Happy Birthday, Nonagenarians!: Thoughts On Surgery In The Very Old

On February 26, my dad became a nonagenarian.

My sister and I, and our offspring, had a brilliant celebratory gathering in Tulsa, Oklahoma for my father’s 90th birthday which included playing “The Priest in the Parish has lost his Considering Cap,” taking photos with queen Elizabeth, dancing to music by Glen Miller and The Beastie Boys, singing karaoke, enchilada and beer consumption, and a Powerpoint presentation on his life.
Nonagenarians, individuals aged 90 to 99 years, are the fastest growing age group in the world: nearly doubling from 6.7 million people in 1995, to 12.2 million people in 2010. Projections suggest that by 2050, there will be 71 million people aged 90 years or older.

Increase In Surgeries In The Very Old

Concomitant with the rise in nonagenarian numbers, we are seeing increasing procedures and surgeries performed on the very old.
My father has had 22 surgeries (itemized in detail in the appendix to Book 2 of his memoirs) including four spinal operations, four hip operations and one total knee replacement at the age of 87.
Obviously, he survived them all, but after one spinal operation, while recuperating at my home in Louisville, he awoke in the middle of the night with severe back pain and the inability to move his legs. He had developed an abscess at the wound site which caused overwhelming sepsis and he spent several weeks in an ICU recuperating from this life-threatening complication.
Is there an age at which individuals should not get elective surgery? Or is it the mileage that counts, not the model year?
Complications of surgery definitely go up with age, but we have all seen 90 year olds like my father who are functioning better mentally  and physically than individuals 20 years younger.
According to the Social Security online calculator, the average man his age can expect to live on average 4.3 more years longer.
A more sophisticated tool is the “Living to 100 Life Expectancy Calculator” which asks 40 questions about your health and family history. When my dad entered his information, it gave him a life expectancy of 98 years (I can expect to live to 99).
If we could be sure that he would continue to have a good quality of life after elective surgery for 4 to 8 years it might makes sense to consider elective procedures and operations that improve mobility and lessen pain.
However, I see a lot of deterioration in the quality of my patients’ lives between the age of 85 and 90, and even more between the age of 90 and 95.
By 95, those who have survived are living a fairly limited life; very few are independent and active, mentally and physically.

Excess and Rationing Of Surgery In The Very Old

Michael Debakey, the legendary cardiothoracic surgeon (read about his amazing medical contributions in this NYT obit here)  developed a tear in his aorta at the age of 97. He requested that the life-saving, but extremely high risk surgery for the disease (a procedure he had developed 50 years earlier), not be performed on him.
When he lapsed into unconsciousness, his wife insisted on the operation being performed. Dr. Debakey survived the 7  hour surgery but spent 8 months in the hospital recuperating at a cost of over a million dollars. He died two years later at the age of 99.
It’s hard to know what his quality of life was after the operation. The obituary and other reports say that he “returned to his office and an active schedule,” but the skeptic in me suspects that he was wheeled into his office in a wheelchair where he met with admirers as his strength allowed.
Alternatively, you can find cases exmplified by this headline: “Sentenced to death for being old: The NHS denies life-saving treatment to the elderly, as one man’s chilling story reveals.”  The     N HS or British National Health Service is a single payor system, about which concerns have often been raised regarding rationing surgery to the elderly.
In 2010 the anti-health reform group 60 Plus engaged former Surgeon General C.. Everett Koop to appear in a  video which suggests that Democrats were meeting in secret to craft “death panel” legislation that would ration certain surgical procedures.

Factcheck.org, however, debunks Dr. Koop’s claims:

Former U.S. Surgeon General C. Everett Koop claims that the United Kingdom’s health care system would consider seniors “too old” to qualify for the artificial joints, heart pacemakers and coronary stent that he’s received in the U.S.
U.K. guidelines make clear that patients of “any age” may receive pacemakers, for example. And in fact, official statistics show 47 patients aged 100 or older got new or replacement pacemakers in a single recent year.

My dad now tells me he is pondering replacement of his other knee..
Like most treatment decisions doctors make with patients, computers can aid in providing statistics about average complication rates, longevity, and recovery time but ultimately the recommendations for each individual should be based on their unique, often unmeasurable physical, mental and emotional characteristics.
Age alone should never determine our treatment approach.
I  have a feeling my dad will be tripping the light fantastic with his great grandchildren on two artificial knees when we celebrate with profound joy his 95th birthday.
-May you all become  happy centenarians!
-ACP
To learn the answer to questions like, “Why is the actual heart beat so old-fashioned, you know, boom-boom, boom-boom?” watch this Ali G interview of Dr. Koop: