The massive increase in the geriatric population has been more than paralleled by a vast increase in the number of patients older than the age of 65 years, or indeed, over any such benchmark, who now seek both elective and emergency surgical care. We discuss the topic of emergency surgery separately near the end of this chapter, because this is such a complex issue that involves by definition issues of life or death, especially in those without treatment. In the United States, 85,000 patients seek elective surgery every working day. A high proportion of these (approximately 50%) are Medicare beneficiaries, that is, older than the age of 65 years. Therefore, the practice of all surgical specialties in most countries is becoming, in fact, more and more a practice of geriatric surgery.

SURGEON–PATIENT COMMUNICATION ISSUES

Profoundly important ethical issues are involved, especially for the elderly who may be impaired and/or with an issue regarding informed consent. One of the most important principles is that the surgeon and the patient have a serious discussion and reach a real agreement about the goals of care. The surgeon should always inquire as to the presence of an advance directive from all older patients, which provides an important entry for discussion in a variety of areas.

This discussion really gets cast into bold relief when the presence of a living will and variably interpreted do not resuscitate orders exist. Under these circumstances, it is essential that the patient and a (preferably the) responsible family member, if at all possible, and the surgeon seriously discuss the patient's interpretation of the living will and the do not resuscitate standard.