What’s the difference between an optimist and a pessimist?
An optimist believes these are the best of times.
A pessimist is afraid he’s right.
It’s an old joke. But, it exemplifies how we expect things will turn out.
My wife and I have long had advance directives. These documents are identical other than our signatures. If the situation becomes hopeless, no heroics. Directions about intubation and CPR. Yada yada. Pretty much the same.
If my wife cannot make her own decisions, I will step in her shoes. And vice versa.
My wife’s disposition is such that if there’s a 1% chance for a miracle, she might want the chance. My disposition is such that if there’s a 99% chance the outcome is clear, I’m ready to check out.
Of course, we have never drafted a matrix calculating the odds of survival and action desired. Deep down, my wife is concerned I’ll pull the plug a little too quickly. Deep down, I’m concerned my wife will let me linger long past my shelf life. And remember, we consciously drafted our advance directives to deal with such matters. And they are identical.
If we were interviewed and videotaped, our subtle differences would be clear. And such differences could be used to guide more appropriate care as to timing and use of aggressive care – and withdrawal of such care. Just reading the paragraph above, a practitioner would have a better idea of what we would want if we could not make decisions on our own.
Last week I attended a conference where a surgeon described his father’s last days. He had surgery for a retroperitoneal tumor. Post-op, the father developed complications and was on a ventilator. He was heavily sedated. Based on the tumor’s pathology and intra-operative findings, it was estimated the father had about 6 months to live. It was possible that the father could have eventually been weaned from the ventilator, but, it was not going to happen overnight. And, it would have been a rocky course.
The surgeon’s mother (or step-mother) had the power of attorney to make medical decisions based on the advanced directive. She stated the father would not have wanted aggressive care. She opted for comfort care only. No aggressive measures were instituted. The surgeon’s father passed away.
The surgeon posed the question as to whether his father should have been afforded the opportunity to be weaned from the ventilator and make his own decision. Pre-op his mental faculties were strong and he was in charge of his destiny. But, weaning off the ventilator would have been a challenge and caused some suffering. The primary reason the mother was charged with making the father’s decisions was because of a reversible condition – the sedation. It’s possible that while the ICU team could have weaned the sedation over time and gotten the father off the ventilator – the outcome would have been the same. Who knows? Such decisions are never easy.
Finally, a recent article in the NY Times discussed the ramifications of the 30 day mortality metric. Hospitals and surgeons are judged by risk-adjusted the death rate at 30 days. 30 days after discharge from a hospital. 30 days after a major procedure – such as angioplasty or coronary artery bypass. The thinking goes if the 30 day mortality is high, that practitioner – or that institution – delivers lower quality care. The article described the story of a 94 year old woman who consented to valve replacement surgery. Her worst fear was ending up in a nursing home. The case was presented at meeting of American Academy of hospice and palliative Medicine. The talk’s title: “The 30-Day Mortality Rule in Surgery: Does This Number Prolong Unnecessary Suffering in Vulnerable Elderly Patients?”
During the procedure, the patient had cardiac arrest. Post-op she developed arrhythmia, pulmonary edema, renal failure, and pneumonia. She had a stroke and moved in and out of the ICU. She was off and on a ventilator. Two weeks post-op “she was depressed and stopped eating.” The geriatricians recommended a “goals of care” discussion to clarify whether the patient even wanted to continue such aggressive treatment. For all of her medical problems, the patient was still cognitively lucid. “The surgeons were optimistic that she would recover” and declined to participate in the discussion.
Discussion of palliative care options were deferred until Day 30. By then, the patient was septic with multiple organ failure. She died on Day #31, after life support was discontinued.
The Times article continued:
A study in JAMA in 2012 compared three states that require public reporting of coronary stenting results to seven nearby states that didn’t report. Older-adult patients having acute heart attacks had substantially lower rates of the stenting in the reporting states. Doctors’ concerns about disclosure of poor outcomes might have led them to perform fewer procedures, the authors speculated; they might also have weeded out poorer candidates for surgery.
The 30 day mortality number may limit care to those who need it. It may also prolong care to those who would be better off with less aggressive care.
Finding the right balance is hard. When I was a resident, it was hard to determine if I was cutting the suture knot with tails too short or too long. Thorny questions indeed.
The 30 day rule shows the stupidity and low information of the bean counters. As your article suggests, doctors not only have in their heads what is best for the patient based upon teaching and their experience; they have to take into account those arbitrary rules forced by government, and whether what they are doing is in line with what the insurance carrier would want them to do. The most harmful rule currently in place, to me, is the 30 day readmission rule. If a patient needs to come back in, and it is in the doctor’s best judgment, then readmit.
Once again the law of unintended consequences rears its head. Contrary to what the government thinks, physicians are not stupid and will do what is required to do our jobs and game the system as best we can. How about asking practicing physicians about what would be realistic metrics? Instead of imposing upon us arbitrary rules that may have nothing to do with actual patient care.