Monday, March 23, 2015

Safety first? Not with my patients!

'Safety first' is a mantra of today's hovering parents.  It's the default explanation that a parent invokes when an edict has been issued that cannot be challenged or reversed.

"Mommy, can I pleeeeeeze have a water pistol?"

"I'm sorry, honey.  You know how Daddy and I feel about guns.  This is a safety issue.  Now go and practice your violin and afterwards help yourself to some kale chips."

Caution! Water Pistol Zone Ahead

The safety concept has crept into the medical arena.  In many cases, safety concerns about our patients are justified.  I see many of our elderly hospitalized patients approaching hospital discharge who face safety concerns at home with respect to falls, understanding complex and new medication lists and monitoring active medical issues.  Hospitals today have a staff of capable and compassionate professionals who do excellent work protecting patients poised for discharge.  This effort saves patients suffering and saves the system cash -  a medical win/win.

It's no victory for a cardiologist to rescue a patient from congestive heart failure if the patient goes home and doesn't take her medicines or veers widely off the recommended diet.

But sometimes safety should not be first.  How safe would you want to be if your quality of life would suffer?  To those who argue that safety is paramount, would you support the following proposals?

  • Outlawing motorcycles
  • Decreasing the speed limit by 10 mph on every road
  • Prohibit high school and college competitive athletics
  • No swimming - anywhere
  • Avoid gluten - the silent killer
Don't take the above too seriously, since I don't.  But, here's my point.  I am often asked to place feeding tubes in elderly individual after they are tested and told that it is not safe for them to take food or drink by mouth.  These patients are found to have imperfect swallowing function. The fear by those who make these recommendations is that the patient will choke while eating with some food dropping into the lungs causing a pneumonia.
  
These concerns are real, but we need some context.  First, if all 80 year old folks were subjected to the conventional swallowing test, many would be found to have swallowing dysfunction, and yet they are eating and drinking without significant difficulty.  So, we have to be cautious about placing a feeding tube just because a swallowing test is abnormal.  Secondly, many elderly patients have few pleasures remaining in their lives.  Are we comfortable convincing them or their guardians to take food away when this may be a singular pleasure for them?   Even if oral feeding has risks, for many of these folks I suggest that it may be the better choice.   I think that we talk many of them and their families into the tube, which has it's own medical risks in addition to its effect on human dignity and quality of life.

Do feeding tubes make sense for some patients?  Definitely.  But, it shouldn't be for everyone,  We can devise a series of rules to live by that would make us much safer than we are now.  Would you want to live like that?

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