From a board conceptual view, surgery is done for one of four basic reasons.  Elective procedures to change appearance are termed cosmetic surgery.  These are always a personal choice.  Secondly, there is a group of procedures done to improve function.  Examples would be cataract surgery, procedures to free up frozen bones in the ear and improve hearing or prosthetic joint surgery that would improve a person’s ability to walk or stand.

      Surgeries done to stop pain comprise the third broad category.  Examples would be: back surgeries to release a pinched nerve, rotator cuff surgery to improve shoulder pain or abdominal surgery to release adhesions that cause chronic abdominal pain.

     All of the above procedures are more or less designed to improve the quality of a person’s life and the procedures thus are elective.  Success rates vary from one procedure to the next and with the type of malady the patient has.  Under the above circumstances, asking if the patient can stand the surgery is a valid consideration.  One must carefully weigh the quality of life that will come after the surgery as compared to what the patient has before.

     Surgeries that save lives are the fourth broad category.  The example that most vividly comes to my mind is one where I had a most difficult time convincing the patient’s family that surgery is an indicated and necessary step.  The gentleman was 77 years old.  Over about 6 months time, he had become progressively less functional and confused.  He had intermittent fevers, and vague back pains.  He was an infrequent visitor to physicians and was brought to my attention when he was due to enter the nursing facility for supportive care in the late part of his life.  Basic blood tests were done that demonstrated he had a major infection although the site of this infection was not clear.  A CAT scan of the gentleman’s upper abdomen demonstrated that he a large abscess on his left kidney.  The left kidney was not functional although the right kidney seemed to have picked up the slack and was carrying on normal kidney function.  The left kidney thus was the source of infection that had been chronic.

     A basic principle in taking care of any infection is that it requires both drainage to the outside and also antibiotics.  In this case, antibiotics alone would not cure the problem.  The patient’s wife and daughter were apprised of the situation that the abscess needed to be drained in additional to antibiotic therapy.

     Their first question was, “Could he stand this surgery?”  They expressed the concern that he was too weak to undergo a surgical procedure and that he would never survive same.  They indicated that he was in the advanced stages of a dementia and they wondered what type of life he would have after the surgery was done.  Acknowledging all of the wife’s and daughter’s concerns, I asked in return, “Do you think he can survive not having the surgery?”  I pointed out that realistic medical expectations in this situation were a continued deterioration and mortal outcome unless the abscess was drained.  I indicated that there was no clear way to indicate that he would recover significant function after the surgery but function would clearly deteriorate further if the surgery was not done.

     After long consideration, they elected to proceed with surgical drainage of the gentleman’s abscess.  His fever resolved in several days and after antibiotic administration for about ten days, he was clearly improving.  Two months later, he had regained relatively normal mental function and returned home.  He passed away in his sleep eight years later.

     A second example involves a 92-year-old lady who came to me for a second opinion.  Her doctor had told her that her heart had a valve that was stopped up but that she was too old to get a new heart valve.  She indicated that she was becoming increasingly infirmed and all that she really wanted to do now is to be able to participate in the family activities.  She indicated that she became too short of breath and too weak whenever she tried to do simple tasks such as set the table.  She said that she wanted something done.  Her family was very divided as to whether or not a new heart valve for this lady was an appropriate step in care but she persisted in wanting something done.  After consultation with the cardiologist and a cardiac catheterization, she elected to proceed with a new heart valve at 92 years of age.  For the next several years she could help in family activities such as setting the table.  It is now seven years later and her ability to participate in the family activities is again impaired but not because of the heart valve.  When a stopped up heart valve causes heart failure, there is a 50% one-year survival.

     A surgery that seems to be elective but really isn’t is the decision to correct a broken hip.  Broken hips tend to occur in the elderly who already have osteoporosis and poor healing.  When the broken hip happens in the elderly, not fixing the fracture leaves the person with a flail hip and inability to walk.  There is no meaningful expectation that the person will ever walk again unless the hip is surgically corrected.  Frequently, the person undergoes a great deal of pain, which by itself is detrimental to the person’s well being.  In addition, the person is lying flat on their back, their bowel habit cannot be re-established normally and for humane reasons, a catheter is placed to drain the bladder so the person does not have to be moved when they need to urinate.  This leads to urinary tract infections.  A very unpleasant mortality is expected within a few months when a person has an uncorrected fractured hip.  Surgically correcting a fractured hip is both humane and life saving.  When families ask if this loved one can survive the surgery to fix a fractured hip, the easy reply is the person cannot survive not fixing a broken hip and the last two months of their life will be miserable with pain every time the person is moved.  Problems with trying to manage pain medications and avoiding delirium that can come from same in elderly presents yet more problems.

     In summary in the case of surgery done to stop pain, the question that needs to be answered is, “Does the patient want to live with the pain that they have and not be surgically treated?”  The second question in the case of life saving surgery is not, “Can the patient stand this surgery?”  Rather, the question is, “Can the patient survive not having the surgery?”  The healthcare providers at your local clinics are aware of these considerations and can help in answering questions and making decisions regarding surgical intervention when the need arises. Granting that these are very, very difficult situations to deal with one has to be careful to ask the right question.  Often it is not, “Can the person stand surgery”.