Dr John M

cardiac electrophysiologist, cyclist, learner

Cardiology and stewardship — New post up at Medscape|Cardiology

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One of the definitions of the noun steward is a person whose responsibility it is to take care of something. Wikipedia calls stewardship an “ethic that embodies the responsible planning and management of resources.”

These apply well to cardiologists–who use powerful (and expensive) tools in the care of fellow humankind. The internal cardiac defibrillator, or ICD, is one such “big hammer.” The $30,000 device automatically terminates sudden cardiac death via internally delivered 750-volt internal shocks. These shocks usually prevent the patient from dying of that arrhythmia at that moment.

The cost of the ICD, however, is not just in dollars. The tradeoff means exposing the ICD patient to harm, such as surgery complications, infection, inappropriate (wide awake) shocks and the worst harm of all: a bad rather than good death.

Said another way, when used well the ICD extends life rather than prolongs death.

This is where stewardship comes in. Our job as cardiologists is to see the whole person rather than a person with a list of diseases. Too often, a patient with a weak heart (low ejection fraction) is told they “need” an ICD, or…and here is the catch…”they will die.”

You can see where I am going because I’ve been there before so many times. First, there’s the issue of using the verb need in the counsel of patients. Gosh, I hate that. Doctors don’t determine whether patients need invasive treatments, patients do. Then there is the issue of using the fear of death. Of course they will die. We all die. Treating death as optional lies at the root of our end-of-life humanitarian crisis.

Two recent studies in the Journal of the American College of Cardiology urge cardiologists to think hard about our role as stewards in the use of the ICD. One study evaluated the appropriateness of ICD-generator change and the other the utility of the six-minute-walk test in predicting ICD benefit.

The ICD generator change story is important because one in three ICDs are implanted as replacement devices for patients whose original device has reached battery depletion. (Approx battery life is 4-8 years.) Many factors combine to make the decision to replace an ICD different from the original implant decision. Mostly, it’s time. Patients with ICDs age, change their views and acquire other life-limiting diseases. And in many cases, as reported by University of Pennsylvania researchers, patients with ICDs actually improve their heart function so that their risk of death by arrhythmia diminishes. Now what should be done? Are ICDs life-long therapies?

The second study involved the use of walking ability (six-minute walk distance) as a means to predict ICD benefit. The role of functional capacity in determining ICD benefit is relevant because it speaks to the whole person rather than the person with a weak heart.

In the post on theHeart.org, which is now called Medscape|Cardiology, I describe the two studies and then explain why they provide a major opportunity for cardiologists to be stewards for both our patients and our profession.

I hope you want to read more. Here is the title and link: ICD Decision Making: An Opportunity for Stewardship

JMM

ICD deactivation in the NY Times — with a quote from a blogger

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The news came via a direct message on Twitter. “You got a plug in the NY times. Congrats.” (Thanks Dr. Jay Schloss.)

Paula Span, author of the NY Times’ The New Old Age Blog, reported today on the issue of cardiac device deactivation in patients who are approaching end of life.

The role I had in the piece stems from the editorial I co-authored with University of Colorado Professor Dr. Dan Matlock in the Journal of the American Medical Association-Internal Medicine. 

I think this is my first mention in the Times. It’s especially nifty because end-of-life care is such an important topic.

Yes, cardiac devices can do a lot of good for people. They improve lives. They extend lives. I’m not sure why my brain works this way, but when I see an ICD printout showing a sudden death episode averted by something I did, I often think that I once was a paper boy. How’s it possible that a goofball like me could save a life? The hashtag here would be…#beautiful. Or…#I’d-still-go-to-med-school-again.

But cardiac devices are no small deal. They come with risks. Serious risks, like this one: essentially every patient with a cardiac device ends up dying with it still implanted. Death is certain, so the once useful device eventually sheds its usefulness. ICDs are implanted to prevent sudden death, but most ICD patients (approximately 14/15) don’t die suddenly; they die of something else, something less peaceful. These truths call doctors to help patients formulate a plan before the inevitable occurs. The ICD discussion presents an ideal chance to speak with patients about their goals for care. Yet, as the Mayo Clinic researchers showed in the study that Dan and I commented on, it rarely happens–even at places like the Mayo Clinic.

This is not surprising. Nothingness is no easy topic. Death is vast. When I had a concussion, and was out of it for 30 minutes, it was as if I was nothing for those minutes. One minute I was here, and the next gone. The weird part is that if I hadn’t come back, I wouldn’t have known I existed. This is heavy stuff. You can see why it gets pushed aside.

