Why ICDs Shouldn't Always be Replaced

The implantable cardioverter-defibrillator (ICD) can save lives by recognizing a life threatening heart arrhythmia and immediately shocking the heart back to a normal rhythm. More than 100,000 are implanted each year.

ICD batteries last an average of five years. Here's how the Mayo Clinic talks about battery life:

The lithium battery in your implantable cardioverter-defibrillator can last up to seven years. During your regular checkups, which should occur every three to six months, your doctor or nurse will check the battery. When the battery is nearly out of power, your old shock generator is replaced with a new one during a minor outpatient procedure.

Notice how the final sentence suggests that replacement will automatically be done. There's no reference to the patient's preferences. The implication is that once an ICD is implanted, it will be with us until we die.

An article in the January 26 New England Journal of Medicine - "Time for a Change - A New Approach to ICD Replacement" challenges that assumption. Health status and life circumstances may have changed since implantation such that sudden death from an arrhythmia now looks like a blessing, not a curse.  Or our experience with the ICD may make us not want to replace it.

The authors describe how in our all-too-often fragmented system of care no one physician is responsible for helping the patient decide whether the battery should be replaced. The care system goes onto automatic pilot. As the Mayo Clinic says - the "old shock generator is replaced with a new one during a minor outpatient procedure."

The authors' recommendations are so obviously sensible it's surprising they aren't routine:

1. A comprehensive medical evaluation should be done before ICD replacement.
2. There should be clear and full communication among the entire medical team.
3. The patient's preferences, past experience with the ICD, and advance care planning, should be explicitly included in decision making.
4. Replacement should only be done if the patient wants it to be done!

I haven't been part of decision-making about an ICD, but I have observed how medicine can go onto automatic pilot. At the end of my first stepmother's life (my father was a three-time widower) she was suffering from terrible shortness of breath. She was put onto a ventilator for comfort. Over a day or two the coma she was in from cancer that had spread to the brain deepened. The ventilator, which initially had relieved suffering, was now prolonging the dying process. I pointed this out to her children (my step-sibs) and they authorized withdrawal of the ventilator, allowing their mother to die peacefully, unattached to any machines.

Not automatically replacing ICDs will save money, but it's not death panel rationing. Ascertaining what our true wishes are and following them is the right way to practice medicine!

Don't Let Medicare Undermine the Health of Future Generations!

Zeke Emanuel, who is becoming the national educator-in-chief about health care in his new role at the University of Pennsylvania, preaches an excellent sermon in today's New York Times - "What We Give Up for Health Care."

Zeke's point is obvious, but, amazingly, it's one our political process has been oblivious to: what we spend on health care we can't spend for other purposes. That creates an ethical imperative to consider opportunity costs for health care expenditures. The proper question is - "does this health care expenditure create more human benefit than other possible expenditures?" - rather than the one we typically ask - "does this health care expenditure produce any benefit for the patient, no matter how small the benefit or how high the cost?" Zeke shows how health care costs have acted as an economic cancer, invading and obliterating investments we would otherwise make in wages (which have been stagnant or declining), education, and other crucial components of our lives.

As important as medical care can be, income and education are also crucial determinants of health. When we reduce wages to pay for health insurance, and reduce educational investments at every level to pay for Medicare and Medicaid, we're reducing overall health and well-being. The real "death panel" is our reflexive investment in medical interventions that produce minimal or no benefit at the cost of investments that would do more for us!

Zeke argues that "liberals" should be as concerned about health care costs as "conservatives" are:

There is an inevitable trade-off between rising health care costs and things liberals really care about, like access to college and good wages for working Americans. We cannot have it all. The health care reform act will help us save — mainly by changing how physicians and hospitals are paid and delivering better care to our most expensive patients. But more can be done: for starters, we could speed up the implementation of payment reform, stop Medicare payments for tests and treatments that provide no benefit and endorse competitive bidding for medical goods and services.

The premise of this blog is that many of us in the Medicare age group - whether we're "liberal" or "conservative" - share a concern about the future, and don't want current Medicare expenditures to undermine the health and well-being of future generations.

Avoiding overtreatment, and the moral imperative to consider opportunity costs, should be our relentless advocacy focus!

