10 Controversial Medical Questions Answered by Dr. Dalrymple
Where do you stand on these challenging ethical and scientific debates?
March 15, 2014 - 8:00 am
From November 2012:
5. As life expectancy increases will the elderly become too much of a burden on society?
Eighty really is the new 70…
At dinner the other night, a cardiologist spoke of the economic burden on modern society of the elderly. This, he said, could only increase as life expectancy improved.
I was not sure that he was right, and not merely because I am now fast approaching old age and do not like to consider myself (yet) a burden on or to society. A very large percentage of a person’s lifetime medical costs arise in the last six years of his life; and, after all, a person only dies once. Besides, and more importantly, it is clear that active old age is much more common than it once was. Eighty really is the new seventy, seventy the new sixty, and so forth. It is far from clear that the number of years of disabled or dependent life are increasing just because life expectancy is increasing.
There used to be a similar pessimism about cardiopulmonary resuscitation. What was the point of trying to restart the heart of someone whose heart had stopped if a) the chances of success were not very great, b) they were likely soon to have another cardiac arrest and so their long-term survival rate was low and c) even when restarted, the person whose heart it was would live burdened with neurological deficits caused by a period of hypoxia (low oxygen)?
A paper in the New England Journal of Medicine examines the question of whether rates of survival of cardiopulmonary resuscitation have improved over the last years and, if so, whether the patients who are resuscitated have a better neurological outcome.
The authors entered 84,625 episodes of cardiac arrest (either complete asystole or ventricular tachycardia) among in-patients in 374 hospitals in their study, which covered the years 2000 to 2009. They found that, between those two years, the rate of survival to discharge from the hospital for patients who had been resuscitated increased from 13.7 to 22.3 percent. This improvement was very unlikely to have been by chance alone. Moreover, the percentage of those who left the hospital with clinically significant neurological impairment as a result of their cardiac arrest decreased from 32.9 percent in 2000 to 28.1 percent in 2009. Extrapolating to figures in the United States as a whole, where there are about 200,000 cardiac arrests per year among hospital in-patients, the authors estimate that 17,200 extra patients survived to discharge in 2009 compared to 2000, and 13,000 extra with no significant neurological disability – if, that is, the 384 hospitals were representative of U.S. hospitals as a whole, which they may not have been.
Of course, it is usually possible to extract pessimistic data from the most optimistic data. The study could have emphasized that, thanks to improvement in cardiopulmonary resuscitation, 4,200 extra patients with significant neurological disability were being discharged from hospitals annually, a burden, as the dinner guest would have put it, on society.
In addition, only 22.3 percent of patients given CPR survived to discharge while 54.1 percent responded initially to it. This means that in 2009, 31.8 percent of patients resuscitated died in the hospital after initial success; in 2000, the figure had been only 29.0 percent. Presumably patients who responded initially to resuscitation but subsequently died used up a lot of expensive resources in the meantime.
The authors are cautiously optimistic. They admit that the improvement might have been due to something other than better technique of CPR: a change in the nature of the patients having it, for example. Nevertheless, these results are more encouraging than those of a previous study, which showed no improvement in survival of CPR patients in the Medicare system between 1992 and 2005.