We have no standards for what an 80-year-old should do, or act like, or what's normal.
With increasing frequency, the oldest members of US society are undergoing medical interventions aimed at prolonging life. Using cardiac care as a case study, this paper explores how a discourse of risk infuses and legitimates high-tech clinical treatments in late life. In particular, we examine how the diminishing risks associated with biomedical procedures produce a sense of medical possibility regarding life extension, and push the definition of ‘old age’ into a receding future. Simultaneously, physicians, patients and families come to understand the management and reduction of future cardiac risks to be germane for individuals even near the end of life. Driven by the logic and language of risk, decisions to intervene are experienced as incremental and largely unremarkable, and the pursuit of an open-ended future via biomedical means is perceived as an ethical imperative, trumping deliberation or discussion of the utility of intervention and the ultimate ends being pursued. For practitioners and patients alike, the engagement of risk, the preservation of hope it facilitates and the routinisation of intervention it produces all contribute to the emerging mandate to treat at ever-older ages.
Risk and the ageing body
This paper examines the pervasiveness of risk as an animating concept in US medicine, and its significance for healthcare delivery to the oldest members of American society. Increasingly, socio-medical mandates to identify and reduce health risks provide the frame within which physicians, older patients and their families make choices about clinical interventions, including decisions about extending or ending very old lives. At the same time, the risks of morbidity and mortality associated with the use of medical procedures, even in very late life, have decreased dramatically in recent decades, and that reduction of risk fuels the desire for intervention. These two features of risk – that, on the one hand, it is everywhere and should be monitored and reduced, and on the other, that it is of diminishing relevance as a byproduct of treatment – support the culturally-pervasive sense of medical possibility and the actual extension of ever-older lives. Here, we consider the ways in which a discourse on risk – its logic and vocabulary – shapes knowledge of old age, the use of medical technologies among the elderly in the United States, and the ethical imperatives that accompany that use.
Numerous scholars have commented on the emergence of risk as a contemporary category of knowledge and the expanded scope it allows for medical surveillance and management. Risk acts to discipline bodies in progressively more thorough ways (Clarke et al. 2003, Lupton 1999, Novas and Rose 2000). Constructions of ‘risk factors’, techniques of medical surveillance and the cultural linkages among health maintenance, individual choice and familial and social obligations today constitute taken-for-granted features of daily life (Crawford 1994, Rose and Novas 2004). Strategies both inside and outside the clinic are aimed at minimising risks and governing what are seen as risky populations, reconfiguring individuals as active partners in the pursuit of health (Clarke et al. 2003, Katz and Marshall 2003). These transformations usher in a new politics of risk, in which the corporeal mutability of the human body renders it a key site for ethical engagement, practice and judgement (Rose 2001). In the context of the ageing body, notions of risk and its identification and management further problematise already complex (and sometimes contradictory) assumptions about late life. The biomedicalised conception of ageing as inevitably accompanied by disease and decline (Estes and Binney 1989) is complicated by expectations of continued health and the successful management of risk in old age (Rowe and Kahn 1998). Old age marked by manageable risks requires rethinking the boundaries of ‘normal’ senescence.
Life-prolonging cardiac care is a useful case study for exploring how risk is understood and acted upon by physicians, patients and families, and how old age is being transformed as a site for medical interventions of all kinds. There have been dramatic shifts in recent decades in how physicians think about their elderly patients and the procedures they use, how older individuals conceive of themselves and their own ageing, and how we, as a society, pursue the treatment of risk as well as disease in order to maximise late life. A group of cardiac procedures are emblematic of the practices and politics surrounding risk in the context of old age and life extension: angioplasty, stents1, coronary artery bypass graft surgery (CABG) and implantable cardioverter defibrillators (ICDs). We describe here how risk provides an animating logic for these medical interventions, life prolongation and ethical obligation in late life.
Specifically, we draw attention to three intertwining aspects of the articulation of risk in the clinical management of old age: first, the proven diminishing risks of cardiac procedures produce a sense of medical possibility regarding life extension, pushing into the future what characterises an ‘older’ and riskier patient. As a result, those in their seventies, eighties and even nineties are being normalised as a new class of medical subjects. Second, risk assessment and preventive medicine are increasingly considered standard medical therapy in late life. Finally, risk, as a dominant lens through which to evaluate and approach ageing, is redefining clinical responsibility and the constitution of appropriate measures. We address each of these dimensions below through an ethnographic exploration of clinicians’, patients’ and families’ engagement with risk, medical choice and the promise and burden of life prolongation.
This paper is part of a larger qualitative study of the use of life-extending medical procedures among persons aged 70 and older in California. The overall two-part goal of the larger study is to investigate how physicians, patients and their families enter into and understand the use of several kinds of life-prolonging clinical interventions and how life extension practices and the socio-medical developments surrounding them are impacting on geriatric medicine and the healthcare of older Americans. The findings reported here are based on in-depth interviews conducted by the first author in 2002–2004 among the following: 16 physicians, including internists, general and interventional cardiologists and cardiac surgeons; 28 cardiac patients who had undergone angioplasty, bypass surgery, stent and/or ICD implantation when they were over the age of 70; and seven family members of patients. Both physician and patient respondents were recruited using a convenience, snowball sampling approach, where each interviewee was asked to provide referrals to other providers and patients. In addition, theoretical sampling (Strauss and Corbin 1998) was used to ensure that the physician sample included clinicians from all the relevant sub-specialties – internal medicine, including geriatrics, general and interventional cardiology, electrophysiology2 and cardiac surgery – and a range of practice settings – from academic medical centres to community hospitals. Patients were further recruited through their physicians, and by contacting cardiac support groups, local cardiac rehabilitation programmes and an American Heart Association consumer newsletter.
The sample of patients included seven women and 21 men, reflecting the fact that more men undergo cardiac interventions than do women, and ages ranged from 72 to 86 years. Eighteen had received bypass surgery when over the age of 70, and 12 (including two bypass patients) had undergone angioplasty with or without stents. Most patient recollections were about procedures that had been performed between six months to six years before the interview, when they were between 70 and 86 years of age; for two-thirds of the patient sample (19 individuals), less than two years had elapsed since undergoing treatment (four of the 28 respondents had undergone treatment 10 or more years earlier). Interview accounts are, of course, necessarily retrospective and thus reveal patients’present perceptions and evaluations of those procedures and their associated benefits and difficulties as they were experienced over time3. The vast majority of patients were Caucasian, but Asian Americans and Latinos were also represented in the sample. Finally, spouses, children and other family members who figured importantly in patients’ decision-making and recovery process were invited to participate in interviews with us.
