Saying No to Medical Technology

As is recommended for all patients, DeBakey had an advance directive: he had stated, while in good health, what approach to medical care he would want if he became ill and unable to speak for himself. He specifically indicated that he would not want to undergo major surgery.

A cardinal principle of contemporary medical ethics is that patients have the right to make this type of decision, and that physicians are obligated to follow their wishes. To disregard a patient’s preferences once he loses the ability to make decisions – as occurred when DeBakey’s wife reportedly stormed into a late-night hospital ethics committee meeting and demanded that the surgery take place – violates the hard-won respect for patients’ autonomy gained over the past 20 years.

Much of the commentary about the case has centered on whether a patient’s wishes can be overridden, even by loving family members. What has largely been left out of the discussion is whether it is ever appropriate to perform invasive, dangerous, and expensive surgery on 97-year-olds – even if they want it.

The operation performed on DeBakey involved putting him on cardiac bypass and opening the aorta, the artery that carries blood from the heart to most of the major organs of the body. The damaged part of the aorta was then replaced with a synthetic graft.

The risks were high: in a group of elderly patients who had the procedure, the oldest of whom was 77, 18% died while hospitalized. Moreover, surviving the surgery does not mean returning to one’s usual state of health in a matter of a few weeks. It typically means, as DeBakey experienced and as his physicians anticipated, an extended hospitalization marked by reliance on machines, multiple complications, and considerable suffering.

DeBakey spent three months in the hospital, much of the time unable to speak or eat, let alone leave his bed, read, or interact with others. He was attached to respirator and to another machine to clear wastes from his body, and was fed through a stomach tube. The cost of his hospital stay is estimated to have exceeded $1 million.

While DeBakey is glad to be alive, how many people should we subject to the grueling treatment that he endured for the chance of a few more weeks or months of life? Is it reasonable for 99 or perhaps 999 people to suffer for days or months, only to die from complications of surgery, because one person might live?

The number of potentially life-prolonging technologies offered by contemporary medicine is proliferating. An implantable cardioverter defibrillator can jolt the heart back to normal if an irregular, life-threatening rhythm develops in patients who have had a heart attack. The left ventricular assistance device is a partial artificial heart used in patients dying of heart failure. Sophisticated biopharmaceuticals – drugs typically used in patients with extremely advanced cancers – are also multiplying.

Some of these therapies can provide additional months or even years of life to people in their prime. But does their use make sense for the oldest old, especially when they are invasive and costly?

When the baby boomers begin turning 65 in the 2010, they will account for 13% of the population in the United States; by 2050, 21% will be over 65, and 5% will be over 85. Medicare expenditure – the money spent by the government insurance program for the elderly – is projected to soar from 2.6% of GDP currently to 9.2% in 2050, with technology accounting for over 50% of the cost increase. If we are to have the resources for public goods other than health care – say, education, national parks, and highways, not to mention medical care for children and the poor – we must put the brakes on technology.

In rich countries, this does not mean rationing care based on age alone. But surely the place to start is to limit treatment that is burdensome and expensive, that has a miniscule chance of success, and that is proposed for people at the very end of life. We need to accept human mortality and, as a matter of both practice and policy, concentrate on improving older people’s quality of life.

This means assuring compassionate nursing home care, coordinated management of chronic diseases, and competent palliative care as death approaches, rather than using ever more technology to try to eke out a little more life. It also means systematically considering cost and life expectancy in decisions about reimbursing high-technology medical care.