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Surgery_Schwartz_13402 | Surgery_Schwartz | it resulted in severe functional or cognitive impairment, respectively.49 Furthermore, it is imperative that the surgeon have a substantive discussion with the patient prior to sur-gery to determine their preferences and expectations and that fam-ily members and potential decision-making surrogates be involved. The ACS NSQIP/AGS Guidelines recommend that the following four points be included in these conversations:1. Ensure that the patient has an advance directive and desig-nated health care proxy.2. Discuss treatment goals and plans with the patient to ensure that the physician understands the patient’s preferences and expectations. This should be documented in the medical record.3. The surgeon should describe the expected postoperative course and possible complications, including the potential for functional decline and need for rehabilitation or nursing home care, if relevant.4. The physician should determine the patient’s family and social support systems. If support is | Surgery_Schwartz. it resulted in severe functional or cognitive impairment, respectively.49 Furthermore, it is imperative that the surgeon have a substantive discussion with the patient prior to sur-gery to determine their preferences and expectations and that fam-ily members and potential decision-making surrogates be involved. The ACS NSQIP/AGS Guidelines recommend that the following four points be included in these conversations:1. Ensure that the patient has an advance directive and desig-nated health care proxy.2. Discuss treatment goals and plans with the patient to ensure that the physician understands the patient’s preferences and expectations. This should be documented in the medical record.3. The surgeon should describe the expected postoperative course and possible complications, including the potential for functional decline and need for rehabilitation or nursing home care, if relevant.4. The physician should determine the patient’s family and social support systems. If support is | [
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Surgery_Schwartz_13403 | Surgery_Schwartz | the potential for functional decline and need for rehabilitation or nursing home care, if relevant.4. The physician should determine the patient’s family and social support systems. If support is insufficient, then a referral to a social worker should be considered.22The American College of Surgeons has created a checklist for the optimal preoperative assessment of the geriatric surgical patient (see Table 47-2).PREOPERATIVE PREPARATIONIn the immediate preoperative period, careful planning is essen-tial to optimize the care of the frail older patient.Patient Goals, Preferences, and Advance DirectivesIt is important that surgeons have a good understanding of patients’ goals and wishes surrounding their medical care, par-ticularly towards the end of life. This should be established in the clinic setting prior to surgery and should be confirmed Brunicardi_Ch47_p2045-p2060.indd 205228/02/19 2:08 PM 2053SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47and documented throughout the | Surgery_Schwartz. the potential for functional decline and need for rehabilitation or nursing home care, if relevant.4. The physician should determine the patient’s family and social support systems. If support is insufficient, then a referral to a social worker should be considered.22The American College of Surgeons has created a checklist for the optimal preoperative assessment of the geriatric surgical patient (see Table 47-2).PREOPERATIVE PREPARATIONIn the immediate preoperative period, careful planning is essen-tial to optimize the care of the frail older patient.Patient Goals, Preferences, and Advance DirectivesIt is important that surgeons have a good understanding of patients’ goals and wishes surrounding their medical care, par-ticularly towards the end of life. This should be established in the clinic setting prior to surgery and should be confirmed Brunicardi_Ch47_p2045-p2060.indd 205228/02/19 2:08 PM 2053SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47and documented throughout the | [
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Surgery_Schwartz_13404 | Surgery_Schwartz | clinic setting prior to surgery and should be confirmed Brunicardi_Ch47_p2045-p2060.indd 205228/02/19 2:08 PM 2053SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47and documented throughout the process. Additionally, patients should be encouraged to designate a health care proxy to help with this process, should they be unable to make their own med-ical decisions. The healthcare team should also consider early palliative care consultation in individuals with poor prognoses who are electing to undergo surgery, particularly if they have a life expectancy of less than 6 months.Preoperative FastingHistorically, preoperative fasting began at midnight the night before elective surgery, whereby, patients were not permitted to have any oral intake of either liquids or solids. However, more recent literature suggests that there may be no clear benefit to extended periods of fasting greater than 6 hours.50 Based on the American Society of Anesthesiologists 2011 practice guidelines for all | Surgery_Schwartz. clinic setting prior to surgery and should be confirmed Brunicardi_Ch47_p2045-p2060.indd 205228/02/19 2:08 PM 2053SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47and documented throughout the process. Additionally, patients should be encouraged to designate a health care proxy to help with this process, should they be unable to make their own med-ical decisions. The healthcare team should also consider early palliative care consultation in individuals with poor prognoses who are electing to undergo surgery, particularly if they have a life expectancy of less than 6 months.Preoperative FastingHistorically, preoperative fasting began at midnight the night before elective surgery, whereby, patients were not permitted to have any oral intake of either liquids or solids. However, more recent literature suggests that there may be no clear benefit to extended periods of fasting greater than 6 hours.50 Based on the American Society of Anesthesiologists 2011 practice guidelines for all | [
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Surgery_Schwartz_13405 | Surgery_Schwartz | literature suggests that there may be no clear benefit to extended periods of fasting greater than 6 hours.50 Based on the American Society of Anesthesiologists 2011 practice guidelines for all adults, fasting should take the form of stopping clear liq-uids at least 2 hours before elective procedures, stopping light food intake and/or nonhuman milk 6 hours before elective pro-cedures and stopping fried, fatty foods and meat at least 8 hours before elective procedures. Of note, patients with comorbidities or diseases that can affect gastric emptying (i.e., diabetes, hiatal hernia) may require additional periods of fasting.Antibiotic Prophylaxis and Venous Thromboembolism PreventionAntibiotic prophylaxis for older adults should comply with standard guidelines put forth by The Society for Healthcare Epidemiology of America/Surgical Infection Society/American Society of Health-System Pharmacists/Infectious Disease Society. Older adults who receive appropriate preoperative antibiotics | Surgery_Schwartz. literature suggests that there may be no clear benefit to extended periods of fasting greater than 6 hours.50 Based on the American Society of Anesthesiologists 2011 practice guidelines for all adults, fasting should take the form of stopping clear liq-uids at least 2 hours before elective procedures, stopping light food intake and/or nonhuman milk 6 hours before elective pro-cedures and stopping fried, fatty foods and meat at least 8 hours before elective procedures. Of note, patients with comorbidities or diseases that can affect gastric emptying (i.e., diabetes, hiatal hernia) may require additional periods of fasting.Antibiotic Prophylaxis and Venous Thromboembolism PreventionAntibiotic prophylaxis for older adults should comply with standard guidelines put forth by The Society for Healthcare Epidemiology of America/Surgical Infection Society/American Society of Health-System Pharmacists/Infectious Disease Society. Older adults who receive appropriate preoperative antibiotics | [
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Surgery_Schwartz_13406 | Surgery_Schwartz | Healthcare Epidemiology of America/Surgical Infection Society/American Society of Health-System Pharmacists/Infectious Disease Society. Older adults who receive appropriate preoperative antibiotics demonstrate a mortality benefit at 60 days.51,52 Appropriate antibiotics should be administered within 60 minutes prior to surgical incision.Older adults are at higher risk for venous thromboem-bolism (VTE), making VTE risk stratification among this population essential. Older individuals undergoing orthopedic procedures (i.e., total hip or knee arthroplasty) or who have suffered a hip fracture should be treated with low molecular weight heparin (LMWH) (starting either 13 hours or more pre-operatively or 12 hours or more postoperatively) for a minimum of 10 to 14 days and up to 35 days. Older adults undergoing nonorthopedic surgery (i.e., general, abdominopelvic, bariatric, vascular plastic/reconstructive, and thoracic surgery) should have LMWH or low-dose unfractionated heparin (LDUH) and | Surgery_Schwartz. Healthcare Epidemiology of America/Surgical Infection Society/American Society of Health-System Pharmacists/Infectious Disease Society. Older adults who receive appropriate preoperative antibiotics demonstrate a mortality benefit at 60 days.51,52 Appropriate antibiotics should be administered within 60 minutes prior to surgical incision.Older adults are at higher risk for venous thromboem-bolism (VTE), making VTE risk stratification among this population essential. Older individuals undergoing orthopedic procedures (i.e., total hip or knee arthroplasty) or who have suffered a hip fracture should be treated with low molecular weight heparin (LMWH) (starting either 13 hours or more pre-operatively or 12 hours or more postoperatively) for a minimum of 10 to 14 days and up to 35 days. Older adults undergoing nonorthopedic surgery (i.e., general, abdominopelvic, bariatric, vascular plastic/reconstructive, and thoracic surgery) should have LMWH or low-dose unfractionated heparin (LDUH) and | [
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Surgery_Schwartz_13407 | Surgery_Schwartz | undergoing nonorthopedic surgery (i.e., general, abdominopelvic, bariatric, vascular plastic/reconstructive, and thoracic surgery) should have LMWH or low-dose unfractionated heparin (LDUH) and mechanical prophylaxis with intermittent pneumatic compres-sion (IPC). Older adults undergoing craniotomy/spinal surgery or cardiac surgery should have IPC. Finally, older individuals who experienced major trauma and spinal cord injury should use LDUH/LMWH and IPC if not contraindicated.23Surgical PrehabilitationOne purpose of the preoperative assessment is to identify potentially modifiable risk factors in order to optimize surgi-cal outcomes. Several prehabilitation programs have emerged in order to help meet this need and have demonstrated prom-ising results. One of the first of such programs was referred to as the Proactive Care of Older People undergoing surgery (POPS) study in the United Kingdom’s National Health Service (NHS). This project was designed to decrease complications leading | Surgery_Schwartz. undergoing nonorthopedic surgery (i.e., general, abdominopelvic, bariatric, vascular plastic/reconstructive, and thoracic surgery) should have LMWH or low-dose unfractionated heparin (LDUH) and mechanical prophylaxis with intermittent pneumatic compres-sion (IPC). Older adults undergoing craniotomy/spinal surgery or cardiac surgery should have IPC. Finally, older individuals who experienced major trauma and spinal cord injury should use LDUH/LMWH and IPC if not contraindicated.23Surgical PrehabilitationOne purpose of the preoperative assessment is to identify potentially modifiable risk factors in order to optimize surgi-cal outcomes. Several prehabilitation programs have emerged in order to help meet this need and have demonstrated prom-ising results. One of the first of such programs was referred to as the Proactive Care of Older People undergoing surgery (POPS) study in the United Kingdom’s National Health Service (NHS). This project was designed to decrease complications leading | [
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Surgery_Schwartz_13408 | Surgery_Schwartz | referred to as the Proactive Care of Older People undergoing surgery (POPS) study in the United Kingdom’s National Health Service (NHS). This project was designed to decrease complications leading to increased hospital length of stay among at-risk older adults undergoing elective surgery. The authors performed a structured geriatric team intervention to identify at-risk patients and to then facilitate coordinated multidisciplinary care in the form of daily inpatient rounds, weekly multidisciplinary meet-ings, and biweekly ward rounds led by a POPS consultant/clini-cal nurse specialist. Outcomes in surgical patients undergoing the POPS intervention were compared to those among patients not undergoing the intervention. The POPS group had fewer postoperative complications, including lower rates of pneumo-nia (4% vs. 20%, P = 0.008) and delirium (4% vs. 19%, P = 0.028), better pain control (2% vs. 30%, P <0.001), lower rates of delayed mobilization (9% vs. 28%, P = 0.-12) and lower rates | Surgery_Schwartz. referred to as the Proactive Care of Older People undergoing surgery (POPS) study in the United Kingdom’s National Health Service (NHS). This project was designed to decrease complications leading to increased hospital length of stay among at-risk older adults undergoing elective surgery. The authors performed a structured geriatric team intervention to identify at-risk patients and to then facilitate coordinated multidisciplinary care in the form of daily inpatient rounds, weekly multidisciplinary meet-ings, and biweekly ward rounds led by a POPS consultant/clini-cal nurse specialist. Outcomes in surgical patients undergoing the POPS intervention were compared to those among patients not undergoing the intervention. The POPS group had fewer postoperative complications, including lower rates of pneumo-nia (4% vs. 20%, P = 0.008) and delirium (4% vs. 19%, P = 0.028), better pain control (2% vs. 30%, P <0.001), lower rates of delayed mobilization (9% vs. 28%, P = 0.-12) and lower rates | [
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Surgery_Schwartz_13409 | Surgery_Schwartz | of pneumo-nia (4% vs. 20%, P = 0.008) and delirium (4% vs. 19%, P = 0.028), better pain control (2% vs. 30%, P <0.001), lower rates of delayed mobilization (9% vs. 28%, P = 0.-12) and lower rates of inappropriate catheter use (7% vs. 37%, P = 0.046). They also demonstrated a reduction in hospital length of stay by 4.5 days.53The Michigan Surgical Home and Optimization Program (MSHOP) is another example of a successful prehabilitation program. This is a structured, home-based preoperative train-ing program that targets physical, nutritional, and psychological interventions. The intervention included the following four com-ponents: (a) a home-based walking program with daily remind-ers and feedback; (b) incentive spirometry instructions starting one week prior to surgery; (c) education on nutrition, stress management, and care planning; and (d) resources for smoking cessation, when appropriate. Eighty-two percent of individu-als enrolled in the study were actively engaged in the | Surgery_Schwartz. of pneumo-nia (4% vs. 20%, P = 0.008) and delirium (4% vs. 19%, P = 0.028), better pain control (2% vs. 30%, P <0.001), lower rates of delayed mobilization (9% vs. 28%, P = 0.-12) and lower rates of inappropriate catheter use (7% vs. 37%, P = 0.046). They also demonstrated a reduction in hospital length of stay by 4.5 days.53The Michigan Surgical Home and Optimization Program (MSHOP) is another example of a successful prehabilitation program. This is a structured, home-based preoperative train-ing program that targets physical, nutritional, and psychological interventions. The intervention included the following four com-ponents: (a) a home-based walking program with daily remind-ers and feedback; (b) incentive spirometry instructions starting one week prior to surgery; (c) education on nutrition, stress management, and care planning; and (d) resources for smoking cessation, when appropriate. Eighty-two percent of individu-als enrolled in the study were actively engaged in the | [
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Surgery_Schwartz_13410 | Surgery_Schwartz | on nutrition, stress management, and care planning; and (d) resources for smoking cessation, when appropriate. Eighty-two percent of individu-als enrolled in the study were actively engaged in the program. Compared to individuals who did not undergo the intervention, patients enrolled in the trial demonstrated a 31% reduction in hospital length of stay and a 28% reduction in cost.64 Collec-tively, the POPS study and the MSHOP studies are illustrative of the notion that attention to preand perioperative assessment in the older population result in improved postoperative out-comes that benefit the patient, hospital, and health care system.Palliative Care Services for Older Surgical PatientsAmong seriously ill individuals, palliative care services have the potential to increase quality of life, improve symptoms and patient satisfaction, and reduce caregiver burden.55-57 The role of palliative care in older surgical patients is not as well under-stood, and it is not widely understood in | Surgery_Schwartz. on nutrition, stress management, and care planning; and (d) resources for smoking cessation, when appropriate. Eighty-two percent of individu-als enrolled in the study were actively engaged in the program. Compared to individuals who did not undergo the intervention, patients enrolled in the trial demonstrated a 31% reduction in hospital length of stay and a 28% reduction in cost.64 Collec-tively, the POPS study and the MSHOP studies are illustrative of the notion that attention to preand perioperative assessment in the older population result in improved postoperative out-comes that benefit the patient, hospital, and health care system.Palliative Care Services for Older Surgical PatientsAmong seriously ill individuals, palliative care services have the potential to increase quality of life, improve symptoms and patient satisfaction, and reduce caregiver burden.55-57 The role of palliative care in older surgical patients is not as well under-stood, and it is not widely understood in | [
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Surgery_Schwartz_13411 | Surgery_Schwartz | improve symptoms and patient satisfaction, and reduce caregiver burden.55-57 The role of palliative care in older surgical patients is not as well under-stood, and it is not widely understood in the surgical population.58 Over a decade ago, the American College of Surgeons Pallia-tive Care Workgroup identified core competencies of surgical palliative care.59 The two key elements of palliative care—pain management and communication skills—are essential. For sur-geons who frequently care for individuals at high risk of mor-bidity and mortality, there are six additional core competency domains: patient care, medical knowledge, practice-based learn-ing, interpersonal skills, communication skills, and profession-alism (Table 47-5).Emerging data suggests that surgical patients benefit from the addition of palliative care principles and services. An interventional trial evaluating a decision-making interven-tion considering procedures that included information about health status and | Surgery_Schwartz. improve symptoms and patient satisfaction, and reduce caregiver burden.55-57 The role of palliative care in older surgical patients is not as well under-stood, and it is not widely understood in the surgical population.58 Over a decade ago, the American College of Surgeons Pallia-tive Care Workgroup identified core competencies of surgical palliative care.59 The two key elements of palliative care—pain management and communication skills—are essential. For sur-geons who frequently care for individuals at high risk of mor-bidity and mortality, there are six additional core competency domains: patient care, medical knowledge, practice-based learn-ing, interpersonal skills, communication skills, and profession-alism (Table 47-5).Emerging data suggests that surgical patients benefit from the addition of palliative care principles and services. An interventional trial evaluating a decision-making interven-tion considering procedures that included information about health status and | [
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Surgery_Schwartz_13412 | Surgery_Schwartz | the addition of palliative care principles and services. An interventional trial evaluating a decision-making interven-tion considering procedures that included information about health status and prognosis increased the likelihood of choosing less aggressive treatment options among patients with frailty (OR 3.41, 95% CI 1.39–8.39) or dementia (OR 1.66, 95% CI 1.06–2.64).60 In a study of preoperative care consultation in frail older adults, Ernst et al found that preoperative palliative care consultations were associated with reduced mortality.61 Several studies have found that postoperative palliative care improves symptoms, including uncertainly, symptom distress, and depres-sion, and improves quality of life.62-63Brunicardi_Ch47_p2045-p2060.indd 205328/02/19 2:08 PM 2054SPECIFIC CONSIDERATIONSPART IITable 47-5Core Competencies in surgical palliative careDOMAINCOMPETENCYPatient Care Possess the capacity to guide the transition from curative and palliative goals of treatment | Surgery_Schwartz. the addition of palliative care principles and services. An interventional trial evaluating a decision-making interven-tion considering procedures that included information about health status and prognosis increased the likelihood of choosing less aggressive treatment options among patients with frailty (OR 3.41, 95% CI 1.39–8.39) or dementia (OR 1.66, 95% CI 1.06–2.64).60 In a study of preoperative care consultation in frail older adults, Ernst et al found that preoperative palliative care consultations were associated with reduced mortality.61 Several studies have found that postoperative palliative care improves symptoms, including uncertainly, symptom distress, and depres-sion, and improves quality of life.62-63Brunicardi_Ch47_p2045-p2060.indd 205328/02/19 2:08 PM 2054SPECIFIC CONSIDERATIONSPART IITable 47-5Core Competencies in surgical palliative careDOMAINCOMPETENCYPatient Care Possess the capacity to guide the transition from curative and palliative goals of treatment | [
