A 92-year-old woman with type 2 diabetes mellitus has developed cellulitis and gangrene of her left foot. She requires a lifesaving amputation, but refuses to give consent for the surgery. She has been ambulatory in her nursing home but states that she would be so dependent after surgery that life would not be worth living for her. She has no living relatives; she enjoys walks and gardening. She is competent and of clear mind.
Which of the following is the most appropriate course of action?
The principle of autonomy is an overriding issue in this patient, who is competent to make her own decisions about surgery. Proceeding with elective surgery without the patient’s consent would place the surgeon at risk of civil prosecution for malpractice as well as criminal prosecution for assault and battery. Consulting a psychiatrist would be inappropriate unless there is some reason to believe the patient is not competent. No such concern is present in this description of the patient. Since the patient is competent, no friend or relative can give permission for the procedure. A court would not override the medical decision of a competent adult unless other lives (eg, that of a minor or an unborn child) were at risk.
A 42-year-old man sees you because of obesity. He played football in high school and at age 18 weighed 250 lb. He has gradually gained weight since. Many previous attempts at dieting have resulted in transient weight loss of 10 to 15 lb, which he then rapidly regains. He has been attending weight watchers for the last 3 months and has successfully lost 4 lb. Recent attempts at exercise have been limited because of bilateral knee pain and swelling. On examination height is 6 ft 0 in, weight 340 lb, BMI 46. Blood pressure with a large cuff is 150/95. Baseline laboratory studies including CBC, biochemical profile, thyroid-stimulating hormone, and lipids are normal with the exception of fasting serum glucose, which is 145 mg/dL.
What is the best next step?
This patient has morbid obesity (BMI over 40) and has comorbidities of hypertension, diabetes, and osteoarthritis of the knees. Two large meta-analyses have established that bariatric surgery is more effective than nonsurgical therapy for achieving sustained weight loss and controlling comorbid conditions for patients with morbid obesity. Surgical mortality is low (< 1%) and surgery is associated with long-term sustained weight loss of 45 to 65 lb. Several professional organizations, including the American College of Physicians, now recommend bariatric surgery as the treatment of choice for patients with morbid obesity, especially if they have comorbid conditions and have failed dietary therapy. Controlled trials have established that caloric restriction and physical activity can achieve modest weight reduction, usually on the order of 2% to 8%. A review of commercial weight-loss programs demonstrated that Weight Watchers was the most effective with a sustained weight reduction of 3% at 2 years. Medications such as orlistat and phentermine are FDA approved for weight reduction but have demonstrated only modest effectiveness. Sibutramine has been removed from the U.S. market due to increased risk of cardiovascular events. This patient has morbid obesity with comorbid conditions and has failed dietary therapy and exercise program. Therefore his physician should discuss the possibility of bariatric surgery for treatment of his obesity.
A 54-year-old man sees you for follow-up of hypertension and a seizure disorder that is well controlled. He established as a new patient 2 months ago and is back for his second office visit with you. At the time of his initial visit he admitted to a 35-year history of smoking 2 packs of cigarettes per day. At that time he indicated that he was not interested in stopping smoking and seemed irritated when you suggested that he quit. Today his blood pressure is well controlled and there are no new medical issues.
With regard to discussing cessation of cigarette smoking during today’s visit, what is the best next step?
Despite overwhelming evidence of the adverse health effects of cigarette smoking that has accumulated over the last 50 years, more than 20% of Americans still smoke cigarettes. Cigarette smoking is the most common health behavior associated with preventable death in the United States. Physicians can play a major role in encouraging patients to stop smoking. Evidence shows that even very brief counseling (as little as 3 minutes) in the physician’s office can improve smoking cessation rates. Even in long-term smokers, smoking cessation has major health benefits. After cessation of smoking, the risk of myocardial infarction declines by over 50% in 1 year and the risk of lung cancer declines by 3% to 5% per year even in long-term cigarette smokers. Many professional organizations (including the American Medical Association) recommend that physicians should ask their patients whether they are smoking at each visit, advise them to quit, and assess their willingness to do so. If the patient is willing to consider smoking cessation, the physician should assist them in their attempt to quit and arrange follow-up to assess compliance. Behavioral counseling and drug therapy improve the likelihood of smoking cessation. Nicotine replacement therapy, bupropion, and varenicline are FDA-approved for smoking cessation. Nicotine replacement therapy is contraindicated in patients with recent myocardial infarction, angina, and severe arrhythmias. Bupropion is contraindicated in patients who have preexisting seizures. Varenicline has been associated with depression and behavioral abnormalities. Smokeless tobacco carries the risk of oral cancer and is not recommended as treatment for cessation of cigarette smoking.
A 70-year-old man with unresectable carcinoma of the lung meta-static to liver and bone has developed progressive weight loss, anorexia, and shortness of breath. The patient has executed a valid living will that prohibits the use of feeding tube in the setting of terminal illness. The patient becomes lethargic and stops eating altogether. The patient’s wife of 30 years now insists on enteral feeding for her husband.
The patient’s autonomy as directed by the living will must be respected. This autonomy is not transferred to a surrogate decision maker, even one who is very credible. A family conference in this case would not change the overriding issue—that a valid living will is in effect. Living wills and other advance directives are completed when patients are competent, and give instructions for their treatment if they become incompetent or unable to express their wishes. A medical power of attorney (POA) assigns decision-making capacity to another person (surrogate) when the patient lacks decisional capacity and when no documentation of the patient’s previous wishes is available. A court order is not necessary given clear written evidence of the patient’s wishes.
A 32-year-old, overweight, diabetic woman is found to have a triglyceride level greater than 1000 mg/dL. Family history is positive for diabetes, pancreatitis, and premature coronary artery disease. TSH is normal. You advise the patient to follow a low-fat diabetic diet, to exercise regularly and to avoid alcohol.
What medication would be most appropriate to start at this time?
A normal triglyceride (TG) level is below 150 mg/dL. A moderate to high triglyceride level is between 150 to 499 mg/dL, and over 500 is considered very high. Obesity increases TG levels by causing increased hepatic VLDL production. In diabetes, insulin insufficiency leads to decreased lipoprotein lipase activity and impairment of VLDL catabolism. In addition, this patient may have familial hypertriglyceridemia or familial combined hyperlipidemia. All such patients should be advised to follow a low-fat diet. Because of the risk of acute pancreatitis with such high levels of TG, medication should be instituted as well. Patients with levels over 500 should be started on a fibrate such as fenofibrate or gemfibrozil. While potent statins such as rosuvastatin and atorvastatin decrease TG modestly, they are second-line agents in this situation. Nicotinic acid also reduces TG levels but often elevates the blood glucose level in diabetics. Fish oil in high doses can lower the TG level but not as effectively as fenofibrate or gemfibrozil.