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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
Are there current guidelines on Surgery in the elderly in Australia in both elective and emergency settings?
Are there studies in the Australian context on what elderly patients and their families desire if they do require major surgery which can improve quality of life but carries significant risks on account of advanced age and co-morbidities?
Are there pro-active measures to cope with increasing number of elderly patients whose numbers will continue to increase and place attendant pressures on the healthcare system both for surgical and medical needs.
I am interested in these aspects and currently doing a literature review on Surgery of the elderly.
Jan Bowman makes a cogent point. In my view, retaining the ability to take risk is part of human dignity. At the end of life, when one loses the ability to protect one’s own airway, pneumonia used to be a natural end. Why can’t we allow the very disabled elderly some sensory pleasure? Some organ system eventually has to fail for death to come about, after all.
Elderly patients and relatives very frequently decline surgery if the real risks are explained to them, especially for a PEG. Aspiration still can occur with a PEG and tasting food or drinks is an essentail part of quality of life. Relaitives do worry about not inserting a PEG in patients who are unable to safely swallow. One of the problems is the hospital Speech Therapist, who labels the patient “Nil by mouth” because they cannot safely swallow, The family do not want them to die of thirst. If they are given oral fluids they may develop aspiration pneumonia and die from that. This seems a much better alternative than staying alive in a vegetative state for years with a PEG, or having thirst becasue they have been labelled “Nil by mouth”. And incidentally, a thickened cup of tea is worse than any of the alternatives.
Now days I encounter too many elderly at my doorstep in ICU after undergoing complex surgical operations to fix one of the nuts or bolts of the sick and tired human vehicles. The fate of these old people may take one of the following pathways: 1. They suffer a horrbile death in ICU. 2.They leave the ICU, but can never leave hospital leaving the public system with angry relatives who were promised a fix by the surgeon. 3.Even if they make it to their home/nursing home they suffer with severe disability and ultimately die. The reasons for our behaviour to treat this elderly Australians is multifactorial. Firstly the community expecations of living eternally is to be blamed. Secondly for some ethnic groups providing comfort care for sick and dying elderly is out of their sight and free Medicare is adds fuel to their ambitions. Thirdly the admitting specialist hardly gets time to take a holistic approach to discuss the final outcome prior to surgery, but rather concentrates on surgical aspects alone. Finally, the patient and family personal interaction is slowly fading away in this fast world and commensense has become a rare feature in our health system. Unless we address this issue in a concrete, transparent, logical and humanistic way, we in the Intensive care community continue to suffer in looking after sick and frail elderly people after complex operations and continue making end of life decisions in ICU. I am afraid that in the next 10-20 years our public hospital ICUs will turn into huge end of life care expensive units caring for these dying patients. The health system should facilitate frail elderly Australians to die in peace and dignity.
I think that Dr Boyd’s views are understandable in a number of respects. The surgeon involved is indeed the best placed to understand the indications and options as they apply to their patients needs and wants and also best advise their patient on what options are most appropriate.
The issue is not however stepping in to take the surgeons place but rather empowering the conversation, between the surgeon and their patient, with additional perspectives, diagnoses and facts. It is not at all unusual and is fairly much the norm that a surgeon is guided, in the options for surgical intervention they offer/advise, by other clinicians – anaethetic review, cardiology consultation re risks of different surgical options or even whether a surgical option is a reasonable option.
In older people however by far the most important issue, in my view, is information and definitive diagnoses about the presence of neurodegenerative disease especially dementing illness. The diagnosis of the presence of dementing illness is difficult and elusive and very infrequently identified early. Indeed in my experience the first opportunity to make that diagnosis is often post operatively when delirium occurs.
Surgeons need to know of the existence of these accompanying syndromes which, in their patients over 75 years becomes the most common and life defining issue that will determine life span more certainly than many cancers. Surgeons, and the options they provide for their patients, need to be informed by these diagnoses.
It really is a patronising notion that a homogenous group of ‘Surgeons’ are in some way deficient when it comes to making life-event decisions for elderly patients. Decisions made by a committee are actually less likely to be meaningful than decisions made by by a singular, professional ‘benign dictator’ who cares for the patient. There are of course several surgical disciplines and much surgery is done for benign conditions. Surgery is done with the intent to improve quality of life of the recipient. I suggest that the authors of this item go back to the drawing board and carefully redefine the group of Surgeons to whom they are addresing their remarks and carefully define the range of afflictions relevant to their ideas.
Bill Boyd
Gynaecologist
Mackay
Qld
To anonymous, re Advance Care Directives:
Thank you for your comment and for the link.
Professor Waxman did discuss Advance Care Directives when interviewed by MJA InSight, as well as directing us to his excellent recent article on the topic http://onlinelibrary.wiley.com/doi/10.1111/ans.12486/full
We were unable to include his comments in full and, as ACDs have been discussed extensively in previous MJA InSight articles (eg https://www.mja.com.au/insight/2013/44/make-advance-care-plans-routine), we chose to focus on the team-care approach for this news story. Thanks again for drawing our readers’ attention to the importance of ACDs in surgical care.
Dr Ruth Armstrong
Medical Editor, MJA InSight
Have the surgeons quoted actually heard of Advance care plans/directives? It would save a lot of stress for their patients to have such a thing in place, so no futile surgery or treatment is inflicted on them, to possibly cause further suffering to no great effect. Have a look at the website:
http://www.health.vic.gov.au/acp and read the policy, launched last month.