June 16th, 2011
Case Study: Advanced Heart Failure in a Prison Inmate
Tariq Ahmad, MD, MPH and James Fang, MD
A 37-year-old prisoner with end-stage nonischemic cardiomyopathy was transferred from a local county hospital to a tertiary care center for heart failure therapy. Soon after his arrival, he developed ventricular tachycardia and cardiogenic shock. He was sent urgently to the cardiac catheterization laboratory, where he underwent placement of an intra-aortic balloon pump (IABP). Right-heart catheterization, on dobutamine and IABP therapy, revealed:
- right-atrial pressure, 15 mm Hg
- pulmonary-artery pressure, 50/33 mm Hg
- pulmonary capillary wedge pressure, 28 mm Hg
- cardiac index, 1.8 L/minute/m2
Efforts to improve the patient’s hemodynamics, in order to allow weaning from the IABP, were unsuccessful.
The patient wants to avail himself of whatever treatments will keep him alive. He has been told about the possibility of heart transplantation or placement of a left-ventricular assist device (LVAD). The patient’s social worker reports that the patient is housed in a maximum-security facility without hope for parole.
Questions:
- Is this patient an appropriate candidate for an LVAD?
- Is he an appropriate candidate for heart transplantation?
- What would be the best course of action for this patient, given his complex personal circumstances?
Response:
James Fang, MD
The comments below from my colleagues all have valid points. Many will recall that a similar case in California about a decade ago received widespread attention when the prisoner ultimately received a heart transplant. Other than a successful transplant, I do not know if the patient did well over the ensuing years. Keep in mind that renal transplantation has also been performed in incarcerated patients as well.
Without more information, it is not yet clear if the patient meets the criteria for an LVAD. The psychosocial aspects are only one consideration. Other medical comorbidities, the nature and extent of medical/device therapy to date, etc. still need vetting.
Clearly, it is a complex decision as is caring for anyone with advanced heart failure. The sophisticated nature of this field has been recently recognized by our community and the ABIM which now acknowledges the cardiovascular subspecialty of advanced heart failure and transplantation. Hopefully, this patient was seen and reviewed by such a subspecialist and a multidisciplinary team well versed in these issues. Most advanced heart disease centers have multidisciplinary groups that routinely review such cases.
An LVAD strategy is increasingly being used as a “bridge to a decision” in the world of advanced heart failure and this patient could fall into this category. Arguably, compliance is less likely an issue in an incarcerated situation where the patient is under constant surveillance.
At the end of the day, it is likely that finances will drive the decision. Many non-incarcerated patients are routinely turned down for transplant and/or VAD because they have no ability to pay. Like this patient, they too generally want whatever treatments will keep them alive. It may not be fair but it is a reality.
As for other courses of action, chronic inotropic management could be used understanding its limitations. I would also revisit other options such as CRT and hemodynamic guided therapy.
6 Responses to “Case Study: Advanced Heart Failure in a Prison Inmate”
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As one of the pioneers in the field of LVAD/Artificial Hearts, I am very familiar with the societal implicatuions of the use of rare and expensive treatnments. Society can ill afford to use resources such as an LVAD–or a cardicac transplant, for that matter–in a situation where the chances of returning to a productive life (and contributing to the GDP usefully) are small, and the societal expense for treatment is disproportionately high. This societal consideration is no different from the same one, analogously, that occurred many years ago on Australia with the limit on funding for renal transplantation.
To answer the question about what should be done in this situation, one would have to know more about the details of the diagnosis. Then, approached like maximal medical/drug therapy, pacemaker, etc. The guiding principle here would be “quality of life”; that would be defined as mitigation of symptoms to a level short of returning the individual to a fully functional capacity as if he were to need that for productive employment.
Competing interests pertaining specifically to this post, comment, or both:
I am a cardiologist, and a cardiac physiologist with experience with the LVAD from the 70’s and the 80’s. I have no investment in the industry, but rather was a clinician and a researcher working with the devices. Thus, I have no conflict of interest, simply an interest here in the societal implications for the appropriate uses of esoteric and expensive therapies.
Dr. La Farge is on quite a few slippery slopes. Productive employment is a prerequisite for an LVAD? How.productive? What if the candidate is disabled? How about retired? Maybe such patients” earned” best care as a “good citizen”..a productive member of society. The line perhaps needs to be drawn somewhere…so why not prisoners? According to the above, maybe only prisoners with no chance of working. The 60 yo with a 20 year sentence?
