Quality of life and ethical concerns in the elderly thoracic surgery patient

The diversity of older patients presents a challenge when deciding whether to recommend thoracic surgery to an individual. Comparable postoperative morbidity and mortality between younger and older patient groups indicate that surgeons are skilled in determining which older patients are most fit for surgery on the basis of comorbidities, performance status, and QOL. Criteria for the inclusion of older patients in thoracic surgical trials have not been described, however. As newer, minimally invasive techniques and limited resections are incorporated into elderly patients' care, criteria for inclusion must be evaluated prospectively in trials designed to establish risk factors for morbidity and mortality in elderly patients traditionally excluded from surgery. In addition, QOL needs to be evaluated specifically in the elderly, and meaningful comparisons need to be made with other elderly patients who do not undergo surgery. Finally, to inform better the ethical debate about whether thoracic surgery benefits a patient of advanced age, longer-term QOL and functional outcomes need to be evaluated. The ethical challenge is finding a delicate balance: on the one hand, avoiding ageism and providing a therapy to older patients that offers the only meaningful chance for improved survival, especially in early-stage disease, and on the other hand, avoiding overzealously providing a therapy with significant morbidity and mortality to older persons who are already at greater risk for functional loss and death.