Yet another study reveals the challenge of mechanical stroke prevention techniques, such as left atrial appendage closure, when applied to older patients
This is such an important reminder about time-to-benefit and competing risks! Two concepts that often get lost when a procedure is technically “successful”. A ~98% implant success rate is impressive, but if 1-year mortality dwarfs stroke risk (especially >85), then the patient-relevant question shifts from “Can we close the appendage?” to “Will this person live long enough, and stay well enough, to actually accrue net benefit?” In practice, I’ve found it clarifying to anchor these decisions in frailty/falls, cognition, functional trajectory, and what the patient is most trying to protect (independence, avoiding hospitalization, minimizing meds/procedures). Until we have convincing trials in the exact group “too high-risk for anticoagulation”, your closing line is the cleanest clinical heuristic: resist the urge.
John ... is there any compelling research which supports the benefits of the Watchman? I really don't want to remain on Eliquis for the rest of my life (I'm 77). I've been free of A-Fib since May (when I quit drinking alcohol). I have a new Boston Scientific pacemaker/ICD which seems to be working fine. I asked my EP if I could discontinue my Eliquis and he recommended that I stay on it in case of possible stroke from a future A-Fib incident. He is pro-Watchman (having been part of the research on it). What's your opinion?
Dont just do something, Stand there! The modern healthcare system has increasingly traded the wisdom of "just because you can, doesn't mean you should" for a high-tech assembly line of billable interventions. We have mastered the technical skill of "fixing" isolated parts—like plugging a heart appendage—while ignoring the reality of the person attached to them. By prioritizing preventive procedures for patients who won't live long enough to benefit, the system often masks a pursuit of profit as a pursuit of health. True medicine requires the courage to do nothing, yet in a system where (patient safety) is consistently outweighed by (billing opportunities), "doing something" has become a lucrative but often hollow substitute for actual care.
I keep thinking about the flip side of this. What about my social group who are in the top 5% for fitness, and no lifestyle diseases or comorbidities. Are there treatments which have been pronounced 'futile/ineffective' in the average person (overweight, low fitness, alcohol use) which would actually see a statistically significant effect in a healthier group, just because there are less competing causes of hospitalisation and death?
Something, they say they don’t know what, is happening with 5% of my left ventricle. They want to do an exploratory catheterization to see what they find. My BP is controlled well with 20mg Olmesartin. Not only can’t they tell me what’s wrong but they can’t tell me if they will go in through my wrist or groin, how long it will take, what they will do whilst in there, or what to expect when I wake up. I’m 70 and have severe medical PTSD from past surgical experience. I need a much clearer picture of what to expect before I sign up for this and give them that kind of control over my body. How does one make these decisions? Who sees the rest of the patient, the person, not just the body part and billing code?
Actually, it is worse than that. The narrow population that ends up being studied in virtually every preventive medicine trial is often nothing like the patient sitting in front of you. They are healthier, more compliant, and well supported by the trial. To extrapolate those results to our patient panels is doing a HUGE disservice.
Well put. With very narrow exceptions, aggressive anticoagulation in those who are frail, or >80 or both are more trouble than they’re worth. But beware the physician who is absolutely certain: (s)he is not likely to accept the concept of nuance, nor the concept of compromise. Hence all those bruises, and all that bleeding…
We see this kind of thing All the Time in ALF care, my wheelhouse.
Taking so many blood thinners can cause all kinds of issues, beyond bleeding. Just today, I got a photo from an aide at my tiny home ALF (6 beds) in South FL, home of Many older adults. Our state is 51% over 65, and rapidly aging. That statistic include far colder north Florida, with my educated estimate being 1/3 of them are in our tri-county region, where "The Golden Girls" series was set.
The photo? Marvin, our only man, and New since Thanksgiving, has said for the past 5 days that he'll "shower at the club later"... He's 91 and taking blood thinners that our MD having seen him only once, declined to moderate or quit. Consequently, looks like we Might be abusing him... All the time. Nothing can be further from the truth, but he insists on wearing his watch with metal band, to bed, so he "won't lose it" (rolls eyes) Men can be quite stubborn, but that's only this woman's view - oh, make that professional view over 16 years - But there are FAR Fewer Men in ALF care.
