Thursday, March 22, 2018

Nearly 1 in 3 Medicare patients undergo surgery in their final year of life. When do we stop operating?

At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.

She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.

When her time came, she wanted to die a natural death, Stanich told her daughter, and signed a "do not resuscitate" directive, or DNR, ordering doctors not to revive her should her heart stop.

Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest ó a medical device to keep her alive by delivering a powerful shock. At the time, Stanich didnít fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.

ABOUT THIS SERIES: Kaiser Health News investigates the causes and consequences of medical overtreatment in "Treatment Overkill," an ongoing series of reports./b>

That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw a defibrillator protruding from the DNR patientís thin chest. To Stanichís horror, the ER doctor explained that the device would not allow her to slip away painlessly and that the jolt would be "so strong that it will knock her across the room," said Giaquinto, who accompanied her mother on both hospital trips.

Surgery like this has become all too common among those near the end of life, experts say. Nearly 1 in 3 Medicare patients undergo an operation in the year before they die, even though the evidence shows that many are more likely to be harmed than to benefit from it.

The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Dr. Rita Redberg, a cardiologist who treated Stanich when she sought care at the second hospital.

"We have a culture that believes in very aggressive care," said Redberg, who at the University of California-San Francisco specializes in heart disease in women. "We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most."

While surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to a 2016 paper in Annals of Surgery.

The cost of these surgeries ó typically paid for by Medicare, the government health insurance program for people over 65 ó involve more than money, said Dr. Amber Barnato, a professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50 percent more time in the hospital than others, and nearly twice as many days in intensive care.

And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.

Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week, according to a 2011 study in The Lancet.

More than 12 percent of defibrillators were implanted in people older than 80, according to a 2015 study. Doctors implant about 158,000 of the devices each year, according to the American College of Cardiology. The total cost of the procedure runs about $60,000.

Procedures performed in the elderly range from major operations that require lengthy recoveries to relatively minor surgery performed in a doctorís office, such as the removal of nonfatal skin cancers, that would likely never cause any problems.

Research led by Dr. Eleni Linos has shown that people with limited life expectancies are treated for nonfatal skin cancers as aggressively as younger patients. Among patients with a nonfatal skin cancer and a limited time to live, 70 percent underwent surgery, according to her 2013 study in JAMA Internal Medicine.

When Less Is More

Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery, 20 percent die within 30 days, studies show.

With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker simply because her doctor suggested it, Giaquinto said. Many people of Stanichís generation "thought doctors were God. Ö They never questioned doctors ó ever."

According to the University of Michiganís National Poll on Healthy Aging, published Wednesday, more than half of adults ages 50 to 80 said doctors often recommend unnecessary tests, medications or procedures. Yet half of those whoíd been told they needed an X-ray or other test ó but werenít sure they needed it ó went on to have the procedure anyway.

TO YOUR HEALTH: Keep track of trends and new developments that affect you. Visit the Times health page.

Dr. Margaret Schwarze, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health, said that older patients often donít feel the financial pain of surgery because insurance pays most of the cost.

When a surgeon offers to "fix" the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will fix all of her medical problems, Schwarze said. "With older patients with lots of chronic illnesses, weíre not really fixing anything."

Even as a doctor, Redberg said, she struggles to prevent other doctors from performing too many procedures on her 92-year-old mother, Mae, who lives in New York City.

Redberg said doctors recently treated her mother for melanoma ó the most serious type of skin cancer. After the cancer was removed from her leg, Redbergís mother was urged by a doctor to undergo an additional surgery to cut away more tissue and nearby lymph nodes, which can harbor cancerous cells.

"Every time she went in, the dermatologist wanted to refer her to a surgeon," Redberg said. And "Medicare would have been happy to pay for it."

But her mother often has problems with wounds healing, she said, and recovery would likely have taken three months. When Redberg pressed a surgeon about the benefits, he said the procedure could reduce the chances of cancer coming back within three to five years.

Redberg said her mother laughed and said, "Iím not interested in doing something that will help me in three to five years. I doubt Iíll be here."

Finding Solutions

The momentum of hospital care can make people feel as if theyíre on a moving train and canít jump off.

The rush of medical decisions "doesnít allow time to deliberate or consider the patientsí overall health or what their goals and values might be," said Dr. Jacqueline Kruser, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University Feinberg School of Medicine.

Many hospitals and health systems are developing "decision aids," easy-to-understand written materials and videos to help patients make more informed medical decisions, giving them time to develop more realistic expectations.

After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26 percent, while knee replacements declined 38 percent, according to a study in Health Affairs. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

In a paper published last year in JAMA Surgery and the Journal of Pain and Symptom Management, Schwarze, Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.

