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Time: Doctors Debate the Ethics of Care and Cost
By Sandeep Jauhar, M.D. I have a patient with congestive heart failure. Tom is a wispy-thin man with a predilection for vintage suits who had a heart defect surgically repaired 50 years ago, when he was 5. The surgeon performed a finger valvuloplasty: he used his little finger to free up the motion of a congenitally rigid valve. The procedure was successful, but over the years, the valve leaked and that eventually caused Tom's heart to weaken and enlarge. Now Tom's heart pumps much less efficiently than normal; its ejection fraction — the percentage of blood pumped out per beat — is less than 20 percent, whereas normal is about 60. He gets winded after only a few steps. Several weeks ago, he collapsed on the stairs leading up to his third-floor walk-up and had to be carried by neighbors. Tom does not want a heart transplant. A few years ago, his only other option would probably have been a hospice program. Today, though, he has other choices. But those options leave doctors with awkward questions. The array of devices designed to help failing hearts can offer some benefits, but at enormous cost. One of them is a biventricular pacemaker, which helps to coordinate the contractions of a failing heart. Implanted under the skin of the upper chest, biventricular pacemakers have been shown to relieve heart-failure symptoms, like breathlessness, and to decrease the frequency of hospitalizations. A study reported last month suggests they may even prolong life. But the devices cost about $20,000 each. In the United States, more than five million patients have heart failure, and half a million new cases are diagnosed each year. If even a small fraction of these patients received this implantable device, the costs could reach billions of dollars. Cardiologists are beginning to ask, Is this a sensible way to spend health care resources? At a recent conference at my hospital, some cardiologists discussed similar questions. In this case, the patient was an elderly man with heart failure who, because of mild dementia, was unable to give consent for an implantable defibrillator. Defibrillators, like the one Vice President Dick Cheney has, are beeper-size devices that monitor the heartbeat and apply an electrical shock if the rhythm degenerates into something dangerous. Sudden arrhythmias are common in patients like Mr. Cheney who have suffered moderate or severe heart attacks, and the irregularities can cause sudden death. Defibrillators can clearly reduce these deaths, and it is estimated that millions of Americans could potentially qualify for the $30,000 devices. But the cardiology fellow who presented the case wondered how hard he should push for his patient to get one, given his age and mental state. It makes sense to implant a device in the chest of a 50-year-old with a good life who is providing to society, the fellow said, but what about a 70-year-old debilitated by heart failure and living in a nursing home? That patient might benefit the most, he added, but would also have the least to offer society in terms of productive years. Should society invest its limited resources in such patients? Someone else wondered whether a defibrillator was even appropriate for those patients. After all, wasn't sudden death a better way to die than struggling for breath as congestive heart failure filled lungs with fluid? The discussion went on, back and forth, for more than an hour. It distilled some of the ethical questions that cardiologists are beginning to face as more and more expensive devices become available to treat very sick patients. Unfortunately, most of these patients will not live very long, with or without devices. For example, in a study published in The New England Journal of Medicine in 2001, mechanical pumps called left-ventricular assist devices prolonged life by an average of eight months in patients with advanced heart failure. Half of the 68 patients in the study who received devices were alive one year later, compared with a quarter of those treated with medication alone. But those who lived longer spent much of their extra time in the hospital. The pumps in the study cost about $250,000 per patient. If only 4,000 patients received the pumps each year, the price would be $1 billion. How much should society pay for those few extra months? I'm not sure what to do about Tom. We have discussed his options; he is not sure what he wants. As his physician, my first responsibility is to him, not to some abstract notion of social justice. If he agrees, I will arrange for the biventricular pacemaker. Still, I wish policy makers would enter this debate. Until they do, doctors are going to be forced to make individual judgments about who should get a device and who should die without one. Though medicine provides awesome technology, it does not tell us how to use it. Copyright
© 2002 Global Action on Aging
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