J R Soc Med 2001;94:232-235
© 2001 Royal Society of Medicine
Surgical decisions in the elderly: the importance of biological age
S M Farquharson FRCS
Ramesh Gupta FRCS
R J Heald MChir FRCS
B J Moran MCh FRCSI
Colorectal Research Unit, North Hampshire Hospital, Basingstoke,
Hampshire RG24 9NA, UK
Correspondence to: Miss M Farquharson FRCS
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SUMMARY
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Surgeons will sometimes advise against an operation because
the patient is
‘old and frail’. A simple starring
system (one to five), based on
performance and lifestyle, has
been devised to assess the biological age of
elderly patients.
10 consultant surgeons and 10 trainees answered questions
about
their treatment recommendations for hypothetical patients of
standard
age and medical history but with various star ratings
and surgical conditions.
1000 decisions were available for analysis.
The four and five star patients (those leading an independent existence)
were recommended 266 interventions, the one and two star patients 55. Trainees
were more inclined to intervene than consultants, recommending operations in
half the patients rather than one-third.
These results indicate that decisions on surgical management are strongly
influenced by the patient's star rating or biological age. If the starring
method proves reproducible in other patient groups and settings, it could
allow better communication on an important factor in clinical decisions.
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INTRODUCTION
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Improvements in perioperative care have enabled surgeons to
undertake major
surgery in the elderly, and excellent results
have been
published
1,2.
There is, however, always a degree of
selection, either before referral or by
the surgeon, and the
mortality figures in published series do not reflect the
true
risk of surgery in advanced age.
Patient selection may occur after thorough physiological investigation and
the prediction of risk with P-POSSUM or a similar
tool3. A
risk—benefit analysis can then be used to guide
decisions4. The
consultation between surgeon and patient, at which a decision must be made
regarding intervention, is vitally important. In theory, the surgeon can
provide all the available figures on risks and benefits and abdicate the
decision entirely. Most patients, however, wish to know what the surgeon
believes is right for them. They have difficulty weighing up the figures and
their implications, particularly in the very elderly. Others sense that the
surgeon has some further information on which to base his advice. They
understand that figures drawn from a large population may not reflect the
risk—benefit equation for an individual. For example, the national
30-day mortality for a standard operation on an 85-year-old with no other
significant medical conditions takes no account of the variation between
individual surgeons' results, the difficulty of anatomical access in different
patients or the size of a tumour. More importantly, a chronological age since
birth gives little indication of how biologically ‘old’ a patient
really is. Turner et
al.5 have
expressed concern that cancer treatment may sometimes be inappropriately
denied to individuals classified as ‘old and frail.’ They state
that no validated scale for frailty exists for general use and ‘we do
not know what variables influence decision making’.
We, however, believe that the apparent or biological age of the patient is
a critical factor in the initial decision which a surgeon makes regarding
advisability of intervention. Clinicians will convey this information to a
colleague with phrases such as ‘remarkable for 88’ or ‘a
rather old 74-year-old’. Various scales for global physical function and
multidimensional assessment have proved useful research tools to measure the
impact of disease or treatment on a patient's life and can also give a measure
of biological age. Their complexity, however, renders them unsuitable for use
in ordinary clinical circumstances.
In 1999 the first author therefore devised a simple grading system for the
elderly. It is biased towards performance and lifestyle and gives a crude
indication of biological
age6. It requires no
physiological measurements or lifestyle questionnaires and merely formalizes
the assessment every surgeon makes of an elderly patient during a
consultation. The details are outlined in
Box 1.
A study was designed to test the hypothesis that an elderly patient's
‘star rating’ or biological age greatly influences the clinical
decisions taken by surgeons.
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METHOD
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10 consultant surgeons and 10 trainees (senior house officers
and
specialist registrars) were interviewed. A hypothetical
referral letter was
shown to them. In the first instance the
patient was described as an
83-year-old widowed retired accountant.
He was on atenolol for hypertension
and there was a history
of a myocardial infarct 8 years ago from which he had
made a
good recovery. He had had a hip replacement. The chronological
age and
medical history was thus standardized.
Five very different elderly men, representing each of the star ratings,
were then the hypothetical patients. The referral letter could have been
applicable to any of them. The brief descriptions of these five patients
(Box 2) were then given in turn
to the participating surgeons.
Each surgeon was asked to consider the correct management for 10 common
surgical problems, first in the 2-star patient and then in the 5, 3, 1 and
4-star patients. The surgical conditions are indicated in
Box 3. Decisions were recorded
as: Y=‘Yes, I would recommend the operation or intervention
suggested’; N=‘No, I feel it would be contraindicated’ or
DK=‘I don't know. I would need more information to make a
decision’.
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RESULTS
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Each patient had 10 interventions considered by 20 surgeons.
1000 decisions
were available for analysis. The ‘don't
knows’ were under 10%
(93).
Table 1 shows the total
number
of recommendations for intervention for each hypothetical patient.
The
4-star and 5-star patients (those maintaining an independent
existence) were
recommended 266 interventions compared with
the 55 interventions recommended
for the 1-star and 2-star patients
(
P<0.001, Wilcoxon rank-sum
test). Trainees were more inclined
to intervene than consultants, recommending
operation in almost
half the patients (243) compared with the consultants'
one-third
(162) (
P<0.01, Wilcoxon ranksum test).
