In vain have you acquired knowledge if you have not imparted it to others.
Introduction
Elderly patients will encounter different professionals, each with a different focus, prior to surgery. This will usually be a surgeon, an anesthesiologist and a nurse Depending on comorbidities and availability, a geriatrician and other medical specialists will also be involved in preoperative screening. A multidisciplinary approach may prove important in defining the optimal treatment strategy for the individual patient, especially in complex elderly patients and/or patients undergoing major surgery. However, in a multidisciplinary team, a clear division of tasks and responsibilities can prove challenging, as required (diagnostic) information may overlap between different specialisms. More importantly, involving several medical specialists may lead to situations where conflicts of professional opinions and interests hamper a unified approach.
Multidisciplinary team meetings aiming to share and understand these views provide the opportunity to learn what information is valuable and can prove useful to come to novel insights regarding the patient’s best treatment. Moreover, from this discussion, a clear identification of team goals and common responsibilities may arise, increasing cohesion among team members, contributing to build a shared interprofessional culture and ultimately improving patients’ outcomes.
This chapter provides a conceptual model for understanding the importance of a stepwise multidisciplinary approach towards preoperative assessment and multidisciplinary decision-making, as has been detailed in Chapters 2–8. With the aim of demonstrating the value of this approach, two cases are presented where the effort of compiling potentially different or mildly conflicting views has led to a better understanding of the patient and a more tailored treatment strategy. Areas in which sharing information among team members is critical to ensure optimal perioperative management and risk reduction are examined.
Cases
Patient A
Mrs A, a 69-year old woman with a history of hypertension, epilepsy and chronic obstructive pulmonary disease (COPD), was referred for a radical re-resection after an incidental finding of gallbladder cancer at cholecystectomy. When escorting her from the waiting room for her surgical consult, the surgeon noticed dyspnea and a slight wheezing. Mrs A complained of fatigue, shortness of breath and had recently had a generalized seizure. On examination, her blood pressure was 230/140 mmHg. The surgeon doubted whether Mrs A was fit enough to undergo extensive surgery. In order to obtain a better view of her general health status and to aid in treatment decision-making, he referred her to the department of elderly medicine. Upon geriatric assessment, it was concluded that Mrs A had a high risk of developing postoperative complications, including pulmonary infections and delirium. A number of somatic and psychosocial problems were revealed. On assessment of her physical function, the geriatrician found that her COPD had worsened in the past months and had poorly responded to multiple courses of prednisolone and inhalation medication. Her hypertension and epilepsy were insufficiently controlled. Laboratory examination showed hyponatremia of 125 mEq/L which was attributed to the syndrome of inappropriate antidiuretic hormone excretion (SIADH) caused by the use of antiepileptics. She was not able to perform any housework and spent most of her days inside the house watching television. Cognitive screening revealed mild cognitive impairments, increasing her risk of developing postoperative delirium. When the geriatrician asked Mrs A about her treatment goals, she indicated that living independently in her own house was very important for her and that she did not want to end up in a nursing home. She did not want to participate in treatment decision-making, but wanted her treating physician together with her two daughters to make decisions for her.
Upon preoperative evaluation by the anesthesiologist, it was concluded that general anesthesia and a surgical procedure with possible substantial blood loss conferred a high risk of complications due to her insufficiently controlled hypertension, COPD and hyponatremia.
At a multidisciplinary meeting where her surgeon, anesthesiologist and geriatrician were present, the pros and cons of surgery were carefully weighed. Although an operation would offer Mrs A a chance of long-term survival, it carried a high risk of peri- and postoperative complications and therefore a substantial risk of subsequent institutionalization. Taking into account the fact that Mrs A had a strong wish to remain independent, it was decided to refrain from surgery. This was discussed with her daughters who agreed with the treatment advice given by the multidisciplinary team.
