The consult read, "d/c coumadin. Consult Dr. Onco-blog." Ok, so this was a weird reason to be called on July 4th, but I'm here. So the lady only speaks Italian. Ok, so we look up the language line. So far, I don't think any of the other four doctors who saw the patient thought to do this, at least not before they dictated their consults.
So the lady used to be on coumadin, but some fancy doctor in Beverly Hills took her off it. She reports some bleeding. She delegates decisionmaking authority to her daughter, though she herself has capacity, in my humble opinion. The translator explains to her in her naitive tongue that she will likely have a stroke if she does not submit to anticoagulation.
I wonder why someone with perfectly decent decisionmaking capacity would delegate like this. Turns out, her daughter is not particularly happy about having to make a decision for the mother. Looks like we have more than a language problem, we also have a communication problem.
So I tell the lady I'll talk to her daughter. That gets a strong reaction from the nurses. Apparently, this is the same daughter who refuses to let any insulin be given for blood sugar less than 250. I call the daughter, and she picks up on the first ring. At least she's around. She had me at hello...So I give my spiel about the coumadin. The lady had a stroke, she has paroxysmal atrial fib, and CHF. She's a setup for a stroke. I give her my disabled-but-not-dead scenario for stroke. She says she's gonna go back to Dr. Beverly Hills for an opinion, and that there's a new anticoagulant available. Sure, there are other anticoagulants out there, but none as good as coumadin in this setting, and there's no contraindication to coumadin. Sure, the patient's an old lady, but that alone ain't enough of a reason to withhold anticoag.
So this is basically denial--if we mount enough of what we think are cogent arguments, we don't have to listen to the doctor. It's a form of ignorance. Nobody would care, except that a lady might have a stroke over it. I told the daughter that anyone preventing this lady from having coumadin would be indirectly responsible if she had a stroke. The nurses appreciated that.
I'm looking up her CHADS2 score, and she has every point out there. She's a diabetic, CHF, HTN, old lady, prior CVA. She has a score of 6, so she would be 1/3 less likely to have an event per year. The benefit would be higher, but her risk is pretty high even with coumadin. The other thing is that she's a 50/50 COPD'er, so that gives her an adverse prognosis.
Maybe my attempt to bring clarity to a holiday consult on a high-risk patient is an exercise in futility. Maybe that's why I made my attempt with such relish.
