Geriatric patients

[thrutheashes]

Hey everyone. I had a call today...ok, a transfer today....that got me thinking.

Was was 92yoF query Abdo obstruction, going from a small tertiary care centre to a major facility for a surgical consult. All in all patient was in relatively good shape, only major exception being the pace maker implanted in the summer. That said the patient was in reasonable shape...for a 92year old. Her hearing was going, definite 1 person+ assist to ambulate, even with a walker. And this was before the questionable blockage. Cognitively she was ok, but according to daughter starting to go.This is the part that got me thinking.

I got into EMS in order to help people, and I love my job. However I couldn't top myself from feeling horrible for this poor patient. Here she is, 92 years old, living in a nursing home, going to see a surgeon for invasive surgery. I know we can't, nor should we, deny the patient the care. But are we really helping her? Or as a medical community have we become so driven to preserve life at all costs, damn the consequences? All of that being said, let me play devil's advocate. We decide to reduce the surgcal interventions in seniors for the "good of the patients". How does medicine decide who they will help? Age? Weight? Predisposition to medical problems? Or previous medical problems? Or how about, better yet, social standing?

I'm probably going to get called out on this thread, however I needed to vent, because, for whatever reason, despite the many geriatric transfers I've done before, this one is kinda bugging me. I know there is no right answer to this topic. Or an easy answer. However I would appreciate any thoughts or feedback anyone has.

Thanks.

Thrutheashes

[Eydawn]

Here's the part you must keep in mind: The patient has a right to decide whether or not to pursue any intervention, no matter how old they may be. If she is cognitively still there, and can still get around with a walker (even needing an assist), and has chosen to go through with this surgery, neither you nor I nor any other person has a right to say "oh, this poor woman, she's just needlessly prolonging her existence in a nursing home." Empathise with the pain she is about to go through, but do not judge her decision. If she is still her own guardian, she had to consent to the surgery; if she is not, one can hope that the POA abides by her wishes (which many times, most do in my experience).

Quality of life is determined by the person living it, not by anyone around them. Even in the meanest of existence, in the darkest pits of dementia, with the most severe chronic illness there is still a value to life. This is why we do not perform euthanasia in Western medicine. I speak from a lot of geriatric experience- I work in a long term care ("unskilled", supposedly) facility with a locked dementia wing.

The decision about who to perform surgery on is a complex one; surgery is much more dangerous and much more likely to result in compromised quality of life in the more elderly patient, therefore other techniques of management will probably be preferentially tried first. I personally think that many of our elderly are over-medicated, which causes so many associated needless problems.

As far as her being cognitively "starting to go" making you think, realize that dementia follows a different rate and track for almost every person who experiences it. If she is just beginning to suffer from short term memory loss and some confusion, she's got a LONG way to go before she hits full blown dementia, and at her age will probably die before reaching that point. Also, "starting to go" may mean something totally different to her daughter than it does to the staff who work with her on a daily basis... so bear in mind that is a very subjective description.

Wendy

CO EMT-B

[thrutheashes]

I just want to say for the record that I do not support euthinasia, and I also know that if my own elderly family were involved I would hope to have everything possible done for them. The transfer yesterday just had me thinking from the other side. How much care is too much? Etc. Just food for thought.

Thrutheashes

[HERBIE1]

If we recall, this topic came up during Obamacare talk. Death panels, denying of care, determining cost effectiveness of treatment, medications, and treatments, etc. I understand and agree with your concerns.

Major surgery on a 92 year old patient? Really? To what benefit for the patient- an extra 6 months- maybe? How does it affect their quality of life- if at all?

Just because we CAN do something, does that automatically mean we SHOULD? Think about extended care and ventilator patients. With our technology we can now keep someone "alive" for a long time- even though there may be no hope for any meaningful recovery, much less independent living.

Who gets to decide what is appropriate/cost effective/worthwhile? Tough questions, indeed.

[fakingpatience]

Major surgery on a 92 year old patient? Really? To what benefit for the patient- an extra 6 months- maybe? How does it affect their quality of life- if at all?

Just because we CAN do something, does that automatically mean we SHOULD? Think about extended care and ventilator patients. With our technology we can now keep someone "alive" for a long time- even though there may be no hope for any meaningful recovery, much less independent living.

Who gets to decide what is appropriate/cost effective/worthwhile? Tough questions, indeed.

Sometimes the surgery, though risky, will actually greatly increase the pt's quality of life. Take for example the elderly person who breaks their hip who has a cardiac hx. The surgery would be risky, and chances for survival are slim, but their options are living the rest of their life in a bed in a nursing home, unable to move, or attempting the surgery, and have a much better quality of life if the surgery is successful. I don' t think there is a blanket answer to the question of care for the elderly, it is entirely case by case.