Why surgery may not be the right choice for some older patients

Although some surgeries are generally considered minor procedures for people in good health, they may pose greater to risk to older people whose condition is more frail. A recent study published in JAMA Surgery found that older patients who were frail were at a higher risk of dying after any type of surgery, whether it could be categorized as minor or major surgery, and even when there are no complications after surgery. Some of the factors that contribute to these poorer outcomes include the fact that frail, older patients experience more problems related to general anesthesia and their wounds can be slower to heal. Even frail, older patients who do survive surgery often find recovery much more difficult and many aren’t able to be as independent as they were before they had the operation.

These surgeries are more common than you might expect. One study discovered that almost one in three Medicare patients undergoes surgery in the year before his or her death in spite of the fact that these procedures frequently cause more harm than benefit.

To lower these risks, older patients and their loved ones should have an in-depth discussion with the doctor before deciding to undergo surgery or other treatments that may be difficult to tolerate and may have a negative effect on quality of life, such as chemotherapy and dialysis. These questions are a good starting point for that discussion:

• What are my surgical and non-surgical treatment options? There may be other, less high-impact treatments you could try, such as physical therapy or medication.
• What is likely to happen if I do have surgery? The doctor should explain the best and worst case outcomes as well as the most likely outcome based on your current health and your diagnosis. Ask how long you will need to be in the hospital, what level of pain and discomfort you should expect during recovery, what potential complications many occur, and whether you will need to spend time in a rehabilitation facility or have help at home for a period of time.
• What is likely to happen if I do not have surgery? Your doctor should explain how your condition may progress, for example if you have heart failure you may become progressively more short of breath, fatigued, and have a persistent cough. Ask how the progression of your condition will affect your quality of life and ability to live independently, as well how not having surgery or treatment will affect your life expectancy.
• How will having or not having the treatment affect my other health issues? If you’re living with other conditions like heart disease, COPD, or diabetes discuss the impact that both treatment and forgoing treatment are likely to have on your other health problems because the progression of these conditions or complications related to them can also have a significant impact on quality of life.
• Would taking part in physical therapy before surgery or treatment improve my ability to tolerate it? In some cases, doing physical therapy before starting treatment or having surgery, which is sometimes referred to as prehab, can improve your strength and cardiovascular fitness. That in turn can make you less frail and better able to recover with fewer complications and less impact on your quality of life.

As part of your decision making process, it’s also wise to make sure you’ve considered what you’d like to happen if you are not able to make your own medical decisions during or after treatment. Make sure your medical power of attorney, HIPAA authorizations, and advance directive are up-to-date and in line with your current wishes.