Dr John M

cardiac electrophysiologist, cyclist, learner

  • Home
  • About
    • About Me
    • About the Blog
      • General Cardiology and Internal Medicine
    • Six Reasons why I Blog
    • What’s Electrophysiology?
    • ICD/Pacemaker
    • Electrophysiology Column / Medscape
    • Contact
  • Afib
    • AFib
    • AF in Athletes
    • The best tool to treat AF
    • Know your CHADS-VASC Score
    • 3 non-warfarin anticoagulants
    • AF ablation
      • 13 things to know about AF
      • Atrial Fib Ablation -2012 Update
      • Gender-Spec results of AF ablation
    • Female gender and stroke risk in AF
    • My AF Story
  • Heart Healthy
    • Heart Disease (by DrJohnM)
    • Healthy Living
    • Exercise
    • Nutrition
    • inflammation
  • Policy
    • Policy
    • Health Care
    • Health Care Reform
  • Doctoring
    • Doctoring
    • Knowledge
    • Reflection
    • General Medicine
      • Does your cholesterol level matter?
    • General Cardiolgy – Medicine
      • What is a normal heart rate?
      • Cardiology/Internal Med
      • General Cardiology
      • Athletic heart
        • The ECG of an athlete
      • General Medicine
      • Stroke
      • Statins
  • Cycling
    • DrJohnM on Cycling
    • How I became a bike racer
    • My top 12 Likes on Cycling
    • Cyclocross
      • A CX-Primer
    • Fitness
    • Athletic heart
    • The Mysterious Athletic Heart

Standing up for a Harvard Doctor

June 8, 2012 By Dr John

There was a very important article written in the NY Times today. It highlighted a common medical scenario in my world—the defibrillator (ICD) world.

I am going to talk about ICDs here, but the big picture inherent in this story illustrates the important issue of how best to apply invasive therapy to elderly and sicker patients.

The Times piece delved into medical decision-making when patients present with battery depletion of their defibrillator. The battery longevity of these devices ranges about 5 years. The default amongst many heart doctors is to assume that patients still need or want their ICD. I can say from personal experience that this is an incorrect assumption. There are other options. The device can be deactivated and left in place, or it can be exchanged for a non-shocking pacemaker.

Times author, Paula Span, smartly featured an interview with Harvard doctor, Daniel Kramer, who has been a strong and sensible voice in the electrophysiology world. He was a great person to interview for the story because he dares question the status quo. I loved the piece, but was surprised by the vitriol of some of the commenters.

Harvard doctors generally do not need mere medical bloggers to come to their support. But after reading the comments, which I am afraid, may be representative of many, I feel compelled to stand up for Dr. Kramer. Though we have never met, I am a huge fan of his work.

As an ICD implanter, I have seen both the good and bad of these potentially lifesaving devices. Like most invasive treatments in Medicine, the good can be very good and the bad, really horrific. One particular ICD patient comes to my mind: A man brave and strong enough to storm the beaches of Normandy in WWII was transformed to a scared and depressed old man in the years after his defibrillator misfired 72 times. It was awful. These stories stick with you.

Readers need to know that this NY Times piece recapped an important article that Dr. Kramer recently published in the NEJM. In it, he and co-workers spoke frankly to the medical community about ICD generator changes. The excellent article garnered little fanfare with heart doctors.

Going against strong headwinds in his own community of heart specialists, Dr. Kramer emphasizes three important issues that come about when older patients with ICDs face battery depletion: First, he asks heart doctors to re-evaluate whether the patient still benefits from the ICD. Perhaps, the original heart problem has improved? Secondly, he points out that a patient’s experience living with the device may have changed their mind about keeping it active. Perhaps, a patient with inappropriate shocks no longer wants the device? Thirdly, since the original implant, a patient may have changed their goals of care. Many patients no longer desire life-sustaining shocks—for whatever reason. It’s their choice; but they aren’t often asked.

You may wonder why such obviousness isn’t the norm?

It’s because our healthcare system imparts significant barriers. Dr. Kramer nicely explains two important hurdles: One is that healthcare in the US is fragmented, especially for the infirmed and elderly. Patients may have many doctors, and care is often not well-coordinated. This means, an installer, a proceduralist like me, is left discussing end-of-life care with patients immediately before ICD surgery. That’s not good. I am married to a hospice doctor, so I sort of know how to manage these conversations. This is not the norm for procedure-oriented heart doctors. The other barrier to getting the elderly the best care is our system’s misguided incentives. In our current fee-for-service system, I am rewarded for doing, not discussing not doing. In fact, not doing stuff is very risky—both legally and professionally (ie, loss of referrals.)

Finally, Dr. Kramer and his colleagues call for heart doctors to take the lead in starting “the conversation” with ICD patients. He wants us to share the decision of using invasive, potentially dangerous or ineffective care with the patient. He also asks the scientific community to study the outcomes of patients who undergo elective ICD generator changes. These should not be controversial recommendations.

It’s a huge mistake to equate this kind of smart thinking to rationing. Aligning evidence-based care, especially potentially burdensome surgery in elderly patients, with the goals of the patient is not rationing; it’s moral, ethical and obvious.

JMM

  • Email
  • LinkedIn
  • Facebook
  • Twitter
  • More
  • Reddit

Related posts:

  1. The doctor’s way, or the…
  2. Denied. Are you serious? I’m a real doctor.
  3. Waiting for the doctor can be a blessing
  4. A Doctor’s Touch

Filed Under: ICD/Pacemaker Tagged With: End of lfe care, Palliative Care, Pateint-centered care, Shared-decision making

John Mandrola, MD

Welcome, Enjoy, Interact. john-mandrola I am a cardiac electrophysiologist practicing in Louisville KY. I am also a husband to a palliative care doctor, a father, a bike racer, and a regular columnist at theHeart.org | Medscape

My First Book is Now Available…

Email Newsletter

Search the Site

Categories

Find me on theheart.org | Medscape Cardiology

  • Electrophysiology commentary on Medscape/Cardiology

Mandrola on Medscape

  • My Medscape column on general medical matters

For patients...Educational posts

  • 13 things to know about Atrial Fibrillation — 2014
  • A new cure of AF
  • Adding a new verb to doctoring: To deprescribe is to do a lot
  • AF ablation — 2015 A Cautionary Note
  • AF Ablation in 2012–An easier journey?
  • Atrial Flutter — 15 facts you may want to know.
  • Benign PVCs: A heart rhythm doctor’s approach.
  • Caution with early Cardioversion
  • Decisions of 2 low-risk cases of PAF
  • Defining success in AF ablation in 2014
  • Four commonly asked questions on AF ablation
  • Inflammation and AF — Get off the gas
  • Ten things to expect after AF ablation
  • The medical decsion as a gamble
  • The most important verb in our health crisis
  • Wellness Requires Ownership

loading Cancel
Post was not sent - check your email addresses!
Email check failed, please try again
Sorry, your blog cannot share posts by email.