October 6, 2011

Late in life surgery

From the NYT:
Surgery Rate Late in Life Surprises ResearchersBy GINA KOLATA

Surgery is surprisingly common in older people during the last year, month and even week of life, researchers reported Wednesday, a finding that is likely to stoke, but not resolve, the debate over whether medical care is overused and needlessly driving up medical costs. 
The most comprehensive examination of operations performed on Medicare recipients in the final year of life found that nationally in 2008, nearly one recipient in three had surgery in the last year of life. Nearly one in five had surgery in the last month of life. Nearly one in 10 had surgery in the last week of life. 
The very oldest patients were less likely to have surgery. Those who were 65 had a 38.4 percent chance of having surgery in the last year of life. For 80-year-olds, the chance was 35.3 percent, but the rates fell off more sharply from there, declining by a third by age 90. ... 
But the sheer number of operations at the end of life was unexpected, said the researchers, at Harvard School of Public Health.

I'm not sure why this is so unexpected. I can imagine a lot of different scenarios under which surgery precedes death, such as:

- "We'll just open up the abdomen like this, remove the one malignant tumor and ... uh-oh."

- "I've extracted the second bullet, so where's the third slug? Where's the third goddam ... Uh-oh."

- "In this kind of routine operation, the only thing we surgeons have to worry about is causing massive sepsis by nicking the bowel with the scalpel. ... Uh-oh."

This kind of study always reminds me of the department store owner who said that half of his advertising budget was wasted, he just didn't know which half. If you knew the exact date of your death you could avoid a lot of wasted medical care, life insurance, and much else.


Anonymous said...

I suppose we could save a lot of money by banning surgery for people over 75.

Of course, those over 75 might object.

Polynices said...

I'm in complete agreement with you. It's a stupid study -- sick people often need surgery. If it works, they live longer. If it fails, they die. Old people are more often sick, so they more often are the ones needing surgery. QED.

There's also something called palliative surgery where a quick operation can greatly reduce pain and suffering in the last weeks of someone's life (debulking of big tumors or fixing broken hips are the two examples I can think of off-hand). I'd hate to have people stop getting this care and start having to die in agony because some bean counter thinks surgery near the end of life is automatically bad.

Anonymous said...

Doesn't the NYT also have that Butterfield guy, who writes and re-writes the same story about the "surprising overcapacity of prisons" when crime is too low to justify that

Fred said...

"If you knew the exact date of your death you could avoid a lot of wasted medical care, life insurance, and much else."

Nailed it.

slumber_j said...

There's a fourth possibility, at least, which my then-91-year-old grandfather essentially used to end his life: suicide by surgeon. I could elaborate, but I don't know that I need to.

agnostic said...

Expect the Baby Boomer vs. Generation X war to start getting hot again...

Anonymous said...

Yeah, I couldn't for the life of me see why this result was anything other than what one would expect.

I mean, surgery and, in general, medical procedures are in the great majority of cases applied to very sick people. When people die, in the great majority of cases, it's because they're very sick.

So if a good number of the cases in which people die are also cases in which they had surgery or serious medical procedures not long before, we should be surprised?

eh said...

...during the last...even week of life...

Yeah, and it's even the proximate cause of death in many cases, which is especially sad when the surgery is elective (e.g. palliative, designed to improve the quality of life), which it is more often than some might imagine.

bgc said...

Well yes but...

There is a lot of evidence that major surgery - with general anaesthetics - is bad for elderly people - bad for their brains - and that they never recover mental function after the surgery.

Yes they often remain alive longer after surgery - sometimes much longer (if you call it living), return home... but not to what they were before, not to normal mental functioning, not to independant life.

(Surgeons and anaesthetists have no idea about this - about what happens when patients are discharged from hospital. They are not interested. Success, for them, means 'well enough to leave hospital', or extended 'survival' - not a return to pre-operation levels of functioning.)

Everybody has to die sooner or later - life (or rather a living organism) can be sustained artificially considerably beyond its natural span.

What we have now is often a choice between an earlier, natural and 'good' death; and a later (sometimes much later) death from something horrible, nasty, debilitating, painful or personality-destroying (progressive dementia, chronic delirium etc).

