Frail Older Patients Struggle After Even Minor Operations
nytimes.com
nytimes.com
What this and the article is pointing towards, is that we need to get better at assessing when it's time to move from curative medicine to palliative care. This is not just about advancing medicine, but about our culture and attitude towards the (current) inevitability of death.
It's not done for a profit motive in general here, but more that nobody loses their medical license, and no NHS trusts get smeared in the gutter press, for trying to "save" a life against all hope (see the controversy surrounding the Liverpool Care Pathway).
The lack of any legal route to assisted dying is also a problem. Even if that was introduced here, it would probably only cover people with a specific terminal diagnosis, not the more common scenario in the elderly of repeat curable problems.
Euthenasia is a contentious topic, rightly so in my opinion, and is a seperate issue to regaining a balanced view of how and if we should treat the seriously ill when the treatment may harm them as much as the illness.
You're wrong. There are many factors in play (family, friends, isolation, stress, money, pain, etc) around the individual's choice, but studies often find that the majority of older people would prefer a palliative approach to end of life. For example https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821585/ Sadly there aren't many studies around this topic. It's important, especially when so many people assume that older people just want to 'not die' rather than listen to what they actually want.
I'd personally rather live so long as I know better. Death might be inevitable now, but that isn't necessarily a set thing. Folks are working on having different sorts of existence and working on extending life and things like that. Sure, some of it seems like a pipe dream now, but who knows when some weird breakthrough will happen. I'll take my few years, and resent anyone trying to take them away - but your few years aren't mine to decide what to do with.
Besides, not everyone in their 80's is necessarily frail. Some are frail sooner, some later.
2. Most people at the bitter end are past the ability to make decisions.
Depends who is paying for them. Voters certainly can take Medicare away, or implement a triaging criteria.
I'm generally against doing procedures that won't really add life to folks - especially weeks. Years, though? That's years. Folks can be frail yet able-minded and so on. It doesn't really matter to me if someone needs to have some assistance to live, regardless of age.
Triaging criteria already exist. It is really a shame that insurance companies and businessmen have their hands in it instead of doctors. But I don't mind these criteria: They are, in general, for emergency situations instead of, say, routine gall bladder surgery.
And the people triaging at insurance companies are doctors and pharmacists themselves. A doctor not employed by insurance companies is also a "businessman", considering they get paid more the more they treat. No one is exempt from conflicts of interest, but since US voters didn't want "death panels", they get to deal with prior authorizations.
It's the same function done by the NHS or government in any other country.
«On February 13, 2014, Belgium legalized euthanasia by lethal injection for children,» from [1].
«Even the controversial head of Belgium’s euthanasia commission is concerned that a well-known Belgian psychiatrist is allowing too many of her psychiatric patients to be euthananised,» from [2].
1: http://www.patientsrightscouncil.org/site/belgium/
2: https://www.bioedge.org/mobile/view/belgium-euthanasia-docto...
https://www.bbc.com/news/world-europe-26181615
Perhaps the law is not being applied this way, but I think the idea here is "this poor child is in agony with no hope of improvement and keeping them alive is torture in a sense" - not "let's take terminally ill children lightly"
That is not what the assisted suicide debate is about. The debate is about the right to kill someone who cannot do so themselves.
https://www.cancerresearch.org/join-the-cause/cancer-immunot...
He’s still alive 4 years later.
And no, just because something works to "save (or extend) one life" does not mean it should be tried for everybody, because "hope". If you read the article - which says nothing surprising anyway - you balance your very few successes with lots and lots of bad cases. For some few to live longer a lot of people have to suffer more.
Completely orthogonal, but since the path this thread took shows people care a lot (too much) about individual examples, I saw this more than once in my own family. My 94 year old grandmother broke here hip, surgery was ruled too dangerous, so she was driven back to her retirement home - where she only spent her last year, when care became too difficult at home - and spent the rest of her days just lying in her bad waiting to die. There was no good option left. That's just how it is near the end. I'm just saying this to show that I'm not talking about something that I only know from discussions such as this one.
