Sigh.....

[radslooking]

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saw this today....73 yo patient comes in with increased confusion over 6-12 months. Has known Alzheimer dementia, mini mental status 13/30 (aka really demented). No symptoms of chest pain, sob. Has a cardiac workup because of a troponin of 0.53, has two 80% stenoses of lad and RCA, gets a bare metal and a drug eluting stent. Congratulations America. A couple more jobs just went overseas....but that doesn't matter, everybody's got to get theirs right?

I hope the current generation of cardiologists has a few more scruples than i see on the job sometimes.

 

[dragonfly99]

Just to play devil's advocate...
difficult not to do the stents once the +trop and the 80% stenoses are discovered, unless the family was against all intervention. medical management definitely should have been discussed with them, but even then the family often wants "everything done". Don't chalk up all aggressive medical intervention to "greedy" physicians. When you do IM and its subspecialties you start to realize how there are a ton of "gray areas" in medicine and it often isn't clearcut what should be done for any particular patient. It's also sometimes difficult to get patients' families to agree to deciding against aggressive care, even in some very elderly, low functioning or demented patients. Sometimes it is hard for families to let go. I'm not saying that's what was going on here, but it may be more than just a "greedy" interventional cardiologist wanting to put in stents to make more money. Also, if the "greedy" interventional cardiology hadn't done the stents, and grandpa comes in next with with troponin of 4.5 and a STEMI, the cardiologist likely could have been sued.

 

[radslooking]

Just to play devil's advocate...
difficult not to do the stents once the +trop and the 80% stenoses are discovered, unless the family was against all intervention. medical management definitely should have been discussed with them, but even then the family often wants "everything done". Don't chalk up all aggressive medical intervention to "greedy" physicians. When you do IM and its subspecialties you start to realize how there are a ton of "gray areas" in medicine and it often isn't clearcut what should be done for any particular patient. It's also sometimes difficult to get patients' families to agree to deciding against aggressive care, even in some very elderly, low functioning or demented patients. Sometimes it is hard for families to let go. I'm not saying that's what was going on here, but it may be more than just a "greedy" interventional cardiologist wanting to put in stents to make more money. Also, if the "greedy" interventional cardiology hadn't done the stents, and grandpa comes in next with with troponin of 4.5 and a STEMI, the cardiologist likely could have been sued.

First of all, we should be educating patients/families to not do this sort of nonsense, not "ask" them what they'd like. Sure, of course everyone wants the everything omelette if you offer it. It should be presented as an aggressive, potentially deadly procedure-. Not "well, we can open up his arteries and that may make him feel better or make his heart function better." No, that's not appropriate. You say, "given his condition, and his lack of being able to make a meaningful recovery, I would recommend aggressive medical therapy". This is bankrupting the hell out of all of us.

Do you know how hard most people in this country work for 15,000 dollars? Now, do you think it's appropriate to dump that money into a demented patient who will not recover? Moreover, I'd be willing to bet the above procedure carries more harm than benefit for this particular gentleman. This is an absolutley preposterous way to spent 15,000 dollars.

I'm sick and tired of people talking themselves into stuff that isn't right. ( i know you are taking the devil's advocacy dragonfly---no intent to harm here)

 

[dphoenix]

Two questions:

It should be presented as an aggressive, potentially deadly procedure-.

Do you believe angioplasty and stenting is really a "deadly" procedure?

Now, do you think it's appropriate to dump that money into a demented patient who will not recover?

So are you saying that if the patient was not demented, the cardiologist would be more right in performing the procedure?

 

[dr niceguy]

Agree with above on both points. Cath has complications but to present it as deadly is just as unethical as not explaining the consequences at all. I'm not saying I agree with the invasive management, but I know enough not to so carelessly second guess the intent or clinical decision making of other physicians.

What if I were to say that his sweet wife of 50 years wants her husband with dementia rather than no husband at all? Does it all of a sudden become more morally and/or economically tenebale? Again, not disagreeing with you, but be careful of injecting your own ethical compass onto a situation that you know little about, and is more complex than initially presented.

 

[dragonfly99]

<First of all, we should be educating patients/families to not do this sort of nonsense, not "ask" them what they'd like.>

Radslooking, are you in a heavy patient contact specialty, such as internal medicine, critical care, fp or peds? If you were, you would see that helping families decide what to do is more complicated than just "educating" them. There are a lot of complex moral, ethical and just plain old personal values that go into patients' and families' decision making processes. I'm not saying it was, or was not, appropriate to stent this particular gentleman. But I am saying you have been very quick to judge another physician's decision, presumable made along with the patient's family, and perhaps the patient. Once you start deciding that every demented patient doesn't "deserve" similar medical care to what you give another person, then who else should we add to the list? How about people with Down's syndrome? Turner's syndrome like my big sister? How about AIDS patients? Criminals/people in jail?