Is it that pesky "rugged individualism" in their DNA or homones? LOL
So, he had his shower, and felt so "normal" that he left the breakfast table to go back to his room to fetch a pair of pants to change into "later at the club"... and of course, his family gave him a smart phone with a better memory than Marvin has, so finding it charged this morning, he took it With him (say it with me, so he "won't lose it" and when holding the aforementioned phone in one hand and the pants in the other, he turned to leave the room and fell... ARGH -
Last week, he had scratched the front of both ankles in his sleep and he picks at whatever breaks occur in his skin, because they're scabs, b/c he bleeds so easily!
This is despite having gained 6 pounds in 6 weeks and now walking at least 1500 ft round trip daily to the park, versus the 300 ft he was exhausted by shakily walking at admission.
The author and the commenter are Both Spot On here, just cut the freaking meds, he's living on borrowed time and happy!
I had SO many similar conversations with my husband’s grandmother and the rest of the family…85 y/o, furniture walker, dementia. EVERYONE was obsessed with her taking her medications, especially the ‘blood thinner’. Despite multiple bruises as evidence, they were all more scared of a blood clot than the intracranial hemorrhage from a fall that caused her death.
Keep advocating for your residents - as stubborn as they are, they can feel your love and care.
It seems we're all so afraid of the bogeyman the medical machine tells us is there, that justifies more drugs, than we are of the falls and bumps We all Experience and See elders have so much more frequently... That we end up not preventing the far more probable/likely issue instead.
I like that line "resist the urge." My go to is usually "just because we can, does it mean we should?" I'm really sad that "Choosing Wisely" https://www.choosingwisely.org/ is no longer an active site/app. I'm a case manager in a Tribal Clinic. I am regularly trying to get my providers to stop and think if that test/procedure/etc. is the best path for that Elder with multiple morbidities and insecure housing.
I could write a whole book on this, not from an MD perspective, but from a PT perspective who sees a vast array of patients. Like a bone density test in a 94 yo woman who has never taken bone improving meds and would we anyway? Or taking a carotid artery test in that same woman? Or a mammogram for her as well. And let's add on another more invasive biopsy of a skin cancer that you removed 10 years ago that looks like it came back and when the biospy was taken a month ago, the margin wasn't clear. Then we can move onto the patient who wants no surgery but wants an MRI "just so they can know" what is going on. Or the MRI for neck pain then refer them to PT. Why not refer them to PT since this person doesn't want surgery or injections anyways. It is endless and small compared to the decision to give an 85 yo surgery at this level. Drives me nuts.
I hear you. The list goes on and on. I think one of the ones at the top of my list for complete futility and cruelty in placing a G-tube in an older adult with dementia with failure to thrive. Either take the time to hand feed, or let them be!
It's one of the reasons I loved working hospice. One of the first conversations with patient and family was to say "you are now in charge. You are out of the land of 'must,' 'should', 'can't." Just reducing medications was such a relief. Telling people it's ok to "eat the damn cookie" (or have that beer you've been depriving yourself of) was always a joy.
We don't know how to have the conversation about death and dying. Maybe with the tribal heritage and connection to land and spirit it is easier? My mom had oral CA, feeding tube after treatments that she never used. Years later had a post op staph infection (funnily enough at Cape Cod Hospital, there was a neurosurgeon who was known to have a high staph rate). She subsequently had a nonhealing wound because she was malnourished (trouble eating after head and neck radiation). So in order to have a skin graft a year later, they wanted her to have a feeding tube again. Well since she never used the first one, I sat with her and said, how do you want to do this? Are you ready to die? Do you want to live? She chose life. It was a lot of work to eat her way out of malnourishment to get enough healing without a graft. It was her hail mary. I think the research is out there that the closer you live to a teaching hospital, the more likely you are to have more procedures, live "longer" at higher expense and less QOL. It is so sad. I must have some weird relationship with death. And I won't know until given the opportunity (or not) what I would do. I just hope I have enough band width to be present and not be snowed into whatever path I choose.
