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A Cardiac Conundrum
February 18, 2013 8:05 AM   Subscribe

“The gap between what patients and doctors expect from these procedures, and the benefit that they actually provide, shows the profound impact of a certain kind of mechanical logic in medicine,” he explains. “Even though doctors value randomized clinical trials and evidence-based medicine, they are powerfully influenced by ideas about how diseases and treatments work. If doctors think a treatment should work, they come to believe that it does work, even when the clinical evidence isn’t there.” posted by latkes (30 comments total) 17 users marked this as a favorite

 
First article is really interesting and concise, thanks. (I wish I could comment further, but it's the middle of the work day.)
posted by gimonca at 8:24 AM on February 18, 2013 [1 favorite]


“Doctors will have to teach patients a new attitude toward abnormal findings on lab tests and x-rays—that some are okay and don’t require intervention in every case,” he says. “That would be a major shift in the culture of medicine."

Also a major shift in medical torts.

The move away from individual doctors making decisions about patient care to the development of a clinical-based system of protocols is very much helped by a move towards a single-payer system. Replacing individual care with one-size-fits-all do-the-best-for-the-most medicine is in many ways a preferable and cost-effective approach to medical care. Unless you are that one person who benefits from procedures that lie outside of protocol.
posted by three blind mice at 8:26 AM on February 18, 2013 [3 favorites]


I'm an EMT and we've known -- for quite some time -- that CPR is borderline useless. Depending on the study in question, CPR has a success rate ("success" usually meaning the person was resuscitated and survived for another few months or so) in the low-to-mid single digits (1-6% usually). Meaning that about 95% of people who need CPR are goners.

I would say that it actually approaches 100% mortality, as most of the people we are able to "successfully" bring back with CPR have been hypoxic for quite some time and end up being vegetables -- eventually succumbing to pneumonia or bed sores a few years after the event, but far enough outside the study window to be counted as a "Success".

As always, there are exceptions. But common people's ability to understand and assess risks/benefits of medical procedures is utterly, completely out of whack. People demand that their love ones be spared no horrifying invasive procedure (if I do CPR on you, I WILL be breaking your ribs. Sorry.) if it means keeping their heart beating a little while longer (no matter if their brain has already long ago turned to mush).

Everyone should consider a DNR. If you are over the age of 60, there is no reason for you to not have one. Period.
posted by Avenger at 8:27 AM on February 18, 2013 [19 favorites]


A success rate of 1-6% sounds pretty good if the cost attached to not having CPR is the utter and complete loss of life.

What is so magical about getting a DNR at 60? Are you in the penson business?
posted by biffa at 8:35 AM on February 18, 2013 [5 favorites]


Even if angioplasty doesn't extend life, it's beyond dispute that it improves the self-perceived health of the patient. Reduction of chest pain is a palpable benefit, and may be enough to justify the treatment.
posted by Chocolate Pickle at 8:38 AM on February 18, 2013 [5 favorites]


As an aside, I remember one patient that I cared for (briefly) a few years ago. He had Stage IV metastatic liver cancer. The cancer was so widespread that it had actually lodged in his face and was slowly breaking through the skin. He was literally rotting from the inside out, but still "alive".

His kidneys started to fail, and so his family demanded that he be placed on dialysis. To, you know, save his life. The doctors told the family that his prognosis "wasn't great" (this is an understatement bordering on a lie) but they demanded continued intervention. I don't know what became of that guy (besides his inevitable demise) but I really felt sorry for him.

If you take away anything from this discussion, let it be this:

1) Metastatic cancer is essentially incurable. If you have tumors everywhere, you're probably going to die soon. Trying to make yourself live longer will probably just hurt you and your family even more.

2) CPR is almost useless.

3) People on ventilators tend to get VAP (Ventilator Acquired Pneumonia) which kills them even if whatever disease they have doesn't.

4) You will die one day. This is ok. Death is inevitable, necessary and provides you with a very intimate connection to all other humans (and animals) that have ever lived. Live your life now, and love all the people you love, so that when you go people will be glad that they knew you.
posted by Avenger at 8:39 AM on February 18, 2013 [18 favorites]


It's kind of strange that the assumption governing the controversy seems to be that "only" relieving symptoms (of severe pain) is an inferior outcome to extending life.
posted by thelonius at 8:40 AM on February 18, 2013 [3 favorites]


A success rate of 1-6% sounds pretty good if the cost attached to not having CPR is the utter and complete loss of life.

