Society of Certified Senior Advisors: Can You Be Too Old for Surgery?

Operating on older adults can have negative outcomes. Is there an age where we should no longer be on an operating table?

Bob McHenry’s heart was failing. At 82, the surgeries he needed were high risk, but otherwise he would die. The surgeon went over possible complications, but it felt to the family like there was only one alternative. They agreed to the operations.

A national study published by researchers at the Yale School of Medicine found that one in seven older adults (65 and up) dies within a year of having a major surgery. A third of those with likely dementia will perish, while older adults with frailty and/or having emergency surgery are even more likely to die. Age plays a role, too. At age 90 and above, patients are six times more likely to die than those aged 65 to 69.

Quality vs. Quantity

Of critical importance to older adults is what their life may look like after surgery. Will they have disabilities? Can they live independently? Will their quality of life be worse?

Bob McHenry had a stroke during his first operation. After the anesthesia wore off, he had severe cognitive impairment and couldn’t swallow or speak. Although he lived another five years, they were marked by increasing dementia and physical decline. His daughter, Karen McHenry, regretted the decision to operate from the day it took place.

More researchers are starting to look at quality of life after surgery, as well as quantity. One of the Yale researchers, Dr. Thomas Gill, found that among older adults, one in three had failed to return to baseline functionality six months following major surgery.

“What older patients want to know is, ‘What’s my life going to look like?’” Dr. Zara Cooper, a professor of surgery at Harvard Medical School and the director of the Center for Geriatric Surgery at Brigham and Women’s Hospital in Boston, said. “But we haven’t been able to answer with data of this quality before.”

The new data may usher in a whole new approach to determining if surgery is ethical.

“This opens up all kinds of questions: Were these surgeries done for a good reason? How is appropriate surgery defined? Were the decisions to perform surgery made after eliciting the patient’s priorities and determining whether surgery would achieve them?” said Dr. Clifford Ko, a professor of surgery at UCLA School of Medicine and director of the Division of Research and Optimal Patient Care at the American College of Surgeons.

As the 65-and-over population increases, they will face two further obstacles. Medicare spends a little over half of its total budget for inpatient and outpatient surgical care, according to an analysis done in 2020. And fewer people are deciding to become physicians, including surgeons in a wide range of specialties. By 2033, there will be 30,000 fewer surgeons than needed to meet the anticipated demand.

One thing doctors can do is talk to patients about expectations before deciding on whether or not to undergo the knife. As it turns out, older adults have different criteria for deciding if surgery is the right answer for them. They most value the ability to live independently and spend quality time with loved ones, according to Ko. Doctors need to engage in shared decision-making with patients, telling them the best outcome and the worst, and letting them know what life will be like if things don’t go well on the operating table.

Five Questions

Surgeons can guide decisions by asking five questions, according to Cooper:

How does your health affect your day-to-day life?
When you think about your health, what’s most important to you? What are you expecting to gain from this operation?
What health conditions or treatments worry you most?
What abilities are so critical to you that you can’t imagine living without them?

Some surgeons are also using standards of care that are particular to their older patients. One of these is “twilight” anesthesia, which uses mild doses of drugs to block pain, reduce anxiety and induce a temporary loss of memory. Another is to provide non-narcotic painkillers after procedures.

As for the McHenry family, Bob’s wife, Marjorie, fell and broke five ribs several years after her husband’s fateful operation. A lung collapsed, and she had internal bleeding. Doctors proposed a complex surgery. Daughter Karen intervened.

“This time around, I knew what questions to ask, but it was still hard to get a helpful response from the surgeons,” Karen said. “I have a vivid memory of the doctor saying, ‘Well, I’m an awesome surgeon.’ And I thought to myself, ‘I’m sure you are, but my mom is 88 years old and frail. And I don’t see how this is going to end well.’”

Her mother discussed her situation with the palliative care team and decided against undergoing surgery. Three years later she is mentally sharp, moves around well with her walker, and enjoys the activities offered in a care facility.

“We took the risk that Mom might have a shorter life but a higher quality of life without surgery,” Karen said. “And we kind of won that gamble after having lost it with my dad.”