Doctoring Hospice/Palliative Care ICD/Pacemaker

The power of the specialist physician — and stewardship

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My latest column over at discusses the disordered balance of power in the doctor-patient relationship.

As most of you know, I harbor strong biases about the quality of medical decisions, especially in the elderly. Attached. Yes, I am attached to the issue of decision quality. Nearly all of electrophysiology, and much of cardiology, involves preference-sensitive decisions. This means doctors are called to align treatments with the goals of the patient. We hold great power; we must use it justly and wisely.

My latest essay arose from an unusual source. The prominent medical journal Circulation Outcomes publishes a section they call Caregiver Viewpoint. The editors aim to understand patients’ experience of cardiovascular disease. Patients, families or caregivers write articles that explore the effects of treatment–on them. (Remember Dr. Montori’s discussion on the burden of care.)

You can imagine that this exercise–of looking at how patients experience communication, decision making, care coordination, access, cost, timeliness and safety–could get thorny for doctors.

In the latest Caregiver Viewpoint, two physician daughters wrote about their Dad’s experience with an ICD at the end of his life. Their father, a retired psychiatrist, survived a cardiac arrest at age 79. He had an ICD and stent placed at that time. He then did pretty well. The ICD never had to act. He aged. So did his ICD, which developed a lead problem that forced a medical decision at age 86. He faced two choices: deactivate the device (because a malfunctioning lead can cause inappropriate shocks) or undergo a risky lead revision surgery.

The bulk of the story centers on the daughters’ view of their Dad’s experience with his specialists. They felt he experienced less than ideal decision quality.

Here is the title and link of my essay: The Specialist: With Great Power Comes Great Responsibility

If you read it, take time to look at the comments. My good friend Dr. Jay Schloss took issue with both mine and the daughters’ one-sided viewpoint. His words made me think.


2 replies on “The power of the specialist physician — and stewardship”

For me – the BEST part of this important essay are the Comments and Discussion that follow the piece. Highly thought-provoking and subject for frank soul-searching. It is not so much what is (or is not) said prior to a medical procedure (the procedure in this case being ICD lead revision surgery – but could be ANY medical procedure) – but it is more HOW the message is conveyed. The identical words being said to a patient (and/or to their family) may exert dramatically different impact depending on HOW the message is conveyed by the clinician about to perform the procedure. Dr. Schloss brings up the valid points that we don’t really know “the other side” (from the physician who did the procedure). I suggest that for the overall GOAL of Dr. John in writing this piece – that other side matters less than awareness of the critical importance of Joint-Decision-Making by patient (and potentially with family, depending on patient desires) with Patient/Family comfortably aware of pros & cons are the KEY. There can be no “set formula” for how informed decision-making is done – since patients, doctors, and circumstances always vary – but awareness of the concept will go a HUGE way toward optimal joint-decision-making that is best (and preferred) by the patient. THANKS for writing this piece!

Thank you Ken. Indeed that was my goal. Jay’s comment and reaction did force me to re-examine my bias, which is strong when it comes to decision-making in the elderly. We are all biased/influenced by what we experience in life. My experience with how the elderly are treated in the name of “healthcare” is too often like a Gawande or Katy Butler book.

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