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“I hope I die before I get old”
The Who, My Generation 1966
“Better to burn out than to fade away”
Neil Young, Rust Never Sleeps 1979
“Live hard, die young and leave a beautiful corpse”
The sympathies expressed above are sympathies expressed by the younger generation. They lie not just with today's younger generation but historically have been the rallying cry of many a younger generation, if not expressed in so many words. The words should not be taken literally; most in the younger generation would not rather die before they get old. In fact, it is most probable that Pete Townsend and Neil Young would tone down their assertions if they were to make them today. Rather, the words reflect the ever present generation gap, the ubiquitous difference in thought and attitudes among generations. These differences are often so strong that members of the younger generation might claim that they would rather not exist than to transform into a clone of an older generation as they age.
At this point you may be asking yourself what this has to do with anything, let alone the field of neurointerventional surgery. I'm quite sure you ask yourself a similar question while reading most of my editorials. Allow me to close the gap, so to speak.
“When I get older, losing my hair
Many years from now.
Will you still be sending me a valentine,
Birthday greetings, bottle of wine.
Will you still need me, will you still feed me
When I'm 64.
The Beatles, Sgt Pepper's Lonely Hearts Club Band 1967
It is repeatedly stated and is true that our population distribution is aging. The aging of the population is the reflection of two trends: members of that population blip know as “baby boomers” growing older and advances in medicine prolonging life. Not only is the population aging but for the most part, persons of a certain age today are also healthier than comparable age cohorts in the past. On a personal level, I have fairly recently passed the half century mark. Although some days at work I may feel as if I'm 90, for the most part I feel pretty good. In fact, there are times when I'm not actually sure I'm in my 50s since I don't feel as bad as I thought I would when contemplating reaching my present age when I was 20. In the same respect, for some among us 80 may actually be the new 60. I am reminded of this yearly when my mother, who is 79 years old, proceeds to wear me out on the dance floor at the dinner reception for the SNIS Annual Meeting.
In this issue of JNIS, Stiefel et al1 examine in retrospective fashion their single institution experience of treating unruptured aneurysms in the elderly with endovascular techniques (see page 11). They define elderly as greater than 70 years old. In their experience, treatment of this age cohort could be accomplished with acceptable procedural morbidity. Their conclusion is that taking into account the natural history of unruptured aneurysms, endovascular therapy may not be an unreasonable option, regardless of age, if the patient's life expectancy can be estimated to be at least 10 years.
This is a refreshing attitude given the present trend of age based treatment decisions. For example, one criterion for Medicare reimbursement of carotid stent procedures is patient age less than 80 years. Additionally, several articles published recently have found a less good outcome in stroke patients greater than 80 years old undergoing thrombolysis, suggesting that this age cohort may not benefit from this therapy. In fact, many ongoing neurointerventional trials exclude patients greater than 80 years old. In my own clinical practice it is not uncommon for members of our cerebrovascular team, including myself, to have experienced bias with respect to treatment decisions after learning the age of the patient.
I am not espousing that an unlimited supply of medical resources be applied to each patient regardless of underlying factors. I am not turning a blind eye to the economic ramifications of the US healthcare expenditure crisis. It is estimated that Medicare spends 50 billion dollars per year in reimbursement for healthcare rendered in the last 2 months of life. This is an unfathomable amount of money which is spent often without effectively prolonging life or improving the quality of life. So certainly we need to learn as a profession and a society how to judicially allocate our healthcare resources to effect the maximum benefit for individuals and society.
How can we refine our decision making process to provide healthcare to those who may benefit most while at the same time conserving healthcare resources in situations where their expenditure will prove to be fruitless? I apologize, but I don't have an answer to this dilemma. These are complex decisions which are layered in shades of gray and are often extremely difficult to make prospectively, especially in the face of an acute illness. We have all experienced patients with grade IV or V subarachnoid hemorrhage who show little or no improvement over a 1–2 week period but who come to clinic 2 months later living independently and thanking you for your care. Alternatively, there are other patients with multiorgan failure who we realize early on will never leave the hospital.
So where does all of this discussion leave us? Perhaps we need to develop a scale which is easy to implement and takes into account multiple patient related factors as well as disease natural history factors to assist in making some of these decisions. Such a scale, however, cannot completely replace judgment which is molded through personal experience. What is clear, at least to me, is that healthcare allocation cannot be made solely on the basis of age which is, after all, only a number.
Competing interests None.
Provenance and peer review Commissioned; not externally peer reviewed.
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