John Mandrola


March 16, 2015

Staci Mandrola is my wife. She is also a palliative-care and hospice physician. She gave the only lecture on palliative care at the entire American College of Cardiology 2015 Scientific Sessions.

That is weird. There were thousands of presentations at the ACC meeting. But only one talk on palliative care. It is strange because, as much as we cardiologists want to deny it, all of our patients will eventually die. And many will not die suddenly and peacefully in their sleep.

Here are 15 (tweetable) nuggets of wisdom from Staci's talk: Commit them to memory and you will be better able to help your patients.

  • Buckle up . . . We are all going to die.

  • "If we wish to know about a man, we ask what is his story—his real, inmost story." —Oliver Sacks, MD

  • Recognize the four horsemen of the apocalypse: weight loss, immobility, increasing hospitalizations, and falls.

  • People don't die because they stop eating, they don't eat because they are dying.

  • People who don't (or can't) move are close to death. People are either getting busy living or they are getting busy dying.

  • Recurrent hospital admissions are a sign that death is near. This study revealed that median survival after four admissions for heart failure is 7 months.

  • Falls are bad. But you have to ask your patient. They know it is bad to fall, so they won't tell you about it unless you ask.

  • Stop the pills. Patients who are close to the end of life benefit when you stop pills. That includes statins, anticoagulants, and blood-pressure medicines.

  • If your patient is dizzy when they stand up, it does not matter what the guidelines say.

  • You would be amazed how much better people get when they eat bacon and eggs for breakfast instead of 15 pills.

  • Ask your patient what their goals of care are. Most people want to be asked what is important to them. (They do. You should try it. I have .)

  • Deactivating an ICD is not physician-assisted suicide or euthanasia. Not even close. Read the Heart Rhythm Society's position paper on this. Then read it again.

  • While you are reading, read Atul Gawande's Being Mortal. Tell your friends about the book. Tell your family. All Americans should read Being Mortal.

  • Any doctor who implants or recommends a cardiac device should have a goals-of-care discussion with their patient before implant.

  • When you ask about goals of care, ask your patient, "What is going on with your heart?" Often, they know, and say. Then it is easier.


PS. You also have to know that this is first lecture I have ever been to where the presenter buys chocolate for the audience.


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