The in-depth interviews were semi-structured, generally following an interview guide that was adapted over time to allow for exploration of emerging themes and questions (Strauss and Corbin 1998). Physicians were questioned about how they made decisions about the use of angioplasty, stents, bypass surgery and ICDs, their criteria for evaluating patients over 70, ethical and practical dilemmas encountered in providing care to older persons, and medical goals and personal views about life prolongation and the end of life. Patients and family members were asked about their experiences with decision-making, treatment and recovery, their communication with medical personnel, thoughts about ageing and illness, and hopes and expectations about medicine, health and the future. Interviews ranged between one and more than two hours, and were audiotape-recorded and transcribed verbatim. The data were analysed using the principles of grounded theory (Strauss and Corbin 1998), in which interview transcripts were open-coded to identify core substantive themes which reappeared in the data; these codes were then grouped into categories. All codes and categories were developed inductively around the phenomena of interest, specifically, the ways in which risk is perceived, understood and acted upon within the context of life-extending cardiac care.
Diminishing technological risks
Individuals in their eighth, ninth, and even tenth decades of life are becoming routine recipients of life-prolonging cardiac treatments (Interdisciplinary Leadership Group of the American Geriatrics Society 2000, Solomon et al. 2000)4. The growing normalisation of cardiac care for the very old is facilitated by the decreasing risks of the medical procedures themselves (Katz et al. 1998, Peterson et al. 2004)5. Those procedures, in turn, are fundamentally remaking societal conceptions of what constitutes old age and risk in the context of clinical intervention. As devices (such as stents and defibrillators) become smaller and lighter, as techniques for implanting them become safer, and as less invasive procedures, overall, are used with greater frequency, physicians and the public learn to view them as relatively low-risk, standard interventions that one does not easily refuse. For example, one cardiologist noted that ICD implantation:
used to be an open-chest procedure in the operating room with the surgeons, and it'd be a foot, foot-and-a-half long incision, and it was a much bigger operation. And now the size [of the defibrillator] has decreased by easily 60 per cent, weight probably by about 50, 60 per cent as well, and the surgical implantation procedure and the risks therefore have probably dropped by easily two-thirds or so.
Coronary artery bypass graft surgery, too, has a safety profile that has vastly improved since its inception in the early 1960s (Peterson et al. 2004), and internists, cardiologists and cardiac surgeons all noted, sometimes with amazement, that even very sick and very old patients now benefit from the procedure. As one cardiac surgeon put it, ‘the great majority of patients, even though they’re older, do very well. I mean, I'm continually astounded by the patient who's 80 years old and you operate on him and he goes home on the fourth day. And you see them in the office in two weeks and they want to know, can they start driving?’.
Because the risks associated with cardiac procedures are lower than ever before (Katz et al. 1998, Peterson et al. 2004), older individuals, their families and physicians feel able to justify their use even when they believe the benefit to be gained may be negligible. One electrophysiologist explained that the relative technical simplicity and safety of defibrillators, for example, are conceptually mobilised in ways that permit and facilitate their routine implantation, even when clinicians doubt whether they would in fact help patients:
If the patient meets the clinical criteria that would allow them to have [an ICD], I would never absolutely refuse to offer it to them. But I can also be fairly persuasive if I point out that their other problems will likely make it such that they won't enjoy any real benefit from this uncomfortable technology – I would say about 50 per cent of the time, we can leave that conversation with them deciding not to have something done. But the other half of the time, I mean, I'm going to kind of bite the bullet and do what I know how to do and get them through this, and then leave the rest for them to live with that decision since we’re not talking about a procedure that has significant life-threatening risks that come with it. Usually people get through it, even really sick ones. It's not like I'm going to do an open heart procedure, and the patient dies on the table, and I have to tell the family. I don't have to worry as much about that scenario, so I never refuse.
The perception that cardiac intervention comes with diminishing risks is communicated to and taken up by older patients and family members in a variety of ways. Some are told outright by their physicians that they need not worry about adverse outcomes: one 83-year-old man recalled that ‘the surgeon that I had, he was very positive. He said, “You’ll be fine. Nothing to worry about”’. Many others we interviewed remarked how ‘common’ and ‘routine’ angioplasties, stents and bypasses seemed to be, that ‘everyone's doing it’, and that they had multiple friends and relatives who had successfully undergone one or more of these procedures and were now leading active and vital lives. A phrase we heard often from patients was that these interventions were ‘not a big deal’. One individual recounted his astonishment at seeing just how many others were waiting for their bypass surgery on the same day that his was performed; as he put it, ‘it was almost like being on an assembly line’. Another described how her hospital had developed a standardised patient and family education programme, one whose routineness and institutionalisation she found ‘very reassuring’. She said that even her cardiologist had remarked, while doing her angiogram, ‘You know, I've done four of these already today’.
Furthermore, many of our elderly respondents could not recall having any significant discussion of the risks of morbidity and mortality with their physicians before undergoing treatment. Patients did not remember, for example, their age ever being mentioned as posing a higher risk for stents and bypass surgery. Thus, the absence of any memorable conversation about procedural risks may itself have contributed to – however subtly or unintentionally – the impression that these interventions were routine and safe. For those patients who were explicitly advised of the risks of intervention by their clinicians as part of a standard informed consent procedure, the routinised way in which these risks were communicated seemed to blunt a serious consideration of them. One man who had undergone two bypass operations and two angioplasties in his sixties and seventies shrugged off our query about the risks of surgery: ‘I'm sure [the surgeon] went into the details; they always do. And then you sign a release and so forth. I don't remember the risks. The surgeon's supposed to do it all the time; they all have to say that, anyhow’. Finally, older patients and their family members frequently minimised the risks of medical intervention by contextualising them within the scope of the hazards of everyday life. An 80-year-old man, for example, declared, ‘You want me to yank my handkerchief out and start crying I got risks? There’re risks no matter where I go and where I turn’. ‘If you’re going to worry about every little thing’, the wife of another patient told us, ‘you’ll never do anything. Everything in life is a gamble’.
