Postoperative recovery also requires some forethought. Because the majority of otolaryngology-associated elective surgeries are deemed outpatient procedures, insurance companies normally won’t pay for an overnight stay unless a patient meets the DRG criteria. After receiving general anesthesia, however, patients are often disoriented. “If it’s an elderly patient who lives by himself, he absolutely needs to have someone staying with him postoperatively, even for a simple operation,” Dr. Archer said.
Explore This IssueOctober 2011
Fortunately, doctors have the postoperative discretion to admit older patients if necessary. Making that call, however, requires attention to details like oxygen levels and a patient’s frame of mind. Dr. Archer also recommends pondering where to schedule an operation for a patient whose surgery or recovery may carry higher risks. Again, an anesthesiologist can often help determine whether a patient is a better candidate for an ambulatory surgery center or for a hospital, where every surgeon has privileges.
Then there’s the question of when. Dr. Archer has delayed surgery for a year or more on patients who receive a cardiac stent, a procedure that requires a follow-up, yearlong course of anticoagulants. “You’ve got to wait until the time is right,” he said. “In some cases, it may never be right, and then you have to say, ‘You’re at horrible risk for this operation, I don’t think it’s worth it.’”
Telling patients that they aren’t good candidates for surgery requires sensitivity and diplomacy, however. “We have to have ways to talk with them that don’t make them feel so bad and allow you to get the message across,” Dr. Dale said. For a patient who may have multiple co-morbidities, he may say something like this: “I’m really more worried about your heart disease. You’ve had a heart attack and a stroke and now we’re considering a really pretty stressful surgery. I’m not sure that the surgery is the highest priority right now, and I think it would be best for us to concentrate on these other problems.”
Surgeons may not have the luxury of time when assessing patients for non-elective surgery, but Dr. Kost said the initial questions are still the same: “How is this going to help the patient, and is there a real benefit at the end of the day to having this procedure?”
Patients must be made aware of the benefits and risks, and involved in the decision-making process. And surgeons need to keep life expectancy in mind. “In some cases, the patient’s comfort is really much more important than trying to add an extra month of living,” Dr. Kost said. “You really want to be careful to not add to their suffering.”