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.

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

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.

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.

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.

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.

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.

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.

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.

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