Palliverse is lucky to have a guest submission from rural General Practitioner (GP) Jonathan Ramachenderan, who reflects here on his role as a GP Anaesthetist, with an interest in aged care and palliative care. (He is currently undertaking further training in palliative medicine.) By luck, his post about peri-operative advance care planning (ACP) coincides with World Anaesthesia Day (16th October) and this year’s theme in Australia and New Zealand is “Anaesthesia and Ageing.”

“There is a real chance that your mum will not survive this operation” I said frankly to Sue.*

Her expression changed immediately to one of disbelief and she replied “What do you mean?!”

“The surgeon said to me that all mum needed was to have her hip fixed and then she would be fine to return back home to the village…I really thought she’d be home pretty soon, I wasn’t expecting you to say this.”

Patiently and well-practiced I said “I am sorry to tell you this but….”

Just then our surgeon burst into our little meeting room (the medication room on the ward). He was smiling, diffusing any thought that I had that I was delaying the operation by talking at length with Ingrid’s daughter.

Sue turned to him and said, “You didn’t tell me that mum may die during or after this operation.”

Her question caught him off guard and his expression changed rapidly to one of seriousness mixed with concern. “Jonathan is right, there is a chance your mum may not leave hospital even after we repair her hip fracture. Given her age, medical issues and frail state, her chances of returning home are significantly reduced”.

This changed the tone of the meeting as it brought into view the real implication of Ingrid undergoing this operation.

The conversation that followed was an important discussion about Ingrid’s stated end of life wishes and how this related to the specific complications of having her hip fracture repaired. Ingrid, aged 85 years old, had importantly completed an Advance Health Directive 3 years earlier with her GP, when she had begun to notice subtle changes in her memory and wanted to make sure her end of life wishes were known. Since then her mobility, general health and memory had declined, which led her to move into a “low level care” village environment, which had revived her zest and enthusiasm for life with the many interesting people and activities. She had suffered a mild heart attack a few years earlier and her breathlessness had recently restricted her movement to only around the house. But a sudden change of direction in the shower had caused her to slip and fall heavily, breaking her right hip.  Standing in that cool medication room on the busy ward, Sue understood the true impact of her mother’s accident and the implications of the proposed operative management.

We took our conversation to Ingrid’s bedside where we further explored the specific complications and implications of having her hip surgery. Sue described “wanting everything to be done” to help her mum survive but her mum’s Advance Health Directive was very specific about not wanting intubation and ventilation in Intensive Care nor any cardiopulmonary resuscitation in the event of a cardiovascular collapse. Ingrid solidified this thought by telling us that she did not want to be sent to Perth (the capital city, 400km away) for treatment under any circumstances.

The intersection of shared interests

This conservation went well because as a rural GP I am blessed to wear several different hats in the retirement capital of Western Australia  Within my anaesthetic work, my objectives are resuscitation, life preservation, and everything associated with the acute life support mnemonic “Airway, Breathing, Circulation”! But equally as important is my palliative and aged care work, where the objective is goal directed end of life medicine, comfort care and symptom control. Whilst these two specialties sit on opposite ends of  the practice of medicine, they both share an intense focus on patient care and the delivery of comfort through symptom control. Being a rural GP has allowed me to appreciate both these sides of patient care and bring attention to the need to engage in end of life planning for certain aged, chronically unwell and palliative care patients undergoing major and emergency surgery.

Perioperative advance care planning

This is not a new issue but formalising the process of perioperative advance care planning has become increasingly important as our population ages and are undergoing major operative procedures later in life. Having a formal process helps to match family expectations, with a patient’s end of life wishes together with their functional and medical status. Most importantly it allows every hospital team member during a patient’s operative journey, to be aware of the goals of treatment but also the limits of care and comfort measures to be applied. It certainly does not mean that appropriate due diligence in preoperative assessment, intraoperative care and post-operative management are not performed but are done so with very clear shared goals. I believe it would be irresponsible for any older patient with multiple comorbidities or frailty or with terminal illness to undergo any major operative procedure without a discussion about clear goals of care, related to their end of life wishes.

Providing a signed not-for resuscitation order does not dignify this precious end of life discussion, which allows patients and their families to make informed decisions about managing the risks and complications of surgery.

Around Ingrid’s bedside, we understood that fixing her fracture would bring her much relief of her pain but solemnly Ingrid was clear that she had lived well and did not want to be resuscitated in the event of a cardiovascular collapse. Together as a team we decided to proceed but understanding that if Ingrid were to suffer a complication during or after her surgery, we would offer her palliation. As I drifted her off to sleep with a gentle dose of induction agent, I believe that she was at peace with her decision. Her family were well informed and that our team in theatre were confident to manage any complications and ensure Ingrid’s comfort and dignity under anaesthesia. As our surgical patient population ages, they present an increasingly complex array of medical concerns and end of life issues that we must consider before undergoing any major surgical procedures. Specific advance care planning must be undertaken to place value on a patient’s end of life wishes as they relate to the risk and complications of major surgery. Ingrid recovered well post operatively but her rehabilitation was slow and she returned home with higher care needs.
 

*patient names and details have been changed