May 9th, 2011

Words, ICDs, and Patient-Centered Medicine…

John Mandrola is a cardiac electrophysiologist and blogger on matters medical and general. Here is a recent post from his blog, Dr John M.

Guess what made the heart rhythm newswire yesterday?

It wasn’t a new medicine,

or a new stent,

not even a new ablation catheter,

and it surely wasn’t a revolution in motivating people to exercise.

It was words. Rhetoric… It seems that one man, Dr. John Wilson, read all of the major implantable cardioverter defibrillator (ICD) trials, dating back more than a decade, and found that the study authors emphasized positive aspects of ICDs while giving less weight to their sobering complication rates.

As reported by Steve Stiles on The, Dr Wilson likened such “message framing” to marketing strategies that try to sell a product.

Though his opinions bordered on the sensational, Dr. Wilson’s advice spoke strongly to me, as here:

“I think the bulk of the information from these trials would suggest that these devices do make people live longer, but I think it’s also very likely that if patients were given a more balanced view about risks and benefits, fewer of them would be willing to take it on.”

And here (emphasis mine),

“Guidelines,” he said, “tend to make it sound like if something is found to be effective, it should be put in all patients with that problem, when in fact what should probably be said is: if it’s effective, patients should be given information about the benefit and the risk and allowed to use their own judgment to decide whether they’d prefer to live a little longer—in many cases just a couple of months longer—or possibly experience infection or get shocked multiple times with the defibrillator.” (If patients received this type of information), “you’d probably find that a lot of them would be very skeptical about having these devices put in.”

That last paragraph slants a little too far to the negative, but it suffices to show how a patient-centered ICD conversation is a tough one. It also highlights the notion of how practicing medicine gets harder as we accumulate better, and more invasive, tools (and provides yet another excuse reason why so many of us fall so woefully behind in the office).

In selected patients, ICDs unequivocally provide benefit. However, as with any invasive treatment, there are risks and alternatives, making ICDs akin to many other expensive and invasive therapies. Cancer chemotherapies (for example, adriamycin with its cardiac toxicity) come to mind.

Most smart doctors read journal articles with a critical eye. They (should) know that the writers are passionate and convinced of their positive findings. Such is human nature.


4 Responses to “Words, ICDs, and Patient-Centered Medicine…”

  1. We live in a relative world, and our decisions are modulated by our philosophy as well as by our experience and knowledge. When someone says:”..whether they’d prefer to live a little longer—in many cases just a couple of months longer-” he/she probably has a scale how long the respective patient would have lived without this device. Or, more probably, doesn’t.
    I am the recipient of such a device. The discussion with the doctor who gave me this option lasted less than 10 minutes, six years ago. At the time, I knew almost nothing about it, but these ten minutes were enough for me to decide that among the other options I had , this was the best. For me, and then.
    We hope that when we present a patient with alternatives, we are dispassionate, correct, comprehensive and objective. In reality we rarely are all these, simultaneously. And never forget that what we perceive as being a very good presentation, might be received by the patient quite different, incomplete, misunderstood.
    So, yes we have to offer alternatives, but rather in a concise manner and always together with our advice- for we have always our opinion of what is best for the particular patient.

    • Thanks for commenting.

      This “dispassionate, correct, comprehensive and objective” presentation is something that pulls on my soul. I am mindful that we–as physicians–are entrusted with enormous powers of persuasions. In discussing the prevention of a painless and peaceful death with something as invasive as an ICD, the reality of keeping bias out of the delivery is harder than it seems, at least for me, at this time. Well-intentioned, very smart people view the benefits and risks of ICDs much differently.

      Patient-centered care tells us to understand the patient as a person, and then present the options for treatment in a manner that allows each patient to decide. I try to do this each and every time, but to be honest, I am frequently unsure how to quantify the benefits of the ICD myself. There is a lot of gray.

  2. Jean-Pierre Usdin, MD says:

    I have an experience with one of my faithful and old patient. He has a severe left ventricular dysfunction following a too late surgery of mitral valve insufficiency (valvuloplasty in 1995)but he is still alive
    in 2007 he suffered from an out-hospital cardiac arrest (documented VF) and recovered well after many weeks (he was 76 year-old) DAI was implanted following the class I A recommendations. Within the first two months after implantation he had two appropriate device shocks.
    And since these two episodes of recurrent long lasting VT no more new event.
    His device was replaced six months ago because of the end of the battery (the patient is pace maker dependent)We did not consider the possibility of inserting only a pacemaker without DAI in spite of the 4 years of non use of the defibrillator! However the patient is in NYHA III but he lives and continues to go in vacation in Mediterranean sea! I can imagine how the family and the patient could react if I said to them: “the replacement of the device is risky because of the poor cardiac status. etc.”
    I think most of the patients (and their family)will choose the risks of the surgery even if the length of their life is not dramatically increased.
    Hope keeps us going.

    Competing interests pertaining specifically to this post, comment, or both:
    No conflicts

    • Dr Usdin,

      Hans was my best friend, my neighbor, my patient, and an American patriot. I met him my first weekend on call in 1996 during a VT-storm. He survived because his abdominal ICD worked.

      He went on to live seven more, mostly beautiful years. Hans’ story, like your patient’s, make ICD decision making very complicated. I hear you loud and clear.