Patient B
Mrs. B, a 75-year-old woman, was referred because of peritoneal carcinomatosis as a result of a colon carcinoma. She was screened for hyperthermic intraperitoneal chemotherapy (HIPEC). This is an invasive surgical procedure with a high risk of complications. Aside from obesity (body mass index (BMI) of 34), her medical history showed no significant comorbidity. She had previously undergone several surgeries (total knee prosthesis and an osteo-synthetic plate of a fracture). She suffered from mildly reduced mobility because of arthrosis and used a cane for walking. Mrs. B had experienced some weight loss in the last months prior to referral, which was in part intentional. She lived alone, with a family member living next door. On the first encounter the surgeon noted that it was mostly her daughter who did the talking and it was unclear if the patient understood all the information provided. The surgeon had doubts whether Mrs. B was able to undergo this type of invasive surgery, taking into account her physical condition and mental status. Therefore, she was referred to both the anesthesiologist and the geriatrician.
During anesthesiologist evaluation, no significant contraindications for this major surgery were discovered. She showed no signs of allergies, no cardiopulmonary complaints, no coagulation or endocrine problems and her physical performance conformed with age. She suffered from mild functional restrictions because of arthrosis, but was able to cycle, ambulate, self-care and to do work in the house and garden. Laboratory examinations revealed an anemia, with an hemoglobin of 6.4 mmol/l (10.24 g/dl). ECG showed a sinus rhythm with a right bundle branch block, but no signs of ischemia.
During geriatric assessment no cognitive dysfunction or mood disturbances were observed. She had a timed up and go < 10 sec. Her only medication consisted of calcium and vitamin D supplements. She had a limited social network, but did have good contacts with her daughter. The patient had clear preferences. She was very motivated to undergo this surgery, her main treatment goal being extension of life expectancy, even if this would be accomplished at the cost of loss of independence.
In this patient it was expected that a HIPEC procedure would not be curative, but would extend her life expectancy. The procedure was likely to lead to some loss of independence as well as an elevated risk of getting a permanent stoma. After carefully weighing the evaluations by the different disciplines and taking the explicit motivation of the patient into account, it was decided to accept her for a HIPEC procedure.
Considerations
Both Mrs. A and Mrs. B are elderly patients who were referred for extensive surgery. They were seen by a surgeon, a geriatrician and an anesthesiologist. In both cases, it proved difficult to weigh the risks and benefits of surgery. Medical technical information alone proved insufficient to make these decisions. With patient A there were several physical problems such as worsening of her COPD and hyponatremia, but it was unclear to both the treating surgeon and the geriatrician how to precisely weigh this in view of the proposed surgery. The expertise of the anesthesiologist was necessary to make a more precise estimation of the risk of perioperative complications, which was deemed high. Geriatric assessment revealed mild cognitive impairment, which increased the chance of postoperative delirium. This patient valued her independence as the most important treatment outcome, but the risk of losing functional capacity and independence was also estimated to be high, based on the surgery performed, information from the geriatric assessment and the expertise of the anesthesiologist. In this patient it proved necessary to combine the available expertise and incorporate the goals of the patient, in order to reach a treatment proposal, which in this case was to refrain from surgery.
With patient B it was unclear to the surgeon whether this patient was capable of understanding the information and there were doubts on both cognitive and functional reserve. However, cognitive screening and information from the daughter on geriatric assessment revealed no cognitive impairment. And, even though this patient used a cane, her timed up and go (a measure of functionality which is a good predictor of surgical complication, see Chapters 2 and 5) was under 10 seconds. The anesthesiologist confirmed that there were no additional risk factors and the proposal was to perform the HIPEC procedure as planned, which was in line with the preferences of this patient.