We are a death denying culture. One of the reasons we have seen things like “death cafes” and death doulas. The best thing anyone can do is start thinking, and start talking - figure out who you would trust to be your proxy if you cannot speak for yourself (also advocate if you can), and start talking about values, goals, and limits. And keep talking, because our choices change as our bodies do and our place in the world.
When I first came to the clinic I found out that our executive director was really advocating for advance care planning. I took that on, and was at first hit with a lot of pushback from co-workers who were also Washoe. They said “no one is going to be willing to talk to you about that.” And it’s true, it’s hard sometimes, but I’ve managed to establish some trust and break down some barriers, and at least some people are coming and doing the work w/me.
I see people with heart failure etc who still want "everything done" for resus, or on home oxygen for COPD and can barely get themselves to the bathroom, yet are angry when palliative care is suggested (and still want full resus)... Medicine has promoted death as the enemy, resus as a lifesaving intervention - I note I will occasionally read the odd good news piece in our national broadcaster about successful resus... But nothing about its failings... So it's not surprising patients have that perspective, when the conversations doctors have with them about resus are vague (the ones I've heard) and I wouldn't come away with the impression that resus on an older heart failure/COPD patient is a frantic undignified brutal activity that's got a 99% (or whatever the number is on frail aged) chance of failure...
Not to mention the expectation that you can shock a flatline.
And the fact that however long it takes to regain a shockable rhythm (if that is even possible) is time the brain is deprived of oxygen. That old and ill family member is potentially coming back even more ill, and with brain damage. They will not be the same as they were before.
There was a study - years ago - where some med students watched TV medical dramas and tallied and described resuscitation on these shows - looked at age, co-morbidities, etc. Totally skewed r/t who was needing resuscitation and successes rates. I went looking for it and found a more recent one that specifically looks at the effect of these shows on patient expectations:
The results, unfortunately are the same - depictions of trauma happening to young, health people when most CPR is done on older adults with multiple co-morbidities:
"The public has unrealistic views regarding the success of cardiopulmonary resuscitation, and one potential source of misinformation is medical dramas. Prior research has shown that depictions of resuscitation on television are skewed towards younger patients with acute injuries, while most cardiac arrests occur in older patients as a result of medical comorbidities. Additionally, the success rate of televised resuscitations on older shows has vastly exceeded good outcomes in the real world. We sought to understand resuscitation outcomes on current medical dramas and to review the literature for evidence that media affects patient decision-making. We reviewed medical dramas to evaluate the demographics of cardiac arrest victims and the success rate of resuscitations and compared the results to outcomes for real-world patients. Medical dramas continue to focus on trauma as the main cause of cardiac arrest and portray favorable outcomes more frequently than should be expected. Patients who believe the overly optimistic prognoses portrayed on television may be more likely to desire aggressive medical care in the face of serious illness. Healthcare workers should anticipate the need to counter misinformation when discussing patient goals of care and end-of-life planning."
When I discuss I do put it in as blunt and harsh terms as I can - They will likely break your bones, if they shove a pipe down your throat, you'll be sedated b/c your body will want to fight the vent, etc. I don't sugar coat, but I also respect that the decision is not mine, but theirs. The best I can do, if it's not an emergent situation, is encourage on-going conversations the patient and their decision-makers. A hard lesson you will learn, M/grad student is that we cannot stop people from making decisions and choices that we disagree with - and the most important corollary - just b/c you don't agree with a patient's decision is not a reason to question their decisional capacity.
We have trouble handling the truth. I think it is a universal experience. And sometimes it's the only thing that should be said. So hard! My mom was DNR (she had fought a lot and at the time her health was good, she just had had enough). So the doc order a full treadmill cardiac stress test. I asked her if she was willing to have surgery since she was a DNR. She said No. I said then why have the test. She said because they say my age says I should. I explained what the test could mean. She called her doc and said no thank you. But her doc should have never ordered the test!
This is such an important reminder about time-to-benefit and competing risks! Two concepts that often get lost when a procedure is technically “successful”. A ~98% implant success rate is impressive, but if 1-year mortality dwarfs stroke risk (especially >85), then the patient-relevant question shifts from “Can we close the appendage?” to “Will this person live long enough, and stay well enough, to actually accrue net benefit?” In practice, I’ve found it clarifying to anchor these decisions in frailty/falls, cognition, functional trajectory, and what the patient is most trying to protect (independence, avoiding hospitalization, minimizing meds/procedures). Until we have convincing trials in the exact group “too high-risk for anticoagulation”, your closing line is the cleanest clinical heuristic: resist the urge.
