The Elderly Are Getting Complex Surgeries. Often It Doesn’t End Well.
People over 65 represent roughly 16 percent of the American population, but account for 40 percent of patients undergoing surgery in hospitals — and probably more than half of all surgical procedures.
Those proportions are likely to increase as the population ages and more seniors consider surgery, including procedures once deemed too dangerous for them.
Dr. Clifford Ko, a colorectal surgeon at the University of California, Los Angeles, recently performed major surgery on an 86-year-old with rectal cancer, for instance.
“Ten years ago, I’d think, ‘My god, can this person even survive the operating room?’” Dr. Ko said. “Now, it’s increasingly common to see octogenarians for these types of operations.”
He and Dr. Ronnie Rosenthal, a surgeon and geriatrician at the Yale University School of Medicine, lead the American College of Surgeons’s Coalition for Quality in Geriatric Surgery.
As older people undergo more operations, the coalition has focused on the results. Perhaps unsurprisingly, older surgical patients often fare worse than younger ones.
One study reviewing major, nonemergency surgery in 165,600 adults over 65 found that mortality and complications increased with age; hospital stays often lengthened.
Patients in their 80s undergoing major surgery for lung, esophageal and pancreatic cancer have substantially higher mortality rates than those aged 65 to 69, another study found; they’re also more likely to go to nursing homes afterward.
Why? Older patients often have chronic health problems, aside from whatever the surgery is supposed to fix, and take long lists of drugs. The hospital itself, where they risk acquiring infections or losing mobility after days in bed, can endanger them.
Frailty, an age-related physiological decline, particularly correlates with increased mortality and complications. “How we talk to them, how we care for them, their outcomes — there’s a lot of opportunity to do better” for older surgical patients, said Dr. Ko.
Hence, the college’s new geriatric surgery verification program, to be unveiled next month at a conference in Washington, D.C., after four years of planning and research. It sets 30 standards that hospitals should meet to improve results for older patients.
In October, hospitals will begin applying for verification, an assurance to patients and families that the best possible surgical care will be provided. The college previously devised similar quality programs for trauma, cancer and pediatric surgery.
“People understand that children are different from adults,” Dr. Rosenthal said. “It’s taken a surprisingly long time to come around to the realization that older adults are also different.”
A team will visit each applying hospital. “We’ll look at charts, we’ll interview people,” she said. “We’ll see if they’re actually meeting the standards, so the public can have confidence.”
Some of the standards, based on published research, relate to staffing or physical changes like “geriatric-friendly” patient rooms. Some involve managing medications, with less reliance on opioids.
Participating hospitals will screen older patients for vulnerabilities — including advanced age, cognitive problems, malnutrition and impaired mobility — that put them at higher risk. Some of these risks can be addressed before surgery, through “pre-habilitation,” to help patients gain strength.
But many of the standards involve not infrastructure and surgical approaches but communication: ensuring that patients truly grasp their risks and alternatives, and that physicians ascertain patients’ wishes.
“The goals of a patient who’s 80 might be very different from someone who’s 50,” Dr. Rosenthal said. “They may value a higher quality of life for a shorter amount of time.”
Without clear understandings, things can go very wrong in the hospital. Consider this account from Dr. Gretchen Schwarze, a vascular surgeon and ethicist at the University of Wisconsin.
Dr. Schwarze helped care for a woman, 77, who contended with multiple health problems, including heart failure, weakened kidneys and emphysema.
“She was on oxygen,” Dr. Schwarze recalled. “She had terrible arthritis and used a walker.”
She also had a large aortic aneurysm extending from her chest into her abdomen — a weakened blood vessel wall that had ballooned and could burst. But she and her doctors had agreed not to repair it; the risks of the surgery, involving an incision from armpit to pelvis, seemed too high.
Then the aneurysm began bleeding, a painful and life-threatening development that sent the woman to the emergency room.
Her surgeon, Dr. Schwarze’s colleague, carefully explained to the woman that her odds of surviving surgery were about 50 percent (“which I think was a little optimistic,” Dr. Schwarze noted). Afterward, the patient would likely require ongoing dialysis and might remain indefinitely on a ventilator.
The surgeon made clear that, alternatively, she could choose a palliative approach to maintain comfort. Despite his concerns, the woman opted for surgery.
The problem, said Dr. Schwarze, was that “the kind of language we use to explain surgery doesn’t really describe the experience.”
After eight hours in the operating room, the woman went to intensive care, then suffered cardiac arrest. She underwent another six-hour operation before returning to the I.C.U.
The next day, “when the surgical team saw her, they were thrilled — ‘Wow, she’s doing great,’” Dr. Schwarze said. “Then her family came in.”
The woman for years had told them, but not her surgeons, that she feared life support and nursing homes. Now — sedated, swollen, breathing through a tube — she was unable to open her eyes, speak or squeeze a hand.
Even had the procedure gone perfectly, she was bound for a nursing facility, probably permanently.
“They had no idea this was part of the routine,” Dr. Schwarze said of the stricken family. “They said, ‘This is not O.K. You can’t do this to her. You have to stop.’”
At their insistence, the hospital discontinued treatment, allowing the woman to die.
The geriatric surgery verification program, now being piloted at eight hospitals across the country, could help prevent such horrors. Eventually, patients and families will be able to choose hospitals that participate over those that don’t.
But that option might be years off. The coalition hopes 100 hospitals will apply in the program’s first year; however, more than 4,500 community hospitals perform adult surgery in the United States.
Some hospitals may balk at the fee the College of Surgeons will charge for verification — “in the low five figures,” Dr. Ko said. Or they’re simply defer: “There’s the response, ‘We’re doing fine. We don’t need anything more.’”
Still, insurers, including Medicare, are already paying attention to how well hospitals meet quality standards. In any event, Dr. Ko said, surgeons can adopt some of the required practices on their own.
Take the frail 86-year-old with rectal cancer. Standard treatment involved radiation, chemotherapy and “a pretty big surgery,” necessitating a colostomy bag afterward. But the patient also had heart disease, pulmonary disease and failing kidneys.
“It was dicey,” Dr. Ko said. “We really needed to talk about quality of life and quantity of life and complications.” The patient could have chosen less aggressive treatments, but wanted curative surgery.
Sensitized by years of discussing geriatric surgery, Dr. Ko prescribed a “pre-hab” program to help his patient stop smoking, begin walking for exercise and increase his protein intake.
Subsequently, “he had the surgery, had a wound infection afterward, but no heart or lung complications,” Dr. Ko said. “Knock on wood, the patient did well and continues to do well.”
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