Right Care Action Week — rational care

I wrote yesterday about how a broken healthcare system favors overuse of procedures.

Today I will discuss rational care. Remember the goals of the Lown Institute: We think healthcare should be affordable, effective, rational and available to all.

Rational means in accordance with reason or logic.

Hardly a day goes by that I don’t see irrational care. Why it happens is complicated. Patients may expect irrational care. Doctors and nurses can get pushed into delivering it. Then, insidiously, unreasonable and illogical care become normal; and rational care stands out as an outlier.

Some examples:

It’s not rational to perform (or offer) CPR to frail emaciated elders. CPR is an intervention–similar to surgery or chemotherapy. We don’t feel compelled to offer drugs or surgery that won’t help. If a patient would get no benefit from CPR, it’s not rational to do it.

It’s not rational to avoid asking patients about their end-of-life goals. As medical experts, we understand that death is normal. In taking the oath of Maimonides, we promised to look after the life and death of our patients.

The best way to help our patients avoid a bad death (death by ICU, death alone or death in pain) is to 1) ask patients what is important to them, and 2) be rational about how we frame the trade-offs. And there are always trade-offs.

We should stand against all who oppose recent the CMS’ proposal to reimburse end-of-life discussions. We let the death-panel trope squash rational reform in the past, let’s not let it happen again. Advance directives should be as normal as Time-Outs.

In general cardiology:

It’s not rational to routinely prescribe the new PCSk9 drugs. The FDA recently approved these drugs on the basis of their cholesterol-lowering properties. Costs will be huge, about $14,500 per year. That’s outlandish because there is not a shred of evidence that the drugs improve outcomes. The trials looking at this question will report in 2016-2017. Two facts to remember: 1) high cholesterol is not a disease. 2) Not all drugs that lower cholesterol reduce the risk of heart disease. Lilly just gave up on a potent cholesterol lowering drug, Evacetrapib.

Two examples in electrophysiology:

It’s not rational to offer primary-prevention defibrillators (ICDs) to patients with life-limiting illnesses, especially those on dialysis. The clinical trials demonstrating benefits from ICDs were performed in mostly young male patients with heart disease as their primary problem. Too often, the benefits of these expensive invasive devices are wrongly extended to those who do not stand to benefit.

It’s not rational to offer ablation of AF to patients who have not been tried on conservative measures. AF ablation is risky and expensive, and the disease AF is not immediately life-threatening. We learned in medical school that when AF occurred with high thyroid levels, we should treat the thyroid problem and the AF would resolve. Now we know most AF stems from typical lifestyle issues, such as obesity, sleep apnea, alcohol excess and high blood pressure. Hospitals and doctors make big money burning the heart for AF, but the rational thing to do is treat the problems that cause the disease first.

Then there is oncology: (I have personal experiences here.)

It’s irrational to offer chemotherapy and radiation to patients with late-stage disease who are debilitated. It defies logic to think people who can’t walk to the bathroom or eat a decent meal will tolerate and benefit from chemo. When my mom died a few years ago from rapidly progressive stage-4 GI cancer, a respected oncologist recommended chemo only 2 days before she died. A brave hospitalist helped my family understand the irrationality of “palliative” chemo. Oncology as a field has done amazing things, but this outside observer thinks it would benefit from a hefty dose of reason and logic.

Rational care needs a following. Many are the caregivers who want it to become normal. If you do, say so. Head over to Right Care Alliance and sign-up. Tweet, blog, write letters, make noise. Feel free to add other examples of irrational care in the comments.

JMM

6 comments

  1. Thanks again, Dr. John, for your wisdom and courage in speaking out in many forums against the absurdities of modern medical practice.

    So many docs are locked into the seemingly soulless and mind-numbing routine of churning patients in and out the door, year after year, creating revenue streams for the medical corporations and huge salaries for their CEO’s.

    You can look into their eyes and tell that they are miserable in their professions, and yet there are no workable alternatives for most. What satisfaction can be derived from an eight minute encounter with a patient? What can you do for the patient except order a pill, a test or a problematic medical device?

    I wish that more doctors would take a stand against the tide of greedy corporate medicine. Perhaps your insightful pieces will inspire needed change.

  2. Excellent and rational points. I have witnessed and commend you for your end of life discussions but how do we move from appropriate use to rational use. Making the subjective into objective is complicated. There most be something better than checklists! Has defensive medicine become so predominant that we have trained the compassion out of our providers?

  3. Wanted to say that I find your opinions and articles very refreshing. I have had two aortic valve replacement surgeries and am now pacer dependent because of damage that staph infection did to my heart tissue after my first surgery.

    I’m on my third pacemaker and have been dealing with afib-aflutter issues for the past 7-8 years and have had two ablations.

    I learned from my original trip to the hospital 14 years ago that the medical field was not all that I had built it up in my mind to be and I do a lot of research myself now and work together with my doctors to make decisions on how I should proceed.

    You are right about most wanting to act immediately and drastically when they see something new, but I do not buy into it.

    After my second ablation only worked for 3 months is when I starting doing more research on my own about afib and ran across your blog. I have lost about 25 lbs over the past 5 months and started doing a little more exercise. I feel so much better and I’m not sure if I’m back in sinus rhythm or not but have no issues getting through my day and doing the things I want.

    I plan on just taking my warfarin daily and BP meds as needed and going about my life until something comes along that needs more attention.

    It is just nice to hear a doctor that has the same attitude about healthcare and the healthcare system that I have developed over the past 14 years dealing with it like I have had too.

    Thanks so much for all you do!

    Sincerely,
    Mark E.

  4. My prof Dr. P V Vasudeva Rao a doyen among medical teachers of that time ,while delivering lecture on CPR in 1974 when I was a medical student told the students not to do CPR in a dying almost emaciated Pulmonary tuberculosis patient. Otherwise one will get PT on their own. Your words remind me his wording even after 41 years and still ringing in my years because of the message of vital importance.

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