How Old Is Too Old for Surgery?

First he made history as a surgeon. Then he made history as a patient.

As he stepped out of the Methodist Hospital in Houston this past September, Dr. Michael DeBakey -- at 97 -- became the oldest survivor of the operation he pioneered himself decades ago.

And though his survival is a testament to both human capacity and will, it also stands as an example of the ethical dilemmas that beset end-of-life care.

Earlier this year, DeBakey had a surgical repair of a dissecting aortic aneurysm -- a tear in the main artery leading from the heart. Aortic dissection is a medical emergency and can quickly lead to death, even with the best treatment.

But the decision to take DeBakey to surgery was not easy for his doctors because of the risks involved. The surgery had never been performed on a 97-year-old, and the chances of success were expected to be minimal at best.

Furthermore, DeBakey himself refused the operation for more than a month for fear of brain damage or permanent disability. But as his condition worsened he lost consciousness.

At this point his family and surgeons decided for him that he would have the surgery -- whether he wanted it or not.

Decision to Go Forward with Surgery Difficult

Surgeons agreed that except for his age, DeBakey overall was in excellent health and had a good chance of making it through surgery.

After consulting with the ethics committee of the hospital and DeBakey's family, they decided to proceed.

The operation lasted more than seven hours but was a success. And after a prolonged recovery, DeBakey is doing well.

"Operations don't come any bigger than this," said Dr. Eugene Grossi, Chief of Thoracic Surgery at the New York Harbor Healthcare Veterans Administration Hospital in Manhattan.

The surgery was also unprecedented for a patient of DeBakey's age.

"While we do occasionally operate on patients in their 90s, this type of surgery is an exception," said Dr. Charles Lutz, Assistant Professor of Surgery and Director of the Robotic and Minimally Invasive Cardiac Surgery at SUNY Upstate Medical University in Syracuse, N.Y.

Episode Highlights Ethical Conundrums

The operation throws the spotlight on the questions associated with operating on a patient of DeBakey's age.

While this is an individual case, the scenario is becoming more common say experts. And as society is faced with more of these tough decisions, the ethical dilemmas that arise from end-of-life care are becoming more apparent.

"This surgery was an exception but it points to where we are heading," said Dr. Peter Libby, chief of cardiovascular medicine at Brigham and Women's Hospital and Professor of Medicine at Harvard Medical School. "More aggressive interventions in those who don't have many other medical problems are becoming common."

Libby says DeBakey's operation represents the future of cardiovascular medicine -- one in which surgeons push the envelope of what is considered "elderly."

"It used to be doing an aortic valve replacement surgery on those in their 90s was considered outlandish, but now it's a regular occurrence," he said.

"Age is not necessarily a contra-indication to surgery," said Lutz. "Many surgeons consider the patient's overall functional status to be more important than chronological age."

Much of the change in the perception of the "ideal" patient is also due to surgeries that are becoming safer and less invasive than ever before.

But experts say that this also brings up the question of when these surgeries should not be performed.

"As we have an aging population who have serious problems that require major interventions, the question becomes whether age in and of itself is a determinant for a particular therapy or not," said Grossi.

"This is where the moral dilemma arises."

"Society must choose what our values are and how to make difficult decisions about allocation and resources," said Libby. "Dr. DeBakey's own illness and his adventurous therapy framed these questions very keenly."

Before DeBakey could be taken to surgery, his family and everyone involved in his care had to answer the difficult question of what he would have wanted. Because DeBakey was unresponsive at the time and had never made his wishes sufficiently clear, it made the decision difficult for his doctors.

There was confusion at a crucial time.

"When a patient is unable to give informed consent for either treatment or to withhold treatment the decision falls on the family as the health care proxy to make the decision," said Grossi.

And experts agree that this is why it is very important for family members to discuss what their wishes are before they face such a situation.

"As physicians we often see patients where it's not clear what their wishes were and the family never found out from their loved one what their wishes were," said Grossi.

"Without making your wishes sufficiently explicit you cannot avoid the dilemma," said Libby. "So it behooves us all to review our health care proxies and living wills to make sure that our wishes are clear."

DeBakey Recovering Well

Regardless of the ethics of his surgery, DeBakey has recovered from his surgery to the extent that he routinely works nearly full days.

"Dr. DeBakey is an exceptional man," said Dr. Antonio Gotto, dean of the Weill Cornell Medical College and a friend of DeBakey's. "His exceptional recovery is a tribute to his faith, family and all his caretakers who made it possible ... and to Dr. DeBakey himself."