How The Rise Of Medical Technology Is Worsening Death by Jessica Nutik Zitter
Our aging population is at risk from a most benign-appearing source—the medical technologies we trust to keep us healthy.
When they were first widely used in the 1930s and 1940s, breathing machines did what humans could never have imagined a generation earlier: They kept young polio victims alive until their bodies cleared the virus that had temporarily weakened their respiratory system. Thanks to these miraculous machines, tens of thousands of these patients recovered and went home to live out the rest of their lives. This bold new use of medical technology riveted the world and set the stage for a new era in medicine, in which an overriding faith in the curative powers of technology prevailed. Over the next several decades, doctors assumed that everyone wanted and deserved access to these treatments. The breathing machine, or mechanical ventilator, was the first of many life-prolonging technologies to come. Now, there are machines to substitute for a wide range of physiological functions, including the pumping of the heart and the oxygenation of the blood.
Ideally, life-support technology should serve as a bridge to recovery, in which the failing organ is supported until the underlying disorder improves. But when the underlying disease or failing organ will not recover adequately to resume independent living, the recipient is likely to remain dependent on the machine. Unlike the polio victims, whose young and otherwise healthy bodies were often able to spring back to life after their illness had passed, the frail elderly and terminally ill are much less likely to recover. And so they are attached surgically to machines, most commonly through a tracheostomy tube in the neck and a feeding tube in the stomach. These patients cannot live at home and must remain in facilities where they are cared for by trained personnel. Most will never get out of bed again, eat independently, or talk. Many will lie in hospital beds, their arms tied down to prevent dislodgment of tubes, until they die.
According to the Department of Health and Human Services, over the next 45 years, the population of people older than age 65 will double. From 46.2 million in 2014, the number will climb to 98.0 million in 2060. In 2030, one out of every five Americans will be older than age 65. If trends continue on the current path, this will translate into millions of elderly patients on life support.
The SUPPORT Trial of 1996 was the first wake-up call to the medical community on the state of dying in America. It reported astonishing rates of mechanized deaths, accompanied by significant patient pain and suffering. Often, patients or their families had little or no prior communication with physicians about decisions to use these treatments. The mechanical ventilator, cardiopulmonary resuscitation, and dialysis machines are familiar mainstays of intensive care, and unless patients opt out, they drive the treatment plan. Doctors reach for them. And most patients, educated on these topics by inaccurate media portrayals, expect them. Substantive conversations about prognosis and treatment plans rarely take place, and patients’ understanding of their condition and treatment options are poor. But despite subsequent efforts by the palliative care community and others to reverse this situation, in 2013, the Journal of the American Medical Association reported an increase in intensive care unit (ICU) stays for patients older than age 65 in their last month of life.
Today, there is a steadily expanding menu of technological treatments designed to support a multitude of failing organs. An example is extracorporeal membrane oxygenation (ECMO), a form of cardiopulmonary bypass (CPB). CPB was developed in the mid-twentieth century for use during heart surgery. Like hemodialysis, which compensates for failing kidneys, CPB can take over for hearts while under the surgeon’s knife. The blood circulates through the machine, transported in and out of the body through large cannulae. The CPB machine oxygenates the moving blood and then pushes it back into the body, maintaining pressure and circulation. ECMO is conceptually and mechanically similar but is intended for longer-term support in patients who will remain, for days, weeks, even months, in the ICU. It was initially conceived in the 1940s but was largely relegated to research purposes and then to the treatment of neonates. However, during the swine flu pandemic of 2009, survival rates for adults receiving ECMO for respiratory failure were found to be higher than seen in earlier studies of the technology. Following that, there was a substantial rise in the number of ECMO centers worldwide, going from 148 in 2008 to 298 in 2015.
The ECMO machine can serve to support diseased lungs, or hearts, or both. Large catheters bring poorly oxygenated blood from the body to the machine, where it is oxygenated and then sent back to feed the tissues of the body. The goal is to support the body until the lungs and/or heart recover, or are transplanted. In the meantime, the patient can live in the ICU on this machine. While some patients are able to move around in the ICU, with staff carefully carrying the machine and catheters behind them, others lie in beds, either too weak to move or dependent on the breathing machine.
