Tuesday, December 26, 2006

Advanced Medicine for the Advancing Aged

While performing a pacemaker implantation today, I asked for DeBakey forceps (seen above) today – forceps named after an iconic figure in cardiothoracic surgery, Dr. Michael E. DeBakey who underwent an operation at the tender age of 97 that he devised to correct a dissecting aortic aneurism. Although the article that appeared yesterday in the New York Times (and again today in the Chicago Tribune) seemed somewhat apologetic regarding the number of resources used, it nonetheless was a reminder of the incredible capabilities of our health care system when it works the way it should. Gratefully for his family, colleagues and friends, Dr. DeBakey made it through the ordeal in what can only be considered a miracle of modern medicine. Certainly the hard work by all of those involved in his care should not go unacknowledged.

But the bigger story beneath this story is a more subliminal and troubling one: just because care can be delivered, should it be delivered to someone at such an advanced age, in such an abysmal condition with such low probability of surviving to discharge? Circumstances in hind-sight would suggest they should. But in the best of circumstances, a healthy 97-year old male in the United States has about a 2.8 to 3.0 year actuarial survival. Now take a ninety-seven year-old with a Stanford Class A, Debakey subclass II, dissecting ascending aortic aneurism which is leaking into the pericardium who is unconcious and near death - well this individual has a much, much lower probability of surviving the surgery, let alone surviving to discharge. And after the surgery, rehabilitating a ninety-seven year-old is an expensive and arduous undertaking. As a doctor practicing in Chicago, I have to ask myself honestly an important question: would I have proceeded along the same course in a patient with a clear “do not resuscitate” order on his chart that demonstrated such a reluctance to proceed with surgery in the first place?

At this time of shrinking resources in health care, physicians are increasingly pressured to ponder such decisions. These decisions are never made lightly. There was a lot of emotion tied to Dr. Debakey’s illness – he mentored many of the colleagues involved in his care. The irony of the affliction was not lost on those caring for him either. They wrestled with the decision to perform surgery, and only when the wife barged into the meeting room, did they decide to proceed.

But Methodist Heart is also a public “non-profit” charitable organization. Money from the institution went to Mr. BeBakey’s care and will likely be itemized under “charitable care” when their income tax Form 990 is filed for 2006. The organization has authority to authorize funds for such care. But with the growing number of uninsured, ever-increasing costs of providing such health and rehabilitative care coupled with the aging of the population, especially the numbers of patients over 90 years of age, who will decide if John Q. Public gets a full court press or more conservative therapy? When such precedents are set, can we continue to turn our cheek to other younger patients with better chances of long-term survival and similarly difficult-to-manage illnesses? Will this level of aggressive care now become the de facto standard of care for all of our patient’s over 90 years of age? Should it? Certainly there were others in Houston with similar concerns.

Hopefully, there not be hard and fast rules guiding us in these circumstances. But while I commend the spectacular care that Dr. DeBakey received, I do so with some trepidation regarding the solvency of our health care system: especially as it pertains to our younger patients in the years ahead.


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