Late in Life, an Agonizing Choice Over Surgery

Late in Life, an Agonizing Choice Over Surgery

The New York Times, November 15th, 2010

Editor's Note:  This one's got nothing to do with retirement finance, but is, in the opinion of this editor, an important story to read for anyone considering a medical procedure with major quality-of-life implications at advanced age.  We make no suggestions or recommendations, as these decisions are and must be intensely personal.

Forgoing a potentially life-saving medical procedure may be easier at age 94 than age 54, but for my patient George Pollack it was a wrenching decision anyway. Suffering from a severe foot ulcer that would not heal, he was told his only chance of a cure was a partial amputation of his leg. Even then, there were no guarantees.

George was a savvy medical customer. He had been a lawyer in New York for more than 60 years — among other things, serving as executor for the estate of Lou Gehrig’s widow, Eleanor, and making sure that any payments from the use of Gehrig’s image went toward A.L.S. research at Columbia University Medical Center. I originally met George when I was doing research on Lou Gehrig’s illness.

George was suffering from peripheral vascular disease, or obstruction of the arteries that feed the limbs. Early on, it is possible to reopen clogged blood vessels with a balloon. But when the disease worsens, blood-starved areas, usually the feet, may develop life-threatening ulcers.

By the time I met George, in 2002, he was already prone to ulcers — a result of flat feet and decades of poor circulation — and he required a complex combination of antibiotics, ointments and dressings. I gave what advice I could, referring him to an infectious-disease specialist who helped cure one of the largest ulcers.

By April 2009, things were worse. George had a large ulcer that would not heal on his left foot and was requiring hospitalizations and intravenous antibiotics. One surgeon strongly advised a below-the-knee amputation of the left leg.

George got a second opinion from Dr. Alan I. Benvenisty, a surgeon and director of the vascular laboratory at St. Luke’s Hospital. In August, hoping to try a balloon procedure, Dr. Benvenisty sent him for an angiogram, a dye study that generates images of the arteries. But the test showed that a balloon was out of the question. Amputation was the only surgical option.

So Dr. Benvenisty did what any doctor should: he laid out the options, pro and con. He told George that surgery was very risky and that the wounds did not heal properly in roughly 30 percent of below-the-knee amputations. A study of 704 such operations, published in The Archives of Surgery in 2004, found that patients were at risk for “significant morbidity and mortality.” In George’s case the odds were even longer: he was 94 and had suffered a mild heart attack during his angiogram.

And then there was rehabilitation. At the very least, George would require two taxing months of aggressive physical therapy in a nursing facility.

What was the other option? Without surgery, Dr. Benvenisty told George, the vascular disease would probably kill him in a matter of months.

I was among the many people to whom George spoke. Part of him clearly wanted to try surgery. After all, he told me, who does not want to live?

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