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.”