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When not to operate

Folke Hammarqvist

By earlier definition a geriatric person and soon a non operating surgeon

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Nothing to disclose

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Do no further harm – Alleviate, comfort and cure

Hippocrates (440 B.C.)

In the oath, the physician pledges to

  • prescribe only beneficial treatments, according to his/her abilities and judgment
  • to refrain from causing harm or hurt
  • and to live an exemplary personal and professional life

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Revised versions

  • I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or chemist’s drug

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To operate, or not to operate:

that is the question

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How to orientate and avoid running aground

Crystal-bowl and compass

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Decision making – a complex process�

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Decision making - Almost as complex as the underground in Tokyo

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Historical perspective

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Herbert Olivecrona – �The Father of Swedish Neurosurgery

Bild på Herbert Olivenkrona

Lennart Nilsson

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Old attitude – ”Stereotypic�Eminence based”

  • When in doubt – cut it out
  • Open and air the abdomen (lufta buken)
  • Operation on vital indication
  • ”No-one remembers a coward”
  • You must dare
  • We must practice and improve our skills

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  • Very often decisions were taken ”above” the patient

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Emergency Abdomen

  • All who have much experience of the acute abdomen will probably agree that early diagnosis is exceptional

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          • Sir Zachary Cope (1881 – 1974)
          • Early diagnosis of the Acute abdomen 1921

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And then – all of a sudden

?

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And then – all of a sudden

The Beatles and Godfrey Hounsfield

EMI

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Modern attitude

  • Team
  • Involve the patient and relatives
  • A lots of alternatives
  • Very good tools for diagnosis
  • Good tools for risk assessments

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  • Hopefully ”more evidence – than eminence”

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When not to operate

No indication

Other alternatives

are better

Severely increased risk and only

microscopic benefits

Ethical ”contraindications”

Restrictions in treatment

End of life/terminal disease

Severe dementia

Non-beneficial

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But first of all – The patients wish to be operated�or the opposite �

    • Provided that the patient and relatives have been informed about the consequences

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No indication

  • Hopefully obvious for everyone

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  • For example: there is no indication to operate a flue

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Non-beneficial surgery

  • No standard definition for ”non-beneficial surgery” / ”non-beneficial treatement”
  • Original definition was patient not surviving to hospital discharge after surgery , more recently failure to survive 48 hours, 3 days, 5 days has also been used
  • Non-beneficial surgery may end up in an even worse situation for the patient.

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The problem – We know first afterwards if it was non-therapeutic/beneficial

  • It is always easier to reflect over the process and result in the rearview-mirror

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  • However. There are signs that we should identify and take into account

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Another rearveiw-mirror point

  • If either the surgeon or the patient regret the decision for surgery
  • Complications

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Severely increased risks compared to possbile benefits

    • Related to the surgical procedure
    • Related to anaesthesia
    • Serious surgical diagnosis and high risk
    • Assessment of risk
      • ASA
      • NSQIP / POSSUM
      • Frailty score

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When to not operate – in following conditions

  • Advanced carcinosis and bowel obstruction
  • Severe comorbidity
  • Severe surgical condition
    • Ruptured AAA
    • Mesenterial ischemia
  • Malignancy in patients with dementia
  • Gastrointestinal bleeding in patientes with severe dementia
  • Malignancy in elderly patients
    • (when the patient is expected to die from a co-morbidity)

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When alternatives are better

    • Drainage
    • Antibiotics
    • Expectance – watchful waiting
    • Postponed surgery

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    • Endoscopic procedures
    • Endoluminal procedures/ angio

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Ethics

  • Do no further harm
  • Tradition
  • Religion
  • The patients whish
  • Conflicts

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SMER – Statens Medicinetiska Råd�The Medical Ethical Council

  • Improved ”routines” since 2018 regarding restrictions in treatment and ethics

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Often decisions about not to operate is linked to ”End of life discussions”

  • Scaring?
  • Needs training
  • Backup from the colleagues
  • Not a ”quick-fix”
  • Continuous information

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Restriction in treatment

  • End of life
  • Terminal disease
  • High age
  • Frailty
  • Severe dementia

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Ethics and decisions in stressed situations

Diversity and ethics in trauma and acute care surgery teams: results from an international survey

Lorenzo Cobianchi et al

W Journal of Emergency Surgery (2022) 17:44

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Questionaire 402 trauma and emergency surgeons from 72 Countries

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Ethics and decisions in stressed situations

Ethics influences the decisions

Diversity is a main topic among the surgical communities

Importance of ethical discussions and education

The team and the leader

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MDT’s

  • Decision that the patient has a disease stage that is not cured by surgery
  • Decision that the patient is to frail and/or has severe co-morbidity
  • Decision that there are other contraindications to surgery

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  • But - without having the summarized picture, and desicions are made based on what is written in the patients file.

