Surgical Decision Making in Geriatrics: A Comprehensive Multidisciplinary Approach

453 Pages·2020·10.42 MB·English

by  Rifat Latifi

Surgical Decision
Making in Geriatrics
A Comprehensive Multidiscipli-
nary Approach
Rifat Latifi
Editor
123
Surgical Decision Making in Geriatrics
Rifat Latifi
Editor
Surgical Decision
Making in Geriatrics
A Comprehensive Multidisciplinary
Approach
Editor
Rifat Latifi
Department of Surgery
New York Medical College
School of Medicine and
Westchester Medical Center Health Network
Valhalla, NY
USA
ISBN 978-3-030-47962-6 ISBN 978-3-030-47963-3 (eBook)
https://doi.org/10.1007/978-3-030-47963-3
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Prologue: COVID-19 Pandemic and the
Elderly, Disparity
When we conceived this book, none of us could imagine that before the book
goes to the print, the world would be in chaos from a disease that would affect
all of us, but particularly will be deadly for the elderly and disparity popula-
tion. None of us thought that the entire world would change as it did. Over the
past six months, not just the world has changed and with that the hospitals
and practice surgery have also changed. For months we did not perform any
elective surgery; we only performed emergency surgery. Everyone has a
mask on, everyone who works in the hospitals and patient alike. But as bad as
it was, we learned a lot during these past months, and chances are we will
continue to learn more about the disease that has spread throughout the world
and that affects every organ.
With each day passing we learned new things. Who is dying, but even
more importantly, why patients are dying? How do we protect each other,
ourselves, our families, our patients, and hospital staff? It is very difficult to
keep up with new information. One paragraph written today on your paper on
COVID-19 or information you read is challenged next day by new data or by
lack of data. The first report on deaths from COVID-19 that came from China
was alarming with death rates of 11.1–14.6% of those infected. However, as
New York become the hottest zone in the world, the study from New York
City reported higher mortality rates. We have learned that elderly, obese
patients, those with hypertension, lung diseases, chronic kidney disease,
malignancy, myocardial infarction, cerebral infraction, and arrhythmia, had
worse outcomes. Those who died from COVID-19 had significantly increased
white blood cell (WBC) count and decreased lymphocyte and platelet counts.
On rounds in the ICU now we talk about biomarkers of inflammation, inter-
leukins 6 (IL-6) and 10 (IL-10), serum ferritin, and neutrophil-to-lymphocyte
ratio (NLR). One thing that we knew, but it became even more apparent from
this pandemic, is the disparity and inequality of healthcare. It has become
evident that blacks, Native Americans, and patients from Hispanic communi-
ties are dying at a much higher rate. In other words, poor people and elderly
in nursing homes are dying in disturbing numbers worldwide, particularly in
Europe and USA. Vascular complications of COVID-19 (thrombosis both of
venous and arterial tree) are severe including causing major abdominal catas-
trophes (Figures). In order to prevent these complications, patients are placed
on anticoagulants, which in critically ill patients can cause major bleeding
such as bleeding from ulcers or other intestinal bleeding. Stopping anticoagu-
lants causes stroke, entering this way in a vicious cycle, that often ends fatally.
v
vi Prologue: COVID-19 Pandemic and the Elderly, Disparity
Due to severely depressed mental status in severely ill COVID-19 patients,
often neither stroke nor abdominal catastrophe is recognized in a timely man-
ner and may have severe consequences. As we were only performing emer-
gency and cancer surgery, there is a fear that many patients stayed at home
and did not seek help. Are patients with gallbladder disease, major hernias,
reflux disease, and cardiovascular problems dying at home because they are
afraid of calling 911 and go to the hospital? Is this the new post-COVID-19
surgical world order where we will continue to operate only when things get
bad? Is this new surgical world order of healthcare: only emergency surgery.
Hope not. Will today’s “elective” surgery become emergency one day, or per-
haps patients will select to suffer or simply die at home? What will the out-
comes of all “emergency surgery only” patients be? More questions than
answers.
Valhalla, NY, USA Rifat Latifi
Preface: The Last Sunset and Dying Alone
The Last Sunset
The times have changed. What was considered old a few decades ago now is
not old at all. In fact, despite the fact that World Health Organization has
defined the elderly as those above 65 years of age, there are significant
changes in demographics of world population, and we researchers of the sub-
ject are struggling with definitions. Should the elderly be defined chronologi-
cally (e.g., those above the age of 85) or based on frailty index and physiology?
