It happens all the time in my field.
Start with an 82-year old with sick sinus syndrome and the need for a permanent pacemaker. Before their procedure, the heart's pumping function, or ejection fraction, is evaluated and found to be, say, 31%. Now, based on data from the NIH-sponsored SCD-HeFT trial, an implantable cardiac defibrillator (ICD) is considered to not only support the heart rate, but also to play potential role in the primary prevention of sudden cardiac death in this higher-than-average-risk patient. But why stop there? After all, the EKG was evaluated and demonstrates an underlying left bundle branch block. A quick review of the chart confirms an admission for heart failure in the last year, and voila', a biventricular ICD is justified on the basis of CARE-HF and the MIRACLE trial to provide cardiac resynchronization in hopes of improving heart failure symptoms, too!
A talk then ensues with the patient and their family. The pros and cons of each technology and the limitations of the data are reviewed. Jointly, the group comes to a clinical consensus about which device to receive. Usually (but not always), a "cover all the bases" approach is taken, since cost is usually not considered in these discussions.
And the difference in price between a pacemaker and biventricular pacemaker-defibrillator?
So what's the best option?
The Heart.org does a nice job reviewing the controversies surrounding "device creep" in those over the age of 80 with sinus node disease as they review a timely article by Dr Michael O Sweeney of the Brigham and Women's Hospital, Boston, MA published before print in the Journal of Cardiac Electrophysiology. Cardiologists, electrophysiologists and heart failure experts weigh in from both sides of the debate: (1) co-morbidities matter, (2)this is a uniquely American debate since other countries already ration these expensive technologies, and (3) the convergence of an aging population and tightening resources will make discussions like these more and more common the field of cardiac electrophysiology. Perhaps Dr. Lynne Warner Stevenson from the Brigham and Women's Hospital said it best:
"As we look at the healthcare problem in the US, we're going to have to make some exceedingly difficult decisions. We're going to have to be either rational or be severely rationed. And a relatively easy target is to reduce the number of expensive procedures that do not provide anticipated benefit."But in when does a person reach the age where technology provides no "anticipated benefit?" What benefits should we measure?
Read the whole thing. It's worth it. Then ask yourself: what if you were 80 and facing this decision: what would you do?