Share elderly surgery decisions

TOO many elderly, frail patients have surgery that may leave them with poor quality of life, but teaching surgeons about teamwork and shared decision making is improving the situation in Australia, say geriatric medicine experts.

Professor Craig Whitehead, president of the Australian and New Zealand Society of Geriatric Medicine, told MJA InSight it was particularly important with older patients for surgeons to improve non-technical skills like teamwork, communication and how to make decisions with other people.

“Many surgeons in Australia have embraced this idea [of shared decision making] and are leading the way”, he said.

Professor Ian Maddocks, emeritus professor of palliative care at Flinders University, Adelaide, and 2013 Senior Australian of the Year, told MJA InSight oncology provided a good model for shared decision making in the care of elderly patients, which surgeons could emulate.

Professors Whitehead and Maddocks were commenting on an article published in the New England Journal of Medicine last week, which reported that a third of elderly Americans underwent surgery in the last 12 months of their lives, “most of them within the last month”. (1)

“Yet three quarters of seriously ill patients say they would not choose life-sustaining treatment if they knew the outcome would be survival with severe cognitive or functional impairment”, the authors wrote.

They called for a diverse assessment of patients, particularly those who were elderly and frail, using other practitioners with different skills and broader views.

“Shared decision making in surgical care requires a culture shift”, the authors wrote. “But with data showing that one of every 150 hospitalised patients dies from a complication, 40% of complications occur in surgical patients, and half of surgical complications are preventable, we need to try something radically new.

“Achieving the best outcomes in the sickest and most frail patients ‘takes a village’.”

Professor Whitehead said although the differences in surgical culture between the US and Australia were “significant”, there were benefits in improving the non-technical skills of surgeons here.

“In my experience, a lot of surgeons here fully understand these issues and will have these conversations [with their colleagues]”, Professor Whitehead told MJA InSight.

Professor Maddocks said that, in oncology, guidelines were now being used to help the oncologist decide on issues such as whether chemotherapy was likely to be well tolerated in an elderly patient, and to weigh up the potential side effects in favour of the therapy or against it.

“Surgeons need to have similar holistic assessments of fitness for a procedure, and also for the consequences of the procedure — what might be ahead for the patient as regards later care and comfort if the operation is undertaken.”

Professor Maddocks said his experience as a palliative care physician suggested that his presence on the hospital floor provided another option for surgeons as he was “readily available as an alternative direction of care for other specialists to consider”.

“Avoiding an operation may allow a focus on what can be done to maintain comfort, dignity and more time at home, and not uncommonly a longer life”, he said.

Professor Bruce Waxman, director of the Academic Surgical Unit at Monash University, Melbourne, told MJA InSight that the most difficult decision a surgeon had to make was when not to operate to avoid futile surgery.

“Surgeons should take the time to convene family meetings, and lead the discussion [about potential outcomes]”, he said.

“Once you bring up the subject … you would be surprised that they’re quite happy to have that conversation.”

A separate article published in Health Affairs reported that shared decision making also had a role to play in improving the care of elderly dementia patients when a feeding tube was a consideration. (2)

“Insertion rates were markedly lower when all of a patient’s attending physicians were hospitalists (1.6 percent), or nonhospitalist generalists (2.2 percent), compared to all subspecialists (11.0 percent) or a mixture [which included a subspecialist] (15.6 percent)”, the authors wrote.

Professor Leon Flicker, professor of geriatric medicine at the University of WA’s Centre for Health and Ageing, told MJA InSight that “subspecialists frequently make the wrong decisions”.

“They have less experience in complex medical problems and probably there needs to be a geriatrician, or another specialist, to make holistic decisions.

“There has been progress made”, he said. “Medicare item numbers now exist for team meetings, comprehensive assessments involving specialists, drug reviews for GPs and pharmacists.

“If we make proper use of the Medicare items then it’s possible to provide a better service and be reasonably remunerated for it.”

1. NEJM 2014; Online 9 April
2. Health Affairs 2014; 33: 675-682