Perhaps you have heard the rather grim joke about how doctors don’t know when to stop treating patients who no longer benefit. It goes something like this: The oncologist goes to the cemetery to find (and treat) Mrs. Jones, since she hasn’t “seen” the latest chemo-cocktail for her recently fatal malignancy. When he asks the grave-digger why she isn’t in her assigned plot, he is told that she is off getting dialysis. Bah dum bump. OK, so it is crude, but everybody “gets” it, because it is just an exaggeration of the kind of aggressive, low-utility care that we often see (or “provide”) at the end of life.
Readers of this blog know that I believe that we, as physicians, often fail our patients by doing more than we would want done for ourselves. I have generally considered this a distinctly “American” issue, fueled in part by unreasonable expectations of the utility of medical interventions, the entrepreneurial nature of a lot of US health care, and the prevalent American sentiment that death is somehow “optional,” or at least to be opposed vigorously at all times regardless of the circumstances.
A recent paper in Heart provided a little international – and, alas, cardiology — flavor.
In it, researchers from the UK, Israel, and France reported on their experience performing primary percutaneous coronary interventions (PCI) for acute ST-segment elevation myocardial infarctions (STEMI) in nonagenarians. It was a retrospective analysis of a series of 145 patients with no control group, which almost certainly means that there was a strong selection bias toward treating only “the best” nonagenarians. The principal finding was a 24% in-hospital mortality, with a 6 month mortality of 39% and 1 year mortality of 47%. Here is what the survival curve looked like: