You’re sitting in your doctor’s office trying to absorb what he or she just told you: you’re going to need major surgery, and soon. You may have known this day was coming, but now that it’s here your mind is racing. Should you go ahead and schedule the procedure? Should you seek a second opinion? What are the questions you should be asking?
This scenario plays out in clinics and doctor’s offices around the country hundreds of times each day. Older patients face a particular dilemma when dealing with the need for a significant surgery, even apart from the risks of the procedure itself. We know recovering in the hospital (or at home, for that matter) can pose a host of health challenges that can make your situation more precarious that it was before.
Because you or someone you love might have to face a decision about major surgery one day soon, we’re bringing you this helpful article from Kaiser Health News, written by seasoned reporter Judith Graham. Her advice: if your physician recommends major surgery, Graham offers seven simple but important questions you should ask before you go ahead. This, we think, is an excellent approach.
Weighing Risks versus Rewards of Major Surgery
Writing in Kaiser Health News, Graham begins her article with the story of a man named Larry McMahon, age 80, as he wrestles with a recent decision about major surgery. She writes, “Over the past five years, his back pain has intensified. Physical therapy, muscle relaxants, and injections aren’t offering relief.”
Then, she poses the real question: “Should McMahon, a retired Virginia state trooper who now lives in Southport, North Carolina, try spinal fusion surgery, a procedure that can take up to six hours?” He had had a lumbar laminectomy, another arduous back surgery, eight years ago, and now McMahon is facing every senior’s dilemma. “Will I recover in six months — or in a couple of years? Is it safe for a man of my age with various health issues to be put to sleep for a long period of time?”
As Graham writes, “Older adults contemplating major surgery often aren’t sure whether to proceed. In many cases, surgery can be lifesaving or improve a senior’s quality of life. But advanced age puts people at greater risk of unwanted outcomes, including difficulty with daily activities, extended hospitalizations, problems moving around, and the loss of independence.”
Graham wrote an article a few months back about a recent study that shed light on some risks seniors face when having invasive procedures. But how does one determine if potential benefits from major surgery are worth the risks? And what questions should older adults ask as they try to figure this out? She interviewed several experts for their recommendations. Here’s what they suggested a patient should ask his or her physician before agreeing to surgery.
Question #1: “What’s the goal of this surgery?”
According to Margaret Schwarze, an associate professor of surgery at the University of Wisconsin, the main core of this first question is: “How is this surgery going to make things better for me?”
Graham adds, “Will it extend your life by removing a fast-growing tumor? Will your quality of life improve by making it easier to walk? Will it prevent you from becoming disabled, akin to a hip replacement?”
It is perfectly acceptable to ask your doctor what impact the surgery will have on your daily life, and to probe for the most practical answer. Graham explains, “Just because an abnormality such as a hernia has been found doesn’t mean it has to be addressed, especially if you don’t have bothersome symptoms and the procedure comes with complications.”
Question #2: “If things go well, what can I expect?”
Schwarze, being a vascular surgeon, understands the levels of scenario that people can expect. In her line of work, she often deals with patients suffering from abdominal aortic aneurysms, which could end in the life-threatening burst of an enlarged blood vessel.
According to Schwarze, a “best case scenario” often looks like this: “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.”
Graham writes, “Among other things people might ask their surgeon, according to a patient brochure Schwarze’s team has created: What will my daily life look like right after surgery? Three months later? One year later? Will I need help, and for how long? Will tubes or drains be inserted?” These are things a patient deserves to know.
Question #3: “If things don’t go well, what can I expect?”
In her interview with Graham, Schwarze also offers a “worst case scenario” she outlines for her patients. It goes like this: “You have surgery, and you go to the ICU, and you have serious complications. You have a heart attack. Three weeks after surgery, you’re still in the ICU with a breathing tube, and you’ve lost most of your strength, and there’s no chance of ever getting home again. Or, the surgery didn’t work, and still you’ve gone through all this.”
Dr. Emily Finlayson, a director of the San-Francisco-based UCSF Center for Surgery in Older Adults, explains, “People often think I’ll just die on the operating table if things go wrong. 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.”
Question #4: “Given my age and general condition, what’s the most likely outcome?”
Finlayson suggests that, after your surgeon has walked you through various scenarios, it’s good to ask, “Do I really need to have this surgery, in your opinion?” and “What outcomes do you think are most likely for me?”
Graham writes, “Research suggests that older adults who are frail, have cognitive impairment, or other serious conditions such as heart disease have worse experiences with major surgery. Also, seniors in their 80s and 90s are at higher risk of things going wrong.”
It’s also extremely important to have trusted family or friends with you in the room for conversations like this, especially if you’re in a high-risk category for surgery. “Many seniors have some level of cognitive difficulties and may need assistance working through complex decisions,” Graham writes. A loved one can act as an empathetic sounding board as you think things through.
Question #5: “What are the alternatives?”
For some ailments, nonsurgical options are best and should be understood before you make any decisions. “Older men with prostate cancer, for instance, might want to consider ‘watchful waiting,’ ongoing monitoring of their symptoms, rather than risk invasive surgery,” Graham writes. “Women in their 80s who develop a small breast cancer may opt to leave it alone if removing it poses a risk, given other health factors.”
Returning to the story of Larry McMahon, his neurosurgeon suggested exploring other interventions before resorting to surgery, especially because of McMahon’s age and other medical issues. McMahon said, “[The surgeon] told me, ‘I make my money from surgery, but that’s a last resort.’” This gave McMahon freedom to consider alternatives to surgery.
Question #6: “What can I do to prepare myself?”
“Preparing for surgery is really vital for older adults: If patients do a few things that doctors recommend — stop smoking, lose weight, walk more, eat better — they can decrease the likelihood of complications and the number of days spent in the hospital,” said Dr. Sandhya Lagoo-Deenadayalan, a leader in Duke University Medical Center’s Perioperative Optimization of Senior Health program (or POSH).
Graham explains, “When older patients are recommended to POSH, they receive a comprehensive evaluation of their medications, nutritional status, mobility, preexisting conditions, ability to perform daily activities, and support at home. They leave with a ‘to-do’ list of recommended actions, usually starting several weeks before surgery.”
If your hospital doesn’t have a POSH program, Finlayson suggests asking your physician, “How can I get my body and mind ready” before having surgery. She also suggests asking, “How can I prepare my home in advance to anticipate what I’ll need during recovery?”
Question #7: “What will recovery look like?”
According to Graham, there are three levels of recovery to think about: “What will recovery in the hospital entail? Will you be transferred to a facility for rehabilitation? And what will recovery be like at home?”
She explains, “Ask how long you’re likely to stay in the hospital. Will you have pain, or aftereffects from the anesthesia? Preserving cognition is a concern, and you might want to ask your anesthesiologist what you can do to maintain cognitive functioning following surgery. If you go to a rehab center, you’ll want to know what kind of therapy you’ll need and whether you can expect to return to your baseline level of functioning.”
The COVID-19 pandemic resulted in a lot of older adults opting to go home instead of risking a stay in rehab, and according to Brigham and Women’s Hospital postoperative director Dr. Rachelle Bernacki, “it’s really important to make sure they have appropriate support.”
But the worst-case scenario should always be part of any planning, especially when it comes to serious surgeries. Graham ends her article with a wise warning: “For some older adults, a loss of independence after surgery may be permanent. Be sure to inquire what your options are should that occur.”
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(originally reported at www.khn.org)