I recently received and read with great interest a book entitled “Heart: An American Medical Odyssey”, co-authored by former American Vice-President Dick Cheney and his cardiologist, Dr. Jonathan Reiner.
In it, they provide both patient and physician perspectives on Mr. Cheney’s longstanding struggles with coronary artery disease, an illness that began with a myocardial infarction in 1978 at age 37, and progressed steadily through the years with several further infarctions, multiple cardiac catheterizations and angioplasties, stenting, coronary bypass grafting, recurring atrial and ventricular arrhythmias, implantation of a cardioverter-defibrillator, endovascular stenting and vigorous application of all available medical preventative therapies. Despite all this, Cheney developed progressive cardiac damage and heart failure refractory to medications, eventually resulting in implantation of a left ventricular assist device, followed by cardiac transplantation, all of which appears to have been very successful in restoring him to good health.
Remarkably, most of this illness and treatment occurred while Mr. Cheney held positions of considerable responsibility and public trust over a 30 year political career, including serving as a Congressman, Secretary of Defense and Vice-President in the Administration of President George W. Bush.
Their book therefore provides a remarkable account of the numerous medical and technologic advances that have occurred within a generation and provide patients with this very common condition so much hope for more quality and length of life. It also provides, particularly for students, a rather touching example of a very effective patient-physician relationship and how a skilled and caring practitioner is able to advocate and guide his/her patient through the myriad of emerging options as they become available.
However, Mr. Cheney was far from the average patient. Access to immediate state-of-the-art care was simply not an issue for him. The book describes several episodes when he would be whisked away immediately by his support staff to hospitals where numerous highly skilled physicians were waiting to provide care. He also had access to very efficient care at his place of work, where numerous specialists would often convene to advise as to various options available to him. He was offered every therapeutic advance, and had the advantage of the counsel and care of leaders (often pioneers) of each of those advances. In short, his story provides an illuminating and somewhat utopian example of what’s possible in the absence of the practical barriers most of our patients encounter.
All this can seem rather distressing to patients and practitioners who struggle with various economic and social access issues in order to take advantage of even standard care. Perhaps most distressingly is the issue of cardiac transplantation, the treatment that effectively reversed what would have been the natural end of Mr. Cheney’s long struggle. Although highly effective, cardiac transplantation is a very limited resource.
As I reflected on all this, discussed it with colleagues and friends, and surveyed the internet for reactions, I experienced and encountered very mixed feelings. The optimism and “good news” of Mr. Cheney’s story was counterbalanced with a vague sense of unease. To many, it seems, the application of so much effort and resource to a single individual seems somehow unjust, unfair, and counter to some very Canadian values of universal and equal access to care. Somewhat distressingly, there appeared to be an undercurrent of resentment fueled by the fact that Mr. Cheney is a very polarizing figure who’s persona is, shall we say, somewhat unsympathetic. Certainly his experience has fueled the popular media that has taken umbrage and humour at his expense. I suspect Dr. Reiner has also come under some criticism from colleagues in the medical community. In the book, he provides a particularly poignant account of an interaction with a colleague who appeared to question the vigour with which he was pursuing end stage treatments for his patient.
It seems that this story provokes a visceral reaction in all of us. For late night television hosts and the general public, this is a source of speculation and casual amusement. But for physicians, it holds much greater significance. It forces us to examine how we engage care on an individual level, particularly when confronted with “special” patients. Advocacy is one of the most difficult lessons for medical students. Its application to the disadvantaged is easy to understand. The appropriate advocacy role for the patient who is demanding, unsympathetic and has the means to access above standard care is more complex and difficult. Was Mr. Cheney’s care “reasonable”, particularly given the large number of Americans without access to even basic care? Did he “jump the queue”? How was he considered worthy of this new lease on life? Was he simply too old, and should this option be reserved for younger patients? Most importantly, should any of these considerations influence the care we provide any individual patient we encounter.
When confronted with such profound and emotionally charged questions, I’ve found it always helpful to return to the facts.
In Canada, the Heart and Stroke Foundation estimates the number of Canadians living with Heart Failure to be about 500,000, with about 50,000 new cases emerging per year (http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483991/k.34A8/Statistics.htm). The annual mortality rate for patients with heart failure is about 10% with about 50% of patients surviving 5 years. The same report indicates that 167 cardiac transplants were carried out in 2010. The major limitation, of course, is the availability of donor hearts, which remains very limited despite high profile campaigns to promote public awareness and expedite the transplantation process, summarized nicely in a June 2009 Parliamentary Report (http://www.parl.gc.ca/Content/LOP/researchpublications/prb0824-e.pdf). The survival rate after cardiac transplantation was recently reported by Dr. Marc Ruel at the Canadian Cardiovascular Congress to be 86% at one year and 75% at 5 years (http://www.theglobeandmail.com/life/health-and-fitness/heart-transplant-survival-rates-improve-study/article558645/). This figure is consistent with the experience of most Canadian and American transplant centres.
It appears, then, that we have a highly effective, but also very limited therapy that will never be adequate to the potential demand. The situation in the United States will feature larger volumes but likely very similar proportions and restrictions. In both countries the access to cardiac transplantation is a highly regulated and understandably controversial process.
What does our society have to say on this issue?
- A comprehensive and excellent consensus document by Dr. Heather Ross and colleagues provides standards guiding the application of cardiac transplantation in Canada (Canadian Journal of Cardiology 2003;19:621). With regard to use of transplantation for patients with end stage coronary disease, the document states:
“Patients with severe coronary artery disease (CAD), although it is an uncommon indication for transplantation, may beconsidered for cardiac transplantation if they experience Canadian Cardiovascular Society class IV symptoms not amenable to high risk revascularization and in whom maximal medical therapy has failed.”
Mr. Cheney would therefore certainly have met our Canadian criteria for cardiac transplantation.
- Mr. Cheney had no condition that would disqualify him from consideration for transplantation. Although he had many medical problems, they all related to his diseased heart. In other words, he had no other life limiting issues.
- According to all accounts, Mr. Cheney and his physicians utilized the standard referral processes available to them, through the United National Organ Sharing (UNOS) registry. He waited 20 months for his transplantation, existing on a mechanical, externally driven assist device during that time. This waiting time is reported to be longer than average.
- According to UNOS, 332 people over the age of 65 received a cardiac transplantation in 2011. To put that figure in perspective, approximately 2300 cardiac transplants are carried out annually in the US. Dick Cheney was 72 at the time of his transplantation.
In addition, public figures like Mr. Cheney must necessarily live their lives under intense scrutiny. As noted previously, his medical issues become public knowledge and the fodder for late night television hosts. He also had to deal with his illness while undertaking major public responsibilities with their attendant stresses, and under continuing public scrutiny, which could be quite cruel (as depicted) and eliminated any possibility of privacy and continually questioned his competence. Admittedly, all this was undertaken with full knowledge and consent.
It appears, then, that Mr. Cheney received a therapy for which he was qualified and for which he engaged a standard and well controlled process. His physician, Dr. Reiner, provided excellent support, directing him to therapies available to him and ensured he gained maximal value from them. I’ve no doubt that he provides similar efforts to the care of all his patients, even those for whom therapy might not be so immediately available for reasons beyond his or their control. We should strive for no less for all our patients.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education