Wednesday, April 14, 2010

Heroic Measures

Take this, scenario lovers: your Uncle John's in the hospital. He told his girlfriend, Tina, that his chest felt tight and that he couldn't breathe around two o'clock last night. These things always happen in the middle of the night, don'cha know. She drove him to the hospital rather than call an ambulance because he was pretty sure it could be the combo of stromboli and Viagra that did it to him. When they got there, the triage nurse immediately put him on a gurney and started O2 because he looked flushed, then white and pain started.

Poor John. Looks like the stromboli together with fast living in general caught up with him far sooner than he expected. Well, he thought, this sucks. His girlfriend was just glad they were in the hospital because she knew, though no one had yet told her in exact language, that john was having a heart attack.

At the moment their thoughts met at this temporal intersection, John's heart stopped dead.

Alarms rang and nurse and doctors rushed to revive John. Tina backed away from the medical melee until her butt met the wall. He was well on his way to zombie-hood when fate intervened. Nature decreed that the electrical stimulation being applied to John's ticker was sufficient to get the sucker beating again. And beat it did, but not quite the same as before.

Valium was applied, since death has a funny way of exciting high levels of anxiety in a patient. Anxiety elevates adrenaline production and adrenaline increases the heart rate - not good for someone with a damaged heart that stopped once today already.

The next step was to perform tests. Blood panels, an echocardiagram, more blood panels, an angiogram and finally, a consult from the attending cardiologist.

"Bill, it's looking a little more urgent than is typical," started Dr. Frost. He was a fit-looking, shorter-than-average fifty-something with longish, thinning hair that allowed a sun-browned scalp to shine through. "First off, do you feel pain?" John said, "No. No pain. And my name is John." The doctor leaned in with a wan smile and touched John's shoulder, "I'm sorry, John, we've just met and I'm terrible with names. But, I'm good with hearts, okay, so this is what you need to know: two blood vessels that bring blood to the left side of your heart are blocked. They were probably blocked for a while because there's some old scar tissue that we can see in the pictures we just took from your last heart attack." John gripped the bed with both hands. "I never had a heart attack before. What are you talking about?" Dr. Frost continued, "Okay, that's good to know, so what probably happened was that your attack was asymptomatic, that is, no pain, no shortness of breath, or maybe, you had unexplained back pain once, a few years ago, didn't connect it to your heart and anyway that part of your heart is permanently damaged." John wasn't taking it well. "So, I'm going to die from this?" Tina whimpered from a corner of the room. She wasn't taking it well either. The nasal cannula that was providing oxygen to help enrich the levels in his blood made him sound nasally and whiny. "Well, John, I don't know that for sure. But there are some things that we can do to prevent another heart attack right now, which, in my opinion, is pretty certain unless we take some steps." "What? What do I have to do?" John practically begged. Dr. Frost lowered his hand to John's arm now, the other hand in the pocket of his white lab coat, his body perpendicular to the bed. "First, I want you to understand that what I'm going to talk about are procedures that we do all the time but still, the results aren't certain because everybody is different, okay?" John nodded. "Okay, here's what we can do. The two occluded, or blocked, blood vessels can be replaced with vessels from another part of your body. You probably heard of 'bypass surgery'?" John nodded again. "We can do this," the good doctor continued, "but you have to know the risks."

Dr. Frost knew that certain patients, very few, however, declined to have surgery even after his accurate and thorough description of the procedure itself, the opening of the ribcage, the scarring "zipper" in the chest, the scar in the leg where the veins would be harvested, the recovery process which included a complete lifestyle change, including things like yoga, daily walking and no more stromboli. And there was one more thing. There was a significant risk that John would die during the surgery. There was a risk that he could die from infection. There was a risk that the transferred veins bled before a graft was complete and that they would have to go in again and fix it. There was the risk that John's genetic make-up made him much more prone to artery-hardening and plaque build-up.
And there was one more concern that Dr. Frost had - John's age. In this scenario, Dr. Frost is going out on a bit of a limb because John is only three months short of his seventieth birthday. Survival rates for elder patients are much more grim than those patients who are a decade younger. And since declining health in other areas is likely for such a patient, that is, one that's older than the mean for this kind of procedure, such a patient is much more "brittle" and is likely to decline very quickly if something lese happens - like diabetes, cancer or even the flu.

The risks aren't only medical. John may have insurance, but the upper limits of his insurance might be tested by the cost of the hospital stay taken together with the surgery, medications, aftercare and therapy. The event that I've described above, that one day in the hospital, would easily top twenty grand in billing. Easily. Heart bypass? Another thirty-five to fifty thousand dollars. Medication? Perhaps three grand a year, depending on the underlying cause of the patient's issues.
But the other side of it is this: should John receive this care? There's no doubt that we all want our loved ones to get the "best" health care, but at what cost to society?

There is somewhat new thinking being posited by bioethicists and contemporary philosophers, such as Peter Singer. In brief, it's suggested that since end-of-life care comprises the bulk of medical costs in the western world and especially in the United States, perhaps it's time to rethink our application of extraordinary measures. Is there a point at which extreme care exceeds a desirable or even tenable level of quality-of-life, as a utilitarian concept?

The application of extreme life-saving measures can be cruel and harmful, in fact, to the patient and it's been shown that such measures don't significantly extend life expectancy. But, as a society, we elevate life to a level at which it's to be preserved by any means and at any cost. Perhaps this is a bad idea, given the downsides which are significant. It's a bitter pill to swallow, but it's certainly something to think about.

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