Medical Ethics: Should Older Patients with Heart and Kidney Failure Be Left to Die?

Older patients with heart and kidney failure can be helped with cardiac resynchronization therapy, a new study finds. But implanting devices to treat them is expensive, invasive, and not a full cure for many patients. Maybe it's better to ask these patients if they wouldn't rather die, two physicians argue.

Older heart failure (HF) patients often also have chronic kidney disease (CKD).

These HF patients are less likely than peers to benefit from new neuro-hormonal regulating drugs. But there is more that can be done for them.

Reporting in the Journal of the American College of Cardiology, Daniel J. Friedman, MD of Duke University Hospital, Durham, NC and colleagues there and at other institutions said these comorbid patients could benefit from an under-used therapy: cardiac resynchronization therapy (CRT) with defibrillator (CRT-D).

But in an accompanying editorial, two UK physicians said it would often be better, cheaper, and easier to let these patients die.

In the study, a nationally representative population of HF and CRT-eligible patients, use of CRT-D was “associated with a significantly lower risk of the composite endpoint of HF hospitalization or death” in these patients, they concluded.

To date most studies on the effectiveness of CRT-D have not focused on this subset of patients.

The team looked at Medicare data on patients with moderate to severe CKD--about 60% of Medicare HF patients, they found..

They determined that 31, 2009 patients met their criteria for getting CRT.

They were interested in seeing whether those who received CRT-D got better results than those who simply got an implanted defibrillator.

Baseline covariates among patients in both groups were about equal, they said.

Among their findings, the team learned that the decision on which therapy to use appeared not to be related to the severity of the patient’s CKD, but was based on other factors: whether the implanting physician was an electrophysiologist, whether the physician’s hospital had a relatively high volume of CRT implants, and was also based on the patients' heart symptoms like left bundle branch block, and longer QRS durations.

Race appeared to play a role, with non-white patients less likely to get CRT-D.

The patients who did get CRT-D clearly benefited. The use of CRT-D was associated with a lower 3-year incidence of HF hospitalization or death (57% vs. 45%) but not progression to end-stage kidney disease.

The authors concluded that randomized controlled studies should be done to see if their findings stand up.

Current guidelines do not make a specific recommendation on when patients with CKD and HF should get CRT-D.

Maybe older patients should not choose that option, two UK physicians said.

Commenting in an editorial, John Cleland, MD, PhD, of Imperial College, London, UK, and Yura Mareev, MD,PhD, of Royal Brompton Hospital, also in London, agreed that CRT-D does indeed appear to be underused in the US.

They also agreed the therapy reduces hospitalization for HF and death by 15% to 20% in the co-morbid patients in the study, an effect the editorial writers called “modest.”

But they question whether the expense of extending life in these patients is worth it.

“Rather than implanting, at some risk and discomfort, an expensive piece of technology, which may be attended by substantial morbidity, that may prolong death rather than prolong life, is it not better to have a frank discussion with the patient about the limits of modern medicine?,” they wrote.

They note that 61% of the end-stage renal disease patients who got an implanted defibrillator died within three years, as did 54% of similar patients who got CRT-D.

The editorial writers also cited a study showing that physician-assisted suicide is an increasingly popular option in some Western European nations where “up to 1 in every deaths is now physician-assisted at the patient’s request.”

That study “Euthanasia in Belgium and the Netherlands: on a slippery slope?” was published in JAMA Internal Medicine last month.