Half of the Story

Today's Philadelphia Inquirer has a front-page discussion about expensive surgical interventions in the very aged. They find a few examples of unusually vigorous geriatric patients (including the world-renown cardiac surgeon Michael DeBakey himself, who had an aortic repair at age 97 and lived productively for another two years) and indulge in the usual extrapolation of costs multiplied by the numbers of aging baby boomers. Once again, they get half the story right.

Pennsylvania Hospital's chief of cardiothoracic surgery, Charles Bridges, is correctly quoted thusly:

You have to get out of the idea that there's a threshold age where we think about this surgery differently. With each patient, you have to lay out: What are the risks if I do this? What are the risks if I don't?

This is an accurate statement of the clinical reasoning required in these scenarios. I agree that there is no arbitrary age threshold above which any given medical intervention should be withheld. Treatment needs to be individualized based on the clinical condition of the patient.

The actual problem is that people in really crappy condition undergo all kinds of heroic interventions all the time, because they're "so young!" Or because some hotshot surgeon thinks he can pull them through, because, yanno, his skills are so extraordinary they can overcome the effect of years of diabetes, smoking and inactivity. (Hint: no, they can't.) Or because the family feels so guilty about neglecting poor demented granny in the nursing home that when she becomes septic and her kidneys fail, of course she need dialysis! You can't let her die!!

There's another great line further on in the article:

[We] are all suffering from a terminal, sexually transmitted disease called life.

So true, yet so difficult for Americans to accept.

A better way to address the issue of health care rationing (yes, I said the r-word) is to base treatment decisions on the patient's clinical condition. Things like whether or not they are still working (like my 81-year-old father), their mental status (why are we performing elective procedures on patients with advanced dementia?), and their co-morbidities (there's a huge difference between the active 85-year-old on only 1 or 2 meds -- yes, they exist -- and the bloated, diabetic, smoking couch potato in his 60s).

A cost-effective, medically appropriate way to address this issue is to curb overtreatment in those patients with advanced dementia and multiple co-morbidites, whatever their age. They are the ones who make all this expensive technology respectively futile and dangerous. Both patients and doctors need to get over the mentality that just because something can be done, it ought to be done. This includes eliminating so-called "screening" tests like annual echocardiograms and stress tests for anyone who's ever seen a cardiologist. It means not starting kidney dialysis in the face of advanced dementia. Perhaps it even means not transferring septic nursing home patients to hospitals in the first place.

We shouldn't be arguing about operating on healthy 90-year-olds. It's the frail, fragile folk in their 70's and younger, bodies wrecked by years of abuse, who ought never to see the inside of an OR in the first place, but who all too often are whisked there without a second thought. We need to start telling the other half of the story.