In a short operation yesterday, surgeons replaced the pacemaker of a 115-year-old Baltimore man. The battery in the original one, implanted when John E. Bell was 104, had run out.
Because of his general good health and the low risk of the operation, physicians at Johns Hopkins Hospital had little doubt that Bell should get the procedure.
His heart's internal system for signaling beats no longer works. Without the pacemaker, he would die.
"He outlived the battery," said Dr. Ronald Berger, the Hopkins cardiac electrophysiologist who performed the surgery.
The case illustrates the questions society faces in the coming years, as huge demographic and economic forces collide.
More Americans are living longer, surviving into their 90s, many past 100. The baby boom is not far behind. In 2000, about 13 percent of the population -- or roughly 36 million people -- will be over 65. By 2040, that will rise to about 23 percent, or about 80 million. Those over the age of 85, the fastest-growing segment of the population, will more than double between 2000 and 2040.
But the high health costs for the elderly are outpacing the dollars available to pay for their care.
While the elderly now make up about 12 percent of the U.S. population, they generate 36 percent of health costs. The Medicare program, which pays for most health care for the elderly, is among the biggest federal expenditures -- and is a target for cuts that would balance the federal budget. Still, last year, experts predicted that the part that pays for hospital bills will be insolvent by 2001.
Easy question to answer
Medicare will pick up most of the bill for Bell's procedure, roughly $6,500. For Bell and the family he lives with, there was little debate.
Alice Brown, 55, asked him: "You want another pacemaker since that one is running out?"
Bell answered emphatically, "Yeah."
Then she asked: "You want to keep on living, don't you?"
Again, he replied, "Yeah."
"We're talking about a device that sustains life on an every-beat basis. This is much more analogous to food. Would you say at some point, 'This gentleman should no longer be given food because he's over 100'?" asked Berger. "He deserves to have a heartbeat for as long as the rest of his body allows him to."
Except for glaucoma that has blinded him in the left eye and a stroke about 10 years ago, Bell is in good health, said Dr. Stephen Achuff, Bell's cardiologist. He isn't on any medications, even though Ethel Johnson, 75, who took him in when he was ill and alone, takes five medicines herself.
Bell has entertained this family with stories of presidents as far back as William McKinley and Theodore Roosevelt. His parents showed him where slaves came into Baltimore through a tunnel near what is now Martin Luther King Boulevard. He was in his late 30s in World War I, and nearly 60 when World War II broke out.
A preacher and good Samaritan, Bell picked up trash in the Oldtown neighborhood, and helped the poor obtain furniture and families get into public housing.
Nicknamed the "Mayor of Oldtown," he was a familiar sight for years, walking the mall in his natty blazer, tie and hat. Over the years, he was often honored for his community work, including one award in 1981, when he was 100.
Yesterday, in the hospital, he explained why he has lived so long.
"I treat everybody like they should be treated," Bell said, in a slightly high-pitched tone, his brown eyes bright. "God said, 'Feed his sheep.' "
Dr. Richard Suzman, director of the office of demography at the National Institute on Aging, said Bell is probably among the oldest men in America. The oldest person who has good evidence of her age is a 122-year-old Frenchwoman, although anecdotes suggest some Asians may be older.
"Manufacturers are going to have to increase the durability of their pacemaker batteries," said Suzman. He said preliminary findings are emerging that once a person gets past age 95 or so, the force of mortality lessens.
"The important question is not just surviving, but surviving in what condition and with what quality of life," Suzman added.
Some believe that increased longevity will create a new paradigm. Rather than rushing -- under pressure to graduate from college, establish a career and start a family -- people would be able to live, in effect, more than one life.
Dr. Ronald Klatz, president of American Academy of Anti-Aging Medicine in Chicago, suggests traveling the world as a poet or artist until age 30. Age 40 would be considered adolescence. He already knows people who are going back to school and starting second careers at age 70.
"Just 20 years ago, living to be 100 was mythical," Klatz said. "This is the most important sociological revolution to happen to men since the invention of the telephone or computer."
There are many reasons for the increasing longevity.
Since the turn of the century, vast improvements in sanitation and the creation of antibiotics and vaccines have cut the death rate for every age category. In the past 30 years, medical advances have saved many, such as victims of heart attack or childhood leukemia. People are living healthier -- exercising, not smoking, and eating better.
Medical technology, such as pacemakers and ventilators, can also extend life. But ethicists say it must be used selectively.
"There is a real tension in taking care of older people. You can't just say because someone's 100 years old, they shouldn't get a pacemaker or even some types of surgery," said Dr. Eric DiJonge, a geriatrician at Hopkins Bayview Medical Center. "But similarly, for many people 80 and 90 years old, much of the drugs and intensive medical care is both not appropriate and very expensive."
In one of his cases, a 90-year-old man has a blockage of his prostate. The man also has dementia. It's unclear whether the blockage is cancerous or benign, but to operate would mean risks, including worse incontinence and possible death. It may be better for the man to live with a mild obstruction than to go through surgery.
"Patients and families need to understand that there is no blank check for unlimited amount of medical care," DiJonge said. But, he believes that if doctors and patients used the expensive technology selectively, costs could be reduced at the bedside -- rather than having some outside entity set limits.
At Hopkins, doctors were expecting to send Bell home from the hospital today. Said Dr. Berger: "I'll be delighted to replace the pacemaker when he's 125."
Pub Date: 4/18/97