Also, both my grandmothers (who both made it into their nineties) had surgery in their 80s and both suffered significantly. Their brains were not the same afterwards. Anesthesia is not easy on the brain, even on top of any stress of the surgery itself on the body. There was a significant difference in mental abilities in both my grandmothers when comparing how they were before and after their surgeries (both had them for broken bones that occurred due to age related osteoporosis). And they both had pretty good starting points, others are much more frail at those ages.
And I doubt hospitals are debuting rediscovered Van Gogh works. Buying affordable works from local artists can fill a massive hospital for well under a million.
For those lacking understanding of the value of art in this context here is a good recent piece of research with many useful references: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5328392/
That's one thing I ave noticed in a lot of US hospitals and doctor offices. Everything is very shiny and new and costs a lot of money.
The economics change with insurance coverage. Once I hit my deductible, why do I care how expensive it is? At that point, might as well get my money’s worth out of my insurance company.
The last time I need non-routine care, the only thing I cared about was:
1. Is this doctor good?
2. Is this doctor/hospital in-network?
The money doesn't come from nowhere. If everybody thinks like this, your insurance costs more money.
If you don't pay for your insurance personally, how about just straight up being paid more by your company?
I do pay for my insurance personally. Health insurance law is somewhat different than most other forms of insurance in that the premium cannot be increased no matter my frequency or magnitude of previous claims. [0]
My marginal use is a merely a rounding error in the context of my health insurer's outlays. Nothing I could do would personally affect my rate. The aggregate of many thousands of people's use determines my rate, and for that, the tragedy of the commons is fully in charge.
[0]: https://www.healthcare.gov/how-plans-set-your-premiums/
Most surgeons are mindless robots. So immersed in their craft, full of themselves and disconnected from the rest of the population that they don't pause to think too much about what they are doing.
Not unlike any other profession with hyper specialization. It takes other members of the team or group to reign them in.
The job involves a whole lot of decision making surrounding ambiguity and uncertainty, and there are certain personality types who are totally unfit to handle such decisions. They get pushed into the room because of other skills and mindlessly do what they are programmed too.
Few months back I saw one jackass more interested in showing a family video clips taken of the surgery on their 80 year old mother, than actually talking about what they had achieved through the 8 hour reconstruction of all her internals. She passed away a few weeks back after all that pointlessness.
After many bad experiences with family and friends, I always ask the specialist how many such ops the team has done in a year. And then, how many have long term positive outcomes. And then, if they can put me in touch with someone who has been through it a few years prior. These days its easy to dig up this information.
This is an extraordinary assertion. Having watched my two elderly parents getting excellent -almost loving - care from surgeons on the NHS, I find it quite an offensive one. In both cases they sat down and spent quite a lot of time going through the pros and cons of surgery at at their advanced age. Dad decided to go ahead with a particularly ticklish piece of back surgery which gave him another 7 years of mobility and independence, even though it wasn’t fully successful.
I’m sorry that you had such an appalling experience. It’s not universal.
The stats you ask for are freely available in the NHS. The surgeon carried out the procedure on dad, knowing full well that it could quite possibly worsen his mortality figures.
I have had good experiences only after putting in a lot of research (that too after some painful lessons). And thats an option if it's not an emergency.
I have had to deal with a couple emergencies over the last couple years, where decisions had to be taken quickly. And I have seen both good and bad outcomes. The bad outcomes almost always are some guy at the ER acting as if palliative care is some unimaginable option.
They frame it simplistically "We have to move patient to the OR or they will be dead in X hours/by tomorrow etc". Just because it's possible to operate doesn't mean a surgery has to happen. Especially on elderly people.
It creates all kinds of cascading problems if it's a bad call. Good outcomes are possible but it needs a certain personality type and experience.