Intended as a bridge to recovery or a bridge to transplant, for some, this technology becomes what is called a bridge to nowhere. If a patient’s organ will not recover and the patient is not a candidate for transplantation, the remaining options are bleak. Such patients will likely suffer many complications aside from their underlying condition, including increased risk of bleeding, profound fatigue, cognitive decline, deconditioning, and serious infections with drug-resistant organisms. But arguably more difficult is the decision they face about how to proceed. Unlike patients on breathing machines, these patients are often awake and able to communicate. And so they must answer an important question. Are they willing to live the rest of their life in an ICU? If not, when to disconnect the machine? Most, once disconnected, will die within a very short period of time. How do doctors ask patients, many of whom didn’t elect for this treatment but were placed on it while in extremis, to decide what day they want to die? And one cannot ignore the issue of resource allocation. If a person does not wish to end his or her life, he or she may be using a precious and scarce resource that could save another patient.
With its rapid explosion in use and new centers popping up around the country and the world, there are voices advising caution. Doctors Daniel Brody and Ken Prager of Columbia Presbyterian, both ICU doctors who manage ECMO patients at their established and experienced center, have concerns about this rapid increase in its use. Their protocols for inclusion are very strict, and they will only accept patients for ECMO who are candidates for transplant, have physiologic reserve and good nutritional status, and have a high likelihood of robust recovery. Their intensive screening of candidates has paid off, and most of their patients do well. But if this technology begins to be used without careful screening, it is likely to create a situation similar to the overuse of the ventilator, where benefits are outweighed by great burden.
ECMO is only one of many emerging technologies or treatments becoming available to the modern physician. While these technologies can be truly miraculous for the right patients, others—specifically, the frail elderly, terminally ill, and the dying—will not be so lucky. As the US population ages, the current epidemic of overly mechanized deaths threatens to explode into a major public health, and fiscal, crisis. For ECMO alone, there was a 433 percent rise in its use in adults between 2006 and 2011. And for each patient, the mean estimated total hospital costs, including pre- and post-ECMO procedures, was $213,246. The projected costs are staggering.
When surveyed about medical preferences at the end of life, most people do not choose this course of treatment. And for patients already in the ICU, data demonstrate that the more information patients are provided about their prognosis and treatment options, the less technology they choose. And so this high use of technology that has become the default course of medical culture does not appear to match the needs of patients.
In the mid-twentieth century, French anthropologist and energy minister Jacques Soustelle noted with concern the powerful draw of humans to new technologies such as the atom bomb. He determined that “since it was possible, it was necessary” and imagined an arms race that might ultimately destroy us all. Many others have warned of a “technological imperative,” in which the mere existence of increasingly sophisticated technical capabilities rendered their use necessary, even inevitable. When it comes to the dying, this tendency can take a substantial toll at a vulnerable time.
Medical technology can indeed be miraculous. It has saved countless lives that in previous times would have been lost. But there can be substantial costs, both human and financial. Many patients die protracted deaths on mechanical ventilators—deaths which, based on data about preferences, many would not have chosen had there been adequate communication. Even a treatment with a powerful record and clear physiologic indication might, in some, cause profound suffering.
Patients need to understand that potential at the outset of their treatment and remain in clear communication with their physicians as their trajectories unfold. Physicians, as stewards of these technologies, have a responsibility to direct the use of these technologies toward patients who are most likely to benefit, instead of viewing these treatments as a default for all patients. And once they have attached their patients to these technologies, physicians must engage in ongoing dialog with the patient or family to ensure that the medical plan remains in alignment with the patient’s preferences, which may change as the prognosis becomes clearer. As new life-support technologies such as ECMO are used more widely, more patients will be left stranded on the “bridge to nowhere.” As a society, we must look carefully at our US tendency to celebrate technology and to assume that “doing something” implies that we care.
Source: http://www.healthaffairs.org/do/10.1377/hblog20171101.612681/full/