Should a 97-year-old man undergo an expensive, dangerous open-heart operation to repair a lethal tear in a main artery of his heart?
No, concluded the patient, Michael DeBakey, the world-famous cardiovascular surgeon who pioneered the operation. Yes, said his family and surgeons, who prevailed after DeBakey lapsed into coma.
DeBakey later said they did the right thing. After a long, touch-and-go recovery, he resumed a busy schedule before his death last July at age 99.
DeBakey was a visionary, a genius, but his dilemma has become increasingly ordinary. Age is no longer the deciding factor, even for invasive treatment such as open-heart surgery.
"You have to get out of the idea that there's a threshold age where we think about this surgery differently," Charles Bridges, Pennsylvania Hospital's chief of cardiothoracic surgery, said. "With each patient, you have to lay out: What are the risks if I do this? What are the risks if I don't?"
A more basic question is whether this never-too-old approach is an example of U.S. medical progress, or an example of why Medicare - federal health insurance for people over 64 - is headed for insolvency.
The answer, experts say, is both. Which is why the current debate over expanding federal coverage to all uninsured Americans is an ethical and economic minefield.
"Forty years ago, it was taken for granted that the elderly were not good candidates for organ transplantation, dialysis, or advanced surgical procedures. That has changed," Daniel Callahan, cofounder of the Hastings Center, a bioethics research institute in Garrison, N.Y., wrote recently. "Under the best of circumstances, age should be irrelevant in the Medicare program. But so far, the cost of care has not been considered, and it can hardly remain irrelevant in a program strapped for money."
Americans 85 and older are a small but exponentially growing bunch, according to census data. Fifteen years ago, there were 3.4 million. Now, there are six million. By 2050, baby boomers will swell the number to 20 million - 5 percent of the U.S. population - including one million centenarians.
Life expectancy at such old ages is relatively short, emphasis on "relatively."
"It's not as short as you might think," Bridges said. "If you're 81 and a woman, your life expectancy is about eight or nine years. At 90, it could be five or six years."
Last fall, when 87-year-old Ruth Fritz of Harleysville consulted Bridges, her outlook was more like a year. Her aortic valve had become rigid and immobile, hampering blood flow through the artery that supplies most of the body's major organs. Despite overall good health, her heart was failing.
"I knew it was either a case of going through the surgery and surviving, or just going on trying to live, never knowing when my heart would give out," the petite widow said last month, immaculately turned out in a kelly green blouse and navy skirt.
For Bridges, Fritz's age posed less of a challenge than did her religious convictions. As a Jehovah's Witness, she said she would rather die than be given a blood transfusion - even though half of open-heart patients require one.
Bridges minimized blood loss with a variety of techniques, including a miniature heart-lung bypass machine and meticulous cauterization of even tiny blood vessels.
Now, five months later, Fritz goes to a senior center three days a week and says her quality of life is excellent. No matter that she relies on a walker, can't yet climb stairs, and is living with her daughter instead of in her own home.
"I'm still in physical therapy and will be for a while," Fritz said. "But I'd tell anyone that they should go ahead and have the surgery."
Over the last decade in the greater Philadelphia area, nearly 1,800 people 85 and older have had their chests cut open to repair or replace cardiac valves or vessels, or both, according to hospital discharge data.
|
|
|
|
|
|
MOST POPULAR PHILLY.COM PHOTOS
Daily Headlines
Subscribe now! Daily Headlines Newsletter
Philly.com news blogs
Philly.com Promotions
