All That Glitters
By Jessica Nutik Zitter, MD, MPH
I used to love “swanning” my patients — — until I realized I was hurting them.
The Swan Ganz Catheter, or “Swan,” was introduced in 1970 as a new way to measure pressures inside the heart and lungs. These numbers would, in theory, be helpful to an ICU physician like myself, trying to maneuver her patient through the physiologic onslaught of shock.
These pressures are hidden in the fragile recesses of the heart, and until the Swan’s debut, were accessible only to interventional cardiologists whose sharp-tipped catheters could easily puncture the wall of the heart, resulting in immediate death. But the Swan’s tip was encased in an inflatable balloon that allowed it to float more safely through the chambers of the heart, and ICU physicians quickly became emboldened to go where only cardiologists had gone before. Placing a Swan became so common that the procedure was honored with its own verb in medicalese. At the height of its use, the catheter was routinely being inserted in 20–40% of all ICU patients, and accounted for 2 billion dollars in Medicare payments annually.
The procedure was almost a religious experience. We prepped the patient’s neck, the only body part left visible, with three rounds of betadine swabs. The sterile kit was unwrapped and waiting on the bedside table, needles lined up, syringes filled with lidocaine and saline. As we threaded the catheter in, the monitor beeped with every heartbeat to alert us to any dangerous change in rhythm. It displayed the pressure readings, waves rising and falling as the catheter crossed from the superior vena cava into the right atrium of the heart, then into the right ventricle, and eventually into the pulmonary artery, where it would be parked for days, sometimes longer.
But the Swan was dangerous, often triggering arrhythmias or damaging delicate tissue. And, as it eventually turned out, it didn’t help patients at all.
By the mid ’80s, small studies had begun to cast doubt on its benefit. And then in 1996, after increased scrutiny, a major study demonstrated that the Swan was being overused, not adding benefit, and causing harm — to the tune of a 24% increased risk of death. The Swan’s numbers, which we collected and analyzed several times a day, were often inaccurate, incorrectly interpreted, and prompted treatments that themselves worsened patient outcomes.
During my fifteen years as an ICU physician, I have felt privileged to be part of a well-oiled, well-intentioned medical machine. We are a tough bunch, fighting an even tougher enemy — critical illness.
But I am also proud to be a specialist in Palliative Care, whose principles are considered by some to be diametrically opposed to critical care. Palliative Care places the patient, rather than her organs, at the center of all medical decisions. Though this subspecialty is relatively new — -it was only recognized in 2006 by the American Board of Medical Specialties — we have over three decades of research on its benefits to patients.
Palliative Care aims to bring the patient into the center of all decision-making by integrating her goals and values into the medical discussion. Its concepts and tools are low-tech and as old as the hills — more listening, less talking; more reflecting, less dictating. And the willingness and ability to acknowledge death’s approach, to step outside the ICU “rescue fantasy” that all death is beatable and treatable. If we do our work within this framework of reality, we end up using our powerful tools more appropriately.
Data demonstrate incontrovertibly that ICU patients who receive Palliative Care input experience less suffering, receive fewer non-beneficial and invasive treatments, and do not die sooner than those who do not receive it. In addition, these patients’ families fare better after the death of their loved ones — not only psychologically, as might be expected, but medically, too.
Yet many ICU physicians remain uninterested at best and resistant at worst to incorporating those principles into their practice. In my early days as an ICU doctor, I too disdained measures I perceived as “touchy feely.” Doing more is more appealing to us ICU doctors than doing less. But the fact is, that bias is hurting our patients.
Unlike the Swan, Palliative Care brings almost no risks, and is of demonstrated benefit to patients in almost every dimension — physical, psycho-social, and spiritual. So why doesn’t the ICU community embrace Palliative Care with the same zeal they did the Swan?
ICU culture was built on the principle of heroics. As such, it tends to attract healthcare providers like myself, who are drawn to dramatic feats of lifesaving. The treatments that the ICU community tends to adopt with zeal are high tech, high-risk, and expensive. But Palliative Care is not a sexy intervention. It doesn’t require rapid-fire checklists and high-stakes procedures. Instead, it asks us to recall our primary responsibility as physicians — to care for the whole patient by communicating well, considering carefully, and collaborating. It is low-tech, low-risk, and actually saves money.
Despite the significant risks of the Swan and audacious interventions like it, we believed in them. Despite the lack of robust evidence of their benefit. I would posit that it was those very risks and dangers that won our loyalty. We were like warriors in battle, firemen to the rescue — heroes saving innocents.
But if we’re truly invested in providing the best patient care, I believe it’s time for some serious collective self-reflection. Indeed, we are warriors — but we are also healers. And that means doing what it takes to best serve our patients, whether they most need a ventilator or an honest conversation about goals of care.
Are we heroic enough to take that on?
Jessica Nutik Zitter, MD, MPH, is author of EXTREME MEASURES: Finding a Better Path to the End of Life (Avery Books, Feb. 21). An expert on the medical experience of death and dying, Zitter is double-boarded in pulmonary/critical care and palliative care medicine. Featured in the Academy Award™ nominated 2016 Netflix documentary Extremis, she is a graduate of Stanford University and Case Western Reserve Medical School, and completed her residency in internal medicine at the Brigham and Women’s Hospital (Harvard Medical School).