Although some physicians caution that procedures always carry some risk, the overwhelming clinical perception is that cardiac technologies like angioplasty, stent and ICDs come with low costs to morbidity and mortality – indeed, that they are practically ‘free’– and that bypass surgery is now a far safer endeavour for elders than ever before. Older patients and their loved ones likewise come to understand these cardiac procedures as reliable and routine. In short, because of clinicians’ understandings of the reduced and relatively low risks of cardiac intervention in late life, and the ways in which ideas about safety and efficacy are taken up by patients and families, these life-prolonging procedures are performed with increasing frequency on the very old.
Receding old age
Physician accounts describe changed and changing norms of what constitutes ‘elderly’, as phrased in terms of higher age ‘thresholds’ for uneventful recovery following cardiac procedures, and ‘advancing lines’ that serve to distinguish older from younger patients. All the physicians we spoke to reflected on the dramatic changes over the past several decades in their perceptions of how old is ‘old’. One cardiologist spoke for other physicians when he remarked, ‘It seems like the definition of “elderly” is always changing. Some people say 65, 75, 85. What you think is an “elderly” patient is going higher and higher. Frequently, an 80-year-old in a cath lab doesn't seem that elderly. They’re elderly, but they’re not really elderly’.
Physicians told us that the age at which the idea of cardiac intervention shifts from feeling ‘routine’ to ‘extreme’ is gradually moving upwards. ‘That line is advancing’, one cardiologist observed, ‘we are more willing to do things. Me – and I'm more conservative than some – I'm more willing to do things on a 70-year-old and people in their eighth decade than I was 25 years ago. We are doing more, and we’re getting much better results than we were in the old days’. An electrophysiologist expressed the change in this fashion:
I really see a difference compared to when I was in training. And the reason it's so clear to me is I remember, in training, being confronted with the notion of putting a defibrillator in an 80-year-old patient and thinking that that was just the most extreme circumstance. How could we justify preventing sudden death in an 80-year-old person? And now, it's commonplace. Now my threshold – I have more of the incredulous reaction to someone who may be over 90. I feel it changing, and I feel me changing as well.
Similarly, a general cardiologist said, ‘I don't even blink when I have a patient that comes up that's 80-something because the 75-, 78-year-old is sort of the standard. I'd say now the number I think twice about is 90 or above. But we have many patients over the age of 90 now’. A cardiac surgeon noted that ‘for bypass surgery, probably to about age 95, it's considered standard therapy’. Another cardiologist told us, ‘This week alone, I've done interventions on 90-year-old patients. You'd think hard about it if they were a hundred, but they wouldn't be excluded. So, no, in general, age alone is not the thing’.
Physicians generally agree that chronological age has become an unreliable predictor of when procedures like angioplasty, stenting and ICD implantation seem warranted and when they do not. In our interviews, doctors often referred to patients, variously, as ‘a young 80-year-old’, or ‘a young 90-year-old’. An electrophysiologist recalled:
I got a call about an 88-year-old man who needed one of the most advanced devices. It really bothered me because the particular doctor that referred the case, in my view, has referred cases of people that look like they’re at death's door. So now I'm thinking about the 88-year-old that's at death's door, and I'm thinking this is just bad form. It's not a good use of resources. It's going to be a horrible thing to do to someone, an irresponsible thing to do to someone. I went to meet this person in the operating room and he was sitting up, the brightest, sort of robust kind of healthy-appearing 88-year-old that I'd ever seen. Chronological age is often a limiting sort of judging factor, but it's just one factor. Here, physiologically, he was more like some of the 70-year-olds that I've seen.
Thus, there seems to be a growing consensus among physicians in the cardiac specialties that ‘“old age” shouldn't be defined by a number’, and that clinical responsibility means performing life-extending procedures, regardless of age, as long as there is the possibility that potential benefits might outweigh the risks.
Physicians’ perceptions of receding old age are further bolstered and indeed largely realised by patients’ post-procedure experiences. Elderly individuals often describe themselves as ‘rejuvenated’ after cardiac intervention. ‘I feel younger’, said one woman who had had bypass surgery, ‘I feel I can do more. It's giving me a new outlook’. Another who had had a stent implanted marvelled, ‘It just changes your life. You can go ahead and play tennis and hike or do anything like that that you want to do. It was just like a new start’. And another who had undergone bypass surgery exclaimed, ‘I felt wonderful. It was like my whole life was renewed. It was amazing. My mind seemed to be a little clearer. I just felt so good’6. That is, patients – whether undergoing angioplasty, stent or bypass surgery – themselves come to understand the experience of advanced age as reversible through biomedical intervention, and to share physicians’ perceptions of old age as being pushed ever later in a technologically-prolonged life.
The growing technical ease of the treatments and the decreased risks associated with their use change the social meaning not only of the cardiac treatments themselves – from aggressive interventions performed on the elderly only under unusual circumstances, to increasingly routine, standard procedures – but also of older patienthood and personhood. Advanced age alone now no longer excludes patients from consideration, and often, procedures such as angioplasty, stenting and ICD implantation require only cursory deliberation before physicians recommend them or patients consent to undergo them. Even in the case of bypass surgery, which tends to give physicians and prospective patients greater pause7, there have been striking changes in practitioners’ perceptions of the procedure's risks and concomitantly, of the kind of patients for whom undertaking such risks is acceptable and appropriate. Elderly individuals themselves endorse the notion that old age now comes later in life. This demographic reality is often actualised by the very application of cardiac treatments themselves, as those who undergo them corporeally experience old age as manipulable and reversible. Couched in the language of risk and reward, the use of cardiac interventions into very advanced age is being framed in a very different way, as is late life itself.
