The conversation between the doctor and patient, below, emphasizes that the ICD can reduce the risk of death. The other feature of the device, its contribution to prolonged dying from heart failure, is not made apparent. Rather, the conversation informs the patient’s way of thinking about desired ends -- in this case, an open-ended and non-symptomatic old age. This scenario resonates with the widespread cultural sensibility that medicine can almost miraculously restore health, despite advanced age and heart disease.
The cardiologist at a major medical clinic greeted Mr. and Mrs. Albert and said, “I want to talk to you about a defibrillator and a pacemaker. The question is whether you might benefit from an ICD with or without pacing of the heart all the time. The defibrillator is a special pacemaker that has the ability to shock the heart in a rhythm that would lead to death. It can be thought of as an insurance policy to prevent that kind of arrhythmia. Do we want to insure the cost – for something we may not need? It’s a balance that needs to be thought of in that way, because it’s hard to predict which individuals will actually benefit from the device.”
“Really,” he continued, “that’s all the defibrillator is. It’s not going to make you feel better. In fact, sometimes, it gives inappropriate shocks when it doesn’t need to. It’s extremely painful. Also, there’s risk of infection. So, it’s that type of decision.”
The physician then offered an additional procedure because there is newer technology that might benefit the patient. The newer, resynchronizer pacer (CRT) could improve the symptoms of Mr. Albert’s advancing heart failure. The doctor continued, “If we decide to do the ICD, should we do a more extensive procedure at the same time? Putting in an extra lead in the heart, to better synchronize the two chambers. It is a more complex procedure. We have to inject dye in the heart, go into a small vein. The cardiac resynchronizer is designed to make you feel better. The problem is, we don’t know who will feel better. About two-thirds of patients will feel better; but one-third won’t. So, you could undergo the surgery, and not feel better.” Though he clearly invoked the range of technological options, he did not paint an unduly rosy picture.
The patient and his wife asked: Is it worth it when you’re in your 80s? What would you do? And of course it was impossible for the doctor to answer definitively. After more discussion, the doctor summarized the rather complex decision tree the patient now faced. He said, “There are two possibilities. First, the defibrillator—you do qualify for it. You are eligible.” This language is used repeatedly, and it is important. The physician is referring to the fact that the patient’s medical condition fits both the clinical trial evidence for a good outcome and the Medicare reimbursement criteria developed from the clinical trials data. To the patient, however, this language sounds as though he has won something in publisher’s sweepstakes, in a lottery. That language contributes to the desire and obligation to accept. “Second,” the doctor noted, “we could go for the ICD and the resynchronizer, in hopes of making you feel better in terms of symptoms. But this is an unknown.”
He concluded, “Considering your risk, it would be appropriate to buy the insurance. It’s not black and white. I’m not the one who is paying the premium, having to live with infections, shocks, etc. I do think it might benefit you, that’s why we are offering it.” Mr. Albert’s reply is a common one. It is based on the clinical expectation that the symptoms of heart failure in later life can be reduced, and on the societal expectation that the signs of aging can be pushed farther away (or even made to disappear) by medical technique. This physician’s clear recommendation shapes the patient’s desire and influences his choice. Mr. Albert replied, “I’m wearing out. Things are degenerating, deteriorating. That’s why I’m here. I think I should have it.” Having given his consent, the doctor scheduled the procedure.
The availability of the device organizes the ways in which life planning strategies based on risk awareness and prevention are embodied and lived. As we see in this clinical encounter, conversations between patients and physicians reflect back to patients their own hopes for the regeneration and continued health of the body/self. Those hopes are bolstered by widespread assumptions that one can both ‘add time’ and reduce or eliminate senescence through biotechniques. This case illustrates how physicians offer and recommend interventions for which patients are considered ‘eligible’ and ‘appropriate,’ according to the results of clinical trial data which document survival benefit, but for patients mostly between ages 60 and 70 (Myerburg, 2008
) and then according to Medicare reimbursement criteria. Those data and criteria are persuasive reasons for patients and families to want and thus ‘choose’ the full range of capabilities that a device currently carries. Those criteria set aside the value question about the actual existential worth of these technologies to persons in late life.
Similar to other technologies, the device enables many to assume that “growing older without aging” (Katz & Marshall, 2003
) is possible, indeed, normal, via the right medical procedures. Because medicine has contributed so powerfully to cultural assumptions about the malleability of the body and the promise for better health into late life (Rose, 2007
) patients expect these technologies to make them ‘feel like themselves,’ that is, to feel the way they did prior to the worsening of their disease (Shim, Russ, & Kaufman, 2007
). There is no natural end point for these aspirations. The fact and inevitability of their eventual failure is not acknowledged.
Importantly, these devices do not ‘act’ alone (Mol, 2008
). Together, the availability and use of more clinical options at ever older ages, their proven efficacy for certain populations in reducing symptoms and pushing back mortality, the subsequent need for physicians to offer what has become routinized as ‘best’ in terms of mortality reduction, and the expanded clinical goals that result – to treat increasing heart failure and risk of death with the best and usually newest tools available for as long as possible – promote the notion that the corporeal symptoms of aging and decline can be treated always
). That notion is not as pervasive in European countries (although the situation there is changing [see, for example Heath, 2010
]), where state-mandated limitations to health care resources are more robust than in the US. (Fairfield, 2010
The ironic feature of the device is not yet apparent to Mr. Albert because the topic of prolonging advanced heart failure is not mentioned. In addition, Mr. Albert is not (yet) aware of what other research has revealed (Pollock 2008
) – that some persons with ICDs become acutely aware of how they will not die, that “terror” is frequently associated with receiving a shock and that there is fear of receiving multiple shocks and then dying. In short, we do not know if Mr. Albert will experience a feeling of the foreshadowing of death and if the fact that he is over 80 matters in that regard. We do not know, also, to what extent the device will extend his time of living with increasing heart failure.
Like Mr. Albert, a growing number of older individuals who receive these devices are enabled to live with progressive heart failure. They then may become candidates for even more complex implantable therapies – such as the left ventricular assist device (LVAD), a mechanical pump that enables a severely weakened heart to pump blood through the body. Increased use of the ICD as ordinary, standard treatment to stave off death paves the way for more practitioners and patients to consider treating end-stage heart failure later, with even more invasive and powerful devices that have the ability both to extend life and prolong dying.