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How Hubris Impairs the Care of the Elderly

An elderly man with atrial fibrillation (AF) asks whether to continue taking a clot-blocking drug to prevent stroke.

This is the gist of a case my colleague Dr Anish Koka recently posted on Twitter. It’s a great thread. Click here to get to the discussion.

The first question Anish raised was whether you would keep a 101-year-old man with AF on an anticoagulant. For the sake of argument, you could make him a her, or you could make him or her 91 years old.

Let’s just say it is a very old person with AF.

The pro-side of using the drug is that the more elderly one is, the more the risk of stroke, and the more devastating a stroke would be. Age is a major predictor of stroke.

The scenario here is similar to the quandary we had with thrombolytic (clot-busting) therapy for heart attacks in the era before stenting: older patients with heart attacks had more risk from the blockage (death, heart failure) but they also had more risk from the clot-dissolving drug (brain bleeding.) Because of the high consequences, the drug delivered greater risk reductions but at the cost of a greater chance of devastating bleeding.

Use of the anticoagulant in an elder therefore provides a robust degree of probability benefit in the future.

The down side of keeping an elder on an anticoagulant is the higher risk of bleeding. Older people have a higher rate of harm (bleeding) from the drug.

Evidence cannot help us here. There are no studies that include patients in their ninth or tenth decade. The word for using evidence acquired in 60 year-olds to the very elderly is… foolish.

Also foolish is the idea of letting the patient decide. How the hell is the patient supposed to know the right answer? The way we frame this decision will surely sway the patient. Yes, it’s right to share the decision with the patient, but the advisor need be square on the decision at hand. Giving patients a menu of choices is akin to abandonment.

This decision, like so many in medicine, requires judgment. It also means resisting hubris.

The typical hubristic reasoning in this case means considering two potential errors. An error of omission occurs here if we choose not to use the anticoagulant and the man has a stroke. We omitted the drug and that omission played a role in his stroke. An error of commission occurs if we choose to use the anticoagulant and he suffers catastrophic bleeding. We committed him to preventive therapy and that commission played a role in his demise.

Many doctors struggle with this choice.

The struggle exposes our hubris. We are falsely confident that we control outcomes of a person who has lived for decades.

I strongly believe we do not control this person’s outcomes.

One need not consult actuarial tables to assess the chance of a 90 or 100 year-old person dying in the next year. It’s high–whether we recommend preventive therapy or not.

That being said, I would not take the nihilistic view that there isn’t a correct answer.I believe there is a best answer.

It is: do not use an anticoagulant.

During a recent trip to the University of Calgary, my electrophysiology colleague Dr George (Yorgo) Veenhuyzen taught me an important lesson about decision making under uncertainty. It applies to this scenario.

The lesson goes like this: when there is true equipoise of a treatment (a complete counterbalance), and that treatment has potential harm and added cost, the right answer is not to treat.

Of course it is. The doctor’s golden rule is first, do no harm.

In the very elderly, there is no proven benefit of anticoagulant drugs. This would require a study of very elderly people. There isn’t one; nor will there ever be. There is however a well-known increased risk of harm due to bleeding and added cost of the drug.

I would also add to my Canadian friend’s logic that people who have been lucky enough to live to old age deserve the right to avoid iatronegensis–or harm brought by us.

In this particular case, Anish tells us the elderly man did not continue with the anticoagulant. He went on to suffer a stroke.

Anish tempts us with further choices: should we “do nothing” or should we recommend clot extraction using the new devices.

This is an easier question to answer. The same thinking applies, only with a special caveat. Of course, I would not recommend a femoral access and invasive procedure in a very elderly man. The studies of these devices were done in much younger patients. Plus, it takes little experience to know the difficulties and potential harm of threading catheters up the blood vessels of 90+ year-olds.

But I would also argue that “do nothing” is not the alternative. One of the greatest errors of our time, one that frustrates me immensely, is the idea that not doing invasive procedures equates to doing nothing. How many times have I heard a nurse or doctor say “we have nothing to offer?”

