A note of clarification before today’s Practice Perfect. It was brought to my attention that in the last Practice Perfect, Biomechanics and Surgery, I stated I went to “medical school.” I did in fact attend podiatric medical school, a term I and I’m sure many others use interchangeably with med school. Doctors go to med school. I’m a doctor. I attended med school. I don’t pretend to be an MD or DO, and I’m sure the meaning was clear; however I wanted to be explicit on this. For those who have a problem with this, I’d ask you to look within yourselves and figure out why. Perhaps then we can move beyond these labels. Now, on to today’s topic.

Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine Western University of Health Sciences,
St, Pomona, CA

When is Enough, Enough?

Most of us go through our training with the intent to actually treat and cure disease whenever possible. We learn the latest surgical techniques and treatment algorithms. We spend years honing our clinical examination and history taking skills. We debate the current literature. We spend countless hours on call and in clinic building our skills. When we graduate from residency and fellowships. we feel ready to take on anything.

And then we meet those patients that cause us to ask that hardest of all questions:

“When should I stop treating this patient?”

We have a family friend who is currently in the hospital with the most severe end-stage congestive heart failure one can have and still be alive. Without violating HIPPA, I can describe this patient as follows: she entered the hospital some time ago for a valvular heart repair procedure and hasn’t yet left the ICU. As time progressed, she has suffered multiple complications, each worse than the next, and is now on dialysis for renal failure and severe fluid overload and is pending placement of a left ventricular assist device (LVAD). This device, the same machine recently placed in Dick Cheney’s heart, is a pump that assists the heart, essentially bypassing the left ventricle. With each day, it seems the doctors have to fight an escalating arms race with her failing body.

This unfortunate situation is not at all unique. As our medical technology becomes increasingly advanced, our previously heroic measures have become more standard. We are able to manipulate our patient’s bodies in ways not previously thought possible. As our life-prolonging skills advance — and we see increasingly complex complications from chronic disease — we become better able to manipulate these complexities. In essence, our patients have become machines that we can control, with their physiological switches and dials. Blood sugar too high? The appropriate insulin regimen will accomplish euglycemia. Potassium too low? Add a potassium supplement. Can’t breathe anymore? Place the patient on a ventilator. We’ve become very good at what we do. But more and more often I see patients on wards in hospitals well beyond the point where it’s questionable if they should remain alive.

Tonight's Premier Lecture is
Tinea Pedis and
Diabetic Foot Infections
byJohn Steinberg, DPM

I’m as guilty as the rest of the medical community. I once had a diabetic patient with ankle Charcot, ulceration, and osteomyelitis, that I worked incredibly hard on for one full year to save her leg. I put her through multiple procedures, wound care protocols, IV antibiotics, and multiple hospitalizations, only to come to the realization after a year that I had lost the fight. She was a wonderful person that was fully invested in her own limb salvage and trusted me fully. However, at the end of what could only have been a terrible year for her, in spite of my ministrations, we decided to call it quits. She had a below knee amputation. About four months later, walking with a prosthetic, she commented to me that in hindsight, she wished she’d had the amputation sooner.

Just because we can do a thing doesn’t mean we should. When do we stop treating our patients? When does the treatment become worse than the disease? These are extremely difficult questions to answer — and I don’t have any pithy responses or bulleted lists. This is the single most difficult question we in the medical field must grapple with, one in which there’s no good answer.

There are only two suggestions I can make on this front. First, this question may be partly answered using the medical literature. An evidence-based approach in which a clinician looks at concepts such as number needed to treat, risk ratios, etc. at least allows us to use this tool to help us help our patients decide their fates. Second, we need to remember the single most important concept in medicine: there’s a person at the end of that foot/blood test/procedure/technology. If we caregivers can remember that most important fact, then at least we can maintain our humanism in the face of disease and be that important support for our patients.

The one thing I know is that I am unable to practice medicine as the distant objective physician. I’ll immerse myself as much in my patients as they want and bring emotion and caring into the decisions I make. If nothing else, perhaps that will allow me to judge when enough is enough. Best wishes.

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Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

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