Sometimes the best treatment is no treatment

My elderly patients are some of the sweetest.  They are always so calm compared to some of the younger ones who sometimes worry excessively.  I had a patient of over 100 years old some time ago who was sent to the hospital from a nursing home because of sudden confusion.  On admission the white blood cell count (WBC) was 20 (normal range 4-11).

When we see an elevated WBC we are quite concerned about possible infection, particularly with some sort of bacteria.  Bacterial infections, especially if they are in the blood stream, can be quite deadly.  But this dear little patient perked right up after getting a drip with some fluids for hydration.  The WBC was still up the next day but there was absolutely no sign of infection anywhere.  The hospitalist (the doctor who admitted the patient to the hospital) felt that she just couldn’t subject this patient to antibiotics without a reason so she asked me to take a look to see if I agreed with her decision.

 

I went and got a bit of history from the patient about what had been happening, did my examination, looked over all the lab results, etc, and agreed that there was really nothing to suggest infection.  As I like to do with patients sometimes, I asked: “what’s bothering you?” The patient said slowly and thoughtfully, “you know…what’s bothering me is my eyesight, my hearing, and my age.  I think my problem is old age.”  This was said so simply and it was so true!  But old age isn’t really a problem it is just a part of life. One for which there is no real treatment.  We have to allow people to go gracefully.  Giving this dear patient, who was so thin and frail, antibiotics, would probably have caused significant stomach upset, severe diarrhea with dehydration and imbalance of the minerals in the blood, and maybe caused early demise.  Our treatment was leaving the patient comfortable and allowing their return to the nursing home.

 

Now, don’t get me wrong.  If there was high suspicion that an infection was present, we would have treated accordingly while trying our best to prevent complications of treatment.  The point is, we should try not to treat abnormal results in isolation, but to look a the whole picture involving the patient in front of us.