People surely do not *have to* choose prolonged and artifical and horrible living, rather than a 'normal' death at an earlier age - even if prolonged living benefits the medical services...

Why so much pressure to do so? Why is it called 'giving up' when somebody simply allows nature to take its course in the seventies or early eighties?

Why is living on to the nineties to die of cancer (after multiple futile cycles of chemotherapy etc) or dementia regarded as necessarily progress?

Why do we *automatically*, unthinkingly, take antibiotics for everything - when bacterial bronchopneumonia (and other acute infections) were known as 'the old man's friend' exactly because they led to a relatively pleasant death?

We have gotten ourselves into the situation where reflex, unthinking prolongation of living by all-out medical intervention whenever possible has made many intellectuals favour deliberate *killing* of the elderly and debilitated - as the only solution!

The 'solution' should come much earlier - we need to recognize that we have no choice about dying; but we do have some choice about how we die - but how we die is linked to the choice of when we die - i.e. how zealously we try to prolong living beyond the natural human span.

G Joubert said...

It is axiomatic that 95% of all the dollars an American spends in their entire lifetime is spent on their last illness. The way it is.

Chris said...

I think your post is misleading for people who don't have first-hand experience with medical care. The post-surgical deficits you are talking about are either minor or simply risk factors for later-term development of major conditions. The case that a person wakes up from anesthesia with major mental deficits is quite rare.

My own grandmother is a good case study here. She died of Alzheimers in her 80s, but had CABG in her 60s. Were you, as her doctor, going to tell her in her 60s that she "ought" to choose the "natural" course of her disease process (likely dying at an unexpected time in a V-fib arrest) because she would be at higher risk of dementia later in life or might have some lingering occasional "vagueness" post-operatively?

As a psychiatric doctor, are you aware of any way of objectively measuring progressive dementia so that we can draw a line and say "now, your quality of life is objectively not worth intervening medically"?

Georgia Resident said...

People in hospitals are much more likely to die than people who are at home. Therefore, hospital care is useless.

Jim O said...

Lets not forget that Obama used to bitch about the hip surgery his own grandmother had a few weeks before she departed this vale of tears. That was back when he was telling us how we needed ethicists and philosophers and all sorts of elites to decide who gets what healthcare.

He's shut up about all that. . . for now.

End the Fed said...

This is an important area to research: the unnecessary and/or ill-advised surgical churn for profit. It's just that the study is so poorly constructed it sheds no insight - doctors and even medical researcher MD/Phd in general are comically innumerate and lacking in intellectual rigour.

Medicine is a business and some doctors pretty ruthlessly pursue the profit motive. That would be fine if medicine wasn't propagandized as something otherworldly and, more importantly, rife with misdirected and malformed economic incentives mostly paid for by the taxpayer.

As in most professions, most practitioners are conscientious, decent and responsible. Still, it would be of tremendous value to know how much of this late life surgery represents unnecessary and even dangerous practice, identify the abusers and put rules and economic incentives in place to curtail it.

You can blame the AMA and other doctors for helping to shelter the abusers by fighting steps necessary to identify abuse via medical insurance databases like medicaid.

bgc said...

@Chris - well, what you say is precisely the conventional wisdom I am challenging.

There is evidence in the literature, there is evidence in my direct experience - but it is one of those things that people don't want to hear about.

As people get older, more and more cross the threshold to formally diagnosable dementia until about half are there in the nineties - but of course that threshold is arbitrary, and there can be significant impairment short of a formal diagnosis. And even a quantitatively small decrement due to surgery/ general anaesthetic can push people over into dysfunction - the proportion increasing with age.

When you say: "so we can draw a line and say "now, your quality of life is objectively not worth intervening medically"?" it makes me suspect you have completely and utterly misunderstood what I was saying.

That approach about is as far away from what I am arguing as it is possible to go - indeed to be put in the position of asking *that* kind of question is exactly what I think we can and should try to avoid by people giving thought much earlier to these matters.

The main contentious aspect of what I propose is the idea of what is 'natural' - e.g. a natural lifespan, and what constitutes a natural intervention - for example food and drink is natural, feeding tubes and drip-feeds are not; making patients comfortable and treating pain is natural, antibiotics and heart meds are not.