John ... is there any compelling research which supports the benefits of the Watchman? I really don't want to remain on Eliquis for the rest of my life (I'm 77). I've been free of A-Fib since May (when I quit drinking alcohol). I have a new Boston Scientific pacemaker/ICD which seems to be working fine. I asked my EP if I could discontinue my Eliquis and he recommended that I stay on it in case of possible stroke from a future A-Fib incident. He is pro-Watchman (having been part of the research on it). What's your opinion?
Dont just do something, Stand there! The modern healthcare system has increasingly traded the wisdom of "just because you can, doesn't mean you should" for a high-tech assembly line of billable interventions. We have mastered the technical skill of "fixing" isolated parts—like plugging a heart appendage—while ignoring the reality of the person attached to them. By prioritizing preventive procedures for patients who won't live long enough to benefit, the system often masks a pursuit of profit as a pursuit of health. True medicine requires the courage to do nothing, yet in a system where (patient safety) is consistently outweighed by (billing opportunities), "doing something" has become a lucrative but often hollow substitute for actual care.
Many elderly people simply want their questions answered and to then be left alone
I keep thinking about the flip side of this. What about my social group who are in the top 5% for fitness, and no lifestyle diseases or comorbidities. Are there treatments which have been pronounced 'futile/ineffective' in the average person (overweight, low fitness, alcohol use) which would actually see a statistically significant effect in a healthier group, just because there are less competing causes of hospitalisation and death?
Something, they say they don’t know what, is happening with 5% of my left ventricle. They want to do an exploratory catheterization to see what they find. My BP is controlled well with 20mg Olmesartin. Not only can’t they tell me what’s wrong but they can’t tell me if they will go in through my wrist or groin, how long it will take, what they will do whilst in there, or what to expect when I wake up. I’m 70 and have severe medical PTSD from past surgical experience. I need a much clearer picture of what to expect before I sign up for this and give them that kind of control over my body. How does one make these decisions? Who sees the rest of the patient, the person, not just the body part and billing code?
indeed!
Actually, it is worse than that. The narrow population that ends up being studied in virtually every preventive medicine trial is often nothing like the patient sitting in front of you. They are healthier, more compliant, and well supported by the trial. To extrapolate those results to our patient panels is doing a HUGE disservice.
Just because you can, doesn’t mean you should.
That’s been one of my practice principles since day 1. It’s something that unconstrained practitioners seem to forget (or perhaps never learned).
Total mortality in comparator group that did not get LAAC? Would be handy to know that data point (propensity matched) in Cape Cod cohort.
Yes, I’m pleased that first do no harm has made a comeback. >80.
Not nearly enough, but maybe growing
I think you really should individualize each situation as not all 85 year olds are created equal
1. First, do no harm.
2. Starkly different from ‘Never let a billing opportunity go to waste’.
Too often, 1<2. Thanks for this article.
Well put. With very narrow exceptions, aggressive anticoagulation in those who are frail, or >80 or both are more trouble than they’re worth. But beware the physician who is absolutely certain: (s)he is not likely to accept the concept of nuance, nor the concept of compromise. Hence all those bruises, and all that bleeding…
Oh my AMEN to that, Michael L
We see this kind of thing All the Time in ALF care, my wheelhouse.
Taking so many blood thinners can cause all kinds of issues, beyond bleeding. Just today, I got a photo from an aide at my tiny home ALF (6 beds) in South FL, home of Many older adults. Our state is 51% over 65, and rapidly aging. That statistic include far colder north Florida, with my educated estimate being 1/3 of them are in our tri-county region, where "The Golden Girls" series was set.