So, I have to admit that even the title of this book, Surgical Decision Making
in Geriatrics, is unclear and may raise an eyebrow of those who are totally
functional but have passed their 70s long ago. A good number of faculty in
my department are there already. Moreover, it is not uncommon for us sur-
geons to perform complex surgeries in patients in their 80s and 90s.
As we age, our bodies and our minds change, our needs change, our goals
and objectives change. Aging is beautiful though. Recently, a well-known
surgeon said while receiving a lifetime achievement award, “I am very happy
to be with you, but frankly nowadays, I am very happy be anywhere.” It is a
beautiful thing to be able to walk without major help, to feed yourself, to love
and be loved, to put clothes on and bathe and take care of your own hygiene,
to go out to dinner with family, friends, or your spouse or partner, to watch
your own grandkids or other kids grow. Simply talking to friends is a beauti-
ful thing. Going to the movies or the park is a wonder. It is all simple stuff
maybe – stuff that we take for granted when we are young.
When my paternal grandfather died at age 54, the kids in our village of
Kllodernice, Kosova, told my uncle that “an old man has died,” not knowing
that he was the son of the dead man. I never met my grandfather, but everyone
has told me that I look like him. When I celebrated my 54th birthday in
Tucson, AZ, thousands of miles from the village I grew up, I was relieved that
at least I had passed that mark. My grandfather died at home – probably from
tuberculosis or lung cancer or both. And he knew that he was dying, like
many patients do. I was told that the night before his death, he finished pray-
ing and looked at the sunset, saying “This was the last sunset I will see.” He
died early in the morning before the next sunrise. There was no doctor at the
bedside, no nurse, no intravenous fluid, no test, no surgery, no therapy, no
vii
viii Preface: The Last Sunset and Dying Alone
nursing home, no rehab center. The nearest place to get a chest x-ray was days
away by horse carriage. He died surrounded by 9 out of 10 of his kids, his
brothers, his cousins, and his friends. The entire village and many people
from surrounding villages came to his funeral to pay their respects.
By the time my grandmother died, I had just finished medical school and
was attending her at home. She was in her 90s and died surrounded by near
100 kids (10 of whom she birthed and raised), grandkids, sons and daughters-
in-l aw, cousins, and friends. I saw her take the last breath. It was a peaceful
death. It was a beautiful death and it took place in her own large bedroom.
Many decades later, my father was 90 years old living in Prishtina, Kosova.
One day, my daughter Kalterina, who at the time was living in Prishtina,
called to tell me that my father was not doing well, and the surgeon would
like to take him to the operating room for a left ruptured iliac artery
aneurism.
I had to make a difficult decision. I was told that he has been anuric for
almost 9 hours. Because he was 90 years old, the prospect of him making it
out of hospital functional was very grim. He had lived a full life and was
functional till the last day of his life. Now it was time for the end. I told the
vascular surgeon not to operate but instead to find him a quiet room and con-
trol his pain while his family gathered to say goodbye.
Three hours later, he died peacefully after waving goodbye to all around
him. He died surrounded by my two sisters and their husbands, my brother,
his grandkids, cousins, friends, and many others. He was a soldier in three
wars, fought the bad guys of the time, nearly died a few times, but lived to be
old. This was a beautiful death.
My mother passed has few years earlier. She was 82 years old. She died at
home, but she had doctors at her bedside, providing care in the last 3 days of
her life. When she died, I was in a surgical mission in Tagbilaran, Philippines,
caring for others. She died peacefully, I was told, at her home being cared by
my two sisters, their husbands, and many grandkids. I went to her funeral in
Prishtine, but for me, my mother died in Philippines, not in Prishtine.
Lonely Death
My grandparents died at their homes, not a bustling and noisy hospital ward
or intensive care unit. They grew old and truly enjoyed their lives. They spent
their years with plenty of family and social interaction, enjoying seeing kids
and grandkids and friends. They enjoyed life as it is meant to be. This is how
we are supposed to live and die – independent and with dignity, fully aware
of our age and life and participating actively in life.
But, unfortunately, this is not the case all the time. With the modernization
of our lives, the family fabric and family supporting infrastructure has
changed dramatically. Kids move out, parents live alone, and they grow old
alone. And they die alone.
Preface: The Last Sunset and Dying Alone ix
One of the most difficult things that I had to do as trauma and general
surgeon in Tucson, AZ, was watch patients die alone without family around.
