COMMENTARY

There Is Always Something Else to Do

John Mandrola

Disclosures

November 10, 2014

Editor's Note: This post originally appeared at drjohhm.org.

If you ever hear your doctor say we are going to do something because there is nothing else to do, be afraid. Be very afraid.

First of all, it should be self-evident that if caring and empathy and relief of suffering count as doing something, there is always something to do for patients.

A growing problem in medicine, especially in death-denying specialties like cardiology and oncology, is that having nothing else to do translates to not having a cure or a promise of immortality. In times past, such misthink wasn't so hazardous. Now, however, the inability to see failing organs as the natural order has never been scarier.

Caregivers in 2014 choose from a vast array of tools to prolong death and, in the process, destroy one's humanity. It has become quite easy to make human beings worse. We have ventilators, dialysis machines, restraints, shocking devices (and vests), mind-altering drugs, and nursing homes—where, contrary to popular speech, elderly patients rarely go to get stronger.

Caregivers in 2014 are also burdened with distorted expectations. When a 90-year-old person dies, he does not die of heart failure, kidney failure, or stroke; he dies of old age. I'm not sure when this notion got lost, but it is long gone.

Here is a case:

An elderly man presented with symptoms of a stroke. The good news was he recovered quickly. The bad news was what he went through. The really bad news was the endemic misthink underlying this case.

The frail but functional gentleman endured a lengthy hospital stay, which I mention because the danger of immobilizing the elderly is underappreciated. During this long stay he underwent numerous expensive and invasive tests, all of which confirmed what was obvious from the original brain scan: he had a small stroke from age-related blood-vessel disease (atherosclerosis).

Now to what almost happened. More than one of his doctors noted that the anticlotting drug he was taking to prevent strokes had failed. Drugs should not fail. And when they do, they must be changed.

That's when I got the call. "Is it okay to change this patient to drug X?"

"No. It is not."

There were numerous reasons I said no. The first was that he was doing well on the "failing" medication. It was doing other important things for him. The second reason was that no drug reduces the risk of stroke or heart attack to zero. The third and main reason for not switching was a complete lack of evidence to support using the new drug for this scenario. Maybe it would be better, but we don't know, because it's not been studied for this problem. What's more, the proposed drug requires good kidney function to maintain balance (steady-state levels). This patient, like many elderly patients, had impaired kidney function.

Perhaps you can see the issue.

Treatment was being switched solely because there was nothing else to do.

How did I deal with this situation?

I leveled with the patient. Literally. I sat down in a chair next to his bed. (I was tired after a long day, so it felt good to sit.) I began with the good news: he was okay, and he was going to be okay tomorrow, too. It was a small stroke. He was going home soon. This truthful news brought a smile, which was nice to see.

He asked about the new medication.

I explained my reasoning.

"Good," he said. "I looked that drug up. It's expensive. I could not have afforded it."

I explained further that I could not predict the future, but he was on the best therapy we had to offer.

This was a mild case. Nothing terrible happened. It's not hard to imagine the trauma that could occur when a nothing-else-to-do mind-set drives caregivers to operate or deliver chemotherapy.

There remain many challenges for healthcare. One is surely how to see the natural order of life and death. Another is to count caring and empathy and relief of suffering as doing something.

JMM

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