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Surgery_Schwartz_13413 | Surgery_Schwartz | 47-5Core Competencies in surgical palliative careDOMAINCOMPETENCYPatient Care Possess the capacity to guide the transition from curative and palliative goals of treatment to palliative goals alone based on patient information and preferences, scientific and outcomes evidence, and sound clinical judgmentPerform an assessment and gather essential clinical information about symptoms, pain, and sufferingPerform palliative procedures competently and with sound judgment to meet patient goals of care at the end of lifeProvide management of pain and other symptoms to alleviate sufferingCommunicate effectively and compassionately bad news and poor prognosesConduct a patient and family meeting regarding advance directives and end-of-life decisionsExercise sound clinical judgment and skill in the withdrawal and withholding of life supportMedical knowledge Acute and chronic pain managementNon-pain symptom managementEthical and legal basis for advance directives, informed consent, | Surgery_Schwartz. 47-5Core Competencies in surgical palliative careDOMAINCOMPETENCYPatient Care Possess the capacity to guide the transition from curative and palliative goals of treatment to palliative goals alone based on patient information and preferences, scientific and outcomes evidence, and sound clinical judgmentPerform an assessment and gather essential clinical information about symptoms, pain, and sufferingPerform palliative procedures competently and with sound judgment to meet patient goals of care at the end of lifeProvide management of pain and other symptoms to alleviate sufferingCommunicate effectively and compassionately bad news and poor prognosesConduct a patient and family meeting regarding advance directives and end-of-life decisionsExercise sound clinical judgment and skill in the withdrawal and withholding of life supportMedical knowledge Acute and chronic pain managementNon-pain symptom managementEthical and legal basis for advance directives, informed consent, | [
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Surgery_Schwartz_13414 | Surgery_Schwartz | in the withdrawal and withholding of life supportMedical knowledge Acute and chronic pain managementNon-pain symptom managementEthical and legal basis for advance directives, informed consent, withdrawal and withholding of life support, and futilityGrief and bereavement in surgical illnessQuality of life outcomes and prognosticationRole of spirituality at the end of lifeInterpersonal and communication skillsSurgeons must be competent and compassionate communicators with patients, families, and other health care providers. They should be effective in communicating bad news and prognosis and in redefining hope in the context of cultural diversity. The interdisciplinary nature of palliative care requires that the surgeon is skilled as both a leader and a member of an interdisciplinary team and maintains collegial relationships with other health care providers.ProfessionalismSurgeons must maintain professional commitment to ethical and empathic care, which is patient focused, with | Surgery_Schwartz. in the withdrawal and withholding of life supportMedical knowledge Acute and chronic pain managementNon-pain symptom managementEthical and legal basis for advance directives, informed consent, withdrawal and withholding of life support, and futilityGrief and bereavement in surgical illnessQuality of life outcomes and prognosticationRole of spirituality at the end of lifeInterpersonal and communication skillsSurgeons must be competent and compassionate communicators with patients, families, and other health care providers. They should be effective in communicating bad news and prognosis and in redefining hope in the context of cultural diversity. The interdisciplinary nature of palliative care requires that the surgeon is skilled as both a leader and a member of an interdisciplinary team and maintains collegial relationships with other health care providers.ProfessionalismSurgeons must maintain professional commitment to ethical and empathic care, which is patient focused, with | [
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Surgery_Schwartz_13415 | Surgery_Schwartz | team and maintains collegial relationships with other health care providers.ProfessionalismSurgeons must maintain professional commitment to ethical and empathic care, which is patient focused, with equal attention to relief of suffering along with curative therapy. Respect and compassion for cultural diversity, gender, and disability is particularly important around rituals and bereavement at the end of life. Maintenance of ethical standards in the withholding and withdrawal of life support is essential.Systems-based practiceSurgeons must be aware and informed of the multiple components of the health care system that provide palliative and end-of-life care. Surgeons should be knowledgeable and willing to refer patients to hospice, palliative care consultation, pain management, pastoral care, social services, etc., and to understand resource utilization and reimbursement issues involved.Data from Mohanty S, Rosenthal RA, Russell MM, et al: Optimal Perioperative Management of the | Surgery_Schwartz. team and maintains collegial relationships with other health care providers.ProfessionalismSurgeons must maintain professional commitment to ethical and empathic care, which is patient focused, with equal attention to relief of suffering along with curative therapy. Respect and compassion for cultural diversity, gender, and disability is particularly important around rituals and bereavement at the end of life. Maintenance of ethical standards in the withholding and withdrawal of life support is essential.Systems-based practiceSurgeons must be aware and informed of the multiple components of the health care system that provide palliative and end-of-life care. Surgeons should be knowledgeable and willing to refer patients to hospice, palliative care consultation, pain management, pastoral care, social services, etc., and to understand resource utilization and reimbursement issues involved.Data from Mohanty S, Rosenthal RA, Russell MM, et al: Optimal Perioperative Management of the | [
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Surgery_Schwartz_13416 | Surgery_Schwartz | care, social services, etc., and to understand resource utilization and reimbursement issues involved.Data from Mohanty S, Rosenthal RA, Russell MM, et al: Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society, J Am Coll Surg. 2016 May;222(5):930-947.SPECIAL CONSIDERATIONSFunctional RecoveryIn the past decade, there has been increasing attention to the examination of functional outcomes after major surgery in the geriatric population. In a large prospective cohort study of patients age 60 years and older undergoing abdominal surgery, Lawrence et al found that older adults required several months to fully return to basic activities of daily living (ADLs) and up to 6 months to become independent in more complex instrumental activities of daily living (IADLs).65 Older adults are frequently discharged to postacute facilities even when they are functional dependent at baseline | Surgery_Schwartz. care, social services, etc., and to understand resource utilization and reimbursement issues involved.Data from Mohanty S, Rosenthal RA, Russell MM, et al: Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society, J Am Coll Surg. 2016 May;222(5):930-947.SPECIAL CONSIDERATIONSFunctional RecoveryIn the past decade, there has been increasing attention to the examination of functional outcomes after major surgery in the geriatric population. In a large prospective cohort study of patients age 60 years and older undergoing abdominal surgery, Lawrence et al found that older adults required several months to fully return to basic activities of daily living (ADLs) and up to 6 months to become independent in more complex instrumental activities of daily living (IADLs).65 Older adults are frequently discharged to postacute facilities even when they are functional dependent at baseline | [
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Surgery_Schwartz_13417 | Surgery_Schwartz | independent in more complex instrumental activities of daily living (IADLs).65 Older adults are frequently discharged to postacute facilities even when they are functional dependent at baseline and have an uncomplicated postoperative course.66Among frail older adults, functional decline after surgery is often substantial and sustained. Studies examining functional outcomes after surgery among nursing home residents have demonstrated that the majority of nursing home residents who undergo surgery do not return to baseline levels of function post-operatively.67-68 Among residents who underwent colectomy for cancer, 53% were dead after 1 year and over half of 1-year survi-vors experienced functional decline.68 For residents who undergo lower extremity bypass, half die within a year of surgery.67 At 1 year, 13% of the initial vascular surgery cohort was ambulatory, and 18% had maintained or improved their baseline functional status—calling into question the efficacy of this procedure in | Surgery_Schwartz. independent in more complex instrumental activities of daily living (IADLs).65 Older adults are frequently discharged to postacute facilities even when they are functional dependent at baseline and have an uncomplicated postoperative course.66Among frail older adults, functional decline after surgery is often substantial and sustained. Studies examining functional outcomes after surgery among nursing home residents have demonstrated that the majority of nursing home residents who undergo surgery do not return to baseline levels of function post-operatively.67-68 Among residents who underwent colectomy for cancer, 53% were dead after 1 year and over half of 1-year survi-vors experienced functional decline.68 For residents who undergo lower extremity bypass, half die within a year of surgery.67 At 1 year, 13% of the initial vascular surgery cohort was ambulatory, and 18% had maintained or improved their baseline functional status—calling into question the efficacy of this procedure in | [
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Surgery_Schwartz_13418 | Surgery_Schwartz | At 1 year, 13% of the initial vascular surgery cohort was ambulatory, and 18% had maintained or improved their baseline functional status—calling into question the efficacy of this procedure in the nursing home. A study of hip fracture repair in nursing home resi-dents found that over a third of residents died and over half of resi-dents had died or experienced functional decline within 180 days after fracture. Residents with multiple comorbidities and advanced cognitive impairment and those who did not undergo surgical cor-rection of the fracture experienced the worst outcomes.5Brunicardi_Ch47_p2045-p2060.indd 205428/02/19 2:08 PM 2055SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47Cancer SurgeryApproximately 50% of cancer diagnoses are currently made in patients age 70 years or older.69 It is predicted that the increase in the older adult population will account for up to a 50% increase in the number of patients undergoing oncologic procedures by the year 2020. The increased | Surgery_Schwartz. At 1 year, 13% of the initial vascular surgery cohort was ambulatory, and 18% had maintained or improved their baseline functional status—calling into question the efficacy of this procedure in the nursing home. A study of hip fracture repair in nursing home resi-dents found that over a third of residents died and over half of resi-dents had died or experienced functional decline within 180 days after fracture. Residents with multiple comorbidities and advanced cognitive impairment and those who did not undergo surgical cor-rection of the fracture experienced the worst outcomes.5Brunicardi_Ch47_p2045-p2060.indd 205428/02/19 2:08 PM 2055SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47Cancer SurgeryApproximately 50% of cancer diagnoses are currently made in patients age 70 years or older.69 It is predicted that the increase in the older adult population will account for up to a 50% increase in the number of patients undergoing oncologic procedures by the year 2020. The increased | [
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Surgery_Schwartz_13419 | Surgery_Schwartz | It is predicted that the increase in the older adult population will account for up to a 50% increase in the number of patients undergoing oncologic procedures by the year 2020. The increased life expectancy of the geriatric patient coupled with the increasing incidence of cancer with advancing age will lead to an increased prevalence of malignant disease requiring surgical intervention. This is an area of great interest given that randomized clinical trials to determine the out-comes of older adult patients undergoing curative resections, as well as neoadjuvant and adjuvant therapy, are lacking. In addi-tion, older adult patients are rarely included in clinical trials; therefore, treatment decisions are often based on individual sur-geon experience and nongeriatric data, and they may be flawed by inherent biases regarding the outcome of complete oncologic resections in older adult patients. Surgeons may also be reluctant to expose older patients to the toxic effects of chemotherapy | Surgery_Schwartz. It is predicted that the increase in the older adult population will account for up to a 50% increase in the number of patients undergoing oncologic procedures by the year 2020. The increased life expectancy of the geriatric patient coupled with the increasing incidence of cancer with advancing age will lead to an increased prevalence of malignant disease requiring surgical intervention. This is an area of great interest given that randomized clinical trials to determine the out-comes of older adult patients undergoing curative resections, as well as neoadjuvant and adjuvant therapy, are lacking. In addi-tion, older adult patients are rarely included in clinical trials; therefore, treatment decisions are often based on individual sur-geon experience and nongeriatric data, and they may be flawed by inherent biases regarding the outcome of complete oncologic resections in older adult patients. Surgeons may also be reluctant to expose older patients to the toxic effects of chemotherapy | [
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Surgery_Schwartz_13420 | Surgery_Schwartz | flawed by inherent biases regarding the outcome of complete oncologic resections in older adult patients. Surgeons may also be reluctant to expose older patients to the toxic effects of chemotherapy and radiation without proven efficacy in this geriatric population. This highlights the need for research targeting the specific needs of older adult patients with malignancy to aid in the development of specific treatment guidelines for various cancers within this age cohort.Numerous studies have documented increased risk of post-operative morbidity and mortality in older adults with cancer. Evaluation of a national surgical registry found that older adults undergoing major gastrointestinal surgery have substan-tially higher risks of complications and death than individuals younger than 65 years.70 The impact of age on risk was present across all operations but had most impact in liver and rectal surgery. Surgeons are challenged to decide whether major sur-gery is justified in older adult | Surgery_Schwartz. flawed by inherent biases regarding the outcome of complete oncologic resections in older adult patients. Surgeons may also be reluctant to expose older patients to the toxic effects of chemotherapy and radiation without proven efficacy in this geriatric population. This highlights the need for research targeting the specific needs of older adult patients with malignancy to aid in the development of specific treatment guidelines for various cancers within this age cohort.Numerous studies have documented increased risk of post-operative morbidity and mortality in older adults with cancer. Evaluation of a national surgical registry found that older adults undergoing major gastrointestinal surgery have substan-tially higher risks of complications and death than individuals younger than 65 years.70 The impact of age on risk was present across all operations but had most impact in liver and rectal surgery. Surgeons are challenged to decide whether major sur-gery is justified in older adult | [
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Surgery_Schwartz_13421 | Surgery_Schwartz | The impact of age on risk was present across all operations but had most impact in liver and rectal surgery. Surgeons are challenged to decide whether major sur-gery is justified in older adult patients, especially those with limited life expectancy. Effectiveness of oncologic surgery in older adult patients depends on whether a cure can be achieved safely without compromise to functional status or quality of life. Postoperative life expectancy should be improved by surgery, or, at the very least, not diminished.Emergency SurgeryEmergent surgery caries exceptionally high risk for older adult patients. In an analysis of patients age 90 years and older, 90-day mortality after emergency gastrointestinal procedures was 54%.71 In a large cohort of patients undergoing endovas-cular repair for ruptured aortic aneurysm, 30-day mortality was 35% after primary aortic repair and 52% after open conversion of endovascular aortic repair.72Frail institutionalized elders are at substantial risk for | Surgery_Schwartz. The impact of age on risk was present across all operations but had most impact in liver and rectal surgery. Surgeons are challenged to decide whether major sur-gery is justified in older adult patients, especially those with limited life expectancy. Effectiveness of oncologic surgery in older adult patients depends on whether a cure can be achieved safely without compromise to functional status or quality of life. Postoperative life expectancy should be improved by surgery, or, at the very least, not diminished.Emergency SurgeryEmergent surgery caries exceptionally high risk for older adult patients. In an analysis of patients age 90 years and older, 90-day mortality after emergency gastrointestinal procedures was 54%.71 In a large cohort of patients undergoing endovas-cular repair for ruptured aortic aneurysm, 30-day mortality was 35% after primary aortic repair and 52% after open conversion of endovascular aortic repair.72Frail institutionalized elders are at substantial risk for | [
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Surgery_Schwartz_13422 | Surgery_Schwartz | ruptured aortic aneurysm, 30-day mortality was 35% after primary aortic repair and 52% after open conversion of endovascular aortic repair.72Frail institutionalized elders are at substantial risk for poor surgical outcomes after emergent surgery. In an analysis of over 70,000 nursing home residents who underwent emer-gent abdominal operations (surgery for bleeding ulcer, chole-cystectomy, appendectomy, and colectomy), operative mortality was twoto threefold higher than among matched community-dwelling elders.73 In addition, invasive life-sustaining interven-tions after surgery were significantly higher in the nursing home population than among noninstitutionalized Medicare enrollees, ranging from 18% vs. 5%, respectively, after cholecystectomy to 55% vs. 43%, respectively, after ulcer surgery. The combined effects of poor nutrition, decreased cogni-tion, and immune impairments due to nutritional or phar-macologic factors create a treacherous circumstance for older adult patients with | Surgery_Schwartz. ruptured aortic aneurysm, 30-day mortality was 35% after primary aortic repair and 52% after open conversion of endovascular aortic repair.72Frail institutionalized elders are at substantial risk for poor surgical outcomes after emergent surgery. In an analysis of over 70,000 nursing home residents who underwent emer-gent abdominal operations (surgery for bleeding ulcer, chole-cystectomy, appendectomy, and colectomy), operative mortality was twoto threefold higher than among matched community-dwelling elders.73 In addition, invasive life-sustaining interven-tions after surgery were significantly higher in the nursing home population than among noninstitutionalized Medicare enrollees, ranging from 18% vs. 5%, respectively, after cholecystectomy to 55% vs. 43%, respectively, after ulcer surgery. The combined effects of poor nutrition, decreased cogni-tion, and immune impairments due to nutritional or phar-macologic factors create a treacherous circumstance for older adult patients with | [
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Surgery_Schwartz_13423 | Surgery_Schwartz | The combined effects of poor nutrition, decreased cogni-tion, and immune impairments due to nutritional or phar-macologic factors create a treacherous circumstance for older adult patients with poorly defined symptoms or who pres-ent with more advanced disease. In acute abdominal conditions, such as acute appendicitis and acute cholecystitis, one-third of older adult patients will lack an elevated white blood cell count, one-third will lack fever, and one-third will lack physical find-ings of localized peritonitis.74 These deficits contribute to a threefold higher rate of perforated appendicitis and of gangrene of the gallbladder in older adult patients compared to young patients. An “unimpressive” physical exam in an older adult patient with acute onset of abdominal symptoms should never be taken as a sign of the absence of surgical disease.Cardiovascular SurgeryWith advances in cardiopulmonary bypass technique, myocar-dial protection, and improved perioperative care, coronary artery | Surgery_Schwartz. The combined effects of poor nutrition, decreased cogni-tion, and immune impairments due to nutritional or phar-macologic factors create a treacherous circumstance for older adult patients with poorly defined symptoms or who pres-ent with more advanced disease. In acute abdominal conditions, such as acute appendicitis and acute cholecystitis, one-third of older adult patients will lack an elevated white blood cell count, one-third will lack fever, and one-third will lack physical find-ings of localized peritonitis.74 These deficits contribute to a threefold higher rate of perforated appendicitis and of gangrene of the gallbladder in older adult patients compared to young patients. An “unimpressive” physical exam in an older adult patient with acute onset of abdominal symptoms should never be taken as a sign of the absence of surgical disease.Cardiovascular SurgeryWith advances in cardiopulmonary bypass technique, myocar-dial protection, and improved perioperative care, coronary artery | [
