April, 2012

Heart of Darkness

By Michael J. Katin, MD

March didn't seem to go out as a lamb or a lion, but more like a pushmepullyou , without resolution of any of the critical issues of this year. Fighting was still going on in Syria, tactics were still unsuccessful in having Iran open up its nuclear development plans, and the Republican presidential candidate had still not been determined. It seemed the only exception was the completion of Lindsay Lohan's probation, which occurred on March 29 -- sort of.

The most controversial continuing epic is the fate of the increasingly inappropriately named Affordable Care Act. Oral arguments were presented to the Supreme Court t on March 26, 27, and 28, and on March 30 the Justices met and decided the fate of the individual mandate and the decision on severability . In June, the vote will be announced. This interval of eight to ten weeks is intended to represent the length of time it will take to get a CBC result once the new system is fully implemented. If the Affordable Care Act is found to be partially or entirely unconstitutional, the medical profession will be able to move on. Well, not exactly. Almost regardless of the outcome, the future is unsettled -- and trying to run a medical practice on a shifting base of regulations and restrictions is not conducive to maintaining sanity (or fiscal viability). {QUESTION: What happens to the Supreme Court's decision if one of the Justices passes away between the time of the vote March 30 and the announcement in June?}

Just several days before the Supreme Court received the case regarding the Affordable Care Act, it was announced that, only 14.43 miles away, former Vice-President Richard Bruce "Dick" Cheney had undergone a heart transplant. This was done at Inova Fairfax Hospital in Falls Church, Virginia. It appears that Mr. Cheney is doing well, having waited 20 months on the transplant recipient list. Compassion , for Mr. Cheney's situation was somewhat muted, as multiple media outlets immediately questioned whether Mr. Cheney, at age 71, was worthy of receiving a transplanted heart and, of course, whether the expense involved in this could best have been expended elsewhere. It appears that the upper age limit for receiving a heart transplant used to be 55 and has been raised as techniques and survival have improved. Strictly speaking, Mr. Cheney would have been 69 years old when he was placed onto the recipient list but was close to the age of 70 that we seem to hear as an unofficial cut-off at which aggressive patient care should be administered without question.

Age 70 is accompanied by minimal restrictions ( inability to rent a car in Cyprus and Malta and needing to start withdrawals from an IRA after age 70 1/2) in the real world and should be an arbitrary landmark for medical care. Unfortunately, as efforts increase to contain medical costs , the increasing population of older Americans is at risk of being targeted for reductions in services,.based, allegedly, on rigorous scientific data

Certainly at the age of 25 most of us would have thought the premises of " Logan's Run " or " Soylent Green " were reasonable, but, for some strange reason, perspectives change as years go on. The biggest motion picture of March involved sacrificing teenagers for the good of the public -- or hasn't that already happened every time there was a war? Now ages 65, 70, or 75 don't seem to be as advanced as they used to seem. We find ourselves taking special notice not of child prodigies but of people who can accomplish things at a later age. Certainly at age 71 Mr. Cheney is not too elderly to participate in many activities , let alone having a heart transplant.

In fact, historically, political figures have undergone complicated and expensive medical procedures. In 1881, President James A. Garfield was shot by Charles Guiteau and died eighty days later, after multiple interventions . The government was billed $85,000 for his medical care, in a year in which the average salary was $16 a week . Woodrow Wilson was incapacitated by a stroke in 1919, at age 63, and remained in office for another 1.5 years and died 4.5 years after the stroke, requiring continuous medical care. Dwight Eisenhower had treatment for a myocardial infarction and ileitis while in office, and Ronald Reagan had two cancer operations in his 70's, while President. Last year former President Jimmy Carter, nearly 86 years old at the time, had what must have been a very expensive stay at the MetroHealth Medical Center in Cleveland when he was admitted because of a "viral illness" while on a book signing tour. Topping the list, however, would be that 93-year-old Gerald Ford had placement of a pacemaker on August 21, 2006, at the Mayo Clinic, and then had angioplasty on August 25. He passed away December 26 of that year and definitely did not put the "ford" in "affordable care." Perhaps at least there was some resale value for a slightly used 2006 Ford Pacemaker

Regardless of efforts to form multispecialty groups , it seems improbable that decisions against approving heart transplants would have a big impact on a radiation oncology practice, but it seems obvious that, despite historical precedent the groundwork is being established to discourage aggressive treatment of older adults for all illnesses. This is not a good situation. The median age for a woman to be diagnosed with breast cancer is 61, and 21.1 per cent of cases are diagnosed in women over 75 years old, representing approximately 48,600 persons. The median age for diagnosis of prostate cancer is 60, with 22.3 per cent diagnosed in men over 75 years old , making up approximately 59,000 individuals per year. The ramifications are obvious This new attitude is evolving despite the fact that, thanks to progress in health awareness and medical care, the life expectancy in the United States for a 65-year-old man is 17.2 years and for a woman is 19.9 years, at for a 75-year old man is 10.6 years and for a woman is 12.5 years . It will therefore take some effort to promulgate the effort that caring for these people is not worth it to society, but, with enough determination, these numbers may finally be able to be reduced.

But in the meantime, Dick Cheney got past the barriers and was able to get his procedure performed. Will he now be reinvigorated to be able to get back into action to run companies to destroy the environment , to bag one or two more campaign donors , or even to start another war based on spurious grounds? Not at all.

When Mr. Cheney awoke and found out he had a heart -- he changed his party registration from Republican to Democrat.