[HSF] Do you believe in miracles?

Fri Aug 17 19:00:48 EDT 2007

Sounds like an Ani professorship to me. If you are an addict, I do think it much more moral to take money from those that throw it at you specifically for what you do insted of taking it from the unwilling taxpayer. 

Humor, including the gallow variety, allows the mind to focus in the confusion that would otherwise induce stupor and disorientation.

Maybe you can take further solice in the fact John Hunter was fascinated with the border of death as it was a clue to the nature of life. 

Looks like your observation has proven that cardiac perfusion is not that defining border...maybe it lags a few weeks or so behind. We will so note that you reported such in HSF.

tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Friday, August 17, 2007 5:16:43 PM
Subject: RE: [HSF] Do you believe in miracles?

Just to update on my patient who was I reported 12 days ago as terminal after an LVAD implant but family would not allow withdrawal of care. Patient eventually dies this morning. By death I mean there was no blood pressure less than 30mm Hg systolic despite grams of vasoconstrictor and functional LVAD, dilated pupils asystolic heart. Even then the family found it had to accept turning of ventilator. Ultimately ventilator and drugs switched off but VAD continued for over 2 hours after he was certified dead. Most interestingly - and to emphasize how the existence of flow through a VAD cannot be indicator of life - the VAD kept pumping between 4 to 5 litres/ minute with no problem through the dead body over 2 hours after there was cessation of respiration. Eventually care was withdrawn 8 weeks after VAD implant and 4 weeks after doctors first suggested it.

At least 4 weeks of futile care has gone into treating a patient in what was an unsurvivable condition because the spouse refused to accept the opinion of over 10 different doctors who unanimously declared he was untreatable. For an untreatable disease to become treatable, there has to be some new discovery, new therapy or miracle. It is interesting though that the spouse felt content in us continuing the care which we had declared could not work. Surely the only was he could survive is if someone could figure a new way to treat his condition - continuing to apply futile treatment surely would not work. And the painful thing to me after all the time, effort and money we put into the patient, and after how we accommodated the families wishes and did not force termination of care over two weeks ago, is that they refused an autopsy. And the reason for refusing an autopsy is that he had suffered enough - surely if the aim was to minimize suffering, we had
 been saying for weeks that treating him was just prolonging his suffering! Spouse did agree it was a selfish thing not to have the autopsy.

So at what expense? I know Michael has the "spend it or lose it" theory to health care economics but the reality is that patients like mine will cripple the system. His health bill I suspect will top 2 to 3 million dollars which in one way or the other is funded by the tax payer. I am happy that society bears the cost of expensive therapies if society agrees to provide them, however when it becomes futile at some point if the tax-payer is paying the tax-payer or their gate-keepers have to be able to stop the spending (and the family if they chose to continue should pay out of pocket for each day of futile or additional experimental therapy.

What have I learnt from this episode? Probably not much, except a bit about human behaviour. Will I change my bad ways? Sadly I suspect not. On Monday I put an IVAD into that 71 year old post MI patient who came to us with a BiVAD...he has died too. Only tonight I was asked if I would consider putting an LVAD into an octogenrian if money was not an issue - the family are willing to fund the treatment and donate a few million to the hospital in return...mmmm sounds enticing. May be I need therapy for addiction to the VAD - ventricular assisted death.

