Feedback: “Think or Die!”

To the Editor: 

I thoroughly enjoyed the evidence-based emergency medicine update and comment by Wyer1 and Cordell2 concerning the use of recombinant tissue plasminogen activator (rt-PA) in acute ischemic stroke. The authors performed an excellent critical analysis of a difficult topic. Severe reservations concerning the use of thrombolytic agents in patients, related to the risk of intracranial hemorrhage, were noted. However, many physicians, imagining which therapy they would choose should they ever have a stroke, may argue the value ethic “walk or die” in selecting rt-PA. The “walk or die” argument ignores the fact that disabled patients may nevertheless have a good quality of life, preferable to other treatment outcomes. The flaw of the “walk or die” argument becomes quite evident when considering the trauma victim who must undergo amputation. Few if any patients (or physicians, for that matter) would choose death over the loss of a limb, despite the resulting disability.

Disability is very commonly an acceptable outcome, chosen over a small chance of return to normal function that carries catastrophic risk. Patients therefore may prefer to forgo thrombolytic therapy where the chance of return to normal function is modest and the occurrence of intracranial hemorrhage catastrophic.

The discrepancy of treatment choices by physicians, when treating patients versus treating ourselves, may be caused by our delusions of grandeur. We may have convinced ourselves that we are the saviors from disease, when in fact we are only servants trying to help our patients escape disability and death. This reality becomes clear when we treat ourselves and make decisions affecting our own families. We can only provide palliative therapy for many diseases and not cures.

An evaluation of hemiplegic patients found that greater than 50% were self-sufficient.4 There is also a close correlation after stroke of social stress with the inability to understand language, not the ability to ambulate.5 Therefore, a better argument may be “cognate or die,” assuming that social stress and disability are worse than life itself.