Risky Medicine: Mailbag

This week's show on risky business in health care generated some heartfelt reaction from you.  The central thesis of the show is that patients and their doctors are increasingly on a collision course regarding risky health decisions.  In medicine, doctors like me tend to think knowing more about the risks and benefits of tests and treatments makes us more qualified than patients to decide what course of action is appropriate.  Hit the jump below to read a selection of your emails.

This argument is at the root of the dispute between doctors and patients regarding feeding tubes - thin plastic tubes inserted into the stomach and the intestines via a hole in the abdominal wall.  Feeding tubes are often recommended when a patient has difficulty swallowing. 

On the program, geriatrician Dr. Michael Gordon told the story of the time doctors recommended his late father Max get a feeding tube, a suggestion Dr. Gordon and his sister rejected.  The elder Mr. Gordon survived his hospital stay and continued to enjoy the taste of food for some time following. 

 "Dr. Goldman, your most recent program about risks resonates with my experience," writes Pat Richardson of Burlington, Ontario.  "My husband who has had Parkinson's for many years was admitted to hospital four months ago and had emergency surgery for a bowel blockage associated with Parkinson's meds.  He ended up with an ileostomy and after an episode of septicaemia.  His swallowing was assessed by a speech pathologist and he was put on thickened liquids which were unpalatable.  It was impossible to maintain hydration, since an ileostomy requires eight to ten glasses of liquid a day.  My husband at no time before or after surgery exhibited any speech or swallowing problems.  I challenged the speech pathologist to no avail and lobbied the doc unsuccessfully.  My husband had three acute episodes of dehydration resulting in unresponsiveness until he was put on IV.  I continued during this time to give my husband large glasses of water, which he had no difficulty swallowing but it was insufficient over the course of the day.  Four days ago the doctor finally overruled the speech pathologist and I now feel my husband has a chance and the risks of aspiration were slight compared to the effects of dehydration.  What can I do to prevent this from occurring with other patients? "

Pat, we can't provide you specific medical advice. What I can say is that speech pathologists have an important role to play in assessing patients for their ability to swallow. That said, it's the responsibility of the attending physician to accept or reject the results of a swallowing study.  Medicine is not pure but applied science.  What was true of one swallowing study may not be true of subsequent tests.

 "I'm glad you're discussing feeding tubes and aspiration," says Allan Lynch of New Minas. "Your side of the gurney hasn't been totally forth-coming with my side. It was eight months after I was convinced to allow a feeding tube to be inserted into my mother that anyone mentioned to me that she could still aspirate! The whole purpose of the feeding tube I was told was to prevent aspiration. My mother was capable of taking food by mouth, but our hospital wouldn't allow it. We battled and I finally took it on myself to feed her dinner. She was able to eat and enjoyed it. But I was treated as a near criminal, someone who was trying to kill her, because I dared go against them.  My mother was hospitalized for nine months and in a nursing home for seven. In that time she coughed once during a meal.  It wasn't because of the food; it was because of a cold. I have to wonder how much of the dishonesty, half-truths and scare tactics health care uses to win their arguments are motivated by ageism."

Fran Lindsay of Victoria writes:  "My mother was 97.  She had a previous agreement with her doctor for no intervention.  She was deemed sound and rational even though she had a stroke which resulting in her "failing" a swallowing test.  She refused a feeding tube, but also refused to eat anything. She was hooked up to an intravenous saline drip, which really distressed her and through gestures and agitation she demanded it be removed.  But is this "informed consent"?  Did she really understand that she would slowly over 5 days become more and more uncomfortable, rattly, laboured in breathing, dependent on a catheter ? And when her organs began to shut down completely, her body still fought to live. This was far from a peaceful "death with dignity" that I think she really was trying to assure for herself. I feel sure that many people who sign living wills or refuse "extraordinary procedures" do not really know what   they are getting into.  Be careful what you wish for!"

"Brian, as a physician I think your show is terrific, daring and thought provoking," writes Marian Macken of Dartmouth. "The dilemma for physicians is, what is informed consent? Unless one has seen and suffered along with someone dying of colon cancer; one cannot know what one is consenting to when deciding to forgo a colostomy at all costs.  Those of us who have seen severely injured patients in the CT scanner know the value of wearing a bike helmet.  How do you explain that someone who hasn't had that experience?  I guess one has to accept the decision of a person to accept the fact that they cannot be sure what the results of their decision will be.  Thanks to you we are discussing these issues."

