The Talks Must Begin Now

At what point do you draw the line? People come in many states of health. Clinically, I say it over and over again. Those who don't smoke and who exercise on a regular basis look much younger than their stated age. Those that smoke and don't exercise look much older than their stated age. There is the physiological age and the birth age. 90 year olds look like 60 year olds. 60 year olds look like 90 year olds.

Walking a day in my shoes involves a continuous evaluation of the whole clinical picture. I don't consider myself a specialist per say of any organ system. But I do consider myself a specialist of all organ systems.  It's called internal medicine.  And I fine tune my practice for hospital based presentations.  Every day I must make decisions. Decisions on how to evaluate new abnormalities that present themselves. Decisions on how to manage known chronic medical conditions. But how do I decide? How do I decide what to do and when to do it. What to order.  What not to order.

Many non practicing policy bench warmers would like to believe that practicing medicine is nothing more than following a guideline. For example, from the public's point of view, if they came across this website, they may be lead to believe that being a doctor is simply following rules. It couldn't be farther from the truth.

Let me give you an example.   What do you do when an independent 95 year old man comes to the hospital with a 3 week history of weakness and found to have anemia. A hemoglobin of 6. What do you do when this same 95 year old man is found to have paroxysmal SVT with bursts of 180 and sinus rhythms of 40? What do you do? What do you do when you find moderate to severe mitral regurgitation with pulmonary pressures of 60 mmHg?

What do you do?  Do you follow the guidelines (if they exist) and treat each problem as an independent entity, devoid of a living person?  Or do you look at the big picture?

How do you make a decision on how aggressive to be? We all want to sit here and say that age should not be an independent predictor for making medical decisions. I ask why shouldn't it be. Why should we not employ age in the equation of resource allocation. Let me ask you this:

Would you put a $30,000 defibrillator into a 60 year old patient with sudden cardiac arrest due to ventricular tachycardia and concurrent colon cancer with metastatic lung and liver lesions? How about a $5,000 pace maker? If you would, why would you. If not why not? What would be the basis of your decision? These are clinical decisions that are made every day. Judgement calls by medical professionals. You can't write guidelines for this stuff. Some doctors lose site of the big picture and do things to patients because they can. Because they lose sight of the big picture.  And sometimes, when you focus on the nail, it's just easier to ignore the house falling apart around you.

Good hospitalists are able to provide a big picture look at patient care and health care utilization in the hospital. You could call it expert medical opinion based rationing.  That's what it is.   And it's perfectly ok to limit ineffective and costly care with limited expected benefit. In the case of my 95 year old man. Imagine if a cardiologist or a gastroenterologist was primary. The gastro consults the heart. When the kidneys get stunted from the cath dye, the kidney docs come on board. When the temperatures start rising after a vomiting episode, on come the ID docs and the lunginators.

When I admit this patient, this patient is mine. I make the decision when a heart doctor is appropriate. When a lunginator or when the fever beavers are needed. But when a specialist admits this kind of patient,  anything outside their organ leads to a cornucopia of specialists with macular degeneration.  With out a hospitalist, or internist, or family practice specialist the big picture is often lost in a sea of  "check with Dr. Fever Beaver.  That's not my area."  I see it all the time when we come on board patients who have compartmentalized.

My 95 year old has an actuarial life expectancy of about 2 1/2 years. Not until you hit age 112 is the life expectancy less than one year. Does that mean we should do everything possible because the patient has a life expectancy of over one year? I don't think so. I make decisions not to pursue abnormalities every day. I make decisions not to make patients lives more miserable. I make calculated decisions based on risk and benefit all the time. Sometimes I discuss my thoughts with the patient. Sometimes I don't.   Sometimes I don't give them the option of a pace maker.   Some times I tell them dialysis is not an option.  Sometimes I tell them that their granny would not survive that procedure or surgery.  And I feel completely at ease because I know that not doing many things by the  guideline is often times cheaper and will have no meaningful change in long term outcomes.  In other words,  death is natural.

Do I think I need to offer a pacemaker to a 95 year old with colon cancer? How about a 95 year old without colon cancer?  Do I even need to offer a colonoscopy to a 95 year old who may have colon cancer?   I often don't know the answer to my own questions because I need to be there, in the thick of things to really understand how to answer my own questions. Guidelines are just that, but often worthless when you are dealing with real life situations. A 95 year old is the equivalent of a patient with cancer with a 2 year expected survival.  As a nation we have to accept our mortality and start serious discussions about resource utilization across many spectrums of disease.  That includes end stage disease.  But that also includes end stage age.  If we are going to realistically fund future generations, then the talks must begin now.