Changing End-of-life Care

When I told my colleague, dear friend, and mentor, Gordon Moore, about this new blog, he showed me the draft of a proposal he had written for Medicare reform. Gordon and I have worked together and exchanged ideas regularly for more than 30 years, so it's not surprising that we agree that we in the Medicare generation are key for reforming the program and reducing its costs. He gave me permission to print what he'd written and to tweak it for length:

To my fellow Medicare recipients, 

I am a retired general practicitioner, now on Medicare.  Like many of you, I am feeling guilty and at the same time defensive about the claim that Medicare expenditures threaten the economic well-being of America.   Defensive because I feel I have earned the right to have good medical insurance as I get older.   But guilty because I know that the growth rate of Medicare does, indeed, threaten the future of our children and grand children.

As I watch the partisan fighting in Congress, I have become increasingly dubious that our government will be able to solve the problem of Medicare costs.  Both sides have staked out positions that block compromise. We are in a stalemate that threatens the nation’s future.

I have concluded that only we Medicare recipients are capable of stepping up to the plate and resolving this dilemma.   I am reminded of Pogo’s famous comment that ‘we have met the enemy and he is us.’

So how could we solve this problem? One answer is that we individually volunteer to remove Medicare expenditures that are wasteful. The greatest waste is in end-of life care.  We spend almost 30% of the Medicare budget on care that ends with death in a year or less.  As a doctor, I saw time and again the relative futility of aggressive medical care in the last months of life.  Not only did I know that such care was vanishingly unlikely to prolong life by any meaningful length, but I also watched the quality of life plummet as aggressive medical care led to hospitalization, loss of function, and prolonged pain and suffering. 

I promised myself that, like Elizabeth Edwards, at a certain point when my doctor calculated that the odds of meaningful survival were low, I would choose to be at home with my family, to receive hospice services for comfort only, and die in dignity. 

How would we know that the time had come to make such a choice?  As a primary care physician, I almost always knew the odds that intensive care would no longer help.  And yet I was relatively ineffective in helping many of my patients accept that conclusion.  Part of the problem is that most doctors find it hard to accept that there is nothing more that they can do to produce a cure.  And for most patients and families, insurance makes care seem “free,” so why not do “everything”?

But we are discovering that this care isn’t free.  It’s just that we are asking our children and grandchildren to pay for our expenditures by reducing the prospects for their own lives.  I’m very uncomfortable with the idea that our end of life care is hurting the generations that follow us, especially “care” that is associated with a miserable quality of life and maximum distraction when our real need is to be comfortable and at peace to come to our own terms about dying.   

So I have been thinking about whether we could start a campaign to reduce the expenses of our own end of life care.  If most or all of us committed ourselves to ask our doctors to inform us when the odds of recovery or significant prolongation of quality of life had dropped below a specific figure (like 1 in 5 or 1 in 10) and if we further committed to asking that all but supportive comfort care be stopped, we could make a significant dent in Medicare’s risking costs.  

But this prospect makes me confront a major barrier to my own participation - that the savings would disappear into relieving our sovereign debt.  That would feel like paying taxes - at best it's a duty, at worst it's taking the money from my sacrifice and using it for many things with which I disagree. 

 As I thought about this, I came to the conclusion that were I to relinquish my ‘right’ to unlimited expenditure at the end of life, I would want it put to a good purpose that would be sufficiently specific to make me proud and others grateful.  

My proposal is that we earmark these savings to make the generations that follow healthy and productive, to make it possible for them to achieve the quality of life that my generation has been able to enjoy.  

To do this I propose that we form a National Health Fund to which our individual contribution, calculated actuarially, be made when we forgo high cost/low yield end of life “care.” This fund would be used in the best way we know to assure healthy productive young people capable of contributing to our common good – to combine public health, education and personal care in initiatives to address the major behavioral factors that lead to illness and disability – obesity, lack of exercise, violence, and smoking.  There is little we could do in personal medical care that would deliver as much improvement in the health of our nation.

We Medicare recipients are capable of improving care and reducing costs.  We can be the generation that says ‘it’s not all about me.’ We can lead the way to a new level of civil discourse about the future of America.  Our parents did this for us with their sacrifices during the Great War; isn’t this crisis the war that we can fight to make this country better for our children?

