Add portable hearts to end of life care dilemma

From the Washington Post:

Surgeons at more than 60 centers in the United States are now implanting at least 1,000 LVADs each year. Smaller, more durable and more easily implanted versions are being developed, including one that was approved just this week. With at least 5 million Americans suffering from heart failure, 550,000 new cases being diagnosed each year, only about 2,000 hearts available for transplant each year, and Medicare willing to pay for LVADs (at a typical cost of $200,000), experts predict the number will soar.

"We are at the cusp of a rapid expansion of this type of therapy," said Park, who estimates that within the next five years, 10,000 Americans annually may get the pumps.

Add one more decision to the mix -- I'm afraid that in practical terms, the decision will be whether to even give the patient a trial of LVAD or not.

I disagree with the bioethicist (there's a link to the Hastings Center article in pdf, here) who says that the pump becomes a part of the patient's body. It's still a piece of artificially introduced technology and medical treatment that requires maintenance and battery charges -- would we replace it if we had a biological heart? There's also the very fact that we're able to discuss "powering down" the motor, which makes it different from a "part of the patient's body."


I know of a patient who, for about a month, has worn a "Life Vest," a portable defibrillator while waiting for the implantation of a demand defibrillator/pacemaker. Even the interventional cardiologists hadn't seen one before and came to check it out. I've had patients ask to have an implanted demand defibrillator turned off because it was firing so often - it was like a kick in the chest each time their heart stopped beating.

The Texas Medical Association has a resolution sent forward by one of the County Medical Associations concerning end of life care. It asks for a study to determine reliable scales or ratings for health status based on objective criteria such as labs, age, history. The goal would be ending Federal and State insurance (Medicare, Tricare, Medicaid) funding for any care other than Palliative once a patient meets certain criteria. The resolution wouldn't restrict private funding -- but so far, Medicare has put pressure on docs who charge patients outside their payment limits.

3 times over the past week, I've heard colleagues comment on the expenses related to current standards of health care - and some abuses, such as sending the patient from the nursing home to the doctor's office by ambulance. Each mentioned that the expenses of these patients will bankrupt "the system."

Frankly, I don't want the State to mandate that I can't treat anymore than I like telling me that I have to treat, if the number crunching and check boxes don't fit with my medical judgment.

(But I did realize how much of an aversion I have to wearing a vest that can give me an electrical jolt, and that I have to keep adjusted. I would probably be a little compulsive about adjusting it, and have to check out whether it [still] works, getting an extra shock each time.