Instead of telling patients that surgery carries a 20 percent risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.

In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just two to three months after surgery.

Schwarze said, "If someone says they canít tolerate the best-case scenario ó which involves them being in a nursing home ó then maybe we shouldnít be doing this."

Maxine Stanich was admitted to the hospital after going to the ER because she felt short of breath. She experienced an abnormal heart rhythm in the procedure room during a cardiac test ó not an unusual event during a procedure in which a wire is threaded into the heart. Based on that, doctors decided to implant a pacemaker and defibrillator the next day.

Dr. Redberg was consulted when the patient objected to the device that was now embedded in her chest. She was "very alert. She was very clear about what she did and did not want done. She told me she didnít want to be shocked," Redberg said.

After Redberg deactivated the defibrillator, which can be reprogrammed remotely, Stanich was discharged, with home hospice service. With nothing more than her medicines, she survived another two years and three months, dying at home just after her 90th birthday in 2010.


KHNís coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation

Cirque du Soleil aerialist who died after fall was performing act for first time, he said on Instagram

Cirque du Soleil aerialist who died after fall was performing act for first time, he said on Instagram

TAMPA ó On the day of his fatal fall during a show in Tampa, a Cirque du Soleil acrobat posted on Instagram that he would be performing a new act for the first time."After so much work and training and staging, our straps duo act is finally in the sh...
Published: 03/19/18
Itís Colorectal Cancer Awareness Month: the latest on the colonoscopy and home screening tests

Itís Colorectal Cancer Awareness Month: the latest on the colonoscopy and home screening tests

The items glide slowly toward checkout. To the keen observer, your destiny is clear: green Jell-O, chicken broth, lemon Crystal Light, white grape juice, lemons and limes, yellow popsicles, soothing "personal care" wipes and a large package of toilet...
Published: 03/16/18
Learn how to handle the everyday stresses that can be harmful to your health

Learn how to handle the everyday stresses that can be harmful to your health

When people talk about harmful stress, the kind that can affect health, they usually point to big, life-changing events, such as the death of a loved one. A growing body of research suggests that minor, everyday stress ó caused by flight delays, traf...
Published: 03/16/18
Mayo Clinic Q&A: Lifestyle changes can reduce cancer risk

Mayo Clinic Q&A: Lifestyle changes can reduce cancer risk

It seems like I see a new story every day about things I should or shouldnít do to prevent cancer. What really makes a difference? Are there steps I can take that science has proved will lower my chance of getting cancer?This is a wonderful question....
Published: 03/16/18

Downward dog, hurting wrist?

You know that pain or discomfort in the wrists that you or your fellow yogis might feel in downward dog?"Wrist pain is one of the most common issues we see in yoga," says Alyson Shade, yoga instructor and co-owner of Realignment Studio in Washington,...
Published: 03/16/18
Oh la la: Chicken With Cider and Pears

Oh la la: Chicken With Cider and Pears

The French know a thing or two about the perfect braise, so I wasnít surprised when I tasted the rabbit in cider, Calvados (apple brandy) and cream that my host family served me during my semester abroad in Nantes. If you ever find yourself in France...
Published: 03/16/18
Try a fresh twist on fish with Cod With Pomegranate and Zucchini en Papillote

Try a fresh twist on fish with Cod With Pomegranate and Zucchini en Papillote

The health benefits of eating fish two or three times a week are well-documented. So, as a mom, Iím always looking for creative ways to add fish into our weekly menu. I love Alaskan cod, which is loaded with omegas and lean protein, and my girls all ...
Published: 03/16/18
Pediatricians are the new allies in the battle against teen depression. They can spot it early.

Pediatricians are the new allies in the battle against teen depression. They can spot it early.

Amid rising demand for mental health care for children and teens in crisis, the American Academy of Pediatrics is calling on front-line doctors to get in the game and help spot the early signs of depression in their young patients.The academy has upd...
Published: 03/15/18
Updated: 03/16/18

Rabies alert issued in northwest Hillsborough County

tampa County warnsof increase in rabies exposureA raccoon has tested positive for rabies near Tannery Avenue, according to the Hillsborough County Health Department, prompting a rabies alert to be issued for the northwestern area of the county.A dog ...
Published: 03/14/18
Indian doctors amputated a manís leg. Then it was used as a pillow.

Indian doctors amputated a manís leg. Then it was used as a pillow.

This week, two Indian doctors joined the ignoble ranks of the surgeon who trash-talked about her patient while he was under anesthesia and the one who forgot to remove a knife blade from a patientís brain.The Indian doctors and two nurses were suspen...
Published: 03/13/18