Monday, February 11, 2013

Reconsidering the Premises of Care: The Patient Perspective and the Relief of Minimalist Medicine

This post is about some half-baked ideas that result from inferences I have made after noticing some patterns in my dealings with patients, inspired by one such interaction today.

Every now and again I have noted that some patients seem pleased by something I say, some perspective I present, and their pleasure I infer from their asking for my name and contact information so that they may pass it on to their other treating physicians.  This is somewhat unusual since I make clear that I am a dedicated inpatient doctor who only briefly contributes to their care in the most acute of settings.  And I have noticed that it is most likely to happen when I offer to them a perspective that gives permission, as it were, to pursue a less aggressive course of care even in patients who are not really at the very end of their lives.

Today, as is often the case, I suggested that a patient may wish to simplify his medication regimen, eliminating medications that, while constituents of an "optimal" regimen, are adding very marginally to his longevity while posing some very real burdens.  This patient has some longstanding chronic conditions but his medical regimen increased dramatically in complexity after a recent cardiac illness, such that he now takes two antiplatelet agents, an anticoagulant, and several medications for blood pressure and heart failure in addition to several medications he has been taking for years.  Since his most recent hospitalization six weeks ago, he has felt terrible.  This is either related to the setback he had with his recent cardiac event, or from the post-hospitalization syndrome detailed in the post about Death by 1000 Needlesticks, or, and this is not to be taken lightly, the cumulative side effects of his now complex medication regimen.  Indeed, the current hospitalization has occurred as a result of bleeding complications triggered by medications from his last hospitalization.

For "optimal" care, care directed at increasing his longevity and forestalling the progression of his well-circumscribed and easily labelled diagnoses (such as coronary artery disease; heart failure; atrial fibrillation) he will take more than a half dozen medications, each individually beneficial for a specific indication.  Some have additive benefits, but the degree to which these additive benefits are subject to declining marginal utility is difficult to know or quantify.  And the additive, and even multiplicative sum of side effects and risks of these combinations of medications is even more nebulous and difficult to pin down.  This is in part because fatigue; aching; nausea; hospitalization; all the side effects of medications and treatment are more difficult to label, not as cool to diagnose, and more easily dismissed as "noise" or negligible costs of the paramount goal of treating circumscribed diagnoses.

So when I remind him that all therapies are elective in nature, and that pursuing a less aggressive or even "suboptimal" course is an option, one that may not negatively impact his longevity while certainly decreasing the complexity and burden of his care, he shows a mixture of jubilation and bemusement.  He seems delighted to think of warfarin as an option, one that can be postponed for a stretch as his ulcer heals, and reconsidered later in light of new developments, new information.  Likewise, backpedaling on the doses of his blood pressure and heart failure medications, to see if his fatigue is reduced, is appealing to him. And he is astonished to learn that warfarin for stroke prevention in atrial fibrillation reduces annual stroke risk from 5% to 2%.  Often, people think that the number needed to treat of these medications is 1, not 35.

And when I think of this, I realize how obvious it ought to be to present all of these therapies and their intensity of administration as options.  Because this is how most people live their lives.  They are NOT consistent maximizers of their own welfare throughout their lives.  They do myriad things that trade off some longevity for comfort, pleasure and thrills, things that sacrifice some long-term outcome for a short-term gain or freedom.  People ride motorcycles; ski in the backcountry; set off fireworks; own firearms; text while driving; watch TV; fail to exercise; drink alcohol; use tobacco products; have multiple sexual partners; skip medications; spend now rather than saving for the future; cycle without a helmet; disobey speed limits; eat hamburgers; drink Coke; experiment with drugs; fail to floss daily - you get the point.  So then, why, when we treat them as patients do we put on rose-colored glasses and pretend that, confronted with an acute health issue, they wish to suddenly become maximizers and take a super complex regimen of medications with a singular goal:  to increase longevity by optimally treating all conditions to the max, regardless of the impact on cost and the quality of their lives?

It is much easier to see this in cases like that which I describe where, in spite of "optimal" treatment, the patient feels terrible.  And I do not take lightly or dismiss the possibility that he would feel even worse if he were not treated so intensively.  But it is certainly worthwhile to question our premises when things are not going as planned.  And the premise of "optimal" or "maximal" care for any condition deserves occasional reconsideration.

In another example of unfounded premises that I deal with all of the time, we have patients on a half of a dozen or more psychiatric medications who are admitted for an intentional overdose, a suicide attempt.  It is easy to dismiss these occurrences as a failure of the medical regimen - if only we could "tweak" the cocktail of drugs and find the optimal combination, the breakthrough mental illness could not rear its ugly head.  But what if it's the cocktail of medications that is causing the suicidal thoughts?  What if the entire premise is false and there is no cocktail of medications that will mollify the psychiatric symptoms?  What if the treatment of the psychiatric illness depends on lifestyle changes, social environment modification, or non-pharmacological therapy that is given only lip-service while the medications are tinkered with?  What if the whole premise of pharmacological treatment of mental illness is inherently flawed?

The analogy I used today is, what if you came to my garden and it was doing poorly, and I showed you a potpourri of chemicals, fertilizers, pesticides and herbicides I was using on it?  Would you think that I should keep trying to find the right combination, or switch to organics, or that maybe I should dispense with them and see what happens if I just watered it and left it alone to grow?

I do not mean to suggest that all our treatments are useless or of limited value.  Far from it.  But I do think that at a certain point, in some cases, we ought to consider that we may be doing more harm than good and that the best course may be to back off or try a fresh approach.

For every case of a patient who prays for a pill to "cure" what ails him, there is another one who would be ecstatic to be given permission to simplify his cocktail of pills.  Whenever someone appears to be doing poorly in spite of optimal care,  it's worth considering if he may be doing poorly because of optimal care.

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