A. Thank you for your very complete description and the very important questions that your Dads history raises. If doctors have noted any changes in the past 20 years it is that patients are getting older, their problems more complicated, the intervention possibilities more sophisticated, and the ethical questions surrounding care more pressing. In the past two weeks I have had to offer opinions regarding the care of a 93-year-old patient with rectal bleeding, an 89 year old patient with diverticulitis, partial bowel obstruction, and bleeding; and a 91-year-old with colon cancer. These questions come up frequently and most physicians make decisions in relationship to the following issues. First, is the problem potentially curable independent of the patient's age? For instance if the patient is 90 year old, has acute leukemia and enters with bleeding, the decision to provide comfort measures would seem potentially more appropriate than if that exact same patient presented with diverticulitis and hemorrhage which could be cured by a single surgical intervention. The second question that arises in consideration of surgical intervention for elderly patients relates to the ability of the patient to tolerate surgery. The total burden of disease that the patient endures when a new medical problem arises influences the decisions regarding care quite independent of age. However, a 90-year-old patient will likely have a greater burden of disease than those younger. Your father had a limited burden of disease and therefore was a better candidate for standard care independent of age. Although he had a pacemaker in place, his mental status was good, his heart and appeared to be working fine, and there was no evidence of kidney disease. Using these criteria the patient is a fairly good surgical risk that is relatively age independent. On the other hand, an 89-year-old patient presenting with diverticulitis and GI bleeding who also has severe heart and lung disease due to long term smoking and diabetes under poor control would be a very poor candidate for curative surgery and surgical intervention may be rejected for medication and comfort measures. The patient may or may not survive but surgery may be equally risky. A common problem is the 90+-year-old patient who develops a malignancy such as colon cancer or ovarian cancer. If the patient has a surgically treatable malignancy and has a low burden of disease, management decisions are relatively independent of age. If on the other hand the patient has a high burden of disease or a very poor likelihood of control of the disease by surgery then surgical intervention would be a less likely choice. None of these decisions are ethically particularly difficult if one uses burden of disease, risk of surgery, and the likelihood of improving the clinical situation as the parameters guiding the medical decisions rather than age alone. These issues are being discussed more regularly in medical circles as examples arise more and more frequently as the population ages.

The Baby Boomers are caring for elderly parents who are in the 70 to 90 age range. Although life expectancy has improved to the 75 to 80 year age range, even the individual patient at age 90 can expect to receive care including surgical intervention because the ethical decisions match those that would apply to a younger patient. The concept that Dad is 93 years of age and it is his time to die is no longer the norm for decision making in the medical community. The advancements in surgery, particularly laparoscopic (minimally invasive) surgical intervention allow most physicians to tailor a medical care program that is linked to capacity to tolerate surgery rather than on the basis of age alone. However, there are two very sensitive additional issues that influence the medical decision-making. These are quality of life and patient support issues. If the 90 year old patient is totally demented, bed-ridden, in pain, and requires total nursing home care, the decision to withhold total available care is probably the most difficult decision a physician and family must consider because it requires one to conclude that a persons life is no longer of sufficient apparent value to support. The issue of family support cannot be over-looked. Your presence, involvement, and willingness to provide insight regarding your father as well as some care always gives doctors more courage to provide advanced care programs to elderly patients. Because end of life issues and family support are so very sensitive and specific, hospital social workers and ethics providers are at times very helpful resources for making such important decisions. I encourage family members to call upon them in times of uncertainty. I hope this answer is helpful with regard to the care of your father and that he fully recovers.

Dr. Costrinis column appears every other week in the Savannah Morning News. Questions can be addressed to the website ncostrinigeorgiagi.com