Shared decision-making for the elderly patient with a surgical condition

As the population ages and patients with serious co-morbidities extend their survival, situations in which surgery might be considered for these patients will increase. Surgery for all indications (palliative, diagnostic, curative) is common in the last year of life1 and the percentage of patients undergoing surgery in their final year of life is increasing2. There is wide regional variability in the frequency of operations, raising doubts about the need for some surgical procedures in this group. The reasons for this variability are not understood clearly, but could include lack, or ignorance, of non-operative alternatives. No specialty of surgery is exempt from the challenge of surgical decision-making for frail and elderly patients. Malignant bowel obstruction in the setting of advanced cancer, a perforated viscus in a patient with endstage pulmonary disease, and a fractured femur in a patient with advanced dementia are all examples of what can be expected in these respective specialties. Even in such emergency situations, when the risk of postoperative complications is even greater than that after elective procedures, the decision to proceed with operative intervention can be almost impossible to resist by surgeon, family and patient, even when the result of surgery is almost certain death or catastrophic decline in quality of life. Why is this? Personal and cultural values pertaining to the inherent value of human life and the cardinal moral principle of non-abandonment bend the trajectory of intervention in the direction of ‘doing something’ in the face of a life-limiting threat. The language of surgeons, patients and their families expresses this sentiment through statements such as: ‘Dad’s a fighter’, ‘We can’t just let her die’, ‘It’s better to die trying’ and ‘I would rather die on the operating table than not try’. Not surprisingly, much of this language is metaphorical because emotional reactions do not lend themselves easily to literal language. The value of metaphorical language, Periyakoil3 has written, is its capacity to create a contextual roadmap to understand and process a complex pattern of feelings through connecting the relational pattern of a new experience with that of a familiar, emotion-laden one. The prevailing metaphorical language of military, sports or machine-like nature so common in surgical situations usually defaults the course of action to surgical intervention. Unfortunately, these same metaphors have limited applicability and can eventually leave the patient in difficulty. For example, a decision to forego an unwanted or futile procedure can be seen as a cowardly ‘retreat’ from ‘the battle’. Becoming collectively stuck in a metaphor, for both patient and surgeon, is difficult to reverse because of the premium placed by both on saving face. Another factor favouring surgical intervention despite questionable benefit is that the surgeon, patient and family frequently do not know what they don’t know. What seemed like an affirmative choice in operating on an acute abdomen to save life might be questioned once it was understood that the hidden cost would be ventilator dependency, possible dialysis and prolonged institutional care. Even the surgeon who is candid about the risk of physical morbidity may not be aware of the potential social and existential morbidity of surgery, not only for the patient but also their family. The surgeon may be unaware that chronic critical illness ensuing after even successful operative intervention may necessitate care in a setting miles from the patient’s social and spiritual support structure. To use a military metaphor, the non-surgical consultant may have the unabashed courage of the non-combatant when exhorting surgical intervention and, conversely, the surgeon may be overly optimistic about the postoperative prospects for a patient with an advanced comorbidity. Too often the decision to proceed with high-risk surgery for the frail and seriously ill is predicated on the question ‘Do you want to die?’ instead of ‘How do you want to live?’. This is a framed question because only the suicidal wish to die. Reframing the question to accommodate the wishes and values of the patient/family by using the second, open-ended question sets the stage for shared decision-making. The spirit of this can be summarized by the surgeon’s acceptance of a narrative approach: ‘I can tell you when surgery will help, when it might help, and when it will not help. I can tell you what I believe is the best match for what surgery could offer and what you are seeking. If surgery is not your