PUMPING IRONY: Operating Principles

Well into her 70s, Mom was still doing some yardwork, hauling clothes down to the basement laundry room, and admirably handling other routine domestic chores. I still have a photo of her at her 80th birthday party, smiling and energetic, steady as a sailing ship cruising under a favorable breeze.

A few weeks later, I learned doctors had discovered a tumor somewhere during a routine check-up. Surgery and an aggressive round of chemo followed, and Mom gradually shrunk into a feeble husk, eventually struggling even to walk across a room. She barely made it to 82.

I was not privy to the conversations leading to the decision to operate; perhaps it was a fast-growing tumor that was causing her some discomfort, though she never spoke of it to me. But I’ve held to the belief that Mom would’ve enjoyed her final years more fully had she avoided the knife, and her experience has strongly reinforced my already skeptical view of invasive medical procedures as I meander through my eighth decade.

U.S. seniors undergo about a million major surgeries each year, yet there’s surprisingly little data available on the decision-making process — and consequences — of these procedures. “As a field, we’ve been really remiss in not understanding long-term surgical outcomes for older adults,” Zara Cooper, MD, director of the Center for Geriatric Surgery at Brigham and Women’s Hospital, tells Kaiser Health News. “What older patients want to know is, ‘What’s my life going to look like?’ But we haven’t been able to answer with [quality] data.”

Thomas Gill, MD, and his team of Yale School of Medicine researchers set out to fill in some of those blanks in a study published in October in JAMA Surgery. Assessing the one-year mortality rate of nearly 5,600 Medicare beneficiaries following major surgical procedures between 2011 and 2018, their conclusions could hardly be called uplifting.

About one in seven seniors died within a year after they were wheeled into the operating room, the study noted. And those suffering from dementia or frailty were especially vulnerable: A third of dementia patients and 28 percent of frail individuals did not survive for a year after the procedure. And the older the patient, the riskier the operation. Those fortunate enough to reach their 90s were six times more likely than folks in their 60s to die in the year after the surgery.

These results buttress Gill’s earlier research showing that one in three seniors were unable to recover their presurgery functioning six months after a major operation.

“This opens all kinds of questions,” notes Clifford Ko, MD, a professor of surgery at UCLA School of Medicine. “Were these surgeries done for a good reason? How is appropriate surgery defined? Were the decisions to perform surgery made after eliciting the patient’s priorities and determining whether surgery would achieve them?”

Gill and his team didn’t delve into the vexing decision-making process involved in those procedures, but Judith Graham, writing last week in a Kaiser Health News piece, surveyed a number of healthcare professionals and came away with seven questions seniors should ask before undergoing major surgery.

1. What’s the goal of this surgery?

It’s key to understand how the procedure will improve your life before deciding whether to give your consent. If your surgeon recommends an operation to remove an asymptomatic growth, for instance, and the procedure may create complications, Gill argues that you could consider delaying any action.

2. If things go well, what can I expect?

Your surgeon should be able to clearly describe the procedure as well as a “best-case” scenario before you consider going under the knife. Margaret Schwarze, MD, a vascular surgeon at the University of Wisconsin, tells Graham how she would prepare a patient for surgery to treat an abdominal aortic aneurysm:

“Surgery will be about four to five hours. When it’s over, you’ll be in the ICU with a breathing tube overnight for a day or two. Then, you’ll be in the hospital for another week or so. Afterwards, you’ll probably have to go to rehab to get your strength back, but I think you can get back home in three to four weeks, and it’ll probably take you two to three months to feel like you did before surgery.”

3. If things don’t go well, what can I expect?

“People often think, I’ll just die on the operating table if things go wrong,” says Emily Finlayson, MD, director of the UCSF Center for Surgery in Older Adults. “But we’re very good at rescuing people, and we can keep you alive for a long time. The reality is, there can be a lot of pain and suffering and interventions like feeding tubes and ventilators if things don’t go the way we hope.”

4. Given my health, age, and functional status, what’s the most likely outcome?

As Gill and his Yale research team pointed out, seniors struggling with cognitive dysfunction and frailty, or heart and kidney issues, are at a greater risk for complications after surgery. Discuss the real risks with your surgeon, enlisting the help of family or friends to arrive at the best decision.

5. What are the alternatives?

Graham describes the plight of 80-year-old Larry McMahon, who has been suffering from increasingly intense back pain over the past five years. He’s tried everything from physical therapy to muscle relaxants without success, and now he is contemplating spinal fusion surgery.

“Will I recover in six months — or in a couple of years?” he asks. “Is it safe for a man of my age with various health issues to be put to sleep for a long period of time?”

His neurosurgeon, citing McMahon’s arthritis and high blood pressure — as well as a 2021 knee replacement that had not completely healed — counseled patience and further physical therapy and injections. “He told me, ‘I make my money from surgery, but that’s a last resort,’” McMahon recalls.

6. What can I do to prepare myself?

You can reduce the risk of complications and shorten your stay in the hospital by ramping up your healthy activities — more exercise, nutritious foods — and curbing unhealthy ones like smoking prior to surgery. Also, seek out advice on preparing your home to best suit your recovery.

7. What will recovery look like?

Ask about your probable length of stay in the hospital and the chance of pain or other after-effects of anesthesia — especially if you’re concerned about cognitive dysfunction. Inquire also about the type of therapy you’ll need if you’re transferred to a rehab facility and how soon you can expect to reclaim normal functioning. If a return to normal is not in the cards, consider your options for assisted living.

These are daunting questions under the best of circumstances; stir in the emotions of loved ones, the fear of death, and the imperious nature of many doctors, and it’s easy to understand how even the most innocuous queries might be overlooked. I understand in retrospect how Mom might have consented to a precarious procedure in order to appease some loved ones who were not yet prepared to consider the prospect of her departure. Maybe that happened, maybe it didn’t. Life is complicated.

And death always gets the last word.

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