Heart surgery for 100-year-olds

JAMES ESTRIN/NEW YORK TIMES

Hazel Homer, 104, poses in her East Rockaway, N.Y. garden. She was given a specialized pacemaker and defibrillator a month before her 100th birthday.

Heart surgery for 100-year-olds

Not all doctors approve of increasingly common aggressive treatments for 'late-elderly' patients

July 20, 2008

Anemona Hartocollis

NEW YORK TIMES

When Hazel Homer was 99, more than one doctor advised that there was little to be done about her failing heart except wait for it to fail a final time. But Homer was not interested in waiting to die.

Now, at 104, her heart is still ticking, thanks to a specialized pacemaker and defibrillator that synchronizes her heartbeat and can administer a slight shock to revive her if her heart falters.

Her operation, a month shy of her 100th birthday, reflects what some doctors are hailing as a new frontier in medicine: successful surgery for centenarians. But others say such aggressive treatment for what are euphemistically known as the "late elderly" can be wasteful and barbaric, warning that the rush to test the limits of technology can give patients false hope and compound their health challenges with surgical complications.

"She's just a peek into the future," said Dr. Steven Greenberg, a Long Island, N.Y., cardiologist who performed Homer's surgery, for which the average Medicare reimbursement at the time was $35,000.

It's hard to track, since people over 75 are scarcely represented in clinical trials, but several geriatricians said procedures that two decades ago were seldom considered for people in their 90s are now increasingly commonplace. They include hip and knee replacement, cataract surgery, heart valve replacement, bypass operations, pacemaker implantation and treatment for slow-growing cancers that afflict areas like the prostate.

The Census Bureau says there were 90,422 centenarians in America in June, up from 50,454 in 2000. Demographers project there could be 1.1 million by 2050.

With such rapid growth of centenarians, debate has mounted over how far to go in providing major medical services to extend already very long lives.

Dr. David Goodman, a co-author of the Dartmouth Atlas of Health Care, said there is much research suggesting most aggressive treatment of late-stage chronic diseases doesn't actually prolong life and can actually decrease its quality.

Of Homer, Goodman said: "The odds are that she's really an amazing exception. The question is not a relatively healthy, smart, sensible 99-year-old getting a life-prolonging procedure, one that prolongs the quality of life. The question becomes the 82-year-old with dementia who has cancer or congestive heart failure."

Greenberg, a cardiologist at St. Francis Hospital in Roslyn, N.Y., said Homer is his oldest patient, and one of a handful of people nationwide her age who have received this type of heart device. But he has implanted about two dozen devices like hers in patients 90 or older over the past five years and he counts among his patients a 93-year-old "with a full head of hair" who got a defibrillator in his 80s and is still practising law.

Then there's Dr. Michael DeBakey, the pioneering heart surgeon who died July 11 at age 99. Two years ago, DeBakey underwent an aortic-dissection repair procedure that he himself had long before devised – but only after doctors convened an ethics committee to decide whether it was appropriate.

Homer did not receive a regular pacemaker but rather a biventricular defibrillator, which synchronizes her heartbeat and can automatically shock her to save her from a fatal arrhythmia. In 2007, about 55,000 people received such combination devices according to Greenberg, a consultant to the three main manufacturers of the device, who estimated that people 90 or older accounted for fewer than 100 of the devices.

Dr. Karen Alexander, an associate professor of cardiology at Duke University, said the defibrillator might go too far. "Many people say that would be a nice way to go when you're 100: to be sleeping and have your heart stop. The defibrillator component would very possibly prevent that."

Greenberg admits he "wouldn't have wanted to advertise" the operation on Homer when it was unclear how long she would survive. Now, he argues that the operation cost less than repeated hospitalizations for heart failure.

"People pay more for their BMW, which will not save their life," he said.