Surgery risks for elderly not always made clear

NEW YORK • The decision seemed straightforward. Mr Bob McHenry's heart was failing, and doctors recommended two high-risk operations to restore blood flow.

Without the procedures, the 82-year-old would die.

The surgeon at a Boston hospital ticked off the possible complications. Ms Karen McHenry, the patient's daughter, remembers feeling there was no choice but to say "go ahead".

On the operating table, he had a stroke. For several days, he was comatose. When he awoke, he could not swallow or speak and had significant cognitive impairment.

Vascular dementia and further physical decline followed until his death five years later.

Before her father's surgery in October 2012, "there was not any broad discussion of what his life might look like if things didn't go well", said Ms McHenry, 49, who writes a blog about caring for elderly parents.

It is a common complaint: Surgeons do not help older adults and their families understand the impact of surgery in terms people can understand, even though older patients face a higher risk of complications after surgery.

Nor do they routinely engage in "shared decision-making", which involves finding out what is most important to patients and discussing the surgery's potential effect on their lives before setting a course for treatment.

Older patients, it turns out, often have different priorities than younger ones. More than longevity, in many cases, they value their ability to live independently and spend quality time with loved ones, said Dr Clifford Ko, professor of surgery at UCLA's David Geffen School of Medicine.

Now, new standards meant to improve surgical care for older adults have been endorsed by the American College of Surgeons. All older patients should have the opportunity to discuss their health goals and goals for the procedure, as well as their expectations for their recovery and quality of life after surgery, according to the standards.

Surgeons should review their advance directives - instructions for the care they want in the event of a life-threatening medical crisis - or offer patients without these documents a chance to complete them.

Surrogate decision-makers authorised to act on a patient's behalf should be named in the medical record.

If a stay in intensive care is expected after surgery, that should be made clear, along with the patient's instructions on interventions such as feeding tubes, dialysis, blood transfusions and mechanical ventilation.

This is a far cry from how "informed consent" usually works. Generally, surgeons explain to an older patient the problem, how surgery is meant to correct it and what complications are possible, backed by references to scientific studies.

"What we don't ask is: What does living well mean to you? What do you hope to be able to do in the next year? And what should I know about you to provide good care?" said Dr Ronnie Rosenthal, a professor of surgery and geriatrics at Yale School of Medicine.

She told the story of an 82-year-old with early-stage rectal cancer. He suffered a stroke 18 months earlier and had difficulty walking and swallowing. He lived with his wife, who had congestive heart failure, and was hospitalised with pneumonia three times since his stroke.

Dr Rosenthal explained to the man that if she operated to remove the cancer, he might land in the ICU with a breathing machine and then end up at a rehabilitation facility.

"No, I don't want that. I want to be at home with my wife," Dr Rosenthal recalled his saying.

He declined the surgery. His wife died 18 months later, and he lived another six months before he had a fatal stroke.

Because of her father's experience, Ms McHenry was cautious when her mother fell and broke five ribs in 2017. At the hospital, doctors diagnosed internal bleeding and a collapsed lung and recommended a complicated lung surgery.

"This time around, I knew what questions to ask, but it was still hard to get a helpful response from the surgeons," she said. "I have a vivid memory of the doctor saying: 'Well, I'm an awesome surgeon.' And I thought to myself: 'I'm sure you are, but my mum is 88 and frail. I don't see how this is going to end well.'"

After consulting with the hospital's palliative care team, her mum decided against the surgery.

Nearly three years later, she is mentally sharp, gets around with a walker and engages in lots of activities at her nursing home.

"We took the risk that mum might have a shorter life but a higher quality of life without surgery," Ms McHenry said. "And we kind of won that gamble after having lost it with my dad."


A version of this article appeared in the print edition of The Straits Times on August 12, 2019, with the headline 'Surgery risks for elderly not always made clear'. Subscribe