Embodying and treating risk
A consequence of the widely pervasive discourse on risk, and the life management strategies that accompany it, is that old age is often conceived as a time of preventable and curable diseases and, especially, preventable mortality. Clinical practices aimed at anticipating, measuring and managing the risk of future disease – sometimes in the absence of symptoms or significant medical history – are increasingly seen as germane for people in late life. We locate this trend within a broader social and cultural landscape in which the treatment of risk is central to the pursuit of health and ‘quality of life’. This landscape is marked by the ever more blurry boundaries between prevention and treatment, risk and disease (President's Council on Bioethics 2003). In part, what makes it possible for late-life cardiac procedures to become routine is the legitimation of the presence of risk itself, rather than disease or symptom, as grounds for treatment (Armstrong 1995). As technologies like angiography, electrocardiograms, cholesterol-lowering medications and even the home blood pressure monitor routinely enable the heightened surveillance of older bodies, and as biomedical practice can intervene earlier and earlier in the disease process, cardiac procedures are often conceived not only as conventional therapy for existing disease, but also as a standard form of risk reduction in late life.
Angioplasty, stents and bypass surgery have become part of the arsenal of defensive, prophylactic medicine for ever-older individuals. Together they represent the standard of care in the prevention of future heart attacks and the risk of future heart attacks. Often cardiologists use these procedures to treat narrowings in coronary arteries that are discovered in the course of routine angiography, but which have not necessarily produced chest pain, other symptoms or heart attacks. Older patients we interviewed described mentioning to their doctors vague feelings of discomfort or breathlessness, or of undergoing tests for other, unrelated reasons, only to find themselves suddenly admitted to the hospital and confronting major decisions about whether to undergo angioplasty, stenting or bypass surgery. One 84-year-old man, for example, recalled telling his physician how he felt unexpectedly warm and tired during his five-mile walks. Two days after completing a treadmill stress test, he found himself scheduled for bypass surgery. Another 80-year-old patient, after choosing a new personal physician, had a stress test done as part of a standard work-up for hypertension. Although he experienced no symptoms whatsoever, his doctor ‘quote, “laid it on the line”’, saying that, ‘“You could walk out of here this afternoon and keel over because your heart is real bad”’. An 86-year-old patient, while having an electrocardiogram for consideration for a pacemaker, was transported precipitously by ambulance to the hospital for emergency bypass surgery.
Given the sense of urgency and the spectre of unpredictable, possibly imminent, and potentially life-threatening cardiac risks their physicians communicated, and their offer of a means to avoid the risk of death, few older patients say that the decisions to undergo intervention were difficult to make, even despite the chaotic or abrupt circumstances under which they were asked to consider them. Indeed, any sense of ‘consent’ or ‘choice’ was largely put aside, as patients and their loved ones came to understand that there were no real alternatives to medical intervention. An 83-year-old man, for example, recalled:
When I went to see the cardiologist after the stress test, and he said, ‘Yeah, you've got a problem. And it's gonna have to be fixed. It's not a choice of whether you want to go through it or not. If you want to live, it's just going to get worse and you’ll have a heart attack, and that’ll be it’. And to me it was not that hard a decision to make. Because when you’re faced with that kind of a choice, your decision, I think, is made for you.
Similarly, the wife of an 86-year-old who had had two bypass operations said:
As it was put to us, if he doesn't have the bypass tomorrow morning, he will not live six months. So it wasn't really an option . . . You know and I know some of the other things that are involved, such as minor strokes, major strokes, things like that. All of that went through my head maybe in about 15 seconds. It's just not even a question of considering risks. If it was offered, he was taking it, and that was how it went.
While angioplasty, stent and bypass procedures affect the greatest numbers of elderly people in the US8, the significance of the treatment of risk per se for the reconceptualisation of normal ageing is perhaps most dramatically illustrated in the case of implantable defibrillators. Recent clinical trials (Bardy et al. 2005, Zareba et al. 2002) have generated new medical indications for which ICDs have been shown to be beneficial. Before 2003, the criterion for defibrillator implantation – and importantly, for Medicare reimbursement for the procedure – was, at minimum, one incident of cardiac arrest or of documented arrhythmia. In 2003, the eligibility criteria were expanded to include those who had had a heart attack and had met certain measures of declining heart function (Phurrough et al. 2003). Now, research suggests that most people with weakened hearts, regardless of any previous cardiac event, would gain life-extending benefits from ICDs (Bardy et al. 2005). The US Centers for Medicare and Medicaid Services estimate that adopting this exceptionally broad criterion would increase the number of Medicare beneficiaries eligible for a defibrillator to more than 500,000, doubling or even tripling the number of defibrillator implantations among elderly people. ICDs would thus be normalised among a sizeably larger pool of older Americans (McClellan and Tunis 2005).
Although ICDs are statistically proven to prolong life, the new, purely risk-based indications for these devices raise ethical questions surrounding their use. One electrophysiologist explained:
The science shows that every person who has had a cardiac arrest would potentially be considered a candidate for an implantable defibrillator. The other criteria would be someone who's had some degree of non-sustained arrhythmia. And then the most aggressive approach, which is currently happening as we speak, is that patients are simply recognised as having a weakened heart muscle, and they may have never had an arrhythmia before. And now we’re being asked to accept those patients for implantable defibrillator placement. So whatever my ethical, moral dilemmas were, they may be increasing now because I'm being asked to consider simply anyone and everyone who has a weakened heart muscle for this technology.
In this blurring of prevention and treatment, the distinctions among risk categories – between those who are ‘at risk’ and those who are not – are rarely if ever clear. ‘All of us are at some risk for sudden arrhythmias’, the same doctor said. But confronting the notion of the risk of life-threatening arrhythmias and sudden death as though they were both pervasive and treatable through the prophylactic use of ICDs, particularly among an ever-older patient population, intensified his sense of moral unease:
Age is not a widely discussed criterion. It's very tricky to sit down with a patient or their loving family – and by now they've heard about this technology – and to say, ‘You know, he does meet the clinical criteria, but, really, at his age, it may not be the right thing in this case. If he were to have a dangerous arrhythmia – that's the way people pass quietly in their sleep. That may be a natural moment at the end of the person's life’. That's a very hard discussion to have. It's just sort of a vague judgement that this person's 88, and they seem mentally alert, but you just get a sense, boy they've been through so much . . . I've found my way into an area of medicine that I, on the one hand, believe in, but on the other hand, it doesn't leave me feeling great about what I'm doing in terms of utilisation of technology. I'm glad the technology's there, but it seems I'm asked to use it at times when I'm not perfectly comfortable. Wouldn't the surgeon say the same thing about some of the people they’re asked to do bypass on? I think so. Wouldn't the coronary specialist say the same thing? I think that's the nature of this project, to say there's a discomfort zone, and for me, it seems to invade my time with some frequency.
