Evidence-based Care for Evidence-based Deniers?

[jmj11]

Okay, I have a family member who is very sick from COVID right now, as is her husband. They are COVID vaccine deniers (for political reasons), use homeopathic treatments to "boost their immune systems" and for acute treatment for COVID. They believe masks are harmful and never practiced social distancing, even in the worst of times. This is their fourth bout with COVID. They were in ICU, near being on a vent, during one episode and this episode may be heading that way. I tried talking to them until I was "blue in the face" in the early days of COVID about preventative care, with no change in their thinking. I no longer bother talking to them about their health. I have heard some propose (which could never happen in the real world) that these deniers should be denied evidence-based medical care if they have done nothing legitimate to prevent the disease. But as an exercise in ethical thinking, what is your opinion? I've gotten so frustrated with these family members, I don't care if they get care in a hospital or not anymore. They usually go in when they are facing death in the face. Mike

[sas5814]

People have a right to make stupid decisions. The thing that frustrates me is they become a huge drag and expense on the system when , basically, they did it to themselves.

When there isn't steam coming out my ears I think its not really much different than smoking, drinking to excess, being morbidly obese, failing to manage your diabetes and/or blood pressure. Its stupid behavior with predictable outcomes. We still treat them all.

 

[ventana]

I think they should be last in line for vents.  

[kettle]

Not giving care because they don't believe in evidence based medicine? Fine line between medicine and playing God.

Once the vaccine became widespread to the public I remember people coming in with covid and the first thing they got asked by many was, "Are you vaccinated? No? Why not?" Then the tech, nurse, provider etc would treat them poorly. For documentation, I would ask if they were vaccinated and if they said no, I left it at that. My job is to be caring and compassionate and help them get better. Not to judge them.

Jmj11

I hope your family members get better soon!!!

[roundabout]

What is the difference between your friends and an individual who spends their entire life smoking cigarettes, eating poorly, and not exercising who ends up with cardiovascular disease, diabetes, and a AAA based on the lifestyle choices they made every day for years knowing that there is unlimited amounts of indisputable evidence that all of those lifestyle choices are linked to higher rates of those diseases? Should they also be denied access to cardiac cath labs, CT surgery, and treatment for diabetic emergencies?

Edited January 18, 2023 by roundabout

[Boatswain2PA]

I can't believe 1/3 of us would do this....

 

Edited - was only an N of 3, didn't realize that.

Edited January 18, 2023 by Boatswain2PA

[ohiovolffemtp]

When I started in EMS 40+ years ago, it was "you call, we haul", and we did.  Grumbling sometimes, but everyone got transported.  Ever since I started "indoor" EM, I've treated anyone who came in who was willing to be treated.  I can't fix stupid, and sometimes I can't fix the consequences of stupid at all, more often I can only help folks survive until the next crisis, but I figure that's what I signed up for.

[thinkertdm]

Makes me think of this: 

“Watch your thoughts, they become your words; watch your words, they become your actions; watch your actions, they become your habits; watch your habits, they become your character; watch your character, it becomes your destiny.”

leave the judging for others, do what you are trained to do.  I yearn for the day no one does stupid things, because that’s the day I become irrelevant as a provider.  Until then, I swore an oath to help my fellow man.  If not I, then who?

[Boatswain2PA]

Should those who took the vaccine be the "last in line" for new hearts if myocarditis takes out their heart?

Of course not.

Despicable thought....

[rev ronin]

3 hours ago, Boatswain2PA said:

Despicable thought....

No, it's a utilitarian thought. It's what would generally be called "natural consequences."

But we're better than that.

Medicine isn't just a job it's a profession and that means it's governed by a code that's bigger than any one of us.  Of course, there are a lot of people who don't remotely value the Hippocratic oath, so yeah, you get punitive medicine sometimes... but it doesn't right any wrongs, it just brings us down to the level of retribution, rather than healing.

[Febrifuge]

In my state, we had discussions on the Ethics team about what would happen if case numbers kept rising and we had to institute the “Crisis Standards of Care,” the way one or two states (I think Utah was one) had to do. In MN, as in just about every state, we normally allocate resources like ICU beds or ventilators based on need, and as long as the supply and the demand work out okay, it’s not a big deal.

If it’s close, but we’re still working within the normal standards of care, it’s first-come, first-served, based on the idea that anyone who needs a vent needs a vent. There were some weeks involving shuttling patients or vents around between cooperating hospitals, as I recall.

The interesting thing is that if Crisis Standards ever need to be activated, the rationale shifts. The limited resources wouldn’t go to whoever needs them the most because they’re the sickest right now, the resources would go to the patient who stands to get the most benefit from that intervention. 