From personal experience, the healthcare system is also bad at determining when it's time to move from curative medicine to palliative care.
We need to get better at elderly healthcare in general.
They really wanted me out of bed to walk a bit within 12 hours. That first walk, I made it half way to the door of the room.
They focused on getting me out of bed and walking regularly (with a frame for support), no matter how short, and breathing into a device to measure lung capacity (which is almost zero with big hole in your side)
It sucked! A lot! But this was a key part of the recovery process. Being vertical is important for many bodily functions, and the less you can be vertical, the longer the recovery will be
I can’t imagine having to do this in another 30 years
https://www.ncbi.nlm.nih.gov/pubmed/31810636
METHODS: Older adults aged ≥65 years were included if they had an isolated hip fracture, were admitted to hospital between July 2009 and June 2016, inclusive, and were registered to the Victorian Orthopaedic Trauma Outcomes Registry. Mortality up to 12 months (365 days) post-injury, and functional outcomes (Glasgow Outcome Scale-Extended; GOS-E) at 12 months post-injury were examined. Multivariable Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs), and multivariable logistic regression was used to identify predictors of living independently compared with severe disability or death on the GOS-E.
RESULTS: 4,912 patients were included, of whom 28% died, 46% had moderate-severe disability, and 26% were living independently 12 months post-injury. Mortality rates were lower in women (aHR=0.56, 95%CI: 0.50, 0.63), and in people injured in a high fall vs low fall (aHR=0.47, 95%CI: 0.31, 0.72). Mortality rates were higher in people in the older age groups (75-84 years: aHR=1.53, 95%CI: 1.21, 1.93; 95+ years: aHR=3.58, 95%CI: 2.68, 4.77), living in areas with the highest level of socioeconomic disadvantage (aHR=1.25, 95%CI: 1.01, 1.55), with a Charlson Comorbidity Index weighting of one (aHR=1.60, 95%CI: 1.36, 1.88) or more than one (aHR=2.21, 95%CI: 1.94, 2.53), whose injury occurred in a residential institution versus at home (aHR=2.63, 95%CI: 1.97, 3.52), that resulted in intensive care unit admission (aHR=1.68, 95%CI: 1.21, 2.32), and in people who did not have surgery versus people who had internal fixation (aHR=1.65, 95%CI: 1.33, 2.04). Independent living was inversely associated with most of the same characteristics; however, people also had lower odds of living independently if they were from metropolitan residential areas versus rural areas (aOR=0.77, 95%CI: 0.62, 0.96), or had mild to moderate (aOR=0.33, 95%CI: 0.27, 0.39) or marked to severe (aOR=0.13, 95%CI: 0.09, 0.20) preinjury disability vs no preinjury disability.
Relatedly, this study from the same institution claims 5% mortality rate after a year for people under 65: https://www.ncbi.nlm.nih.gov/pubmed/27527378
But it does point slightly towards surgery bring beneficial (fixation reduced risk)
This passes the smell test without problem.
My grandfather who rode a bicycle everywhere into his 80s, never owned an automobile (Europe) broke his hip in a minor fall. He was moved to the USA to get the operation and lived with us permanently afterwards, it was definitely the beginning of the end.
Pretty simple way to reverse the osteoporosis.
The main result is prolonging age until occurrence anyway, not prevention. And definitely not cure.
It's just pushing it back a bit, of course she saw some improvement relative to a completely sedentary condition and that's great. It's not going to stay on that trajectory indefinitely, which is what's implied by "reverse".
(I was running down a steep hill and pitched forward onto the pavement face first. I ended up scraping one knuckle, leaving a very tiny scar. Yes, that would probably have looked a lot uglier had I somehow been 65 at the time.)
If that extrapolates out, then you may be right. Because of the demographic that breaks a hip, a shockingly large group of people who break a hip die within a year.
