How do our patients and their families define a good outcome from a surgical procedure, particularly if it is a high risk surgical procedure (defined as >1% 30-day mortality)? What if the patient has dementia? Have you had patients with advanced dementia with acute displaced hip fractures where the traditional best option offered has been surgical repair?
In the USA, over 50% of surgeries occur in those >65 y/o, which translates into about 2 million surgeries per year. Of those surgeries, 1/3 occur in the last year of life and 18% of these in the last month of life. The latest data on Medicare death certificates finds dementia as a part of the certificate 50% of the time.
In a recent GeriPal podcast on Dementia in high risk surgery (https://geripal.org/dementia-and-high-risk-surgery-joel-weissman-and-samir-shah/#summary ), important questions were raised about the decision support we provide our patients who are living with dementia, as well as to their families. For instance, the outcomes for persons with advanced dementia who have an acute hip fracture repaired are similar to those who don’t have a repair with very little evidence for improved pain management, quality of life or significant prolongation of life expectancy. Though persons with dementia are known to have a higher risk of post-op delirium, mortality, and other 30-day post-op complications, the commonly used surgical risk score tool NSQIP, didn’t include dementia, until just recently. In addition, the adverse results that likely matter most to our patients and families like persistent pain, impaired mobility, loss of independence, and other QOL (quality of life) issues are not outcomes measured and reported by surgeons for most procedures.
The responsibility for having serious illness conversations prior to elective high risk surgeries or for those facing acute surgeries haven’t been well defined. Outside of fully capitated HMOs, most surgeons are paid for doing surgery and not so much for having these conversations. By the time our patients see a surgeon, there is “Clinical Momentum” to have the surgery that is hard to curtail. The speakers in this podcast discussed their recent study in JAGS (Journal of the American Geriatrics Society) in which they found only 7.5% of persons living with dementia had a bill for ACP (Advance Care Planning) in the 6 months before or after a high risk procedure. Most of these bills occurred in the 6 months afterwards suggesting the occurrence of a poor outcome after the procedure as the reason for the ACP conversation.
As a frontline internist with a palliative care focus, I must admit I have seen my share of patients with dementia who have had persistent poor outcomes after high-risk surgery. Even if they no longer have the ability to express “buyer’s remorse”, I have heard it expressed by their families. I agree with the speakers that we have a duty to prepare our patients and families to request the best possible information about the likely outcomes for what’s important to them, if they were to undergo or not undergo a procedure. As PCPs, we should start these conversations prior to referrals and prior to predictable emergencies like hip fractures.
Let’s reduce preventable “buyer’s remorse”.