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Surgery_Schwartz_13424 | Surgery_Schwartz | be taken as a sign of the absence of surgical disease.Cardiovascular SurgeryWith advances in cardiopulmonary bypass technique, myocar-dial protection, and improved perioperative care, coronary artery bypass grafting (CABG) and valve replacement operations have become safer in older patients. When considering cardiovascular surgery in elders, it is essential to consider that advanced age is not the strongest predictor of poorer outcomes or increased mor-tality compared in older patients. It has been demonstrated that emergency operations, preoperative New York Heart Association (NYHA) functional class 3 or greater, and chronic renal failure are the strongest independent predictors of increased operative mortality.75 In one study, preoperative renal dysfunction, cere-brovascular disease, valve surgery, and catastrophic state were independent predictors of increased mortality in older adult patients.76 Older adult patients with non–dialysis-dependent renal dysfunction had a 60% chance of | Surgery_Schwartz. be taken as a sign of the absence of surgical disease.Cardiovascular SurgeryWith advances in cardiopulmonary bypass technique, myocar-dial protection, and improved perioperative care, coronary artery bypass grafting (CABG) and valve replacement operations have become safer in older patients. When considering cardiovascular surgery in elders, it is essential to consider that advanced age is not the strongest predictor of poorer outcomes or increased mor-tality compared in older patients. It has been demonstrated that emergency operations, preoperative New York Heart Association (NYHA) functional class 3 or greater, and chronic renal failure are the strongest independent predictors of increased operative mortality.75 In one study, preoperative renal dysfunction, cere-brovascular disease, valve surgery, and catastrophic state were independent predictors of increased mortality in older adult patients.76 Older adult patients with non–dialysis-dependent renal dysfunction had a 60% chance of | [
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Surgery_Schwartz_13425 | Surgery_Schwartz | surgery, and catastrophic state were independent predictors of increased mortality in older adult patients.76 Older adult patients with non–dialysis-dependent renal dysfunction had a 60% chance of death during a 5-year follow-up period compared to 25% in older adult patients with-out a history of renal dysfunction. Similarly, the presence of cerebrovascular disease resulted in a two-fold increase in mor-tality among older adult patients.76 Even patients who were 80 years of age or more did not have any significant increase in surgical risk and within this population, and the 4-year actuarial survival was 70.5% with an event-free survival of 60.6%.There has been an increase in definitive operative interven-tion to older patients with operable coronary artery disease. The Society of Thoracic Surgeons reports that perioperative mortality rates range from 1.6% in patients 51 to 60 years of age to 7.7% in those 81 to 90 years of age.77 Older patients are more likely to have significant | Surgery_Schwartz. surgery, and catastrophic state were independent predictors of increased mortality in older adult patients.76 Older adult patients with non–dialysis-dependent renal dysfunction had a 60% chance of death during a 5-year follow-up period compared to 25% in older adult patients with-out a history of renal dysfunction. Similarly, the presence of cerebrovascular disease resulted in a two-fold increase in mor-tality among older adult patients.76 Even patients who were 80 years of age or more did not have any significant increase in surgical risk and within this population, and the 4-year actuarial survival was 70.5% with an event-free survival of 60.6%.There has been an increase in definitive operative interven-tion to older patients with operable coronary artery disease. The Society of Thoracic Surgeons reports that perioperative mortality rates range from 1.6% in patients 51 to 60 years of age to 7.7% in those 81 to 90 years of age.77 Older patients are more likely to have significant | [
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Surgery_Schwartz_13426 | Surgery_Schwartz | Surgeons reports that perioperative mortality rates range from 1.6% in patients 51 to 60 years of age to 7.7% in those 81 to 90 years of age.77 Older patients are more likely to have significant three-vessel disease accompanied by poor ejec-tion fraction, left ventricular hypertrophy, significant valvular disease, and previous history of myocardial infarction than are younger patients.77 Older patients also are more likely to be clas-sified as NYHA functional class 3 or higher and are more likely to present on an emergent basis, in part because of reluctance to provide elective surgical intervention because of presumptive poorer outcome. Despite the increased risk of morbidity and mortality compared to younger patients, older adult patients, including those >80 years old, can undergo CABG with accept-able mortality risk. The overall mortality rate is approximately 7% to 12% for older adult patients, including those in whom CABG is performed under emergency conditions. The mortality | Surgery_Schwartz. Surgeons reports that perioperative mortality rates range from 1.6% in patients 51 to 60 years of age to 7.7% in those 81 to 90 years of age.77 Older patients are more likely to have significant three-vessel disease accompanied by poor ejec-tion fraction, left ventricular hypertrophy, significant valvular disease, and previous history of myocardial infarction than are younger patients.77 Older patients also are more likely to be clas-sified as NYHA functional class 3 or higher and are more likely to present on an emergent basis, in part because of reluctance to provide elective surgical intervention because of presumptive poorer outcome. Despite the increased risk of morbidity and mortality compared to younger patients, older adult patients, including those >80 years old, can undergo CABG with accept-able mortality risk. The overall mortality rate is approximately 7% to 12% for older adult patients, including those in whom CABG is performed under emergency conditions. The mortality | [
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Surgery_Schwartz_13427 | Surgery_Schwartz | with accept-able mortality risk. The overall mortality rate is approximately 7% to 12% for older adult patients, including those in whom CABG is performed under emergency conditions. The mortality rate decreases to approximately 2.8% when CABG is performed electively with careful preoperative evaluation.78Valve ReplacementAs the population ages, the incidence of senile calcific aortic stenosis and referral for aortic valve replacement are increas-ing. The operative mortality from aortic valve replacement is estimated to be between 3% and 10%, with an average of approximately 7.7%.76 If aortic stenosis is allowed to progress without operative intervention, CHF will ensue. The average survival of these patients is approximately 1.5 to 2 years. If a patient is deemed fit for operative intervention, age should not 6Brunicardi_Ch47_p2045-p2060.indd 205528/02/19 2:08 PM 2056SPECIFIC CONSIDERATIONSPART IIbe a deterrent, especially considering the potential to increase life expectancy. It | Surgery_Schwartz. with accept-able mortality risk. The overall mortality rate is approximately 7% to 12% for older adult patients, including those in whom CABG is performed under emergency conditions. The mortality rate decreases to approximately 2.8% when CABG is performed electively with careful preoperative evaluation.78Valve ReplacementAs the population ages, the incidence of senile calcific aortic stenosis and referral for aortic valve replacement are increas-ing. The operative mortality from aortic valve replacement is estimated to be between 3% and 10%, with an average of approximately 7.7%.76 If aortic stenosis is allowed to progress without operative intervention, CHF will ensue. The average survival of these patients is approximately 1.5 to 2 years. If a patient is deemed fit for operative intervention, age should not 6Brunicardi_Ch47_p2045-p2060.indd 205528/02/19 2:08 PM 2056SPECIFIC CONSIDERATIONSPART IIbe a deterrent, especially considering the potential to increase life expectancy. It | [
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Surgery_Schwartz_13428 | Surgery_Schwartz | age should not 6Brunicardi_Ch47_p2045-p2060.indd 205528/02/19 2:08 PM 2056SPECIFIC CONSIDERATIONSPART IIbe a deterrent, especially considering the potential to increase life expectancy. It has been recommended that the carefully selected, minimally symptomatic octogenarian with aortic ste-nosis should be considered a low-risk patient and be expected to experience an uneventful operative course and expedient recov-ery. More importantly, if elective procedures are delayed until symptoms or left ventricular dysfunction develop, patients may suffer from unnecessary increased operative risk and mortality.75 Early intervention results in a demonstrable improvement in quality of life in these patients, with many improving their NYHA functional classification.Older patients are candidates for mitral valve surgery when ischemic regurgitation is present. Surgery for mitral valve disease carries a higher morbidity and mortality risk than for aortic intervention, with an estimated mortality | Surgery_Schwartz. age should not 6Brunicardi_Ch47_p2045-p2060.indd 205528/02/19 2:08 PM 2056SPECIFIC CONSIDERATIONSPART IIbe a deterrent, especially considering the potential to increase life expectancy. It has been recommended that the carefully selected, minimally symptomatic octogenarian with aortic ste-nosis should be considered a low-risk patient and be expected to experience an uneventful operative course and expedient recov-ery. More importantly, if elective procedures are delayed until symptoms or left ventricular dysfunction develop, patients may suffer from unnecessary increased operative risk and mortality.75 Early intervention results in a demonstrable improvement in quality of life in these patients, with many improving their NYHA functional classification.Older patients are candidates for mitral valve surgery when ischemic regurgitation is present. Surgery for mitral valve disease carries a higher morbidity and mortality risk than for aortic intervention, with an estimated mortality | [
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Surgery_Schwartz_13429 | Surgery_Schwartz | mitral valve surgery when ischemic regurgitation is present. Surgery for mitral valve disease carries a higher morbidity and mortality risk than for aortic intervention, with an estimated mortality rate as high as 20%.77 Left ventricular function usually is compromised in patients requiring intervention, leading to a poorer outcome in these patients. The surgical outcome for mitral valve proce-dures depends on the extent of the disease, age of the patient, presence of pulmonary hypertension, and extent of coronary artery disease. The presence of comorbid conditions combined with the emergent nature of surgery in a large percentage of older patients further worsens the outcome. Therefore, a deci-sion regarding management of mitral valve disease should be individualized to each patient. Another concern regarding older patients who are candidates for valve disease surgery is the additional need for coronary revascularization—an important contributor to morbidity and mortality from | Surgery_Schwartz. mitral valve surgery when ischemic regurgitation is present. Surgery for mitral valve disease carries a higher morbidity and mortality risk than for aortic intervention, with an estimated mortality rate as high as 20%.77 Left ventricular function usually is compromised in patients requiring intervention, leading to a poorer outcome in these patients. The surgical outcome for mitral valve proce-dures depends on the extent of the disease, age of the patient, presence of pulmonary hypertension, and extent of coronary artery disease. The presence of comorbid conditions combined with the emergent nature of surgery in a large percentage of older patients further worsens the outcome. Therefore, a deci-sion regarding management of mitral valve disease should be individualized to each patient. Another concern regarding older patients who are candidates for valve disease surgery is the additional need for coronary revascularization—an important contributor to morbidity and mortality from | [
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Surgery_Schwartz_13430 | Surgery_Schwartz | Another concern regarding older patients who are candidates for valve disease surgery is the additional need for coronary revascularization—an important contributor to morbidity and mortality from surgical interven-tion. To mitigate risk, an older patient with multiple comorbid conditions in need of a combined procedure should only have critically stenosed vessels bypassed.79 Neurologic complications from valve surgery are particularly common in older patients. It has been estimated that approximately 30% of patients >70 years old who undergo valve procedures develop either transient or permanent neurologic dysfunction.22 This often is a result of embolism from debris dislodged from the valve during the procedure or from a formed thrombus in the right atrium.An important consideration in valve replacement proce-dures in older patients is the type of prosthesis to be used. Older patients are at increased risk from bleeding-associated anticoagu-lation complications. This risk is | Surgery_Schwartz. Another concern regarding older patients who are candidates for valve disease surgery is the additional need for coronary revascularization—an important contributor to morbidity and mortality from surgical interven-tion. To mitigate risk, an older patient with multiple comorbid conditions in need of a combined procedure should only have critically stenosed vessels bypassed.79 Neurologic complications from valve surgery are particularly common in older patients. It has been estimated that approximately 30% of patients >70 years old who undergo valve procedures develop either transient or permanent neurologic dysfunction.22 This often is a result of embolism from debris dislodged from the valve during the procedure or from a formed thrombus in the right atrium.An important consideration in valve replacement proce-dures in older patients is the type of prosthesis to be used. Older patients are at increased risk from bleeding-associated anticoagu-lation complications. This risk is | [
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Surgery_Schwartz_13431 | Surgery_Schwartz | in valve replacement proce-dures in older patients is the type of prosthesis to be used. Older patients are at increased risk from bleeding-associated anticoagu-lation complications. This risk is especially significant in patients who have experienced falls and minor trauma that have resulted in intracranial hemorrhage. To avoid the lifelong requirement for anticoagulants, bioprosthetic valves should be used in place of mechanical valves whenever possible.79 Although the biopros-thetic valves are not as durable as mechanical valves, studies demonstrate excellent structural integrity 10 years post proce-dure, making it an appropriate choice in older patients.Transcatheter aortic valve implantation/replacement (TAVI/TAVR) is increasingly being used to treat aortic stenosis. Initially, this technique was reserved for individuals with high surgical risk. A systematic review of transcatheter aortic valve implantation versus surgical aortic valve replacement revealed that, compared to | Surgery_Schwartz. in valve replacement proce-dures in older patients is the type of prosthesis to be used. Older patients are at increased risk from bleeding-associated anticoagu-lation complications. This risk is especially significant in patients who have experienced falls and minor trauma that have resulted in intracranial hemorrhage. To avoid the lifelong requirement for anticoagulants, bioprosthetic valves should be used in place of mechanical valves whenever possible.79 Although the biopros-thetic valves are not as durable as mechanical valves, studies demonstrate excellent structural integrity 10 years post proce-dure, making it an appropriate choice in older patients.Transcatheter aortic valve implantation/replacement (TAVI/TAVR) is increasingly being used to treat aortic stenosis. Initially, this technique was reserved for individuals with high surgical risk. A systematic review of transcatheter aortic valve implantation versus surgical aortic valve replacement revealed that, compared to | [
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Surgery_Schwartz_13432 | Surgery_Schwartz | this technique was reserved for individuals with high surgical risk. A systematic review of transcatheter aortic valve implantation versus surgical aortic valve replacement revealed that, compared to surgical repair, the transcatheter approach may have similar or better early and midterm outcomes, including among lowto intermediate-risk patients.80 Furthermore, there is increasing evidence that suggests TAVI results in acceptable long-term results in the older adult population.81,82Endovascular Aortic SurgeryWith increasing use of screening abdominal CT scans and ultrasounds for evaluation of various abdominal complaints, abdominal aortic aneurysms (AAA) are being identified with greater frequency, The percentage of AAA rises from about 1% at age 55 to 60 years to approximately 10% in patients 80 years of age or older.83 Historically, very old patients were deemed poor operative candidates for the traditional open repair given the frequent presence of comorbid conditions and limited | Surgery_Schwartz. this technique was reserved for individuals with high surgical risk. A systematic review of transcatheter aortic valve implantation versus surgical aortic valve replacement revealed that, compared to surgical repair, the transcatheter approach may have similar or better early and midterm outcomes, including among lowto intermediate-risk patients.80 Furthermore, there is increasing evidence that suggests TAVI results in acceptable long-term results in the older adult population.81,82Endovascular Aortic SurgeryWith increasing use of screening abdominal CT scans and ultrasounds for evaluation of various abdominal complaints, abdominal aortic aneurysms (AAA) are being identified with greater frequency, The percentage of AAA rises from about 1% at age 55 to 60 years to approximately 10% in patients 80 years of age or older.83 Historically, very old patients were deemed poor operative candidates for the traditional open repair given the frequent presence of comorbid conditions and limited | [
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Surgery_Schwartz_13433 | Surgery_Schwartz | 80 years of age or older.83 Historically, very old patients were deemed poor operative candidates for the traditional open repair given the frequent presence of comorbid conditions and limited car-diopulmonary reserve to tolerate a major operation or the many hours of required operative time and general anesthesia. The dissemination of endovascular techniques for repair of AAA, however, has shifted the risk-benefit ratio for operative inter-vention, allowing greater life expectancy for the elective repair of this potentially life-threatening condition with the benefits of a minimally invasive approach.Multiple studies have demonstrated that endovascular aortic repair (EVAR) is feasible and efficacious in older adult patients, including those previously considered unfit for open repair. EVAR is a minimally invasive technique in which a pros-thetic graft is introduced into the aortic lumen via the common femoral artery to exclude the aortic aneurysm sac. EVAR sig-nificantly reduces | Surgery_Schwartz. 80 years of age or older.83 Historically, very old patients were deemed poor operative candidates for the traditional open repair given the frequent presence of comorbid conditions and limited car-diopulmonary reserve to tolerate a major operation or the many hours of required operative time and general anesthesia. The dissemination of endovascular techniques for repair of AAA, however, has shifted the risk-benefit ratio for operative inter-vention, allowing greater life expectancy for the elective repair of this potentially life-threatening condition with the benefits of a minimally invasive approach.Multiple studies have demonstrated that endovascular aortic repair (EVAR) is feasible and efficacious in older adult patients, including those previously considered unfit for open repair. EVAR is a minimally invasive technique in which a pros-thetic graft is introduced into the aortic lumen via the common femoral artery to exclude the aortic aneurysm sac. EVAR sig-nificantly reduces | [
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] |
Surgery_Schwartz_13434 | Surgery_Schwartz | EVAR is a minimally invasive technique in which a pros-thetic graft is introduced into the aortic lumen via the common femoral artery to exclude the aortic aneurysm sac. EVAR sig-nificantly reduces operative and anesthesia times, blood loss, intensive care needs, length of stays, and major postoperative morbidity associated with open AAA repair. This procedure also can be done using epidural anesthesia for high-risk candi-dates who may tolerate general anesthesia poorly (Fig. 47-2).Careful consideration of the life expectancy and the risk of rupture dictate the necessity for intervention. EVAR remains a viable option in older adult patients. Nonoperative management is justified in frail older adult patients with multiple comorbidi-ties and reduced life expectancy whose operative risks outweigh the risk of rupture and in those who are unlikely to survive long enough to benefit from the repair.Palliative SurgeryPalliative surgery is defined as surgical intervention targeted to alleviate | Surgery_Schwartz. EVAR is a minimally invasive technique in which a pros-thetic graft is introduced into the aortic lumen via the common femoral artery to exclude the aortic aneurysm sac. EVAR sig-nificantly reduces operative and anesthesia times, blood loss, intensive care needs, length of stays, and major postoperative morbidity associated with open AAA repair. This procedure also can be done using epidural anesthesia for high-risk candi-dates who may tolerate general anesthesia poorly (Fig. 47-2).Careful consideration of the life expectancy and the risk of rupture dictate the necessity for intervention. EVAR remains a viable option in older adult patients. Nonoperative management is justified in frail older adult patients with multiple comorbidi-ties and reduced life expectancy whose operative risks outweigh the risk of rupture and in those who are unlikely to survive long enough to benefit from the repair.Palliative SurgeryPalliative surgery is defined as surgical intervention targeted to alleviate | [
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Surgery_Schwartz_13435 | Surgery_Schwartz | the risk of rupture and in those who are unlikely to survive long enough to benefit from the repair.Palliative SurgeryPalliative surgery is defined as surgical intervention targeted to alleviate a patient’s symptoms, thus improving the patient’s quality of life despite minimal impact on the patient’s survival.54 With an increasing number of older patients presenting with advanced disease, surgeons must be familiar with the concept of palliation to control symptoms. This concept focuses on pro-viding the maximal benefit to the patient using the least-invasive intervention. Ideally, this intervention leads to symptom relief and preservation of the quality of life in terminal disease states by alleviating symptoms such as intractable vomiting and severe pain. The success of palliative surgery is a careful bal-ance between achieving symptom relief without the develop-ment of new symptoms from the intervention itself. A recent meta-analysis of outcomes after palliative surgery for | Surgery_Schwartz. the risk of rupture and in those who are unlikely to survive long enough to benefit from the repair.Palliative SurgeryPalliative surgery is defined as surgical intervention targeted to alleviate a patient’s symptoms, thus improving the patient’s quality of life despite minimal impact on the patient’s survival.54 With an increasing number of older patients presenting with advanced disease, surgeons must be familiar with the concept of palliation to control symptoms. This concept focuses on pro-viding the maximal benefit to the patient using the least-invasive intervention. Ideally, this intervention leads to symptom relief and preservation of the quality of life in terminal disease states by alleviating symptoms such as intractable vomiting and severe pain. The success of palliative surgery is a careful bal-ance between achieving symptom relief without the develop-ment of new symptoms from the intervention itself. A recent meta-analysis of outcomes after palliative surgery for | [
