Rat Poison in the Nursing Home

In the Washington Post on August 4th an article entitled “Health inspectors alerted to blood-thinner dangers” discussed the dangers of blood thinners like Coumadin in nursing home residents. The article makes the point that many nursing home residents using blood thinners suffer harm, even death, when their doses are not closely monitored, essentially blaming the nursing homes for not following blood levels of the drug closely enough. High doses of blood thinners can cause severe bleeds. In fact, Coumadin has been used as a rat poison for years because it will kill rats by causing them to bleed out and die. But it is not simply the failure of nursing homes to monitor levels that causes problems with patients on Coumadin. The real problem is typically that they are on the drug in the first place.

The Post article states something that virtually every doctor accepts as gospel, which is echoed by the press and pharmaceutical commercials as fact, and which is inscribed into virtually every clinical practice guideline to which we doctors are required to comply. “Although Coumadin has clear benefits and is lifesaving for those taking the right dose, and number of peer-reviewed studies suggest that it can be dangerous if not closely monitored.” What is meant by clear benefits and lifesaving? The pundits cite that people with a condition called afib who take Coumadin are 50% less likely to get a stroke compared to people who take the much safer drug aspirin. Sounds impressive! But the truth is much less convincing. In fact, of 1000 people who take Coumadin vs aspirin, approximately 6 of them will avoid having a disabling stroke. In other words, 99.4% of people taking Coumadin derive no benefit from the drug. This is a clear benefit and lifesaving?

Juxtapose those clear benefits with the known risks of Coumadin. The drug is very difficult to take, has to be monitored closely with blood tests, interacts with virtually every drug/supplement and many foods, and causes bleeds. Even at normal doses it causes dangerous bleeds more than aspirin; the danger of Coumadin does not only occur when levels escalate, as the article stipulates. In fact, more than 12 people on Coumadin out of 1000 who take it suffer from severe life-threatening bleeds, including many who bleed into their brain, which is another form of stroke. Many, many more people on Coumadin have less major bleed s and bruises, and the danger is especially high in people who fall often, who are confused, and who are on many other drugs. In other words, frail elderly nursing home residents are particularly vulnerable to Coumadin’s lethal side effects, while deriving very little benefit from the drug. And yet the drug is considered standard of care, life saving, and beneficial, while its dangers are blamed on the failure of nursing homes to adequately monitor drug levels.

The real problem, something completely ignored by the Washington Post article, is that so many nursing home patients are on a glorified rat poison. Why expose this frail group of people to a drug whose risks are much higher than its benefits? The answer is that our medical culture promotes aggressive treatment even when such treatment offers marginal benefit and substantial risk. Most nursing home residents are on more than 10 drugs. Do these drugs really improve their quality and length of life? Typically not, but they do often cause more fatigue, falls, and confusion. Lab companies typically visit nursing homes daily, as do portable x-ray companies, and ambulance drivers, often shoving elderly men or women into the hospital where they can get the most aggressive care possible, care that has not been proven to benefit this population and which can cause substantial harm and disability. Coumadin in nursing homes is illustrative of so much that is wrong with how we view our health care crisis. The Post article is calling for more regulation to monitor a drug that is assumed to be necessary, while not asking why so many frail elderly are on this drug in the first place. It is time we start questioning why we are treating the frail elderly in nursing homes with such expensive, ineffective, and often cruel aggressive medical care, instead of treating them with the dignity and comfort that so many of them really want. It is time we stop pretending that flooding people with drugs and tests and procedures will cure their aging, and instead accept that often the best care is least amount of care. It is time we stop "fixing" our frail elderly with rat poison.