The clinical term is “air hunger.” This is not as descriptive as “drowning on the inside”which is what folks say it feels like after they have been made symptom-free. When you see folks initially, they are wide eyed, gasping for breath, with a panic in their face that must be the reflection of Death.
The human body is marvelously designed, but when things go wrong, things go very wrong. Having a failing heart is one of those “very wrong” experiences. Pumping about 5 liters (1 1/2 gallons) out into the body every minute, the heart must collect 5 liters from the body, pump 5 liters into the lungs, and then collect 5 liters from the lungs every minute. If you only collect 4 liters from the lungs, after about 5 minutes your lungs will be filled up with a gallon of water. The clinical term is heart failure but the sensation is very similar to drowning.
The heart is fed by 2 main arteries, one of which splits into about 3 more. Heart failure is a disease that occurs not all at once but generally following the blockage of several of those arteries over time. Most people already know that heavy smoking contributes to heart failure. Not dying of your heart attack all at once is also helpful, as it gives the heart failure time to take hold. The 911 system, which works best for heart attack victims, may actually have contributed to the increase in heart failure in the US.
This brings us to Vice President Cheney. As you may or may not be aware, he had a heart transplant yesterday. We were all made aware of his long history of heart disease, beginning at age 37 and fueled by family history and a 3 pack-per-day cigarette habit. After his initial blockage, he had multiple interventions (some of which have been proven to do more harm than good) culminating in the use of a Left Ventricular Assist Device as a bridge for these 20 months until a donor heart was located. The bill for the transplant is likely to come in at just under $1,000,000, likely putting the former Vice President in the top 1% of health care utilizers for the third year in a row.
Although this procedure is covered by Medicare, it is unusual for older Medicare recipients to get one. The outcomes are no different in 60-year-olds than they are in 70-year-olds, but some feel that hearts taken from accident victims and such (a scarce resource) should be reserved for younger people. Some, such as the Arizona legislature, are against public funding for certain organ transplants, at least for the poor.
Almost 300,000 die of congestive heart failure annually, many of whom are Medicare eligible. It is my hope that this starts a conversation around the wise use of resources. Can we and should we use public resources more wisely? In discussing a related issue involving heart failure, the AMA Journal of Ethics had this to say:
We implanted almost 200,000 cardiac defibrillators (ICDs) at $40,000 each with the intention of preventing fatal cardiac arrhythmias. Does it matter that 81 percent of them never fired over a 5-year period, at which time a battery would have to be replaced for $20,000 ? Does that represent a wasteful use of health resources? We have a test that can identify with 98.7 percent accuracy who among these potential ICD recipients will not have a fatal arrhythmia over the next 2 years. We could save $2 billion per year by using that test. But getting it wrong 1.3 percent of the time represents 800 lives that would be lost each year. How should we assess that outcome, morally speaking? Does that represent a morally objectionable “pricing of human life”?
Perhaps Vice President Cheney had a rare medical condition that made him one of the 300 people to qualify for a Medicare-funded transplant after the age of 70. Perhaps he elected to spend several million dollars of his own money after opting out of Medicare and he was able to use a heart unfit for a younger man. I hope he will be forthcoming about the details of this process. If so, when I counsel my older patients who have intractable heart failure, we might be able to frame the conversation as follows: “What would Dick Do?”