We have plenty to offer people at the end of life. We can offer caring. Nowhere in the definition of caring is doing invasive procedures.

We can care for this man by attending to his needs and by trying to relieve any of his suffering.

Another thing we can do is reframe our thinking. Rather than bemoan this man’s fate, we could celebrate the fact that he lived a long life, one that will be mostly compressed without much morbidity. That is, assuming he receives adequate palliative care.

Finally, in this era of death denial and increasingly invasive medical technology, it would be wise to heed the words of the late Ivan Illich, a critic-philosopher, and once catholic priest.

In his prescient book Medical Nemesis (circa 1975), Illich wrote of three forms of iatrogenesis wrought by the medical establishment. Clinical iatrogenesis is harm from medical error. Social iatrogenesis is the medicalization of normal life.

But the most insidious form of harm from the medical guild is a cultural iatrogenesis–or medicalization that corrupts the essence of what it is to be human.

Illich wrote that “the medicalization of society has brought the epoch of natural death to an end. Western man has lost the right to preside at his act of dying.”


16 replies on “How Hubris Impairs the Care of the Elderly”

Interesting post. Anticoagulant for a very elderly person or not. Stroke versus massive brain bleed risk.

I am 71, had apparently one episode of afib 2 years ago. Am on an anticoagulant. I am female and between age 65 and 74, so these 2 factors say to taken the medicine. Next month, the electrophysiologist and I talk about stopping the medicine or not. He said the decision is complicated. He said in the end it will be my choice, something I’m not comfortable with.

Your article is timely and in a way, confuses this for me.

I find this to be very informative & reminds me how proud I am of the man who is an Outstanding Doctor but even Better Man♥️

Thank you Dr John for remembering Ivan Illich. I read his book Medical Nemesis in early 80’s and was very impressed. I have referred his thoughts in many discussions during decades with doctors, philosophers, admirers of “how medicine has rescued the world” (forgetting all other developements). Also in this context his thoughts are relevant. Now I am having PAF and following your posts. with great interest.

I wonder if additional research might segment an elderly population at risk of stroke into groups that might derive more or less benefit from anticoagulation. Left atrial appendage morphology, for example.

I am a family physician. These are challenging cases but often also very rewarding. A greater challenge for me is having this discussion, making the decision to not anticoagulate, only to have the cardiologist (or cardiology NP!) put the patient back on an anticoagulant when they happen to see the patient in follow up. Nowadays, when I have this discussion with a patient, I tell them that “your cardiologist may well disagree with me…”

Thanks for your comment Mark.

What is funny is that I often stop statins in the elderly and you will never guess what happens: the primary care clinician puts them back on it.

I also get many requests to hold anticoagulation for screening colonoscopies–in 80 year-olds! I’m like, really?

I guess my point is that chasing immortality and following mindless algorithms may not correlate with specialty.

Thanks for reading and taking the time to comment.

Indeed. I unfairly singled out cardiology. Seems like everyone is eager to offer an opinion to the patient, except orthopedics and general surgery…but their patients also see a hospitalist who will often start them on a statin or warfarin or whatever. Stopping statins in the elderly is a Sisyphean task.

You fellows are still speaking as if the patient were a tennis ball, racketted mindlessly from one discipline to another. What became of having the conversation?
When (if) I reach my 80s and errant coagulation seems to be the most likely cause of my imminent demise, you WILL have the conversation with me.

Why is it that no one wants to address reduced dosing of anti coagulation in cases such as the subject of this blog post?

I see both these issues as hubris from the other end of the telescope.

Thanks for exploring this dilemma – I appreciated learning more about possible outcomes of each option. Having said that, as a layperson/patient am left with the question: Of the two options which would be described as the ‘better’ way to die. Not to sound morbid, but at 101 isn’t that also consideration? Thanks!

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