Every. Single. Time. since then this has been true in my anecdotal experience. Sometimes I've really regretted mentioning it because I've mentioned it to coworkers sort of casually and then, sure enough, their parent was dead within 6 months of the break.
After the first few came true I said it more seriously like, "Listen, you need to prepare for their death..."
The only appropriate thing to see say to a co-worker in that situation is a polite "I'm so sorry to hear about that, I hope your mom feels better soon." Keep the prepare for death conversations for close friends and family. Even if in was a close friend you happened to work with, the workplace is not an appropriate place for such a conversation.
If you do not wish to discuss it with coworkers, some of whom may or may not be friends, it's your choice to raise them or not. Focusing the attention on important matters could be done tactfully, which is very different from not talking about things.
If it's by fiat, there is an ulterior motive of "think happy thoughts, preferably shallow". There are such workspaces. There are also those that keep grave silence by fiat or unspoken convention.
But he died shortly afterward.
https://startingstrength.com/article/strength-training-for-p...
I've got a planned surgery coming up in february (I'm 23), and despite it being a major surgery, part of the recovery process is that I'll have to be able to stand upright - even if just for a few minutes per day - already on the first day after surgery. This is also why, if you absolutely have to stay in bed, you should use the remote for your hospital bed to at least sit in bed for as much time as possible (and why you should buy beds which have such a mode at home, too)
Edit: If you would, in my circumstances, please share why.
I do get ~annual PSA tests. And if I tested positive, I'd have a biopsy. And if it was low-grade, I'd just get tested more often.
And then there's this study, which I have taken to heart: "Ejaculation Frequency and Risk of Prostate Cancer: Updated Results with an Additional Decade of Follow-up".[0]
> Patient summary: We evaluated whether ejaculation frequency throughout adulthood is related to prostate cancer risk in a large US-based study. We found that men reporting higher compared to lower ejaculatory frequency in adulthood were less likely to be subsequently diagnosed with prostate cancer.
0) https://sci-hub.se/https://doi.org/10.1016/j.eururo.2016.03....
> Trichomoniasis is one of the most common STIs in the United States, with a prevalence estimated at 8 million cases annually; however, exact numbers are difficult to obtain because the infection is not nationally reportable and many infections are asymptomatic. ... Prevalence is also thought to be underestimated owing to the low sensitivity of the commonly used wet mount technique.
Yet another reason for safe sex. Or no sex, which is safer.
0) https://www.webmd.com/sexual-conditions/guide/trichomoniasis
Current standards for treatment are based on how advanced the cancer is and what the patient's life expectancy would be in the absence of cancer.
For a small cancer, because of the slow pace of the cancer, it's common to do nothing ("watchful waiting") or take androgen suppressants. For a cancer large enough to be viewed as threatening in the more short-to-middle term, you'd usually go for radiation therapy if you expect the patient to die within 10 years, and surgery if you expect the patient to last longer than that.
The reason for the radiation-surgery divide is that the very unpleasant side effects of the radiation generally show up about 10 years after treatment. (Whereas the side effects of surgery show up immediately and, hopefully, get better over time.)
The father-in-law in question is in his late 60s, but would be expected to live into his 80s if he were otherwise healthy. His father reached the age of 95. So I can understand why everyone recommended surgery in his case.
No real bottom line here, but I hope this was helpful to someone.
Although I'd likely opt out of androgen suppressants. In my experience, life without testosterone was unpleasant. My arthritis was worse, and I was prone to tendonitis. I lost muscle mass, and got fatter. I became borderline diabetic. My acne got much worse. And I lost all interest in sex.
Testosterone supplementation reversed all of that.
My grandmother had two EGDs and hip surgery after 90 with no long term deficits from them that we can see. She was even classified as frail at the time, although in retrospect I'm pretty sure that was incorrect.
From what I've read it's a good idea to stay away from GA, but there's a lot that can be done with mild sedation and a spine block.
