Opinion

FROM Risks, Benefits, and What Matters to the Patient

THE HEART

Nancy E. Lundebjerg, Some years before my mom died,1 I found myself sit-
MPA ting with her in a quiet, dark cardiology stepdown unit
American Geriatrics on a snowy holiday weekend. From my brief walks
Society, New York,
around the unit, I observed that most of the patients
New York.
were older, and some were without family or friends.
Mom, however, was stuck with me, which led to the first
challenge for the young cardiologist covering the unit:
knowing whom to address to obtain informed consent.
Even something as simple as where to stand or sit in the
room seemed to mirror her conundrum. Should she
gravitate toward Mom, nodding off in her bed; toward
the caregiver daughter in the chair next to the bed; or
perhaps to the 1 remaining chair in the room?
She announced to the room that she had come to
obtain consent as she sat down in the chair, swathed in
her white coat, her stethoscope around her neck. Since
Mom was dozing, I leapt into the fray. We began to make
our way through a lengthy consent form for an inter-
ventional diagnostic test with multiple risks that would
help us understand what was causing the fluttering
feeling in my mom’s chest.
When I tell this story, I always talk about the physi-
cian’s lack of inflection when delivering those risks.
On the one end was a small allergic reaction to the dye;
on the other, a disclosure that if my mother coded, the
clinical team would take her for open-heart surgery.
Because of the monotone, it took me a minute to
notice that one of the risks was open-heart surgery—
but once that was digested, I hit the pause button on
what had been to that point a monologue: “Um, wait
a minute. Could we talk about that last one? Mom is
89 years old with multiple chronic conditions, and I’m
pretty sure she wouldn’t want open-heart surgery.”
At this point, Mom’s eyes flew open (or so it
seems, in my misty memory of that day) as she chimed
in with a “What?” I explained that the cardiologist had
come to get consent for the next day’s diagnostic pro-
cedure, which included a risk of open-heart surgery.
My mom fixed that physician with her best steely-eyed
glare and replied, “I don’t want open-heart surgery.”
Corresponding With that decision made, we finished up the consent
Author: Nancy E.
Lundebjerg, MPA,
process, leaving my mom’s do not resuscitate (DNR)
American Geriatrics order intact, and sending the physician on her way
Society, 40 Fulton St, with a signed form.
Floor 18, New York, NY
I sighed to myself and asked Mom’s nurse when
10038 (nlundebjerg
@americangeriatrics I should plan to be at the hospital the next day to talk to
.org). the cardiologist about my mom’s consent. I was pretty
sure we would be having this discussion all over again.
Sure enough, as the young interventional cardiologist
and I went over the consent form the following morn-
ing, he noted that the lead interventional cardiologist
on the team was not going to like keeping my mom on a
DNR order and not allowing for open-heart surgery—to
which I replied that it would be good if I spoke with him.
To his credit, the lead interventional cardiologist
engaged me in a good discussion that delved into the
intricacies of what concerned him about the existing
consent and what concerned my mom about any
changes to it. For several minutes, we covered 2 distinct
topics: lifting the DNR (so that if my mom’s heart got
knocked out of rhythm, they could do cardiopulmonary
resuscitation and possibly shock her heart back into
rhythm) and deciding what the team would do if they
could not restore rhythm. We arrived at my agreeing to
lift the DNR for the duration of the procedure and the
lead interventional cardiologist agreeing that, if his team
faced a decision about open-heart surgery, he would
come discuss with me whether my mom would want to
take that step. We explained this to Mom, and she
agreed that this was a reasonable compromise.
In full disclosure, I work with geriatricians.2 So, when
I tell stories about my experiences as a serial caregiver,
they often conclude by asking a question that begins
with “what if.” To this day, I wonder what would have hap-
pened if I had not been listening intently to that young
cardiologist as she led us through the consent discus-
sion, if the procedure had then gone wrong, and if my
mom had been sent up for open-heart surgery. Per-
haps more importantly, I wonder what steps we can take
to help trainees across specialties and professions who
need to understand a patient’s priorities before they start
to recommend treatments and discuss risks and ben-
efits. I imagine a health care world in which physician-
patient conversations start with this question: what
matters to you? That is a world where decisions and
consents are always framed by a patient’s priorities for
life and not by the current disease that we are trying to
treat. As some colleagues describe it, it is a move from
“You need (_____ treatment) for your (_____ disease)” to
“Knowing all your conditions, your overall health, and
what matters most to you, I suggest we try (_______).”3
Knowing what matters to the person in front of you
should be at the top of everyone’s list. We can work
together to make that happen.

Published Online: September 19, 2018.
doi:10.1001/jamacardio.2018.2906
Conflict of Interest Disclosures: The author has
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest.
No disclosures were reported.
1. Lundebjerg NE. My mom is dead (and that is OK).
J Am Geriatr Soc. 2018;66(3):629-630. doi:10.1111
/jgs.15239
2. Lundebjerg NE. How geriatrics saved this family
caregiver. J Am Geriatr Soc. 2018;66(4):833-834.
doi:10.1111/jgs.15279
3. @PTPriorities. Patient Priorities Care moves
decision making from “you need (_____ treatment)
for your (_____ disease)” to “knowing all your
conditions, your overall health, and what matters
most to you, I suggest we try (_______).” https:
//twitter.com/PtPriorities/status
/1017026947954683904. Published July 11, 2018.
Accessed August 6, 2018.

jamacardiology.com (Reprinted) JAMA Cardiology Published online September 19, 2018 E1

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