Re: Real doctors treat more than one species. Author replies

Thanks to Dr Byrne for writing in response to my article, “Real doctors treat more than one species.” As I mentioned in the article, this was a superficial analogy to get people thinking. And it seems to have triggered some thinking in Dr Byrne that I would like to address.

Dr Byrne suggests that my article advocates a “simple, one-size-fits-all” approach to medicating frail older patients. There is nothing simple about discussing preferences for care with patients. It is time consuming and requires emotional energy. Deprescribing according to time-to-benefit requires a prognosis estimate and knowledge of the medical literature.

Dr Byrne notes that the few medications that cause frequent hospitalizations in older adults are the same medications as those in adults of any age. What I was pointing out in the article is that the medications that cause hospitalizations (warfarin, anti-platelet agents, insulin, and hypoglycemic) are medications that are highly unlikely to benefit those in their last months of life, and I was urging physicians to stop these medications when possible. Dr Byrne also criticizes the Beers criteria because they identified less than 10% of drugs causing emergency room adverse-event visits. Adverse events can cause symptoms and signs that result in needless investigations, further medications, and poor quality of life, and may never result in an emergency visit. 

Perhaps Dr Byrne felt that an analogy to veterinary practice was too simplistic, but a veterinarian treating an animal would not look at the species as the only factor in deciding on therapy. Age, habits, renal or liver function, route of administration (even our vet is challenged getting a pill into one of my cats!), and preferences for care (as expressed by the owner) would all be considered prior to therapy.

Dr Byrne advocates looking to physics for advice on complex systems as an approach to frail older adults. While I agree this approach may add a greater understanding of how frailty, disability, and morbidity relate to each other, I am not sure it would acknowledge the significant role that prognosis awareness and an individual’s preferences should have in the care we provide for older adults.
—Romayne Gallagher, MD, CCFP(PC), FCFP
Geriatrics and Palliative Care Committee