Ani

> Date: Mon, 6 Aug 2007 06:36:00 -0400> From: msfirst at gmail.com> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] Do you believe in miracles?> CC: > > Ani,> Obviously (I hope) that it the family were actually paying for the care then> the plug would have been pulled a long time ago. I have taken care of> several "million dollar babies" and like your few leave the hospital alive -> and of those that do, few survive long enough to have meaningful lives -> although some do. What is the equation 1 week of ICU = 1 month of rehab?> The problem with health care dollars in the country is that it is not like> the $1,000,000.00 that you spent prevented someone else from getting care or> by not spending that money it gets put into an envelope and sent to Africa> for AIDS/TB care. We have a use it or lose it mentality - or even worse -> the more you spent the more resources you get so that you can spend more.> Hospitals make tons of money on VAD patients (at
 least ours does, as I am> told). Is our VAD treatments any different then some of the futile care> given elsewhere? Until we actually live in a system were health care is in> fact rationed - then go for it. It is not wasted resources? (ok, getting> ready for the flaming arrows). The money that is being spent (wasted?) on> this one individual is paying salaries (RN, Rad Tech, yours, residents,> Thoratec's R&D people), allows your hospital to buy another CT scanner. It> all keeps the economy going - put bread on the table somewhere - keeps the> lights on. It is not like you are taking the cash out of starving children,> remember that is different dollars, and tossing it into a bonfire. In fact,> you can argue that your spending is more effiecient than elsewhere in the> economy. Yes, you probably make a nice salary as do many people in> healthcare (compared to the rest of the U.S. or the world for that matter) -> and you buy your Sony's your iPods your new
 cars, your new homes etc. It> can be argued that they are productive $$$ - not all going into some Paris> Hilton birthday bash or some Hamptons drink fest. Maybe this is all> Reaganomics speaking, but money has to keep moving to keep the economy> going. Besides, if you dont spend it, then it may get used to justify more> bombs in Iraq or other "futile" government activities.> > If your hospital is truely full 100% - then some bean counters can argued> something - but hey, let them come down to the bedside and tell the family> to pull the plug. You are giving them hope. At least you are trying, you> are caring - they probably sense that and when the time comes, the time with> come - or he may get better. My young advice, do what you can - support the> nurses and those at the bedside all of the time.> > Debride his wound at the bedside (or take him back) and put a VAC on> -remember the surgical motto - pus must pass. Who knows, cleaning up his> abdominal
 wound will help drain all of those evil humors. That is a low> cost easy intervention compared to everything else that you have done. In> for a yard, in for a mile - and the family wants the whole mile (remember> they have been paying taxes their entires lives, so in fact they have some> rights or entitlement?).> > Yes, at some point some fat cat Congressman who lives in Camelot and never> has (or had) to face these issues will start saying NO. Gee - where has> Bill Frist been all of these years??? But, until then - you are the one> facing the families at the bedside - do what you can and what YOU think is> right. Sure the GI docs say the liver is dead - but they always give up> before we do. We live on the fringe and experience things that no one else> dares.> > Go home and watch the movie "Miracle" (the story of the US 1980 Olympic> Hockey team) or "The Guardian" with Kevin Costner.> > -michael> > > > > > On 8/5/07, Ani Anyanwu
 <anianyanwu at hotmail.com> wrote:> >> > Michael> >> > Interesting reply which I found very reflective, somewhat saddening but a> > true reflection of the reality we are in today.> >> > Case wasn't futile as such but was a high-risk Heartmate XVE destination> > implant. Pre-operatively we had estimated a 30% chance of success - not> > excellent but a chance the patient and family wanted. However immediately> > post implant progressed into severe liver failure. Placed RVAD for a week> > but no effect. Since then was plagued by host of problems - persistent> > hyperbilirubinemia, coagulopathy from liver failure, renal failure on> > dialysis, major pulmonary haemorrhage requiring bronchial blockade on a> > number of occasions, questionable neurological status, usual ICU sepsis,> > ventilator dependency, and in last week pus coming out of his abdominal> > wound. He is now six weeks post op and despite VAD flows of 5 to 6 litres> > his mulit-organ failure has
 persisted. Many argued 3 weeks ago that we> > should withdraw but I only accepted to do so a week ago when his VAD pocket> > became infected - an untreatable condition in the current circumstance.> >> > Besides the ethical issues, there are economical ones. Hal raised> > something which we had discussed last week that if the family were paying> > for his daily care they would have accepted our advice and withdrawn care. I> > estimate would be that this hospitalization will cost $1 to 2 million and> > for each day we extend this futile care we are expending an additional> > $5,000 to $10,000 dollars. At that to the opportunity cost of his care in> > terms of resources lost to other patients (e.g. ICU beds, staff efforts,> > radiology slots etc) and also to the indirect costs acquired by family who> > lose income being at the bedside.> >> > Economic issues are such that this situation is ONLY sustainable in the> > United States. I have practiced medicine
 in 3 continents. In Africa, this> > kind of health care (if it were available) could only be funded by> > self-payment. However, I doubt anyone - no matter how rich - would spend 2> > million dollars of their own money on an effort to artificially sustain life> > which has a low chance of success and even if successful will only be> > shortlived. I suspect most would rather leave that money for their loved> > ones. In Europe I worked in a welfarist system where the health purchasers> > would not fund such an effort - they would rather use the money to pay for> > 500 hip replacements. If by chance you managed to operate on the patient, be> > sure care would have been withdrawn within the first post-op week, quoting> > prasanna's formula that 3 organ failure is 100% fatal. Even if it was not> > deemed fatal they would not invest the 2 or 3 months of intensive care> > required to bail the patient through - other patients need the bed and can> > use it more
