Doctors too readily provide dubious treatments to vulnerable seniors

aspirinDoctors subject older patients to risky, costly, invasive, and painful tests and treatments, perhaps with good intention but also because they fail to see that the seniors in their care are individuals with specific situations with real needs that must be considered.

If  physicians too readily accept conventional wisdom in their field, for example, they may push patients 65 and older to take low-aspirin, with the popular but mistaken belief that this practice will help prevent heart attacks, strokes, and dementia. This doesn’t work, and, it increases the risk in seniors of “significant bleeding in the digestive tract, brain or other sites that required transfusions or admission to the hospital,” the New York Times reported.

The newspaper cited a trio of studies, published in the New England Journal of Medicine and based on “more than 19,000 people, including whites 70 and older, and blacks and Hispanics 65 and older. They took low-dose aspirin — 100 milligrams — or a placebo every day for a median of 4.7 years.”

The studies’ results upend what has become almost a magical belief in aspirin and its anti-inflammatory qualities, The New York Times reported, adding:

The news may also come as a shock to millions of people who have been dutifully swallowing their daily pills like a magic potion to ward off all manner of ills. Although there is good evidence that aspirin can help people who have already had heart attacks or strokes, or who have a high risk that they will occur, the drug’s value is actually not so clear for people with less risk, especially older ones. The new report is the latest in a recent spate of clinical trials that have been trying to determine who really should take aspirin. One study published in August found no benefit in low-risk patients. Another found that aspirin could prevent cardiovascular events in people with diabetes, but that the benefits were outweighed by the risk of major bleeding. A third study found that dose matters, and that heavier people might require more aspirin to prevent heart attacks, strokes and cancer.

Researchers stressed that patients should discuss anew with their doctors whether to take and to keep taking aspiring. They should not stop the dosage suddenly and on their own.

Getting physicians to engage in a thoughtful discussion of this and other matters in which therapies may differ in their safety, effectiveness, and appropriateness in older patients can be a challenge, though, especially knowing that doctors, on average, spend just 15 minutes or so with patients per visit. Can a caregiver get a full picture of patients’ needs in that time, especially with seniors who may have more and chronic conditions as well as overall physical and mental declines to be weighed?

Breast cancer surgeries for nursing home residents

Women, who live longer than do men, may get some of the roughest and most difficult to defend medical services as they age, at least considering recent reports about mortality rates among frail female nursing home patients undergoing breast cancer operations.

As Liz Szabo of the independent, nonpartisan Kaiser Health News Service reported, researchers scrutinized records on “nearly 6,000 nursing home residents who had inpatient breast cancer surgery [in] the past decade [finding] that 31 percent to 42 percent died within a year of the procedure. That’s significantly higher than the 25 percent of nursing home residents who die in a typical year.”

Those results and practical experiences have, Szabo reported, “led some experts to question why patients who are fragile and advanced in years are screened for breast cancer, let alone given aggressive treatment.”

When researchers looked at the patients’ health status, besides their cancer, it also made them question surgical care, even a relatively low-procedure like breast operations, because, among the women studied, average age 52, “57 percent suffered from cognitive decline, 36 percent had diabetes, 22 percent had heart failure, 17 percent had chronic lung disease, and 12 percent had survived a heart attack.”

Older women who are in better physical and mental condition might well be better candidates for breast cancer surgery, which could benefit their health, well-being, and longevity, researchers said.

Szabo’s story also included this eyebrow-raising information:

Surgery late in life is hardly uncommon. One-third of Medicare patients undergo surgery in the year before they die, according to a 2011 study in the Lancet, and 18 percent of Medicare patients have surgery in their final month of life and 8 percent in their final week.

It is, of course, impossible to predict a life term, and statistics like these can mislead, because doctors may operate on older patients with good hopes of improving and extending their lives, only to see them die during procedures or shortly thereafter.

In my practice, I see the harms that patients suffer while seeking medical services, and their struggles to access and afford safe, effective, efficient, and even excellent medical care. If it’s not clear to patients already, let’s emphasize it again: All treatments and surgeries carry risks, and they should not be taken lightly, especially by older patients. Indeed, all caregivers have a duty to provide their patients with informed consent — their fundamental right to get all the important facts to make an intelligent decision about what treatment to have and where to get it.

It may be more of a challenge for doctors to fulfill this critical responsibility with older patients, trying to help them sort through their already complicated medical situations and doing so, while pressed, and perhaps with patients who may be scared, weary, and confused. Even doctors who treat many seniors still may lack specialized training and knowledge to best help them — and the nation, besides its overall MD shortages, has a dearth of experience geriatric experts. It also can’t be easy to assist patients with complex issues in nursing homes, where, as I and my colleagues at the firm have seen, abuse and neglect is all too common.

Tough choices about medical devices

Meantime, Sandeep Jauhar, a cardiologist and author of the book “Heart: A History,” has raised yet more difficult questions about medical care given the aged, particularly those with heart conditions severe enough to require internal defibrillators, devices he explains in a New York Times Op-Ed are “inserted in his chest to monitor [the] heartbeat and apply an electrical shock if the rhythm turned into something dangerous.” He reported:

In 2015, about 160,000 defibrillators were implanted in Americans, more than double the number from the decade prior. The population of patients who are eligible for an implantable defibrillator has expanded drastically, too: You used to have to be a survivor of cardiac arrest to be eligible; now the eligible population includes those who have merely an increased risk of sudden death. In America today, if everyone who qualified for a defibrillator were to get one, the costs could reach billions of dollars.

But are these a good option, especially for patients who already may be old and failing? He pondered the issue with just such an elderly patient and friend, noting:

Sudden cardiac death has always been something of a paradox. It is at once the most desirable way to die and the most feared. Abrupt life-threatening arrhythmias are a leading cause of mortality in the United States. Approximately 350,000 Americans experience them every year, and 90 percent of the victims die before or soon after they get to a hospital.

And, he says:

[Defibrillators’] cost, even with our country’s skyrocketing health care expenditures, is not the main issue. The main issue, in my view, is that defibrillators may send the dying process down a long and winding path that it might not otherwise have taken. No one wants to die prematurely, but when it’s their time, most people want to go quickly and painlessly. Defibrillators can prevent this from happening. They help prevent sudden death, to be sure. But they also can take away the sudden-death option.

Patients should have choices — and doctors especially need to offer them better ones, in a more robust, dignified fashion to the vulnerable old. With 10,000 baby boomers turning 65 each day (and doing so until 2030), there are lots of Americans who should and will demand this.

Patrick Malone & Associates, P.C. listed in Best Lawyers Rated by Super Lawyers Patrick A. Malone
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