I want to (a) thank Gordon for letting me publish his vision of Medicare reform and (b) invite other readers to send me their best ideas!

Is Death Optional?

An old joke spoofs the way we in the U.S. think about death:

In India, death is seen as a potential step away from reincarnation and towards blissful Nirvana. In Europe, death is seen as an existential tragedy we must face. In the U.S., death is seen as optional!

Last summer, Daniel Callahan, author of "Taming the Beloved Beast: How Medical Technology Costs are Destroying our Health Care System," and Sherwin Nuland, author of "How We Die: Reflections on Life's Final Chapter," (both have written many other books as well) took on the American myth of eternal youth in the New Republic. They argued that "the war against death as the highest priority should give way to a new goal: aiming to bring everyone’s life expectancy up to an average age of 80 years (already being approached), reducing early death, and shifting the emphasis in the direction of improving the quality of life of those in every age group. The highest priority should be given to children, the next highest to those in their adult years (the age group responsible for managing society), and the lowest to those over 80."


This is the kind of discussion we need to have in the U.S. in place of the vacuous tit-for-tat between Republicans and Democrats over who loves Medicare the best and who is out to destroy it. Medicare is an amazing achievement for a society in which many, perhaps a majority, agree with President Reagan that "government is not the solution to our problems; government is the problem." Medicare is cherished by its beneficiaries and by the generation concerned about care for their parents. Medicare's popularity is so deep that it's been known as the "third rail" of American politics since the Clinton presidency. Touch it and you're dead!

Callahan and Nuland could argue for giving priority to children and younger adults because they're both over 80. The ordinarily lethal accusation of being "granny bashers" is hard to pin on grandparents themselves. I'd guess that in a forced choice, a majority of Medicare recipients would agree with Callahan and Nuland's perspective.

Medicare costs must be brought into line with general inflation. But we won't make progress until our political leaders develop more backbone, and that won't happen until they hear from us Medicare constituents ourselves. I think the right starting point for that advocacy process is for those of us in the Medicare age group to demand that Medicare focus more on interventions that promote quality of life and less on costly hi-tech interventions that may forestall death by prolonging deterioration and suffering.

As Callahan and Nuland noted in their article, this will require a heightened political and medical awareness among Medicare recipients, and will engender economic losses for those who currently profit from the way health care is provided. Overtreatment is always bad medicine, but it can be economically rewarding for those who provide it inflict it.

In a followup to the New Republic article cited above, the July 3 New York Times featured a letter on the topic from Dan Callahan along with several responses. Among the responders, Doris Fenig wrote "We are a very strong lobby. We have a very loud voice. Let’s use it...for 'common civic sense.'"

Doris got it right! Her letter was one of the prods for me to start this blog.

[This post is a tweaked version of a post I wrote on my healthcareorganizationalethics blog shortly after the Callahan/Nuland article appeared.]

Going to Heaven with our Stitches in

A team at the Harvard School of Public Health published a disturbing article in Lancet on "The intensity and variation of surgical care at the end of life."

The group studied the 1.8 million Medicare beneficiaries who died in 2008 to determine the frequency of surgery during the last year of life. 32% had an inpatient surgical procedure during their last year. 18% had surgery during their last month. And 8% had surgery during their last week.

This is a population study, so it doesn't tell us how often the surgery was required by the patients' true needs and wishes. But I'd bet dollars to pennies that most readers of this post have seen surgery done in situations where a better informed patient and family would have rejected the proposal.

My beloved late father-in-law, who I wrote about two days ago, was vigorous until he turned 90, at which time angina limited how far he could walk in New York City's Central Park. Early in his life he'd been in the plumbing supply business, so when a revascularization procedure was proposed to him he thought of it as a common sense plumbing repair. He didn't consult with his family before deciding to do it. The result was five months of intractable heart failure before his death.

He was a gentle, fair-minded man and forgave his physicians for a recommendation they shouldn't have made and he shouldn't have accepted: "My doctors were young men. They were thinking about young hearts, not about 90 year old hearts."

Dr. Ashish Jha, leader of the Medicare study, told a similar story from experience at his own hospital:

A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine.

