A colleague of mine who is a cardiology fellow recently made this confession: \u201cI really love doing procedures. I can\u2019t wait until the new patient gets here so we can Swan him.\u201d<\/p>\n
Playing devil\u2019s advocate, I asked: \u201cWould you want to be \u2018Swanned\u2019 if you were admitted to the CCU?\u201d<\/p>\n
Astonished, she replied, \u201cOf course not. I hate needles. You have to fight hard to even place an IV in me. Besides, I don\u2019t think most nurses or doctors here would want to be treated aggressively if their prognosis is dire.\u201d<\/p>\n
For the next few days, I asked nurses, doctors, and attending physicians how \u201caggressively\u201d they would want to be treated if they were admitted to the CCU. Many of them said they favored a gentler approach, with more focus on comfort and less on invasive procedures, if their prognosis was grim.<\/p>\n
I recently came across an interesting article by Ken Murray<\/a>, a retired family physician who contends that doctors know too much about the futility of aggressive end-of-life treatment to subject themselves to it. His observations are similar to those I made about aggressive treatment in the CCU.<\/p>\n Research on the topic does exist. One study focuses on 818 physicians<\/a> who had graduated from Johns Hopkins from 1948 to 1964. On questionnaires about end-of-life issues that they filled out at a mean age of 69, most opted for less-aggressive options. Similar findings have been documented in a study of 72 internists<\/a>.<\/p>\n In contrast to health care providers,\u00a0patients have been shown to opt for chemotherapy<\/a> to obtain much smaller improvements in outcome. And patients with heart failure have been shown to overestimate their life expectancy<\/a>. I wonder whether physicians are uncomfortable providing their patients with honest information about prognosis. If so, why?<\/p>\n I am a trainee interested in heart failure, a subfield in which \u201canswers\u201d often take the form of invasive procedures and implanted devices. We readily recommend \u201cstate-of-the-art\u201d therapies such as ablation of arrhythmias, ICD implantation, cardiac surgery, and even ventricular assist devices. But do we focus enough on the fact that, despite their statistically significant benefits, these therapies often confer high levels of morbidity?<\/p>\n I have two main questions for fellows like me and for practicing cardiologists:<\/p>\n Do cardiologists spend enough time stressing the downsides of \u201caggressive\u201d therapies that they may recommend for their patients?<\/em><\/p>\n What drives our current approach: training that focuses on intervention, the reimbursement system, a perception of patient preferences, fear of litigation, or a combination of all these factors?<\/em><\/p>\n","protected":false},"excerpt":{"rendered":" A colleague of mine who is a cardiology fellow recently made this confession: \u201cI really love doing procedures. I can\u2019t wait until the new patient gets here so we can Swan him.\u201d Playing devil\u2019s advocate, I asked: \u201cWould you want to be \u2018Swanned\u2019 if you were admitted to the CCU?\u201d Astonished, she replied, \u201cOf course […]<\/p>\n","protected":false},"author":406,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[14,9],"tags":[1149,1150,643],"class_list":["post-16188","post","type-post","status-publish","format-standard","hentry","category-heart-failure","category-interventional-cardiology","tag-catheterization","tag-critical-care-units","tag-end-of-life-care"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/16188","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/406"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=16188"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/16188\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=16188"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=16188"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=16188"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}