Individualize Medicine!

[Publicola]

Recently I was in a situation where a 90 yo severely demented women, DNR/DNI, for altered mental status ultimately attributed to a UTI was admitted to our service. Pt was on tele monitoring and asymptomatic atrial flutter was noted. Now rather than going home the pt will spend an extra one to two days hospitalized for treatment of her a-flutter which she did not notice. Additionally our cardiology service recommends anticoagulation now with followup INR checks and cardiology clinic followup.

It is no wonder that our health costs our soaring when we are going to these measures in a 90 yo demented person who declared DNR/DNI status prior to dementia. Medicine has become so algorithimized with treatment fit for populations, where is individualization? Sure we are going to follow the currently recommended treatment options for a-flutter, that's easy and docs feel good following the these flowcharts but where is the part in taking each individual case in to account? Should this lady really be spending extra hospital time, with extensive followup and INR checks?

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[deleted87716]

Should this lady really be spending extra hospital time, with extensive followup and INR checks?

Depends...what did her legal decision maker want to do?

 

[docB]

I agree with the OP but is it doctors clinging to algorithms that is causing this or is it fear of liability coupled with the ethical obligation to let patients/families choose how far they want to go with care?

 

[Arcan57]

And how does that sentiment (blindly following guidelines has destroyed medicine) jive with research that have repeatedly shown that patient outcomes improve with standardization of care? Although I'm not sure exactly what outcome you can improve in a 90-yr old end-stage dementia patient.

 

[Rendar5]

The problem is that published research doesn't individualize well.

E.G: The NINDS trial standardized TPA to the point that it is standard of care. But if you look at the re-evals of their existing data (Hoffman did it int he last 12 months I believe) of the NINDS trial, that standardized benefit of improved 30-day/90-day outcomes may not apply to people at the extremes of the stroke scale (either minimal deficit or maximal deficit). You basically have to pull the data part to make conclusions about individualizing medicine.

 

[elwademd]

lots of arguments to be made...

why was she on tele in the first place? if you didn't have her on tele, you wouldn't have known about the a flutter...

and was it a flutter or afib? a flutter is generally thought of as responsive to cardioversion or ablation... which brings another set of arugments!

with that said, if the patient wasn't a candidate for cardioversion or ablation... and her dementia is that severe... she doesn't sound like the greatest candidate for coumadin anyway... so one could argue for aspirin...

but lets step back... why consult cardiology?

which really gets to the management of the patient in the first place...

consultants give advice/consultation... primary service makes the final decision. or at least should be. just because a consultant gives a recommendation doesn't mean that you are bound to do it. its not the way we typically think about it, i know.

I agree with the OP but is it doctors clinging to algorithms that is causing this or is it fear of liability coupled with the ethical obligation to let patients/families choose how far they want to go with care?

i think its oftentimes both.

think of that patient that you admitted to me a week or so ago. 80 something year old from a nursing home with hypoxia and hypotension... dnr/dni... but somehow the decision gets made to intubate the patient... to admit to me.... to wait for the family to come... for the patient to die in the icu the following morning.

you knew she wouldn't make it.
i knew she wouldn't make it.
yet we put her in the unit.
for her to die in less than 24 hours.

it was a weird situation for us both, i think.

still not sure whether we did the right thing or not.

 

[dragonfly99]

You don't have to anticoagulate a 90 year old woman who is DNR/DNI, especially if life expectancy is limited or if there are likely to be problems with compliance. With dementia, you could definitely make the argument that the risk of bleeding and/or overdosing the warfarin outweighs any potential benefit.

You don't have to keep somone hospitalized for asymptomatic atrial flutter unless the rate is really out of control. This applies whether the person is 50 or 90.

Agree w/docB...it's not that physicians want to do these crazy things, it's usually that they fear liability and/or the patient's family wants "everything" to be done despite the dementia, very advanced age, DNR/DNI status, etc.

I actually don't think it's the little old ladies staying 1 extra day in the hospital that are bankrupting us...it's the end of life patients who end up intubated for weeks in the ICU, the refractory cancer patients getting their 7th round of chemo, and the obese diabetics who are on 10 meds and in and out of the hospital with HTN, repeated infections, etc.

 

[elwademd]

You don't have to anticoagulate a 90 year old woman who is DNR/DNI, especially if life expectancy is limited or if there are likely to be problems with compliance. With dementia, you could definitely make the argument that the risk of bleeding and/or overdosing the warfarin outweighs any potential benefit.

You don't have to keep somone hospitalized for asymptomatic atrial flutter unless the rate is really out of control. This applies whether the person is 50 or 90.

Agree w/docB...it's not that physicians want to do these crazy things, it's usually that they fear liability and/or the patient's family wants "everything" to be done despite the dementia, very advanced age, DNR/DNI status, etc.

I actually don't think it's the little old ladies staying 1 extra day in the hospital that are bankrupting us...it's the end of life patients who end up intubated for weeks in the ICU, the refractory cancer patients getting their 7th round of chemo, and the obese diabetics who are on 10 meds and in and out of the hospital with HTN, repeated infections, etc.

i think its all of the above.

1 extra day in 5 patients per hospital... say a city has 10 hospitals (las vegas, where i am, has 14 or 15 acute care hospitals; and isn't a large city by any stretch of the imagination)...

say a day costs 1k... 5k/day/hospital... 50k/day in a city...

it adds up.

 

[Impromptu]

How specific was the do not rescusitate/intubate advanced directive? If it only involves rescusitation/intubation, then treating her for other illnesses does not not violate that directive.