I don't disagree that we should think about the risk/benefit whenever we do ANYTHING medically, but to represent a cath as a "potentially life threatening intervention" would be untrue because I think the risk of death is way <5%. If this guy was being considered for a CABG that would be a whole other discussion with the family (and patient, if he is able to participate). We get your point though radslooking.

 

[radslooking]

"deadly" is an overstatement as it happens infrequently. However, people have clearly died or had very severe complications from a cath, no question. nobody would argue with that.

 

[mrantarctica]

Certainly, i think this is a fundamental point that is often missed. Any patient with chronic functional limitation should be assessed as to what the appropriate level of care during their stay will be. This is not limited to what treatments we offer, but also what investigations we do in the first place. Indeed - why do an investigation if you will not treat the associated pathology?

This should be a decision made with a combination of the underlying illness, the family's wishes, best medical advice at the time, and what is practical given the resources at your disposal.

Unfortunately, it's all easier said than done - and I think the spectre of legal 'embarassment' means that very few doctors are prepared to stand by sound ethical principles, to save their own ass. It's easier to just "do everything", and not worry about the huge cost of these seemingly 'unneccessary' interventions.

 

[radslooking]

Certainly, i think this is a fundamental point that is often missed. Any patient with chronic functional limitation should be assessed as to what the appropriate level of care during their stay will be. This is not limited to what treatments we offer, but also what investigations we do in the first place. Indeed - why do an investigation if you will not treat the associated pathology?

This should be a decision made with a combination of the underlying illness, the family's wishes, best medical advice at the time, and what is practical given the resources at your disposal.

Unfortunately, it's all easier said than done - and I think the spectre of legal 'embarassment' means that very few doctors are prepared to stand by sound ethical principles, to save their own ass. It's easier to just "do everything", and not worry about the huge cost of these seemingly 'unneccessary' interventions.

thanks antarctica. That sounds reasonable to me.

 

[radslooking]

you know, honestly, if you described the situation logically to the family, most families will agree with medical management, if you actually have the discussion. Actually, my major problem is that we don't even take the time to have the discussion. We just do the procedure.

And i don't mean to throw stones here, but maybe if the procedure wasn't quite so remunerative, people would start having a discussion of whether it needs to be done or not. Just take a time out and ask yourself if you're doing the right thing.

 

[radslooking]

Two questions:



Do you believe angioplasty and stenting is really a "deadly" procedure?



So are you saying that if the patient was not demented, the cardiologist would be more right in performing the procedure?

I think it is our job to tell the family if the procedure will improve somebody's quality of life. And if someone is demented, you have to ask the family if this is the life someone wanted. I don't believe in treating people differently. I believe in treating people with dignity and using our resources effectively.

 

[dragonfly99]

radslooking,
The fact is that there are more families than you think who, even when one "describes the situation accurately" still will choose very aggressive management for family members because they couldn't cope with the fact that they didn't "do everything" for said family member, or because they have unrealistic expectations. We see this all the time in internal medicine, particularly in the MICU. Also, people are only paying a fraction of the true costs of their care, so they don't have a financial motive to NOT have us always doing more, doing everything, etc.

There are many families who are very reasonable, but a lot who aren't either. Families and patients don't always make decisions based on logic, since they are in an emotional situation and also many are not scientifically trained and may not even be that educated. You can tell them grandpa, who has end stage COPD and has been intubated twice in the past already, probably isn't going to recover and very unlikely to be weaned from the vent, but all they remember is the two prior times he had pneumonia and later WAS able to come off the vent, so they think, "Why should I believe the doc?". There are those who believe we are not acting in their family member's best interests and do things "just to save money" (i.e. "You would save Uncle Joe but you don't want to spend the money/effort" or "You're treating him differently because of his race", etc.). These situations come up particularly in the hospital, where the docs often don't have a prior relationship with the patient and family. It's a little easier for you to be critical b/c you are in rads...all I'm saying is don't judge too harshly until you've walked in the cardiologists moccasins. Also, there is a lot of difference in quality of life for various dementia patients...I think for some it affects the family's quality of life more than the patient's, at least at first.

I'm not saying the financial incentives aren't screwed up in medicine, just am not convinced you have enough info in the case you are describing to just chalk it up to "greedy cardiologist" or "dumb internist/cardiologist can't explain to the family why medical management would be preferable".