Posted by: notdeaddinosaur | January 2, 2012

In the Trenches: Quality of Life

First in an occasional series on the differences between public policy healthcare discussions and life in the trenches of primary care:

Why is it easier to talk about quality of life with patients who are dying? Why don’t we factor these considerations into the decision-making for patients with conditions that aren’t fatal?

The presence of a terminal illness serves to focus everyone’s attentions. Widespread cancer metastases? Concerns about tight blood glucose control fade away. End-stage liver disease? Blood pressure control doesn’t matter so much any more. Bony pain from prostate cancer? Narcotic and sleeping pill addiction doesn’t even occur to anyone. I find it far more problematic to deal with patients with debilitating but non-fatal conditions when treatment options are perceived as limited because of co-existing diseases that produce so-called contraindications to certain medications.

I have a patient in his mid-70s with severe pain from osteoarthritis. Several fractures and a couple of unsuccessful joint replacement surgeries haven’t helped matters. Several years ago he found that a little drug called Vioxx worked extremely well for him, reducing his pain considerably and allowing him to do pretty much watever he wanted. As we all know, however, that drug was pulled from the market because of an unacceptable increased risk of heart attacks and other untoward cardiovascular events. Interestingly, one other drug (Celebrex) from the same medication class (COX2 inhibitors) remains on the market. However because of this gentleman’s diabetes, high blood pressure, high cholesterol (all treated to acceptable guidelines, as it happens) and age, all the red flagged warnings about increased cardiovascular risks go off if I were to try prescribing it for him.

Actually, most other doctors would probably make the unilateral determination that the risk from this medication class outweighs any potential benefit, and would therefore not even broach the topic with the patient. I disagree (surprise, surprise!) Here’s why:

“Risk” is an abstract concept. Having a risk factor for a disease or condition is not the same thing as having it, or even a modified or mild version of the condition. Right up until the moment the brain of an un-helmeted motorcyclist splatters across the pavement, he’s feeling just fine. This is also why diabetic hypertensive smokers with cholesterols of 300 walk around obliviously content to continue stuffing their faces with Big Macs. Discomfort with risk is purely emotional, and is a function of one’s perception of the risk. This is why doctors can seem more uncomfortable than patients about certain courses of medical treatment. We know more about what can go wrong, so there are times that we really fear for our patients, for whom ignorance can be quite blissful. It’s like when  little kids barge into a busy street, only to have their mothers freak out as they haul them back. The kid has no idea why Mom’s so upset; he’s just fine.

In this case, though, we have a patient for whom a particular medication holds a real chance for significant improvement in quality of life despite a known, documented increased risk of an adverse cardiovascular event. Why don’t we factor quality of life considerations into the decision-making for patients who aren’t dying? The RISK of a heart attack is not the same as a heart attack. Whose comfort level with risk is more important here, the doctor’s or the patient’s?

I explained all this as best I could to the patient, providing him with various educational materials and information online as well as handouts from my office. I also included prescribing information for Celebrex, complete with all the warnings. Obviously a significant risk issue is medicolegal on my part. But I’ve known this guy long enough, and I plan to explain (and document) out my ass to make sure he understands the trade-offs here. Bottom line is that I offered him a prescription if he wants it. (By the way, he’s currently taking OTC naproxen for his pain, a drug with exactly the same cardiovascular risk profile, but not nearly as much bad press as the COX2 inhibitors.)

What happens if (hopefully when) I try actually writing the prescription, though? First, his pharmacy benefits manager will likely require prior authorization. (Why can’t he use cheaper meds? Because they don’t work well enough.) Second, a pharmacist will probably call and tell me that the drug is contraindicated in the elderly because of increased cardiovascular risk. True. But what we have here is a case where guidelines conspire to keep someone miserable. Shouldn’t the patient be the one to decide if he wants to live ten more years as a crippled invalid, or risk maybe five more while living his life the way he wants?

Take home message: Here in the trenches of primary care, “quality of life” doesn’t apply just at the end of life. It’s something we have to help our patients consider every day.


Responses

  1. [...] In the Trenches: Quality of Life [...]

  2. [...] In the Trenches: Quality of Life [...]

  3. With my patientis in this situation I tell them all the possible bad things that can happen, and then say, “but maybe you’d like to be able to walk and tie your shoes>” If they decide it’s worth the risk for them I write the rx, and document the conversation. Quality of like is totally an ongoing issue.

  4. I agree with your premise, but differ on one little factoid.
    Of all the NSAIDs, Naproxen has been shown to be the safest from a cadiovascular standpoint and is, in general, the NSAID of choice in someone with a higher cardiac risk profile.
    I still have a similar cardiac risk/GI risk versus pain management benefit discussion with my patients when prescribing it.
    I realize in your case you state that naproxen is not working as well and that is part of the reason for the change. But it’s cardiac risk is not as high as other NSAIDs. In addition, it’s dirt cheap, smaller than Ibuprofen 800mg, and only BID.

  5. When does “elderly” start? I’m just curious, hubs is on Celebrex, it helps his arthritic hands a lot. At what point is he going to start hearing contraindicated for the elderly? He’s 65 now, and plans on taking it forever because he has no risk factors yet.

  6. People often assess risk in personal, idiosyncratic ways that have nothing to do with actual statistical likelihood. Even a small risk can be intolerable, given the right emotional associations. Someone whose parent died of cardiovascular causes — or who was incapacitated by osteoarthritis — might feel very differently about the various treatment options than someone without that history.

  7. Thank you. Bless you. May other doctors follow your example.

  8. The last 18 or so months of my mother’s life, she was constantly bothered by chronic right shoulder pain from her none repairable rotator cuff injury. The doctor prescribe Ultram which usually gave her some relief. At first, I was a bit leery because it seemed to make her sleepier than usual. I feared that this might make her less able to go out and do things. Then I realized that she would be equally unable to go out and do things if she was in agony from the shoulder.

    I realized that making her as comfortable as possible was the best thing for her and doing the best thing for her, not us, was what was important.

  9. Thank you, thank you, thank you. Could you please move to the West Coast to become my mother’s PCP? She has an acoustic neuroma, which is (as you know) not immediately fatal, but whose effects require intensive medical management. She badly needs someone like you. The neurologist, the neurosurgeon, the family-practice NP, and the psychiatrist are all acting like they think she’s somebody else’s “problem.” She’s nobody’s problem: she’s a person, a patient, and my mother.

    Are you still precepting residents and med students? I hope so – then at least a fraction of PA’s new docs will see each patient as an entire person, like you do.

  10. [...] [...]

  11. I agree alongside your principle, but vary in one minimal factoid.
    Of all of the NSAIDs, Naproxen has been shown to be the safest from a cadiovascular standpoint and also is, in general, the NSAID of preference in somebody alongside a higher cardiac danger profile.
    I nevertheless have a similar cardiac risk/GI risk vs pain control perks discussion alongside my clients whenever prescribing it.
    I understand in your case you state which naproxen is certainly not performing and as well as that is part of the factor for the change. But it’s cardiac possibility is certainly not as tall because other NSAIDs. In addition, it’s dirt cheap, smaller than Ibuprofen 800mg, and also merely BID.


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