Therapeutic nihilism is inadequate in geriatric medicine

Abstract

Patients' wishes should guide therapeutic considerations in the face of options and necessities, particularly when an intervention carries the risk of death. Therefore, in the medical management of the young and the old, everything should be attempted as long as the patient has a strong will to live.

Patients' wishes should guide therapeutic considerations in the face of options and necessities, particularly when an intervention carries the risk of death. Therefore, in the medical management of the young and the old, everything should be attempted as long as the patient has a strong will to live.

1. INTRODUCTION

Discrimination through negative stereotypes and prejudice puts elderly patients’ physical and mental health at risk. This case uniquely highlights through the patient's own perception that, in medical management in the young as in the old, everything should be attempted as long as the patient has a strong will to live.

It is well established that discrimination against patients on the basis of their age “has a negative impact on their health, well‐being, and quality of health care received”.¹

2. CASE HISTORY, INVESTIGATIONS, AND TREATMENT

Here, we present the history of an 82‐years old lady with a past medical history of chronic obstructive pulmonary disease, coronary heart disease previously treated with stent‐protected angioplasty, mixed aortic valve disease, diabetes mellitus, hypertension, and spondylosis of the spine, who survived several life‐threatening illnesses and surgical procedures and eventually regained a good quality of life.

Due to severe osteoarthritis, the patient was supposed to undergo elective replacement of her right hip. While packing her bags for hospital admission, she stumbled, fell, and suffered a pertrochanteric hip fracture and a multi‐fragment capital fracture of the humerus, both on the contralateral side. Considering her generally reduced condition, the hip injury was treated with a dynamic hip screw, while the humeral fracture was treated conservatively. A few days later, she developed swelling of her left leg and dyspnea due to thrombosis of the deep femoral vein. Pulmonary embolism was excluded by CT‐pulmonary arteriography. As an incidental finding, a high‐density space‐occupying lesion was noted in the dorsal spinal canal. An additional MRI of the thoracic spine was performed, demonstrating a large meningioma (Figure 1). While formication in both legs had previously been attributed to degenerative changes in the patient's lumbar spine, an intermittently present positive plantar reflex (Babinski sign) on her right side indicated an imminent paraplegic syndrome, and the meningioma was surgically removed 5 weeks following her admission to hospital. Thereafter, her clinical course was complicated by episodes of diarrhea caused by norovirus and Clostridoides difficile, pneumonia, acute cardiac failure, hemorrhage into the right thigh, and an episode of retrosternal pain. Given that the initial thoracic CT scan also showed a potentially malignant pleural‐based soft tissue density in the right lower lobe (not shown), the chest CT scan was repeated. This now showed a dissection of the immediate postvalvular ascending part of the thoracic aorta (Stanford group A; Figure 2), explaining the retrosternal pain. Following careful consideration of the relative risks and benefits of the conservative and operative approaches, the patient explicitly opted to undergo surgery and received replacement of the aortic valve and the ascending part of the aorta.

FIGURE 1.

Para‐sagittal reformatted image of contrast medium‐enhanced CT scan showing an intraspinal high‐density space‐occupying lesion, consistent with a partially calcified or a contrast‐medium enhancing tumor (A). The corresponding unenhanced sagittal T2‐weighted MR image shows a central hypointensity within an otherwise high signal intensity lesion and demonstrates the mass effect upon the adjacent spinal cord (B). The additional contrast medium‐enhanced axial T1‐weighted image confirms the severe cord compression (arrows) by the centrally calcified but otherwise enhancing well‐defined intradural‐extramedullary mass, consistent with a meningioma (C)

FIGURE 2.

Sagittal‐oblique reformatted image (A) and transverse‐axial section (B) of the contrast medium‐enhanced CT‐arteriogram at the level of the ascending part of the aortic arch, visualizing the intimal flap (arrows) and opacification of two lumina. Please note that the origins of the great vessels to neck, head, and upper extremities are not involved

3. OUTCOME AND FOLLOW‐UP

Then, the patient made a slow recovery. Five months after admission, she was discharged home, fully orientated, and able to walk with the aid of a Zimmer frame and to climb stairs.

One year after suffering her fractures, the patient wrote to us, stating “my case history demonstrates that, in the young as well as the old, everything should be attempted as long as they have a strong will to live (paraphrased)”. Almost nothing further needs to be said!

4. DISCUSSION

Published for the first time in the context of psychiatry by Butler,² therapeutic ageism or nihilism has long been a matter of debate in many fields of medicine, as recent as during the ongoing COVID‐19 pandemic.³ In their recent systematic review and meta‐analysis, Burnes et al¹ concluded that ageism has well‐established negative effects, but that interventions equally effective in young and old patients are associated with substantial reduction in ageism. The authors call for an international strategy to improve perception of the wishes and needs of older people,¹ a measure our patient would certainly support.

CONFLICT OF INTEREST

The authors declare that no funding was received in the conduction of this work and that it was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

AUTHOR CONTRIBUTIONS

RN: cared for the patient, wrote the second draft of the manuscript, and revised its final version critically. MG: cared for the patient, undertook the aortic surgery, and revised the final version of the manuscript critically. VR: cared for the patient, undertook the operation of the spinal meningioma, and revised the final version of the manuscript critically. EK: cared for the patient on the ward and wrote the first draft of the manuscript. JD: cared for the patient, undertook the operation on the patient's hip, and revised the final version of the manuscript critically. JL: wrote the radiological part of the manuscript, arranged the figures, wrote the figure legends, identified the references, wrote the discussion section, and revised the final version of the manuscript.

ETHICS STATEMENT

Our patient provided informed consent to publish the details of her case.

Nau R, Großmann M, Rohde V, Knopf E, Dörges J, Larsen J. Therapeutic nihilism is inadequate in geriatric medicine. Clin Case Rep. 2021;9:e04148. 10.1002/ccr3.4148

DATA AVAILABILITY STATEMENT

This being a clinical case report, our patient's records cannot be made publicly available for reasons of confidentiality.