Sunday, July 20, 2008

Surgery on the Elderly

This article in the NY Times caught my attention the other day. The ethical implications of performing potentially life saving invasive procedures on the extreme elderly (nonegenarians and centarians) is addressed in the usual superficial, newspaper way. But it's a topic that will become more and more relevant as the American population continues to age.

Certainly, rationing of health care is something that is an inevitable component of any potential "universal" health care system that gets implemented in the future. Resources are limited and there's a finite amount of federal money to finance the endeavor. Something has to give. Certain subsets are going to have to do without.

But you start to tread in dangerous waters when you use arbitrary data points like chronological age as a determining factor in who gets the colectomy and who has to die with the bleeding sigmoid tumor. Age is a number. As is weight and height and your 40 yard dash time. Statistically, a patient who is 95 years old obviously has a higher risk of having major complications following routine surgery compared to a 35 year old. But are the risks any higher than in a 58 year old obese male with CAD, DM, three stents in his coronaries, on Plavix and aspirin? I'll choose the 95 year old who takes lipitor and last visited a hospital for the birth of her last child 60 years ago every single time.

Last week I rushed a 97 year lady to the OR for an incarcerated inguinal hernia. She lived in an assisted living facility near her son, was completely coherent, and spent most of her afternoons listening to classical music and chatting with her little old lady friends. The surgery went well. She went back to the facility on post op day 3. What if there was a policy limiting what I could offer her, just because she was older than say, 95 years old? Why is that even an ethical question? Someone on my post on the passing of Michael DeBakey questioned the "ethics" of his thoracic aorta surgery when he was 97. Well, he recovered and went ultimately went home. There isn't anything "ethical" about operating on a coherent, informed, vibrant human being who chooses to undergo a potentially dangerous procedure for the purpose of alleviating a source of unnecessary suffering. It transcends all questions of ethics. We don't need committees to meet and pontificate and decide what to do in those situations. It's simply treating a human being with the respect and dignity that they deserve. That ought to come natural, if you're a physician who's worth a damn. Let's save the ethics committees for the truly vexing cases; the demented 82 year old languishing in an ICU with decubitus ulcers who's only live family member wants her to have a PEG tube and an AV fistula for dialysis....

By the way, I had posted about an emergency operation on a 99 year old lady. She actually recovered and went back to her nursing home, celebrating her 100th birthday last month....

12 comments:

make mine trauma said...

At age 94 my grandmother's fall resulted in a femoral neck fx. She was in the hospital (in your town) and fortunately had only a hip pinning, she was out of the hospital in no time and into rehab where she complained about the food so loudly that she refused to eat it (she is still a farm girl used to eating out of a garden. My aunt had to come down and bring her food so she would eat!) She breezed through rehab, is home now and her 95th is this week. I fully expect her to make it to 100.

MedZag said...

Was just at a talk about this very topic at a CT conference the other day. The presenter agreed with your points for the most part, as do I. The "ethics" of rationing medical care transcend anything as arbitrary as age. Studies have shown that morbidity/mortality in surgical interventions in octogenarians vs. septuagenarians (and nonegenarians vs. octagenarians) rose only ~2% with still very high % of good outcomes when the study population bases are adjusted for disease. Age itself is not the damning factor, progression and severity of various diseases were. Obviously a 3 pack a day diabetic 58 year old vasculopath screams "post-op complications" compared to a 91 year old man who has never touched a cigarette in his life and is still independent and mobile.

Bongi said...

last night i operated a 91 year old with perforated peptic ulcer and atrial fibrillation. now, sinus rhythm and recovering.

if i didn't operate her, she would have died. with an operation i expected about a 70% chance of dying (thumbsuck). still, i think the decision was easy, even without hindsight.

Alice said...

I have an 91yr old patient who came in septic with perforated bowel about to leave the hospital, coherent and happy, in less than a week, and a 70yr old who came in with an incarcerated hernia, dying after a month in the ICU. Their age is not what separated them.

The Happy Hospitalist said...

It becomes ethical if you are forced to choose between doing surgery on a 98 year old or a 2 year old. Take your pick. The government can only afford to pay for one. Which one do you chose?

We will eventually get there at the rate of financial disaster our Medicare system is heading toward.

Anonymous said...

But of course. The 98 year old has paid for his surgery during a lifetime of contributions. The 2 year old has not paid any dues and his contributions are only potential.

Anonymous said...

Let's stop the expensive futile care (in ICU for 2 months, multi-organ failure, still on the vent)...

Then we can talk about stopping the expensive care that actually improves quality of life.

rlbates said...

So glad the little old lady from the earlier post got to celebrate her 100th birthday!

Steve said...

Would anyone know what kind of surgery a 90 year old male (sedentary but no other major problems) with a partially obstructing sigmoid cancer tumor should have?

Our surgeon does not exactly know what he will do, but decide as he performs the operation.

It could be just a colostomy done, under mild anesthesia, leaving the cancer in. Or it could be a removal of the tumor with a cut-and-stitch only (somewhat risky for leaks) or with colostomy. Laparoscopic surgery would be favored over open cut.

Can 90 year old stand being under anesthesia for a long surgery like this? Should open cut be performed to speed up the operation even though the recovery time is longer/ more risk of infection?

We will get a 2nd opinion, but I'm just curious if anyone can shed some more light.

Anonymous said...

Currently in America only convicted criminals have a Constitutional right to health care so we need to spend on the 98's and the 2 year old and pray the system changes for the better.

My mother is 91 and was just told she has colon cancer. We are currently having the conversations about should she have surgery or not. She is in general good health and takes no meds except over the counter stool softener, but the pain she has been suffering has caused her to sit more and she is becoming weaker all the time. Families are faced with the same hard decisions drs make. I hope we make the right one for her.

Clayton said...

I WAS HAPPY TO SEE YOUR ARTICLES ABOUT SURGERY ON OLDER CITIZENS.

I AM 80 YEARS OLD WITH AN INGUINAL HERNIA THAT DOCTORS REFUSE TO OPERATE BECAUSE THEY FEAR THAT THE GENERAL ANESTHESIA COULD BE A GREAT RISK.MEANWHILE I SUFFER FROM PAIN AND DEPRESION BECAUSE I CAN HARDLY LIVE SUFFERING ANY MORE.

I don't care if you censor this. said...

Eat shit with your "Healthcare will be rationed" It hasn't happened anywhere in the world, and it won't happen in America if universal healthcare is handled with any decency or humanity.