How can doctors stop drugs prescribed by other physicians that are no longer effective?

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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  • Regina Holliday

    Thank you for addressing this topic. A decision to go into hospice care will help with some of these instances of unnecessary medications. I know as we decided on Hospice placement, the MAR was down-sized to reflect a choice in comfort care. Taking pills is stressful for the patient and caregiver. It is stressful to the body as well as the mind.

    I gave my husband his last meds. at 7am on June 17th, he was having trouble breathing and could barely wake up to swallow. I only had to give him four pills but it was hard to administer them in his state. He died about four hours later.

    I can understand how families feel; they want to do the right thing. Thank you for being willing to tell people that sometimes it is time to stop past medicines, and look at the new reality of the current presentation of disease. We need more conversations like this for people to get better end-stage care.

    -Regina Holliday

  • http://trishatorrey.com Trisha Torrey

    Dr. John – thank you for putting form to this argument.

    My mother, ten years into her Alzheimer’s diagnosis, was as you described – end stage with no ability to relate to the world around her. Yet my father was told Mom needed her pacemaker replaced because it was no longer working as well as it should. Had I not insisted many more questions be asked and answered, he would have put Mom through that surgery for no reason.

    You ask why doctors would do this… and I suggest most answers come from following the money. Explanations to the family take time, and time is… well, you know. If a drug that another doctor has prescribed is stopped, then the prescribing doctor is confronted by a drug rep who wants to know why his numbers are down. OR, the drug is kept on the prescription list for defensive reasons – take the patient off that heart drug, the patient has a heart attack and the family sues….

    Until payers begin rewarding physicians for the time they spend with patients and families in addition to (or sometimes in place of) procedures, then I don’t see this travesty changing anytime soon.

    Trisha Torrey
    Every Patient’s Advocate

  • Accidental Pharmacist

    I wholeheartedly agree with you in these cases. This is an issue that many pharmacists face too. Though it’s often believed that pharmacists promote drug use, for many, our first question is about what can be stopped. Throw in prescribing conflicts, concerns over ageism and the grey areas of EBM and the waters get very murky indeed.

  • imdoc

    Docs and medical facilities are fearful of not aggressively treating everything as no one wants to be charged with negligently withholding care, so one approach is to involve the patient to review the care. If I were actively dying of cancer, I would discontinue taking my lipid meds. The problem, of course, is that such care and counseling presumes an active primary care relationship. When “discussing with a room full of family members” is financially and professionally rewarded as much as putting in the pacemaker, I expect we will see improvement.

  • Mike

    I think the biggest problem here is that our treatment model is symptom and disease-focused. I’m not saying everyone should be a primary care physician, but there should always be some level of thought about the patient as a whole, as opposed to the particular organ system each physician is there to treat.

  • gerridoc

    I think that many physicians become fearful of disrupting the “status quo” with respect to a patient’s medication regimen. Practitioners can easily recall disastrous consequences of discontinuing a medicine that was thought to be “unnecessary.” It tends to make them gun-shy, but that should not be an excuse to “rubber stamp” an endstage dementia patient’s poly-pharmacy.

  • Primary Care Internist

    I agree that this population is, in general, way overmedicated. Ironically though, I find a lot of the meds are cardiac, or perceived to be primarily cardiac, e.g. antihypertensives, ACE inhibitors, statins, plavix, coumadin, etc.

    And “cardiac” is very emotional, rather than logical, to most laypeople without a medical background. How many times have our patients described their sole anti-hypertensive drug as “the heart pill”, and everyone’s seen the dramatic cartoons on TV commercials of platelets sticking to the wall of a coronary artery, with an impending massive fatal heart attack, that only plavix can (and will) prevent. Some people might even feel that if they stop taking their “heart pills” their heart will just immediately stop ticking and that will be it, that these meds are literally causing the heart to keep pumping. I think the media (and cardiologists) can perpetuate this myth.

    Then if such a patient sees a cardiologist (even at 90+ with an advanced dementia), they still get the gamut of testing, which inevitably leads to aspirin, plavix, ace-i, coreg, possibly amiodarone (???), and perhaps even cardiac cath & stent. Taking the patient off these meds, letting them be hypertensive & eventually dying of an MI (which maybe statistically is the likeliest cause of death anyway in this population) can be viewed as negligence, especially by ambulance chasers like John Edwards, who are prevalent and politically-connected.

    I think as we move away from a primary care model, this problem will get worse. I think the best one can hope for, for a family member with advanced dementia, is to wind up having a good sensible primary care doctor who will do what’s right for the patient, despite the malpractice & reimbursement climates out there. This is definitely a dying breed.

  • http://theexaminingroom.com drcharles

    Change the game from defense to offense, protect those clinicians who practice beneficence. The hypothetical clinician decisions you’ve cited are unfortunately quite rational moves in a game where the rules are tipped towards litigants, and against those whose withdrawal of intervention is portrayed as abandonment or immorality. Until the game is changed, clinicians will behave by the implicit rules, or risk serious professional and financial penalty. Health care courts might be a step towards restoring the proper balance of trust, establishing the rule of evidence-based medicine, and enforcing reasonable standards of care.

  • andymc

    I agree with the last 2 posts. I teach residents and most of the time our dementia/nursing home patients meds are minimized but is is not always easy because of the issues mentioned above. Each case must be individualized, true benefits and risks weighed, issues discussed with families, etc… On occasion, specialist have disagreed and restarted the meds. Overall, I think the issue of polypharmacy is becoming more of an issue and the residents I deal with to a good job….and by the way, have never not stopped a medicine for fear of “being confronted by a drug rep”, nor have the docs I work with.

  • R Watkins

    82 year old female with advance ALS came back from the cardiologist on Crestor 20 mg and an LDL of 17.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    We GIs see many patients who swallow a dozen or so pills each day who have nausea. Wonder why.

  • http://www.drjohnm.blogspot.com John Mandrola

    Great feedback all. So much to consider in these words. We who care and are engaged in the race have much work to do in delivering the most intelligent application of such technologically advanced care in the present healthcare milieu.

    So many factors are in play; our own spiritual beliefs, our interpretation of the science, poor reimbursement for non-procedural pursuits, liability concerns and as so eloquently pointed out by the Primary Care Internist, the maintenance of the heart beat with “those heart pills”

    It is true that us doctors of the heart are often most resistant in the offering of the alternative to continuing aggression in therapy. Since we are good at “squishing” and ablating and installing devices and less well versed in the art of offering alternative strategies including less aggressive comfort emphasizing treatments we naturally tend to the former approach -like a geometric theorem.

    Another side effect of such good squishing and ablation technology is the seeming lack of need for attention to lifestyle modification. In the subconscious of a cardiologist is it conceivable that beating a young patient up on their poor health choices seems futile given the rescue available in the future? A question: what if the government said they were dramatically raising reimbursement for cardiac rehab centers and also there would be bonuses for each patient that achieved a 50% gain in mets achieved on a treadmill. Might there be rehab centers all over, and wouldn’t this be a positive and far superior to the for profit heart hospital explosion.

    Lots of questions.

    JMM

  • Kristin

    It doesn’t help even the most caring and thoughtful of doctors to make the right recommendations when there are so many idiots out there talking about “death panels” and “pulling the plug on Grandma.”

    Judging by the mumber of people I meet who regurgitate these inanities, a sensible recommendation to withhold Crestor, say, from an elderly person with advanced ALS would be met with a lawsuit. Frankly, it makes me despair.

  • http://trishatorrey.com Trisha Torrey

    So many of these comments seem to assume that suggesting to a caregiver or loved one that a dementia or end-stage patient not be given a drug or a procedure would result in upset from the family or a lawsuit later… and I suggest to you that is wrong.

    There is nothing wrong with opening the dialogue to suggest that some of those drugs, or a specific procedure is unnecessary. Especially in cases of palliative care, the cost to the patient and family, for no improvement to the patient’s quality of life, just makes no sense. And I suggest that most caregivers would realize that and agree that those drugs should be stopped or that procedure not take place.

    If a caregiver says no, don’t stop – then don’t! But many, if not most, would be willing to stop treatment that only prolongs misery and takes a toll on their wallets, too.

    So I go back to my previous argument…. if that dialogue isn’t taking place, it’s because the conversation takes too much time. And time is money. So — follow the money.

  • ninguem

    >>How can doctors stop drugs prescribed by other physicians that are no longer effective?

    I assume you are talking about doctors no longer on the case. You have taken over care for any of a number of reasons.

    I get patients like that all the time. I stop the meds. I change within a family, to medicines I prefer.I find meds that made sense when the original doc prescribed, but no longer makes sense.

    If I have taken over care, I manage the patient as I see fit, and I don’t see a reason to continue a medicine I don’t think is still needed. I don’t understand why someone would consider it a dilemma. I suppose a dilemma if you are not sure whether or not the drug is needed, but if no reason anymore, I just stop.

  • Erik

    The reason is very simple: denial. No one wants to tell a patient’s family that their relative is dying; ev ern fewer families are willing to hear it.

    If more conversations started with “this is a 90 year old man dying of end stage dementia” instead of “this is a 90 year old man with end stage dementia” maybe we docs would get it.

    Maybe instead of BMI, we should calculate life expectancy of every admission. MIght lead to a lot less testing, especially in the ICU.

  • joe

    Dr. John:
    On patient #1 Maybe I am missing something but why would an end-stage dementia patient be referred to you the cardiologist anyways? Does the family truly understand what is going on here and the outcome? Does the family have unreasonable expectations? Is this a situation where there is a nursing home doc or NP who is just on autopilot and manages patients by referral. I suspect there is more to this story.

    Patient #2: Any history of thrombosis? That would change the equation.

    Trisha:
    re: “….then the prescribing doctor is confronted by a drug rep who wants to know why his numbers are down.”

    I think you are living in the past on this one. Any drug rep who confronted me on anyting related to prescribing would get be told to get the $^%*&# out of my office and not come back. Every year more and more entities/institutions are banning drug reps. The pharma industry even has it’s own gift guidelines now (they were looking bad and they knew it).My own state (and others) has essentially banned all gifts (including meals, pens, etc) to doctors. Frankly I don’t have a problem with it, but am I the only one who sees the hypocrisy of those same legislators taking PAC money? Look at the supreme court rulng of last week opening the door for unlimited spending in campaigns.

  • Kristin

    Trisha, I trip over litigious people every day–anything and everything is a a potential lawsuit, in their minds. That’s why doctors pay all those juicy malpractice premiums.

    Our own (non-litigious) family has recently gone through this, however–my mother in law was extremely ill at 79, having had cancer three times and now an over-irradiated colon that was literally falling to pieces and kidneys that were not working well. At her bedside a) FIL in total denial, believing that she would pick up her bed and walk and b) my hysterical SIL who was determined that this was it, the doctor was absolutely right and MIL was going to die, would not want to be on dialysis and we needed to all let go and not do unnecessary treatment.

    In the end, after all the drugs were out of her system, MIL came out of the drug-induced dementia and made the dialysis decision herself. She’s now doing great and is happy as a clam.

    Slightly different scenario, but as a big believer in being realistic about life and death and the potential of treatment, it gave me pause for thought. FIL in denial was actually more or less right, and the doctor (who gave her 24 hours) was wrong. There is never any one right answer to this very real dilemma.

    All you can ask is to try to get one primary care doctor looking at all the info and presenting it to the family, preferably in writing via email so that everyone understands the issues.

  • http://michaelguzzo.blogspot.com Guzzo

    How can doctors stop drugs prescribed by other physicians that are no longer effective?

    I’m not sure where the difficulty lies? If one sees a potential problem, call the prescriber to question it, discuss it, or to leave a message about your concerns. I do it all of the time.

    I’ve also discussed my concerns with patients themselves, or with their caregivers, if I cannot get in touch with the prescriber or if the prescriber declines to speak with me. Patients (or their caregivers) are very capable of making informed decisions themselves if needed.

  • http://www.drjohnm.blogspot.com John Mandrola

    Joe,

    I share my life with a palliative/hospice doctor. She is the source of many interesting cases. Her job has taught me much about end of life care.

    The second patient had no thrombosis issues. Specifically, the warfarin was initiated for paroxysmal atrial fibrillation 3 years ago. He had been in SR recently and had 2 prior admissions with INR’s above 5 and also had significant anemia.

    I also agree with the drug rep comments. As an electrophysiologist, nearly all the meds used are generic except, dofetilide, plavix and dronedarone (barely used). We barely see reps anymore and ours are not pushy at all.

    To Ningeum,
    Congratulations. Agreed. It is supposed to be this way but often is not. And, the look on the second patients family when I said we were going to stop some of the heart meds.

    To Trisha,

    You are right, and this is why those who are lucky enough to see a palliative care doctor or team are benefited greatly. Frankly talking about death and setting the stage for a patient and family is the key. My point, though is how this is frequently not done by the non-palliative care doctor and many of the reasons have been outlined above. I consider myself a somewhat “enlightened” heart doctor but these are very difficult discussions indeed, for which most of us are poorly trained for and realistically stated, poorly reimbursed for as well.

    Thanks for the comments…

    JMM

  • ninguem

    John Mandrola – thanks. For what it’s worth, I usually tell the patient the doctor who prescribed the medicine in the first place did the right thing at the time, but the circumstances have changed.

    Had a new patient who got digitalis toxic. He was put on digitalis decades before, in the days of “once on dig, always on dig”. The indication no longer existed, though it likely did at the time. doctor did the right thing back then, but it’s not the right thing now.

    I dunno, I don’t experience problems with it. They’re usually more than happy to have an excuse to dump certain drugs.

    Had one a couple months ago, that really did have a stroke, and had some pain. Previous docs treated as a thalamic pain syndrome, with the anticonvulsants and antidepressants, and all sorts of side-effects. Came to me. Seemed to me, for all the world……a “trochanteric bursitis” or whatever you want to call that entity. Steroid injection, pain gone. Off the meds.

    Family thinks I’m a genius. heh. It’s easy to look smart. All the other avenues of diagnosis and treatment were already tried by other docs, and failed.