Sunday, November 9, 2008

When Should the Heart Stop Beating?

By Richard P. Holm MD

In the end, we will all die of something. As a guy who has to fill out death certificates, it is interesting that when the cause of death cannot be defined I find myself stating that the person died of heart disease. Think about it, even when the ultimate reason is due to cancer, stroke, pneumonia, or a motor vehicle accident, when a person gets sick enough from anything, ultimately the doctor calls them dead when their heart stops beating.

Recently at a medical meeting I listened to a cardiologist speak about just that issue. He explained about the implantable cardioverter defibrillator (ICD). The device is a small-computerized battery buried under the skin, which is connected to the heart with a wire. It monitors the heart rhythm and automatically triggers the heart when the beat is too slow, or shocks it back to normal rhythm when the heart goes too fast. 

He explained we should be providing this for many more people than who are presently receiving it. He didn't tell us that the cost for putting in an ICD is roughly $50,000, and it needs replacement every 3-5 years.

It is pertinent that the very next lecturer spoke about health care costs. We listened in dismay about the ever spiraling out of control cost of health care. The expert explained that our country soon would no longer be able to pay for "everything for everybody right now". In order to provide for reasonable and basic health care for everybody, she explained we would have to limit some of the stuff that is so very expensive, especially when the value and benefit to the individual is minimal or unproven. 

The presentation was well received by the room full of doctors, and yet the real and scary future task of determining who gets what care when resources are limited, left us all uneasy.

The back-to-back lectures left me with several questions. When is the patient too old, or too sick to get one of those devices? How can we afford such a thing for so many people? And if we take away the easier death of an abnormal heart rhythm, then how will people die? These are tough questions, and we need to talk about them.

Take home message:
1. We have fabulous life-saving devices that can keep people alive when they shouldn't die.
2. How do we know when it is time to let people die?

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