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Surgery_Schwartz_13436 | Surgery_Schwartz | surgery is a careful bal-ance between achieving symptom relief without the develop-ment of new symptoms from the intervention itself. A recent meta-analysis of outcomes after palliative surgery for malignant bowel obstruction from peritoneal carcinomatosis revealed that although palliative surgery can benefit some patients, many patients experience serious complications, incomplete resolu-tion of symptoms, and substantial hospitalization relative to the patient’s remaining survival time.84 It is essential to provide patients with realistic information about expected outcomes after palliative surgery to ensure that this surgical intervention is in line with their care preferences. The core competencies for surgical palliative care are shown in Table 47-5.SUMMARYMajor surgery in older adults requires careful consideration. In addition to chronic medical conditions, many elders have geriat-ric syndromes that put them at high risk for increased morbidity, Brunicardi_Ch47_p2045-p2060.indd | Surgery_Schwartz. surgery is a careful bal-ance between achieving symptom relief without the develop-ment of new symptoms from the intervention itself. A recent meta-analysis of outcomes after palliative surgery for malignant bowel obstruction from peritoneal carcinomatosis revealed that although palliative surgery can benefit some patients, many patients experience serious complications, incomplete resolu-tion of symptoms, and substantial hospitalization relative to the patient’s remaining survival time.84 It is essential to provide patients with realistic information about expected outcomes after palliative surgery to ensure that this surgical intervention is in line with their care preferences. The core competencies for surgical palliative care are shown in Table 47-5.SUMMARYMajor surgery in older adults requires careful consideration. In addition to chronic medical conditions, many elders have geriat-ric syndromes that put them at high risk for increased morbidity, Brunicardi_Ch47_p2045-p2060.indd | [
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Surgery_Schwartz_13437 | Surgery_Schwartz | requires careful consideration. In addition to chronic medical conditions, many elders have geriat-ric syndromes that put them at high risk for increased morbidity, Brunicardi_Ch47_p2045-p2060.indd 205628/02/19 2:08 PM 2057SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47Figure 47-2. Endovascular repair of abdominal aortic aneurysms (AAAs) has gained favor for suitable older adult patients to prevent rupture. Through minimal groin incisions, this 82-year-old patient underwent repair of an AAA and right iliac artery aneurysm and was discharged on post-op day 2.mortality, and poor functional recovery after surgery. Screen-ing for and optimization of multiple domains of vulnerability is essential to improve outcomes in this vulnerable population. Furthermore, the incorporation of palliative care principles into the surgical care of frail elders will improve patient-centered decision-making, symptom management, and quality of life.REFERENCESEntries highlighted in bright blue are key | Surgery_Schwartz. requires careful consideration. In addition to chronic medical conditions, many elders have geriat-ric syndromes that put them at high risk for increased morbidity, Brunicardi_Ch47_p2045-p2060.indd 205628/02/19 2:08 PM 2057SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47Figure 47-2. Endovascular repair of abdominal aortic aneurysms (AAAs) has gained favor for suitable older adult patients to prevent rupture. Through minimal groin incisions, this 82-year-old patient underwent repair of an AAA and right iliac artery aneurysm and was discharged on post-op day 2.mortality, and poor functional recovery after surgery. Screen-ing for and optimization of multiple domains of vulnerability is essential to improve outcomes in this vulnerable population. Furthermore, the incorporation of palliative care principles into the surgical care of frail elders will improve patient-centered decision-making, symptom management, and quality of life.REFERENCESEntries highlighted in bright blue are key | [
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Surgery_Schwartz_13438 | Surgery_Schwartz | care principles into the surgical care of frail elders will improve patient-centered decision-making, symptom management, and quality of life.REFERENCESEntries highlighted in bright blue are key references. 1. McRae PJ, Peel NM, Walker PJ, de Looze JW, Mudge AM. Geri-atric syndromes in individuals admitted to vascular and urology surgical units. J Am Geriatr Soc. 2014;62(6):1105-1109. 2. McRae PJ, Walker PJ, Peel NM, et al. Frailty and geriatric syndromes in vascular surgical ward patients. Ann Vasc Surg. 2016;35:9-18. 3. Flacker JM. What is a geriatric syndrome anyway? J Am Geri-atr Soc. 2003;51(4):574-576. 4. Fried LP. Frailty. In: Medina-Walpole A, Pacala JT, Potter JF, eds. Geriatric Review Syllabus. 9th ed. New York: American Geriatrics Society; 2016. 5. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a pre-dictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901-908. 6. Suskind AM, Jin C, Cooperberg MR, et al. Preoperative frailty is associated with | Surgery_Schwartz. care principles into the surgical care of frail elders will improve patient-centered decision-making, symptom management, and quality of life.REFERENCESEntries highlighted in bright blue are key references. 1. McRae PJ, Peel NM, Walker PJ, de Looze JW, Mudge AM. Geri-atric syndromes in individuals admitted to vascular and urology surgical units. J Am Geriatr Soc. 2014;62(6):1105-1109. 2. McRae PJ, Walker PJ, Peel NM, et al. Frailty and geriatric syndromes in vascular surgical ward patients. Ann Vasc Surg. 2016;35:9-18. 3. Flacker JM. What is a geriatric syndrome anyway? J Am Geri-atr Soc. 2003;51(4):574-576. 4. Fried LP. Frailty. In: Medina-Walpole A, Pacala JT, Potter JF, eds. Geriatric Review Syllabus. 9th ed. New York: American Geriatrics Society; 2016. 5. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a pre-dictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901-908. 6. Suskind AM, Jin C, Cooperberg MR, et al. Preoperative frailty is associated with | [
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Surgery_Schwartz_13439 | Surgery_Schwartz | PJ, et al. Frailty as a pre-dictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901-908. 6. Suskind AM, Jin C, Cooperberg MR, et al. Preoperative frailty is associated with discharge to skilled or assisted living facili-ties after urologic procedures of varying complexity. Urology. 2016;97:25-32. 7. Suskind AM, Walter LC, Jin C, et al. Impact of frailty on compli-cations in patients undergoing common urological procedures: a study from the American College of Surgeons National Surgical Quality Improvement database. BJU Int. 2016;117(5):836-842. 8. Robinson TN, Wu DS, Pointer L, Dunn CL, Cleveland JC Jr, Moss M. Simple frailty score predicts postoperative complica-tions across surgical specialties. Am J Surg. 2013;206(4):544-550. 9. Robinson TN, Wu DS, Sauaia A, et al. Slower walking speed forecasts increased postoperative morbidity and 1-year mortal-ity across surgical specialties. Ann Surg. 2013;258(4):582-588; discussion 588-590. 10. Revenig LM, Canter DJ, Kim | Surgery_Schwartz. PJ, et al. Frailty as a pre-dictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901-908. 6. Suskind AM, Jin C, Cooperberg MR, et al. Preoperative frailty is associated with discharge to skilled or assisted living facili-ties after urologic procedures of varying complexity. Urology. 2016;97:25-32. 7. Suskind AM, Walter LC, Jin C, et al. Impact of frailty on compli-cations in patients undergoing common urological procedures: a study from the American College of Surgeons National Surgical Quality Improvement database. BJU Int. 2016;117(5):836-842. 8. Robinson TN, Wu DS, Pointer L, Dunn CL, Cleveland JC Jr, Moss M. Simple frailty score predicts postoperative complica-tions across surgical specialties. Am J Surg. 2013;206(4):544-550. 9. Robinson TN, Wu DS, Sauaia A, et al. Slower walking speed forecasts increased postoperative morbidity and 1-year mortal-ity across surgical specialties. Ann Surg. 2013;258(4):582-588; discussion 588-590. 10. Revenig LM, Canter DJ, Kim | [
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Surgery_Schwartz_13440 | Surgery_Schwartz | Slower walking speed forecasts increased postoperative morbidity and 1-year mortal-ity across surgical specialties. Ann Surg. 2013;258(4):582-588; discussion 588-590. 10. Revenig LM, Canter DJ, Kim S, et al. Report of a simplified frailty score predictive of short-term postoperative morbidity and mortality. J Am Coll Surg. 2015;220(5):904-911 e901. 11. Revenig LM, Canter DJ, Master VA, et al. A prospective study examining the association between preoperative frailty and postoperative complications in patients undergoing minimally invasive surgery. J Endourol. 2014;28(4):476-480. 12. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M156. 13. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of def-icits as a proxy measure of aging. Sci World J. 2001;1:323-336. 14. Sternberg SA, Wershof Schwartz A, Karunananthan S, Bergman H, Mark Clarfield A. The identification of frailty: a systematic literature | Surgery_Schwartz. Slower walking speed forecasts increased postoperative morbidity and 1-year mortal-ity across surgical specialties. Ann Surg. 2013;258(4):582-588; discussion 588-590. 10. Revenig LM, Canter DJ, Kim S, et al. Report of a simplified frailty score predictive of short-term postoperative morbidity and mortality. J Am Coll Surg. 2015;220(5):904-911 e901. 11. Revenig LM, Canter DJ, Master VA, et al. A prospective study examining the association between preoperative frailty and postoperative complications in patients undergoing minimally invasive surgery. J Endourol. 2014;28(4):476-480. 12. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M156. 13. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of def-icits as a proxy measure of aging. Sci World J. 2001;1:323-336. 14. Sternberg SA, Wershof Schwartz A, Karunananthan S, Bergman H, Mark Clarfield A. The identification of frailty: a systematic literature | [
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Surgery_Schwartz_13442 | Surgery_Schwartz | York: American Geriatrics Society; 2016. 18. Kronzer VL, Jerry MR, Ben Abdallah A, et al. Preoperative falls predict postoperative falls, functional decline, and surgical complications. EBioMedicine. 2016;12:302-308.Brunicardi_Ch47_p2045-p2060.indd 205728/02/19 2:08 PM 2058SPECIFIC CONSIDERATIONSPART II 19. Marcantonio ER. Delirium. In: Medina-Walpole A, Pacala JT, Potter JF, eds. Geriatric Review Syllabus. 9th ed. New York: American Geriatrics Society; 2016. 20. Christmas C, Pacala JT. Perioperative care. In: Medina-Walpole A, Pacala JT, Potter CT, eds. Geriatric Review Syllabus. 9th ed. New York: American Geriatrics Society; 2016. 21. McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Int Med. 2002;162(4):457-463. 22. Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preop-erative assessment of the Surgeons National Surgical Qual-ity Improvement Program and the American Geriatrics Society. J Am Coll Surg. | Surgery_Schwartz. York: American Geriatrics Society; 2016. 18. Kronzer VL, Jerry MR, Ben Abdallah A, et al. Preoperative falls predict postoperative falls, functional decline, and surgical complications. EBioMedicine. 2016;12:302-308.Brunicardi_Ch47_p2045-p2060.indd 205728/02/19 2:08 PM 2058SPECIFIC CONSIDERATIONSPART II 19. Marcantonio ER. Delirium. In: Medina-Walpole A, Pacala JT, Potter JF, eds. Geriatric Review Syllabus. 9th ed. New York: American Geriatrics Society; 2016. 20. Christmas C, Pacala JT. Perioperative care. In: Medina-Walpole A, Pacala JT, Potter CT, eds. Geriatric Review Syllabus. 9th ed. New York: American Geriatrics Society; 2016. 21. McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Int Med. 2002;162(4):457-463. 22. Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preop-erative assessment of the Surgeons National Surgical Qual-ity Improvement Program and the American Geriatrics Society. J Am Coll Surg. | [
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Surgery_Schwartz_13443 | Surgery_Schwartz | WB, Rosenthal RA, Merkow RP, et al. Optimal preop-erative assessment of the Surgeons National Surgical Qual-ity Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466. 23. Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016;222(5):930-947. 24. Stefan M, Iglesia Lino L, Fernandez G. Medical consultation and best practices for preoperative evaluation of older adult patients. Hosp Pract. 2011;39(1):41-51. 25. Shelkey M, Wallace M. Katz index of independence in activities of daily living (ADL). Director. 2000;8(2):72-73. 26. Robinson TN, Eiseman B, Wallace JI, et al. Redefining geri-atric preoperative assessment using frailty, disability and co-morbidity. Ann Surg. 2009;250(3):449-455. 27. Graf C. The Lawton instrumental activities of daily liv-ing | Surgery_Schwartz. WB, Rosenthal RA, Merkow RP, et al. Optimal preop-erative assessment of the Surgeons National Surgical Qual-ity Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466. 23. Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal Perioperative Management of the Geriatric Patient: A Best Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016;222(5):930-947. 24. Stefan M, Iglesia Lino L, Fernandez G. Medical consultation and best practices for preoperative evaluation of older adult patients. Hosp Pract. 2011;39(1):41-51. 25. Shelkey M, Wallace M. Katz index of independence in activities of daily living (ADL). Director. 2000;8(2):72-73. 26. Robinson TN, Eiseman B, Wallace JI, et al. Redefining geri-atric preoperative assessment using frailty, disability and co-morbidity. Ann Surg. 2009;250(3):449-455. 27. Graf C. The Lawton instrumental activities of daily liv-ing | [
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Surgery_Schwartz_13446 | Surgery_Schwartz | Available at: https://pubs.niaaa.nih.gov/publications/aa65/aa65.htm. Accessed August 21, 2018. 36. Gal J, Bogar L, Acsady G, Kertai MD. Cardiac risk reduction in non-cardiac surgery: the role of anaesthesia and monitoring techniques. Eur J Anaesthesiol. 2006;23(8):641-648. 37. Puig-Barbera J, Marquez-Calderon S, Vila-Sanchez M. Car-diac complications of major elective non-cardiac surgery: incidence and risk factors (in Spanish). Rev Esp Cardiol. 2006;59(4):329-337. 38. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evalu-ation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Developed in collaboration with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for | Surgery_Schwartz. Available at: https://pubs.niaaa.nih.gov/publications/aa65/aa65.htm. Accessed August 21, 2018. 36. Gal J, Bogar L, Acsady G, Kertai MD. Cardiac risk reduction in non-cardiac surgery: the role of anaesthesia and monitoring techniques. Eur J Anaesthesiol. 2006;23(8):641-648. 37. Puig-Barbera J, Marquez-Calderon S, Vila-Sanchez M. Car-diac complications of major elective non-cardiac surgery: incidence and risk factors (in Spanish). Rev Esp Cardiol. 2006;59(4):329-337. 38. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evalu-ation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Developed in collaboration with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for | [
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Surgery_Schwartz_13447 | Surgery_Schwartz | with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Vascular Medicine Endorsed by the Society of Hospital Medicine. J Nucl Cardiol. 2015;22(1):162-215. 39. Ansaloni L, Catena F, Chattat R, et al. Risk factors and inci-dence of postoperative delirium in older adult patients after elective and emergency surgery. Br J Surg. 2010;97(2):273-280. 40. Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative myocardial infarction. Circulation. 2009;119(22):2936-2944. 41. Smetana GW, Macpherson DS. The case against routine preop-erative laboratory testing. Med Clin North Am. 2003;87(1):7-40. 42. Smetana GW, Cohn SL, Lawrence VA. Update in perioperative medicine. Ann Intern Med. 2004;140(6):452-461. 43. Johnson RG, Arozullah AM, Neumayer | Surgery_Schwartz. with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Vascular Medicine Endorsed by the Society of Hospital Medicine. J Nucl Cardiol. 2015;22(1):162-215. 39. Ansaloni L, Catena F, Chattat R, et al. Risk factors and inci-dence of postoperative delirium in older adult patients after elective and emergency surgery. Br J Surg. 2010;97(2):273-280. 40. Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative myocardial infarction. Circulation. 2009;119(22):2936-2944. 41. Smetana GW, Macpherson DS. The case against routine preop-erative laboratory testing. Med Clin North Am. 2003;87(1):7-40. 42. Smetana GW, Cohn SL, Lawrence VA. Update in perioperative medicine. Ann Intern Med. 2004;140(6):452-461. 43. Johnson RG, Arozullah AM, Neumayer | [
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Surgery_Schwartz_13448 | Surgery_Schwartz | testing. Med Clin North Am. 2003;87(1):7-40. 42. Smetana GW, Cohn SL, Lawrence VA. Update in perioperative medicine. Ann Intern Med. 2004;140(6):452-461. 43. Johnson RG, Arozullah AM, Neumayer L, Henderson WG, Hosokawa P, Khuri SF. Multivariable predictors of postop-erative respiratory failure after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1188-1198. 44. White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recom-mended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275-283. 45. Barnett SR. Polypharmacy and perioperative medications in the older adult. Anesthesiol Clin. 2009;27(3):377-389. 46. Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements | Surgery_Schwartz. testing. Med Clin North Am. 2003;87(1):7-40. 42. Smetana GW, Cohn SL, Lawrence VA. Update in perioperative medicine. Ann Intern Med. 2004;140(6):452-461. 43. Johnson RG, Arozullah AM, Neumayer L, Henderson WG, Hosokawa P, Khuri SF. Multivariable predictors of postop-erative respiratory failure after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1188-1198. 44. White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recom-mended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36(3):275-283. 45. Barnett SR. Polypharmacy and perioperative medications in the older adult. Anesthesiol Clin. 2009;27(3):377-389. 46. Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements | [
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Surgery_Schwartz_13449 | Surgery_Schwartz | older adult. Anesthesiol Clin. 2009;27(3):377-389. 46. Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA. 2008;300(24):2867-2878. 47. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in older adult patients. Am J Geriatr Pharmacother. 2007;5(4):345-351. 48. Seckler AB, Meier DE, Mulvihill M, Paris BE. Substituted judgment: how accurate are proxy predictions? Ann Intern Med. 1991;115(2):92-98. 49. Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-1066. 50. American Society of Anesthesiologists C. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Com-mittee on | Surgery_Schwartz. older adult. Anesthesiol Clin. 2009;27(3):377-389. 46. Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA. 2008;300(24):2867-2878. 47. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in older adult patients. Am J Geriatr Pharmacother. 2007;5(4):345-351. 48. Seckler AB, Meier DE, Mulvihill M, Paris BE. Substituted judgment: how accurate are proxy predictions? Ann Intern Med. 1991;115(2):92-98. 49. Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-1066. 50. American Society of Anesthesiologists C. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Com-mittee on | [
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Surgery_Schwartz_13450 | Surgery_Schwartz | agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Com-mittee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495-511. 51. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibi-otics and the risk of surgical-wound infection. N Engl J Med. 1992;326(5):281-286. 52. Silber JH, Rosenbaum PR, Trudeau ME, et al. Preopera-tive antibiotics and mortality in the older adult. Ann Surg. 2005;242(1):107-114. 53. Harari D, Hopper A, Dhesi J, Babic-Illman G, Lockwood L, Martin F. Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating, and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing. 2007;36(2):190-196. 54. Englesbe MJ, Grenda DR, Sullivan JA, et al. The Michigan Surgical Home and Optimization | Surgery_Schwartz. agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Com-mittee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495-511. 51. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibi-otics and the risk of surgical-wound infection. N Engl J Med. 1992;326(5):281-286. 52. Silber JH, Rosenbaum PR, Trudeau ME, et al. Preopera-tive antibiotics and mortality in the older adult. Ann Surg. 2005;242(1):107-114. 53. Harari D, Hopper A, Dhesi J, Babic-Illman G, Lockwood L, Martin F. Proactive care of older people undergoing surgery (‘POPS’): designing, embedding, evaluating, and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing. 2007;36(2):190-196. 54. Englesbe MJ, Grenda DR, Sullivan JA, et al. The Michigan Surgical Home and Optimization | [
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Surgery_Schwartz_13451 | Surgery_Schwartz | geriatric assessment service for older elective surgical patients. Age Ageing. 2007;36(2):190-196. 54. Englesbe MJ, Grenda DR, Sullivan JA, et al. The Michigan Surgical Home and Optimization Program is a scalable model to improve care and reduce costs. Surgery. 2017;161(6): 1659-1666. 55. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Eng J Med. 2010;363(8):733-742.Brunicardi_Ch47_p2045-p2060.indd 205828/02/19 2:08 PM 2059SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47 56. Kavialieratos D, Corbelli J, Zhang D, et al. Association between palliative care and patient and caregiver outcomes. A systematic review and meta-analysis. JAMA. 2016;316(20):2104-2114. 57. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a clusterrandomised controlled trial. Lancet. 2014;383(9930): 1721-1730. 58. Olmsted CL, Johnson AM, Kaboli P, et al. Use of pal-liative care and | Surgery_Schwartz. geriatric assessment service for older elective surgical patients. Age Ageing. 2007;36(2):190-196. 54. Englesbe MJ, Grenda DR, Sullivan JA, et al. The Michigan Surgical Home and Optimization Program is a scalable model to improve care and reduce costs. Surgery. 2017;161(6): 1659-1666. 55. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Eng J Med. 2010;363(8):733-742.Brunicardi_Ch47_p2045-p2060.indd 205828/02/19 2:08 PM 2059SURGICAL CONSIDERATIONS IN OLDER ADULTSCHAPTER 47 56. Kavialieratos D, Corbelli J, Zhang D, et al. Association between palliative care and patient and caregiver outcomes. A systematic review and meta-analysis. JAMA. 2016;316(20):2104-2114. 57. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a clusterrandomised controlled trial. Lancet. 2014;383(9930): 1721-1730. 58. Olmsted CL, Johnson AM, Kaboli P, et al. Use of pal-liative care and | [
