PUMPING IRONY: Risky Business

The elderly often climb on the operating table unprepared for the risks of surgery. New guidelines aim to help them — and their doctors — make more informed decisions.

hospital surgery room stretcher

When I blew out my right knee playing basketball back in 1998, the decision to go under the knife to fix it was pretty straightforward. I was a mere pup of 47 and yearned to keep playing well into my 50s. My surgeon looked over the pictures of my shredded meniscus and explained how he’d drill a couple of small holes in my knee and trim away the damaged tissue. I’d be back on the court in no time, he promised.

On the day of the operation, though, the anesthesiologist happened to mention that I could choose to be numbed below the waist with an epidural during the surgery rather than be put under completely. That way, he explained, I could watch the surgeon slicing and dicing inside my knee on the monitor above the operating table.

“I don’t know if I’d want to do that,” I recall replying after some consideration. “Why not just sleep through it all?”

That’s fine, he said, before explaining that I’ll stop breathing when I’m under general anesthesia. He described the act of shoving a breathing tube down my throat to remedy that situation, and noted that there’s a slight chance that it could damage my vocal chords.

This was news to me. I’d been under the knife a couple of times before and nobody had ever disclosed anything about respiratory failure — or the side effects of intubation. I thanked him and opted for the shot.

That brief interaction came to mind last week after learning about new guidelines issued by the American College of Surgeons (ACS) to improve the way doctors and elderly patients discuss the risks of surgery. As Judith Graham reports in Kaiser Health News, the ACS Geriatric Surgery Verification Program is based on the belief that “all older patients should have the opportunity to discuss their health goals and goals for the procedure, as well as their expectations for their recovery and their quality of life after surgery.”

Graham describes the case of 82-year-old Bob McHenry, who underwent two risky surgeries in order to restore blood flow to his failing heart. Though his surgeon explained some of the possible complications that could result from the procedure, McHenry’s daughter, Karen, told Graham that the family felt they had no choice but to go through with it.

McHenry suffered a stroke during the surgery, fell into a coma for several days, and awoke unable to swallow or speak. Until his death five years later, he struggled with dementia and continued physical decline. “There was not any broad discussion of what his life might look like if things didn’t go well,” Karen recalled. “We couldn’t even imagine what ended up happening.”

This is not an isolated case, said Ronnie Rosenthal, MD. The professor of surgery and geriatrics at Yale School of Medicine and co-leader of the ACS coalition that developed the new guidelines told Graham that surgeons don’t typically offer their elderly patients much helpful counsel. “What we don’t ask is: What does living well mean to you? What do you hope to be able to do in the next year? And what should I know about you to provide good care?”

Zara Cooper, MD, associate professor of surgery at Harvard Medical School suggested drilling down even further:

  • How does your health affect your everyday life?
  • When you think about your health, what’s most important to you?
  • What are you expected to gain from this operation?
  • What health conditions or treatments worry you most?
  • What abilities are so critical to you that you can’t imagine living without them?

That’s the approach Karen McHenry took when, soon after her father died, her mother, Marjorie, fell, breaking several ribs and collapsing her lung. When doctors suggested surgery to deal with the internal bleeding caused by the fall, Karen was better prepared to help her 88-year-old mom through the decision-making process. They decided against an operation. Almost three years later, Marjorie is doing well. “We took the risk that Mom might have a shorter life but a higher quality of life without surgery,” she said. “And we kind of won that gamble after having lost it with my dad.”

The results of my own modest gamble on knee surgery two decades ago was slightly less clear cut. On the one hand, I did not stop breathing during the procedure or leave the operating room without my vocal chords, and I eventually returned to the basketball court. But by the time My Lovely Wife arrived to fetch me from the hospital, I was struggling in vain to identify the source of a dull, throbbing pain issuing forth from the vicinity of my gradually awakening lower back. Kidney stones? I wondered. Appendicitis?

Nobody told me that I might not recognize the need to pee.

is an Experience Life deputy editor.

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