July 25, 2011
In March, I published “Possible vs. Probable” (http://livewellthy.org/2011/03/29/possible-vs-probable.aspx). The premise of the article was that, while everything is possible, what is truly important is what the probability of an illness or outcome is. Today, I want to apply the premise of “Possible vs. Probable” to the realities of getting old and being ill.
Mrs. “X” is in her 70s. She has diabetes, high blood pressure and her kidneys aren’t up to par (renal insufficiency). Mrs. “X”’s most pressing problem is her arthritis. Her neck, low back, hips, and knees hurt all day long. It takes Mrs. “X” “forever” just to get out of bed in the morning. Mrs. “X” also worries about everything.
Mrs. “X” worries mostly about her kidneys. Her kidney doc has warned her not to take any NSAIDs (ibuprofen, naproxen, etc.). Theoretically, NSAIDs can adversely affect kidneys causing a decrease or worsening in kidney function. Realistically, Mrs. “X” is in pain on a daily basis and NSAIDs are the treatment of choice for her arthritic pain. Mrs. “X” knows that NSAIDs work as on the days she takes ibuprofen, she feels 10 years younger.
What should Mrs. “X” do? Should she listen to her kidney doc and live in pain or use NSAIDs and risk further loss of kidney function? Should she try other treatments?
Mrs. “X” does great on steroids. She becomes pain free! Theoretically, steroids can worsen her diabetes and hypertension, cause cataracts, osteoporosis, mood swings and an assortment of other problems. The reality is that they make her better and without steroids or NSAIDs, she is crippled with pain.
What should she do? She has tried acetaminophen and it has failed to offer any relief. Narcotics constipate her and make her unsure on her feet. Physical therapy did not help.
In my book, reality trumps theory every time. Is it better to protect your kidneys, avoid possible worsening of your diabetes/hypertension and live longer in pain or is it better to relieve pain and potentially shorten your life?
I often find myself treating Mr. and Mrs. Xs who fit the above scenario. A day with minimal or no pain is always better than ten days in pain. Many of my patients go for quality over quantity. What is remarkable is that most tolerate their NSAIDs or steroids well and do not significantly shorten their life or worsen their bodily functions. Theory is not reality.
Because doctors believe in informed consent; because doctors are afraid of being sued for caring for their patients, they teach their patients about the theoretical problems a treatment may pose. Because pharmacists have the same concerns as doctors, they glue and staple warnings all over Mrs. “X”’s prescriptions. Unfortunately, patients often are scared by the warnings of theoretical doom and refuse treatment, leaving them to suffer day after day.
Remember, theory is not reality! Remember, each of us is unique and how we respond to a given treatment is not preordained by scientific studies. Life is about weighing risks and benefits and then hoping the decision you make is the right one. When making decisions about potential treatments, the reality of today should receive much more weight than the theoretical tomorrow.
If you noted a sense of frustration in this article, you would be correct. Our system of informed consent often backfires. Rather than protecting patients from theoretical side effects and risks of treatments, informed consent often harms the patient it is meant to protect. It’s frustrating to offer a patient relief from suffering and then, doing your duty as a physician, talk that patient out of doing what you feel is best for them. Sounds schizophrenic? It is and therein lies my frustration!