 successfully like road accident victims, coronary bypass,> > esophagectomies etc. America is different though - because of a families> > insistence we spend spend and spend. I remember once we put an RVAD, LVAD> > and then ECMO and kept a dead patient 'alive' for a week just because the> > family insisted we cannot stop till everything was tried. Surely this is an> > unethical use of healthcare resources which even in the USA is not> > limitless. Such spending, together with medicolegal costs, are the biggest> > threats to US healthcare which is on the path to self-destruct as the> > current situation is unsustainable. This year alone I have personally placed> > 30 LVADs at such enormous cost and low yield and I suspect next year I could> > end up twice the number as the demand is there (for expensive treatments> > with low probability of success) and unwisely so, the insurers and Medicare> > are funding it. The truth is that it is becoming a right in
 North America to> > live forever.> > However, I believe as physicians that our duty to a dying patient includes> > a duty to the family for these final moments are ones that they will> > remember forever. Certainly I would never force a decision to withdraw on a> > family but will inform them of the futility. Some people need time to come> > in terms with their loss and as much as is possible we should grant that. In> > the US because patients believe the funds are limitless they sometimes take> > their time to accept.> >> > My reason for bringing this up was not to do with any decision I have made> > but to discuss the issue of what to do when all is hopeless and a family> > refuses to accept and whether we as doctors could actually be wrong one and> > subject patients to death when they could end up surviving.> >> > Ani> >> >> >> >> >> > > From: msfirst at gmail.com> Subject: Re: [HSF] Do you believe in miracles?>> > Date: Sun, 5 Aug 2007 11:00:23 -0400>
 To: OpenHeart-L at lists.hsforum.com>> > CC: > > Ani,> > Of course we all probably want to know the details of your> > case - > being a VAD guy (especially in NYC) the speciality is grounded on >> > hopeless, futile causes, when there is only maybe a glimmer of hope. > That> > is what we do - provide hope, when there is none - and when > everyone else> > has given up or there is "nothing else" that can be > done. The problem in> > your case is that you have gone down a path and > boxed yourself into a> > corner. Often we find ourselves in for yard > and in for a mile - just give> > us one more week and see if he or she > turns around. Yes, brain dead is> > brain dead - as Hal said - get an > EEG and nuke med study, etc. But, to> > answer your question - YES.> > I have only been in this for a few short time> > - compared to the > decades of experience that exist on this forum - but I> > have seen > futility walk out of a hospital. No, I have no seen brain
 dead >> > people survive, but - I have seen amazing cases of the human will and >> > spirit and things that science can not explain. I have seen patients > with> > systemic ICP for days walk out, horrific sepsis/infections > recover, I> > personally got on a bed to do CPR on a 20 year/old with > totally occluded> > PAs from a massive PE who was gray - not blue, but > gray for almost an hour> > walk out. I have seen paralyzed patients > walk, I have seen massive doses> > of air pumped into a brain from a > broken ECMO cannula walk out (and> > re-enroll in a major private > university).> > Ani - if we don't have hope> > and believe in things that we can not > understand, then who is going to> > fight the losing battles and > sometimes we win. Obviously the wife still> > wants to believe - give > her a break - afterall how many times have YOU> > convinced families to > go on when they had no hope, but you did (right or> > wrong and for > whatever reason).>
 > Yes, a good topic for a Sunday> > morning.> > good luck> > -michael> > > > > On Aug 5, 2007, at 10:10 AM, Ani> > Anyanwu wrote:> > > Some questions for a Sunday morning, lunchtime or night> > depending > > on where you are.> >> > I have a patient I am in the middle of> > an ethical dilemma with > > because I believe further treatment is futile> > but the family > > believes otherwise and is waiting for a miracle. I> > recommended we > > discontinue treatment a week ago but spouse wants to keep> > going. I > > have so far refused to undertake further surgery because I> > believe > > it is unethical as treatment will be futile, but we have> > continued > > to support him maximally - LVAD, Dialysis, Ventilator, big gun> > > > antibiotics and all. Spouse though is convinced he is neither dying > >> > nor dead, communicates with her everyday and will walk home. Other > >> > medical staff looking after him think he has been dead a while now > > - I> > was
 sort of the last man standing and only recently ceded that > > there was> > not more we (medical staff) could do as humans.> >> > So my questions are>> > >> > - Has anyone ever told a family that all is done and we need to > >> > withdraw support and then the patient subsequently walked home > > because> > the family wouldn't give up and insisted you continue > > treatment ?> >> >> > - Has anyone experienced a survival from an unsurvivable condition > > that> > could not be explained on scientific grounds i.e. a state that > > would> > be regarded as universally fatal and the patient survives and > > walks home> > (NOT a case were odds are low and patient survives > > against odds which we> > all have seen).> >> > Thank you> >> >> > Ani> >> > _________________________________________________________________> > 100's> > of Music vouchers to be won with MSN Music> >> > https://www.musicmashup.co.uk/ > >> >
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