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Leveraging the Preoperative Clinic to Engage Older Patients in Shared Decision Making About Complex Surgery: An Illustrative Case

Murthy, Sushila MD, MPH*; Hepner, David Lerner MD, MPH; Cooper, Zara MD, MSc; Javedan, Houman MD§; Gleason, Lauren Jan MD§; Chi, John H. MD, MPH; Bader, Angela Maria MD, MPH

doi: 10.1213/XAA.0000000000000331
Case Reports: Case Report
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The decision to pursue surgery is often complicated in older adults. A multidisciplinary, shared approach to decision-making may improve communication between patients and their providers and facilitate complex risk assessment. We describe a case of an older adult presenting for complex surgery in which the preoperative anesthesia clinic visit was used to facilitate involvement of the geriatrics service. This multidisciplinary approach allowed for re-evaluation and reiteration of risks and benefits, in-depth discussion of the patient’s values and goals, and recommendations for care teams downstream in the patient’s surgical pathway to ensure treatment consistent with patient goals and clinical recommendations.

From the *Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Anesthesia, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts; §Division of Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts.

Accepted for publication January 29, 2016.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Sushila Murthy, MD, MPH, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., 680 Dulles Bldg., Philadelphia, PA 19104. Address e-mail to sushila.murthy2@uphs.upenn.edu.

The older population presents a unique set of concerns when considering the decision to have surgery.1,2 The possibility that perioperative insults may worsen existing physiologic and cognitive deficits, precluding a return to baseline functional status, should be balanced against benefits that the procedure could confer. A multidisciplinary approach to decision-making around surgery may improve communication between patients and their providers, facilitate complex risk assessment, and lead to decisions that better incorporate patients’ values and goals. We describe a case of an older adult presenting for complex surgery in which the preoperative anesthesia clinic visit was used to facilitate involvement of the geriatric medicine service. Written consent for publication of this report was obtained from the patient.

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CASE DESCRIPTION

Preoperative Course

In April 2015, a 91-year-old man with C1 to C2 spinal stenosis and significant diffuse idiopathic skeletal hyperostosis presented to the preoperative anesthesia clinic of a tertiary medical center for evaluation before decompression of his cervical spine from C1 to C3. The patient had been experiencing progressive weakness of bilateral upper and lower extremities and sustained multiple falls in the preceding 8 months. He was given the diagnosis of C1 to C2 chronic dens fracture with pseudotumor pannus causing cord compression at the cervical medullary junction. The patient sought the opinions of multiple neurosurgeons at different tertiary care institutions who felt that the risks of medical and neurocognitive complications from surgery far outweighed the benefits and declined operating. Continuing to seek symptomatic relief, the patient consulted a neurosurgeon at our institution. The neurosurgeon, together with the patient’s son, evaluated the patient. The son noted that his father’s functional decline had been rapid over the last 6 months, which argued for a surgically reversible problem rather than an irreversible degenerative one. The neurosurgeon agreed to perform the operation contingent on an evaluation in our comprehensive preoperative assessment clinic.

Given the patient’s age-associated connective tissue, renal, pulmonary, hepatic, and cognitive changes that could increase the risk of surgery, the evaluating anesthesiologist at our preoperative clinic arranged for further preoperative evaluation by a geriatrician with expertise in perioperative management. Evaluation by the geriatrician helped to further elucidate the patient’s physiological and cognitive reserve and prompted an informed discussion of his goals of care. A more detailed functional assessment confirmed that his activities of daily living had remained intact despite his sentinel fall and that a subsequent fall had resulted in a rapid loss of his activities of daily living because of symptoms associated with cord compression. Although his current functional status was equivalent to the diminishing of physiologic reserves associated with normal aging, the geriatrician confirmed that the timing was not congruent with the aging process. The geriatric assessment also discovered cognitive impairment (impaired recall and mild executive dysfunction) that was not because of cord compression. Finally, a third area of concern was brought to light, which included a recent bout of presumed aspiration pneumonia. After conducting his own swallow evaluation in the clinic, the geriatrician confirmed the patient’s current aspiration problem. The cause of this was uncertain, because it could be associated not only with the aging process in the setting of rapid deconditioning, but also with cord compression.

With this background, the geriatrician had an explicit discussion of values and goals with the patient. The patient stated that he would “rather die than live in the state [he] is living in,” and this was clearly documented. He was disappointed with his conservative therapy thus far and viewed surgery as the only hope to regain function and an acceptable quality of life. The geriatric and anesthesia providers reiterated the risks of surgery. The risk of paralysis from surgical misadventure, prolonged postoperative ventilation from airway edema associated with prone positioning, and aspiration was quite high. There were also risks of postoperative cognitive decline and postoperative delirium. All members of the care team as well as the patient and his family were involved in these discussions and the decision to proceed with surgery.

During the preoperative visit, a health care proxy form was completed and the patient named his son. There was also a detailed discussion of code status. During the surgery, the patient would allow intubation, defibrillation, and use of pressors, but no chest compressions. The patient decided that, on extubation, he would be “do not resuscitate/do not intubate.” If the surgery was not successful and the patient was to become ventilator-dependent, he decided that he would rather receive “comfort measures only.” The patient’s goals and preferences were clearly documented in the chart. Because of the risk of perioperative aspiration, the geriatrician recommended placement of a temporary percutaneous endoscopic gastrostomy (PEG) tube during the spine surgery to avoid a second anesthetic and procedural insult. To prevent postoperative delirium, the geriatrician recommended avoiding specific deliriogenic medications in the postoperative period when the patient was in the intensive care unit or surgical ward. The geriatrician also recommended several postoperative reorientation and nursing care measures as well as a geriatric pain regimen of acetaminophen and low-dose opioids as needed. It was made clear that the PEG was to be temporary and also that the patient would not want a tracheostomy tube under any circumstance.

