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.