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Surgery_Schwartz_13456 | Surgery_Schwartz | Thorac Surg. 2007;6:308-313. 76. Srinivasan AK, Oo AY, Grayson AD, et al. Mid-term survival after cardiac surgery in older adult patients: analysis of predic-tors for increased mortality. Interact Cardiovasc Thorac Surg. 2004;3:289-293. 77. Davis EA, Gardner TJ, Gillinov AM, et al. Valvular disease in the older adult: influence on surgical results. Ann Thorac Surg. 1993;55:333-337. 78. Richmond TS, Kaunder D, Strumpf N, et al. Characteristics and outcomes of serious traumatic injury in older adults. J Am Geri-atr Soc. 2002;50:215-222. 79. Aziz S, Grover FL. Cardiovascular surgery in the older adult. Cardiol Clin. 1999;17:213-231. 80. Garguilo G, Sannino A, Capodanno D, et al. Transcatheter aortic valve implantation versus surgical aortic valve replace-ment: a systematic review and meta-analysis. Ann Intern Med. 2016;165(50):334-344. 81. Chakos A, Wilson-Smith A, Arora S, et al. Long term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival | Surgery_Schwartz. Thorac Surg. 2007;6:308-313. 76. Srinivasan AK, Oo AY, Grayson AD, et al. Mid-term survival after cardiac surgery in older adult patients: analysis of predic-tors for increased mortality. Interact Cardiovasc Thorac Surg. 2004;3:289-293. 77. Davis EA, Gardner TJ, Gillinov AM, et al. Valvular disease in the older adult: influence on surgical results. Ann Thorac Surg. 1993;55:333-337. 78. Richmond TS, Kaunder D, Strumpf N, et al. Characteristics and outcomes of serious traumatic injury in older adults. J Am Geri-atr Soc. 2002;50:215-222. 79. Aziz S, Grover FL. Cardiovascular surgery in the older adult. Cardiol Clin. 1999;17:213-231. 80. Garguilo G, Sannino A, Capodanno D, et al. Transcatheter aortic valve implantation versus surgical aortic valve replace-ment: a systematic review and meta-analysis. Ann Intern Med. 2016;165(50):334-344. 81. Chakos A, Wilson-Smith A, Arora S, et al. Long term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival | [
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Surgery_Schwartz_13457 | Surgery_Schwartz | Ann Intern Med. 2016;165(50):334-344. 81. Chakos A, Wilson-Smith A, Arora S, et al. Long term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival and beyond. Ann Cardiothorac Surg. 2017;6(5):432-443. 82. D’Onofrio A, Facchin M, Besola L, et al. Intermediate clini-cal and hemodynamic outcomes after transcatheter aortic valve implantation. Ann Thorac Surg. 2016;101:881-8; discussion 888. 83. Biebl M, Lau LL, Hakaim AG, et al. Midterm outcomes of endo-vascular abdominal aortic aneurysm repair in octogenarians: a single institution’s experience. J Vasc Surg. 2004;40:435-442. 84. Olson P, Pinkerton C, Brasel KJ, et al. Palliative surgery for malignant bowel obstruction from carcinomatosis: a system-atic review. JAMA Surg. 2014;149(4):383-392.Brunicardi_Ch47_p2045-p2060.indd 205928/02/19 2:08 PM | Surgery_Schwartz. Ann Intern Med. 2016;165(50):334-344. 81. Chakos A, Wilson-Smith A, Arora S, et al. Long term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival and beyond. Ann Cardiothorac Surg. 2017;6(5):432-443. 82. D’Onofrio A, Facchin M, Besola L, et al. Intermediate clini-cal and hemodynamic outcomes after transcatheter aortic valve implantation. Ann Thorac Surg. 2016;101:881-8; discussion 888. 83. Biebl M, Lau LL, Hakaim AG, et al. Midterm outcomes of endo-vascular abdominal aortic aneurysm repair in octogenarians: a single institution’s experience. J Vasc Surg. 2004;40:435-442. 84. Olson P, Pinkerton C, Brasel KJ, et al. Palliative surgery for malignant bowel obstruction from carcinomatosis: a system-atic review. JAMA Surg. 2014;149(4):383-392.Brunicardi_Ch47_p2045-p2060.indd 205928/02/19 2:08 PM | [
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Surgery_Schwartz_13459 | Surgery_Schwartz | Ethics, Palliative Care, and Care at the End of LifeDaniel E. Hall, Eliza W. Beal, Peter A. Angelos, Geoffrey P. Dunn, Daniel B. Hinshaw, and Timothy M. Pawlik48chapterDedicated to the advancement of surgery along its scientific and moral side. June 10, 1926, dedication on the Murphy Auditorium, the first home of the American College of SurgeonsWHY ETHICS MATTEREthical concerns involve not only the interests of patients but also the interests of surgeons and society. Surgeons choose among the options available to them because they have particu-lar opinions regarding what would be good (or bad) for their patients. Aristotle described practical wisdom (Greek: phronesis) as the capacity to choose the best option from among several imperfect alternatives (Fig. 48-1).1 Frequently, surgeons are confronted with clinical or interpersonal situations in which there is incomplete information, uncertain outcomes, and/or complex personal and familial relationships. The capacity to choose | Surgery_Schwartz. Ethics, Palliative Care, and Care at the End of LifeDaniel E. Hall, Eliza W. Beal, Peter A. Angelos, Geoffrey P. Dunn, Daniel B. Hinshaw, and Timothy M. Pawlik48chapterDedicated to the advancement of surgery along its scientific and moral side. June 10, 1926, dedication on the Murphy Auditorium, the first home of the American College of SurgeonsWHY ETHICS MATTEREthical concerns involve not only the interests of patients but also the interests of surgeons and society. Surgeons choose among the options available to them because they have particu-lar opinions regarding what would be good (or bad) for their patients. Aristotle described practical wisdom (Greek: phronesis) as the capacity to choose the best option from among several imperfect alternatives (Fig. 48-1).1 Frequently, surgeons are confronted with clinical or interpersonal situations in which there is incomplete information, uncertain outcomes, and/or complex personal and familial relationships. The capacity to choose | [
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Surgery_Schwartz_13460 | Surgery_Schwartz | are confronted with clinical or interpersonal situations in which there is incomplete information, uncertain outcomes, and/or complex personal and familial relationships. The capacity to choose wisely in such circumstances is the challenge of surgi-cal practice.DEFINITIONS AND OVERVIEWBiomedical ethics is the system of analysis and deliberation dedicated to guiding surgeons toward the “good” in the prac-tice of surgery. One of the most influential ethical “systems” in the field of biomedical ethics is the principalist approach as articulated by Beauchamp and Childress.2 In this approach to ethical issues, moral dilemmas are deliberated using four guiding principles: autonomy, beneficence, nonmaleficence, and justice.2The principle of autonomy respects the capacity of indi-viduals to choose their own destiny, and it implies that indi-viduals have a right to make those choices. It also implies an obligation for physicians to permit patients to make autonomous choices about their medical | Surgery_Schwartz. are confronted with clinical or interpersonal situations in which there is incomplete information, uncertain outcomes, and/or complex personal and familial relationships. The capacity to choose wisely in such circumstances is the challenge of surgi-cal practice.DEFINITIONS AND OVERVIEWBiomedical ethics is the system of analysis and deliberation dedicated to guiding surgeons toward the “good” in the prac-tice of surgery. One of the most influential ethical “systems” in the field of biomedical ethics is the principalist approach as articulated by Beauchamp and Childress.2 In this approach to ethical issues, moral dilemmas are deliberated using four guiding principles: autonomy, beneficence, nonmaleficence, and justice.2The principle of autonomy respects the capacity of indi-viduals to choose their own destiny, and it implies that indi-viduals have a right to make those choices. It also implies an obligation for physicians to permit patients to make autonomous choices about their medical | [
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Surgery_Schwartz_13461 | Surgery_Schwartz | their own destiny, and it implies that indi-viduals have a right to make those choices. It also implies an obligation for physicians to permit patients to make autonomous choices about their medical care. Beneficence requires that proposed actions aim at and achieve something good whereas nonmaleficence aims at avoiding concrete harm: primum non nocere.* Justice requires fairness where both the benefits and burdens of a particular action are distributed equitably.The history of medical ethics has its origins in antiquity. The Hippocratic Oath along with other professional codes has guided the actions of physicians for thousands of years. However, the growing technical powers of modern medicine raise new questions that were inconceivable in previous gen-erations. Life support, dialysis, and modern drugs, as well as organ and cellular transplantation, have engendered new moral and ethical questions. As such, the ethical challenges faced by the surgeon have become more complex and | Surgery_Schwartz. their own destiny, and it implies that indi-viduals have a right to make those choices. It also implies an obligation for physicians to permit patients to make autonomous choices about their medical care. Beneficence requires that proposed actions aim at and achieve something good whereas nonmaleficence aims at avoiding concrete harm: primum non nocere.* Justice requires fairness where both the benefits and burdens of a particular action are distributed equitably.The history of medical ethics has its origins in antiquity. The Hippocratic Oath along with other professional codes has guided the actions of physicians for thousands of years. However, the growing technical powers of modern medicine raise new questions that were inconceivable in previous gen-erations. Life support, dialysis, and modern drugs, as well as organ and cellular transplantation, have engendered new moral and ethical questions. As such, the ethical challenges faced by the surgeon have become more complex and | [
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Surgery_Schwartz_13462 | Surgery_Schwartz | and modern drugs, as well as organ and cellular transplantation, have engendered new moral and ethical questions. As such, the ethical challenges faced by the surgeon have become more complex and require greater attention.The case-based paradigm for bioethics is used when the clinical team encounters a situation in which two or more val-ues or principles come into apparent conflict. The first step is to clarify the relevant principles (e.g., autonomy, beneficence, nonmaleficence, and justice) and values at stake (e.g., self-determination, quality of life). After identifying the principles and values that are affecting the situation, a proposed course of action is considered given the circumstances.Much of the discourse in bioethics adopts this “principal-ist” approach in which the relevant principles are identified, weighed, and balanced, and then applied to formulate a course of action. This approach to bioethics is a powerful technique for thinking through moral problems because the | Surgery_Schwartz. and modern drugs, as well as organ and cellular transplantation, have engendered new moral and ethical questions. As such, the ethical challenges faced by the surgeon have become more complex and require greater attention.The case-based paradigm for bioethics is used when the clinical team encounters a situation in which two or more val-ues or principles come into apparent conflict. The first step is to clarify the relevant principles (e.g., autonomy, beneficence, nonmaleficence, and justice) and values at stake (e.g., self-determination, quality of life). After identifying the principles and values that are affecting the situation, a proposed course of action is considered given the circumstances.Much of the discourse in bioethics adopts this “principal-ist” approach in which the relevant principles are identified, weighed, and balanced, and then applied to formulate a course of action. This approach to bioethics is a powerful technique for thinking through moral problems because the | [
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Surgery_Schwartz_13463 | Surgery_Schwartz | principles are identified, weighed, and balanced, and then applied to formulate a course of action. This approach to bioethics is a powerful technique for thinking through moral problems because the four princi-ples help identify what is at stake in any proposed course of action. However, the principles themselves do not resolve ethi-cal dilemmas. Working together, patients and surgeons must use wise judgment to choose the best course of action for the specific case.Why Ethics Matter 2061Definitions and Overview 2061Specific Issues in Surgical Ethics 2062Informed Consent / 2062The Boundaries of Autonomy: Advance Directives and Powers of Attorney / 2064Withdrawing and Withholding Life-Sustaining Therapies / 2065Living Donor Liver Transplantation / 2066Palliative Care 2066General Principles of Palliative Care / 2066Concepts of Suffering, Pain, Health, and Healing / 2067Effective Communication and Negotiating the Goals of Care / 2067Care at the End of Life 2068The Syndrome of Imminent | Surgery_Schwartz. principles are identified, weighed, and balanced, and then applied to formulate a course of action. This approach to bioethics is a powerful technique for thinking through moral problems because the four princi-ples help identify what is at stake in any proposed course of action. However, the principles themselves do not resolve ethi-cal dilemmas. Working together, patients and surgeons must use wise judgment to choose the best course of action for the specific case.Why Ethics Matter 2061Definitions and Overview 2061Specific Issues in Surgical Ethics 2062Informed Consent / 2062The Boundaries of Autonomy: Advance Directives and Powers of Attorney / 2064Withdrawing and Withholding Life-Sustaining Therapies / 2065Living Donor Liver Transplantation / 2066Palliative Care 2066General Principles of Palliative Care / 2066Concepts of Suffering, Pain, Health, and Healing / 2067Effective Communication and Negotiating the Goals of Care / 2067Care at the End of Life 2068The Syndrome of Imminent | [
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Surgery_Schwartz_13464 | Surgery_Schwartz | of Palliative Care / 2066Concepts of Suffering, Pain, Health, and Healing / 2067Effective Communication and Negotiating the Goals of Care / 2067Care at the End of Life 2068The Syndrome of Imminent Demise / 2068Common Symptoms at the End of Life and Their Management / 2068Pronouncing Death / 2072Aid in Dying / 2072Professional Ethics: Conflict of Interest, Research, and Clinical Ethics 2072Conflict of Interest / 2072Research Ethics / 2072Special Concerns in Surgical Research / 2072Surgical Innovation / 2073The Ethics of Authorship / 2073Clinical Ethics: Disclosure of Errors / 2074*“First do no harm.”Brunicardi_Ch48_p2061-p2076.indd 206119/02/19 1:49 PM 2062Figure 48-1. Bust of Aristotle. Marble, Roman copy after a Greek bronze original by Lysippos from 330 b.c. (From http://en.wikipedia.org/wiki/File:Aristotle_Altemps_Inv8575.jpg: Ludovisi Collection, Accession number Inv. 8575, Palazzo Altemps, Location Ground Floor, Branch of the National Roman Museum. Photographer/-source | Surgery_Schwartz. of Palliative Care / 2066Concepts of Suffering, Pain, Health, and Healing / 2067Effective Communication and Negotiating the Goals of Care / 2067Care at the End of Life 2068The Syndrome of Imminent Demise / 2068Common Symptoms at the End of Life and Their Management / 2068Pronouncing Death / 2072Aid in Dying / 2072Professional Ethics: Conflict of Interest, Research, and Clinical Ethics 2072Conflict of Interest / 2072Research Ethics / 2072Special Concerns in Surgical Research / 2072Surgical Innovation / 2073The Ethics of Authorship / 2073Clinical Ethics: Disclosure of Errors / 2074*“First do no harm.”Brunicardi_Ch48_p2061-p2076.indd 206119/02/19 1:49 PM 2062Figure 48-1. Bust of Aristotle. Marble, Roman copy after a Greek bronze original by Lysippos from 330 b.c. (From http://en.wikipedia.org/wiki/File:Aristotle_Altemps_Inv8575.jpg: Ludovisi Collection, Accession number Inv. 8575, Palazzo Altemps, Location Ground Floor, Branch of the National Roman Museum. Photographer/-source | [
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Surgery_Schwartz_13465 | Surgery_Schwartz | Ludovisi Collection, Accession number Inv. 8575, Palazzo Altemps, Location Ground Floor, Branch of the National Roman Museum. Photographer/-source Jastrow [2006] from Wikipedia.)Choosing wisely requires the virtue of practical wisdom first described by Aristotle (see Fig. 48-1). Along with the other cardinal virtues of courage, justice and temperance, practical wisdom is a central component of virtue ethics which comple-ment principalist ethics by guiding choices toward the best options for treatment. Practical wisdom cannot be learned from books and is developed only through experience. The appren-ticeship model of surgical residency fosters the development of practical wisdom through experience. More than teaching merely technical mastery, surgical residency is also moral training. In fact, the sociologist Charles Bosk argues that the “postgraduate training of surgeons is above all things an ethical training.”3SPECIFIC ISSUES IN SURGICAL ETHICSInformed ConsentAlthough a relatively | Surgery_Schwartz. Ludovisi Collection, Accession number Inv. 8575, Palazzo Altemps, Location Ground Floor, Branch of the National Roman Museum. Photographer/-source Jastrow [2006] from Wikipedia.)Choosing wisely requires the virtue of practical wisdom first described by Aristotle (see Fig. 48-1). Along with the other cardinal virtues of courage, justice and temperance, practical wisdom is a central component of virtue ethics which comple-ment principalist ethics by guiding choices toward the best options for treatment. Practical wisdom cannot be learned from books and is developed only through experience. The appren-ticeship model of surgical residency fosters the development of practical wisdom through experience. More than teaching merely technical mastery, surgical residency is also moral training. In fact, the sociologist Charles Bosk argues that the “postgraduate training of surgeons is above all things an ethical training.”3SPECIFIC ISSUES IN SURGICAL ETHICSInformed ConsentAlthough a relatively | [
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Surgery_Schwartz_13466 | Surgery_Schwartz | fact, the sociologist Charles Bosk argues that the “postgraduate training of surgeons is above all things an ethical training.”3SPECIFIC ISSUES IN SURGICAL ETHICSInformed ConsentAlthough a relatively recent development, the doctrine of informed consent is one of the most widely established tenets of modern biomedical ethics. During the nineteenth and early twentieth centuries, most physicians practiced a form of benign paternalism whereby patients were rarely involved in the deci-sion-making process regarding their medical care, relying instead on the beneficence of the physician. Consensus among the wider public eventually changed such that surgeons are now expected to have an open discussion about diagnosis and treatment with the patient to obtain informed consent. In the United States, the legal doctrine of simple consent dates from the 1914 decision in Schloendorff vs. The Society of New York Hospital regarding a case in which a surgeon removed a diseased uterus after the patient | Surgery_Schwartz. fact, the sociologist Charles Bosk argues that the “postgraduate training of surgeons is above all things an ethical training.”3SPECIFIC ISSUES IN SURGICAL ETHICSInformed ConsentAlthough a relatively recent development, the doctrine of informed consent is one of the most widely established tenets of modern biomedical ethics. During the nineteenth and early twentieth centuries, most physicians practiced a form of benign paternalism whereby patients were rarely involved in the deci-sion-making process regarding their medical care, relying instead on the beneficence of the physician. Consensus among the wider public eventually changed such that surgeons are now expected to have an open discussion about diagnosis and treatment with the patient to obtain informed consent. In the United States, the legal doctrine of simple consent dates from the 1914 decision in Schloendorff vs. The Society of New York Hospital regarding a case in which a surgeon removed a diseased uterus after the patient | [
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Surgery_Schwartz_13467 | Surgery_Schwartz | the legal doctrine of simple consent dates from the 1914 decision in Schloendorff vs. The Society of New York Hospital regarding a case in which a surgeon removed a diseased uterus after the patient had consented to an examination under anesthesia, but with the express stipulation that no operative excision should be performed. The physician argued that his decision was justified by the beneficent obligation to avoid the risks of a second anes-thetic. However, Justice Benjamin Cardozo stated:Every human being of adult years and sound mind has a right to determine what shall be done with his body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages . . . except in cases of emergency, where the patient is unconscious, and where it is neces-sary to operate before consent can be obtained.4Having established that patients have the right to deter-mine what happens to their bodies, it took some time for the modern | Surgery_Schwartz. the legal doctrine of simple consent dates from the 1914 decision in Schloendorff vs. The Society of New York Hospital regarding a case in which a surgeon removed a diseased uterus after the patient had consented to an examination under anesthesia, but with the express stipulation that no operative excision should be performed. The physician argued that his decision was justified by the beneficent obligation to avoid the risks of a second anes-thetic. However, Justice Benjamin Cardozo stated:Every human being of adult years and sound mind has a right to determine what shall be done with his body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages . . . except in cases of emergency, where the patient is unconscious, and where it is neces-sary to operate before consent can be obtained.4Having established that patients have the right to deter-mine what happens to their bodies, it took some time for the modern | [
