Jeffrey J. Houlton, MD, assistant professor of otolaryngology at the University of Washington Medical Center in Seattle, opened the session on head and neck surgery in the elderly by describing the aging population in the United States. He explained that the current life expectancy in the United States is 78 years and that there are now 45 million Americans who are 65 years or older. Moreover, people aged 80 and older are one of the fastest growing U.S. demographics and, increasingly, they are high functioning. These elderly patients also have an increasing number of head and neck malignancies when compared with younger patients. In many cases, surgery is their only real therapeutic option. The question for surgeons then becomes, “How do we decide which elderly patients are going to respond well to surgery?”
How to Predict Postoperative Outcomes
Jason T. Rich, MD, assistant professor of otolaryngology–head and neck surgery at Washington University School of Medicine in St. Louis, Mo., talked the audience through the process of predicting postoperative outcomes. In the case of the elderly, these outcomes include not only traditional surgical outcomes, but also outcomes such as physical and mental function. Surgeons should acknowledge that there are limited data about the risks of surgery for elderly patients. Because of this, each surgeon must find his own specific way to counsel elderly patients.
“Each of us has a different style of interacting with our patients,” said Dr. Rich. But he also asked each surgeon to look closely at his own ageism bias to make sure that any advice given is not founded on prejudice or discrimination based on the patient’s age.
Surgeons can use tools to objectively stratify patients by risk. Specifically, the American College of Surgery National Surgical Quality Improvement Program (ACS NSQIP) has a risk calculator that predicts which patients will suffer complications or even mortality. Most studies agree, however, that age alone is not a prognosticator for outcomes, because not all elderly patients have a similar functional status. Instead, frailty is a better predictor of surgical outcome. Frailty, which can also be measured using the ACS NSQIP calculator, is a state of reduced physiologic reserve associated with increased susceptibility to disability.
Dr. Rich then presented his data (not yet published) on the prediction of mortality and morbidity in head and neck patients 80 years and older. The study included 219 patients who underwent 241 procedures. The patients had a mean age of 85 years, and 60% of them were male. Dr. Rich and colleagues found that, at 30 days post-surgery, one-third of the patients had serious complications, and approximately 75% of the patients had at least one complication. The 90-day mortality in the cohort was 10%.
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.
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.
Because age alone is a poor predictor of postoperative outcomes, the focus of the risk assessment should instead be on patient frailty and comorbidities, both of which are more predictive of outcomes than age. If the patient does opt for surgery, the surgeon should consider that free-flap reconstruction in the elderly can be performed with a high degree of success and that the flap outcome does not appear to be solely affected by age.
Dr. Pullen is a freelance medical writer based in Illinois.