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Old person/patient and frailty

Dr Jugdeep Dhesi will reveiw this topic

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Elderly and surgery

  • 1/3 of older patients undergo surgery in their last year of life
  • 18% in their last month of life
  • Most people express a wish not to die in hospital – yet man will, often after invasive treatment and surgery, carried out on patients sometimes at the expense of dignity

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Kwok AC, Semel ME, Lipsitz SR, et al (2011) The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet 378:1408–1413

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ERAS Emergency Laparotomy�Guideline part 3 - 2022

  • If possible MDT’s or at least decision involving experienced clinicians
  • Decisions should be clearly documented.
  • Goals of care should be included
  • Staff should have training in palliative care conversation and basic end of life management

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  • Emergency laparotomy studies and databases should include ”No-lap” population.
  • Cultural, religious differences has to be taken into account and should be included in research
  • BRAIN methodology (Benefits, Risks, Alternatives, Intuition or Nothing) or best/worst case scenario

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LÖF – Behandlingsrekommendationer för den sköra äldre patienten vid akut laparotomi - 2022��Recommendations for treatment of the fragile old patient undergoing emergency laparotomy

  • Lovisa Strömmer - surgeon
  • Pelle Gustafson - LÖF
  • Peter Bartelmess - surgeon
  • Karol Biegus -geriatrician
  • Lina de Geer - anesthetist
  • Anne Ekdahl - geriatrician
  • Marja Lindqvist - anesthetist
  • Anna Ohlsson – anesthetist
  • Andreas Wiklund - anesthetist

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When not to operate – Based on

Ethical principles

Non-beneficial

Risk - assessment

Patients wish

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Try to aviod complicated situations

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NELA – �National Emergency Laparotomy Audit

  • A large proportion of older patients undergo emergency surgery
    • Median age 67
    • Age > 65
      • Worse clinical outcome
      • Increased LOS (15.2 versus 11.3 days)
      • Increased 30- and 90 day mortality (15.3 vs 4.9 and 20.4 vs 7.3%)

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  • Fowler AJ, Abbott TEF, Prowle J, et al. Age of patients undergoing surgery. Br J Surg. 2019;106(8):1012-8.20.4

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Frailty

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Non-Frail

Frail

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Background for discussion

  • Palliative care in surgical training
  • Serious Illness Conversations Guide – structured communication framework for older patients requiring emergency surgery
  • Objective mortiality scores and frailty score can support the conversation
  • SDM (Shared decision making) is challenging in patients with pain and acute physiologcal deterioration
  • Less time to develop at clinician patient/relative relationship

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Background

  • 2/3 of older patients undergoing Emergency Laparotomy had baseline palliative care needs before surgery
  • Poor communication between surgeons, patients and relatives may lead to non-beneficial procedures
  • Communication about end-of-life issues increases the patiens distress
  • The surgeon does not always know the patient from before, fails to provide enough information about progonosis and allow apporpriate decisions.

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  • Complex situation with a patient in pain and distress, rapid deterioration and relatives that may have specific aspects.
  • Lack of confidence in talking to patients and relatives about withdrawal of therapy and palliative care
  • Older patients undergoing emergency surery often receive poor quality end of life care

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Likhet mellan världsidrottaren och den mycket svårt sjuka patienten

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Impact of surgery on functional status

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Severe co-morbidities

  • COPD
  • Cardiac failure
  • Dementia

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The patients wish

  • Either a patient
    • With exacerbation of chronic abdominal pain – that now can’t stand the situation expressing, I’ll do anything for an operation, I’ll rather die

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    • That absolutely don’t want to be operated

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ACS/NSQIP�American College of Surgeons�National Surgical Quality Improvement Project

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Indications for surgery

In patients with increased risks the indication for surgery needs to be strong

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Decision making

  • Elective
    • Stable conditions
    • Time for investigation
    • Risks are identified
    • Time for optimization
      • ”Prehabilitation”
    • MDT – Second opinion
    • Patient is prepared physiologically and mentally
    • Proper time to inform patients and relatives
    • The team is prepared
    • The stress response can be blocked and minimized.
    • Scheduled operation
  • Emergency
    • Unstable
    • Limited time for investigation and desicion
    • Risks may be unknown
    • Limited time for optimization
    • No MDT
    • Limited time to prepare and inform the patient and relatives
    • Other ongoing operations, not always optimal scheduling
    • The stressrespons, inflammation, infections has already started and might have an impact on physiology

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Klinisk bedömning / bedside

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Frailty

  • Contributes to negative outcome after surgery
  • NELA 20% of patients had a CFS (Clinical Frailty Score) 5-7
  • Associated with increased mortality, complications and LOS

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References

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Background III Risk assessment

  • Estimate mortality or complications at 30 days on a population basis
  • Should only be used as a part of overall assessent
  • NELA risk predictor (emergency laparotomy) (Ref 174)
  • POTTER (Predictive Optimal Trees in Emergency Surgery) in patients undergoing EGS (175)
  • Frailty independent association for mortality
  • NELA risk score combined with modified frailty (mFI) and nutritional state, good predictor of mortality

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Background IV – ”No-lap” patient group

  • NELA (National Emergency Laparotomy Audit)
  • PELA (Perth Emergency Laparotomy Audit)
    • 43% of patients did not undergo surgery
  • ”No-lap” patients should also be discussed at M&M