Almost a third of people undergo an operation in their last year of life, many for serious conditions like cancer or bowel obstruction. For some, these surgeries can lessen symptoms or prolong life. For others, choosing surgery means spending their last weeks or months in a hospital or nursing home. But many people may not be aware of the risks that undergoing surgery at this point in their lives can have – which may mean some aren't making the choice that best suits them when faced with the decision.
Getting older makes surgery more hazardous. This is largely because as we get older, frailty increases – meaning our body's systems gradually lose their ability to function well, and it may become more difficult for us to recover from illness or surgery. Research shows frailty is associated with poorer outcomes after many types of surgery – especially emergency abdominal surgery.
Many health systems already have protocols in place to ensure that elective surgeries (such as a hip replacement) have the greatest chance of success in older people. This includes assessing frailty and other risk factors, and modifying them before surgery – such as having patients improve their diet, or adjusting medications that may be harmful (like blood thinners).
Elective surgeries also give people time to choose a hospital and a surgeon who will best meet their needs and to plan ahead for their recovery. There's also time to carefully consider whether or not to have an operation, and to fully understand the benefits and trade-offs.
Unfortunately, surgery often happens as an emergency – especially for abdominal problems, such as bowel obstruction or diverticulitis. Not only is emergency surgery more dangerous, more than half of people having emergency abdominal surgery are over 65.
The risk of complications from emergency abdominal surgery for over-65s are double those of younger people – with research even suggesting over-65s have a 20% chance of dying within 90 days of the operation. This is why emergency abdominal surgery is among the most risky procedures performed for over-65s.
Risk of death after emergency abdominal surgery is a major concern – especially because of severe infections that may occur. But loss of independence is also a frequent outcome for patients, and may be another thing to consider.
Our research shows that most patients over 65 have a greater chance of being discharged to a nursing home following emergency abdominal surgery than of dying in hospital. Long hospital stays are common too, and half of over-80s die or require nursing home admission after an emergency abdominal operation. Unplanned nursing home admission usually signals loss of independence and increasing frailty.
But in an emergency, there's no time to modify risks or look for better care – and sometimes the person is too ill to truly participate in shared decision making. This is why it's important for patients to know the risks, and to already have a decision made before the situation happens.
Of course, many conditions require emergency abdominal surgery to alleviate symptoms or extend a person's lifespan. But in some cases – such as for people with advanced cancer – this type of operation may have little chance of success, and may merely represent end-of-life care. In this situation, some older people may decide not to have an operation in order to prioritise quality of life or independence.
Improving risks
There are many things that can be improved to ensure emergency abdominal surgery doesn't carry as many risks for older adults. This include public health systems improving care before and during surgery, and offering better access to rehabilitation services both in-hospital and at-home. Access to specialist care can also reduce the risk of death and disability in older people undergoing emergency abdominal surgery.
There are also things older people can do for themselves to ensure they recover well after an emergency surgery. This includes staying healthy and active, and getting on top of existing medical problems. If an emergency operation happens, get up and walk as soon as possible after surgery, with help if needed. Getting moving after surgery reduces muscle wasting, improves independence and shortens the duration of hospitalisation – all factors that improve outcomes.
Thinking ahead about how best to respond to health emergencies and discussing preferences with family members is important. Surgery can sometimes prolong life, but it doesn't always improve quality of life. Saying no to an operation in an emergency is hard. But knowing your risk, and sharing your priorities with loved ones and your doctors before an emergency happens helps everyone make better decisions in the moment.
This article was originally published on The Conversation on 3 August 2021.
Deborah McNamara is a Consultant General and Colorectal Surgeon at Beaumont Hospital, Dublin; Clinical Professor in Surgery and member of Council at RCSI; and Co-Lead of the National Clinical Programme for Surgery.
RCSI is committed to achieving a better and more sustainable future through the UN Sustainable Development Goals.