Society has made some exclusions to” best care” decisions. Illegal immigrants ..noncitizens do not get transplanted (no matter how” productive” they are). But society..as far as I know…has not relegated any subset of prisoners to a less costly plan of care. In fact, society has decided to spend a very large amount of money incarcerating the above described forever “nonproductive” prisoner. Can we as physicians ethically make such a decision to deny care? I think not. We can and should be part of the societal process that formulates such rules.
In this particular person, with criminal record it is waist of resources and of course money. If this person is let out of prison he will continue to commit crime.
I agree with Dr Powell. I may well be very junior in this field but ethically it would be wrong to deny this young patient the only treatment that will improve his long term life expectancy. Having completed my residency from Cook County Hospital in Chicago, I have seen many cases similar to this one. Given the severity of his medical illness, I am sure a case could be argued for his early release and alternate punishment for his crimes. What he really needs is a good social worker and a lawyer.
Competing interests pertaining specifically to this post, comment, or both:
None
I am not sure the patient is in a position to be able to commit to assuming and maintaining the lifestyle changes (including but not limited to diet, medication schedules, family support, and follow-up visit scheduling) that transplantation demands, a key requirement in patient selection.
See
http://www.columbiasurgery.org/pat/hearttx/candidate.html
http://www.mayoclinic.org/heart-transplant/candidates.html
Mehra,M., Kobashigawa, J., Starling, R., Russell, S., Uber, P., Parameshwar, J., Mohacsi, P., Augustine, S., Aaronson, K., Barr, M. Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates—2006. The Journal of Heart and Lung Transplantation – September 2006 Vol. 25, Issue 9, Pages 1024-1042.
Olbrisch ME , Levenson JL . Psychosocial evaluation of heart transplant candidates: an international survey of process, criteria, and outcomes . J Heart Lung Transplant. 1991;10:948–955V
Levenson JL, Olbrisch ME. Psychosocial evaluation of organ transplant candidates (A comparative survey of process, criteria, and outcomes in heart, liver, and kidney transplantation). Psychosomatics. 1993;34:314–323.
Paris W, Muchmore J, Pribil A, Zuhdi N, Cooper DK. Study of the relative incidences of psychosocial factors before and after heart transplantation and the influence of posttransplantation psychosocial factors on heart transplantation outcome. J Heart Lung Transplant. 1994;13:424–430.
Harper RG, Chacko RC, Kotik-Harper D, Young J, Gotto J. Self-report evaluation of health behavior, stress vulnerability, and medical outcome of heart transplant recipients. Psychosom Med. 1998;60:563–569.
Shapiro PA, Williams DL, Foray AT, Gelman IS, Wukich N, Sciacca R. Psychosocial evaluation and prediction of compliance problems and morbidity after heart transplantation. Transplantation. 1995;60:1462–1466.
Competing interests pertaining specifically to this post, comment, or both:
None.
Stanford University in fact performed a heart transplantation on a young prisoner-patient with severe heart failure without other medical contraindications to transplantation and who carried (as I recall) a life sentence. The medical issue is rather straightforward. As far as compliance with medications and follow-up, an inmate is far better positioned for (transplant) care than many patients living outside.
As far as professional issues, the major one is ethical, which requires, I believe, that physicians responsible for his care disregard his personal vices or criminal history (as we routinely do for prisoners of war or for injured criminals who are brought to emergency rooms with wounds incurred during encounters with law officers) and seek the best care available. In this case, the budget for corrections could probably provide support.
However, the major issue here is societal, not medical. The majority opinion of those -both medical and non-medical- not involved with the patient I cared for felt that it was inappropriate to devote societal wealth to an individual with this criminal record and sentence and prognosis. As physicians I believe we are expected to defend our profession’s dedication to the individual patient for whom we are responsible. But we must live in a society which controls our profession legally and financially and we will, from time to time, find ourselves at odds with prevailing opinions and with the ability to command the necessary resources to care for our patients appropriately, as may happen with this individual. We need a wider and more comprehensive debate on matters such as these, rather than addressing them only on a case-bycase basis.
Competing interests pertaining specifically to this post, comment, or both:
No conflicting interests.