Monday, 5 June 2017

Life quantity or more quality?

Ventricular assisting devices, VAD, or LVAD if for the left ventricle (the most common) are implantable instruments that help pump blood in situations where ventricular ejection force is severely compromised. In some cases the implantation of an LVAD facilitates the waiting for a cardiac transplant, but in others it’s adopted as a definitive solution. The price of the device is around $150,000 while the cost per QALY (cost per year of life earned) is between $200,000 and $400,000. The cost-effectiveness studies still don’t line up much, but the range of documented amounts is nowadays far above the $30,000 of Spanish per capita income. Remember that the WHO introduced the criterion of considering if a treatment is cost-effective when it doesn’t exceed three times the per capita income of a country.

Regarding LVAD implantation in people with end-of-life heart failure, Health Affairs has published the case of Richard and Brenda in the Narrative Matters section. According to the authors of the article, when doctors asked Richard about the possibility of an LVAD device, as a last resort to lengthen his life in exchange for accepting the probability of some complications, he and his wife did not hesitate: they wanted to fight, they wanted to do everything they could, but then followed a very difficult time for Richard and also for Brenda with eight hospitalizations in six months, which included two additional interventions for device replacements due to clogging, vocal cord paralysis caused by intubations and various subcutaneous infections. Finally, Richard did not get past a long, recurrent and painful postoperative.

According to one study, 52% of cardiologists, at least in the US, are reluctant to raise the alternative of palliative care in patients with advanced heart failure. For these professionals, offering palliative medicine is tantamount to admitting the loss of hope. The authors of the article, after Richard's death, asked Brenda whether, despite the ordeal they experienced in the last months of her husband, she thought they would decide the same thing again. She replied that they probably would, because the struggle for life is instinctive, and the device (which ended up being three) that the cardiologists earnestly proposed to them, was for them something to hold on to.

Richard's doctors (probably among those 52% reluctant to palliative medicine) posed the patient and his wife a dilemma between acting (hope) or doing nothing (hopelessness). Those cardiologists did not realize, and probably don’t yet know, that this is an inappropriate (even unfair) dialectic for the real expectations of people with advanced heart failure.

To overcome the risk of disproportionate actions in poor prognosis processes, professionals must know how to open the palliative option as soon as possible, and therefore the alternatives they must show patients, must be sincere: choosing between more quantity or more quality of life, because let’s face it, these options are incompatible, even though a study (in the field of oncology) showed that people who chose more quality of life ended up, surprisingly, living more.

If you are interested in the advancement of palliative medicine, don’t miss the article signed by two internists from the University of Pittsburgh (Schenker Y, Arnold R.) "The next era of palliative care" published in JAMA.

Jordi Varela

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