And life-support and resuscitation are un-natural - therefore using them requires specific justification (as contrasted with the current practice that specific justification is required for *omitting* these interventions).

David said...

The conundrum is easily solved. Simply pick a date on which to commit suicide. Say, one's 85th birthday. Then cost/benefit etc. will become much clearer; you will have to stick to your plan, though. If you die before then, it won't matter to you anyway. If you reveal the date to your accountant, doctor, and family, it can only increase the rationality and efficiency of society. Why leave it to chance?

Larry, San Francisco said...

My 86 year old father had a slow growing colon tumor that would have killed him in 5 or 6 years. He had it removed but never recovered from the surgery. He was dead 3 months later. In retrospect it is easy to see that this surgery should not have been done. It is ridiculous that no centralized database exists that track this sort of thing.

Carol said...

The story is so stupid, that when I first saw it I thought they were talking about plastic surgery...lol! It would be just like us Boomers to go in for more chin lifts and boob jobs. Of course that's not covered by Medicare so it wouldn't matter anyway.

"That was back when he was telling us how we needed ethicists and philosophers and all sorts of elites to decide who gets what healthcare."

There seems to be no way to talk about this subject without sounding like an idiot. The fact is, at the end of life people are managing these things one way or another. The patient gives up, or the family makes the decision. Just not soon enough for the quants.

variously ashamed Dodgers/49ers fan said...

I was curious if Mr. Sailer would return to this bit of local news:

The 50 Million Dollar Man

That VDARE column practically writes itself

Get Off My Lawn! said...

People surely do not *have to* choose prolonged and artifical and horrible living, rather than a 'normal' death at an earlier age - even if prolonged living benefits the medical services...

I'll tell you what: When you're an otherwise healthy and independent 80 year-old and you develop a bowel obstruction or acute cholecystitis, come back and tell me whether you're ready to die a "natural" death right then and there or want to take a chance that surgery will prolong your life with a greater or lesser - or, if you're lucky, perhaps NO - degree of debilitation and deterioration in quality of life.

And what is "quality of life"? When you're young or middle-aged, it's easy to image that the limited life a typical 85-year-old leads is not worth living, but very old people are often reasonably content with their restrictions, or, at least, prefer it to the alternative.

Assistant Village Idiot said...

George Burns: It says here that 90% of all accidents happen within five miles of home.

Gracie Allen: Gee, do you think we should move?

Captain Jack Aubrey said...

By all reports surgeons tend to zealously guard their mortality stats. They don't go looking to operate on anyone likely to die on the table or shortly thereafter. So to suggest this is just greedy surgeons looking for bucks...

Anonymous said...

If you knew the exact date of your death you could avoid a lot of wasted medical care, life insurance, and much else.

You could do a lot of things. :-)

Allison said...

or maybe suregeons are killing old sick people with medical mistakes but no one can prove it because of the confounding variables.

Chris said...

Yes, apparently, I don't understand what you're getting at. When you say that someone will have a "horrible...personality-destroying" death and, therefore, should not seek medical intervention, it seems you're suggesting people should give up their last 20 years so that they don't spend, say, 5 of them with a progressive disease process. I don't really understand that line of thinking, especially when you're dealing with odds rather than certainties.

No one is in favor of dementia, but how to know its real impact? That's why I asked about objective measures. If one could say that, from the beginning of a certain course of medical treatment (such as CABG), 75% of a person's remaining life was "horrible," then I could understand not pursuing that treatment. What you seem to me to be saying is that the idea of a "natural life span" is a way of avoiding having bean-counters make this type of assessment at all. The problem is that I don't see any intrinsic value in the concept of a "natural life span" (nor can I define a "good death" without reference to specific and antique belief systems). There is utilitarian value reflected in the bean-counting, and I am fine with being against bean-counting, but the only value I see in "natural life span," is the avoidance of bean-counting, not an intrinsic one, as I say.

I know someone who is seeking cancer treatment not in the hope of full remission but only to eek out more time by keeping the cancer at bay. In the meantime, he can no longer do any of the things that gave pleasure or meaning to his life. I also know someone who has been hospitalized multiple times for pneumonia, but has a vibrant mental life and has gotten almost a decade more so far from the abx. I don't see that the same approach to end of life care is appropriate for both.

