"Good advice. If I listened earlier, I wouldn't be here. But that's just the trouble with me. I give myself very good advice, but I very seldom follow it." From Alice in Wonderland, by Lewis Carroll.

I agree with what you say. My own travels in medicine have led to the point where I simply aspire to explain, to each patient, everything i know, to let s/he and family decide what makes sense, and then to do my best to support the decision. 

In addition, if you (as I) are interested in the prospects of your children and this country, the issue of medical need should be weighing more and more heavily upon you. This of course ignores the absurd context of starvation and malaria as common causes of misery and mortality in less fortunate parts of the world.

However, given that we as physicians are increasingly employed by Big Medicine, how strong is your moral compass?

well said.......we need to treat the patient... not the ekg/blockage/ number /lab /xray etc  he tho was a good consumer/customer... most people want to defer the /a decision to someone else or ask more qestions at the local fast food restaurant tan about what if i dont do this.. or if i do   doctors too quick to say need this/do this order this... cause of pay for performance also

As a Licesed Mental Health Counselor specializing in cardiac patients, and a WomenHeart Spokesperson, I have often talked about open dialogue with all of the patient's medical team.  One of the large challenges patients and blogs have reported is the decision over when is the right time for a medication or a procedure, and what are truely the pros and cons involved.  In addition, both need from the doctors perspective and need from the patient perspective may be different.  Terminology, years of medical experience on one side vs years of living with X challenge on the other may lead to passionate words that may not fully be understood by the other side. 

It is time for a major shift in which both the Doctor conveys clearly, the options available to the patient with the pros and cons involved.  And the patient takes on the responsibility to fully lay out their ideas and here comes that word, "Needs". On a daily basis I come across patients that have been placed on medications without full understanding of why, nor the ramifications of that medication.  Likewise, I also come across patients that did not realize the options involved, until they selected a particular medical path without knowing all of the ramifications associated with that decision.  Meanwhile, I have also met with many Doctors who truly want the best for their patient but have faced challenges in communicating effectively with their patients.  Some Doctors have said if I only had a therapist on staff, to help address some of these questions, then allowing for some time to make a decision by the patient.

It is time to think from the perspective of, "if this was my mom or sister" what would I want them to know or consider in this decision. 

Yes, I believe the question is what is best for the patient and what options could be considered.  Not what does this patient "Need". 

And as a side note I have also been a heart patient.  I had reparative surgery on both my cleft mitral valve and ASD.

 Thanks for listening.

Allison Teger, M.Ed., LMHC

As a very seasoned ICU nurse I had the opportunity to observe a physician obtaining informed consent from a patient of mine who, "needed", open heart surgery.

The patient declined the procedure. The physican, not happy with the answer, proceeded to discuss it with the patient's family. He wanted them to "talk" with the patient and "convince" him to have the surgery since the "patient's life depended" upon it.

The family "talked" to the patient and told him what the physician had said. The patient declined to give the family an answer at that time.

After the family left, I had an opportunity to talk with the patient. I asked him how he felt about the procedure, answered all of his questions, and told him about my experiences with open heart patients.

The most important thing I said to him was that I would support his decision regardless of what it was. He felt more comfortable talking with me because I was not "pressuring" him to consent to something he was not sure he "needed".

The patient did consent, had the surgery, and did very well.

I am within two weeks of an ablation procedure to treat atrial fibrillation that has galloped along for seven years paroxysmally. The fibrillation events endure for many hours, leaving me so wasted it seems inconceivable. I have spent the past many months researching all the journals the cognoscente publish within to teach myself the jargon and refresh what I used to know before I quit being a premed student in college. The past 6 weeks I have ingested verapamil once a day and it keeps my heart rate in the low 40s, leaving me so ragged at the end of the work day I just come home and sleep. I am grateful for the absence of atrial fibrillation events, but stunned at how hard that medication is on all the rest of my body. I am now 66 years old and I work all day every day outside in the oilfield, as I used to do all the rest of my life in agriculture and construction. I greatly appreciated this discussion of 'need' from the medical field. I recently had three cardiologists in Amarillo, Texas name of Chappin, Jewel and Haddad tell me that I was not a candidate for their services because I researched my condition so hard and deep and wanted to talk this over with them, and they refused my participation in my own treatment. I call their names herein because their behavior was so far out of line with the spirit of this discussion piece by Mandrola. I think I have a couple decades plus to live, and so I want to pursue a treatment that will allow for the fruitful conduct of those remaining years. For me to die is gain, as the Apostle Paul wrote, but living is good also, methinks, at this time. I think it would be real efficacious if the medical practitioners would stand back every year and survey the extent of the arrogance they push, and read and reread this article.

I'm a layman. I don't suppose I know any more about modern medicine than the average person, but I do know this: Lingering is not living. A long slow decline gives those around us time to adjust to the idea of ones' death, but there is a downside. The procedures that prolong ones' life can be brutal. The drugs and side effects can be brutal as well.  The stress and strain of caregiving take a toll on ones' survivors, the financial impact often means the estate you might wish to leave to your loved ones is decimated, and, while I don't mean this to be a slam on the medical field and long term care providers, there is simply no way to truly maintain ones' dignity while dying in a prolonged manner. If it goes far enough, at some point people start feeling sad for what you have become.  I have had family members go to bed seemingly healthy and happy and just not wake up the next day, and I have had family members go the Alzheimers route.  I am very clear on which I would pick, given a choice. I believe everyone has a responsibility to honor their own existence by living the best life that they are capable of living. I also believe that if we are graced in our old age with the mental acutity to understand that our time has come, the very act of choosing to let ourselves die with grace and dignity is what I would consider the crowning achievement of a life well-lived.

I value what modern medicine and skilled medical professionals bring to our lives, but medical professionals can learn from the lesson that old man was teaching. I don't know who he was, but I am certain I'd liked to have known him. I don't know how well he was educated, but he was wise.

want V need
simply what does the patient 'want'. the patient may 'need' a PPM but may not want it.therfore next time just ask what do you 'want' after explaining the options.i.e. of course you will recommend the need for a PPM to stay alive but what does the pt want.