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DISCUSSION
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Advancing biological age was perceived by the surgeons in this
study as a
major risk factor separate from chronological age
and other medical
conditions. It seemed to weigh particularly
with the more experienced
clinicians, although the difference
from trainees was not significant. Other
risk assessment tools
such as P-POSSUM use chronological age which, as already
discussed,
is of limited value in the elderly as natural lifespans vary.
The
physiological variants measured often do not highlight the
physiological
frailty of extreme age. These can be defined as
the lack of capacity to adapt
to stress, in this case
surgical
7.
Japanese
workers report that in octogenarians total lymphocyte
count and performance
status correlate positively with survival
after abdominal
surgery
8. A
questionnaire survey of UK vascular
surgeons showed that the level of
independence of a patient
was a greater influence on management than cardiac,
respiratory
or renal
function
9. The
relevance of performance status to surgical
decisions is underlined by the
findings in the present study:
independent 4-star and 5-star patients had
intervention recommended
in 66% of the decisions, the dependent 1-star and
2-star patients
in only 13%.
Not every aspect of risk can be easily measured by mortality and morbidity
statistics. The elderly patient leaving hospital within 24 hours of a
herniorrhaphy and experiencing no surgical or medical complication may still
have his life ruined by the operation. After 2 weeks' convalescence he
realizes he has lost confidence on his bicycle and can no longer cycle daily
to the village for provisions. A move to sheltered accommodation follows. Many
such factors are informally assessed in all clinical decisions and the
surgeon's ‘gut feeling’ should not be
dismissed10.
Subjective opinions may not always be inferior to objective measures: complex
computer systems are still inferior to the average man in determining the
gender of a face11.
It is, however, important to ask whether the surgeon is making the
right decision and whether the level of risk acceptable to a patient
is similar to that acceptable to the surgeon. In the 10 scenarios outlined in
Box 3 the implications of
advising no intervention are various. Without surgery the patient with the
symptomatic aortic aneurysm will die within a few days. Patients with known
malignancy are likely to die of the disease if it is left untreated, but this
may be some months or even years hence. In the remaining six scenarios the
advantages of intervention are more tenuous, but in most of them inaction
could still result in life-threatening complications.
Superficially it might seem that there was nothing to lose by attempting
surgery on every patient with a symptomatic aortic aneurysm. This might be so
if those who died succumbed during the operation or immediately afterwards.
Unfortunately, if operative and postoperative intensive management is offered
to all, many who finally die will have spent several weeks in intensive care
with needless additional suffering both to themselves and to close family
members. In addition, amongst the elderly survivors there will be others who
have deteriorated so profoundly that they are unable to regain a life-style
they would have regarded as worthwhile before their operation. Such factors
are difficult to quantify but patients and relatives often expect the surgeon
to take them into account. They will, however, wish to be sure he is not
influenced by other concerns. The surgeon may be worried over falling staff
morale in the face of multiple postoperative deaths. Intensive care is
expensive, and if measured against an infrequent successful outcome becomes
progressively more expensive. Intensive care beds are precious, and elective
cases are cancelled or postponed when the intensive care unit is full. All
these considerations are reasonable in a rationed health service but the
surgeon who takes these factors into account can no longer act as the
individual patient's advocate.
The decisions in the known malignancies are also a complex balance of risk.
The patient may initially only see the advantage of a possible cure. If,
however, an operation offers only a 25% chance of a final cure then a 15% risk
of postoperative death becomes more telling. The length and quality of
survival without treatment is also important. A mean 2-year survival without
severe symptoms is a devastating prognosis at 30 years but not at 80 years.
The 2-year survival of extreme biological old age in the absence of
disease is not even known. The ill, elderly patient cannot be expected to
weigh all these risks and make decisions without guidance from the surgeon. A
new and pernicious influence on the surgeon could be the pressures of national
audit and hospital league tables. Good figures can always be produced by
denying intervention to the highest risk patients.
An encouraging observation emerged from this study. When the data showed
the consultants overall less keen than the trainees to operate on the elderly,
scenarios 1, 2, 4 and 10 were analysed separately: these all represented cases
in which intervention would carry a high risk but in which the patient was
likely to die without operation. The consultants recommended surgery in 37% of
these scenarios, the trainees in only 33%. The small difference here contrasts
with the trainees' greater enthusiasm for intervention in general. This is the
group of conditions in which concerns over resources and audit would be higher
and such concerns, if they were unduly influencing decisions, would have been
more likely to have impinged on the decisions of the consultants. The
consultants were only more cautious in recommending non-essential surgery.
Conclusion
This study suggests that an elderly person's biological age or ‘star
rating’ is highly influential in surgical management. However, future
studies may be required to test the general assumption that biological age, or
increasing frailty, is a good predictor of surgical outcome. ‘Star
rating’ is little more than formalization of the assessment a surgeon
makes during every consultation. If it proves reproducible in other patient
groups and by other clinicians, it could prove a valuable aid to communication
between clinicians.
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Acknowledgments
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We thank all surgeons who took part in this study.
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SUMMARY
INTRODUCTION
