Background <p>As life expectancy increases, emergency surgeries such as laparotomies are being performed more frequently in older adults, who face disproportionately high risks of morbidity, mortality, and functional decline. The concept of surgical futility, defined as an intervention offering minimal likelihood of meaningful benefit, has become increasingly relevant. However, definitions remain inconsistent, and current risk assessment tools rarely capture the outcomes most valued by elderly patients, including independence, functional recovery, and quality of life.</p> Methods <p>This narrative review examined literature published within the past 10&#xa0;years using searches conducted in PubMed and Google Scholar. Studies were selected for their contributions to defining surgical futility, evaluating approaches to quantifying risk in elderly surgical patients, and exploring ethical and cultural considerations in emergency decision-making.</p> Results <p>Quantitative definitions of futility frequently focus on very short-term outcomes, such as postoperative death within 48–72 h, which excludes qualitative measures central to patient well-being. Commonly used prediction tools, including NELA and ACS NSQIP, primarily estimate short-term mortality and provide limited insight into long-term functional recovery. Frailty, one of the strongest predictors of adverse outcomes, remains underutilised in emergency surgical risk stratification. Studies also report that the term “futility” may appear dismissive, complicating communication and shared decision-making, particularly across culturally diverse patient groups.</p> Conclusion <p>Emergency surgical decision-making for elderly patients requires a&#xa0;broader, patient-centred framework. Incorporating frailty, long-term outcomes, patient goals, and culturally sensitive communication is essential to achieving ethical and value-aligned care. Clearer definitions and improved decision-making tools are needed to guide practice.</p>