Clinicians would better serve their seriously ill elderly patients by improving communication to avoid emergency surgery that could prove to be too intense and potentially harmful, according to a study published online in Annals of Surgery (Ann. Surg. 2014 May 23 [doi: 10.1097/SLA.0000000000000721]).
Dr. Zara Cooper and her colleagues from Brigham and Women’s Hospital, Boston, conducted a wide-ranging literature review to ascertain factors that lead to communication challenges and nonbeneficial surgery at the end of life.
Dr. Zara Cooper
"Elderly patients with serious illness often receive poor-quality end-of-life care, leading to high rates of emergency department use, hospital and intensive care unit admissions, and in-hospital death, and low rates of hospice referral. High-intensity treatments near the end of life often are burdensome and prolong suffering without meeting patients’ personal goals," the researchers wrote.
If surgeons assume that patients favor life-prolonging treatment, they may opt to provide interventions that are immediately lifesaving but add little to the patient’s quality of life and may prolong, or even accelerate, the dying process, the researchers said. Studies have shown that nearly 1 in 10 Medicare patients who die have surgery in the last week of their lives (Lancet 2011;378:1408-13).
"Unable to quickly elucidate the gravity of the underlying illness and assess the patients’ understanding of their disease, surgeons may hesitate to engage in conversations about patient preferences and aggressive palliation as an alternative to invasive treatment," the authors wrote.
To avoid such communication pitfalls, the study recommends:
• Advance care planning around surgery: Even in an emergency setting, clinicians can set treatment goals early and revisit them if the patient’s condition deteriorates. Emergency surgeons should engage the patient’s primary and specialty providers whenever possible to participate in clinical decisions.
• Education and training: Surgeons routinely encountering seriously ill elderly patients should consider learning evidence-based communication strategies, including how to handle intense emotions, discuss prognosis, and deliver basic palliative-care interventions in a structured format with expert guidance.
• Structured communication: The goal is not to divert elderly patients with limited life expectancy from potentially life-prolonging surgery, but instead to determine patients’ priorities up front to better enable surgeons to recommend treatments. Such communication also should determine health states unacceptable to the patient, and affirm the clinician’s commitment to the patient’s well-being.
• Further research: More information is needed on patient-centered surgical outcomes for elderly patients with serious illness, including survival beyond 30 days, functional outcomes, health-related quality of life, transitions of care, and quality of death.
According to the study, physicians likely opt for invasive treatment of this vulnerable population out of concern about possible legal repercussions if they withhold it. But even when the patient’s prognosis is clear, legal concerns are minimal, and the patient is willing to discuss death and dying, many surgeons lack training in how to discuss death or provide a palliative approach to care, the researchers said.
Thus, surgeons may fail to respond to social cues relevant to end-of-life care or provide support, and instead "frequently employ defensive strategies" such as focusing on medical details, the study found.
Patients in distress often rely on surrogate decision-makers, the researchers noted. Given the disconnect between surrogates’ expectations and what medical treatment realistically can offer, surrogates may consent to treatments that they believe will prolong and restore quality of life when in fact such interventions are associated with physical or psychological suffering and scant, if any, benefit.
The authors did not receive funding support for this work and declared no conflicts of interest.