Reviving Tithonus

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The better we get at bringing the dead back to life, the harder it is to reckon with the consequences.

expert_cpr_eganBy David Casarett | First, the good news: If you drop dead today of a cardiac arrest, your chances of rejoining the living are better than they’ve ever been. The odds might be as good as one in three.

You can thank relatively recent advances in technology for your second lease on life. Two hundred years ago, the best resuscitation science involved tickling cardiac arrest victims with feathers, rolling them over a barrel, and strapping them to the back of a trotting horse. Now paramedics can bring specialized medical care to your doorstep, defibrillators can restart your heart, and intensive care units can make sure it keeps beating. That’s progress.

You can also thank a new kind of CPR. Bringing people back to life is no longer solely the responsibility of paramedics and physicians. It’s been taken over by friendly bystanders.

One of the oddest—yet most emblematic—examples of this happened in 2011, when 9-year-old Tristin Saghin successfully performed CPR on his 2-year-old sister, Brooke. He explained later that he was emulating a scene he remembered from the film Black Hawk Down, in which a character was “like, pushing on [the victim’s] chest and giving him rescue breaths.” Brooke recovered, and Tristin got a congratulatory message from the film’s producer, Jerry Bruckheimer.

The fact that anyone can do CPR without formal training was good news for Brooke Saghin, who is now leading a normal life thanks to her brother’s quick thinking. (Not to mention his taste in film. Imagine where Brooke would be now if her brother had stuck to The Sound of Music.)

Better still, good Samaritans now have access to more advanced tools of resuscitation, like automated external defibrillators (AEDs). These devices let bystanders restart a heart, making anyone a paramedic, at least for a few milliseconds. AEDs are already common in public places, and they may become even more prevalent thanks to lawsuits like the one that the family of Mary Ann Verdugo brought against Target several years ago. It argued that Verdugo’s 2008 death in a Target store could have been avoided if the store had made an AED available on the premises. Although the California Supreme Court recently decided that Target didn’t have a common-law duty to provide AEDs, Verdugo’s case isn’t over, and it goes next to the US Ninth Circuit Court of Appeals.

No business wants that kind of negative publicity, so it’s not difficult to imagine that AEDs will proliferate in public and commercial spaces. Numerous states already require them in certain settings, like health clubs (California), schools (Maryland), and state offices (Nevada). And it seems likely that stores like Target might decide that installing the devices is the best way to avoid future lawsuits.

The increasing availability of CPR and AEDs will revive some people like Brooke Saghin, which is certainly good news. But they will also revive other people who are older and sicker, and who have multiple complex medical problems that will still be there when they wake up—if they wake up.

This is the Tithonus problem. Tithonus is described in Greek mythology as one of the lovers of Eos, goddess of the dawn. That, you’d think, would be enough to make any guy happy. Who could ask for more?

Well, Eos and Tithonus did. They asked Zeus to grant Tithonus immortality so they could be together forever.

The problem was that neither of the happy couple thought to ask Zeus for eternal youth. And Zeus, no doubt chuckling quietly, didn’t suggest it either. So although Tithonus lived forever, he continued to age. Gradually he became frail, weak, and incoherent. In the end, Homer tells us, when he had no strength in his limbs, Eos locked him away. (In some versions of the tale, Eos turned him into a grasshopper, which isn’t much better.)

Tithonus’s fate illustrates why some people might not want to be brought back to life. They don’t want to become victims of the same practical joke that Zeus played on those two lovers. Resuscitation can revive cardiac arrest victims, at least in the short term. But it can’t restore youth. Nor can it treat many of the other maladies that come with age.

As a hospice doctor, I often take care of patients who have been brought back from the dead. They’re alive when they wouldn’t otherwise be. But their brains are failing, their kidneys aren’t working, and their hearts are weakened. And their limbs, as Homer would have put it, are without strength.

