Primary Prevention of Sudden Cardiac Death: The Time of Your Life
To the Editor:
In a recent Focused Perspective article on the use of implantable defibrillators for the primary prevention of sudden cardiac death, Dr Eric Prystowsky concludes with the statement “… for those worrisome patients who don’t ‘fit the rules,’ I often apply the concept of family-based medicine—what would I do for my parents, siblings, or spouse? This usually keeps me out of trouble” (p 1075).1 Physicians whose practices are guided by the American Medical Association Code of Medical Ethics should be reluctant to heed his advice. Policy 8.19 of the Code reads, “Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physician’s personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered.”2
There are two points in Dr Brennan’s letter, one that he makes and the one that he missed. I agree with the practice of not treating one’s own family members, a situation in which objectivity may be compromised.1 Unfortunately, Dr Brennan misinterpreted the concept of “family-based medicine,” which is not treating your own family but thinking through the therapeutic options in a manner in which you would hope a physician would do for your family.2 While this may seem obvious, it is often not followed. For example, at a recent meeting I gave a lecture on the use of implantable cardioverter defibrillators (ICD) to prevent sudden cardiac death. Afterwards, using a computerized audience response system, the physicians were presented a case history and given the option of using an ICD, initially for the patient but in a subsequent question for a family member. Interestingly, the ICD use substantially increased when a family member was involved. Although this might be due, in part, to loss of objectivity when treating the physician’s own family, it is equally possible that a “knee-jerk” response was given initially for the patient.
ICD therapy is expensive and not without risks, but it is also key to reducing mortality in many patients. Randomized clinical trial data have helped us to select appropriate patients for an ICD, but there are many situations in which data are insufficient and one has to apply clinical judgment. In such cases, patients often ask their physician what he/she would do if it were their mother, father, sibling or spouse. It is my hope that physicians will then apply the concept of family-based medicine to help answer their patients’ questions.