How Old is Too Old?

Yesterday I saw a 90 year old woman in consultation.  She presented to the emergency room in September with abdominal pain, and in the process of working her up, a chest X-ray was taken which showed an infiltrate in her lingula, part of the left lower lobe of her lung.  As it turned out, there was nothing wrong with her belly, but a follow up CT scan of her chest showed this strange fluffy area in the left lung—not quite a tumor, but not quite a pneumonia either.  She had smoked for years but quit in 1980 and she had no symptoms of cough or shortness of breath.  The decision was made jointly between the patient and her primary care physician to just “watch it”.  A repeat scan was done two months later, in November, which showed that the area had “slightly” enlarged.  She was seen by a pulmonary specialist who recommended that she have a biopsy and she was referred to interventional radiologists who were asked to put a needle in it and withdraw cells for analysis.  They declined, unfortunately, citing that the risk of causing a lung collapse or bleeding was too great in this elderly woman.  The pulmonologist could have tried to reach it with a bronchoscope, but he doubted that he could—it was a little too far in.  So two months later, she was referred to me for consideration of radiation therapy, still entirely well, with no lung symptoms whatsoever–and no diagnosis of cancer.

Yesterday she and her equally intact and otherwise healthy 90 year old husband sat in my exam room as I explained to them that, while there is a high likelihood that this abnormality in her chest is indeed a cancer, to operate to remove it could be fraught with complications, even fatality, and to give her radiation without a diagnosis was equally unconscionable, given the fact that the area was very near her heart and that radiation itself can cause serious inflammation in the lung.  She looked at me without a trace of irony and said, “Doctor, all I want is another ten years.”

And there we have it.  Next week she will have a PET-CT scan to see if the abnormality is positive on PET (a clearer indication of cancer than a plain CT scan), and to rule out cancer elsewhere in her body.  If it is larger now, and PET avid, she will be referred to a tertiary care center for a specialized bronchoscopy which can reach the lesion for biopsy.  If the biopsy is positive for cancer, she will be treated with whatever modality is deemed most appropriate for her type of tumor, be it surgery, radiation therapy, or chemotherapy.  It is what she wants, and what her husband wants for her and they clearly understand the risks.  She is ninety.

People say to me all the time, “What would YOU do if this was your parent?”  The answer, honestly, is I do not know.

5 thoughts on “How Old is Too Old?

  1. When my mother was 83 she had a heart attack and the doctors recommended a quadruple bypass. I went home to NJ and accompanied her to the cardiologist. I was very impressed with the cardiologist, who. in addition to discussing the surgery, also very kindly and adroitly brought up the idea that she did not have to go through with the surgery.

    “Oh no,” said my mother. “Do the surgery.”

    But the reality is that my parents, though very intelligent, were medically naive. And neither of them realized, nor were they told, the potential side effects.

    Frankly, I wish my mother had just let things be. But so many people believe that things can be cured, and easily so. They do not understand that medicine is an inexact science.

    If there are blockages in the cardiac arteries, there are blockages in other parts of the body. Such as the brain. And my mother had the early stages of dementia. And the dementia was made noticeably worse by the anesthesia and surgery. But it allowed her to live a whole lot longer…….in her demented state……with me caring for her.

    You raise a good question. How old IS too old? And who makes that decision?

    I am not advocating no care at all. But one of the reasons that health insurance is so expensive is that SO MUCH money is spend on end of life care. Where is the common sense?

    • Margaret, so sorry that happened to your Mom.

      Here are some interesting statistics:

      Average life expectancy for a 90-year-old today is 4.6 years vs. 3.2 years in 1929-31. Those who live to 100 have a life expectancy of another 2.3 years.
      Most (85 percent) of those 90 and older say they have one or more physical limitations. About 66 percent have difficulty walking or climbing stairs.
      Nearly 20 percent of those aged 90 to 94, 31 percent of those aged 95 to 99 and 38 percent of those aged 100 or older live in nursing homes, compared with about 3 percent of those aged 75 to 79.
      Women 90 and older outnumber men by almost three-to-one. From 2006 to 2008, women made up about three-quarters of those aged 90 and older.
      Whites make up 88.1 percent of those aged 90 and older. Blacks make up 7.6 percent, Hispanics 4 percent and Asians 2.2 percent.
      The annual average income for people aged 90 and older was $14,760. Men had a higher income than women — $20,133 vs. $13,580. Social Security made up about 48 percent of total income.

      Miranda

  2. At this point in my life, closer to 63 than 62, I cannot fathom making that decision for myself at age 90. Knowing what I know now as a nurse of 40+ years, 20 spent as a PACU (Recocery Room) RN! I have no doubt this influences my position. Something is going to end my life; I may or may not have input on this fact.

    I have seen 90 year olds on the op schedule and wonder – what do they really grasp about the short term and long term realities about
    the reality of the situation? OTOH I have had pts that age who look, act much younger. I just don’t have a real clue as what to say for someone other than myself. I am, however, glad my son and DIL are both RNs as they know how I feel (yes, it’s in my HCPOA)

    the situation? What do their families really grasp?
    .

  3. Nice article, I should probably sign up with WordPress. In any case, here is my story.

    I am working in Monmouth Maine when an 89 y.o. lady comes in after not having seen a provider in over 40 years to say she has a bruise on her right breast. After obtaining her history which is unremarkable for anything but a cataract surgery 20 years ago, I ask her if it turns out to be a malignancy, would she want to do anything about it and she says “of course!”

    She disrobes and we peel away the dressing and exposes what looks like a donut shaped cherry “whoopie pie” (those of you on the East Coast should know what this is) which turns out to be a fungating tumor. I refer her to a oncology surgeon who then calls me up to let me know that she had significant cardiac disease including atrial fibrillation and was going to refer to to cardiology before doing anything. It was amusing that the intake folks asked for a mammogram or CT and I responded, they would not need one, it was pretty obvious what was going on.

    Fast forward several weeks, I find out the surgeon has fractured both of her wrists in a horseback riding accident and that my patient is being followed by another surgeon. In the meantime, I believe the cardiologist has placed her on blood pressure medications, coumadin and statins.

    Fast forward several more weeks and I receive her postoperative reports. She had a radical mastectomy, was sent home with JP drains before a weekend. Her daughter found her unarouseable and called the ambulance. She was later transfused with 12 units over several days, and when stable, went home.

    I saw her a week or so later and she said she was proceeding with radiation. She was an incredible trooper (troopa as we say in Maine!) and I am sure today she is doing well and living the life she wants. Far be it for me to tell a patient they are too old for….

    Reply ↓

    • Debi, thank you for that wonderful story. As I was reading I was afraid it wasn’t going to have a happy ending! My elderly patient had a PET-CT last week, which showed that the infiltrate in the lung is likely cancer. It also showed a 3 cm lesion in the sigmoid colon. She has been counseled to have a bronchoscopy and sigmoidoscopy for biopsies. She WANTS to live. Updates will follow. Miranda

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