And these advances in the science of bringing back the dead don’t just extend life, they also change how—and how expensively—we die. If bystanders are successful in bringing you back from the dead, then you’ve traded a quick, sudden (and often unexpected) death for one that’s likely to be more gradual, prolonged, and uncomfortable. Granted, if you’re young and healthy, as Brooke Saghin was, then that’s a pretty good deal. But for many people, that choice isn’t an obvious one.

Absent from the discussion of the advances in resuscitation is any mention of costs. But the bill for all the extra treatment it makes possible can be staggering.

The costs of resuscitation and hospitalization alone can be more than $20,000 per day. And that doesn’t include the cost of procedures that would have been rejected as too risky in some patients 20 years ago— hip replacements, heart bypass surgery—but which are now possible thanks to the new science of resuscitation. Our growing ability to bring someone back to life provides a safety net that makes other treatments possible. Doctors are now able to be more aggressive than they would otherwise be. They can push the envelope of what they’re able to do, because they know that if a patient really gets into trouble, they’ll probable be able to save her.

So for a true reckoning of resuscitation’s costs, you’d need to consider the price of a hip replacement for a woman who wouldn’t have been an operative candidate 10 years ago, or a man who is now eligible for dialysis because there’s a safety net.

When a safety net encourages risk-taking, it creates what’s known in the insurance business as a “moral hazard.” It’s a little like bankruptcy laws that give debtors a way out. Bankruptcy may leave you with little or nothing, but at least you can erase your debts and start over.

That seems like a small thing, perhaps. But it’s actually a big change from the historical treatment of bankruptcy, in which debts were punishable by slavery (ancient Greece), imprisonment (19th-century England) or death (Genghis Khan’s mandate, at least for repeat offenders). Just as bankruptcy laws may encourage more risky financial behavior, the availability of resuscitation creates a moral hazard, too.

So treatments that would have been “too risky” only 20 years ago because of the risk of cardiac arrest are now routine. That’s true of surgeries and procedures, of course, but it’s also true of treatments like chemotherapy that come with a risk of complications. Many of my oncology colleagues tell me they’ve become more aggressive in using chemotherapy because they’re more confident that they will be able to rescue a patient from serious complications such as infection or renal failure.

The most fascinating thing about this safety net is that there’s a good chance that most of us have been affected by it. Advances in CPR have impacted far more people than just victims of cardiac arrest. If you’ve undergone a medical procedure as an outpatient, for instance, that procedure was probably made possible by advances in life-saving technology. Hernia repairs, endoscopies, and even wisdom tooth extractions used to be conducted in the operating room, but can now be conducted in an outpatient surgery suite. That’s because, even in a small clinic, the science of resuscitation is light years ahead of what could have been accomplished by an entire team in an operating room as little as 10 years ago.

Is that a good thing? Remember that most people who suffer a cardiac arrest have other health problems, like coronary artery disease, kidney failure, lung disease, or the early stages of Alzheimer’s disease. They’re trading a quick death due to cardiac arrest for a slow death due to other illnesses. Which would you choose?

That question is going to become more common as the science of resuscitation gets more effective—and as our healthcare expenditures continue to eat up a growing portion of our wealth. Just as we’ve come a long way since the days of feathers, horses, and barrels, the future is likely to bring more spectacular successes. And every day there are more people trained to do CPR, more AEDs available, and more bystanders ready to wield them.

Those bystanders only have the best intentions, of course. But so did Eos. And every time one of my patients survives a cardiac arrest only to spend weeks in an ICU, I imagine that Zeus is up there, somewhere, wondering why we humans never learn.

David Casarett is the director of hospice and palliative care and a professor of medicine at the Perelman School of Medicine. This essay is adapted from SHOCKED: Adventures in Bringing Back the Recently Dead, by David Casarett, with permission of Current, a member of Penguin Group (USA) LLC, A Penguin Random House Company. Copyright © David Casarett, 2014.
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