Fran and Marian, you've raised some important points.  In a few weeks, we'll have internist and bioethicist Dr. Stephen Workman on the show to talk about getting patients and their next of kin to sign 'do not resuscitate' (DNR) orders.  He talks at length about the obtaining consent not to perform CPR.  It's striking to me how pertinent his comments are to the issues the two of you have raised.  Our show on DNR will air early next month.

Dr. James Salwitz,
a cancer specialist in New Jersey, told us about a patient with colorectal cancer who wanted to forego cancer surgery because he didn't want to end up with a colostomy or bag to empty his bowels.  As a physician, Dr. Salwitz said he was uncomfortable with his patient's decision because it was a riskier choice.  However, as a patient, Salwitz found himself much more open to his patient's point of view.

 "It made me sad, and a little angry, to hear Dr. Salwitz agree with his patient that a colostomy is worse than death," writes Judith Wouk of Ottawa."  I have had a colostomy for nearly ten years, and am by far not the oldest ostomate in our local association.  My quality of life is as good as, or better than, it ever was; I have travelled to Europe, Asia, and South America, am actively involved in community affairs, and enjoy life and health.  Modern appliances are safe, comfortable, and easy to use.  As far as I am concerned, there is no down side to a colostomy, and even several benefits."

Point taken, Judith. Your email makes me realize just how subjective the perception of personal risk is.

By far, the most reaction we received was in response to my interview with B.C.'s Provincial Health Officer regarding the province's move to make flu shots mandatory for health care workers.  I have gone on the record supporting the move, and I received a fair amount of personal criticism from health care workers for doing so.

"I am not your regular listener, but I try to listen to your show from time to time," writes Robert Rogoz of Bellingham, Washington.  "I was very surprised and shocked by your remarks on flu vaccinations I also work in the healthcare, and I can't agree with anything that is mandatory as far as medications taken. For one, there needs to be a comprehensive study on influenza transmissions in healthcare facilities with and without vaccination.  I strongly disagree with the statement made by your interview subject, who kept repeating phrase "we think".  In science there is now "we think", but only counts what we know. Right now there is not a single study showing if vaccinating healthcare workers in hospitals and clinics changes rate of influenza infections.  We also do not have long term idea on the effects of virus mutations. Look what over prescriptions of antibiotics brought us now: necrotizing fasciitis , MRSA and antibiotic resistive TB. Are we going to look back in twenty years and deal with viral mutations?  I also think that forcing people to take medications (even in the forms of vaccinations) is a slippery slope.  I hope you explore my concerns in the follow up. I would be very interested in hearing other experts in this regard."

"I just finished listening to your program on mandatory vaccines for health professionals and would like to comment," writes Sharri Harfman of Prince George, British Columbia. "I am among the 60 percent of health professionals who do not accept flu vaccines and I will continue to refuse vaccination. Despite the abundant research, the key information that is missing, to my way of thinking, is what effect year upon year vaccination over decades has on our immune system.  Mass flu vaccination has not been in effect long enough to answer this question thoroughly.  Furthermore, 20- plus years of working as an RN has developed in me a healthy scepticism for research that proclaims to have the final answer.  As more knowledge is gained and new technology developed, I have watched many previously accepted and researched ideas be proven wrong or incomplete.. The draconian measures implemented by health authorities put unvaccinated staff in a very difficult position.  Should there be a flu outbreak in my work site, I will be excused from work without pay until the outbreak is over, even if I am completely symptom free and wear a mask. Choice....I don't think so."

And finally, as the saying goes, if you're going to make a boo-boo, might as well make a good one.  That was certainly the case when yours truly identified daredevil Felix Baumgartner as Australian.  Boy, did we hear from you!

"Brian, love your show, but you need to know that Felix is Austrian, not Australian!!!!" writes Heidi Jungwith of Courtenay.  "Austria is home to many innovators, but still I have to put Austria, Europe when I mail a package, because otherwise it could very well end up in Australia!!"

Thanks for your understanding. Boy do we have Kaiserschmarrn on our faces!  It was as they also say, a slip of the tongue.  You'll be happy to hear that we've repatriated Felix to his rightful home in our podcast and online program.

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