Patients get seen. Ejection fractions measured. Devices implanted. Paperwork completed. All are happy. No one dies. No one talks about dying.

Taking this path, however, the one where action obscures the reality of death, has never been more risky. ICUs and nursing homes overflow with patients stripped of their dignity, mostly because these poor souls had no plan to avoid death-prolonging care.

The ICD provides a great opportunity for a caring physician to make a difference.

Ms. Span explains:

Dr. Matlock argues that any doctor who knows how to implant a cardiac device — any doctor, period — can also learn to have a conversation about what a patient wants to do about it as the years pass, and to renew that dialogue (it should also include the matter of replacing I.C.D.’s when their batteries die, which requires additional surgery) at follow-up visits…

…But the current reality, Dr. Matlock says, is that “a lot of doctors would have trouble with this conversation. It’s much easier to say, ‘Your device looks fine. See you in a year.’”

My friend is right. Specialists, like electrophysiologists, cardiologists, oncologists, surgeons, are the caregivers best positioned to align therapy with a patient’s goals. We understand what our treatments can and cannot do. We know the downsides. We (should) know the patient.

Here it seems right to quote one of the most famous cardiologists of our era. During a debate at a national gathering of cardiologists, distinguished professor Dr. Mark Josephson, said that he hated the term proceduralist. “You are not proceduralists, you are doctors.”

JMM

Here’s a link to my original post on DrJohnM

Shelley Wood, managing Editor for theheart.org|Medscape Cardiology, covered the story as well.

End of life care – A great American tragedy.

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“Why don’t we die the way we say we want to die? In part because we say we want good deaths but act as if we won’t die at all.”

Katy Butler, WSJ

There is a humanitarian crisis unfolding right now in nearly every hospital in this nation. Aggressive life-prolonging care of the elderly too often results in extending suffering and loss of autonomy. “Bad deaths” are on the rise. As a physician witness to this, I feel shame. As a fellow human, I feel sadness.

Acclaimed American journalist Katy Butler has written an essay (and book) that I believe may help spark the changes needed to quell this crisis. I’ve been writing on the Internet for almost four years, and no one essay has moved me more. This is the most important piece I have ever hyperlinked. By far.

Two recent cases illustrate the problem: In the last two months, I have been asked to operate on two elderly frail patients; both had expected lifespans measured in weeks to months. One patient weighed less than 90 pounds; the other wore a diaper and ate honey-thickened liquids. Nothing I (or any sub-specialist) had to offer would have changed their elderliness or frailty. These poor souls needed compassion, candor and comfort measures, not cardiac procedures. So why was I asked to consider intervening? Why weren’t these patients receiving palliative care? Where was the appreciation that death is a natural part of life?

Ms. Butler’s WSJ essay, written from the perspective of both a loving daughter and an investigative journalist, gets us close to the answers to these questions. One could even draw a potential solution to the crisis in end-of-life care from her story. At least I did.

Ms. Butler was forced to face down the paternalistic death-is-a-failure mentality of typical US healthcare for both of her parents. First was her father’s tragic case. This award-winning essay, published in the NY Times, told the story of how a hastily implanted and unwanted pacemaker prolonged her father’s suffering. A daughter and wife learned important lessons from this sad interaction with caregivers.

Now, years later, Ms. Butler writes about how her 84-year-old mother “fought the medical establishment and avoided what most Americans fear: prolonged, plugged in suffering.” In this case, both patient and family displayed extraordinary vision and courage.

Surveys consistently find the majority of Americans want to die peacefully at home. Most do not get their wish. Rather, it’s the opposite: nearly 50% die in a hospital and 20% die tethered to machines in an ICU. Ms. Butler writes:

“Family members who once wiped the brows of the dying were restricted to visiting hours. Often there were no “last words” because the mouths of the dying were stopped with tubes and their minds sunk in chemical twilights to keep them from tearing out the lines that bound them to Earth.”

This is not hyperbole. This is real. I could show you. Any hospital doctor could.

Why can’t intelligent people see death as a normal part of life?

End of life care is complicated. Start with the premise that death isn’t easy to think about—for either patient or caregiver. Ms. Butler tells how her mother struggled to accept her own mortality. Her mom was active, aware and full of life until the end. Being well made it hard to give up on life. Why wouldn’t it? When life is good, wanting to hold on to it is normal.

