Monday, October 12, 2009

The Rationer

Every cardiac electrophysiologist has been there: a relatively young individual in their 50’s presents to the Emergency Room short of breath, sitting bolt upright in bed and is found to be in congestive heart failure. This is not their first admission; several others have come before and each with a common theme: a positive urinary screen for cocaine.

The EKG shows left bundle branch block. Catheterizations occur, coronary disease absent or moderate, discussions held, patient recommended for defibrillator or biventricular pacing to improve their heart failure after medications have been ineffective for the past year. The person seems sincere – “No more drugs, doc, really” – a line uttered near the conclusion of every one of the patient’s prior hospitalizations, but this time, really, they mean it.

I wrestle with the ethics of the management of these patients every time I’m called to see them. Our guidelines state that ejection fractions of 15% should be treated with defibrillators, especially if no improvement on adequate, aggressive medical therapy. Our guidelines also say that patients with significant social or psychological disease that precludes careful follow-up of their device should not get a defibrillator. Outside the room the decision seems obvious; inside the room after a glance at the eyes of the desperate its another thing entirely - the suffocating feeling of heart failure having taken its toll. The family, at the patient's side, is concerned and wants to help, wondering if there’s anything that can be done.

Will the patient really quit using cocaine? My father’s voice whispers in my head: “What a person has done is an indication of what they will do.” Our business manager wonders why our volumes have slipped recently. What if they die shortly after leaving the hospital suddenly?

No matter what I decide, I will fail it seems. Is the patient sincere or playing me the fool? Can I tell? Put in the defibrillator or pacemaker perhaps it will help. But if I have guessed wrong, then resources are wasted and the patient is exposed to another risk, like infection. Don’t put in the defibrillator and I revoke a lifeline or effective therapy.

On the surface, these decisions should be easy. In reality, they are anything but.



Anonymous said...

I wrestle with this too. The usual drug of choice here is meth. I fall back on the fact that non-ischemic CM guidelines indicate that the pt needs to be on optimal medical therapy. So the pt needs to demonstrate medication adherence and f/u in clinic before I refer them.

Jay said...

Generally, these patient's are best treated as outpatients after recovery. Moreover, guidelines indicate that their medical therapy should be optimized and treatment carried out for at least 3 (maybe 9) months before proceeding with device therapy.

If they can keep all of the office followup and maintain compliance, then we may be in a position to talk about a device. If they can't keep follow up before the device, then it's not too likely, they'll be able to take care of their device post op. We don't go to great lengths to chase them down.

This is a practice I exercise with all patients, drug abusers or not. The number of patients I've seen come back with normal EF after medical therapy is rather high. I'm aware that lots of EPs don't follow these guidelines, and that's a shame.

On a side note, I had an interesting situation with a cardiac arrest survivor who was a cocaine abuser a while back. After he got his device, I told him that if he did crack again, he'd be at risk for inappropriate shocks. Sure enough he came back later with an inappropriate shock with sinus tachy at something like 200 bpm after a hit of crack. I was left with an ethical dilemma and ultimately decided that the ICD was not a Pavlovian machine to provide aversive therapy against drug abuse. I reprogrammed his device as best I could and warned him that I'd tried, but could not guarantee that the same thing would happen again. To the best of my knowledge, that was the last time he used cocaine (at lease we never saw any more similar high sinus rates).