Dr. Rich felt that the message from his study was positive: Two-thirds of patients 80 years or older made it through surgery without a serious complication. When the researchers performed a conjunctive consolidation analysis of the patients who died within 90 days of surgery, they found several risk factors for mortality: preoperative dysphagia, age greater than 90 years, comorbidities, and extent of surgery.
Explore this issue:November 2017
Susan McCammon, MD, associate professor of otolaryngology at University of Texas Medical Branch in Galveston, Texas, then addressed the palliative and ethical issues associated with head and neck surgery in the elderly. She began by stating, “We have a huge role as head and neck surgeons to be story tellers, to explain to patients the middle road.” To do this, surgeons must develop a common understanding of the goals of care, specifically the outcomes that matter to the patients and their families. The patient may be most concerned about 300-day mortality or transient complications. In Dr. McCammon’s experience, however, destination at discharge is “hugely important to patients.”
The initial conversation should also include discussions of palliative care, survivorship, and the value of proactive planning. In some cases, these discussions may prove challenging, because the surgeon senses that the patient’s medical decision-making capacity may be decreasing. Dr. McCammon acknowledged, however, that concerns about capacity “really only happen when the patients disagree with what the surgeon wants to do.” Since these conversations will typically involve families, the surgeon will also need to assess whether the families are demonstrating guardianship or coercion.
Frequently, patients and their children and grandchildren experience conflicting realities that must be addressed. Children may be paternalistic towards their parents, and that paternalism is not necessarily bad. However, because “paternalism has gotten a very bad rap in medical ethics,” said Dr. McCammon, patients, families, and physicians should come together in shared decision making. In some cases, the best decision is palliative care and, in order to truly have the conversation about palliative care, patients and families need to understand the difference between palliative care and hospice. They also need to be informed about financial reimbursement for palliative care, what services are available, and where the services can take place.
Focus on Outcomes
The panel agreed that elderly patients require good preoperative evaluations and counseling, and that discussion should focus on the outcomes that matter most to the patient. While having these discussions, surgeons should honestly consider any ageism bias they may be bringing to the decision-making process.