We debated yesterday during the ward round, as to whether I should discontinue one of my patient’s medicines.
85, he’s not in good shape; struggles to walk, confused at night, the stroke ten years ago took his ability to speak.
Of all the drugs that are forced upon him morning and night, one is to lower cholesterol. A statin. I know that one or two of you reading this will be taking a similar drug – they all have the same ending – Simvastatin, Atorvastatin, Pravastatin; they are a variety of drugs discovered twenty or thirty years ago that have magical properties in modulating levels of cholesterol, manipulating the lipids that flow through your body.
It was in my home town of Glasgow that one of the early studies demonstrated the dramatic effect the tablets had on reducing death amongst a group of inactive, overweight Glaswegians. As a result, folk lived who otherwise would have died. Since then, thousands of lives have likely been saved and drug companies have made billions. At one time statins were the most commonly prescribed drug in the world; now I think it is antidepressants (or, in the US, Opiates), but that is another matter.
My patient, I’ll call him Alf – not his real name, can’t talk with me – because of the stroke; his wife is frail, but able. Should we or shouldn’t we stop the drug? Is the burden of the medicine worth the benefit of the treatment? One little tablet surely can’t do much harm, and, remember, he’s had a stroke – he doesn’t want another. We talk with his wife, try to explain the ins and outs – not venturing too much into statistics which for most normal people results in a shutdown of attention.
You see, the drug is to lower cholesterol to prevent him having a heart attack or stroke, and, yes, he is at risk of these following his previous stroke; but, then there is his current situation – his quality of life; his ability to communicate is limited. And then, there are the costs of the medicine – does it cramp his muscles, limiting his walking? Does it raise his blood sugar causing him diabetes? Does it result in a nightly battle with the nurses to convince him to take a drug that he can’t comprehend? And, another stroke what would that do?
Not forgetting that none of these medicines are panaceas. None of them help everyone every time; numbers needed to treat means the numbers of people who must take a tablet for one person to benefit – the numbers range from 20 to 100; that is, for every 100-people taking a pill, 99 won’t gain any benefit – it will be as if they had never taken it in the first place, and this, balanced against numbers needed to harm – how many people will need to take a drug before someone is harmed – falls, vomits, collapses, dies. Difficult to calculate given individual variability and was it drug X that cause him to fall, or the uneven stairs, the poor light or a bad dream?
And then, continuing from the number of people needed to treat is the duration of treatment – if you take drug A for two days it is unlikely to make much difference; if you take it for five or ten years, it might prevent the growth of a tumour or the strengthening of your bones preventing a fracture. The body, its physiology and anatomy change at different rates, different speeds. Bone grows slowly; my stomach ulcer can heal overnight.
We debated this way and that; to stop, suspend or continue. Perhaps over-thinking what another doctor wouldn’t have considered an issue – some would just ignore – gloss over and move on to the next question, others would have crossed-off without a second thought.
And in the end, given the likelihood that no matter my action things will happen – he will walk, improve or deteriorate, with nothing to do with me – we can offer love and attention, affection and care, but we cannot modify time’s arrow.
Just like a Shaman, stomping around my garden at twilight, chanting, shaking a stick at the clouds, frightening young children, these are all forms of the same thing – all modifications of self-belief, of concepts of good and bad.
At least I am trying and we are open to discussion; to listen to others, respect their opinions, ideas and considerations/
Tomorrow is another day.
PS We stopped it.
PPS Please don’t stop taking prescribed medicines without talking to someone in-the-know (doctor/nurse/pharmacist).