Yet, as the risks of ICD implantation diminish, as the scientific evidence for their life-prolonging benefit accumulates, and as the criteria for their use are broadened to include simply the existence of the risk of sudden death rather than a demonstrated history of arrhythmia or heart attack, their potential to extend older lives becomes increasingly harder to ignore clinically:
Now we've come all the way to the point where we realise, scientifically, that you can put an ICD in someone who's never had an event at all, without doing any other testing, but just bring them in from the office and put it in. Because at some point, they may face this arrhythmia risk, and, scientifically, they’ll be better if they have this than someone who doesn't have it. We've all grown to accept that. So I think I've changed in terms of my thinking about what's treatable or when it should be treated.
Do I end up implanting defibrillators in people that might not need it? And the answer is yes. But my sense is, as long as the patient and the family feel comfortable with it, I don't mind having a safety net in place and never using it.
These changes in the meaning of ICDs, one of cardiology's more recent innovations – as preventive device, safety net and an increasingly standard means to treat the existence of risk– are contributing, along with the other procedures, we suggest, to a reconceptualisation of old age as a stage of life when risks can be managed and should be averted, when clinicians must ‘look forward for risk’ and ‘actually treat for risk, not just look for risk’. While ICD technology is the most glaring example of this trend, it is also indicative of the overall pressure in American biomedicine to ‘treat’ risk. While varying opinions exist about the extent to which proactive risk management should constitute standard medical treatment of the very old (and thus, the extent to which cardiac risk and disease should be considered a ‘normal’ part of ageing), physicians’, older patients’ and families’ choices about whether to treat risk are increasingly scripted for them by the normalisation and increased success of clinical intervention. Biomedicine, as a set of social and cultural practices, delineates the risks of old age, promotes treatments for them, and routinises attempts to realise the possibility of an open-ended late life.
The ‘technology parade’
The discourse of risk often provides the rationale for intensifying the frequency and aggressiveness of treatments in a phenomenon we call technological incrementalism, a process in which the standard use of comparatively non-invasive treatments legitimates more invasive procedures, and aggressive procedures in turn pave the way for additional, less aggressive ones. Physicians often view cardiac technologies along a kind of interventional continuum, from ‘heroic’ measures taken in the operating room to procedures that are also high-tech but significantly less invasive. Technological incrementalism captures the sense in which the use of one treatment along the continuum makes additional procedures conceivable, possible and ethically necessary. As a result, the overall scale of intervention escalates, both in the sense that successive treatments on an individual can become more invasive, and that an increasing number of procedures of varying levels of invasiveness are felt to be acceptable and, indeed, warranted to improve health, stave off death and minimise future health risks.
One site in which technological incrementalism is built into clinical practice is the cardiac catherisation lab where patients undergo both diagnostic and therapeutic procedures including catheterisation, angioplasty and stenting. One cardiologist observed that at institutions with round-the-clock access to a cath lab,
the treatment algorithm is primarily angioplasty. So from a whole hospital culture, it's a very invasive cardiology approach. All the emergency room doctors and all the cardiology house staff and faculty are of the mindset here that there's an aggressive approach to patients with heart attacks. There's a written practice guideline saying anybody with a suspected heart attack goes to the cath lab. That's the treatment plan.
Significantly, when an individual is brought into the catheterisation lab, even just for diagnostic purposes, s/he is typically asked to consent to a spectrum of interventions, not only for the original diagnostic catheterisation, but also for possible angioplasty, stenting and emergency bypass surgery should the need arise. Moreover, do-not-resuscitate (DNR) or do-not-intubate (DNI) orders are typically reversed while the catheterisation, angioplasty or stenting is being performed, so that transient problems (e.g. a potentially fatal heart rhythm) encountered in the course of the procedure can be treated. The prevailing assumption is that because the individual has consented to intervention to begin with, s/he should also logically agree to other additional procedures, even including resuscitation. As one cardiologist put it, ‘It would be a shame to do this whole heroic procedure if you’re not going to do everything you can to get the patient through it’. In these kinds of scenarios, patients must consider at the outset whether they would accept a panoply of potential cardiac interventions as a prerequisite to undergoing catheterisation to diagnose or treat a seemingly limited and bounded problem.
Actual clinical practice, therefore, systematically exposes ever-older individuals to the possibility of cumulative and successive treatments, each one legitimated in an incremental fashion. The end product of this kind of incrementalism is a ‘technology parade’, as one physician described it, in which a stream of cardiologists, cardiac surgeons and electrophysiologists each provide life-extending procedures that are, in part, facilitated by those that came before:
One of the scenarios that troubles me the most is that the patient that comes into the hospital, they arrive with a heart attack, they’re rushed to the heart room, the blockage is identified and they have an appropriate intervention with a stent. They have other blockages that are not causing their acute problem but will be a problem later. They then have a discussion about the need or the role for bypass. They go to bypass surgery. They then have some extra beats noted on the heart monitor because they’re monitored; they do have a weakened heart muscle. They’re felt to be at risk for future dangerous arrhythmias. And then I get called, and I'm just part of this two-week extravaganza of cardiology where we basically pull out all the stops. And the person leaves, having had three separate types of intervention, ending with a device that is very expensive and of proven benefit and value. But sometimes we do all of this for someone who's very old. I become party to a technology parade where I'm the last part of it. The reason that we do it is not really as a protection of everyone's investment, but more because you couldn't have gone through all of this and not also cover that base. If you’re going to offer this sort of aggressive open-heart surgery procedure, then you surely would offer them something as easy – even though it's expensive – as an implantable defibrillator.
A cardiac surgeon compared the escalation of intervention to a speeding train from which patients and their doctors cannot get off:
Once you've got that stent, it gets progressively harder to pull back from sending the patient on to someone like me. By the time they get involved with me, I mean, the train's going down the track about 75 miles an hour. And I walk in, and the patient is a surgical candidate, and everyone's pretty well committed to it. And that's what sweeps them up, and they don't hear the issue of, ‘Do you know how bad you’re going to feel and how long it's going to take you to feel well?’
