Cath Lab Digest - September 2007 - (Page 55)

55 Refusal of Medical and Surgical Interventions Common Among Chronically Ill Elderly C hronically ill older persons frequently refuse medical and surgical interventions recommended by their physicians, according to a recent study by Yale School of Medicine researchers. The study suggests that physicians continue to recommend invasive or risky interventions for people with advanced illness despite the patient’s view that these treatments may be too burdensome, or that the treatment doesn’t fit with their goals of care. “Physicians need to offer treatment alternatives that better fit their patients’ goals and preferences,” said first author Marc Rothman, MD, postdoctoral fellow in geriatrics in the Department of Internal Medicine at Yale. Published in the July Journal of General Internal Medicine, the study explored the treatment preferences of 226 persons age 60 and older with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease. Trained research assistants conducted in-home interviews with participants at least every four months for up to two years, but more frequently if the patient’s health status changed (i.e., hospitalizations or initiation of hospice services). Patients were asked whether they had refused or undergone any treatments recommended by their physicians, and why. They were asked to estimate their own longevity, about their desire for prognostic information from physicians, and about their prior experiences with medical decision-making. Researchers found that 16 percent of these patients reported refusing one or more medical or surgical interventions recommended by their physician. The most frequently refused interventions were cardiac catheterization and surgery, with refusal rates of over 10 percent. Other interventions refused included chemotherapy, radiation, intubation, dialysis, and transplantation. Hospitalization was rarely refused. The most common reasons given for treatment refusals were fear of side effects. Patients who refused treatments were more likely to have congestive heart failure, to rate their own longevity at less than two years, and to want their physicians to discuss their prognosis with them. The mortality rate among those who had refused treatments was higher than those who had not. “Our study highlights the frequency with which older persons with advanced illness refuse treatments recommended by their physicians,” said Rothman. “This frequency of refusal suggests that physicians may be recommending treatments for these patients that pose unacceptable burdens or that fail to meet patients’ goals. Patients with advanced illness may require a broader range of treatment alternatives, so that they can select the option that best meets their goals of care.” ■ Early Treatment Can Reverse Heart Damage U niversity of Minnesota researchers have discovered that treating people who have early cardiovascular abnormalities, but show no symptoms of cardiovascular disease, can slow progression and even reverse damage to the heart and blood vessels. In a recent double-blind study, researchers enrolled 76 asymptomatic subjects with early markers for cardiovascular disease, based on a 10-factor scale called the Rasmussen Disease Score. During the first six months of the study, 38 subjects received a placebo, and the other 38 subjects took 160mg of Valsartan, a drug that blocks a hormone that is detrimental to the blood vessels and the heart. During the next six months, both groups took Valsartan. Those who took the drug for the first six months significantly reduced their Rasmussen Disease Score compared with those who took the placebo. At the 12-month mark — after both groups were taking the drug — every patient showed better Rasmussen Disease Scores, effectively demonstrating that Valsartan can slow progression and even reverse early cardiovascular disease in asymptomatic high-risk patients. The findings of the study are published in the Aug. 28, 2007 issue of the Journal of American College of Cardiology. “Cardiovascular disease is the No. 1 killer in our society — not only in the U.S. but in the rest of the world,” said Daniel Duprez, MD, professor of medicine, and the principal researcher. “These patients have no symptoms, so most of them would have waited to seek treatment. Asymptomatic people are still treated based on risk factors, such as elevated blood pressure and cholesterol, but not on a personalized assessment of the presence of early cardiovascular disease. This is the first study that shows if you interfere early, you can cause regression of these cardiovascular abnormalities.” Most cardiovascular diseases are a result of a progressive problem that can be detected long before symptoms develop. Identifying individuals with early indications of disease can help doctors target the problem with lifestyle counseling and drug treatment to prevent future damage, Duprez said. That’s why the concept and validity of the Rasmussen Disease Score is a significant step toward the management of cardiovascular disease. The Rasmussen Disease Score, developed by Jay N. Cohn, MD, and This is the first study that shows if you interfere early, you can cause regression of these cardiovascular abnormalities. director of the University’s Rasmussen Center for Cardiovascular Disease Prevention, helps doctors identify early cardiovascular abnormalities that tend to lead to symptomatic cardiovascular disease. The 10 tests in the Rasmussen Disease Score include: large and small artery elasticity; resting and treadmill exercise blood pressure; carotid artery initial-media thickness; retinal vascular photography; micro-albuminuria; electrocardiography; echocardiography; and plasma B-type natriuretic peptide blood levels. This battery of tests together with a medical exam and counseling is performed in two hours in one location. The University of Minnesota Medical Center, Fairview is the only facility in the world that provides this screening process. ■ We Invite You to Write for Cath Lab Digest! All topics are welcome, but we are especially seeking articles for brandnew, inexperienced staff. Gain increased respect from your peers. Submit an article to Cath Lab Digest. For more information and a copy of CLD author guidelines, email managing editor Rebecca Kapur at rkapur@hmpcommunications.com

Table of Contents Feed for the Digital Edition of Cath Lab Digest - September 2007

St. Dominic Hospital The Genous Bio-engineered R Stent Percutaneous Treatment of Peripheral Arterial Chronic Total Occlusions: Device Options and Clinical Outcomes Contents Clinical Editor’s Corner Percutaneous Revascularization of Peripheral Chronic Total Occlusion — Which Patients, Why, and How? Myocardial Infarction and Syncope: A Manifestation of the “Raynaud-Prinzmetal Syndrome”? Essential Technical Components of the Transradial Approach If You Build It, Will They Come? Evidence-Based Medicine with Drug-Eluting Stents Back to School: The Value of Education in Cardiovascular Services The ACVP Standards and Competencies: Are You Using Them Effectively? What Do You Think? My Experience with Fibromuscular Dysplasia and Stroke A Brief Review of Fibromuscular Dysplasia Letter to the Editor A Look at On-the-Job Training: Perceptions, Reality and Our Profession Doing the Wave: Inventory Management with RFID The Ten-Minute Interview with… Paul Pinsker, RCIS CLD’s Annual Salary Survey Harrisburg Area Community College Volunteer Survey CEU Education Center SICP* Section Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Clinical & Industry News

Cath Lab Digest - September 2007

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