A typical "success" of CPR involves the person's heart being restarted while the rest of their body rots in a nursing home until they succumb to bed sores in a year or so.

I'd argue that a quick and painless death is preferable. You can make whatever choice you want, of course.
posted by Avenger at 8:42 AM on February 18, 2013 [3 favorites]


What is so magical about getting a DNR at 60?

That's the age where the success rate of resuscitation procedures starts to go way down, regardless of how "success" is defined. You're more likely to die, and you're more likely to suffer permanent impairment even if you don't.
posted by valkyryn at 8:50 AM on February 18, 2013 [4 favorites]


Replacing individual care with one-size-fits-all do-the-best-for-the-most medicine is in many ways a preferable and cost-effective approach to medical care.

One of only things I like about single-payer is that it tends to take many treatment options away from patients.

Of course, that's the main reason not to like it too.

But I'm pretty firmly convinced that if you aren't paying for a particular service, you don't necessarily get to have the last say in what that service includes. As I understand it, many single-payer systems basically say "Look, you want treatment for [condition]? Okay, [treatment] is what you can have, and we've got an opening for you [later]. If you want something different, or sooner, you're welcome to pay for it yourself."

I'd be pretty much okay with that, provided (1) [treatment] is a minimally-adequate medical option (e.g., we aren't offering only blood pressure meds to people who really need bypass surgery), (2) that [later] is soon enough to avoid increasing harm due to the delay (e.g., if you're scheduled for a knee replacement, you can wait a while on that, but if you're scheduled for bypass surgery, you probably can't), and (3) that [treatment] is offered to everyone with the same basic medical condition.

Call it "death panels" if you like, I just call it "Not writing a blank check for health care expenditures."
posted by valkyryn at 8:59 AM on February 18, 2013 [6 favorites]


My favorite cardiac intervention is the pretordial thump. It's cartoonishly televisable medicine, punching the patient in the sternum to interrupt fibrillation. Googling, the success rate is surprisingly high (25%). Since it's performed immediately as fibrillation is just beginning the risk of brain damage would be extremely low if it works, and it's quick enough not to delay for other methods if it doesn't.

I'm not sure if shouting "LIVE! LIVE!" is officially part of the procedure but it really should be.
posted by justsomebodythatyouusedtoknow at 9:01 AM on February 18, 2013 [4 favorites]


CPR might not work, but it doesn't sound horrifyingly invasive as medical interventions go. Tumours coming out your face, on the other hand, oh my god.
posted by jeather at 9:02 AM on February 18, 2013


“Doctors will have to teach patients a new attitude toward abnormal findings on lab tests and x-rays—that some are okay and don’t require intervention in every case,” he says. “That would be a major shift in the culture of medicine."

I wonder if this is different in countries/health services where doctors want to maximise procedures/treatment to maximise income, versus where doctors want to minimise procedures/treatment to minimise expenditure.
posted by EndsOfInvention at 9:03 AM on February 18, 2013 [1 favorite]


CPR might not work, but it doesn't sound horrifyingly invasive as medical interventions go.

If the CPR was likely to bring about a good outcome, then it would seem well worth it to me to try it. But when I think about resuscitating a family member, it's not so much breaking ribs I worry about, it's forcing them to stay barely alive in a hospital bed on multiple medications, attached to tubes and lines, being woken up all through the night for vital signs and blood draws, with a moaning roommate, very likely contracting bladder infections, pneumonia and bed sores, with a huge baseline reduction in their ability to think and use their body, that makes me hesitate. I'd honestly rather my loved one got to die right away of that heart attack then was kept in that half-alive state for months or years, which is a very real possibility if you do CPR, and then continue to agree to other interventions in the hospital.
posted by latkes at 9:14 AM on February 18, 2013 [2 favorites]


I'm an EMT and we've known -- for quite some time -- that CPR is borderline useless.

This is broadly true, but there are important exceptions. For example, CPR in cases of a sudden drop in body temperature (e.g. falling into an icy lake) can be pretty effective, particularly in children. For example, here's a remarkable case of hypothermia to 13.7ºC (56ºF) (!) with "good physical and mental recovery" after 9 hours of resuscitation and stabilisation.