The photo? Marvin, our only man, and New since Thanksgiving, has said for the past 5 days that he'll "shower at the club later"... He's 91 and taking blood thinners that our MD having seen him only once, declined to moderate or quit. Consequently, looks like we Might be abusing him... All the time. Nothing can be further from the truth, but he insists on wearing his watch with metal band, to bed, so he "won't lose it" (rolls eyes) Men can be quite stubborn, but that's only this woman's view - oh, make that professional view over 16 years - But there are FAR Fewer Men in ALF care.
Is it that pesky "rugged individualism" in their DNA or homones? LOL
So, he had his shower, and felt so "normal" that he left the breakfast table to go back to his room to fetch a pair of pants to change into "later at the club"... and of course, his family gave him a smart phone with a better memory than Marvin has, so finding it charged this morning, he took it With him (say it with me, so he "won't lose it" and when holding the aforementioned phone in one hand and the pants in the other, he turned to leave the room and fell... ARGH -
Last week, he had scratched the front of both ankles in his sleep and he picks at whatever breaks occur in his skin, because they're scabs, b/c he bleeds so easily!
This is despite having gained 6 pounds in 6 weeks and now walking at least 1500 ft round trip daily to the park, versus the 300 ft he was exhausted by shakily walking at admission.
The author and the commenter are Both Spot On here, just cut the freaking meds, he's living on borrowed time and happy!
I had SO many similar conversations with my husband’s grandmother and the rest of the family…85 y/o, furniture walker, dementia. EVERYONE was obsessed with her taking her medications, especially the ‘blood thinner’. Despite multiple bruises as evidence, they were all more scared of a blood clot than the intracranial hemorrhage from a fall that caused her death.
Keep advocating for your residents - as stubborn as they are, they can feel your love and care.
It seems we're all so afraid of the bogeyman the medical machine tells us is there, that justifies more drugs, than we are of the falls and bumps We all Experience and See elders have so much more frequently... That we end up not preventing the far more probable/likely issue instead.
I like that line "resist the urge." My go to is usually "just because we can, does it mean we should?" I'm really sad that "Choosing Wisely" https://www.choosingwisely.org/ is no longer an active site/app. I'm a case manager in a Tribal Clinic. I am regularly trying to get my providers to stop and think if that test/procedure/etc. is the best path for that Elder with multiple morbidities and insecure housing.
I could write a whole book on this, not from an MD perspective, but from a PT perspective who sees a vast array of patients. Like a bone density test in a 94 yo woman who has never taken bone improving meds and would we anyway? Or taking a carotid artery test in that same woman? Or a mammogram for her as well. And let's add on another more invasive biopsy of a skin cancer that you removed 10 years ago that looks like it came back and when the biospy was taken a month ago, the margin wasn't clear. Then we can move onto the patient who wants no surgery but wants an MRI "just so they can know" what is going on. Or the MRI for neck pain then refer them to PT. Why not refer them to PT since this person doesn't want surgery or injections anyways. It is endless and small compared to the decision to give an 85 yo surgery at this level. Drives me nuts.
I hear you. The list goes on and on. I think one of the ones at the top of my list for complete futility and cruelty in placing a G-tube in an older adult with dementia with failure to thrive. Either take the time to hand feed, or let them be!
It's one of the reasons I loved working hospice. One of the first conversations with patient and family was to say "you are now in charge. You are out of the land of 'must,' 'should', 'can't." Just reducing medications was such a relief. Telling people it's ok to "eat the damn cookie" (or have that beer you've been depriving yourself of) was always a joy.
We don't know how to have the conversation about death and dying. Maybe with the tribal heritage and connection to land and spirit it is easier? My mom had oral CA, feeding tube after treatments that she never used. Years later had a post op staph infection (funnily enough at Cape Cod Hospital, there was a neurosurgeon who was known to have a high staph rate). She subsequently had a nonhealing wound because she was malnourished (trouble eating after head and neck radiation). So in order to have a skin graft a year later, they wanted her to have a feeding tube again. Well since she never used the first one, I sat with her and said, how do you want to do this? Are you ready to die? Do you want to live? She chose life. It was a lot of work to eat her way out of malnourishment to get enough healing without a graft. It was her hail mary. I think the research is out there that the closer you live to a teaching hospital, the more likely you are to have more procedures, live "longer" at higher expense and less QOL. It is so sad. I must have some weird relationship with death. And I won't know until given the opportunity (or not) what I would do. I just hope I have enough band width to be present and not be snowed into whatever path I choose.
