Here are two vignettes illustrating the failure of doctors to master the obvious and maybe a window onto the future struggles to control medical costs.
A 90-year old is referred for care due to “end stage dementia.” End-stage dementia is medical speak and as such does not really convey the appropriate imagery. It means a skeletal man, in a wheelchair or mostly in bed, with diapers, who has does not know when to eat, or pee, or who his family is and most tragically who he is.
The question put to me is why would he be taking multiple medicines for high blood pressure, high cholesterol, two pills for depression and one for urinary frequency. He has seen many doctors of late, but none have decided to stop any of these currently (but not years previously) useless medical treatments?
The second case involves a man seen for recurrent fainting from either a lung tumor pressing on the vagus nerve in the chest or the inflammatory effects of radiation (for bone metastasis) on the vagus nerve. Additionally, on two previous admissions he had presented with low blood counts and excessively thin blood form the blood thinner warfarin. He was put on the blood thinner 3 years ago for atrial fibrillation but was in regular rhythm presently. His risk of stroke per year without the blood thinner is only 3-5% but his chance of surviving a year with the lung cancer is less than 10%.
One would think that stopping of the heart medications started 3 years ago for a much more benign problem which is not currently manifest and causing potential bleeding problems would be a no-brainer. No, there is angst from the family and some other doctors; “he was told that he needed these for his heart -3 years ago before the lung tumor.”
Both patients in their present conditions would benefit from less preventive medical therapy and more symptom and comfort control. But yet, despite an obvious lack of benefit currently these therapies were continued, perhaps because they once were indicated or the obvious question: Do doctors feel they have permission to stop therapies no longer effective?
These notions are from a believer in science – that B-blockers, ACE inhibitors, statins, anti-platelet agents and defibrillators all decrease mortality in the appropriate cohorts. Patients with advanced lung cancer and dementia were not included in the trials that document benefit of the above mentioned therapies because the scientists know that severe co-morbidity would preclude benefit. In other words, how can blood pressure or cholesterol medicines improve longevity if another problem will cause death in months? Seems obvious.
Why can’t the clinician know this, or do they, and are fearful of stopping any sort of treatment lest there is liability? Or is it much harder to have the “discussion” than to continue the medicine – like the possibility that too many pacemakers are implanted because it is often easier to implant a pacemaker than explain to a room full of family members why it is not indicated? Maybe in medical school or residency (now with government mandated limits on hours worked by residents) there is insufficient emphasis on the interpretation of, and clinical applicability of scientific studies?
Many more questions remain, but it is certain that the likelihood of meaningful cost control in our present paradigm is bleak.
John Mandrola is a cardiologist who blogs at Dr John M.
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