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Surgery Standard Scrutinized for Elderly Patients

At the American Academy of Hospice and Palliative Medicine conference earlier this month, Dr. Perla Macip spoke at a talk entitled “The 30-Day Mortality Rule in Surgery: Does This Number Prolong Unnecessary Suffering in Vulnerable Elderly Patients?” In recent years, a number of doctors and other medical professionals have questioned the thirty day mortality standard as a measure of success, particularly when it comes to elderly patients. Some go as far as argue that the standard of thirty days alive after surgery may undermine appropriate care for seniors.

Example of the Thirty Day Standard

One of Dr. Macip’s patients, “Mrs. S.” was a 94 year old patient who prior to surgery was fit and still lived in her own home. She consented to a valve replacement surgery and told physicians that her main goal was to return home. During the surgery, Mrs. S. sustained cardiopulmonary arrest and needed resuscitation. A series of complications followed, including an irregular heartbeat, fluid in her lungs, kidney damage, and pneumonia. Then, Mrs. S. had a stroke and was moved in and out of the intensive care unit, off and on a ventilator.

After two weeks in the hospital, Mrs. S. become depressed and stopped eating. Her geriatricians recommended discussing “goals of care” in order to determine whether she wanted to continue such aggressive treatment, but surgeons were optimistic that she would recover. As a result, Mrs. S. was not consulted about palliative care until Day 30, when she was septic and had multiple organ failure. She died the next day, 31 days after surgery.

Thirty Day Mortality Standard

For most surgeons, Mrs. S.’s case would be seen as a success because thirty day mortality is considered the normal standard for surgical quality. Several states require public reporting of thirty day mortality rates after certain surgeries, and even Medicare uses risk-adjusted thirty day mortality measures. However, some experts believe pressures for better thirty day statistics can cause more harm than good, discouraging surgery for patients who could benefit in addition to sentencing others to long stays in hospitals and nursing homes.

At other conferences, doctors have admitted that they could not operate on a person because it would hurt their thirty day mortality statistics. The debate is particularly urgent for seniors and elderly patients who are more likely to undergo surgery and to have complications. Surgeons may decline to operate on high-risk patients because of fears that their deaths could hurt the thirty day results.

Effects on Elderly Patients

Not only may surgeons decline to operate on elderly patients, even if the patient understands the risks, but the thirty day rule has other potential ramifications for seniors. When things go wrong in surgery, surgical teams are more concerned about their thirty day metrics than things like palliative care, hospice, or even try to override advance directives. One doctor admitted that “”Surgeons are reluctant to withdraw life support before 30 days, and less reluctant after 30 days.” However, many older patients and their families have different ideas about what is worth sustaining and would rather appreciate an honest discussion before the month passes.

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