I've never had surgery. I opted out of gall bladder removal, and changed my diet instead. And I haven't had further problems.
So sure, if I get multiple opinions that I need surgery for something that'll kill me in a few years, I'l likely agree. But if I'm otherwise not happy with my situation and health, I might opt out.
To be fair, I think everyone should have the same critical approach to any treatment and/or diagnosis, but it's especially important with higher risk treatments like surgery.
I did indeed feel pretty awful after - was off work for six weeks. Now I am a good bit older I'd be pretty reluctant to undergo surgery requiring general anaesthesia unless it was really required.
--
Also, there's another subthread about falling, hip surgeries, etc.
My current understanding is that maintaining lean muscle mass and balance are crucial to preventing future falls.
To keep this short: I now believe everyone 40+ should get regular physical therapy assessments and tuneups. Then do all those core strengthening and balance exercises. (I was actively running, jogging, lifting, and pretty trim. I was shocked to learn how much function I had lost. Like balancing on one foot to put on a sock.)
Dr. Peter Attia (The Drive podcast) is giving similar (complimentary) advice for people who want to pace themselves to live to 100.
--
PS- I will now suggest to my care providers to begin tracking both IQ and balance. I'm surveyed and tested yearly for so many other things. I don't know why this has never occurred to me before. Duh.
Then, there's the financial side: they have bills to pay so, so, at least, they lean on side of surgery.
My recent submission [0] was about how the system defaults to expensive treatments that are marginally effective, and that doctors frequently have no ability to provide what patients actually need.
My one grandfather died soon after his pacemaker was replaced - the wounds from his IVs became infected. I like to say that when he heard the doctor ask him if wanted his pacemaker replaced, he said to himself "this is my chance": If not for the surgery he certainly would have lived many more months while the battery gave out...
I mention it because of, Moreover, living longer is not older people’s only concern, or even their primary one, Dr. Rosenthal pointed out. “We don’t ask patients often enough, ‘What’s important to you?’”
The primary though should be understanding what the patient wants. The patient might accept risk of death for quality of remaining life. That is a classical dilemma for a pacemaker in the eldery. And it is simply a calculated, rational risk. The problem is when patients are not given the all their options and realistic risk for each (including the risk of no action).
edit: and I take this for granted, but a pacemaker can improve quality of life substantially. When it corrects a heartbeat it can prevent vertigo, falls, broken bones, and any other number of incidental effects of irregular rhythm. It is not a defibrillator.
"Frail older patients" wasn't even a word in anyone's vernacular 50 years ago, you just died if you were in that state. This is a result of us pushing the boundaries of what current modern medicine is capable of doing. Now there are more people living longer that, quite frankly, wouldn't have in earlier environments. In a way we are bypassing selection for "strong older people"
I find it harder and harder to believe that Insurance is the Bad Guy in US healthcare, as insurance companies make fairly normal level insurance industry margins (like, less than car insurance). The magnitude of total spend is the real problem, and that's a provider-side problem, not a payer side problem, but its hard to talk about doctors and pharmacy benefit managers being the potentially evil ones. People can't stomach the thought that its not a faceless insurance company, and that it might be doctors, in aggregate, over-prescribing and over-practicing well beyond actual need. (And proponents of EU style healthcare costs never mention EU style doctor salaries, and the difference w.r.t. those and the USA).
It sure would be terrible if tons and tons of these interventions done on frail people had no real medical use, and hundreds of them were found to be ineffective (not budging mortality, etc), and surgeons just wanted to get paid. Totally terrible if journals had meta-analyses of that.
https://elifesciences.org/for-the-press/94d42de3/almost-400-...
https://en.m.wikipedia.org/wiki/Being_Mortal
I found it to be thought provoking, moreso as I've gotten older.
Add-ons like DOM delete can also help.
Or even cash by mail.
It took over a year to get rid of them, after they kept jacking up the price.
I will never again give them a card number.