January FY24

[kristenhorsman]

This month's journal club is presented by Ben Waldbaum. He recently had a 93 year old patient for a complicated paraesophageal repair who was asymptomatic which created an ethical dilemma. On the one hand, surgery had a higher risk of leading to death or disability. On the other hand, the patient felt strongly about getting the repair completed. The article he chose can be useful in such a situation to educate the patient and help them make an informed decision.



You will find the article here. 

Please answer the following two questions:


1.) How would you calculate this 93 year old patient's risk given his excellent exercise tolerance, cognition intact, afib, DM2, HTN, and former smoker. How would you present the data to the patient in an objective manner to help them make an informed decision?



2.) In the situation where the patient's post-operative risk of death or disability is rated over 22 points, and the provider feels a moral conflict that they will harm the patient if they proceed; what advice would you tell the provider in how to resolve this conflict that does not involve them violating their beliefs?

[Jackie Howell]

1. I would try to stick with the normal ASA classification system for risk. I would specifically try to assess how controlled each of the coexisting diseases were (DM, HTN) and optimize them prior to surgery. I feel if the patient is cognitively intact and has been provided the facts of the surgical and anesthetic risks, it's the patients decision to make and we should respect it. It may not be what we would chose for ourself or our loved ones. Having that level of empathy for our patients is a testament to the high quality provider one is.

2. I like to believe the CRNA profession is one built on highly trained individuals with a strong moral compass. I don't think any provider should be involved in a case in which their own personal values are challenged or invalidated if their is an alternative provider available to step in. Another example of this is CRNA's providing anesthesia for elective D&E procedures.

[Jackie Howell]

Jan 4, 2024 9:49:29 GMT -5 Jackie Howell said:

1. I would try to stick with the normal ASA classification system for risk. I would specifically try to assess how controlled each of the coexisting diseases were (DM, HTN) and optimize them prior to surgery. I feel if the patient is cognitively intact and has been provided the facts of the surgical and anesthetic risks, it's the patients decision to make and we should respect it. It may not be what we would choose for ourselves or our loved ones. Having that level of empathy for our patients is a testament to the high-quality provider one is.

2. I like to believe the CRNA profession is one built on highly trained individuals with a strong moral compass. I don't feel any provider should be involved in a case in which their own personal values are challenged or invalidated if there is an alternative provider available to step in. Another example of this is CRNA's providing anesthesia for elective D&E procedures.

[Dahlia Rouchon]

1. I would evaluate the patient's risk according to degree of preoperative control of co morbidities. If the Afib is rate controlled, whether and what the recent echo results read, exercise tolerance, hypertension controlled and what medications are taken day of surgery (ACEI, ARB?), HbA1c results, PFTs and whether the patient feels his health is optimized I would then discuss my concerns with the patient, decide if an arterial line is warranted, likely ICU recovery and implement an appropriate anesthetic with theses considerations. Careful attention to volume resuscitation, tight hemodynamic ventilation strategies, cerebral oximeter use, consideration of surgeon's surgical skill (length of operative time), and assessing stat lab findings.
I would present the data of possible increased risk due to what these findings are, what strategies will be used to help mitigate the risk but that all risks cannot be removed, controlled and they must accept them if wishing to proceed.

2. If the provider feels a moral conflict that they will harm the patient, they should ask to be reassigned if possible but reconsider a different work environment where these types of cases are not being done.

[Kels]

I would need to know more information about the Pt's DM , a-fib and HTN in order to have an informed discussion about the Pt's anesthesia risks. I too would use the ASA classification system for risk. As with all of our pts we should present all of the known and unknown risks to our pts. Unfortunately we can not 100 % predict the future but presenting all of the information is the best we can do .


If a provider has a moral conflict that they will harm the patient if they proceed with a surgery then that provider should not proceed with the case .

[Benjamin Waldbaum]

1.) Unfortunately it seems that the previous comments did not answer the question based on the content of the article. The ASA classification system seems to be inadequate for quantifying risk in the elderly. The article presented a validated scoring system so that providers can educate the patient about the risks. The scoring system was a point score model was created assigning a score to each of the predictor variables:
Baseline WHODAS score (%): 1.5 points per 10% age points, Age at date of surgery (yr): 2 points per 10 yr, Dementia: 6 points, and Chronic kidney disease: 1 point. This patient was 93 years old which is 18 points. Completing the WHODAS scale, results in another 4.5 points. He had no dementia and no known chronic kidney disease. His total score was 22.5. This score means there is at least 75% chance of death or disability at 6 months. Based on this score, I would educate the patient about that the likely outcome of surgery is death or disability and that they must be ok with that.


2.) Given the 75% chance that the surgery will result in death or disability, personally I consulted with legal if we should proceed with the case given there was only a 25% chance of helping the patient without harm. We as providers need to know when to say no.

[Amy Swank]

1. It is a interesting tool to quantify risk in the elderly and an important one. To be informed that one's risk of death or disability after undergoing surgery is a significant one and one that needs further discussion. However, usually anesthesia just uses the ASA guidelines and NPO status and just keeps ding cases. A discussion with the surgeon and family about these legitimate concerns is crucial.

2. I would proceed with providing anesthesia after having an honest discussion with the team and family about these concerns.

[aileenm4]

1. This 93 year old is still considered extreme of age and has higher risk for anesthesia complications, I would have to investigate current disease status, DM control,HTN meds, metabolic status, statins, the anticoagulation and arrythmia treatment for the Afib, and rate admissions, Echo,etc. I would include discussion with patient and family members as allowed by patient to discuss Power of attorney, risks for major events including MI, stroke, delerium post op due to age.

2. I believe that these patients need care, after having an indepth discussion with patient and family members about all possible major outcomes based om patients age and frailty score, I would proceed with all discussion of how the anesthsia team will do all possible things to make the success as best as possible like invasive monitoring, transfusion needs etc. If the family an patien sttill want to proceed knowing the risks including M&M and verbalized understanding of risks then I would proceed.

[Tracey Trainum]

1. This article discusses means of quantifying potential risk of death and disability in patients 70 years or older having elective surgery. Currently, there is not a concrete method outside of the ASA classification scale to quantify this risk. Having a valid measurement tool is important for patients and providers to help the decision-making process as it pertains to risk assessment. The article references the WHODAS scale - which is the World Health Organization Disability Assessment Scale as means of measuring disability risk after surgery. This self-assessment asks patients how much difficulty they have had due to health problems in specific functional domains over the last 30 days. A Likert scale of 1-4 is used, 12 items are included in the WHODAS assessment. These values are translated into a percentage to predict risk of disability after surgery. Researchers then incorporated the WHODAS score into a more detailed risk assessment which included the following: Baseline WHODAS score % (1.5 points per 10% age points), 2 points per 10 years of age, dementia 6 points, chronic kidney disease 1 point. Based on the patients age and WHODAS points, he would score greater then 22, putting him at 75% risk of being dead or disabled within 6 months of surgery.

2. Ethical/moral conflicts are tricky. If I were the provider, I would have a discussion with the patient. Maybe the patient has a reason or perspective to share regarding his decision for surgery despite the risk that I haven't considered. As a provider I always try to consider the patient's perspective and I try to put my own beliefs aside. So, I would encourage the provider to have this discussion with the patient to see if that relieves any moral conflicts he/she is having about the care. If this discussion still results in a moral dilemma for the provider, then the provider should excuse him or herself from the case. A provider that can support the patient's decision in lieu of the risk should be at the head of the bed.