A Stepwise Approach to Multidisciplinary Decision-making
Together with issues traditionally evaluated in the general population during surgery and anesthesia consultation, the preoperative evaluation of elderly patients should be extended on multiple domains (physical, psychosocial and functional) through a Comprehensive Geriatric Assessment (CGA). Depending on local circumstances, a full or abbreviated geriatric assessment can be performed by a geriatrician, a trained nurse or a trained anesthesiologist (see Table 9.1). It is important that, at the time the decision-making process takes place, all the information exploring functional status (FS) has been collected, as it can substantially affect both the care plan and the decision about surgery (see also Chapter 2).
| Domain | Items to be assessed | Examples of assessment tools |
|---|---|---|
| Physical | Comorbidity | Charlson Comorbidity Index (CCI) |
| Cumulative Illness Rating Scale for Geriatrics (CIRS-G) | ||
| Nutritional status | Mini Nutritional Assessment Short-Form (MNA-SF) | |
| Patient-Generated Subjective Global Assessment (PS-SGA) | ||
| Substance abuse | ||
| Poly-pharmacy | STOPP/START criteria | |
| Psychological | Cognitive function | Mini-COG |
| Mini Mental State Examination (MMSE) | ||
| Montreal Cognitive Assessment (MoCa) | ||
| Mood | Geriatric Depression Scale (GDS) | |
| Hospital Anxiety and Depression Scale (HADS) | ||
| Risk of delirium | ||
| Functional | Gait and balance | Six-minute walk test (Awdeh et al. 2015) |
| Timed up and go (TUG) (Huisman et al. 2014) | ||
| ADLa | Katz Index of Independence in Activities of Daily Living (Applegate et al. 1990) | |
| iADLb | Lawton Scale for Instrumental Activities of Daily Living | |
| Use of functional aids (visual, hearing, mobility, dentures) | ||
| Risk of falls | ||
| Social | Social support | |
| Caregiver burden | Caregiver Strain Index (CSI) |
a ADL: activities of daily living
b iADL: instrumental activities of daily living
After a surgical and geriatric assessment and inventory of patient preferences have been performed, multidisciplinary decision-making should take place in a stepwise manner. In order to reach a patient-tailored treatment proposal, the expertise of the different healthcare providers that are involved needs to be combined and shared. Especially in complex elderly patients, this can best be done by discussion in a multidisciplinary team (MDT) setting. This MDT should consist of at least a surgeon, an anesthesiologist, a nurse, a geriatrician and, depending on the medical problem, other medical specialists such as a cardiologist, pulmonologist, medical oncologist, radiotherapist, palliative specialist and others. A nurse can play an important role in the coordination of care, gathering information on patient preferences and performing a short geriatric assessment. Information on multiple domains should be available in order to assess the risk of perioperative mortality and postoperative morbidity (e.g. delirium, infection, acute renal dysfunction, respiratory or cardiac failure and functional decline). If possible, optimization of different domains should be performed (see Chapter 12). The benefits of surgery should be carefully weighed against the risks of complications or functional decline. This should be tailored to the individual patient and be in line with personal goals and preferences. The time perspective should also be taken into account: what is the life expectancy of this individual patient and what is the time to benefit from surgery (or time to expected problems when refraining from surgery)? The expertise of the different team members is pivotal in estimating these outcomes. Discussing all the different perspectives in an MDT has the benefit of sharing expertise and reducing fragmentation of care. It enables the treating physician to combine the available information into a treatment proposal.
The basic steps that should be taken into account in the multidisciplinary decision making process are reported in Box 9.1.
Box 9.1 Steps that can be taken in the multidisciplinary decision-making process
| 1. Encounter between surgeon and patient: diagnosis and indication for surgery. Are there alternative treatment options? Is there a living will? |
| 2. Inventory of patient treatment preferences and geriatric assessment. Involvement of other specialists based on specific symptoms or comorbidities, or if more extensive geriatric assessment is necessary. |
| 3. Multidisciplinary team discussion. |
| 4. Weighing all available information and reaching one or more treatment proposals. |
| 5. Discussing these proposals with the patients and caretakers and reaching a decision through shared decision-making. |
MDT meetings
In order to reach patient-centered multidisciplinary treatment proposals, the information provided by different team members will have to be discussed. Different specialists will be consulted as needed and the order in which the patient is seen by different specialists may differ (see Chapter 2). This MDT discussion will contain medical technical information, as well as information on patient preferences and goals. In elderly patients the following questions need to be answered by the team in order to reach optimal treatment proposals (see Box 9.2) (Mohanty 2016):