Sometimes their family was living on the other side of the country and the
patient was alone in Tucson, trying to avoid the harsh winters of the East
Coast. Often, when finally, I would get a hold of someone on the phone to
give the bad news or the good news, the conversation was strange. Almost
non-human. The kids often would not even know that their parents were in
Tucson. They may not have seen them for years.
Once, I performed a complex abdominal wall reconstruction on an elderly,
pleasant woman, a known medical illustrator, for disruption of the abdominal
wall from a seatbelt injury. She survived two surgeries and was doing great
but her son, a priest, insisted on us stopping everything and extubating her.
“She suffered enough,” was what he kept saying, but it felt like he was in a
rush to return to his church in Connecticut. I did not agree with his opinion
and his decision and refused to extubate her prematurely. At his insistence,
while I was out of town, one of my partners extubated her. To everyone’s
surprise, she lived and recovered and went to rehab. I asked her to be an illus-
trator of my book on abdominal wall reconstruction. She replied softly “I will
give it the best shot.” I never forgot her and often wonder if she eventually
died alone.
About 2 years ago, my youngest daughter Lulejeta and her dance team
Pulse from Katonah, New York, were performing at the nursing home in our
town. The nursing home is a beautiful complex of many buildings on the hill
overseeing the reservoir, and I pass by it daily. I went to see the show and
support my daughter. Watching the interaction of support staff with the resi-
dents and seeing how the staff were treating the patients like they were in
kindergarten, I became acutely depressed and told my wife I had to leave. It
was depressing to see how these old people were being treated like kids. Old
people are not kids. I made my wife promise me that if and when I grow old,
no one will take me to a nursing home. No one; I will not go. Recently, my
friend’s mother was in the IC for few days; an old lady with serious problems.
She was visibly upset when nurses were calling her mother “honey,” “sweet-
heart,” “baby.” As a patient is Mr. and Ms. or Mss., and not honey or baby or
sweetheart.
Do We Have to Die from Surgery?
So much has changed since my grandfather died. We live longer but we also
require more resources, more medical care, and more extensive surgical care.
We have the most sophisticated medical and surgical advances to postpone
death and have the ability to perform the most complex surgical procedures
to sustain life. As surgeons, we can operate in any cavity, any organ, any part
of the body. We can repair, remove, or replace an organ. That is not a question
anymore.
x Preface: The Last Sunset and Dying Alone
The fundamental question that we, as surgeons, and for that matter health-
care providers, must ask ourselves is, what is the mission and the goal of the
treatment that we are proposing to our elderly patient? My personal answer to
this is: restore the function, relieve the suffering, and improve the quality of
life. We must also ask at what cost? This book will explore this fundamental
question. One of my dearest friends, Tom, underwent radical cystectomy and
prostatectomy with creation of a neobladder. I had significant reservations
and suggested much less radical surgery. He had significant complications
postoperatively. And once he recovered the pathology report came back.
“Suspicious for invasion…” The recommended treatment was chemo-
radiation therapy. I pleaded with him not to undergo either one. He did. He
did not survive. At his funeral, his grandson read from Ecclesiastes: “There is
time for everything, and a season for every activity under the heavens: A time
to be born and a time to die….” The truth is that we should not offer therapies
with significant complications for any kind of suspicions to frail 76-year-old
men. We should not.
About this Book
While there are other books in the field of geriatric surgery, this is a unique
book that deals with surgical decision-making and other elements in caring
for the elderly. Just like the majority of healthcare institutions around the
country and the world, the fastest growing population that we care for at
Westchester Medical Center Health Network, Valhalla, New York, is the geri-
atric population. More than 35% of all surgical procedures performed occurs
in this population.
As it is evident from all chapters in this book, the fastest growing segment
of the US population is over 65 years of age. Similar growths are seen and
projected to continue globally. This demographic shift in the population has
serious implications in many aspects of life, but from the surgery standpoint,
the elderly will undergo increasingly frequent major surgeries and other
interventional procedures to maintain quality of life and physical and social
independence. At the same time, the cost of health services will increase and
the elderly will become the major consumers of healthcare and hospital
resources. Deciding what surgical approach to take for an elderly patient is
not an easy task. Should we perform definitive surgery in the elderly at the
time of presentation or should we try a minimalistic approach initially and
give time for the patient to recuperate and then perform the definitive sur-
gery? This book will explore surgical decision-making in this population,
particularly, in all aspect of surgery. The hardest decision that we surgeons
have to make is whether everyone who has a potential surgical problem actu-
ally needs surgery? Does an 80-year-old lady with serious comorbidities and
massive hernia for about 20 years need an operation? The answer is complex
and must be searched for with care.