Date Published: March 4, 2008
Publisher: Public Library of Science
Author(s): Janet K Shim, Ann J Russ, Sharon R Kaufman
Abstract: The treatment imperative, say the authors, refers to the almost inexorable momentum towards intervention that is experienced by physicians, patients, and family members alike.
Partial Text: In this Essay, we offer reflections based on our previously published ethnographic study of physician and patient responses to life-extending cardiac procedures that are increasingly performed on ever older individuals in the United States . In that study, we examined how providers and patients considered advanced age in their decision-making about various treatments (angioplasty, stents, bypass surgery, and implantable cardioverter defibrillators), using in-depth interviews with physicians from internal medicine and cardiac subspecialties, cardiac patients aged 72–86, and their family members. The project received institutional review board approval from the University of California, San Francisco, and all interviewees gave informed consent prior to participation.
Underlying the treatment imperative are at least three changes in the socio-clinical landscape of cardiac intervention in the US. First, the social meaning of cardiac treatments has shifted, from aggressive, high-risk interventions to increasingly routine, standard procedures. As less invasive procedures are used safely, effectively, and with greater frequency among older Americans to enhance well-being and longevity [4–6], both consumer demand for and the ethical pressure to offer them have increased. Second, norms of “old age” have shifted in US society and in clinical medicine [7,8]. Physicians described changing definitions of “how old is ‘old.’” In addition, physicians viewed old age not as a time of inevitable decline and death but as one of preventable morbidity and mortality, when clinicians must “look forward for” and “treat for risk.” Third, the framing of medical choices for elderly Americans and their physicians is shaped by the Medicare system, in which reimbursement is tied to procedures performed.
Patients and families experienced the treatment imperative as well. Their desire to maximize quality of life and longevity, together with their sense of familial obligation, made it extremely difficult to forego medical options. But, in addition, patients rarely recalled any communication regarding potentially negative treatment outcomes, other than during informed consent procedures which many viewed as mandatory, cursory, and overly general. Most indicated that they were not offered the option of no treatment. One woman related that her physician told her baldly, “‘It’s not a choice of whether you want to go through [treatment] or not if you want to live.’ When you faced with that kind of a ‘choice,’” this patient said, “your decision is made for you.”
Medical intervention in late life can be characterized by a tension between the desire for prolonged life and a wish for a dignified end. Conventional framings of this debate have usually resolved this tension, at least in the hypothetical, by invoking patient “autonomy” and shared decision-making [14–16]. By facilitating these values, it is suggested, patients will be able to decide for themselves whether to prolong life or allow death, and physicians will be able to adjust their recommendations to reflect patients’ desires. But the ideal of patient choice and the discernment of patients’ authentic values are extremely elusive [17,18].