Recently, I received a phone call from a community hospital about my grandmother’s care since my mom was out of town (NB. My grandma is 101!). She had been sent to the ER because she was coughing and her retirement home was worried that she might have aspirated part of her dinner. While my grandmother is quite ‘good’ for 101, she is 101 and there are some times when age does matter. My first words to the ER physician were, “whatever you do, please don’t intubate or code her.” Much to my surprise, they didn’t have that request on her records. The worst thing I can imagine would be her dying in the hospital intubated and getting chest compressions, in particular, because I know her and that is not what she would want.
Challenges:
- Aging is complex and becomes even more so as people are living longer and longer. As surgeons caring for patients more and more of our care is given to older patients as they are the fastest growing group. And while, a 75 year old may be “a good” 75, many studies have shown that age is an independent predictor of poor surgical outcome.
- Counseling patients is often based on data for younger patients (as many older patients are not eligible for RCTs)
- Goals may change throughout the care process.
As surgeons, we need to:
- Establish patient preferences early, while the patient can make choices and talk about “what ifs.”
- Establish goals of care with the patient and the family-in high risk patients it is important to have these conversations with family/caregivers so everyone is on the same page.
- Build a network family and support for the patient while they are undergoing their care.
- Work with a patient’s medical team. Consult with their primary physician and or geriatrician to optimize them for surgery
- Set realistic expectations for surgery, risks, benefits and life after surgery.
There are multiple resources available to help us deal with geriatric patients. Their care and management should be a joint collaboration of caregivers. A focus should be made on optimizing patients for surgery as a team. In fact, in 2012 the American College of Surgeons and American Geriatrics Society collaborated to develop guidelines for the preoperative care of geriatric patients.¹,²
These guidelines recommend the following preoperative assessments for every geriatric patient:
- A complete history and physical examination
- Conducting a cognitive assessment, including the patient’s ability to understand the purpose and likely outcomes of the procedure
- Screening for depression
- Determining risk factors for postoperative delirium
- Screening for substance abuse/dependence, including alcohol
- Performing cardiac evaluation following the American College of Cardiology/American Heart Association algorithm for patients undergoing noncardiac surgery
- Assessing risk factors for postoperative pulmonary complications and implementing suitable preventive strategies
- Documenting functional status and fall history
- Calculating frailty score at baseline
- Assessing nutritional status and considering implementation of preoperative interventions for high-risk patients
- Taking a complete medication history, making needed perioperative adjustments, and monitoring for polypharmacy
- Identifying the patient’s treatment goals and expectations in light of anticipated and unexpected treatment outcomes
- Assessing the family and social support system; and
- Performing suitable diagnostic tests as needed for elderly patients
These guidelines are important, but still underutilized.
An exciting next step for surgeons as a group is that many of our societies are placing an emphasis on aging. In August of this year, the ACS announced a joint initiative with the Hartford Foundation aimed at improving the health of older surgical patients through the creation of a standards and verification program for hospitals in an effort to improve quality care.³ An important step in the forward, but needs commitment from us as individual surgeons caring for our aging patients.
My grandma has made it back to her facility, she is doing well. We have clarified her goals of care and I now feel confident that when she goes, it will not be intubated and alone in a hospital. Although, at 101, she does still remember I’m her favorite grandchild. So I guess, that there are some things that transcend age.
[1] http://geriatricscareonline.org/ProductAbstract/american-college-of-surgeons-national-surgical-quality-improvement-program-acs-nsqipamerican-geriatrics-society-ags-best-practices-guidelines-optimal-preoperative-assessment-of-the-geriatric-surgical-patient/CL016
[2] https://www.facs.org/media/press-releases/jacs/geriatric0912
[3] http://bulletin.facs.org/2015/08/acs-and-hartford-foundation-launch-four-year-geriatric-initiative/