Medicine of the Future in America

The Paradox of High-Tech Health Care: Ethical Dilemmas in High-Tech Health Care

More subtle, perhaps, is the application of the most intensive forms of health care treatment modalities to patients with diseases for whom we clearly know the prognosis is hopeless. For example, patients in their 70s and 80s with a ruptured abdominal aneurysm, renal shutdown, and shock have had almost a 100 percent fatality rate with operation, yet any patient who comes into the emergency room with this diagnosis usually receives the ultimate in intensive care, the most intensive operative intervention, long-term respirator therapy, and costly hospitalization. Will younger patients with more salvageable disease and better long-term prognosis, as acutely ill, go untreated because facilities are lacking in a particular facility, having treated the hopeless older patient?

Prolonging hopeless cases is, of course, often related to defensive medicine, that is, those tests and procedures that physicians and hospitals perforin in lieu of making reasonable judgments about patients for fear they will be liable for legal action at some later date. This insidious concept is probably responsible for untold billions of dollars of wasted and needless medical, laboratory and clinical services that unfortunately escalate the cost of health care. natural breast enhancement
No greater ethical dilemma exists in medicine today than the fact that we in the United States are facing an increasingly elderly population, in their 70s and 80s, who desire to live as long as possible and who have a variety of maladies requiring high-tech medical and surgical care. The reason Medicare has predicted financial difficulties is the unexpected number of 70-and 80-year-olds requiring this kind of care, obviously totally unpredicted in 1966, when the Medicare bill was signed. For example, Table 1 shows the number of coronary bypass patients older than 70 years operated on at the Brigham and Womens Hospital this past calendar year, five years ago, and ten years ago. Note that the incidence is 4 percent from 1973 to 1979, 19 percent for 1980-86, and 29 percent for calendar year 1986. Naturally, there is a concomitant increase in operative mortality, stroke, respirator dependency, etc, in this age group. In Table 2 are projected figures for the percentage of elderly of the US population in the next 60 years. In Table 3 is the utilization of high-tech care modalities for elderly patients. Regardless of costs, can we deny patients in this age group the right, for example, to have coronary bypass surgery when they are otherwise reasonably healthy and might profit from a few pain-free years?
Table 1—CABG-BWH

Years Total <70, % >70, %
1973-79 1,562 1,495 (96) 67 (4)
1980-86 3,694 3,006 (81) 688 (19)
1986 637 455 (71) 182 (29)

Table 2—Growth of the Older Population: 1980-2050 (Numbers in Thousands)

Year Total Population, All Ages 65 Years and Over
No. %
1980 226,505 25,544 11.3
1990 249,731 31,799 12.7
2000 267,990 35,036 13.1
2010 283,141 39,269 13.9
2020 296,339 51,386 17.3
2030 304,330 64,345 21.1
2040 307,952 66,643 21.6
2050 308,856 67,061 21.7

Table 3—Utilization of Life-Sustaining Technologies for Patients of AU Ages and for Elderly Patients in AU Settings

Technology Total No. of Patients, All Ages Patients over 65
No. %of Total
Dialysis* 90,621 27,641 31
Resuscitation 370,000-750,000 204,000-413,000 55 est.
Mechanicalventilation 3,775t-6,575 l,250t-2,200§|| 34
Nutritionalsupportf 1,404,500 680,000 48 est.
Enteral (tube) 848,100 450,000 53 est.
Parenteral (IV) 556,400 230,000 40 est.
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