”We devote vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more.” — Atul Gawande, The Heroism of Incremental Care, New Yorker, January 2017
Recently, a dear long-term patient came to see me in some distress. At age 90, she had developed some shortness of breath and needed oxygen. Her new cardiologist told her she needed heart surgery, a valve replacement, to fix the problem. As her primary care doctor, I knew she was extremely frail. She had cognitive problems, osteoporosis, fall risk and suffered from severe chronic back pain. While heart surgery “wouldn’t be that invasive” according to the cardiologist, I advised she would suffer more from the surgery and potential complications than it would be worth. She and her daughter were grateful that I looked at the big picture of her as a whole person, not just a person with a hole in a valve.
Instead, we elected for a gentler, less invasive approach, continuing oxygen, reducing medications that were damaging her kidneys, causing bruising and bleeding and decreasing her quality of life.
Polypharmacy, hospital induced delirium, complications of bedrest and medical procedures increase dramatically with the elderly. Treating them as we do younger patients isn’t evidence based nor safe. We must do what we can to keep them well and comfortable, but need to do so with clinical judgement, sagacity and with the whole person in mind. Most advanced elderly people value quality of life over quantity, independence, living in their own home and preserving cognitive function.
In a similar case, a 92-year-old underwent a bypass surgery after a fainting spell and ended up in a wheelchair after numerous post-operative complications, unable to recognize even his own family. The iatrogenic disaster struck leaving a previously functional person irrevocably damaged.
Recently, another robust, wellness-oriented patient I care for was placed on a new medication by his three consulting cardiologists, who all agreed it would get him to an ideal target profile. The trouble was, he developed flu-like symptoms, muscle and joint pain, liver enzyme elevations, and felt miserable. He and I agreed that the minimal risk benefit from hitting that target level wasn’t worth the loss of his quality of life. Using primary care reasoning, knowledge of him as a person and common sense, I made the call to stop the new medication. He thanked me.
Our medical system has become fragmented, hyper-specialized, technology and protocol-driven. While many benefits accrue from our ability to fix certain things we never could, it comes at the risk of overlooking the full context, beliefs and quality of life of the person involved. Because a procedure or drug is the standard of care, can be done and is reimbursed by insurance doesn’t mean it should be done.
The primary care doctor is the quarterback who looks at the whole person and all their health issues, then counsels the family as to the safest, most common sense path forward and avoids unnecessary and hazardous medical or surgical interventions.