Which might mean in some cases that the person who didn’t get vaccinated, and has permanent lung damage from 4 prior bouts of COVID, and is an obese 45-yr-old smoker, could in theory get passed over, while the vaccinated healthy 70-yr-old gets the vent instead. It really is basic triage, in the Mass-casualty sense. Thankfully we didn’t ever get to that point in prior waves, and we hope never to have to worry about it… but I do sometimes wonder if maybe that part of the discussion should be out there a little more. 

[Boatswain2PA]

I make that kind of decision almost every shift regarding who gets this helo or ambulance.  Last month had to bounce a NSTEMI from 2 rides to put more critically ill folks first.

 

It's the totality of the circumstances, and ALL of the circumstances, at that point.

But that is a far cry from the despicable thought posted above that anyone who chose not to get the vaccine goes to the back of the bus.

 

Edited January 18, 2023 by Boatswain2PA

[roundabout]

15 hours ago, Boatswain2PA said:

I can't believe 1/3 of us would do this....

 

Edited - was only an N of 3, didn't realize that.

the fact that OP had to post this in the first place as if it were an "ethical dilemma" is pathetic. 

[jmj11]

I hope you know, while I try to raise interesting questions, this is my sister I'm talking about and as of this morning she is doing better. Would I offer her good evidence-based care? Absolutely, even though it has been frustrating to watch her suffer, often needlessly. But of course, this is just a simple micro-cosom. But these kind of decisions are made in some areas of medicine. I don't mean to talk about myself, but I have MM with related renal failure. Up until recently, we were not offered renal transplants but would be left to die, because it was considered unethical to give a good kidney to someone with incurable cancer. However, with MM treatments getting better, there are exceptions to this rule. But I digress only to point out that life and death rationing does occur in medicine. I am not advocating that we decline good care to patients like my sister, but since I've heard some say we should, I wanted to throw this question out to see how many agree with that view. But I have stopped trying to talk to people like my sister with the hopes of persuading them to change their views. 

[sas5814]

When I was young in the profession I used to get steaming mad when people made poor choices and would not follow good evidence based advice.

I have decided I am a purveyor of information. People are free to take it or leave it. This shift in attitude improved my work life substantially.

Edited January 18, 2023 by sas5814

[jmj11]

1 hour ago, roundabout said:

the fact that OP had to post this in the first place as if it were an "ethical dilemma" is pathetic. 

Did you not take Ethics in your PA program? This was exactly the same type of questions and exercises that we did in ethics class. We had pretend "death boards" where we had to ration ventilators, and other care, just to bring our views to the surface for an intelligent discussion. I have heard both physicians and PAs say that they wish they could deny care to people who were not following preventative care for certain disease. It is good to raise controversial questions and don't assume to know the viewpoint of the poster if they do so. I would never withhold good care to any patient as my pledge was to do no harm, and to do my damnist to make all patients well regardless of their views. But thanks for thinking about it. I will add, if you ever work in the developing world or in a war zone, triage and rationing is a common and hard decision that providers have to make.

Edited January 18, 2023 by jmj11
Clarity

[Boatswain2PA]

Mike (jmj)- you are frustrated for your loved ones and vented about it here and brought up an ethical question....all reasonable things.

It is others who said those who chose to not be vaccinated should go to the back of the bus.  THAT is what I find despicable (but yet predictable).

Hope your family gets better quick.  I'm surprised to hear covid is having such an affect on them.  We are still swimming in covid, but it is mostly mild flu-like sx.

Edited January 18, 2023 by Boatswain2PA

[LKPAC]

Just as side not: covid denial is not a political thing.  There are stupid people of all political persuasions.  

[sas5814]

3 hours ago, jmj11 said:

if you ever work in the developing world or in a war zone, triage and rationing is a common and hard decision that providers have to make.

Idealism is a luxury of people who have not had to make these kinds of choices. One of the things I learned as I got old(er) is to stop saying "If I were you I'd" anything. Until you triage mass casualties...until you have cancer...until your child commits a horrible crime.....until you are homeless and hungry... you don't know what you would do. If you think you do you are kidding yourself.

[roundabout]

7 hours ago, jmj11 said:

Did you not take Ethics in your PA program? This was exactly the same type of questions and exercises that we did in ethics class. We had pretend "death boards" where we had to ration ventilators, and other care, just to bring our views to the surface for an intelligent discussion. I have heard both physicians and PAs say that they wish they could deny care to people who were not following preventative care for certain disease. It is good to raise controversial questions and don't assume to know the viewpoint of the poster if they do so. I would never withhold good care to any patient as my pledge was to do no harm, and to do my damnist to make all patients well regardless of their views. But thanks for thinking about it. I will add, if you ever work in the developing world or in a war zone, triage and rationing is a common and hard decision that providers have to make.

