Patient Selection and Disclosure Emily Finlayson MD MS

Patient Selection and Disclosure Emily Finlayson, MD, MS Department of Surgery University of California, San Francisco

What we’re going to cover • Mortality after surgery in the elderly – Fact v Fantasy • Recovery after surgery – Longer than your surgeon said it was going to be • What patients value – Not always the same as your family or your surgeon 2

Context • Population is aging – 274 million 352 million – 13% of population 20% of population • An increasing number of very elderly patients will be candidates for major surgery • Are these patients undergoing surgery? 3

It’s a cancer, so it has to come out, right? 4

Some Decisions are Pretty Easy 5

Some Decisions Are Pretty Easy 6

Other Decisions Are Not So Easy 7

Are Older Patients with Cancer Undergoing Surgery? 8

O’Connell et al, Ann Surg Oncol, 2004

Assumptions • Surgery in the elderly is getting safer • ‘Esophageal resection for carcinoma in patients older than 70 years old. ’ Ann Surg Oncol. 2002; 9(2): 210 -214. • ‘Pancreaticoduodenectomy in the very elderly. ’ Jour GI Surg. 2006; 10(3): 347 -56.

Are These Results Generalizable? • Selective submission, publication bias • Consider the source – Centers of Excellence • Trial data – Sick and elderly patients often excluded • “Real world” mortality and survival data – The ‘benefits’ side of the equation 11

National Benchmark Data: Mortality after Major Cancer Surgery • Retrospective cohort study of patients 65+ undergoing major cancer resections (n=14, 088) – Lung – Esophageal – Pancreas • SEER-Medicare (1992 -2001) • Outcomes – Operative mortality – 5 -year survival Finlayson et al, J Am Coll Surg, 2007

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If Elderly Cancer Patients Make It Through Surgery, Do They Survive Long Term? 14

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Comorbidity Counts Cancer 5 year survival (%) Lung <2 comorbidities 37 2+ comorbidities 28 Esophagus <2 comorbidities 21 2+ comorbidities 17 Pancreas <2 comorbidities 18 2+ comorbidities 5 16

National Benchmark Data: Discharge Disposition • Retrospective cohort study of patients undergoing major cancer resections (N= 601, 081) – Lung – Esophageal – Pancreas • Nationwide Inpatient Sample (1994 -2003) – Discharge disposition stratified by age Finlayson et al, J Am Coll Surg, 2007 17

Discharge to SNF after Surgery, by age Operation Age 6569 Age 7080 Age 80+ Lung resection 4% 8% 16% Pancreatectomy 8% 16% 24% Esophagectomy 6% 12% 30% 18

OK…but those are big operations. What about the bread and butter stuff? 19

GI surgery in NH Residents • NH residents 65+ undergoing GI surgery in the US • Medicare inpatient file + MDS (1999 -2006), N=70, 719 – Bleeding DU – Benign colon disease – Cholecystitis – Appendicitis • Operative mortality compared to 1. 1 million Medicare beneficiaries 65+ Finlayson et al, Ann Surg, 2011 20

Outcomes of Interest • Operative mortality • Secondary interventions – Mechanical ventilation > 96 hrs – Central venous catheterization – PA catheter placement – IVC filter placement – Bronchoscopy – Feeding tube placement – Tracheostomy placement Finlayson et al, Ann Surg, 2011 21

Operative Mortality Finlayson et al, Ann Surg, 2011 22

Any invasive intervention (%) NH Resident General Population Survivors 42. 2 36. 2 Deaths 63. 0 61. 2 Survivors 40. 7 22. 4 Deaths 56. 8 54. 6 Survivors 15. 0 4. 5 Deaths 40. 7 36. 0 Survivors 18. 3 5. 5 Deaths 40. 3 Diagnosis Bleeding DU Benign colon Cholecystitis Appendicitis 43. 2 Finlayson et al, Ann Surg, 2011 23

What other choice do we have? • Life and death situations…. • Consider alternative therapies in patients with limited life expectancy – Antibiotics – Cholecystostomy tube – Colonic stents – IR for bleeding 24

What do we know about the trajectory of recovery after major surgery?