From a 10 year review of 75 accidental hypothermia patients in Finland published in 2003:
23 were in refractory cardiac arrest due to primary hypothermia and rewarmed using cardiopulmonary bypass (CPB). The aetiology of hypothermia was immersion in cold water in 48%, exposure to cold environment in 39% and submersion in 13% of these patients. Their median age was 50 years, and 83% were males. The patients received a total of 70 min of conventional CPR before institution of CPB. Fourteen of these patients (61%) survived to discharge from hospital. Factors associated with survival were age (P=0.015) ... .It is concluded that patients with cardiac arrest due to primary hypothermia tolerate long periods of conventional CPR before institution of CPB.
In general, children do better than adults after CPR because they tend to lack co-morbidities. "In the case of children who are resuscitated from acute hypoxic insults, the quality of life is generally good and, in the specific instance of survivors from near-drowning, some 95% will lead lives relatively unmodified." Pearn, Successful cardiopulmonary resuscitation outcome reviews, 47 Resuscitation 311 (2000).
posted by jedicus at 9:33 AM on February 18, 2013 [3 favorites]


On the other hand, CPR in children...
posted by legospaceman at 9:35 AM on February 18, 2013


Doctors will have to teach patients a new attitude toward abnormal findings on lab tests and x-rays—that some are okay and don’t require intervention in every case,” he says. “That would be a major shift in the culture of medicine."

Every time I get a test or imaging done, the results are prefaced with "The findings may include some abnormal values which are not clinically significant." It's been that way since I've been with my current clinic, which is close to 20 years now. I thought this was a common understanding, particularly with imaging; not everyone's body is the same, and often that's just fine.
posted by KathrynT at 9:47 AM on February 18, 2013


Angioplasty works, at least in some cases. It is especially useful when you catch the problem (blocked arteries) before any actual heart attack damage occurs. 2.5 years after I got 2 stents, I'm doing vastly better than I was for several years prior. And calling it a 'major' procedure is silly. How major can it be, if you are in hospital for less than 24 hours, and walk to the train from which you needed a taxi, on your way in? Or is the word 'major' a reference to the bills? It does take a team and lots of high-tech gear.

But I don't know, that article isn't very accurate. The blockage is not from material in the artery where the blood is. It's the walls of the artery that are inflamed. Such a common misconception, what's it doing in such a serious article?

Of course, folks dieing sooner is good for the economy, so there is that. Any volunteers?
posted by Goofyy at 10:49 AM on February 18, 2013 [1 favorite]


I wonder if this is different in countries/health services where doctors want to maximise procedures/treatment to maximise income, versus where doctors want to minimise procedures/treatment to minimise expenditure.

Or in other word, incentivizing overtreatment by paying per procedure is going to result in overtreatment.
posted by emjaybee at 11:02 AM on February 18, 2013


I'm doing vastly better than I was for several years prior

What's hard about talking rationally about medical intervention is that just about everyone has a story like this - either about themselves or a loved one. But the truth is, there is no way to know if you are doing better now than you would have had you not had the procedure, because there is no "control" case for yourself. So the best we can do is look at large studies that compare outcomes of people who have had, and have not had the procedure. And those large studies don't support the claim that "angioplasty works".

Not to underplay the value of comfort - if you feel better, that is a better outcome than feeling crappy. But there's not evidence that the procedure extends lives.
posted by latkes at 11:18 AM on February 18, 2013 [2 favorites]


The article doesn't contradict Goofyy 's experience, does it? It says that these interventions may well make symptoms disappear (and this, I'd say, improves quality of life). It just says that this doesn't translate to length of survival, right? Am I misunderstanding it?
posted by tyllwin at 11:57 AM on February 18, 2013


CPR is also remarkably useful for iatrogenic arrest. Similarly there are plenty of scenarios in which intubation is temporary and lifesaving. Rather than DNR (with all the subtext that brings talking to patients), I would like a "measures which are indicated and likely to work, but not pro-forma abuse of my dead body" order.
posted by a robot made out of meat at 12:37 PM on February 18, 2013 [2 favorites]


The majority of people who receive CPR probably have pretty poor outcomes, but speaking as a 35 year old in good cardiovascular health, things don't look great for me if I have a sudden heart attack, but there's still a pretty good chance of near complete recovery if CPR is administered.
posted by ambrosen at 1:37 PM on February 18, 2013


That is, the chance seems good enough that if someone's strong enough to be in a public place on their own and they collapse and don't have a heartbeat, my reading of it is that it would be very wrong not to do CPR once you've called for help. Obviously I'm not saying that CPR is Clean Pretty and Reliable.
posted by ambrosen at 1:41 PM on February 18, 2013


What is so magical about getting a DNR at 60?

I'm 31 and in good health, and I sometimes debate getting one. I'm an RN in a large city hospital.

