Friday 5 September 2008

Life and death

I had a letter informing me that I needed to reply to an invitation to attend a conference and it "was vital" that I replied by mid September. It was a meaningless conference put on by a drug company that I had no intention to ever attend so it was carefully filed in the bin.

But it got me thinking.

Lungs. Important things, lungs. Hearts, too. Wouldn't want to have those stop working, it all goes rather badly then. Knowing they're necessary to stay alive, when in receipt of health care it's common for symptoms and signs to be sought. Clinical indicators of cardiac function and ventilation are recorded, as pulse and respiratory rate. These are known as "vital signs" since in addition to symptoms, these signs help guide on severity.

If you have a pulse rate or respiratory rate of 0 and they've stopped, the prognosis is not good. These are signs necessary for life. Vital signs.

An online medical dictionary describes "vital" as meaning :
Pronunciation: 'vIt-&l
Function: adjective
1 a : existing as a manifestation of life b : concerned with or necessary to the maintenance of life vital fluids>
2 : characteristic of life or living beings
3 : recording data relating to lives
4 : of, relating to, or constituting the staining of living tissues —vi·tal·ly /-&l-E/ adverb
Merriam-Webster's Medical Dictionary, © 2002 Merriam-Webster, Inc.

Not writing to a drug rep about a spurious and somewhat tawdry conference where folk are trying to peddle their wares with a veneer of civility and propriety, hmmm, who's going to die as a result of this, then? No. It is not "vital" at all. To tell medics it is, well, that's a rather astonishing act of hubris that never fails to irritate me.

Having mused over the implications of "vital" and what this means to health, I've been thinking about causation, disease, consequence and interventions.

It's common, in medicine.

Cause (a virus), disease (a cold), consequences (knackered and can't work that day), interventions (rest in bed with paracetamol).
Cause (cigarettes), disease (lung cancer), consequences (knackered, breathlessness, weight loss), intervention (surgery, radiotherapy)
Cause (bereavement), disease (adjustment disorder), consequences (housebound, not seeing friends, not shopping or cooking), intervention (support)
Same process can be thought through with diabetes (pancreatic islet cells) or bladder or stomach cancer (analine dyes or nitrosamines in smoked foods) or most any condition you'd care to consider.

What of conditions that arise which could be prevented? Weight gain from antipsychotic medication can be an issue, but in older adults often isn't. Usually it's the other way around, with a gain in weight being positively beneficial. Obesity more generally is seen as an elective life choice. After all, we choose what we eat and how physically active we are.

This can lead, from past experience, to interesting conversations that GPs have with their patients :

Am I overweight, doctor? Why, yes I am.

Is this impacting adveserly 'pon my physical, mental and social wellbeing? Why, yes it is.

So this constitutes a situation where my physical state is impacting adversely upon my health? Evidently so.

Having now poled up for this health matter to be addressed, I'd therefore like appropriate clinical care to address my health problem.

What, no, you can't fix it? You say it's a lifestyle choice? So's skiing, but you treat sprained ankles. So's sex, but you manage contraception and abortion. So's going to work, but you treat occupational injuries and health problems. So's smoking, but you treat COPD and lung cancer.
So come on, over to you doc, treat me, make me better.

Simply because the causation wasn't a random event, should that impact on the condition, the consequences and the interventions (in terms of clinical care offered) at all?

A Nice Lady Doctor notes the medicalisation of ordinary and everyday life. GeePeeMum notes that a lady with end stage bronchitis is chided for past choices she made. The Ferret Fancier (and those commenting) recognise obesity is best addressed through social/public health measures rather than Primary Care.

Although my attendance at drug companies peddling pills for all ills is not "vital" I do think joined up thinking matters on management of health issues where lifestyle choices (cycling -> RTA, smoking -> Ca lung, eating -> obesity, sex -> teenage pregnancy, whatever) that impacts on health in the here and now doesn't result in different care because the aetiology of the disorder was within the patient's gift to influence. Addressing current clinical need can truly be "vital."


Anonymous said...

I know I haven't posted but I really love reading your blog, so I've included you as a nomination in "I Love Your Blog". Cheers.

Anonymous said...

Lifestyle choice is a difficult one I've yet to determine right from wrong. Even with my super-reductionist powers the Root Cause Analysis gives me no better information for an informed and balanced opinion.
You can add tropical diseases to those who go on holiday to foreign climes and stress to those who work in highly responsible jobs. The list is endless and only those with congenital or latent genetic disorder would be valid recipients of free health care interventions.

Dr.Rutledge said...

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frontierpsychiatist said...

Occasionally a friend who is not medical will ask me how I feel about treating people who are smokers (for physical disease) or drug addicts (physical or mental) I always say to them the same thing:

1. If no one smoked or did drugs we doctors wouldn't have jobs

2. I don't see a moral difference between hurting yourself on another voluntary activity such as motorcross and hurting yourself on cigarettes
3. Although this is a 'free society' our ability to make choices is often very restricted through, for instance income and education

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