Old age is no place for sissies.
-Bette Davis

“I want the surgery today!” She started to cry. “I’m ninety-four years old. I’ll accept any risk. Just take this thing out!”

She looked back and forth between the anesthesiologist and me. Her golf-ball sized tongue cancer had been growing over the past six months. It wasn’t changing from day-to-day, but it had increased over the course of the three weeks since we had first met. A misunderstanding about stopping medications before surgery had led her to discontinue both her aspirin (a good idea) and her blood pressure pills (not a good idea). She was lying on the cart that was supposed to roll her into the operating room decked out in a hospital gown, paper hat, and booties. Her family was with her, trying to comfort her but also looking frustrated and worried. Her IV was in place. Everything was ready. Her blood pressure, though, was sky high.

“I’m sorry, but it’s not safe to put you to sleep when your pressure is so elevated,” the anesthesiologist explained. “You are at risk for a stroke or heart attack. If you restart your pills, your blood pressure will probably be back in the normal range in a week or two.”

“Oh, no! Oh, Doctor, I can’t live with this another two weeks!” She buried her face in her hands and wept.

There were a lot of issues at play.

First and foremost, safety is always our top concern. No matter how insistent she was, there was no way that we should put her to sleep.

I considered whether I might be able to remove it with a local anesthetic. Unfortunately, the cancer was relatively large and it might be difficult to completely anesthetize. Given its size, I preferred having her asleep with an endotracheal tube in place to prevent blood or secretions from being accidentally inhaled into her lungs.  If the case turned out to be more complex than I could anticipate before we started, we might face some very difficult choices.

Finally, there are always increased risks unique to the elderly. Solid data demonstrate higher rates of postoperative death and complications when older people undergo surgery.

On the other hand, I remembered an elderly, much more frail woman who had seen me for a small, painful tongue mass. Seeing no other options, she had allowed me to remove the cancer under local anesthesia. Happily, the procedure and recovery had been smooth. During my training, older surgeons shared stories of procedures they had performed under local anesthesia for which we now routinely put people to sleep; for example, one of my mentors performed all tonsillectomies on adults under local. To me, it seemed scary and unfamiliar, but it was possible.

I also recalled a personal decision. One day near the end of my residency training, my father called me.  “What should we do? The doctor says your grandmother needs surgery.”

My 91-year-old bedridden grandmother was living out her last days in a nursing home not far from where she had spent her entire life. She had severe dementia and recognized no one any more. Over the course of a few months, one of her feet lost all blood circulation. She was in no pain and was completely unaware that part of her leg was dead. One day, a surgeon called my father recommending that she undergo an amputation.

“Dad, what did the doctor say? Why do they want to operate?”

“Her tissues are worsening. If they don’t take off her foot, they think that an infection might spread through her body.”

I could not imagine that an operation would improve her quality of life. This was no longer the energetic woman who had lived her life on the family farm, weathering the depression, milking cows, raising and slaughtering chickens, and sending her sons off to war. The woman we had known and loved had disappeared into the fog of Alzheimer’s years before.

The surgeon was correct that an amputation might stave off an overwhelming infection. If we let him operate, though, the procedure would not make her feel better. She clearly did not have long to live, no matter what.

I weighed the potential ethical issues, as well. If we decided to “let her go,” might we stand to gain from the decision? Fortunately, her nursing home costs were covered by insurance. For some families, though, a shorter nursing home stay can translate into a larger inheritance. And, I wondered, why was the surgeon making the recommendation for surgery now?

“Dad,” I said finally, “tell him ‘no.’ The nursing home can make her comfortable. I don’t think the surgery will make her better.”

My dad did not give the surgeon permission and my grandmother died — comfortably — a few weeks later.

But, what should I do with my patient with the tongue cancer? Unlike my grandmother, this woman was in otherwise good health. The anesthesiologist agreed to give her a little sedation but would not put her completely to sleep. Other than the blood pressure problems, she was ready for surgery. Even though there were real risks to proceeding, I decided that we had a reasonable chance of a successful outcome.

“OK,” I told her, “today is the day.” The patient gripped my hand and smiled. Her family members asked again about the risks and agreed. Soon we were underway.

I had to modify my surgical approach and the cancer was a bit larger than expected, but everything went well. An hour later, we were finished and she was in the recovery room.

She returned to the office the following week, tearfully thanking me for the operation. I thought about my grandmother, still believing we made the correct choice in her situation, as well. The decisions in these two cases were relatively easy but for people in the middle — the gray zone where patients have more complex tumors or are more frail — their options will never be so clear-cut.

Surgical decision making is based on evidence but choosing the option for any one individual person can still boil down to an imperfect weighing of benefits and risks. Primum non nocere — first, do no harm — Hippocrates instructed us. I weigh the odds, make a choice, and act, still amazed and gratified when things turn out for the best.

Bruce Campbell is an otolaryngologist who blogs at Reflections in a Head Mirror.