Medicine is about balancing risk and benefit. Certainly, as healthcare providers, we attempt to provide the best care for our patients based on available evidence. Physicians often are seen as shepherds, helping to guide patients through disease and therapy. As I have mentioned in previous blogs, ultimately medicine will be personalized and tailored to one’s particular genetic make-up. However, the need for a clear discussion of treatment options with patients will remain a necessary and important part of the doctor patient relationship–even in the era of genomics.
Recently an article was published in the Archives of Internal Medicine that examined the way in which cardiologists communicated with patients prior to implantation of an Implantable Cardioverter Defibrillator (ICD). As an Electrophysiologist who routinely performs ICD implantations, this particular study hit pretty close to home. The authors used patient focus groups to determine just how well each was informed prior to their respective procedures. Researchers found that many patients felt inadequately prepared specifically for the emotional and psychological impacts of ICD therapy prior to proceeding with implantation. Moreover, many patients felt that they did not fully understand the reason for the procedure or its possible complications.
For the most part, I think that procedurally based physicians do a fair job of explaining the technical aspects of the planned procedure and readily quote complication rates (as required by informed consent). What we don’t do a great job of is making sure the patient actually understands the explanation or the risks. Physicians who are procedurally focused often do not consider the long term emotional and psychological impacts that procedures such as ICD implants may have on the patient down the road. As Electrophysiologists, we are aware that there is a growing body of evidence to support the significant psychosocial and emotional side effects for patients living with an ICD (mostly thanks to the outstanding work by colleagues such as Dr Sam Sears). In the last decade, device recalls and lead failures have led to significant patient morbidity and mortality. All of these complications come with a price–both physical and emotional.
Clearly, we are not doing enough when discussing a potential procedure with a patient. I do not believe this is in any way limited to Electrophysiologists who are implanting ICDs. I think that this study brings up an important issue for every physician to consider. The results of these patient focus groups should cause us all to pause and evaluate our ability to communicate with our patients. In my practice, I make a conscious effort to carefully explain the procedure, why it is indicated and what the potential side effects are to both patient and family. But, after reading the Archives piece, I am left wondering, do I do enough?
Given the shortcomings that are illustrated in ICD consents in this survey, Where do we go from here? I think that we must reevaluate the way in which we discuss procedures with our patients. Certainly the principles of informed consent must continue to be documented for the lawyers of the world. However, we must go beyond basic informed consent and make sure that we are able to provide a reasonable explanation of possible long term emotional and psychological side effects (as well as the immediate impact on our patient’s lives). We must also do more than simply discuss the statistics and the potential for risk vs. benefit. We must provide the patient the opportunity to ask questions and to explore with our patients how the implant of an ICD may impact their lives–both positively and negatively. Only then, can we feel as though we have truly served as a guide for those we are charged with caring for. After all, one of our most important jobs is to communicate options in a way that allows our patients to make the best treatment decisions for themselves and for their families over the long haul.