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J Thorac Cardiovasc Surg 2003;125:S34-S35
© 2003 The American Association for Thoracic Surgery

Editorials

"We don't do that here": Reflections on the Siena experience with dissecting aneurysms of the thoracic aorta in octogenarians

From the Department of Surgery and Joint Centre for Bioethics, University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.

Received for publication Sept 18, 2000. Revisions requested Sept 29, 2000; revisions received Oct 5, 2000. Accepted for publication Oct 13, 2000. Address for reprints: Martin F. McKneally, MD, 77 Forest Grove Dr, Toronto, Ontario, Canada M2K 1Z4 (E-mail: martin.mckneally@utoronto.ca).

The first 20% of the full text of this article appears below.

In this issue of the Journal [J Thorac Cardiovasc Surg 2001;121:259-67], Neri and his colleagues provide empirical evidence to support sparing octogenarians, their families, and their caregivers from the tragic experience the authors encountered with operative treatment of type A dissections of the thoracic aorta. Of 24 consecutive surgically treated patients in this age group, 8 died intraoperatively, 12 more died without leaving the hospital, and none of the 4 who were discharged lived beyond 6 months. No survivor returned to "a normal, functioning, integrated" life, the criterion used by the Massachusetts courts to justify a physician's decision to withhold resuscitative measures. ¹ Their report is courageous, because poor outcomes are rarely published; authors and journals usually compete instead to proclaim favorable results of cardiac surgery in older patients. The Siena group recommends a professional guideline that excludes octogenarians from surgical treatment of type A aortic aneurysms. In this commentary, I will argue that creating a local institutional policy, with public as well as professional participation, is a more prudent approach.

When patients, families, and surgeons are required to make decisions about the initiation or withdrawal of heroic life-sustaining treatments, a clear and reasonable institutional policy can be helpful to all. Judicious policies are now . . . [Full Text of this Article]