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End-of-Life Surgery

By March 9, 2018Commentary

An article at the Kaiser Family Foundation summarizes research and issues in regard to surgeries for patients near the end-of-life.   (KFF Article)   End-of-life care attracts a fair amount of attention because it accounts for a significant portion of health spending, and especially since by definition the patients die soon, it can appear that the care is futile.  On the other hand, it may not always be apparent that the patient is going to die in the near term, so deciding when care is essentially wasted isn’t really that easy.  One category of care that raises special concern is surgery, since it is very expensive and has risks for patients.  The Kaiser article notes that about one-third of Medicare patients have an operation in the year before they die, 18% in their last month of life and 8% in their last week.  12% of defibrillators were implanted in patients over 80.  While the authors seem to believe that financial incentives for physicians drive many of these surgeries, I suspect it is more an issue of patients, and especially family caregivers, being reluctant to not try every measure that might keep people alive for some longer period of time.  Guilt avoidance and over-optimism about the potential benefits of medical care are common among caregivers.

While surgery may often help younger patients be healthier and more functional, it often has the opposite effect in older patients, according to research.  There are risks from surgery itself, and operations are always a shock to the body, one that an older person has little reserves to cope with.  The surgery often leaves these patients in the hospital for extended periods, rather than at home, and means that many patients die in the hospital when they would prefer to spend their last days in their house.   About 20% of seniors who underwent emergency or urgent abdominal surgery died within 30 days of the operation.  Decision-making aids have been shown in studies to help patients resist these often inappropriate surgeries a significant portion of the time, but those aids are not currently in widespread use.  Medicare should consider mandating their use and having informed consent for surgeries be more than a just sign this form event, which it typically is today.  Physicians or other clinicians perhaps should be paid for taking the time to really explain in a neutral and comprehensive manner the likely outcomes of surgery.  And family caregivers need to be encouraged to be fully aware of the patient’s real desires.  None of this will be easy, so we shouldn’t expect big savings from reductions in end-of-life care anytime soon.

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