When ‘do not resuscitate’ is disregarded
End-of-life surgery for patients common, costly
At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.
She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.
When her time came, she wanted to die a natural death, Stanich told her daughter, and she signed a “do not resuscitate” directive, or DNR, order- ing doctors not to revive her should her heart stop.
Yet a trip to an emergency room in San Francisco for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest — a medical device to keep her alive by delivering a powerful shock. At the time, Stanich didn’t fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.
That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw a defibrillator protruding from the DNR
patient’s thin chest. To Stanich’s horror, the ER doctor explained that the device would not allow her to slip away painlessly and that the jolt would be “so strong that it will knock her across the room,” said Giaquinto, who accompanied her mother on both hospital trips.
Surgery like this has become all too common among those near the end of life, experts say. Nearly 1 in 3 Medicare patients have an operation in the year before they die, even though the evidence shows that many are more likely to be harmed than to benefit from it.
The practice is driven by financial incentives that reward doctors for doing procedures as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Rita Redberg, a cardiologist who treated Stanich when she sought care at the second hospital.
“We have a culture that believes in very aggressive care,” said Redberg, who at the University of CaliforniaSan Francisco specializes in heart disease in women. “We are often not considering the chance of benefit and chance of harm and how that changes when you get older. We also fail to have conversations about what patients value most.”
While surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to a 2016 paper in Annals of Surgery.
The cost of these surgeries — typically paid for by Medicare, the government health insurance program for people older than 65 — involve more than money, said Amber Barnato, a professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who have surgery within a year of death spent 50% more time in the hospital than others and nearly twice as many days in intensive care.
And although some robust octogenarians have many years ahead of them, studies show that surgery also is common among those who are far more frail.
Eighteen percent of Medicare patients have surgery in their final month of life and 8% in their final week, according to a 2011 study in The Lancet.
Procedures performed in the elderly range from major operations that require lengthy recoveries to relatively minor surgery performed in a doctor’s office, such as removal of non-fatal skin cancers, that probably would never cause any problems.
Research led by Eleni Linos has shown that people with limited life expectancies are treated for non-fatal skin cancers as aggressively as younger patients. Among patients with a non-fatal skin cancer and a limited time to live, 70% had surgery, according to her 2013 study in JAMA Internal Medicine.
When less is more
Maxine Stanich celebrated her 90th birthday with friends and family in
2010 more than two years after physician Rita Redberg had deactivated a defibrillator and discharged her with home hospice service. Stanich, at age
87, had signed a “do not resuscitate” directive ordering doctors to not revive her should her heart stop, but doctors gave her a defibrillator anyway.
Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery,
20% die within 30 days, studies show.
With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker simply because her doctor suggested it, Giaquinto said. Many people of Stanich’s generation “thought doctors were God. … They never questioned doctors — ever.”
Margaret Schwarze, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health, said older patients often don’t feel the financial pain of surgery because insurance pays most of the cost.
When a surgeon offers to “fix” the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will fix all of her medical problems, Schwarze said. “With older patients with lots of chronic illnesses, we’re not really fixing anything.”
Finding solutions
The momentum of hospital care can make people feel as if they’re on a moving train and can’t jump off.
The rush of medical decisions “doesn’t allow time to deliberate or consider the patients’ overall health or what their goals and values might be,” said Jacqueline Kruser, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University Feinberg School of Medicine.
Many hospitals and health systems are developing “decision aids,” easy-to-understand written materials and videos to help patients make more informed medical decisions. The material gives them time to develop more realistic expectations.
In a paper published last year in JAMA Surgery and the Journal of Pain and Symptom Management, Schwarze, Kruser and colleagues suggested creating narratives to illustrate surgical risks rather than relying on statistics.
Instead of telling patients that surgery carries a 20% risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.
In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just two to three months after surgery.
“If someone says they can’t tolerate the best-case scenario — which involves them being in a nursing home — then maybe we shouldn’t be doing this,” Schwarze said.
Maxine Stanich was admitted to the hospital after going to the ER because she felt short of breath. She experienced an abnormal heart rhythm in the procedure room during a cardiac test — not an unusual event during a procedure in which a wire is threaded into the heart. Based on that, doctors decided to implant a pacemaker and defibrillator the next day.
Redberg was consulted when the patient objected to the device that was now embedded in her chest. She was “very alert. She was very clear about what she did and did not want done. She told me she didn’t want to be shocked,” Redberg said.
After Redberg deactivated the defibrillator, which can be reprogrammed remotely, Stanich was discharged, with home hospice service. With nothing more than her medicines, she survived another two years and three months, dying at home just after her 90th birthday in 2010.
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