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Surgery in the super old: Success at what price?

But she certainly can walk if she wants to, and often does, thanks to the total knee replacement surgery she had two years ago, when she was merely 100.

“She can’t do distance, but she walks,” says Vette’s 75-year-old daughter, Carolyn Nelson of Denver. “She takes her roll of nickels and goes gambling.”

The operation was Vette’s third joint replacement — she had one hip done in her 70s and the other in her 80s — and it makes her part of a fast-growing but ethically challenging group of patients: very elderly people who opt for late-life surgery.

Improved medical technology and techniques, combined with a rapidly aging population, mean there’s more need — and more opportunity — for senior surgeries than ever, said Dr. Mark Katlic, director of Thoracic Surgery at the Geisinger Wyoming Valley Medical Center in Wilkes-Barre, Penn.

“All of the conditions that require surgery increase with increasing age,” said Katlic, who has researched geriatric surgery for 25 years. “Suddenly, there’s been an explosion in operations in the very elderly.”

Along with the rise, though, have come the questions: In a country where health care costs are fast outpacing the ability to pay, and where it’s feared that the federal Medicare program could fail within a decade, should doctors perform surgery on the elderly just because they can? Or are limited resources better reserved for younger people who will benefit longer?

“It’s an ancient problem: the individual good over the common good,” said Daniel Callahan, a medical ethicist and founder of the Hastings Center, a bioethics think-tank in Garrison, N.Y.Callahan is a longtime critic who comes down squarely on the side of the larger society.

“It’s the duty of medicine to get young people to become old,” he said, “not to keep old people alive forever.”

Americans aged 85 and older make up the fastest-growing segment of the population, according to the U.S. census bureau. The number of centenarians — people 100 or older — is expected to rise from about 65,000 now to more than 208,000 by 2030.

Plus, recent research shows that the elderly can fare as well as their younger counterparts after procedures ranging from open-heart surgery and aortic valve repair to spine surgery, joint replacements and organ transplants.

Last month, scientists at the American Heart Association’s annual conference reported that octogenarians in Miami Beach, Fla., who had heart bypass surgery posted survival rates nearly the same as similarly aged people who didn’t have the operations. And patients 80 and older with leaky aortic valves in three New England states survived operations as well as their peers who didn’t need the repair, research showed.

‘80 is the new 50’

“Geriatricians have known for a while that you can’t make treatment decisions based on age alone,” said Dr. Thomas T. Perls, director of the New England Centenarian Study at the Boston University School of Medicine. “I think the medical literature is just catching up with the social observations that 80 is the new 50.”

Certain elderly people are as vital and alert as others decades younger. Thelma Vette, for instance, possessed the health and vigor of a 70-year-old when she showed up for her operation at age 100, said her surgeon, Dr. Richard Evans, chief of adult reconstruction at the University of Arkansas for Medical Sciences in Little Rock.

Aside from a knee deformed by arthritis, she was perfectly capable of surviving surgery and thriving afterward, as are many others, Evans said.

“If you live into your 80s and you’re relatively healthy, your chance of living to 100 is pretty good,” Evans said.

Until very recently, however, many doctors dismissed the notion of surgery in anyone older than about 70, said Katlic. While there were no formal medical prohibitions against the operations, the practice was colored by prejudice, he said.

“It’s ageism,” Katlic said. “Just as racism is an irrational prejudice against the color of one’s skin, ageism is the same against the elderly.”

That’s beginning to change, especially as more doctors perform surgery in old people — with good results. No reliable figures exist about overall surgeries in people older than 85, said Katlic, who expressed frustration at the lack of data.

But snapshots in several fields confirm that more procedures are being performed in the elderly. Between 1996 and 2005, for instance, the number of organ transplants in people 65 and older nearly tripled in the United States, from 1,145 to 3,154, according to federal statistics.

Between 2000 and 2005, the number of hospital discharges for patients 85 and older who had  total or partial hip replacements rose from about 52,000 to 56,000, according to the federal Agency for Healthcare Resarch and Quality. The number of insertions or removals of cardiac defibrillators and pacemakers rose from more than 46,000 to nearly 60,000.

The primary risk for elderly candidates isn’t the surgery itself, but the recovery afterward, Katlic said. Although seniors do well with planned surgeries, emergency surgery in very old people remains risky.

''The biggest change in the human body is the lack of reserve,” he said. “They tolerate operations, but not complications.”

Hard choices with limited resources

The question for some critics, however, is not whether older people can tolerate the surgeries, but whether they should. Two decades ago, Callahan, the ethicist, suggested that age 80 should be a cut-off for expensive operations like open-heart surgery.

He has since softened his stance, and, at 78, said he’s not sure how he would respond himself to the need for life-saving surgery. “I’m willing to concede that age alone isn’t it,” he said.

But in a country where spiraling health costs mean the federal Medicare program could reach 20 percent of all government spending by 2016, up from about 16 percent now, Callahan said there’s no avoiding hard choices about resources.

“If the whole Medicare program is threatened by costs, there will be a whole number of people who will be harmed: Young, old, everyone,” he said.

The financial situation is dire, agreed Katlic and Perls, but any health reform solution has to take factors other than age into account.

“If people are out there saying, ‘Aren’t we wasting money on people at 100 or older?’ I’d say if the person is functionally doing well, as long as it can be done safely, I think it should be done,” Perls said. “If it is a quality-of-life issue, one needs to consider if it was their own mother or father, what would they do?’”

For Thelma Vette’s daughter, there’s no question that her mother — and other elderly patients — should have had the surgery, which cost hospitals an average of more than $38,000 in 2006. Medicare reimbursement was about $12,000, federal figures showed.

“Why should they have to be in pain,” Nelson said. “I don’t think anyone should be shut out because of age. If you’re in good health, why should you suffer?”