But Ms. Butler’s mother had an advantage. She saw her husband suffer. On some level, all people understand that death cannot be avoided, but in reality, few people see the risks of a bad death. People are optimistic; they focus on good outcomes. Loss of autonomy in a hospital, ICU, or nursing home won’t happen to them. The will to live (or avoid death) obscures the ability to see the risks of a bad death. So in part, the problem lies with human nature: “we act as if we won’t ever die at all.”

This is where trained caregivers—like cardiologists and oncologists—should be able to help. But for some reason, in far too many cases, neither doctors nor nurses can see the risks of a bad death either.

“Her later cardiologists were disturbed by her decision. But I would discover that people of my mother’s age are often like Humpty-Dumpty, seemingly vigorous until a mishap, a traumatic surgery or a hospital-acquired infection sets them on a rapid downward spiral.”

In the case of Ms. Butler’s mother, caregivers from the highest echelon of Medicine (at Harvard) failed to align care with their patient’s goals. They failed because they didn’t consider death as a natural part of life. Rather, death was the enemy that had to be defeated. Her heart surgeon spoke of living to age 90; a heart failure nurse urged her to reconsider and another cardiologist recommended (and nearly strong-armed her into getting) aggressive experimental heart surgery immediately before she died.

This was a total failure of patient-centered care. Only the primary care doctor understood:

I called my mother’s internist. “I know your mother well enough, and I respect her,” he said. “She doesn’t want to risk a surgery that could leave her debilitated or bound for a nursing home. I think I would advise the same decision if it was my Mom.”

Patient-centered care is part of the solution

Aggressive medicine served Ms. Butler’s mother well when she was in her forties. At that time, surgery and radiation were aligned with her goals to live longer. She was young and strong. In her eighties, things were different. She knew life was finite and death was unavoidable. Facing this reality didn’t mean she wanted to die. She didn’t. In fact, it took great strength on her part to accept death. But at age 84, her primary goal was avoiding a horrible outcome, like a stroke, loss of autonomy, suffering, and being a burden to her family. To increase the chance of a good death, she chose to accept a sooner death.

The take home…

For patients: the message is awareness.

First, all humans must grow more aware of their own mortality. This is not morbid; it’s just an important fact. Acting as if you will never die at all increases the risk of prolonged plugged in suffering. Think about your goals for care. Share them with loved ones. Second, be aware of the risks of aggressive medical care. Third, be aware of the death-is-a-failure mindset of doctors and nurses. Don’t expect the average doctor to offer no intervention or symptom-control as a viable option. Expect the average doctor to say, “if you don’t have this procedure, you will die.” Until the mindset of the medical establishment changes, you may need to demand patient-centered care, like the Butler’s.

For caregivers, especially specialists like me who wield the big hammers of medical care: We must work to improve the care of the elderly. Plugged-in suffering and loss of autonomy should be considered a major complication to avoid. It’s not a success when a fiercely independent elderly patient has to live out his days in a nursing home.

The first step for us is the same as it is for patients: namely, accept that death is normal, and not the only enemy. A bad death should be equally feared. Beautiful technologies, like the ICD, open-heart surgery, or chemotherapy, do not offer the elderly the same risk/benefit choices. We need to pay more attention to Ms. Butler’s use of the Humpty-Dumpty analogy. My wife, a palliative care doctor, speaks of the elderly as a house of cards. Pull out just one card, from, say aspiration pneumonia, post-op AF, UTI, VTE, the list is endless in the elderly, and the once independent elderly patient is no more.

Realizing that death is a normal part of life is only the first step. The next step is to embrace the notion of patient centered care. This is critical in the elderly. Consider the case of Ms. Butler’s mother: only her primary care doctor respected her wishes. Why didn’t her heart specialists offer her the same respect?

Here’s a post I did on an ACC board question on valvular heart disease in an elderly patient. Nowhere in the list of ‘best options’ was the choice not to intervene. That’s my point: not intervening, choosing to live with the disease is an option that must be offered to the patient. And not just as a side-note, but as a real option. The elderly patient who decides not to have heart surgery may not get the benefit of the surgery, but they get to avoid the risks of a bad death from a complication.

A theory: If we specialists were more candid about the risks of a bad death (be it from complications of heart procedures or chemotherapy), we would find that the primary goal for many of our patients would be to remain independent until the end, whether that came sooner or later.

Finally, the highest quality medical care is that which aligns with the goals of the patient. It is their life and their death. The ultimate job of the caregiver is to care. And that means, as described in the Oath of Maimonides, “to watch over the life and death of Thy creatures.”