Others concurred that cumulative cardiac interventions on older individuals are ‘hard to grind to a halt, especially if you’re talking about your heart because often, that's the last thing – you are talking about possibly an end-of-life decision if we choose not to treat’9.
The phenomenon of technological incrementalism points to how the risks and benefits of clinical intervention are weighed in a step-by-step, piece-meal fashion. Once intervention of any kind is initiated, the hazards and gains of employing additional treatments are considered in light of the procedures that came before. Each technology or procedure is therefore seen as only incrementally more or less risky as the previous intervention, which subsequently renders it easier to justify. Clinicians legitimate successive interventions through the life-extending benefits they may afford an older patient.
The momentum towards risk-reducing, proactive cardiac treatments is normalised by physicians and experienced as routine and necessary by patients. Thus no potentially life-extending procedure is seen as clearly unreasonable or inappropriate – except, physicians told us, at the very extremes of old age, dementia and/or terminal disease. In fact, when asked to describe the kinds of scenarios where cardiac interventions felt ‘extreme’, physicians had a difficult time answering. They reported very often feeling compelled to provide cardiac treatments, though they expressed variations in their willingness to do so and in the degree of discomfort they experienced. Clinicians simply did not want to run the risk that their fears – that is, their ethical misgivings about whether the intervention was warranted, that the patient might not survive or not survive well – would be proven wrong.
Incrementally, and on a case-by-case basis, individual treatments involving angioplasty, stents, bypass surgery and ICDs can be medically justified. But together, they comprise an extraordinary cumulative effort to postpone death. As growing numbers of elderly people receive more kinds of interventions, not only does the use of the procedures themselves shift from feeling ‘extreme’ to ‘routine’, but also the full court press of the entire spectrum of high-tech cardiac care (Kolata 2004) – the ‘extravaganza of cardiology’ itself – becomes an increasingly accepted and naturalised part of advanced age. Technological incrementalism tends to displace consideration of the overall desirability of the technology parade and to mask recognition of situations – that are increasingly common, according to the physicians we spoke to – in which the parade is more like a runaway train. The societal sense of the limits both of medical intervention and of the human life span are pushed further out into a vanishing horizon, and our expectation of medicine's capacity to deliver a seemingly open-ended and disease-free future becomes increasingly insistent.
Risk-based and procedure-driven ethics
The vocabulary of medical risk and the logic and growing ease of its reduction support an ethical imperative to intervene in late life. When therapies that seek to reduce cardiac risk are considered routine, the technological imperative to employ them is transformed into a moral imperative to offer (and undergo) them (Koenig 1988). Some doctors framed accountability – to themselves as well as to their older patients – in terms of proactively treating probable risks, even in the face of past and future adverse outcomes, in order to maximise their patients’ chances for a prolonged life. The following story is representative:
We had a very elderly patient who died very shortly after a complicated angioplasty procedure. It was unexpected. She was 87, otherwise healthy, had a heart attack. We put a stent in and opened up the artery that was causing the acute heart attack. And she did very well. Four days later she came back to the catheterisation lab to have her other artery angioplastied. It was not involved in a heart attack, but it was felt to be severe, and she would potentially have problems with that artery. Unfortunately, during the stent procedure, she developed a tear in one of her heart arteries, got very sick very quickly, needed a lot of resuscitation, ended up going for emergency bypass surgery and died during that operation. She was old, but we were very surprised. But the next time a very similar patient comes, I think we’ll be wrong to shy away and not do procedures at all on anybody who's older.
Even when physicians expressed their occasional discomfort with life-extending treatments, the logic of risk reduction and its increasingly routine technical enactments tend to silence discussion and to trump any doubts about the appropriateness of clinical intervention. An interventional cardiologist who performs angioplasties and stenting cautioned: ‘I can get the patient through a lot, but you've got to think, what's your end point?’. A cardiac surgeon talked about the need to identify patients who are:
going to have a huge amount of difficulty going through the procedure that involves marching them through cardiology, catheterisation lab, surgeon, operating room, intensive care unit, hospital course, recovery facility and home. Those patients often can be spotted. They shouldn't be sent to cardiology. Or the discussion should be had at that point, with the patients and the family: ‘Do you really want to embark on this journey? Is this surgery going to prolong your life in a meaningful way that you can function and is it of worth to you? Do you want to subject yourself to the risk of this operation to marginally improve your ability to function, and maybe not improve at all, and maybe prolong your life and maybe not?’.
But medical professionals confide that they find it difficult to know how and when to pose such questions or to voice the doubts that underlie them, because interventions are so normalised, and because clinical responsibility is defined, more often, in affirmative and proactive terms of offering and performing procedures that will reduce risk. As one physician noted, the usual course of action is to ‘err on the side of doing interventions, to give the patient the benefit of the doubt’, unless s/he were extremely old and clearly demented.
Moreover, although both enhanced quality of life and increased suffering loom as potential results of life-extending treatment and attempted risk reduction, particularly among elderly people, predicting which patients will experience which outcomes is an extremely elusive endeavour for physicians. As a result, practitioners say they are often disinclined to discuss with patients and families the appropriateness of intervention in anything other than technical terms. Instead, they prefer to engage with problems they can address – managing the risks of their older patients with technological means. One electrophysiologist noted, ‘I sense that some of my colleagues don't hesitate and don't feel it's any part of their responsibility to ask questions about utilisation, about who really is a good candidate, about when sudden death might be a more appropriate exit strategy for that person. They simply see it as, the patient meets these X, Y, Z criteria, so they’re going to proceed’. The choice to intervene is aimed at maximising the possibility for life extension regardless of the probability of success or the actual outcome. Another physician stated:
Some doctors just recognise they can't really predict the future, so why sweat it? Why try? Just do what you know to do. Go with what you know, and get it over with. And there’ll be a cancer doctor to worry about that metastatic cancer. But don't try to get in on that because you’re going to just stumble. Because push comes to shove, if the family pushes you and the patient pushes you, you can't predict whether it's going to be six months, 12 months, 18 months. One of the biggest problems that we get into as physicians is that we say, ‘Your loved one has six months to go, less than six months to live’. And who wants to be part of that miscalculation? So I think a lot of my colleagues just say, ‘I'm not even going to sweat that. If they meet the criteria, let's go’.