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Intraoperative and Postoperative Course

Figure 1.

Figure 1.

The patient underwent C1 to C2 laminectomy decompression. The intubation and anesthetic were uneventful. The estimated blood loss was 200 mL, and the patient was tracheally extubated in the operating room at the end of the case. After his preoperative evaluation, the patient rethought his preferences for a PEG tube and ultimately declined the procedure; he updated his providers on the morning of surgery and the PEG tube was not placed. The geriatric medicine service followed up the patient postoperatively as an inpatient and continued to make medication recommendations. On postoperative day 1, the patient reported improvement in the numbness of his hands bilaterally. The patient did not become delirious; he was discharged to a rehabilitation unit on postoperative day 3 (Fig. 1). When the patient met with his surgeon 1 month postoperatively, he reported significant improvement in his functional status. He was still in the rehabilitation unit, and, with the help of his therapist, he was now able to ambulate 120 feet with a walker and hand dexterity was much improved. The patient was very happy with his perioperative care and course.

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DISCUSSION

This case serves as an example of how a change in process, namely the implementation of thorough multidisciplinary preoperative evaluation, can help engage older adults in improved shared decision-making when deciding to have surgery by clarifying risks and benefits and elucidating the patient’s values and goals. Shared decision-making has 3 main components. First, the patient must be informed in an objective manner of treatment options and their attendant risks and benefits. Second, the patient must think about his/her own goals, values, and concerns and how they relate to each treatment option. Third, the patient must discuss these goals, values, and concerns with his or her provider so that together they can decide about future treatment.3 The patient’s family should also be involved in all discussions if the patient derives support from them.

Surgeons often assume patients’ “surgical buy-in”—a patients’ preoperative commitment to postoperative life-supporting care—before complex surgery.4,5 In one study, 60% of surgeons surveyed endorsed the practice of sometimes or always refusing to operate on patients who preferred to limit life support; 62% of surgeons reported that they would create an informal contract with patients describing agreed-on limitations of aggressive therapy and 20% reported that they would formally document this contractual agreement.6 However, surgical patients often display suboptimal understanding of their medical condition and the risks and benefits of their upcoming surgery.7 Moreover, they often do not discuss their treatment preferences about advanced care planning or, in particular, their preferences about how aggressively care should proceed if complications should occur.8

There has been an increase in the number of geriatric surgical patients in recent years, and this trend is projected to continue.9,10 These patients often have significant medical comorbidities and increased frailty.1 Risk assessment is often complicated, and patients’ values and goals of care may therefore be more nuanced than simply to “cure.”11 Moreover, cognitive decline, with or without dementia, is a significant concern among elderly patients and complicates the decision-making process.12 A greater depth of communication is often required to engage these patients in shared decision-making.

In the case of our patient undergoing surgery, the preoperative comprehensive geriatric assessment includes thorough evaluation of medical and functional problems as well as a consideration of psychosocial issues and has been shown to improve postoperative outcomes. In our case, it directly addressed many aspects of making a true shared decision.2,13,14 First, the patient’s cognitive status was evaluated, and it was determined that he had the ability to make decisions on his own. Second, there was a detailed discussion of the goals of care, which were clearly documented. The provider was better able to understand the patient’s values regarding functional independence by eliciting a thorough history of his functional status. Finally, plans were made about what to do if complications occurred. Particularly in frail, geriatric patients, it may be beneficial to have built-in mechanisms to continuously re-evaluate treatment progress after surgery and to determine how well the treatment aligns with patients’ values.15 In this case, the patient expressed the desire to pursue surgery, but that if there were severe postoperative complications, including requirement for postoperative ventilation, he would prefer reassessment and rapid de-escalation of care. This was clearly documented. In addition to the multidisciplinary preoperative assessment, the appropriate inpatient consultations were arranged and the geriatric medicine service followed up the patient along with his surgical team postoperatively. The documentation provided recommendations for care teams downstream in the patient’s surgical pathway to ensure treatment consistent with patient goals and clinical recommendations.

It has been well established that preoperative patients should be stratified based on the medical comorbidities; for instance, patients with high-risk cardiac disease should undergo further evaluation, particularly if undergoing high-risk surgery.16 We propose that there may be other factors by which to stratify preoperative patients. Our patient, scheduled to undergo surgery with uncertain outcomes, benefited from preoperative consultation with a geriatrician in addition to his anesthesiologist and surgeon. We hope to serve older patients with innovative and sustainable changes to perioperative care models. Currently, the geriatric medicine service assesses 4 patients a week at our preoperative assessment clinic. The cost per patient is approximately $200 for geriatric input, and approximately $100 of this is reimbursed. We have preliminary data that hospital length of stay is reduced approximately 2 days with these patients, and, assuming the hospital is able to backfill these beds, this yields a saving of up to $1.9 million for the institution. For our patient, adding a geriatrician to the multidisciplinary preoperative evaluation led to re-evaluation and reiteration of risks and benefits from the perspectives of clinicians with different areas of expertise, in-depth discussion of the patients’ values and goals of care, and thorough perioperative advanced care planning.

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