‘Sometimes it’s better not to treat’

As a doctor you have to make people better. Or, if that doesn’t work, at least extend the lives of patients as much as possible. In a nutshell, that is the message with which many doctors are trained. The fact that they have more and more techniques and medicines at their disposal for this means that they also treat more and longer. Sounds logical, right? That’s what doctors are for.

Yet everyday reality is not nearly so simple, according to geriatrician Yvonne Schoon of Radboudumc in Nijmegen. As a doctor specializing in elderly care, she sees many elderly patients with fragile health. For them, available treatment is not necessarily the most appropriate care, she says. “It all depends on the personal situation. Every treatment has risks, with possible complications as a result. As a result, people are less able to recover, for example, no longer doing the things they liked to do or even end up in an institution. It is therefore important to carefully consider the possible advantages and disadvantages in advance.”

Don’t doctors do that now?

“Certainly. But they mainly judge from their own perspective. Doctors think in possibilities. If they find a problem, they are eager to solve it. For example, by repairing damage to a heart valve or fighting a tumor. In my opinion, they too often ignore what older people themselves consider important.”

They also want to get better and live as long as possible, right?

“Not at all costs. Various studies have shown that older people attach a lot of value to how they grow old. In other words, the quality of life is more important to many people than its length. At that point, the wishes of a patient and the commitment of a doctor can start to get in the way.”

How for example?

“A while ago I had a patient of around 80. The cardiologist wanted to replace her calcified heart valve with an artificial one. As a result of her condition, she was quickly short of breath and tired. As a result, she could no longer do the shopping herself, something she really wanted. During my examination, however, she also turned out to have two worn knees. Even with a new heart valve, she would therefore not be able to walk to the shops on her own. The cardiologist hadn’t mentioned that. When the patient heard this, she decided to forgo the heart surgery. For her, the risks no longer outweighed the potential health gain.”

How do you think it should have gone in this case?

“In the preliminary phase – when doctors assess whether a certain treatment is appropriate – they should look more closely at whether a patient is fit enough for it and whether the possible risks do not conflict with other interests of the patient. Suppose there is a chance that he or she will not be able to move properly after surgery. Then a patient whose greatest passion is getting out and enjoying nature may make a different decision than someone who spends a lot of time indoors.”

You want to help doctors with this.

“Precisely. As geriatricians, we naturally look at the whole person. We assess not only how a person is physically and mentally, but also how he functions in daily life. Whether he is mobile, can take good care of himself and has a network on which he can fall back, for example. But that is not always enough. A patient cannot be vulnerable and yet not have enough resilience to endure severe treatment. In my research I develop and test methods that can help specialists to assess this. In the first instance for acute care, oncological care and cardiovascular diseases. Hopefully we can further expand the number of fields in the future.”

How does that work in practice?

“Let’s go back to the example of that narrowed heart valve. This operation is mainly performed on the elderly, 10 percent of Dutch people between 80 and 89 suffer from this. In order to determine the degree of frailty, we look at the walking speed in these patients, among other things. This appears to be a very suitable measure for determining whether or not someone is too vulnerable for the procedure. But with a different type of cardiovascular surgery, to repair a weak spot in an artery, testing the walking speed is less suitable. It is better to use other methods for those patients. For example, by seeing how long they can squeeze their hands with force or how quickly their blood pressure recovers when they get up from a lying position. If you know that, you can make an even better estimate in advance of whether a treatment will be successful. And thus ensure that as many elderly as possible receive the most appropriate care.”

In short, customization.

“Precisely. With the help of these types of methods, we can inform patients even better and weigh up the best approach in close consultation. The outcome can therefore also be not to treat, an option that is rarely suggested spontaneously by doctors.”

If people read this, they may fear that she will be withheld from treatment.

“That is certainly not the intention. My aim is to consider all aspects of a person’s life when choosing a treatment. The result may indeed be that you treat less. But the other way around also happens. For example, I recently had an 85-year-old patient with a broken hip. Because she had serious heart problems, the surgeon at another hospital refused to operate on her; he thought the risk of her dying was too great. As a result, she would have to spend the rest of her days in a wheelchair. But this lady was completely mobile before her breakup. The idea of ​​a wheelchair proved unbearable for her. All things considered, we therefore operated on her. Fortunately with success.”

Your chair has been made possible in part by health insurer VGZ, with whom Radboudumc has had an alliance since 2015. How do you prevent the health insurer from determining which treatments are still ‘allowed’?

“VGZ pays part of my salary as a professor and therefore of my research. It has nothing to do with which treatments doctors prescribe or not. In any case, I am completely independent in terms of content. I decide for myself what I do research into and how I shape it. We have made clear agreements about that.”

Why is this subject so close to your heart?

“During my medical studies I wanted to become an internist. To be honest, I found it quite difficult to deal with the elderly at the time; it felt very uncomfortable. That changed when I was later asked to work in a geriatric ward. There I discovered how broad the profession is, precisely because you look at the whole person. That makes it interesting and challenging. I also feel an enormous drive to stand up for vulnerable people. As a geriatrician I would like to give them a voice.”

Yvonne Schoon (52) studied medicine in Maastricht and then specialized as a clinical geriatrician. She has been working at Radboudumc since 2004. From 2015 to 2020 she was department head of the Emergency First Aid (A&E). She has been head of the geriatrics department since September 2020. In October 2021, Schoon was appointed professor by special appointment of ‘The right care for the right elderly person’ for three years.

This article previously appeared in Plus Magazine April 2022. Want to subscribe to the magazine? You can do that in an instant!

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