I don't think I'll actually do it until I'm closer to 60 (unless my health takes an unexpected turn for the significantly worse between now and then). But I've seen that (a) CPR rarely helps, (b) CPR is incredibly violent and not how I'd want to spend my last minutes "alive," and (c) people who survive after CPR are usually in a condition that I would find worse than being dead.

Then again, my dad survived a cardiac arrest outside the hospital in his late 50s and spent about 30 minutes without a detectable heartbeat, and he's doing fine now. He's one of the miniscule percentage who made it. Would I recommend similar interventions in general? Nope. But each individual life is not a statistic, and you never know if you'll be the 1 in 10,000* who recovers well. At 58 I might have a DNR, but my dad didn't, and the year he turned 63 I got to dance with him at my wedding.

Despite all of that, I'm not really conflicted about making myself DNR when I get a bit older. I remember the moment in the ICU when the relief at thinking he might survive turned into the horror that he would probably survive with severe brain damage, needing 24-hour nursing care, face bedsores and indignities beyond belief, all while draining any financial resources that my mom might have had. The neurologist said she had seen one other person in her career who survived similar circumstances, "but it was not a good outcome." The fact that someone I love beat the odds doesn't change the realities of the odds.

CPR might not work, but it doesn't sound horrifyingly invasive as medical interventions go.

Oy. It is horrifying, and invasive. It breaks ribs. They basically electrocute you. They will likely shove a tube down your throat to help you breathe. I'd rank it as one of the most horrifying and invasive interventions we have, but sometimes it's worth it if it keeps a person from dying. Trouble is, you can't know for sure in advance whether it'll be worth it.

* (statistic invented, but it's really rare)
posted by vytae at 12:06 AM on February 19, 2013 [3 favorites]


Angioplasty gave me what I needed to reform behaviors responsible for my debilitated condition, at age 53. I was overweight and a heavy smoker. I quit smoking before the procedure when I faced the simple fact that the pains hit about 2 minutes after a cigarette. Curiously, there is room to argue that the cigarettes provided an early-warning sign that my arteries were inflamed. The condition worsened over a period of weeks, even after I quit smoking.

6 months after the procedure, I finally got the combo of dieting and exercising, and suddenly pounds disappeared. HUGE positive feedback!

But yea, it's not a very good thing for the economy. Now that I'm well and getting exercise, we discover some other expensive things that may require treatment (joint replacements). So, yea, angioplasty is bad for keeping down those medical expenditures. (typo edited)
posted by Goofyy at 2:45 AM on February 19, 2013 [1 favorite]


vytae, I strongly suggest you read the BMJ article I linked above. CPR in the community has a non minuscule success rate (c. 20% for adults having cardiac events in the community given CPR by amateurs).
posted by ambrosen at 4:07 AM on February 19, 2013


Makes sense Goofyy, re: angioplasty enabling you to make lifestyle changes.
posted by latkes at 8:33 AM on February 19, 2013


ambrosen, I'm looking at that article and Table 2 puts the "neurologically favorable one month survival" at 4.6 - 5.6%, depending on whether the person got rescue breaths or just chest compressions. The number is less with increasing age, and with longer time to starting CPR (even a few minutes makes a big difference). And their definition of "neurologically favorable" includes this:
Moderate cerebral disability. Conscious. Sufficient cerebral function for part-time work in sheltered environment or independent activities of daily life (dressing, traveling by public transportation, and preparing food). May have hemiplegia, seizures, ataxia, dysarthria, dysphasia or permanent memory or mental changes.
The other 95ish percent of people do worse than that. So you're right, my statistics were exaggerated, but for me the calculation remains the same.

It's a really well-done study, though. Japan has only one EMS service, so they were able to collect data on all out-of-hospital cardiac arrests for 2 years. It's a great set of data.
posted by vytae at 8:44 AM on February 19, 2013


vytae, I did elide my description somewhat (quite possibly making it inaccurate), and I'm limited bandwidth so I can't go back to it, but I was looking at the middle graph, which I read as being caused solely by a cardiac event*, and at the young-lower middle aged age range, I got the 20% positive outcome, for all treatments. I suspect a fair proportion of the lower quality outcomes would come from slowed reactions or insufficiently violent** CPR.

*Presumably a lot of CPR in the community is due to alcoholic collapses, drug overdoses and traumatic injury, as well as the proportion of people who are severely ill from other causes.

**I guess it's not violence if it's in someone's best interests, but we don't really have a word for "deliberately using your full strength against someone regardless of whether you break their bones".
posted by ambrosen at 8:07 AM on March 16, 2013


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