Thus, clinicians feel caught in situations where the imperative to treat and act – itself seen as an ethical-clinical obligation – is perceived to trump a more thorough discussion about the utility of intervention, the ultimate ends being pursued, and the seemingly indefinite postponement of death in light of a patient's predicted quality of life.
Physicians’ difficulty with questioning procedure-driven life extension is compounded by the fact that patients and/or family members mostly want and encourage intervention. One woman told us:
I thought I was too old. My idea was not to have surgery. But I kept thinking it over and my son and the doctor kept working on me: ‘Well, Mom, you better have it, because the longer you wait, the worse it's gonna be, and just think, you could have another 10 or 15 years of good life’. I have a daughter in Chicago, and her husband had it done, and she was for it. She says, ‘Go ahead, Mom, look, John had it done, and he's doing great’. It gave me some encouragement. I kept thinking of that, and I thought, well, he's younger than I am, but he had it done, so I might as well try it. Everybody's doing it.
At times, family members’ pushing for medical action can be quite forceful, in part because the ready availability of life-prolonging options creates a moral obligation to use them. One 73-year-old man recounted his conflicted decision to undergo bypass surgery and the fact that his family and doctor convinced him to proceed:
I just saw that I had no choice, and either I'm going to slowly die, or have a bypass. And my preference would have been just to let it go – what the hell, I'm 73. But my wife was kind of hysterical about it. [My surgeon] also encouraged me, and so everybody was on my case for a while. Even today, I really don't know – why the hell am I hanging around now? I'm tied here by love, being loved and cared for.
Yet, despite his distress at being compelled to prolong his life, this patient later acknowledged that the surgery ‘gave me the promise of perhaps something positive in the future, which I had given up. That's why I said, truth to be known, who knows, maybe I will open the door to life again. I will not climb to the attic and get my revolver’. People deeply desire and are compelled to pursue life extension via technological means in the hope that this pursuit will gain them a new lease on life and an open-ended future. Older individuals in our study commonly spoke of wanting to stay with spouses, to see children and grandchildren and even great-grandchildren grow up, to continue active and vital lives full of gardening, intellectual work, skiing, the ballet and theatre, marathon-running, whatever the case may be. Several had the goal of reaching 100 years old – a ‘nice, round number’. ‘I'm gonna get everything out of life that I can, to squeeze every drop of juice out of it’, one man told us, and many patients shared his sentiment.
Together, the hope of medical intervention, the difficulty of prognostication and the actual gains to life that a great many cardiac procedures confer, contribute to the ethical viability and imperative of treating risk. For practitioners and patients alike, understandings of the mandate to treat at ever-older ages contribute, pragmatically, to the elimination of any significant deliberation about whether or not to treat. Instead, standard practice replaces choice. Moral reflection is rarely made explicit, yet ethical ‘decisions’ are being made all the time in the very routinisation of life-extending procedures. Although physicians baulk at making what they view as subjective moral judgements regarding life and death, physicians continuously enact ethical choices, by default, in the very process of performing life-prolonging procedures. Actual medical practice thus defines clinical ethics, rather than a priori ethical ‘decisions’ shaping practice. By engaging risk, high-tech cardiac treatments preserve hope – in the malleable body, in life extension, in the possibilities afforded by receding old age and in the promise of additional time.
Engaging risk, avoiding death: hope and the pursuit of medical possibility
Using the case of cardiac procedures, this paper has explored the mobilisation of the logic and vocabulary of risk in the clinical care of ageing bodies and the capacity of this discourse to drive technological routinisation. With this example, as in much of medical life extension, the rhetoric of treatment ‘choice’ for both doctors and patients is an over-simplification. The routinisation of intervention, the spectre of present risk and future danger and the perceived opportunities and need to extend life into ever-older age provides the medico-cultural script in which ‘choice’ takes place. The broad cultural incitement to manage risk, the growing technical ease of clinical interventions to do so, the incremental calculation of the risks and benefits of life-prolonging technologies and the normalisation of ever-older persons as patients, together create a socio-ethical landscape in which aggressive medical options are increasingly made available to elderly people, and it is increasingly inconceivable to refuse them when they are offered.
The proactive management of risk and the routinisation of life-extending treatments mobilise hope and dampen uncertainty about the necessity or appropriateness of some procedures. In doing so, this medical activism provides a morally tenable path of action for physicians as well as for patients and families. Many older individuals, their loved ones and their healthcare providers seem to experience the technological imperative as hope materialised and actualised. They place considerable faith in the reliability of biomedical technologies, and are caught up in the promise of a life prolonged by the eradication of risks and the assumed ability of cardiac procedures to deliver on this promise. Thus, doctors, patients and families together heed the imperative to act and to treat risk, failing to warn or see that the risk for disease still remains and that the procedures come with their own risks and sometimes questionable gains. Instead, hope based on possibility, on the chance that their time might be extended – rather than belief rooted in probability, or the actual likelihood of a longer life – is what contemporary biomedical practices of risk management in old age evoke, and what drives their routinisation. In turn, medical intervention in the name of hope, possibility and optimism takes on a moral imperative, and comes to embody new ethical obligations to pursue clinical solutions to the ‘problems’ of ageing and risk (Kaufman et al. 2004).
This inexorable push to reduce risk and prolong late life has important ramifications for how we, as individuals, families and a society, approach ageing, death and their inevitability. The model of ‘successful ageing’, of which technological life extension and the incessant management of risk is a major part, presents an ideal of growing older without ageing (Katz and Marshall 2003), of optimal lifestyles and of strategies to maximise health and longevity. Holstein and Minkler (2003: 795), in their analysis and critique of this ‘successful ageing’ paradigm, ask, ‘How can we respect aging if we do everything in our power to deny it?’. Older individuals, along with their loved ones and their clinicians, when faced with the routine interventions to reduce the risks of cardiac disease and death, understandably find it difficult and even impossible to refuse them. Such interventions, after all, allow hope for the future. As the management of risk via medical care is further routinised, the options for all of us are narrowed to the biomedical sphere, and there is little incentive or inclination to fashion alternative approaches to very late life.
