A Delicate Balance

When Clara (alias) first came in, I admired her meticulous appearance and the special care she evidently took to look elegant and impressive at the age of almost 80 years. Widowed, she moved to a retirement home but remained emphatically independent. I was always glad to meet her and listen. Never grumpy, never complaining, she spoke enthusiastically of her friends there and the hobbies she could pursue at her new home. She had a remarkable zest for living and proudly told me that she still had her old clients and continued working as an accountant. She came from Cernowitz, a town on the Polish‐Rumanian border, a child who survived the Holocaust alone against all odds and married young to another survivor whom she felt could understand her.

But we did not only chat. Clara had rheumatic heart disease in childhood, which, as the classic saying goes, “Licks the joints but bites the heart.” With cardiac murmurs almost audible without a stethoscope, overweight, diabetes, hypertension, chronic kidney disease, gout, and hypothyroidism, I treated her carefully, and followed her uneventfully for years. On candesartan and apixaban her blood pressure and chronic atrial fibrillation were controlled. On 40 mg of oral furosemide every 2 days she was normally active and never had signs or symptoms of heart failure. On faithful adherence to diet, semaglutide and empagliflozin her HbA1C was 6.8% and rosuvastatin/ezetrol kept her LDL at < 60 mg/dL. Low‐dose allopurinol and levothyroxine concluded the long, but essential list of medications. Looking at my notes, I was so pleased with her, that I wrote: we could perhaps change this and adjust that, but: “If it ain't broke, don't fix it.”

Until, with the best intentions, her family physician referred her 1 day to an ambulatory care cardiologist, who sent her to a valvular disease clinic in the local hospital, which arranged for her to see a cardiac surgeon, who was “concerned,” she told me. On their first meeting he offered major valvular surgery. She was indecisive, whereas I was frankly shocked, although I did not show it. She was a brittle old lady, doing well on conservative treatment, and most of all, she was enjoying life with almost no symptoms. Why risk all that for an uncertain future? I cautiously expressed my surprise and uncertainty that this was a sound move, even saying that for a man with a hammer, everything may seem to be a nail…But did the cardiologists see something that I was missing? Should I interfere in their shared decision‐making? Nevertheless, I still strongly felt that I had the advantage of a long‐term relationship and an appreciation of the whole picture. Finally, I took the middle road, suggesting a second opinion. I proposed my colleague, a senior cardiologist for whose sound, holistic judgment I had the greatest respect. As it turned out, she did not go. Alas, “the road not taken…”

Noting that I had not seen her quite a while, I called her only son and reviewed the electronic chart. Apparently, the wheels started rolling, with an alarming speed and an almost inevitable cascade followed. Coronary catheterization was quickly done, in preparation for open‐heart surgery. I still saw her once after, a sad last meeting. She looked beaten, was noticeably dyspneic, and I will never forget her last sad words: “I cannot do anything…” A massive thigh hematoma caused Hb drop of 1.5 g/dL, and the GFR deteriorated to an alarming 15 mL/min. The coronary arteries were unremarkable…she was in other hands now, but I felt compelled to study the chart, and follow Clara's journey with my mind's eye. A long, complicated open heart surgery was performed, replacing both mitral and aortic valves, correcting the tricuspid valve, and placing a left atrial appendage closure device to reduce the risk of stroke. One month hospital stay with repeated episodes of delirium, depression, multiple CNS‐active medications, and several courses of antibiotics to treat associated infections were dryly recorded. A long rehabilitation followed, lasting 2 months at hospital, during which she made little progress. Finally, she developed fever, and was readmitted with positive blood cultures and probable infective endocarditis. I was devastated to read the next few lines in the hospital discharge summary, and to visualize my formerly dignified patient. She no longer could bear it, and discharged herself after 1 day “against medical advice,” wishing to die at home and signing a “do not resuscitate” directive. Empathy and attachment have their price. I still carry this painful story with me as I go.

A fool may throw a stone into a well which a hundred wise men cannot recover. In this tragic tale, there was no fool, only well‐meaning but unwary physicians, whose judgment did not see beyond upsetting a brittle equilibrium of a jolly old lady. She no doubt would have preferred to continue her fulfilling life as long as she could, but was persuaded to take a wrong turn, heedless, as unfortunately, some of her providers were, of the very high risk of deleterious cascades awaiting her [1, 2]. Should I have been more explicit in expressing my concerns? Should I have called the surgeon directly, or her son? After the traumatic cardiac catheterization, it was already too late to intervene: the train has already left the station….

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Signed by next of kin and patient de‐identified (to be enclosed when required).

Conflicts of Interest

The author declares no conflicts of interest.