“No one had talked to him about how close he was to death,” Dr. Jha said. “It’s the worst kind of conversation to have.”

Instead, doctors did an endoscopy and a colonoscopy because the man had internal bleeding. Then they did abdominal surgery. “We did all of this because we were trying desperately to find something we could fix,” Dr. Jha said.

The man died of a complication from the surgery.

“The tragedy is what we should have done for him but didn’t,” Dr. Jha said. “We should have given him time to have the conversation he wanted to have with his family. You can’t do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea.”

Instead, Dr. Jha said, “we sent him to the O.R.”

The election year concern is with Medicare costs. But the primary problem for my father-in-law and the patient Dr. Jha describes is care, not cost. Overtreatment is a serious problem for Medicare beneficiaries. More appropriate care for folks like my father-in-law and Dr. Jha's patient would have had the secondary benefit of reducing cost. That's better medicine, not "death panel rationing"!

[This post is a slightly modified version of a post I wrote in October on my  healthcareorganizationalethics blog.]

Harmful Hospital Errors are Vastly Underreported

In an article by the always informative Robert Pear in yesterday's New York Times we learn that a just-released study from the Inspector General of the Department of Health and Human Services reports that only one in seven errors, accidents, or other events that harm hospitalized Medicare beneficiaries gets recognized and reported. (As of today, the report itself isn't available on line.)


Quality improvement gurus teach that "every defect is a treasure." Sometimes recognizing that avoidable harm has occurred lets us help the involved patient, but there are always important lessons that can prevent repetition and help other patients in the future.


The unreported events were identified from detailed study of hospital records. They included

medication errors, severe bedsores, hospital-acquired infections, delerium from overmedication, and excessive bleeding linked to improper use anticoagulants. The Inspector General calculated that more than 130,000 Medicare beneficiaries experience this kind of injury each month!

What I found most disturbing is the Inspector General's surmise that the primary reasons for the underreporting were (a) not recognizing that avoidable harm had occurred or (b) seeing the incident as so common that it didn't need to be reported.

"Developing a culture of safety" is a common mantra, but we clearly have a long way to go to make it more than an empty cliche.

Two Common Sources of Overtreatment

Experts, most recently former CMS administrator Don Berwick, tell us that 20% - 30% of medical care is "waste." At the very least, "waste" is harmful to all those who pay for Medicare. But often it's directly harmful to the patient as well.

I recently saw a friend at a holiday party. Since we'd last seen each other my friend's spouse had died. (I'm deliberately avoiding gendered pronouns and omitting other identifying details.) My friend contrasted the excellent hospice care with problem-ridden hospital care. Here are two examples of "waste" that were thwarted only by my friend's vigilance.

My friend's spouse ("the patient") was declining rapidly, and was admitted to the hospital. While my friend was attending to some bureaucratic aspects of the admission, the hospitalist ordered a CT and insertion of a "picc line" ("picc" = "peripherally inserted central catheter").

On returning to the patient's bedside my friend pointed out that an identical CT scan had been done four days earlier.

The hospitalist responded - "I don't have it."

My friend replied - "Rather than putting such a sick person through another CT and spending another few thousand dollars, let's get it."

With regard to insertion of the catheter, my friend asked: "what aspect of the plan does it serve?" The answer was - it was an automatic part of a protocol, not tailored to the wishes of the patient and family. When their goals were clarified, the picc line idea was dropped.

I know from my own practice experience that getting test results and records can be difficult. But repeating an identical test four days after it had been done elsewhere is a very expensive workaround that would have imposed avoidable distress on the patient. And although threading a catheter to place near the heart is a fairly routine hospital procedure, it carries risks (such as infection) and burdens (being hooked up to tubing). The hospital protocol should have required clarity about treatment goals before a non-emergency intervention was set into motion.

What struck me about these examples of overtreatment is how mundane they were. The hospitalist meant well. It was important for him to have the information the CT scan would provide, but repeating it wasn't the right way to get it. And having routines can promote patient safety - but only when the routine is tailored to the true situation. In a non-emergency, clarity about the treatment goals of patient and family should be part of the what we routinely expect of ourselves.