Evidence-Based Practice Corner: What We Talk About When We Talk About Surgery

In the United States, older adults have more than one-third of all operations. Each year, some 500,000 elders consider major surgery, such as coronary bypasses or organ transplants.

As people are leading not only longer but also healthier lives, physicians are more likely to suggest aggressive treatment options for older adults. Many elders benefit from major surgery, but they are more at risk for complications that may impact their independence and quality of life, especially if they have chronic conditions.

This makes decisions about potential surgeries especially challenging for older adults and their loved ones.

“Older adults have all these different health issues that need to be considered,” says Kristen Pecanac, MS, RN, a PhD student at the University of Wisconsin–Madison School of Nursing. Her research focuses on decision-making regarding life-sustaining treatment in the ICU, and how conversations between healthcare professionals, patients and their families shape those decisions.

Kristen Pecanac

“Sometimes with surgeons, discussions can be too focused on their area of specialization,” Pecanac says. “There’s a ‘fix-it’ approach that doesn’t necessarily look at the whole picture. It’s a narrow view that implies, ‘If we fix this, you’ll be completely fine.’ The problem with that is that major surgery can cause its own set of problems.”

Working with Margaret “Gretchen” Schwarze, MD, MPP, of the UW–Madison School of Medicine and Public Health and colleagues, Pecanac studied pre-operative meetings between surgeons and patients, most of who were over age 60. They wanted to see whether surgeons discuss with patients the potential extended use of life-supporting treatments, such as prolonged mechanical ventilation or dialysis.

“Surgeons believe that when they have this pre-operative discussion that they have buy-in from patients, that patients agree to everything that might come with this surgery, including any kind of life-sustaining treatment or complications,” says Pecanac.

She and her colleagues found that surgeons do stress the risks of surgery during pre-operative meetings, as well as discuss benefits and alternatives. However, they rarely talk about the potential use of prolonged life-supporting treatment.

“Surgeons seemed to try and emphasize to the patients over and over again that this is big surgery,” Pecanac says. “It was as if they were trying to convey how dangerous it was and how this could lead to something you don’t want it to, but not explicitly laying that out.”

As a nurse, Pecanac sees a disconnect between simply mentioning possible complications and spelling out how they could affect an older adult’s health and well-being.

“If a surgeon mentions the risk of infection, that doesn’t sound that bad to a patient,” explains Pecanac. “As a nurse, you think infection could lead to sepsis, which could lead to having lots of [vaso]pressors, which could lead to amputating legs, because we’ve seen that. … Or before brain surgery, surgeons say there might be swelling. A patient might think, ‘My knee swells, that’s not so bad.’ But in the brain, swelling’s a big deal!”

To improve communication with and decision-making by older adults considering major surgery, Schwarze launched the Patient Preferences Project. Working with an advisory council of patients and family members, the project team developed sample questions for older adults meeting with a surgeon.

The questions cover treatment choices, what a good surgical outcome looks like, and what potential complications could arise. The team is now evaluating if the questions improve pre-operative discussions, as well as a graphic that surgeons can use to illustrate the likely outcomes of different treatment options.

Older adults and their loved ones don’t have to wait for the study results to take action. Simply talking about your priorities and “the kind of life you want to live,” even informally, is helpful, says Pecanac. If or when you’re facing major procedures, you can share that information with health care professionals.

“It’s good to have these conversations, even when you’re younger or healthier,” Pecanac stresses. “And if someone does get a diagnosis like COPD or heart failure, talking about what does this mean for the next five, ten or 20 years for my quality of life—not just my survival—is also helpful.”

While our culture often discourages talking about illness, disability or death, many people—including nurses—can help start the conversation.

“The great thing about nurses, especially at the bedside, is that you get to know the patient,” says Pecanac. “You can have these informal, mundane conversations where someone might make a comment that sounds important and you can ask, ‘Have you talked to your family or physician about that?’ That’s a huge role that nurses can play.”

–Diane Farsetta