Blog | Monday, September 12, 2016

No way out


Perhaps you have heard the rather grim joke about how doctors don't know when to stop treating patients who no longer benefit. It goes something like this: The oncologist goes to the cemetery to find (and treat) Mrs. Jones, since she hasn't “seen” the latest chemo-cocktail for her recently fatal malignancy. When he asks the grave-digger why she isn't in her assigned plot, he is told that she is off getting dialysis. Bah dum bump. OK, so it is crude, but everybody gets it, because it is just an exaggeration of the kind of aggressive, low-utility care that we often see (or provide) at the end of life.

Readers of this blog know that I believe that we, as physicians, often fail our patients by doing more than we would want done for ourselves. I have generally considered this a distinctly American issue, fueled in part by unreasonable expectations of the utility of medical interventions, the entrepreneurial nature of a lot of U.S. health care, and the prevalent American sentiment that death is somehow optional, or at least to be opposed vigorously at all times regardless of the circumstances.

A recent paper in Heart provided a little international—and, alas, cardiology—flavor.

In it, researchers from the UK, Israel, and France reported on their experience performing primary percutaneous coronary interventions (PCI) for acute ST-segment elevation myocardial infarctions (STEMI) in nonagenarians. It was a retrospective analysis of a series of 145 patients with no control group, which almost certainly means that there was a strong selection bias toward treating only “the best” nonagenarians. The principal finding was a 24% in-hospital mortality, with a 6 month mortality of 39% and 1 year mortality of 47%. No data on post-infarct functional status or quality of life were presented.

They concluded: “These results should encourage primary PCI to be offered to selected nonagenarians with acute myocardial infarction.” Really?

Leaving aside the fact that there was way too little information provided to support that conclusion, I just can't get past the idea of doing these procedures in the first place. It is not “age discrimination” to point out that everyone dies of something, and that employing aggressive interventions in the extreme elderly is, at best, a choice to take a different path to the same certain destination; a path that itself often encounters its own pain and suffering.

Kids, if you are reading this, please don't let them do this to me if I make it to my 90s. Make me comfortable and draw the curtain.

What do you think?