Medical ethics collides with public policy: LVAD for a patient with leukemia.

There is a general perception that too much money is being spent on health care, and that costs are rising too rapidly. One source of the problem is believed by some to be the widespread use of expensive technologies, and this logically leads to a potential solution: get physicians to stop using such technologies. Obvious targets are cardiothoracic surgeons who have access to a substantial number of expensive technologies and a substantial number of patients to use them on. To highlight some of the issues underlying the question of whether utilizing such technologies is justified, a case was constructed to illustrate the use of an expensive technology in a marginal clinical situation: a left ventricular assist device (LVAD) implanted in an older man with leukemia and an uncertain prognosis. To argue the question of whether or not the procedure was warranted, we recruited two outstanding proponents of differing views: Dr Patrick McCarthy, a cardiac surgeon who has broad experience with LVADs, and former Governor Richard Lamm of Colorado, one of the few public figures audacious enough to use the word “rationing” publicly. They presented their viewpoints at the Forty-first Annual Meeting of The Society of Thoracic Surgeons. The case that served as the focal point of their discussion is detailed as follows. A 62-year-old male carpenter, Mr I. Sandy Wood, noticed that he was tiring much earlier in the day than he had just a few weeks before, and that the frequent small cuts he received at work bled much longer than in the past. His family doctor ordered a battery of laboratory tests that revealed acute myelogenous leukemia. Echocardiogram at that time was normal, with a left ventricular ejection fraction of 63%. He was told that the chance of ultimately curing his acute myelogenous leukemia with appropriate chemotherapy was about 40%, and that nearly all relapses occur within 2 years of treatment. He underwent a full course of chemotherapy, including both cytosine arabinoside and idarubicin for induction, later followed at 3 and 5 months by consolidation courses of high-dose cytosine arabinoside. Aside from nausea and fatigue during chemotherapy, he did well. Five months after the end of chemotherapy, Mr Wood noticed increasing shortness of breath, generalized weakness, and ankle edema. An echocardiogram demonstrated a left ventricular ejection fraction of 19% and cardiac catheterization showed mild obstruction (25%) of the left anterior descending artery. Endomyocardial biopsy showed damage consistent with idarubicin-induced cardiomyopathy. Medical management included appropriate doses of an ACE inhibitor, beta-blocker, loop diuretic, spironolactone, and digoxin. Despite intensive outpatient management, his dyspnea and edema continued to worsen, and he became dyspneic at rest. He was hospitalized 3 times during a 4-month period, requiring intravenous inotropic support and highdose intravenous diuretics. During his third hospitalization, he failed to respond to intravenous drug therapy, and a repeat echocardiogram demonstrated an ejection fraction of 10%. He was deemed not to be a candidate for heart transplantation because of his recently active leukemia. Because he appeared unlikely to survive for more than a few weeks, he was evaluated as a candidate for support with a left ventricular assist device (LVAD) as destination therapy, was found to meet the criteria for support, and underwent placement of a HeartMate LVAD.