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Surgery_Schwartz_13468 | Surgery_Schwartz | and where it is neces-sary to operate before consent can be obtained.4Having established that patients have the right to deter-mine what happens to their bodies, it took some time for the modern concept of informed consent to emerge from the ini-tial doctrine of simple consent. The initial approach appealed to a professional practice standard whereby physicians were obligated to disclose to patients the kind of information that experienced surgeons customarily disclosed.5 However, this dis-closure was not always adequate for patient needs. In the 1972 Key Points1 The physician should document that the patient or surrogate has the capacity to make a medical decision.2 Sufficient details regarding diagnosis and treatment options should be disclosed to the patient so that the patient can pro-vide informed consent.3 Living wills are written to anticipate treatment options and choices in the event that a patient is rendered incompetent by a terminal illness.4 The durable power of attorney | Surgery_Schwartz. and where it is neces-sary to operate before consent can be obtained.4Having established that patients have the right to deter-mine what happens to their bodies, it took some time for the modern concept of informed consent to emerge from the ini-tial doctrine of simple consent. The initial approach appealed to a professional practice standard whereby physicians were obligated to disclose to patients the kind of information that experienced surgeons customarily disclosed.5 However, this dis-closure was not always adequate for patient needs. In the 1972 Key Points1 The physician should document that the patient or surrogate has the capacity to make a medical decision.2 Sufficient details regarding diagnosis and treatment options should be disclosed to the patient so that the patient can pro-vide informed consent.3 Living wills are written to anticipate treatment options and choices in the event that a patient is rendered incompetent by a terminal illness.4 The durable power of attorney | [
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Surgery_Schwartz_13469 | Surgery_Schwartz | informed consent.3 Living wills are written to anticipate treatment options and choices in the event that a patient is rendered incompetent by a terminal illness.4 The durable power of attorney for healthcare identifies sur-rogate decision makers and invests them with the authority to make healthcare decisions on behalf of patients in the event that they are unable to speak for themselves.5 Surgeons should encourage their patients to complete a liv-ing will and clearly identify their surrogates early in the course of treatment.6 Earlier referrals and wider use of palliative and hospice care may help more patients achieve their goals at the end of life.7 Seven requirements for the ethical conduct of clinical research studies have been articulated: value, scientific validity, fair subject selection, favorable risk-benefit ratio, independent review, informed consent, and respect for enrolled subjects.8 Individuals working together on research endeavors should have clear discussions early | Surgery_Schwartz. informed consent.3 Living wills are written to anticipate treatment options and choices in the event that a patient is rendered incompetent by a terminal illness.4 The durable power of attorney for healthcare identifies sur-rogate decision makers and invests them with the authority to make healthcare decisions on behalf of patients in the event that they are unable to speak for themselves.5 Surgeons should encourage their patients to complete a liv-ing will and clearly identify their surrogates early in the course of treatment.6 Earlier referrals and wider use of palliative and hospice care may help more patients achieve their goals at the end of life.7 Seven requirements for the ethical conduct of clinical research studies have been articulated: value, scientific validity, fair subject selection, favorable risk-benefit ratio, independent review, informed consent, and respect for enrolled subjects.8 Individuals working together on research endeavors should have clear discussions early | [
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Surgery_Schwartz_13470 | Surgery_Schwartz | favorable risk-benefit ratio, independent review, informed consent, and respect for enrolled subjects.8 Individuals working together on research endeavors should have clear discussions early in the planning process about authorship, and those discussions should be continued throughout the project or study.9 Disclosure of error is consistent with recent ethical advances in medicine toward more transparency, openness with patients, and the involvement of patients in their care.Brunicardi_Ch48_p2061-p2076.indd 206219/02/19 1:49 PM 2063ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Patient establishes selfas decision-makerNoYesEngage patientdirectly in informedconsent process andin all aspects of careIdentify patient’s culturalidentity and, if possible,explicit preferences formaking decisions,including degree of familyinvolvementMaintain heightenedawareness of patient-family or patient-surrogate interactionsMake sure family orother surrogate is willingparticipant in | Surgery_Schwartz. favorable risk-benefit ratio, independent review, informed consent, and respect for enrolled subjects.8 Individuals working together on research endeavors should have clear discussions early in the planning process about authorship, and those discussions should be continued throughout the project or study.9 Disclosure of error is consistent with recent ethical advances in medicine toward more transparency, openness with patients, and the involvement of patients in their care.Brunicardi_Ch48_p2061-p2076.indd 206219/02/19 1:49 PM 2063ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Patient establishes selfas decision-makerNoYesEngage patientdirectly in informedconsent process andin all aspects of careIdentify patient’s culturalidentity and, if possible,explicit preferences formaking decisions,including degree of familyinvolvementMaintain heightenedawareness of patient-family or patient-surrogate interactionsMake sure family orother surrogate is willingparticipant in | [
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Surgery_Schwartz_13471 | Surgery_Schwartz | formaking decisions,including degree of familyinvolvementMaintain heightenedawareness of patient-family or patient-surrogate interactionsMake sure family orother surrogate is willingparticipant in informedconsent processContinuously reassessfor signs that patient isunhappy with current role ininformed consent processSecure private discussionwith patient and remindpatient of right toinformed consent processMake sure patient hasnot deferred decision-making involuntarilyFigure 48-2. Algorithm for navigating the process of informed consent. (Modified with permission from Childers R, Lipsett A, Pawlik T. Informed consent and the surgeon, J Am Coll Surg. 2009 Apr;208(4):627-634.)landmark case, Canterbury vs. Spence, the court rejected the professional practice standard in favor of the reasonable person standard whereby physicians are obliged to disclose to patients all information regarding diagnosis, treatment options, and risks that a “reasonable patient” would want to know in a similar | Surgery_Schwartz. formaking decisions,including degree of familyinvolvementMaintain heightenedawareness of patient-family or patient-surrogate interactionsMake sure family orother surrogate is willingparticipant in informedconsent processContinuously reassessfor signs that patient isunhappy with current role ininformed consent processSecure private discussionwith patient and remindpatient of right toinformed consent processMake sure patient hasnot deferred decision-making involuntarilyFigure 48-2. Algorithm for navigating the process of informed consent. (Modified with permission from Childers R, Lipsett A, Pawlik T. Informed consent and the surgeon, J Am Coll Surg. 2009 Apr;208(4):627-634.)landmark case, Canterbury vs. Spence, the court rejected the professional practice standard in favor of the reasonable person standard whereby physicians are obliged to disclose to patients all information regarding diagnosis, treatment options, and risks that a “reasonable patient” would want to know in a similar | [
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Surgery_Schwartz_13472 | Surgery_Schwartz | person standard whereby physicians are obliged to disclose to patients all information regarding diagnosis, treatment options, and risks that a “reasonable patient” would want to know in a similar situation. Rather than relying on the practices or consensus of the medical community, the reasonable person standard empow-ers the public (reasonable persons) to determine how much information should be disclosed by physicians to ensure that consent is truly informed. The court did recognize, however, that there are practical limits on the amount of information that can be communicated or assimilated.5 Subsequent litigation has revolved around what reasonable people expect to be disclosed in the consent process to include the nature and frequency of potential complications, the prognostic life expectancy,6 and the surgeon-specific success rates.4 Despite the litigious environ-ment of medical practice, it is difficult to prosecute a case of inadequate informed consent so long as the | Surgery_Schwartz. person standard whereby physicians are obliged to disclose to patients all information regarding diagnosis, treatment options, and risks that a “reasonable patient” would want to know in a similar situation. Rather than relying on the practices or consensus of the medical community, the reasonable person standard empow-ers the public (reasonable persons) to determine how much information should be disclosed by physicians to ensure that consent is truly informed. The court did recognize, however, that there are practical limits on the amount of information that can be communicated or assimilated.5 Subsequent litigation has revolved around what reasonable people expect to be disclosed in the consent process to include the nature and frequency of potential complications, the prognostic life expectancy,6 and the surgeon-specific success rates.4 Despite the litigious environ-ment of medical practice, it is difficult to prosecute a case of inadequate informed consent so long as the | [
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Surgery_Schwartz_13473 | Surgery_Schwartz | life expectancy,6 and the surgeon-specific success rates.4 Despite the litigious environ-ment of medical practice, it is difficult to prosecute a case of inadequate informed consent so long as the clinician has made a concerted and documented effort to involve the patient in the decision-making process.Adequate informed consent entails at least four basic ele-ments: (a) the physician documents that the patient or surrogate has the capacity to make a medical decision; (b) the sur-geon discloses to the patient details regarding the diagno-sis and treatment options sufficiently for the patient to make an informed choice; (c) the patient demonstrates understanding of the disclosed information before (d) authoriz-ing freely a specific treatment plan without undue influence (Fig. 48-2). These goals are aimed at respecting each patient’s prerogative for autonomous self-determination. To accomplish these goals, the surgeon needs to engage in a discussion about the causes and nature of the | Surgery_Schwartz. life expectancy,6 and the surgeon-specific success rates.4 Despite the litigious environ-ment of medical practice, it is difficult to prosecute a case of inadequate informed consent so long as the clinician has made a concerted and documented effort to involve the patient in the decision-making process.Adequate informed consent entails at least four basic ele-ments: (a) the physician documents that the patient or surrogate has the capacity to make a medical decision; (b) the sur-geon discloses to the patient details regarding the diagno-sis and treatment options sufficiently for the patient to make an informed choice; (c) the patient demonstrates understanding of the disclosed information before (d) authoriz-ing freely a specific treatment plan without undue influence (Fig. 48-2). These goals are aimed at respecting each patient’s prerogative for autonomous self-determination. To accomplish these goals, the surgeon needs to engage in a discussion about the causes and nature of the | [
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Surgery_Schwartz_13474 | Surgery_Schwartz | goals are aimed at respecting each patient’s prerogative for autonomous self-determination. To accomplish these goals, the surgeon needs to engage in a discussion about the causes and nature of the patient’s disease, the risks and ben-efits of available treatment options, as well as details regarding what patients can expect after an operative intervention includ-ing possible outcomes and complications.7-14Certain clinical settings make obtaining informed consent challenging. For example, obtaining consent for emergency surgery can be difficult, as the clinical team is forced to make decisions with incomplete information. Emergency consent requires the surgeon to consider if and how possible interven-tions might save a patient’s life, and if successful, what kind of disability might be anticipated. Surgical emergencies are one of the few instances where the limits of patient autonomy are freely acknowledged, and surgeons are empowered by law and ethics to act promptly in the best | Surgery_Schwartz. goals are aimed at respecting each patient’s prerogative for autonomous self-determination. To accomplish these goals, the surgeon needs to engage in a discussion about the causes and nature of the patient’s disease, the risks and ben-efits of available treatment options, as well as details regarding what patients can expect after an operative intervention includ-ing possible outcomes and complications.7-14Certain clinical settings make obtaining informed consent challenging. For example, obtaining consent for emergency surgery can be difficult, as the clinical team is forced to make decisions with incomplete information. Emergency consent requires the surgeon to consider if and how possible interven-tions might save a patient’s life, and if successful, what kind of disability might be anticipated. Surgical emergencies are one of the few instances where the limits of patient autonomy are freely acknowledged, and surgeons are empowered by law and ethics to act promptly in the best | [
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Surgery_Schwartz_13475 | Surgery_Schwartz | anticipated. Surgical emergencies are one of the few instances where the limits of patient autonomy are freely acknowledged, and surgeons are empowered by law and ethics to act promptly in the best interests of their patients according to the surgeon’s judgment. Most applicable medi-cal laws require physicians to provide the standard of care to incapacitated patients, even if it entails invasive procedures without the explicit consent of the patient or surrogate. If at all possible, surgeons should seek the permission of their patients to provide treatment, but when emergency medical conditions render patients unable to grant that permission, and when delay is likely to have grave consequences, surgeons are legally and ethically justified in providing whatever surgical treatment the surgeon judges necessary to preserve life and restore health.4 This justification is based on the social consensus that most people would want their lives and health protected in this way, and this | Surgery_Schwartz. anticipated. Surgical emergencies are one of the few instances where the limits of patient autonomy are freely acknowledged, and surgeons are empowered by law and ethics to act promptly in the best interests of their patients according to the surgeon’s judgment. Most applicable medi-cal laws require physicians to provide the standard of care to incapacitated patients, even if it entails invasive procedures without the explicit consent of the patient or surrogate. If at all possible, surgeons should seek the permission of their patients to provide treatment, but when emergency medical conditions render patients unable to grant that permission, and when delay is likely to have grave consequences, surgeons are legally and ethically justified in providing whatever surgical treatment the surgeon judges necessary to preserve life and restore health.4 This justification is based on the social consensus that most people would want their lives and health protected in this way, and this | [
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Surgery_Schwartz_13476 | Surgery_Schwartz | surgeon judges necessary to preserve life and restore health.4 This justification is based on the social consensus that most people would want their lives and health protected in this way, and this consensus is manifest in the medical profession’s gen-eral orientation to preserve life. It may be that subsequent care may be withdrawn or withheld when the clinical prognosis is clearer, but in the context of initial resuscitation of injured patients, incomplete information makes clear judgments about the patient’s ultimate prognosis or outcome impossible.The pediatric population also presents unique challenges for the process of consent. For many reasons, children and ado-lescents cannot participate in the process of giving informed 1122Brunicardi_Ch48_p2061-p2076.indd 206319/02/19 1:49 PM 2064SPECIFIC CONSIDERATIONSPART IIconsent in the same way as adults. Depending on their age, children may lack the cognitive and emotional maturity to participate fully in the process. In addition, | Surgery_Schwartz. surgeon judges necessary to preserve life and restore health.4 This justification is based on the social consensus that most people would want their lives and health protected in this way, and this consensus is manifest in the medical profession’s gen-eral orientation to preserve life. It may be that subsequent care may be withdrawn or withheld when the clinical prognosis is clearer, but in the context of initial resuscitation of injured patients, incomplete information makes clear judgments about the patient’s ultimate prognosis or outcome impossible.The pediatric population also presents unique challenges for the process of consent. For many reasons, children and ado-lescents cannot participate in the process of giving informed 1122Brunicardi_Ch48_p2061-p2076.indd 206319/02/19 1:49 PM 2064SPECIFIC CONSIDERATIONSPART IIconsent in the same way as adults. Depending on their age, children may lack the cognitive and emotional maturity to participate fully in the process. In addition, | [
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Surgery_Schwartz_13477 | Surgery_Schwartz | 2064SPECIFIC CONSIDERATIONSPART IIconsent in the same way as adults. Depending on their age, children may lack the cognitive and emotional maturity to participate fully in the process. In addition, depending on the child’s age, their specific circumstances, as well as the local jurisdiction, children may not have legal standing to fully par-ticipate on their own independent of their parents. The use of parents or guardians as surrogate decision makers only partially addresses the ethical responsibility of the surgeon to involve the child in the informed consent process. The surgeon should strive to augment the role of the decision makers by involving the child in the process. Specifically, children should receive age-appropriate information about their clinical situation and therapeutic options delivered in an appropriate setting and tone so that the surgeon can solicit the child’s “assent” for treatment. In this manner, while the parents or surrogate decision makers formally give the | Surgery_Schwartz. 2064SPECIFIC CONSIDERATIONSPART IIconsent in the same way as adults. Depending on their age, children may lack the cognitive and emotional maturity to participate fully in the process. In addition, depending on the child’s age, their specific circumstances, as well as the local jurisdiction, children may not have legal standing to fully par-ticipate on their own independent of their parents. The use of parents or guardians as surrogate decision makers only partially addresses the ethical responsibility of the surgeon to involve the child in the informed consent process. The surgeon should strive to augment the role of the decision makers by involving the child in the process. Specifically, children should receive age-appropriate information about their clinical situation and therapeutic options delivered in an appropriate setting and tone so that the surgeon can solicit the child’s “assent” for treatment. In this manner, while the parents or surrogate decision makers formally give the | [
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Surgery_Schwartz_13478 | Surgery_Schwartz | delivered in an appropriate setting and tone so that the surgeon can solicit the child’s “assent” for treatment. In this manner, while the parents or surrogate decision makers formally give the informed consent, the child remains an inte-gral part of the process.Certain religious practices can present additional chal-lenges when treating minor children whose parents disallow medically indicated blood transfusions; however, case law has made clear the precedent that parents, regardless of their held beliefs, may not place their minor children at mortal risk. In such a circumstance, the physician should seek counsel from the hospital medicolegal team, as well as from the institutional ethics team. Legal precedent has, in general, established that the hospital or physician can proceed with providing all necessary care for the child.Obtaining “consent” for organ donation deserves spe-cific mention.15 Historically, discussion of organ donation with families of potential donors was | Surgery_Schwartz. delivered in an appropriate setting and tone so that the surgeon can solicit the child’s “assent” for treatment. In this manner, while the parents or surrogate decision makers formally give the informed consent, the child remains an inte-gral part of the process.Certain religious practices can present additional chal-lenges when treating minor children whose parents disallow medically indicated blood transfusions; however, case law has made clear the precedent that parents, regardless of their held beliefs, may not place their minor children at mortal risk. In such a circumstance, the physician should seek counsel from the hospital medicolegal team, as well as from the institutional ethics team. Legal precedent has, in general, established that the hospital or physician can proceed with providing all necessary care for the child.Obtaining “consent” for organ donation deserves spe-cific mention.15 Historically, discussion of organ donation with families of potential donors was | [
