Correspondence
Clinical Problem-Solving: Sounds in the Attic
N Engl J Med 1993; 328:1499-1500May 20, 1993
- Article
To the Editor:
Duffy's commentary on the case of pneumococcal pneumonia presenting as abdominal pain followed by shock and death (Jan. 7 issue)1 states that the case highlights “any number of interesting and important aspects of today's medical conundrums.” The aspect of the case that struck us, as geriatricians concerned with preventive measures, is that the pneumococcal vaccination history is not mentioned. Austrian and Gold2 observed in 1964 that an apparently irreducible mortality accompanied pneumococcal infection despite appropriate and rapid treatment. Their data suggested that more than 10 percent of patients presenting with pneumococcal infection were destined to die within five days; antimicrobial therapy had little or no effect on this outcome, and the majority of the early deaths were among older patients. Although they were a small proportion of total deaths in the era before antibiotics, such deaths made up the majority of those among patients treated with antibiotics.
Prevention was thought to be the sole way to avoid this early mortality, and advocacy for reviving the production and use of pneumococcal vaccine was based on these observations. Vaccination is recommended for patients over the age of 65 and for those with chronic illnesses such as pulmonary, renal, or cardiac disease -- conditions met by the patient in Duffy's article. Shapiro et al.3 have demonstrated the efficacy of vaccine in preventing invasive pneumococcal infections in immunocompetent patients, although efficacy does decrease with increasing age. Vaccination rates of only 13 and 20 percent were reported in the study, numbers far too low in view of the deaths of nearly 15 percent of patients treated with appropriate antibiotics. The woman discussed by Duffy was a regular patient in the health care system and had ample opportunity to be vaccinated. We need to implement strategies to ensure higher rates of vaccination among those at risk for pneumococcal infection in an attempt to avoid disease, rather than spend thousands of dollars on resuscitative measures in the final hours of life.
3 ReferencesAnne M. Kenny, M.D.
Richard W. Besdine, M.D.
University of Connecticut Health Center, Farmington, CT 060301
Duffy TP . Sounds in the attic. N Engl J Med 1993;328:44-47
Full Text | Web of Science | Medline2
Austrian R ,Gold J . Pneumococcal bacteremia with especial reference to bacteremic pneumococcal pneumonia. Ann Intern Med 1964;60:759-776
Web of Science | Medline3
Shapiro ED ,Berg AT ,Austrian R , et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med 1991;325:1453-1460
Full Text | Web of Science | Medline
To the Editor:
As estimated by a San Antonio hospital administrator, the cost to the patient described by Duffy for the first 24 hours of hospitalization was $6,580, excluding physicians' fees. This 87-year-old woman with multiple medical problems and a living will received triple antibiotic coverage, intensive-care-unit care, mechanical ventilation, an arterial line, a Swan-Ganz catheter, pressor agents, steroids, and multiple laboratory tests including a cortisol measurement before being removed from her ventilator and subsequently dying. Had she in fact had ischemic bowel disease and undergone a laparotomy, as was the intention, her hospitalization would have been more complicated and prolonged, with a high risk of the same outcome.
This article is of interest in that U.S. physicians are often criticized for performing tests and procedures because of the profit motive. Dr. Duffy's exercise for the purposes of education illustrates that physicians are trained to be thorough despite the costs. Most medical residents learn early that they receive less criticism in a morning report if they perform a more extensive evaluation. These practice habits often continue after the completion of training, with reinforcement by our legal system.
Although the presentation of pneumonia is certainly important to understand, the more difficult and pressing issue for the practicing clinician in such cases is how and when to limit care. The same presentation would be of interest with a step-by-step discussion of the ethical decisions and dilemmas involved in treating this patient, with consideration of no intensive-care-unit care, mechanical ventilation, or surgery.
Bradley B. Kayser, M.D.
7210 Louis Pasteur, San Antonio, TX 78229To the Editor:
The decision to terminate mechanical ventilatory support and pressor agents and allow an elderly woman to die only 24 hours after admission to the hospital for a still undefined condition because she had executed a living will raises questions about the decision makers' understanding of advance directives. The directives of a living will are limited in scope. In Illinois and many other states, the living will enables patients to instruct their physicians to withhold or withdraw further treatment only if they should have an incurable and irreversible injury, disease, or illness judged to be a terminal condition by an attending physician, who also judges that death is imminent in the absence of death-delaying procedures. The existence of a living will is not evidence that an elderly patient would not wish to endure the intensive care necessary for potential recovery to an acceptable (to the patient) functional state. A consensus among the patient's health care providers that further treatment would only prolong dying would be needed to ensure that the conditions of the living will had been met.
Kenneth Simpson, M.D.
Illinois Masonic Medical Center, Chicago, IL 60657Author/Editor Response
Dr. Duffy replies:
To the Editor: The emphasis Drs. Kenny and Besdine place on prophylaxis with pneumococcal vaccine is an important addition to my article. Unfortunately, the patient I described represents a failure of the vaccine, since she had received this prophylaxis two years before her death. This sort of failure may be due, as Shapiro et al. point out,1 to infection with a serotype not represented in the vaccine or to the decline in the efficacy of the vaccine with a patient's increasing age. This patient's outcome, however, does not lessen the appropriateness of the admonition to use this vaccine.
Drs. Kayser and Simpson are both concerned with setting limits on the care of the elderly, and the polarities of their concern demonstrate the unresolved issues that exist in this arena. Dr. Simpson's clarification of the living will actually buttresses the stand my commentary took. Without sound clinical evaluation and judgment on the part of physicians, the conditions of the living will cannot be fulfilled, and our care of patients, young and old, will be inadequate2. Technical competence remains the foundation on which an ethical practice of medicine is based.
Dr. Kayser's suggestion that the focus in this case be shifted to an ethical perspective is a good one: I explored the problem of setting limits briefly in a previous essay3. Unfortunately, the controversy remains unresolved.
3 ReferencesThomas P. Duffy, M.D.
Yale University School of Medicine, New Haven, CT 065101
Shapiro ED ,Berg AT ,Austrian R , et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med 1991;325:1453-1460
Full Text | Web of Science | Medline2
Jackson DL ,Youngner S . Patient autonomy and “death with dignity”: some clinical caveats. N Engl J Med 1979;301:404-408
Full Text | Web of Science | Medline3
Duffy TP . Rationing health care: its impact and implications for hematology-oncology. Yale J Biol Med 1992;65:75-82
Web of Science | Medline