Functional Status after Surgery • 372 patients age 60+ • Elective major abdominal operations (GS, GYN) • Functional assessments – Preoperative – 1, 3, and 6 weeks, 3 and 6 months Lawrence et al, J Am Coll Surg, 2004

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What about functional recovery in the very frail?

Functional Outcomes in NH Residents • NH residents 65+ undergoing colectomy for cancer • Medicare inpatient file + MDS (1999 -2006), N=6822 • Functional trajectories after surgery – MDS-ADL score (0 -28) • 1 year mortality Finlayson et al, JAGS, in press 32

Functional trajectories and 1 year morality Finlayson et al, JAGS, in press 33

Functional trajectories and 1 year morality, stratified by baseline function Finlayson et al, JAGS, in press 34

ADL decline, maintenance of ADL, and death 100% 90% 80% 70% 60% ADL maintained 50% ADL decline Dead 40% 30% 20% 10% 0% 3 months 6 months 9 months 12 months 35

Predictors of Functional Decline Characteristic % declined RR, 95% CI 1. 53 (1. 15 -2. 04) 1. 21 (1. 11 -1. 32) 1. 15 (1. 03 -1. 29) Age 80+ 52. 8 Pre-op decline 59. 9 Hospital readmission 51. 8 Surgical complication 55. 3 1. 11 (1. 02 -1. 21) Urgent admission 52. 5 1. 10 (1. 03 -1. 18) Finlayson et al, Ann Surg, 2011 36

What outcomes are really valued by older patients with limited life expectancy?

Treatment Preferences in Patients with Limited Life Expectancy • 226 subjects with limited LE given hypothetical scenarios • Burden of treatment – LOS, testing, invasive procedures • Expected outcome – Restoration of current health – Death – Functional impairment – Cognitive impairment Fried et al, N Engl J Med, 2002

Treatment Intensity Health Outcome Wants treatment Low Burden Return to Current Health 98. 7% High Burden Return to Current Health 88. 9% Low Burden Functional Impairment 25. 6% Low Burden Cognitive Impairment 11. 2% 39

There are Important Differences Between Decisions Made by Elder Patients and Their Surrogates 41

Patient-Surrogate Agreement about Acceptable Outcomes • >80% for health states – Current health, mild memory impairment – Coma • 61 -65% for severe pain – Patients/surrogates equally likely to rate as acceptable • 58 -62% for severe functional impairment – Surrogates more likely to rate as acceptable Fried et al, Arch Intern Med, 2003 42

How Can We Improve Surgical Care in Frail Elders? 43

Developing Quality Indicators for Elderly Surgical Patients • RAND/UCLA project – Expert panel from surgery, geriatrics, anesthesia, critical care, internal, and rehabilitation medicine – Formally rated the indicators using a modification of the RAND/UCLA Appropriateness Methodology – Identified 91 candidate indicators rated as valid Mc. Gory et al, Ann Surg, 2009 44

Developing Quality Indicators for Elderly Surgical Patients • 6 Domains Unique to Elderly Patients – Comorbidity assessment – Evaluation of elderly issues – Medication use – Patient-to-provider discussions – Postoperative management – Discharge planning Mc. Gory et al, Ann Surg, 2009 45

Elderly-Specific Process Measures • Patient-to-provider discussions – Assess patient’s decision-making capacity – Specific discussions on expected functional outcomes – Advanced directives: life-sustaining preferences, surrogate decision maker – Clarify goals of care Mc. Gory et al, Ann Surg, 2009 46

Summary • Nationwide, operative mortality remains high and survival is low among the very elderly undergoing major cancer surgery • Even for less complex procedures, mortality is very high in frail patients • Functional recovery after major surgery is protracted in elders • Patients with poor prognosis value function, cognition, and quality of life very highly

Implications • Comprehensive assessment – Medical – Functional – Cognitive • Realistic expectations essential for true informed consent • Need for multidisciplinary approach, care pathways for geriatric patients 48