February 22nd, 2012

What’s Good for the Goose Is Good for the … Swan?

A colleague of mine who is a cardiology fellow recently made this confession: “I really love doing procedures. I can’t wait until the new patient gets here so we can Swan him.”

Playing devil’s advocate, I asked: “Would you want to be ‘Swanned’ if you were admitted to the CCU?”

Astonished, she replied, “Of course not. I hate needles. You have to fight hard to even place an IV in me. Besides, I don’t think most nurses or doctors here would want to be treated aggressively if their prognosis is dire.”

For the next few days, I asked nurses, doctors, and attending physicians how “aggressively” 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.

I recently came across an interesting article by Ken Murray, 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.

Research on the topic does exist. One study focuses on 818 physicians 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.

In contrast to health care providers, patients have been shown to opt for chemotherapy to obtain much smaller improvements in outcome. And patients with heart failure have been shown to overestimate their life expectancy. I wonder whether physicians are uncomfortable providing their patients with honest information about prognosis. If so, why?

I am a trainee interested in heart failure, a subfield in which “answers” often take the form of invasive procedures and implanted devices. We readily recommend “state-of-the-art” 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?

I have two main questions for fellows like me and for practicing cardiologists:

Do cardiologists spend enough time stressing the downsides of “aggressive” therapies that they may recommend for their patients?

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?

2 Responses to “What’s Good for the Goose Is Good for the … Swan?”

  1. Great piece, Tariq. Another issue is that physicians typically overestimate patients prognosis in heart failure and this further complications the information given to patients to help make their decision (as discussed in editorials by Dr Cowie in Heart 2003;89:587-588 and Dr Yancy in JAMA 2008;299(21):2566-2567). Also, I feel it is difficult to stress the downsides of aggressive therapies because we are want to focus on giving hope to our patients.

  2. Doctors are human beings. What I’ve observed is that most physicians emphasize the treatment/no treatment that they think is appropriate, with the occasional one being influenced (probably mostly subconsciously) by financial gains or losses.