Demystifying Medicine One Month at a Time

Tag: Zeke Emanuel

The Inflection Point(s) of Aging

A new column of mine has been posted on NPR’s website about “de-prescribing,” the art of pruning medications from older adults that take too many of them, a condition we refer to as polypharmacy.

Katherine Streeter for NPR

Katherine Streeter for NPR

It’s well-known that being on too many medications can lead to more side effects and drug-drug interactions, so anything medical professionals can do to minimize such negative outcomes is welcome. Thus we revert to our Hippocratic doctrine: First, do no harm.

Contrast that with the competing ethical imperative toward beneficence — to do good for patients. Medical science teaches us that many (though far from all) of the medications we prescribe for chronic illnesses (e.g. cardiovascular conditions) lead to fewer ‘events’ (think heart attacks & strokes), which prolong lives.

As a result, doctors wind up prescribing a lot of stuff — and decades of medical practice and now guidelines and quality metrics push us to do this even further.

One area I’d like to see science help us is in identifying “The Inflection Point of Aging,” which I define as the point in a person’s life when we can pare down ‘aggressive’ treatment of chronic conditions because it becomes counterproductive: when taking the “medically proper” action is likely to cause more harm than good.

This whole notion arises out of recent discourse: As I recently blogged, the SPRINT Trial, which was stopped early because it showed that treating blood pressure even more aggressively than we’d previously thought leads to fewer bad ‘events.’ How low, I wonder, is too low?

Also, an article in the Atlantic by medical pundit Ezekiel Emanuel titled “Why I Hope to Die at 75” emphasized this idea.

Emanuel is a known iconoclast, but I appreciate his efforts to stir up dialogue and get us talking about important issues that we are otherwise reluctant to discuss. In this case, I think his editors at the Atlantic did him a disservice, because the provocative headline of the article caused a furor and detracted from his real message, which was simply this: There comes a point where undergoing standard medical practices no longer makes sense. That point is different for everybody and is dependent on a person’s values as much as their physiology. Emanuel never said he wants to die at 75, merely that he plans to stop seeking medical interventions at that age — two very different ideas.

If you click over to the NPR column, you can see that anecdotally, we care for patients for whom physiology does change — and it therefore doesn’t make sense to keep doing the same things over and over. It’s trite to say it (and you’d be amazed at how challenging it can be to fight medical inertia), but we must think about each patient individually and truly weigh the risks and benefits of adhering to population-based norms and recommendations when goals and bodies change.

Age is Just a Number, Right?

In case you missed them, a couple of lay press articles hammered home the idea of our lifespans being finite.

ezekiel_emanuel_0First there was Zeke Emanuel’s provocatively titled “Why I Hope to Die at 75” in the Atlantic.

The title was unnecessarily inflammatory. A lot of people saw that and thought “Health Care Rationing…” and “what a jerk!

One of the core points of his article is well-taken: when we hit a certain age (75? 80? 85?), it no longer makes sense to “look for disease.”

Health care must continue improving and striving to reflect and honor the wishes of patients, but in addition, we should be more rational about whom we screen for disease and how often. It makes no sense to perform colonscopies in octogenarians to “screen” for colon cancer. Even if they have it, the colonoscopy  is unlikely to extend their life or improve its quality.

I think readers are right to quibble with Emanuel’s contention that at 75 creativity takes a nose dive. He was using that opinion, and the statistical evidence of age-related slowdown, in support of his point about the cutoff age for aggressive medical care. I hope sensible debate is not lost because of his tone and the fact that he’s seen as too political. He did work for the administration during President Obama’s first term, after all.

cohen-01-by_david_boswell

Cohen in younger days.

That same week, the New York Times published an opinion piece by Jason Karlawash of Penn, who wrote about musician Leonard Cohen’s decision to resume smoking (something he’d quit) upon turning 80. Titled “Too Young to Die, Too Old to Worry,” Karlawash examined how the 80+ population has grown from a half of one percent of the population to more than 3.5%. Doesn’t seem like a huge percentage, but it is certainly a significant increase and a huge demographic shift.

As Karlawash writes in the key paragraph of his piece

…Mr. Cohen’s plan presents a provocative question: When should we set aside a life lived for the future and, instead, embrace the pleasures of the present?

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