The ethics of AICD's

[Annette]

Why do we put AICD's in people with EF's of <10%? How much longer is their life extended? What about quality of that life? What about the cost of the AICD and placement, plus the hospitalizations when it inevitably fires? What about when it misfires? Is this less than what it would cost to care for these people otherwise?

While I believe that my role as a physician is to advocate for my patient- to do and provide what is best for the patient- who advocates for society? Is putting in an AICD in a 39 year old still using cocaine more important than say paying for 3 more people to get primary health care (in terms of medicare/medicaid spending and availablility)? Who's job is it to decide this?

Who gets to decide what is futile? The AICD isn't going to stop or reverse cardiomyopathy. Is it futile? The patient is still going to die. What about intubating a decrepit 98 year old? What about a 97 year old? A 50 year old with the health of a decrepit 101 year old? The patient is ideally the person to chose, but where are we supposed to get the time to educate the patient and or family that health care is not like it is on TV? That medicine is not magic, and everyone, including a dearly beloved grandmother has to die eventually? Why do we continue care we know to be most likely futile when the family can't say stop because of guilt/anger?

I mentioned time because the ICU service at my hospital had been booming for awhile. There were no unit beds for approx 100 miles around. When you have multiple consults at once, it is hard to give the family all the support to make an appropriate decision. "Sorry, I'd love to give you all the information I have and support you through this decision process, but there is someone else threatening to die I have to attend. Grandma is not going to make it through this. Do her a favor and don't make me intubate her." is hardly appropriate. Our population is growing older and sicker, and we can keep them that way longer.

Sorry this is long and rambling. Had a patient admitted to the hospital with a bad infection that could have been prevented had she been able to afford a doctor, let alone have the time between her two minimum wage jobs, and had a coke addict, who had never worked a day in his life, get an AICD.

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[TommyGunn04]

The patient is ideally the person to chose, but where are we supposed to get the time to educate the patient and or family that health care is not like it is on TV? That medicine is not magic, and everyone, including a dearly beloved grandmother has to die eventually? Why do we continue care we know to be most likely futile when the family can't say stop because of guilt/anger?...

I'll respond to the above part of your post. There are a number of researchers who've looked into this problem, and much of the data suggests that commnication difficulties are at the center of the frustration you expressed, particularly in ICU settings. We have a fantastic internist here at Duke who's done some of this work and often lectures about it, and he likes to emphasize how residents often take the wrong approach with families, thinking "if I can only explain it well enough, they'll change their minds." In his experience doing decades of palliative care work, this never works, yet this is what residents are taught to do, or at least shown by example. Instead, he advocates having a family discussion where specific scenarios are NOT discussed. Don't ask if they would want to be intubated or shocked or whatever. Rather, the focus of the discussion should be about the GOALS of the patient, and the fears/concerns/perspective of the family. Once you flesh out the patient/family goals, you can make a RECOMMENDATION. Instead of just throwing data at them and saying "you decide," this switches things back around, but not in a paternalistic way. Here, you're simply interpreting their stated goals, plugging in your medical knowledge, and giving a suggestion. It's often helpful to summarize and say something like, "I'm hearing that Mr. soandso's goals are..." and then give a recommendation based on your expertise. You'll be surprised what you learn...maybe they just wanted to survive for one more month to see their daughter's graduation, but you'll never know unless you ask. With this sort of information, what seems unreasonable at first may be entirely appropriate. Furthermore, many of these researchers will argue that patients and families don't know enough about risks, benefits and outcomes to be able to make a fully informed decision, so just like you wouldn't ask a patient what antibiotic they want, you also shouldn't necessarily ask "would you like to be shocked." This is very contrary to what's often taught, but I've seen it work fantastically and find it to be a superior approach.

In addition, many times there are social issues that cause families to be too aggressive about intubation and other such measures, when they're really just struggling with letting go, as if to try to show you "this is how much I love my mother." Having a discussion like the one I described above, led by an experienced member of a palliative care team, will often result in 180 degree change in the care plan for the patient, and everyone will finally be on the same page instead of talking past each other as often happens. Sometimes all it takes is a recognition of their love and dedication, saying something like, "I can see how much you truly love your mother." Empathy goes a long way, and in my opinion it's sadly underused in medicine today.

Research suggests that residents are, on average, rather poor communicators. This is an issue we really need to work on nationally, in both graduate and undergraduate medical education. Sadly, it typically takes a back seat to the academic aspects of medicine, seemingly ignoring the fact that without the patient there would not BE a medical profession!

And so ends my rant for the day

In all seriousness though, this is a VERY helpful approach, especially when used by an experienced clinician.