JMM

Take fear and ignorance out of end-of-life decisions — A rebuttal to Dr Paul McHugh’s WSJ editorial

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Perhaps it’s because I love the practice of medicine so much. Or maybe it’s because doctors (and teachers) have always been my heroes.

I’m trying to sort out why I feel so offended by Dr. Paul McHugh’s editorial in the Wall Street Journal last weekend. His sensational and paternalistic view of physician-assisted suicide can be summed up in one word—shameful.

It is true, thankfully so, that in the United States offensive speech is protected. And we can agree that right-minded people may see the merits of physician-assisted suicide differently. But Dr. McHugh is a senior physician, an author, a commentator and a Wall Street Journal essayist. This sort of influence brings a great responsibility to be cautious with words, especially when attacking colleagues.

My view of physician-assisted suicide is that we would do better to view it from the lens of the man whose pancreatic tumor is eating through his spine, or the women whose head and neck mass is eroding into her windpipe or the women whose oxygen level is so low that her blood turns acidic. Be mindful also that only a fraction of those suffering in the US get access to skillful palliative care. More frightening even, imagine it is you who are suffering, and you don’t get a choice because of the paternalism of your doctor, who, by the way, isn’t suffering.

All dissent should begin with areas of agreement: Dr. McHugh rightly points out that most patients suffering at the end of life desire pain control—the key word here being ‘control.’ In fact, many of those who are prescribed lethal doses of drugs do not take them in lethal doses. Why? Because they are comforted from being in control of their destiny. Humans desire autonomy.

There shall be no more agreement.

Dr. McHugh’s likening of the fair-minded people in the death with dignity movement to Schwarzenegger’s “terminators” drips of hyperbole, and really offensive hyperbole at that. Have we really devolved back to the scare tactics of death panels?

What is so egregious about this sort of hyperbole is that the United States has a humanitarian crisis in end-of-life care. A recent study in JAMA, shows that hospitalizations and ICU stays at the end of life are on the rise. Though hospice referrals have increased, most occur in the hours before death, after a patient has been exposed to aggressive care.

Dr. McHugh says he works with doctors in ICUs and testifies “all of them realize that human life is itself limited in duration and scope.” My experience and the research suggests otherwise. Even now, in 2013, with the percent of “enlightened” caregivers on the rise, too many elderly, frail, and poorly informed patients whither in the abrasive environment of ICUs. They are there, hooked to tubes and blinking monitors, robbed of their autonomy and dignity, because of people like Dr. McHugh and a former vice-presidential candidate. Hyperbole has contributed to the fear of even having the discussion of different paths for care.

For over ten years, I have sat on the peer review board of our hospital. I can testify that most cases brought for review involve elderly patients with advanced disease. These cases come for review because of errors in management of complex disease states, but the elephant in the room is nearly always, “why was this 89 year-old nursing home resident getting such aggressive care?” Would she have wanted this? Had anyone asked her what her goals of care were before she got ill? Did anyone (skillfully) present the non-surgical or non-chemotherapy path of care?

Dr. McHugh quotes the Hippocratic oath and Dr. Leon Kass. We learn that “the doctor is the cooperative ally of nature, not its master.” Another way to interrupt that sentence is to consider death as part of nature, and, as fellow humans, it is our job to use skill and compassion to help patients at the time of death. The Institute of Medicine calls on doctors to provide care that is respectful of and responsive to individual patient preferences, needs, and values, and ensure that patient values guide all clinical decisions. Rather than defaulting to aggressive care, isn’t it the job of caregivers to remove fear and ignorance from the decision-making process? This way, we can cooperate with our patients’ wishes, not master them.

Although the Hippocratic oath does indeed say not to administer a lethal dose of a drug, it also calls us to prescribe treatments for the good of our patients and keep them from harm and injustice. Walk through an average ICU in the US and you will be immersed in harm and injustice.

Many medical students take an alternative version of the Hippocratic oath, from Maimonides: “May I never see in the patient anything but a fellow creature in pain.” And… “Oh, God, Thou has appointed me to watch over the life and death of thy creatures.” If only this happened in real life.

But the real foul in Dr. McHugh’s essay comes when he suggests that those who seek to provide patients with autonomy and dignity at the end of life are interested in killing in the name of technocratic progressivism and population control. This idea strains any credibility. It’s outrageous and an insult to physician colleagues. That doctors do this to each other saddens me.

Optimism is heart healthy, so let us end with a hope that the ignorance and paternalism embodied in Dr. McHugh’s words will focus attention on our crisis in end-of-life care. Across this country, a nation known for freedom, Americans too often lose autonomy at the end of their life. As human beings we desire a sense of control; we are drawn to compassion. If we had these things at the time of death, many fewer people would feel they needed a doctor to help end their life.

JMM

P.S. And as a matter of dissent to my favorite newspaper: I understand the business model, but isn’t journalism, even opinion journalism, supposed to serve the greater good? Publish Dr. McHugh if you must, but also publish the opposing view beside it. Your country is in the midst of a crisis in end of life care, and people like Dr. McHugh are making it worse.

Heart Rhythm Society Meeting 2013 — Hyde Park Lecture

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Hi Everyone,

This may be the longest I have ever gone between posts. As all bloggers do, I will tell you the reason.

photo 2 I was preparing for my invited lecture at HRS 2013. It was a Hyde Park Talk. This means you stand in one of the busiest parts of the convention, and just start talking. You have a mic and the more you talk, the more people gather around. It’s different.

My topic was ICDs, goals of care and end-of-life conversations.

Here is the thing that put me under so much pressure:
photo

The names on that list are the biggest in the field. These talks are usually (and after mine will probably revert back to being) given by distinguished professors. So why would a non-academic like me get a spot on that podium? I’m not sure exactly, but here is what I surmise: Dr. Rich Fogel, the HRS program director, called me up months ago and said he read one of my posts on theHeart.org about ICD decision making. He wanted someone to speak about the state of the quality of the decision to implant an ICD. He knew the evidence base surrounding doctor-patient communication on sudden death prevention and ICD therapy was bleak. I can’t remember his words exactly, but it was something like, “this stuff needs to be said.”

When I agreed, I had no idea how hard it was going to be to understand a topic so well that you can talk, off the cuff, without PowerPoint, and to your peers.. First, you had the mountains of clinical data in support of the ICD that needed to be critically appraised. Then you had the matter of risk stratification–or said another way: the fact more than 80% of the time we implant an ICD, the patient gets no benefit. Next, was the evidence base on the decision making. Surveys of doctors’ and patients’ perceptions paint a bleak picture. I kept looking for one study that said we did a good job; I found none.

I interviewed experts all over the country. Many of the most published doctors on these topics were generous with their time. That was cool. They helped me find areas of improvement. For instance, at the time of ICD replacement surgery, and the decision to use a CRT-Pacemaker rather than a CRT-Defibrillator, and also, a focus on the ethics and legality of ICD deactivation at end-of-life.

The talk went well. A good crowd showed. I liked the fact a prominent thought leader (who will remain nameless) came up after and berated me for giving a slanted view of the data and being totally wrong about the fact that deactivation of devices at end-of–life was NOT physician-assisted suicide. He felt it was–and our discussion was spirited. I liked that. Of course, I was surrounded by folks, who by their attendance at such a talk, supported my view.

Two people mentioned to me that is was telling that such a talk was given in this format–out in the convention hallway, with no CME. That’s a topic for a blog in the future.

I expect a transcript to come up soon over at theHeart.org.

Here is the link: ICDs, goals of care, and end of life: Difficult conversations (Hyde Park talk at HRS 2013)

Today, I will be presenting in a session on Social Media for the Physician with friends Wes Fisher, Jay Schloss and internet lawyer Bob Coffield.

JMM

Standing up for a Harvard Doctor

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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

Going gently…

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…is how doctors die.

Few essays written by doctors are more relevant to today’s crisis in end of life care than Dr Ken Murray’s now famous, Why Doctors Die Differently.  It made it to the WSJ today, thank goodness. It’s available for free in its original (and longer) form at Zocala Public Square.

We discussed two cases this week in a review committee. Both patients were elderly and had multiple organs failing, but both underwent aggressive procedures that failed to prevent death. The debate centered on why the bad outcomes had occurred. I suggested that maybe the procedures should not have been done in the first place. Blank faces appeared. One person muttered, “they would have died.” But they died anyways, with a lot of tubes, bright lights and pain.

Dr Murray has it right…

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits.

Knowing our limits. That’s a tough one. My greatest challenge as a doctor in 2012 is not moving catheters, or sliding leads through s-shaped veins; these are easy, compared to honing the skills needed to help patients decide whether they should, or should not have such fury done onto them.

JMM