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Surgery_Schwartz_13479 | Surgery_Schwartz | with providing all necessary care for the child.Obtaining “consent” for organ donation deserves spe-cific mention.15 Historically, discussion of organ donation with families of potential donors was performed by transplant professionals, who were introduced to families by intensivists after brain death had been confirmed and the family had been informed of the fact of death. In other instances, consent might be obtained by intensivists caring for the donor, as they were assumed to know the patient’s family and could facilitate the process. However, issues of moral “neutrality” as part of end-of-life care in the intensive care unit have caused a shift in how obtaining “consent” for organ donation is handled. Responsibility for obtaining consent from the donor family is now vested in trained “designated requestors” (or “organ procurement coordinators”)16 or by “independent” intensivists who do not have a therapeutic clinical relationship with the potential donor.17 In this way, the | Surgery_Schwartz. with providing all necessary care for the child.Obtaining “consent” for organ donation deserves spe-cific mention.15 Historically, discussion of organ donation with families of potential donors was performed by transplant professionals, who were introduced to families by intensivists after brain death had been confirmed and the family had been informed of the fact of death. In other instances, consent might be obtained by intensivists caring for the donor, as they were assumed to know the patient’s family and could facilitate the process. However, issues of moral “neutrality” as part of end-of-life care in the intensive care unit have caused a shift in how obtaining “consent” for organ donation is handled. Responsibility for obtaining consent from the donor family is now vested in trained “designated requestors” (or “organ procurement coordinators”)16 or by “independent” intensivists who do not have a therapeutic clinical relationship with the potential donor.17 In this way, the | [
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Surgery_Schwartz_13480 | Surgery_Schwartz | “designated requestors” (or “organ procurement coordinators”)16 or by “independent” intensivists who do not have a therapeutic clinical relationship with the potential donor.17 In this way, the donor family can be allowed to make the decision regarding donation in a “neutral” environment without erosion of the therapeutic relationship with the treating physician or perceived undue pressure from the transplant team.The process of informed consent also can be limited by the capacity of patients to assimilate information in the context of their illness. For example, despite the best efforts of surgeons, evidence suggests that patients rarely retain much of what is dis-closed in the consent conversation, and they may not remember discussing details of the procedure that become relevant when postoperative complications arise.18 It is important to recognize that the doctrine of informed consent places the most emphasis on the principle of autonomy precisely in those clinical situa-tions | Surgery_Schwartz. “designated requestors” (or “organ procurement coordinators”)16 or by “independent” intensivists who do not have a therapeutic clinical relationship with the potential donor.17 In this way, the donor family can be allowed to make the decision regarding donation in a “neutral” environment without erosion of the therapeutic relationship with the treating physician or perceived undue pressure from the transplant team.The process of informed consent also can be limited by the capacity of patients to assimilate information in the context of their illness. For example, despite the best efforts of surgeons, evidence suggests that patients rarely retain much of what is dis-closed in the consent conversation, and they may not remember discussing details of the procedure that become relevant when postoperative complications arise.18 It is important to recognize that the doctrine of informed consent places the most emphasis on the principle of autonomy precisely in those clinical situa-tions | [
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Surgery_Schwartz_13481 | Surgery_Schwartz | postoperative complications arise.18 It is important to recognize that the doctrine of informed consent places the most emphasis on the principle of autonomy precisely in those clinical situa-tions when, because of their severe illness or impending death, patients are often divested of their autonomy.The Boundaries of Autonomy: Advance Directives and Powers of AttorneySevere illness and impending death can often render patients incapable of exercising their autonomy regarding medical decisions. One approach to these difficult situations is to make decisions in the “best interests” of patients, but because such decisions require value judgments about which thoughtful peo-ple frequently disagree, ethicists, lawyers, and legislators have sought a more reliable solution. Advance directives of various forms have been developed to carry forward into the future the autonomous choices of competent adults regarding healthcare decisions. Furthermore, the courts often accept “informal” advance | Surgery_Schwartz. postoperative complications arise.18 It is important to recognize that the doctrine of informed consent places the most emphasis on the principle of autonomy precisely in those clinical situa-tions when, because of their severe illness or impending death, patients are often divested of their autonomy.The Boundaries of Autonomy: Advance Directives and Powers of AttorneySevere illness and impending death can often render patients incapable of exercising their autonomy regarding medical decisions. One approach to these difficult situations is to make decisions in the “best interests” of patients, but because such decisions require value judgments about which thoughtful peo-ple frequently disagree, ethicists, lawyers, and legislators have sought a more reliable solution. Advance directives of various forms have been developed to carry forward into the future the autonomous choices of competent adults regarding healthcare decisions. Furthermore, the courts often accept “informal” advance | [
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Surgery_Schwartz_13482 | Surgery_Schwartz | various forms have been developed to carry forward into the future the autonomous choices of competent adults regarding healthcare decisions. Furthermore, the courts often accept “informal” advance directives in the form of sworn testimony about state-ments the patient made at some time previous to their illness. When a formal document expressing the patient’s advance directives fails to exist, surgeons should consider the comments patients and families make when asked about their wishes in the setting of debilitating illness.Living wills are written to anticipate treatment options and choices in the event that a patient is incapacitated by a terminal illness. In the living will, the patient indicates which treatments she wishes to permit or prohibit in the setting of terminal illness. The possible treatments addressed often include mechanical ventilation, cardiopulmonary resuscitation, artificial nutri-tion, dialysis, antibiotics, or transfusion of blood products. Unfor-tunately, | Surgery_Schwartz. various forms have been developed to carry forward into the future the autonomous choices of competent adults regarding healthcare decisions. Furthermore, the courts often accept “informal” advance directives in the form of sworn testimony about state-ments the patient made at some time previous to their illness. When a formal document expressing the patient’s advance directives fails to exist, surgeons should consider the comments patients and families make when asked about their wishes in the setting of debilitating illness.Living wills are written to anticipate treatment options and choices in the event that a patient is incapacitated by a terminal illness. In the living will, the patient indicates which treatments she wishes to permit or prohibit in the setting of terminal illness. The possible treatments addressed often include mechanical ventilation, cardiopulmonary resuscitation, artificial nutri-tion, dialysis, antibiotics, or transfusion of blood products. Unfor-tunately, | [
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Surgery_Schwartz_13483 | Surgery_Schwartz | The possible treatments addressed often include mechanical ventilation, cardiopulmonary resuscitation, artificial nutri-tion, dialysis, antibiotics, or transfusion of blood products. Unfor-tunately, living wills are often too vague to offer concrete guidance in complex clinical situations, and the language (“termi-nal illness,” “artificial nutrition”) can be interpreted in many ways. Furthermore, by limiting the directive only to “terminal” conditions, it does not provide guidance for common clinical sce-narios like advanced dementia, delirium, or persistent vegetative states where the patient is unable to make decisions, but is not “terminally” ill. Perhaps even more problematic is the evidence that demonstrates that healthy patients cannot reliably predict their preferences when they are actually sick. This phenomenon is called “affective forecasting” and applies to many situations. For example, the general public estimates the health-related qual-ity of life (HRQoL) score of | Surgery_Schwartz. The possible treatments addressed often include mechanical ventilation, cardiopulmonary resuscitation, artificial nutri-tion, dialysis, antibiotics, or transfusion of blood products. Unfor-tunately, living wills are often too vague to offer concrete guidance in complex clinical situations, and the language (“termi-nal illness,” “artificial nutrition”) can be interpreted in many ways. Furthermore, by limiting the directive only to “terminal” conditions, it does not provide guidance for common clinical sce-narios like advanced dementia, delirium, or persistent vegetative states where the patient is unable to make decisions, but is not “terminally” ill. Perhaps even more problematic is the evidence that demonstrates that healthy patients cannot reliably predict their preferences when they are actually sick. This phenomenon is called “affective forecasting” and applies to many situations. For example, the general public estimates the health-related qual-ity of life (HRQoL) score of | [
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] |
Surgery_Schwartz_13484 | Surgery_Schwartz | are actually sick. This phenomenon is called “affective forecasting” and applies to many situations. For example, the general public estimates the health-related qual-ity of life (HRQoL) score of patients on dialysis at 0.39, although dialysis patients themselves rate their HRQoL at 0.56.19 Similarly, patients with colostomies rated their HRQoL at 0.92, compared to a score of 0.80 given by the general public for patients with colostomies.19 For these and other reasons, living wills are often unable to provide the extent of assistance they promise.20An alternative to living wills is the durable power of attor-ney for healthcare in which patients identify surrogate decision makers and invest them with the authority to make healthcare decisions on their behalf in the event that they are unable to speak for themselves. Proponents of this approach hope that the surrogate will be able to make decisions that reflect the choices that the patients themselves would make if they were able. | Surgery_Schwartz. are actually sick. This phenomenon is called “affective forecasting” and applies to many situations. For example, the general public estimates the health-related qual-ity of life (HRQoL) score of patients on dialysis at 0.39, although dialysis patients themselves rate their HRQoL at 0.56.19 Similarly, patients with colostomies rated their HRQoL at 0.92, compared to a score of 0.80 given by the general public for patients with colostomies.19 For these and other reasons, living wills are often unable to provide the extent of assistance they promise.20An alternative to living wills is the durable power of attor-ney for healthcare in which patients identify surrogate decision makers and invest them with the authority to make healthcare decisions on their behalf in the event that they are unable to speak for themselves. Proponents of this approach hope that the surrogate will be able to make decisions that reflect the choices that the patients themselves would make if they were able. | [
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Surgery_Schwartz_13485 | Surgery_Schwartz | unable to speak for themselves. Proponents of this approach hope that the surrogate will be able to make decisions that reflect the choices that the patients themselves would make if they were able. Unfortunately, several studies demonstrate that surrogates are not much better than chance at predicting the choices patients make when the patient is able to state a preference. For example, a recent meta-analysis found that surrogates predicted patients’ treatment preferences with only 68% accuracy.21 These data reveal a flaw in the guiding principle of surrogate decision making: Surrogates do not necessarily have privileged insight into the autonomous preferences of patients. However, the dura-ble power of attorney at least allows patients to choose the person who will eventually make prudential decisions on their behalf and in their best interests; therefore, respecting the judgment of the surrogate is a way of respecting the self-determination of the incapacitated patient.22There is | Surgery_Schwartz. unable to speak for themselves. Proponents of this approach hope that the surrogate will be able to make decisions that reflect the choices that the patients themselves would make if they were able. Unfortunately, several studies demonstrate that surrogates are not much better than chance at predicting the choices patients make when the patient is able to state a preference. For example, a recent meta-analysis found that surrogates predicted patients’ treatment preferences with only 68% accuracy.21 These data reveal a flaw in the guiding principle of surrogate decision making: Surrogates do not necessarily have privileged insight into the autonomous preferences of patients. However, the dura-ble power of attorney at least allows patients to choose the person who will eventually make prudential decisions on their behalf and in their best interests; therefore, respecting the judgment of the surrogate is a way of respecting the self-determination of the incapacitated patient.22There is | [
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Surgery_Schwartz_13486 | Surgery_Schwartz | decisions on their behalf and in their best interests; therefore, respecting the judgment of the surrogate is a way of respecting the self-determination of the incapacitated patient.22There is continuing enthusiasm for a wider use of advance directives. In fact, the 1991 Patient Self Determination Act requires all U.S. healthcare facilities to (a) inform patients of 334Brunicardi_Ch48_p2061-p2076.indd 206419/02/19 1:49 PM 2065ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48their rights to have advance directives, and (b) to document those advance directives in the chart at the time any patient is admitted to the healthcare facility.4 However, only a minority of patients in U.S. hospitals have advance directives despite concerted efforts to teach the public of their benefits and pro-vide resources to help patients prepare and maintain them. For example, the ambitious SUPPORT trial used specially trained nurses to promote communication between physicians, patients, and | Surgery_Schwartz. decisions on their behalf and in their best interests; therefore, respecting the judgment of the surrogate is a way of respecting the self-determination of the incapacitated patient.22There is continuing enthusiasm for a wider use of advance directives. In fact, the 1991 Patient Self Determination Act requires all U.S. healthcare facilities to (a) inform patients of 334Brunicardi_Ch48_p2061-p2076.indd 206419/02/19 1:49 PM 2065ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48their rights to have advance directives, and (b) to document those advance directives in the chart at the time any patient is admitted to the healthcare facility.4 However, only a minority of patients in U.S. hospitals have advance directives despite concerted efforts to teach the public of their benefits and pro-vide resources to help patients prepare and maintain them. For example, the ambitious SUPPORT trial used specially trained nurses to promote communication between physicians, patients, and | [
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Surgery_Schwartz_13487 | Surgery_Schwartz | and pro-vide resources to help patients prepare and maintain them. For example, the ambitious SUPPORT trial used specially trained nurses to promote communication between physicians, patients, and their surrogates to improve the care and decision making of critically ill patients. Despite this concerted effort, the interven-tion demonstrated “no significant change in the timing of do not resuscitate (DNR) orders, in physician-patient agreement about DNR orders, in the number of undesirable days (patients’ experiences), in the prevalence of pain, or in the resources consumed.”23Some of the reluctance around physician–patient agree-ment about DNR orders may reflect patient and family anxiety that DNR orders equate to “do not treat.” Patients and families should be assured, when appropriate, that declarations of DNR/do not intubate will not necessarily result in a change in ongoing routine clinical care. The issue of temporarily rescinding DNR/do not intubate orders around the time of an | Surgery_Schwartz. and pro-vide resources to help patients prepare and maintain them. For example, the ambitious SUPPORT trial used specially trained nurses to promote communication between physicians, patients, and their surrogates to improve the care and decision making of critically ill patients. Despite this concerted effort, the interven-tion demonstrated “no significant change in the timing of do not resuscitate (DNR) orders, in physician-patient agreement about DNR orders, in the number of undesirable days (patients’ experiences), in the prevalence of pain, or in the resources consumed.”23Some of the reluctance around physician–patient agree-ment about DNR orders may reflect patient and family anxiety that DNR orders equate to “do not treat.” Patients and families should be assured, when appropriate, that declarations of DNR/do not intubate will not necessarily result in a change in ongoing routine clinical care. The issue of temporarily rescinding DNR/do not intubate orders around the time of an | [
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Surgery_Schwartz_13488 | Surgery_Schwartz | that declarations of DNR/do not intubate will not necessarily result in a change in ongoing routine clinical care. The issue of temporarily rescinding DNR/do not intubate orders around the time of an operative procedure may also need to be addressed with the family.Patients should be encouraged to clearly identify their sur-rogates, both formally and informally, early in the course of treatment and before any major elective operation. Often, around the time of surgery or at the end of life, there are limits to patient autonomy in medical decision-making. Seeking an advance directive or surrogate decision maker requires time that is not always available when the clinical situation deterio-rates. As such, these issues should be clarified as early as pos-sible in the patient–physician relationship.Withdrawing and Withholding Life-Sustaining TherapiesThe implementation of various forms of life support technol-ogy raise a number of legal and ethical concerns about when it is permissible to | Surgery_Schwartz. that declarations of DNR/do not intubate will not necessarily result in a change in ongoing routine clinical care. The issue of temporarily rescinding DNR/do not intubate orders around the time of an operative procedure may also need to be addressed with the family.Patients should be encouraged to clearly identify their sur-rogates, both formally and informally, early in the course of treatment and before any major elective operation. Often, around the time of surgery or at the end of life, there are limits to patient autonomy in medical decision-making. Seeking an advance directive or surrogate decision maker requires time that is not always available when the clinical situation deterio-rates. As such, these issues should be clarified as early as pos-sible in the patient–physician relationship.Withdrawing and Withholding Life-Sustaining TherapiesThe implementation of various forms of life support technol-ogy raise a number of legal and ethical concerns about when it is permissible to | [
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Surgery_Schwartz_13489 | Surgery_Schwartz | and Withholding Life-Sustaining TherapiesThe implementation of various forms of life support technol-ogy raise a number of legal and ethical concerns about when it is permissible to withdraw or withhold available therapeu-tic technology. There is general consensus among ethicists that there are no philosophic differences between withdrawing (stopping) or withholding (not starting) treatments that are no longer beneficial.24 However, the right to refuse, withdraw, and withhold beneficial treatments was not established before the landmark case of Karen Ann Quinlan. In 1975, Quinlan lapsed into a persistent vegetative state requiring ventilator support. After several months without clinical improvement, Quinlan’s parents asked the hospital to withdraw ventilator support. The hospital refused, fearing prosecution for euthanasia. The case was appealed to the New Jersey Supreme Court where the justices ruled that it was permissible to withdraw ventilator support.25 This case established a | Surgery_Schwartz. and Withholding Life-Sustaining TherapiesThe implementation of various forms of life support technol-ogy raise a number of legal and ethical concerns about when it is permissible to withdraw or withhold available therapeu-tic technology. There is general consensus among ethicists that there are no philosophic differences between withdrawing (stopping) or withholding (not starting) treatments that are no longer beneficial.24 However, the right to refuse, withdraw, and withhold beneficial treatments was not established before the landmark case of Karen Ann Quinlan. In 1975, Quinlan lapsed into a persistent vegetative state requiring ventilator support. After several months without clinical improvement, Quinlan’s parents asked the hospital to withdraw ventilator support. The hospital refused, fearing prosecution for euthanasia. The case was appealed to the New Jersey Supreme Court where the justices ruled that it was permissible to withdraw ventilator support.25 This case established a | [
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Surgery_Schwartz_13490 | Surgery_Schwartz | fearing prosecution for euthanasia. The case was appealed to the New Jersey Supreme Court where the justices ruled that it was permissible to withdraw ventilator support.25 This case established a now commonly recognized right to with-draw “extraordinary” life-saving technology if it is no longer desired by the patient or the patient’s surrogate.The difference between “ordinary” and “extraordinary” care, and whether there is an ethical difference in withhold-ing or withdrawing “ordinary” vs. “extraordinary” care, has been an area of much contention. The 1983 Nancy Cruzan case highlighted this issue. In this case, Cruzan had suffered severe injuries in an automobile crash that rendered her in a persistent vegetative state. Cruzan’s family asked that her tube feeds be withheld, but the hospital refused. The case was appealed to the U.S. Supreme Court, which ruled that the tube feeding could be withheld if her parents demonstrated “clear and convincing evidence” that the incapacitated | Surgery_Schwartz. fearing prosecution for euthanasia. The case was appealed to the New Jersey Supreme Court where the justices ruled that it was permissible to withdraw ventilator support.25 This case established a now commonly recognized right to with-draw “extraordinary” life-saving technology if it is no longer desired by the patient or the patient’s surrogate.The difference between “ordinary” and “extraordinary” care, and whether there is an ethical difference in withhold-ing or withdrawing “ordinary” vs. “extraordinary” care, has been an area of much contention. The 1983 Nancy Cruzan case highlighted this issue. In this case, Cruzan had suffered severe injuries in an automobile crash that rendered her in a persistent vegetative state. Cruzan’s family asked that her tube feeds be withheld, but the hospital refused. The case was appealed to the U.S. Supreme Court, which ruled that the tube feeding could be withheld if her parents demonstrated “clear and convincing evidence” that the incapacitated | [
