Case Scenario

I have a 65-year-old patient with a body mass index (BMI) close to 50 kg per m². Her weight dramatically affects her quality of life. She uses a wheelchair and has difficulty getting around. Her weight also has affected her health: she has congestive heart failure, sleep apnea, and pulmonary hypertension. A thallium stress test has shown that she has minimal coronary artery disease. The patient has been unable to lose weight with diet and exercise. I thought she was an acceptable candidate for gastric bypass surgery, and I referred her to a surgeon to discuss this option. But soon afterward, my patient returned to my office devastated. The surgeon had informed her that she was not a candidate for gastric bypass surgery because of her age.

Should this patient be allowed to have the surgery? Should I try to find another surgeon who is willing to perform the risky procedure? What are the ethical implications of allocating an expensive resource such as gastric bypass surgery?

Commentary

This case scenario brings up two issues: (1) whether the patient should undergo a risky procedure that might benefit her and (2) responsible allocation of health care resources. First, American College of Physicians (ACP) guidelines¹ recommend optional bariatric surgery for those who have BMIs greater than 40 kg per m² and obesity-related comorbidities (e.g., hypertension, diabetes, obstructive sleep apnea) but who could not lose weight with dietary drugs, diet, or exercise.¹ Although the patient in the above scenario fits the ACP criteria for bariatric surgery, published studies may help the physician decide whether or not the procedure would be in the patient's best interest. A national study² of bariatric surgeries showed several trends: more patients are undergoing bariatric surgery, the average age of patients undergoing bariatric surgery has increased from 39 to 41 years, and in-hospital complication rates have remained stable. However, the increase in bariatric surgeries was seen mostly in patients 50 to 64 years of age. The number of patients 65 years and older undergoing bariatric surgery remained stable, accounting for 0.6 to 1.3 percent of procedures from 1998 to 2002.²

Mayo Clinic investigators followed 20 patients older than 60 years with multiple chronic medical conditions who received laparoscopic Roux-en-Y gastric bypass surgery and compared them with 110 younger patients who underwent the same procedure.³ The study showed that older patients not only had similar complication rates as younger patients but also benefited more from the procedure; the differences were not statistically significant, however. Older patients used an average of two fewer medications after surgery than younger patients, and one half of those who used sleep-assist devices before surgery no longer used them postsurgery.³

However, one study⁴ that included more than 16,000 Medicare beneficiaries showed that early postoperative mortality rates after bariatric surgery were higher for patients 65 years or older than they were for younger patients. The authors acknowledged that these findings were partially attributable to a high number of older patients whose surgeons were not highly experienced in performing the procedure. A retrospective study⁵ showed that hospitalization rates for morbidly obese patients doubled and remained elevated after Roux-en-Y gastric bypass surgery, and that these rehospitalizations primarily were for procedure-related complications. This study did not specifically evaluate age as a factor, however.⁵

Although the patient in the scenario is a candidate for bariatric surgery, her age puts her at increased risk of morbidity and mortality. The physician could obtain a second opinion from another surgeon who has performed at least 50 procedures (data⁴ suggest this may reduce the risk of adverse events in older patients). As with all medical interventions, the physician, surgeon, and patient should have a conversation using shared decision-making principles. Proper informed consent should be obtained to ensure that the patient indeed wants the surgery and understands the risks.

Even after deciding whether a patient needs a procedure, medical treatment in the United States is sometimes rationed (i.e., some patients are offered a treatment, whereas others are not). Cost-effectiveness analysis combined with other information (e.g., quality-of-life assessments) can provide guidance when making decisions regarding who should receive a medical procedure. A systematic review⁶ evaluated three studies that reported costs per quality-adjusted life year for bariatric procedures. The investigators concluded that until further cost-effectiveness analyses are conducted, the outcomes of bariatric surgery appear to be worth the costs of the intervention. The studies did not focus on older patients, however. A study⁷ on age-based rationing of medical procedures showed that Americans agree with using criteria to exclude a patient from a medical procedure if it was voluntarily initiated by the patient.

In the scenario, the physician and patient made the decision to pursue surgery, whereas the surgeon made the decision to withhold surgery. Unfortunately, there is minimal guidance as to what to do about conflicting decisions. Until more guidance is available for making these difficult decisions, each physician should use his or her professional and personal judgment.