoxin poisoning: 20-year retrospective analysis. J Toxicol Clin Toxicol. 2002;40(6):715-757. [CrossRef] [PubMed]
 
Ganzert M, Felgenhauer N, Schuster T, Eyer F, Gourdin C, Zilker T. Amatoxin poisoning—comparison of silibinin with a combination of silibinin and penicillin [in German]. Dtsch Med Wochenschr. 2008;133(44):2261-2267. [CrossRef] [PubMed]
 
Ofri D. When doing nothing is the best medicine. New York Times. October 20, 2011.
 
Groopman J. How Doctors Think. Boston, MA: Houghton-Mifflin; 2007.
 
Giugliano D, Esposito K. Clinical inertia as a clinical safeguard. JAMA. 2011;305(15):1591-1592. [CrossRef] [PubMed]
 
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