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Surgery_Schwartz_13491 | Surgery_Schwartz | refused. The case was appealed to the U.S. Supreme Court, which ruled that the tube feeding could be withheld if her parents demonstrated “clear and convincing evidence” that the incapacitated patient would have rejected the treatment.26 In this ruling, the court essentially ruled that there was no legal distinction between “ordinary” vs. “extraor-dinary” life-sustaining therapies.27 In allowing the feeding tube to be removed, the court accepted the principle that a competent person (even through a surrogate decision maker) has the right to decline treatment under the Fourteenth Amendment of the U.S. Constitution. The court noted, however, that there has to be clear and convincing evidence of the patient’s wishes (con-sistent with the principle of autonomy) and that the burdens of the medical intervention should outweigh its benefits (consistent with the principles of beneficence and nonmaleficence).In deliberating the issue of withdrawing vs. withholding life-sustaining therapies, | Surgery_Schwartz. refused. The case was appealed to the U.S. Supreme Court, which ruled that the tube feeding could be withheld if her parents demonstrated “clear and convincing evidence” that the incapacitated patient would have rejected the treatment.26 In this ruling, the court essentially ruled that there was no legal distinction between “ordinary” vs. “extraor-dinary” life-sustaining therapies.27 In allowing the feeding tube to be removed, the court accepted the principle that a competent person (even through a surrogate decision maker) has the right to decline treatment under the Fourteenth Amendment of the U.S. Constitution. The court noted, however, that there has to be clear and convincing evidence of the patient’s wishes (con-sistent with the principle of autonomy) and that the burdens of the medical intervention should outweigh its benefits (consistent with the principles of beneficence and nonmaleficence).In deliberating the issue of withdrawing vs. withholding life-sustaining therapies, | [
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Surgery_Schwartz_13492 | Surgery_Schwartz | intervention should outweigh its benefits (consistent with the principles of beneficence and nonmaleficence).In deliberating the issue of withdrawing vs. withholding life-sustaining therapies, the principle of “double effect” is often mentioned. According to the principle of “double effect,” a treatment (e.g., opioid administration in the terminally ill) that is intended to help and not harm the patient (i.e., relieve pain) is ethically acceptable even if an unintended consequence (side effect) of its administration is to shorten the life of the patient (e.g., by respiratory depression). Under the principle of double effect, a physician may withhold or withdraw a life-sustaining therapy if the surgeon’s intent is to relieve suffering, not to has-ten death. The classic formulation of double effect has four ele-ments (Fig. 48-3).Withholding or withdrawing of life-sustaining therapy is ethically justified under the principle of double effect if the phy-sician’s intent is to relieve | Surgery_Schwartz. intervention should outweigh its benefits (consistent with the principles of beneficence and nonmaleficence).In deliberating the issue of withdrawing vs. withholding life-sustaining therapies, the principle of “double effect” is often mentioned. According to the principle of “double effect,” a treatment (e.g., opioid administration in the terminally ill) that is intended to help and not harm the patient (i.e., relieve pain) is ethically acceptable even if an unintended consequence (side effect) of its administration is to shorten the life of the patient (e.g., by respiratory depression). Under the principle of double effect, a physician may withhold or withdraw a life-sustaining therapy if the surgeon’s intent is to relieve suffering, not to has-ten death. The classic formulation of double effect has four ele-ments (Fig. 48-3).Withholding or withdrawing of life-sustaining therapy is ethically justified under the principle of double effect if the phy-sician’s intent is to relieve | [
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Surgery_Schwartz_13493 | Surgery_Schwartz | double effect has four ele-ments (Fig. 48-3).Withholding or withdrawing of life-sustaining therapy is ethically justified under the principle of double effect if the phy-sician’s intent is to relieve suffering, not to kill the patient. Thus, in managing the distress of the dying, there is a fundamental eth-ical difference between titrating medications rapidly to achieve relief of distress and administering a very large bolus with the 55Double effectConditionsActionGood effectBad effectGood effectBad effectActIntrinsic moral wrongAgentIntendsGood effectBad effect1234ActBad effectGood effectFigure 48-3. The four elements of the double effect principle: (1) The good effect is produced directly by the action and not by the bad effect. (2) The person must intend only the good effect, even though the bad effect may be foreseen. (3) The act itself must not be intrinsically wrong, or needs to be at least neutral. (4) The good effect is sufficiently desirable to compensate for allowing the bad | Surgery_Schwartz. double effect has four ele-ments (Fig. 48-3).Withholding or withdrawing of life-sustaining therapy is ethically justified under the principle of double effect if the phy-sician’s intent is to relieve suffering, not to kill the patient. Thus, in managing the distress of the dying, there is a fundamental eth-ical difference between titrating medications rapidly to achieve relief of distress and administering a very large bolus with the 55Double effectConditionsActionGood effectBad effectGood effectBad effectActIntrinsic moral wrongAgentIntendsGood effectBad effect1234ActBad effectGood effectFigure 48-3. The four elements of the double effect principle: (1) The good effect is produced directly by the action and not by the bad effect. (2) The person must intend only the good effect, even though the bad effect may be foreseen. (3) The act itself must not be intrinsically wrong, or needs to be at least neutral. (4) The good effect is sufficiently desirable to compensate for allowing the bad | [
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Surgery_Schwartz_13494 | Surgery_Schwartz | the bad effect may be foreseen. (3) The act itself must not be intrinsically wrong, or needs to be at least neutral. (4) The good effect is sufficiently desirable to compensate for allowing the bad effect.Brunicardi_Ch48_p2061-p2076.indd 206519/02/19 1:49 PM 2066SPECIFIC CONSIDERATIONSPART IIintent of causing apnea. It is important to note, however, that although the use of opioids for pain relief in advanced illness is frequently cited as the classic example of the double effect rule, opioids can be used safely without significant risk. In fact, if administered appropriately, in the vast majority of instances the rule of double effect need not be invoked when administering opioids for symptom relief in advanced illness.28In accepting the ethical equivalence of withholding and withdrawing of life-sustaining therapy, surgeons can make dif-ficult treatment decisions in the face of prognostic uncertainty.24 In light of this, some important principles to consider when con-sidering | Surgery_Schwartz. the bad effect may be foreseen. (3) The act itself must not be intrinsically wrong, or needs to be at least neutral. (4) The good effect is sufficiently desirable to compensate for allowing the bad effect.Brunicardi_Ch48_p2061-p2076.indd 206519/02/19 1:49 PM 2066SPECIFIC CONSIDERATIONSPART IIintent of causing apnea. It is important to note, however, that although the use of opioids for pain relief in advanced illness is frequently cited as the classic example of the double effect rule, opioids can be used safely without significant risk. In fact, if administered appropriately, in the vast majority of instances the rule of double effect need not be invoked when administering opioids for symptom relief in advanced illness.28In accepting the ethical equivalence of withholding and withdrawing of life-sustaining therapy, surgeons can make dif-ficult treatment decisions in the face of prognostic uncertainty.24 In light of this, some important principles to consider when con-sidering | [
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Surgery_Schwartz_13495 | Surgery_Schwartz | of life-sustaining therapy, surgeons can make dif-ficult treatment decisions in the face of prognostic uncertainty.24 In light of this, some important principles to consider when con-sidering withdrawal of life-sustaining therapy include: (a) Any and all treatments can be withdrawn. If circumstances justify withdrawal of one therapy (e.g., IV pressors, antibiotics), they may also justify withdrawal of others; (b) Be aware of the sym-bolic value of continuing some therapies (e.g., nutrition, hydra-tion) even though their role in palliation is questionable; (c) Before withdrawing life-sustaining therapy, ask the patient and family if a spiritual advisor (e.g., pastor, imam, rabbi, or priest) should be called; and (d) Consider requesting an ethics consult.Although the clinical setting may seem limited, a range of options usually exists with respect to withdrawing or with-holding treatment, allowing for an incremental approach, for example (a) continuing the current regimen without adding | Surgery_Schwartz. of life-sustaining therapy, surgeons can make dif-ficult treatment decisions in the face of prognostic uncertainty.24 In light of this, some important principles to consider when con-sidering withdrawal of life-sustaining therapy include: (a) Any and all treatments can be withdrawn. If circumstances justify withdrawal of one therapy (e.g., IV pressors, antibiotics), they may also justify withdrawal of others; (b) Be aware of the sym-bolic value of continuing some therapies (e.g., nutrition, hydra-tion) even though their role in palliation is questionable; (c) Before withdrawing life-sustaining therapy, ask the patient and family if a spiritual advisor (e.g., pastor, imam, rabbi, or priest) should be called; and (d) Consider requesting an ethics consult.Although the clinical setting may seem limited, a range of options usually exists with respect to withdrawing or with-holding treatment, allowing for an incremental approach, for example (a) continuing the current regimen without adding | [
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Surgery_Schwartz_13496 | Surgery_Schwartz | limited, a range of options usually exists with respect to withdrawing or with-holding treatment, allowing for an incremental approach, for example (a) continuing the current regimen without adding new interventions or tests; (b) continuing the current regimen but withdrawing elements when they are no longer beneficial; and (c) withdrawing and withholding all treatments that are not tar-geted to relieve symptoms and maximize patient comfort.34The surgeon might consider discussing the clinical situ-ation with the patient or proxy decision maker, identify the various therapeutic options, and delineate the reasons why with-holding or withdrawing life-sustaining therapy would be in the patient’s best interest. If the patient (or designated proxy deci-sion maker) does not agree with withholding or withdrawing life-sustaining therapy, the surgeon should consider involving consultants who have participated in the patient’s care, experts in palliative or end-of-life care or recommend a second | Surgery_Schwartz. limited, a range of options usually exists with respect to withdrawing or with-holding treatment, allowing for an incremental approach, for example (a) continuing the current regimen without adding new interventions or tests; (b) continuing the current regimen but withdrawing elements when they are no longer beneficial; and (c) withdrawing and withholding all treatments that are not tar-geted to relieve symptoms and maximize patient comfort.34The surgeon might consider discussing the clinical situ-ation with the patient or proxy decision maker, identify the various therapeutic options, and delineate the reasons why with-holding or withdrawing life-sustaining therapy would be in the patient’s best interest. If the patient (or designated proxy deci-sion maker) does not agree with withholding or withdrawing life-sustaining therapy, the surgeon should consider involving consultants who have participated in the patient’s care, experts in palliative or end-of-life care or recommend a second | [
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Surgery_Schwartz_13497 | Surgery_Schwartz | or withdrawing life-sustaining therapy, the surgeon should consider involving consultants who have participated in the patient’s care, experts in palliative or end-of-life care or recommend a second medical opinion. If the second opinion corroborates that life-sustaining therapy should be withheld or withdrawn but the patient/family continues to disagree, the surgeon should consider assistance from institutional resources such as the ethics committee and hospital administration. Although the surgeon is not ethically obligated to provide treatment that he or she believes is futile, the surgeon is responsible for continued care of the patient, which may involve transferring the patient to a surgeon who is willing to provide the requested intervention.24Living Donor Liver TransplantationOne unique ethical issue that deserves special mention is that of living donor liver transplantation. Living donor kidney transplantation has been practiced for almost 50 years and has become a routine | Surgery_Schwartz. or withdrawing life-sustaining therapy, the surgeon should consider involving consultants who have participated in the patient’s care, experts in palliative or end-of-life care or recommend a second medical opinion. If the second opinion corroborates that life-sustaining therapy should be withheld or withdrawn but the patient/family continues to disagree, the surgeon should consider assistance from institutional resources such as the ethics committee and hospital administration. Although the surgeon is not ethically obligated to provide treatment that he or she believes is futile, the surgeon is responsible for continued care of the patient, which may involve transferring the patient to a surgeon who is willing to provide the requested intervention.24Living Donor Liver TransplantationOne unique ethical issue that deserves special mention is that of living donor liver transplantation. Living donor kidney transplantation has been practiced for almost 50 years and has become a routine | [
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Surgery_Schwartz_13498 | Surgery_Schwartz | unique ethical issue that deserves special mention is that of living donor liver transplantation. Living donor kidney transplantation has been practiced for almost 50 years and has become a routine part of clinical care, but living donor liver transplantation was first performed in the late 1980s with par-ent-to-child grafts and in the late 1990s for adult-to-adult grafts. These procedures are unique in that there are two patients, one with a diseased organ who requires intervention to be made well and one who is healthy and is being made unwell, albeit usu-ally temporarily, during the intervention. Performing an ethi-cal analysis of this situation requires considering both risks and benefits to each of the patients individually.For the recipient, the benefits of receiving a living donor organ as opposed to a deceased donor organ are many: first, there is reduced risk of death on the waitlist, and second, there is a potential for improved post-transplant outcomes due to improved | Surgery_Schwartz. unique ethical issue that deserves special mention is that of living donor liver transplantation. Living donor kidney transplantation has been practiced for almost 50 years and has become a routine part of clinical care, but living donor liver transplantation was first performed in the late 1980s with par-ent-to-child grafts and in the late 1990s for adult-to-adult grafts. These procedures are unique in that there are two patients, one with a diseased organ who requires intervention to be made well and one who is healthy and is being made unwell, albeit usu-ally temporarily, during the intervention. Performing an ethi-cal analysis of this situation requires considering both risks and benefits to each of the patients individually.For the recipient, the benefits of receiving a living donor organ as opposed to a deceased donor organ are many: first, there is reduced risk of death on the waitlist, and second, there is a potential for improved post-transplant outcomes due to improved | [
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Surgery_Schwartz_13499 | Surgery_Schwartz | organ as opposed to a deceased donor organ are many: first, there is reduced risk of death on the waitlist, and second, there is a potential for improved post-transplant outcomes due to improved matching between relatives and the absence of hemo-dynamic instability often present before organ procurement in a deceased donor.30 Furthermore, the use of living donor organs is supported by the principal of utility, maximizing efficient use of organs.32The benefit to the organ donor is in fulfillment of an altru-istic ideal and satisfaction associated with having extended the recipient’s life, while the risks are those associated with partial hepatectomy, a procedure that is not without risks including postoperative complications and mortality, the risk of which is estimated to be 0.15%.29 The ethical concern in this case is hav-ing possibly violated the principle of nonmaleficence.This particular ethical issue emphasizes the importance of truly informed consent. The donor should be | Surgery_Schwartz. organ as opposed to a deceased donor organ are many: first, there is reduced risk of death on the waitlist, and second, there is a potential for improved post-transplant outcomes due to improved matching between relatives and the absence of hemo-dynamic instability often present before organ procurement in a deceased donor.30 Furthermore, the use of living donor organs is supported by the principal of utility, maximizing efficient use of organs.32The benefit to the organ donor is in fulfillment of an altru-istic ideal and satisfaction associated with having extended the recipient’s life, while the risks are those associated with partial hepatectomy, a procedure that is not without risks including postoperative complications and mortality, the risk of which is estimated to be 0.15%.29 The ethical concern in this case is hav-ing possibly violated the principle of nonmaleficence.This particular ethical issue emphasizes the importance of truly informed consent. The donor should be | [
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Surgery_Schwartz_13500 | Surgery_Schwartz | The ethical concern in this case is hav-ing possibly violated the principle of nonmaleficence.This particular ethical issue emphasizes the importance of truly informed consent. The donor should be provided with information on local complication and mortality rates and allowed sufficient time to consider the risks and benefits with-out pressure from healthcare workers.30 Furthermore, experi-enced centers have recommended that living donors have access to sufficient resources and strong support from an institutions’ ethics committee, given substantial pressure exerted by the criti-cal illness of a family member.31PALLIATIVE CAREGeneral Principles of Palliative CarePalliative care is a coordinated, interdisciplinary effort that aims to relieve suffering and improve quality of life for patients and their families in the context of serious illness.33 It is offered simultaneously with all other appropriate medical treatment, and its indication is not limited to situations associated with a | Surgery_Schwartz. The ethical concern in this case is hav-ing possibly violated the principle of nonmaleficence.This particular ethical issue emphasizes the importance of truly informed consent. The donor should be provided with information on local complication and mortality rates and allowed sufficient time to consider the risks and benefits with-out pressure from healthcare workers.30 Furthermore, experi-enced centers have recommended that living donors have access to sufficient resources and strong support from an institutions’ ethics committee, given substantial pressure exerted by the criti-cal illness of a family member.31PALLIATIVE CAREGeneral Principles of Palliative CarePalliative care is a coordinated, interdisciplinary effort that aims to relieve suffering and improve quality of life for patients and their families in the context of serious illness.33 It is offered simultaneously with all other appropriate medical treatment, and its indication is not limited to situations associated with a | [
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Surgery_Schwartz_13501 | Surgery_Schwartz | and their families in the context of serious illness.33 It is offered simultaneously with all other appropriate medical treatment, and its indication is not limited to situations associated with a poor prognosis for survival. Palliative care strives to achieve more than symptom control, but it should not be confused with noncurative treatment.The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threat-ening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”34 Palliative care is both a philosophy of care and an organized, highly structured system for delivering care.Palliative care includes the entire spectrum of intervention for the relief of symptoms and the promotion of quality of life. No specific therapy, including | Surgery_Schwartz. and their families in the context of serious illness.33 It is offered simultaneously with all other appropriate medical treatment, and its indication is not limited to situations associated with a poor prognosis for survival. Palliative care strives to achieve more than symptom control, but it should not be confused with noncurative treatment.The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threat-ening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”34 Palliative care is both a philosophy of care and an organized, highly structured system for delivering care.Palliative care includes the entire spectrum of intervention for the relief of symptoms and the promotion of quality of life. No specific therapy, including | [
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