We are a death denying culture. One of the reasons we have seen things like “death cafes” and death doulas. The best thing anyone can do is start thinking, and start talking - figure out who you would trust to be your proxy if you cannot speak for yourself (also advocate if you can), and start talking about values, goals, and limits. And keep talking, because our choices change as our bodies do and our place in the world.
When I first came to the clinic I found out that our executive director was really advocating for advance care planning. I took that on, and was at first hit with a lot of pushback from co-workers who were also Washoe. They said “no one is going to be willing to talk to you about that.” And it’s true, it’s hard sometimes, but I’ve managed to establish some trust and break down some barriers, and at least some people are coming and doing the work w/me.
They are lucky to have you at their side.
I see people with heart failure etc who still want "everything done" for resus, or on home oxygen for COPD and can barely get themselves to the bathroom, yet are angry when palliative care is suggested (and still want full resus)... Medicine has promoted death as the enemy, resus as a lifesaving intervention - I note I will occasionally read the odd good news piece in our national broadcaster about successful resus... But nothing about its failings... So it's not surprising patients have that perspective, when the conversations doctors have with them about resus are vague (the ones I've heard) and I wouldn't come away with the impression that resus on an older heart failure/COPD patient is a frantic undignified brutal activity that's got a 99% (or whatever the number is on frail aged) chance of failure...
Not to mention the expectation that you can shock a flatline.
And the fact that however long it takes to regain a shockable rhythm (if that is even possible) is time the brain is deprived of oxygen. That old and ill family member is potentially coming back even more ill, and with brain damage. They will not be the same as they were before.
There was a study - years ago - where some med students watched TV medical dramas and tallied and described resuscitation on these shows - looked at age, co-morbidities, etc. Totally skewed r/t who was needing resuscitation and successes rates. I went looking for it and found a more recent one that specifically looks at the effect of these shows on patient expectations:
https://pmc.ncbi.nlm.nih.gov/articles/PMC8112599/
The results, unfortunately are the same - depictions of trauma happening to young, health people when most CPR is done on older adults with multiple co-morbidities:
"The public has unrealistic views regarding the success of cardiopulmonary resuscitation, and one potential source of misinformation is medical dramas. Prior research has shown that depictions of resuscitation on television are skewed towards younger patients with acute injuries, while most cardiac arrests occur in older patients as a result of medical comorbidities. Additionally, the success rate of televised resuscitations on older shows has vastly exceeded good outcomes in the real world. We sought to understand resuscitation outcomes on current medical dramas and to review the literature for evidence that media affects patient decision-making. We reviewed medical dramas to evaluate the demographics of cardiac arrest victims and the success rate of resuscitations and compared the results to outcomes for real-world patients. Medical dramas continue to focus on trauma as the main cause of cardiac arrest and portray favorable outcomes more frequently than should be expected. Patients who believe the overly optimistic prognoses portrayed on television may be more likely to desire aggressive medical care in the face of serious illness. Healthcare workers should anticipate the need to counter misinformation when discussing patient goals of care and end-of-life planning."
When I discuss I do put it in as blunt and harsh terms as I can - They will likely break your bones, if they shove a pipe down your throat, you'll be sedated b/c your body will want to fight the vent, etc. I don't sugar coat, but I also respect that the decision is not mine, but theirs. The best I can do, if it's not an emergent situation, is encourage on-going conversations the patient and their decision-makers. A hard lesson you will learn, M/grad student is that we cannot stop people from making decisions and choices that we disagree with - and the most important corollary - just b/c you don't agree with a patient's decision is not a reason to question their decisional capacity.
We have trouble handling the truth. I think it is a universal experience. And sometimes it's the only thing that should be said. So hard! My mom was DNR (she had fought a lot and at the time her health was good, she just had had enough). So the doc order a full treadmill cardiac stress test. I asked her if she was willing to have surgery since she was a DNR. She said No. I said then why have the test. She said because they say my age says I should. I explained what the test could mean. She called her doc and said no thank you. But her doc should have never ordered the test!