Dr John Mandrola


October 22, 2012

Before starting, in the interest of full disclosure, I want to admit something.

I've been trying to write about this topic for more than a decade. I'm just going to start and see where it leads.

Years before we used the phrase "shared decision making," or my wife became a palliative-care doctor, or I saw a World War II veteran imprisoned for years with depression and anxiety after receiving 36 inappropriate ICD shocks (recalled RV lead fracture), I felt cardiologists overused the word . . .

. . . Need.

Not all that we do in cardiology needs to be done at the speed of acute coronary intervention for MI. We have time—to listen, to teach, and to share alternative options.

So entrenched, however, is the word "need" that even I catch myself saying a patient "needs" this or that device, or an ablation, or a medicine.

But is it true? Do patients need our treatments? Does any patient need an ICD? An ablation? An anticoagulant? A stent? A beta blocker in stable CAD? Surely, no one needs an antiarrhythmic drug?

If not these things, then what? What do our patients really need from us?

More and more, I wonder about this important question.

Here's a story that I would like to share as a prologue: (I'll never forget this patient. I even remember his room.)

He was in his early 80s. Other than mild high blood pressure for which he took only one medicine, he was near perfect. He was able of body and mind. Widowed for a number of years, he lived alone.

Then one day, he found himself dizzy and weak. Third-degree AV block was what the ECG showed. His heart rate was 32.

The first doctor told him he "needed" a pacemaker. It would take only 30 minutes to implant and he would go home as good as new.

Then something strange happened: The patient said he did not want or need the pacemaker.

My instructions were clear: "Mandrola . . . go see this guy and straighten him out."

I trotted down to the ER, shook his hand, and overconfidently went on to explain why he needed the pacemaker—which I would skillfully install. Graciously, he accepted my explanation.

But he still said no thanks.

"Okay then," I thought. I'm pretty tired; it's late in the day. I'll admit you to the heart floor, and we can talk some more tomorrow. He agreed. I figured the nurses would explain further, and we would go to the lab in the morning for the pacemaker.

The next morning his heart rate was still 32. And he still said no thanks to the pacemaker. Now it was time for serious words. "Sir, you need this pacemaker, because without it you will die," I firmly told him.

In a gentle tone, as if he was more worried about me than I was him, he explained that he understood the situation and was okay with what nature brought. His life had been wonderful. He had no regrets. He had watched his wife linger on with chronic illness. It was time. He was done. This was his exit.

His decision shocked us. Remember, as a patient on a cardiac unit, he was immersed in a sea of devout life-prolongers. We had other docs speak with him. Maybe it was our delivery; perhaps we were not clear? We sent in a chaplain, a parade of seasoned nurses, and even a friend. Still the decision was thanks, but no thanks.

He lasted days, slowly declining into a peaceful death. Over those days, the staff made peace with his decision. They accepted it and shifted their priorities to making him comfortable, which they did compassionately and skillfully.

This story unfolded years ago. If it happened now, things would be different. I'd call my wife, and she would reassure me that older patients are either getting busy living or getting busy dying. She would tell me that once patients decide they have had enough, well, then, they have indeed had enough. That one's life and one's death are their decisions.

It was a great teaching case for me. Here was a vital man that 100 of 100 doctors would have agreed on the need for a pacemaker. But yet, this remarkable man taught us about something very relevant to today's medical climate--a milieu where doing more is the default. This was the first time that I had thought about connecting the word "need" and medical procedures. He taught me that ultimately what patients need isn't determined by us. It's determined by them. Our job is to present the options, teach, counsel, and then support their decision.

Our job is rarely to dictate need. In fact, I'm going (to try) to stop saying the word "need."


PS. I've been thinking a lot about ICDs and the word "need." (And AF ablation and "need.") I plan to write more on these thorny topics. EP doctors speak of "learning while burning." A similar process could be called "learning while writing."

Three recent editorials have got me thinking about the notion of how best to select patients for ICDs. I'm struggling with our horrible ability to risk-stratify patients for sudden death. Or . . . said another way: does the two-decade old notion of uselessly exposing 19 of 20 patients to the risks of an ICD to get one appropriate shock (that may not be lifesaving) bother you?

  1. Epstein AE. "Please implant a defibrillator in my patient": It's déjà vu all over again. Heart Rhythm 2012; 9:47-48 .

  2. Buxton AE. Implantable cardioverter-defibrillators for primary prevention of sudden death: The quest to identify patients most likely to benefit. J Am Coll Cardiol 2012; 60:1656-1658 .

  3. Kramer DB, Buxton AE, Zimetbaum PJ. Time for a change—a new approach to ICD replacement. N Engl J Med 2012; 366:291-293 .


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