Anonymous said...

I think there would be less surgeries in old people if people had to spend their family's money instead of Medicare.

Elli said...

This is somewhat offset because surgeons are reluctant to operate on patients who are likely to die on the operating table and mess up their statistics - even if the surgery is the patient's only chance.

Hunsdon said...

Sarah Palin got a lot of mileage out of her "death panels" line, but if government is in the business of providing health care to the elderly, someone has to draw the line, and that someone can fairly be described as being, or working on, a "death panel." Unless we're the United States of Funding Medical Research on Geriatrics.

Get Off My Lawn! said...

I think there would be less surgeries in old people if people had to spend their family's money instead of Medicare.

I think there would be less medical care in general if people had to spend their own money instead of having insurance coverage of any kind, Medicare or otherwise.

Fewer people would slip and fall in the bathtub if fewer people had indoor plumbing.

Fewer people would be killed in car accidents if fewer people had cars.

We could avoid a lot of problems of modern life if we decided to be less modern.

epobirs said...

A huge part of the problem is you never know when an elderly person is on the verge of systemic collapse with a serious insult to their body. On the one hand, there are physical strains that can leave my 82-year-old mother knocked out for hours. But this same woman had a breast tumor removed a few months ago and nearly two-third through her course of radiation treatments is still driving herself to and from her appointments.

Any time she seems to take an unusually long time to come out of her room in the morning I worry what I'll disocver if I go and check but she still cooks, does laundry, and other tasks, goes to the Y for an exercise class twice a week, is in several book clubs, and generally still a part of the world.

She is fragile in many ways but still functioning. If she needed major surgery I'd have to trust the doctors to assess whether she would recover well enough to make it worth doing.

bgc said...

@Chris - we probably don't disagree that much - but when you say:

"especially when you're dealing with odds rather than certainties."

I think that we get close to the way I think such things must be discussed.

In life we only have odds, and also any policy will be (must be, whatever we may hope) very simple and dichotomous. That is always how it will work out to be in practice.


What this means is that all we can do is set up a simple default set of assumptions, knowing that there will be exceptions (because we are dealing with odds) and trying to have feedback loops which detect and respond to these exceptions.


I am saying that our current default is the wrong way about, and that the odds are in the opposite direction than is generally perceived.

Unfortunately, by getting this wrong, the outcome has been a very large and exponentially doubling proportion of extremely elderly and utterly dependent people with severe debility (some in extreme pain and distress) - of which the most common form is dementia, which is typically extremely distressing for the patient as well as others - such that there are increasingly strident calls, backed by the most influential of the ruling elites (in the UK and Europe) for official arrangements to encourage both large scale suicides among, and deliberate killings of, such people.

The media are full of this stuff and people talk about it a lot.


Opposed to them are misguided religious people who make no ditsinction between natural and unnatural, and apprently want ever more, and ever-more-extreme medical/ technological life support for everybody as a 'right' and without exceptions...

- the end state of which would be something like the majority of the population demented and in a coma living on respirators tended by armies of (what would need to be) conscripted nurses... (I mean, shortly before civilization collapsed).

My suggestions are meant to avert these hideous possibilities before they move even closer than they already are.

The suggestion is simply that the default be that we may choose, as individuals, to allow our lives to end naturally when we reach the natural life span (or what we feel in ourselves is our own personal natural life span - and many people perceive this clearly); and at that point forgore life-extending medical and technological treatments (such as curative surgery, antibiotics, heart meds etc) while continuing to avail ourselves of life-enhancing treatments such as effective pain killers etc.

Taking or imposing life extending medical treatment *after* the natural lifespan must be seen as something artifical and optional which requires specific justification - not as something automatic (and certainly NOT a matter of "rights").

Glaivester said...

My father just died of gastric antral vascular ectasia, which was likely a complication of his metastatic prostate cancer. His life was prolonged for about a year by blood transfusions once to twice a week. He could not do much, but I am glad that we had that time with him, and he seemed to be glad of it as well.

He decided to stop the transfusions once they stopped helping him for more than a day. I think he made the right decision at the right time.

jz said...

I think there would be less surgeries in old people if people had to spend their family's money instead of Medicare.

Underline. also, some surgeries are done purely for defensive legal reasons.