 

[yesh]

I don't think it's my job to judge anybody's lifestyle, bad habits, etc....just to heal if im lucky...to comfort at a minimum....the cocaine addict is the same as the priest to me. In terms of "wasting" money...how can you place a $ value on life?? Why don't you question the billions of dollars wasted in this country through the miraiad of other venues and find solutions there if you really want to help society. You really should be the ultimate advocate for your patient...

 

[hyperbaric]

Empathy goes a long way, and in my opinion it's sadly underused in medicine today.

Research suggests that residents are, on average, rather poor communicators. This is an issue we really need to work on nationally, in both graduate and undergraduate medical education. Sadly, it typically takes a back seat to the academic aspects of medicine, seemingly ignoring the fact that without the patient there would not BE a medical profession!

Well said.

 

[Apollyon]

We have a fantastic internist here at Duke who's done some of this work and often lectures about it, and he likes to emphasize how residents often take the wrong approach with families, thinking "if I can only explain it well enough, they'll change their minds." In his experience doing decades of palliative care work, this never works, yet this is what residents are taught to do, or at least shown by example. Instead, he advocates having a family discussion where specific scenarios are NOT discussed. Don't ask if they would want to be intubated or shocked or whatever. Rather, the focus of the discussion should be about the GOALS of the patient, and the fears/concerns/perspective of the family.

Are you talking about JoGo?

 

[Annette]

I don't think it's my job to judge anybody's lifestyle, bad habits, etc....just to heal if im lucky...to comfort at a minimum....the cocaine addict is the same as the priest to me. In terms of "wasting" money...how can you place a $ value on life?? Why don't you question the billions of dollars wasted in this country through the miraiad of other venues and find solutions there if you really want to help society. You really should be the ultimate advocate for your patient...

First, thanks TommyGunn for the advice. It seems a much more reasonable approach. I had a patient once tell me in response to the cpr/intubate questions, if they would be bed bound for the rest of their lives, they would not want the treatment.

I do believe in advocating for the patient. My question is who is advocating for society? Like it or not, money for health care IS limited. The states' medicaid programs have only so much money. If we spend $20,000 to implant an AICD in a patient, that is $20,000 less we can spend on other things, such as giving another person medicaid. Is it important to implant AICD's? Yes, but at what point do we, as in society, say enough?

As an example of "rationing", we deny people who are still drinking liver transplants. Why? Because the new liver will be destroyed, the drinking may interact with the medicines required to prevent rejection, and because livers are limited resources. Money is a limited resource as well, just not as limited as livers.

And who advises society on what is appropriate and what isn't in medical care? Physicians do. That is why not only do we need to advocate for our patients, but to look at the bigger picture as well.

 

[TommyGunn04]

Are you talking about JoGo?

Who's JoGo???

 

[Dr. J?]

I'll respond to the above part of your post. There are a number of researchers who've looked into this problem, and much of the data suggests that commnication difficulties are at the center of the frustration you expressed, particularly in ICU settings. We have a fantastic internist here at Duke who's done some of this work and often lectures about it, and he likes to emphasize how residents often take the wrong approach with families, thinking "if I can only explain it well enough, they'll change their minds." In his experience doing decades of palliative care work, this never works, yet this is what residents are taught to do, or at least shown by example. Instead, he advocates having a family discussion where specific scenarios are NOT discussed. Don't ask if they would want to be intubated or shocked or whatever. Rather, the focus of the discussion should be about the GOALS of the patient, and the fears/concerns/perspective of the family.

Good post Tommy Gunn. How about some citations for all of us out here who are interested in this approach.

 

[DaBigDawg]

If any of you are interested in the ethics/details behind rationing of health care, try to get a copy of Pricing Life. I don't remember the author at the moment. The book does a pretty good job explaining the topic.

Anyone who thinks that our society does not put a $ value on life is living in a utopian fantasy.

 

[powermd]

I don't think it's my job to judge anybody's lifestyle, bad habits, etc....just to heal if im lucky...to comfort at a minimum....the cocaine addict is the same as the priest to me. In terms of "wasting" money...how can you place a $ value on life?? Why don't you question the billions of dollars wasted in this country through the miraiad of other venues and find solutions there if you really want to help society. You really should be the ultimate advocate for your patient...

Physicians are in the best position to understand both the costs and benefits of medical treatments. We see the miserable, depressed, bedbound, barely conscious patient who we continue to torture with therapy upon therapy because "the family wants everything done". We watch as that patient circles the drain, consuming hundreds of thousands of dollars in resources, only to die within a few days, weeks, or months. I'm a doctor, but I'm also a taxpayer, and a human being. Just because we can do something, doesn't mean we should. I think it everyone's business to decide how certain expensive or futile treatment get rationed; patients will be better served for it. It's cowardly to wuss out and say "it's not my decision."