You didn’t ask if they should be triaged based on their choice. You asked if they should be denied evidenced based medical care. That’s not an ethical question, that’s an obvious “no they should not be”.

[kettle]

9 hours ago, jmj11 said:

I hope you know, while I try to raise interesting questions, this is my sister I'm talking about and as of this morning she is doing better. 

Most importantly I'm glad your sister is doing better!!!

[SedRate]

On 1/17/2023 at 2:48 PM, jmj11 said:

I have heard some propose (which could never happen in the real world) that these deniers should be denied evidence-based medical care if they have done nothing legitimate to prevent the disease. But as an exercise in ethical thinking, what is your opinion?

Can I ask for clarification on what constitutes "deniers?"

Are overweight/obese individuals (2/3 of America) who refuse to lose weight and exercise deniers and thus be denied treatment for their obesity and sequelae? What about ESRD being denied dialysis because they refused to control their diabetes? Tension/stress headachers denied treatment because they refuse to change their stressful lifestyle? (I know you're a headache specialist, so don't rip me a new one if this is a bad example :).) Should drunk drivers who get into an MVC be denied surgery for their femur fx because they didn't legitimately prevent unsafe driving conditions? What about elderly ladies who break their hip because they developed osteoporosis. Should they be denied surgery to restore function and improve morbidity and mortality if they didn't legitimately prevent it?

What about the obese individuals above who couldn't legitimately work on diet/exercise because of something like an injury, worked 80h/week while caring for a disabled family member, genetics, lived on a food island, etc. Or ESRD on dialysis because they couldn't afford insulin and thus their DM advanced. (Maybe because they lost their insurance. Maybe because they spent their money on a new car.) Or headachers who have to support their family by working two jobs? Or the drunk driver who broke his femur because he was actually hit by a wrong-way driver? Or ladies who don't amass enough bone density in their 20-30s and therefore suffer a fragility FX in their 50s+ from osteoporosis? After all, they didn't legitimately do anything to prevent it despite being told EBM by their PCP/specialist (I hope)... Are these examples "deniers" of EBM? Or are you selectively referring to people who deny things like COVID vaccine/precautions? 

[CAAdmission]

The issue isn't evidence, the issue is trust. Our government is generally not an honest, ethical entity. It has become apparent that it has colluded with media, industry and social media to control a variety of narratives.

When you work so vigorously to quash any dissenting viewpoint it will cause many - particularly those prone toward paranoia - to wonder if something is being concealed.

[rev ronin]

8 hours ago, SedRate said:

Are overweight/obese individuals (2/3 of America) who refuse to lose weight and exercise deniers and thus be denied treatment for their obesity and sequelae?

Counterfactual assumption alert: Most people who lose weight don't keep it off, 75% have regained the weight by the end of a year, 95% by the end of three.

Less well established, but with an increasing amount of evidence, is that obesity per se is not causally responsible for all outcomes assumed to be due to obesity: both co-occurring sedentary lifestyle, as well as anti-fat bigotry leveled at higher BMI patients by their medical caregivers, play some role in the total morbidity and mortality.

[SedRate]

11 hours ago, rev ronin said:

Counterfactual assumption alert: Most people who lose weight don't keep it off, 75% have regained the weight by the end of a year, 95% by the end of three.

Less well established, but with an increasing amount of evidence, is that obesity per se is not causally responsible for all outcomes assumed to be due to obesity: both co-occurring sedentary lifestyle, as well as anti-fat bigotry leveled at higher BMI patients by their medical caregivers, play some role in the total morbidity and mortality.

I asked a question about what constitutes a "denier" and whether a denier such as an obese person who chooses (whether voluntarily or not) not to treat their obesity by not losing weight (despite legitimate things like an injury or perhaps osteoarthritis which makes activity painful), should be denied EBM care (e.g., TKA for osteoarthritis) because they didn't legitimately follow EBM for obesity treatment. If these obese individuals legitimately tried to lose weight but were unsuccessful (whether by their own accord or not, as your comment discusses), then that's different. We're talking about people who don't even try in which case I'll refer you back to my example above with an obese person who doesn't try. But what if they pretty much can't because, say, an injury or arthritis? Is it ethical to deny them care (TKA) because they didn't try? Obviously we could talk about whether they tried other EBM such as healthy eating, but that's another topic that even dietary professionals can't agree on. 

But to address your tangent about the poor long-term success of maintaining weight reduction, shouldn't obese pts still try to treat their obesity? Or are you saying obese people shouldn't treat their obesity because it won't likely stick?