Correspondence
Cardiac Surgery at 87
N Engl J Med 1994; 330:1160April 21, 1994
- Article
To the Editor:
The December 2 issue included two letters that disturbed me. Objecting to the recommendation and implementation of “an extensive . . . course of treatment for a hopelessly ill 87-year-old woman,” Dr. Reich suggested that “you send your experts back into clinical practice”1. I reread the original case report2 because I recalled that the 87-year-old patient was healthy and vigorous until a month before surgery, when an intercurrent infection tipped her into heart failure. My recall was good: she survived her surgery to resume a vigorous, independent life. Dr. Thibault, who cared for the patient, was too timid when he replied that “this is a complex decision about which reasonable people might disagree”3.
I am a long way from 87, but if I get there in good shape I hope to find a doctor who does not think that age alone makes me hopelessly ill. Age notwithstanding, there are patients whose condition is such that further efforts would be futile. We should honor those patients' wishes concerning terminal care. However, patients whose health can be restored should have the benefit of doctors who have more heart than Dr. Reich and more courage than Dr. Thibault.
3 ReferencesRonald Feldman, M.D.
898 Oyster Bay Rd., East Norwich, NY 117321
Reich JS . Criticism of Clinical Problem-Solving. N Engl J Med 1993;329:1743-1743
Full Text | Web of Science | Medline2
Thibault GE . Too old for what? N Engl J Med 1993;328:946-950
Full Text | Web of Science | Medline3
Thibault GE . Criticism of Clinical Problem-Solving. N Engl J Med 1993;329:1743-1744
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Dr. Feldman and I agree on the care of the 87-year-old patient. I was responsible for her care, and I recommended surgery on the basis of my knowledge of her wishes, lifestyle, and physiologic state. I do not think this is an issue of “courage” on the part of the physician; the courage resided totally with the patient. I am comfortable that this was the right decision for this patient. In my discussion and response to letters I thought it important to acknowledge, however, that these are not easy decisions and that others (both patients and physicians) might have made a different decision if faced with similar circumstances.
The patient is still leading an active, vigorous life two years after surgery.
George E. Thibault, M.D.
Veterans Affairs Medical Center, West Roxbury, MA 02132Author/Editor Response
Dr. Feldman missed the main point of my objection. My objection was not to the provision of medical care to an 87-year-old patient but rather to the provision of intensive, extremely expensive medical care to an 87-year-old patient who had no reasonable hope of returning to a good-quality life.
I think we must all realize that in a society in which almost 50 percent of our children do not receive routine vaccinations, nearly 40 million young adults have no medical insurance and are receiving minimal or no care, and community-hospital emergency rooms are jammed full of people who have no other place to go because they have no access to other kinds of medical care, we must reevaluate such expensive treatment of people who have minimal or no chance of resuming a life of any quality. I would hope that if I reach the age of 87 and have all the problems this patient had, the thousands and thousands of dollars spent on this patient would be spent not on me but on vaccinating children or preventing correctable illnesses in young adults.
Jerome S. Reich, M.D.
16800 N.W. 2nd Ave., North Miami Beach, FL 33169