A long life with as few medical risks as possible, the untethering of our futures from our corporeal limits and the promise of vital time left are the objects of desire pursued in cardiac procedures for ever-older adults. Hope and the pursuit of medical possibility obscure the reality that while risk can be (and increasingly is) treated, it cannot be eliminated. We do not take an ideological stand on whether, when or to what extent life-prolonging cardiac procedures, or any other treatment available in late life, should be used among the very old. Rather, as social scientists, we have tried to show that the routine practices of life extension are changing the facts about old age, ageing and standard clinical care. Successful risk-reducing procedures legitimate clinical intervention on ever-older bodies, and their normalisation constitutes a mode of ethical engagement for medicine that questions the goals of medicine for an ageing and risk-oriented society.
A stent is a short tube of stainless steel wire mesh. It holds open the artery so that blood can flow through it.
Electrophysiology is the sub-specialty within cardiology that focuses on heart rhythms and treatments for abnormal rhythms, like pacemakers and implantable cardioverter defibrillators.
Ideally, future studies would report actual patient-doctor conversations regarding, and interactions around, procedures and their risks. We are indebted to an anonymous reviewer for pointing this out.
CABG procedures among those aged 65 and older increased from 204,000 in 1990 to 279,000 in 2002 (Bernstein et al. 2003). Bypass surgery is now commonplace for persons in their eighties and not unusual for persons in their nineties (Schmitz et al. 1998, Stemmer and Aronow 1998). There has been phenomenal growth in the use of stents, increasing from 85,000 procedures among those 65 and older in 1996, to 233,000 in 2000 (Graves and Kozak 1998, Kozak et al. 2002).
For example, Peterson and colleagues (2004), in an analysis of clinical registry data on patients aged 75 years or more who had undergone percutaneous coronary intervention (PCI) – which includes angioplasty and stents – and coronary bypass surgery, found that mortality for PCI declined from 2.7 per cent in 1991 to 1.15 per cent in 1997. Similarly, mortality rates for bypass surgery also decreased from 5.9 per cent in 1991 to 4.98 per cent in 1998.
While our analysis reveals that most older patients reported continued good or significantly improved physical function following angioplasty, stent and/or bypass surgery, and described very positive feelings regarding their ability to engage in activities and everyday life, some participants expressed disappointment regarding their health status following their treatment. Five respondents were dissatisfied in some way by the outcomes of their procedures: one individual found his recovery to be going very slowly with no clear indication that his physical condition would eventually improve, three were experiencing continued symptoms (such as chest pain and breathlessness) and one had suffered a heart attack some six months after undergoing surgery. Four of the 28 patients in our sample (including two who expressed feeling dissatisfied) reported that they were ‘depressed’ following their cardiac interventions; we should note however that we did not solicit this information specifically nor did we measure depression in any way, but rather asked participants to describe their recovery in the months following their treatment. The literature on outcomes of coronary bypass surgery documents that about 20–25 per cent of patients experience depression following the procedure (McKhann et al. 1997, Pirraglia et al. 1999), and that the existence of significant depressive symptoms is an independent risk factor for increased morbidity and mortality following bypass surgery (Blumenthal et al. 2003, Connerney et al. 2001) or cardiac catheterisation (Sullivan et al. 2003).
The only specific bodily feature physicians designated as ‘old’ in our interviews was coronary arteries. For example, one surgeon explained that ‘once the patients get really old, bypass surgery is very difficult just technically, the sewing on very old, brittle arteries. They have a lot more bleeding, they have more strokes, they have – just technically, it's a very difficult thing to do’. Another surgeon recounted, ‘About a decade ago, a 90-year-old lady talked one of my associates into a bypass surgery. She got the bypass. She sat in the hospital for two weeks, not getting better, not getting worse. And one of the grafts occluded and she died. I mean 90-year-old vessels are 90-year-old vessels. Even though she's a, quote, “young” 90, the vessels are old’.
In 2002, a total of 608,000 operations for the insertion of stents, 279,000 coronary artery bypass surgeries, and 659,000 cardiac catheterizations were performed among those 65 years of age and older in the US (DeFrances and Hall 2004). That same year, 358,000 operations for the insertion, replacement, removal and revision of pacemaker leads and devices – a procedure category that includes defibrillator implantations – were performed among people aged 65 years and older.
The question arises as to who might be left out of the ‘technology parade’, whether it is uniformly available to patients, or if it is differentially available based on, for example, race, social class, gender, insurance status, degree of patient proactiveness and regional differences. The data used for the analysis in this section comes from interviews with physicians working in a variety of practice settings, ranging from academic medical centres to community hospitals, located in fairly well-to-do neighborhoods as well as in inner-city communities. All of the physicians in our sample treat patients with coverage under Medicaid (the US federal health program for low-income individuals), and in fact, many of the physicians in their comments said explicitly that they did not know the insurance status of their patients. However, we do not have the data to address whether and how patients’ sociodemographic characteristics affect the extent to which technological incrementalism and the ‘technology parade’ get played out. Certainly, there is a significant and growing body of literature that documents that men receive cardiac procedures more often than women (e.g. Ayanian and Epstein 1991, Epstein et al. 2003, Krumholz et al. 1992), and white patients more so than racial minorities (e.g. Epstein et al. 2003, Groeneveld et al. 2005, Holmes et al. 2005). In particular, some research indicates the potential relevance of provider perceptions and their effects on referral patterns and clinical decision-making (Kressin et al. 2004, Mosca et al. 2005, Schulman et al. 1999). Not only may these gender and racial disparities in cardiac care be in part a product of the dynamics of technological incrementalism and the momentum to treat that we point to here, but also the disparities may only tell part of the picture: if, as our study suggests, those patients who undergo procedures are then more likely to be offered additional interventions, then the treatment gap between those receiving interventions and those who do not may in fact widen over time. Further studies should explore these possibilities.
This research was funded by the National Institute on Aging, grant AG20962, to Sharon R. Kaufman, Principal Investigator. This article represents a collaboration among the authors and is part of an ongoing study of life extension and an ageing society. We are indebted to the health professionals, patients, and families who welcomed our interviews in 2002–04.