An explosion of life-extending interventions for older persons is changing the face of many medical specialties in the United States Routine and innovative treatments are prolonging more lives at older ages than ever before, and the average age of patients who receive surgery and other nonprimary care interventions that extend life is rising. Indeed, octogenarians comprise the most rapidly growing group of surgical patients, and there is a growing medical literature on the justification and benefits for performing many procedures on persons over age 80. These practices are reshaping medical knowledge and societal expectations about “normal” old age, longevity and the time for death.

For clinicians, there are no longer steadfast assumptions about technological or biological limits to what medicine can do for older persons. Patients, for their part, have become medical consumers responsible for questing after their own health and longevity. Desire for therapeutics into advanced age has grown along with the aging of the population.

Four and a half million people in the U.S. are 85 years old or older. By 2050, 20 million persons will be over age 85. There are enormous pressures from multiple sources – patients, their families, the “technological imperative” in medicine, the structure of health care financing, the specter of litigation, the excitement surrounding new interventions, professional training and subspecialization, and, above all, the cumulative successes of clinical medicine – to attempt to stop the course of end-stage disease late in life. Together, the availability of more options and the normalization of life-extending treatments at older ages promote the notion that aging and death are not inevitable and foster the assumption that one can and should choose to intervene. (That assumption is not as pervasive in Europe, where the limitations to health care resources are widely acknowledged.)

Examples of the expanding use of four kinds of therapies are emblematic for the rising age for interventions of all kinds. Their success in extending lives and well-being contributes to the cost challenges that accompany medical interventions in an aging society. As clinical criteria for performing these procedures expand to include older, sicker people, two accompanying social trends contribute directly to rising costs and the problem of limiting them. One trend, diminishing the risks of death by whatever clinical means available, has already become standard practice and is seen to be ethically appropriate, even necessary (for those who can access services). The other is that of ever-new biotechnological tools that create a more perceived need to intervene, in order to treat the risk of death.

Cardiac procedures

Coronary artery bypass graft surgery, angioplasty, stent procedures are now commonplace for persons in their 80s and not unusual for persons in their 90s. Cardiac valve replacement therapies are becoming more common in the ninth decade as well. Studies indicate that successful outcomes for those procedures can be obtained for select groups of patients aged 90 or older, although hospitalization may be longer and morbidity higher than for younger patients.

Advances in treatments for strokes and heart attacks have prolonged lives, although they have led also to emerging epidemics of heart failure and atrial fibrillation among the elderly. The prevalence of heart failure has been increasing over the last decade, with approximately 550,000 new cases diagnosed each year. Available interventions for severe heart failure include hospice care, the automatic implantable cardiac defibrillator (AICD), the left ventricular assist device (LVAD), and heart transplant. These dramatically distinct offerings include both ends of the intervention spectrum in contemporary medicine – from end-of-life palliation to heroic (yet only potential) life-extension. This range of treatments complicates choice because hope is always embodied in heroic interventions. A recent study shows that patients who think their chances of relatively long-term survival are favorable want aggressive therapies – despite prognostic models to the contrary.

Relatively few individuals consider and receive a LVAD or cardiac transplant, although cardiac transplant in the seventh decade is not uncommon. In contrast thousands of older Medicare recipients now qualify for the AICD device (with or without pacemakers). Use of the device is rising substantially because the Centers for Medicare and Medicaid Services in 2005 approved the expansion of the eligibility criteria to include primary prevention for patients who have never suffered a cardiac event. The device regulates a lethal cardiac rhythm, thereby reducing the risk of a fatal heart attack. In 2005 more than 100,000 individuals received an AICD, up from 48,000 in 2001.

Although a recent study shows the device to be effective in reducing mortality for older patients, opinions diverge about whether the AICD for very old individuals is appropriate. Meanwhile use of this device is on the rise because it prevents death, the treatment of risk itself has become important in medicine, and specialist and subspecialist referrals pave the way for its use. As devices become smaller, as techniques for implanting them become safer, and as less invasive procedures are used with greater frequency and success, physicians and the public have learned to view them as standard interventions. Reduced risks associated with all of these procedures produces a sense that life extension is open-ended.

Kidney dialysis

Since 1972, when Medicare benefits were extended to all persons with end-stage renal disease (ESRD), the earlier more stringent criteria for dialysis selection have fallen away. At the same time, advances in dialysis care mean that physicians are now more successful at treating ever-older patients with complicated disease. Many health professionals feel that it is morally unjustified not to offer dialysis to any patient with ESRD. Projected trends for the next decade indicate an increasing proportion of new dialysis patients older than age 75. Currently, 25 percent of all U.S. dialysis patients are over 75; 14 percent are over age 80. The goals of treatment, however, have not evolved from half a century ago to reflect this shift in demographics. With few exceptions, the medical literature has not addressed the role of palliative care and the acknowledgment of the nearness of the end of life in dialysis settings, which indicates that clinicians are disinclined to discuss death with patients.

Kidney transplant

Medical evidence shows that transplantation is the treatment of choice for suitable patients with ESRD, and there is growing demand for kidney transplantation among older persons with kidney disease – both from patients on dialysis and those who would like to avoid dialysis altogether. The number of kidneys transplanted to people over 65, from both living and cadaver donors, has increased steadily in the past two decades in the U.S. In 2008 15 percent of all kidney transplants went to persons age 65 and over. Transplants are no longer unusual in the seventh decade of life and are sometimes performed into the early 80s. As the waiting time for cadaveric kidneys increases (often beyond five years), there has been greater ethical pressure on family members and friends to become living donors.

Cancer treatments

Many cancers have become chronic illnesses today, manageable and sometimes curable because of the explosion in new, specifically targeted and less toxic treatments. Older patients who in the past did not receive treatments are now receiving them for several reasons. There is an unprecedented willingness of older cancer patients to undergo aggressive and long-term treatments. Physicians do not want to deny older patients therapies that may make them more comfortable or extend life, and clinical investigators are becoming increasingly interested in including older persons in clinical trials. As a result, potentially life-extending treatments have become routine into the eighth decade, and, in much smaller numbers, into the 90s. Yet there is controversy about how aggressively to treat cancers at older ages; doctors, patients, and families are often uncertain about how to proceed.

Without medical guidelines or explicit discussions between doctors and patients about the end of life or the toxicity of treatments, many patients and families proactively choose aggressive, toxic, and costly treatments up until the time of death, even when clinicians also offer hospice care. Recent medical studies express a concern about the growing numbers of patients who receive aggressive chemotherapy up until a few days and weeks before death.

Complicating medical success

Standard procedures are difficult to refuse. It seems against medical progress and common sense to say no, especially if interventions are immediately lifesaving or preventive, and current medical discourse emphasizes that refusing a procedure today may increase the risk later for other problems and especially for death. Success in extending older lives creates the grounds for individuals to decide whether and how to seek more time for themselves and their loved ones. These examples point to the growing difficulty of defining medical success and the “best treatment” plan in an aging society. Ethics and best practices insure that those patients who can access all that medicine has available will be offered state-of-the-art treatments. Patients, when faced with serious disease and options about what to do, often find themselves contemplating a calculus about how much more time they want to live. Because the value of life is neither age-dependent nor quantifiable, their deliberations provide one reason why debates about age-rationing remain lively and unresolved.

Sharon R. Kaufman, PhD, is professor of medical anthropology at the University of California, San Francisco. Her current primary research focus is on the impact of medical technique on individuals in an aging society. Her most recent book is …And a Time to Die: How American Hospitals Shape the End of Life; sharon.​kaufman@​ucsf.​edu; 415–476-3005.