Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_827_Библиотеки_им_академика_М_И_Перельмана
.pdf
204 M.F. Perkal
https://t.me/med1917
usually develops slowly. In delirium, the ability to attend is
primarily affected. In early stages of dementia, memory
rather than attention is affected, although in late stages attention may be severely impaired.
Delirium is best treated by addressing the underlying
cause (i.e., a urinary tract infection, dehydration, or untreated
pain). Multicomponent nonpharmocologic interventions are
effective and should be utilized first [65]. These include frequent reorientation with voice, calendars, and clocks, maintaining a quiet calm environment, eliminating the use of
restraints, having familiar objects in the room, and ensuring
that the patient has the use of assistive devices (glasses and
hearing aids). Pharmacologic therapy should be saved for
those patients who are suffering from agitation and hallucinations. Haloperidol starting at low doses (0.5–1.0 mg) is the
first line of therapy. It is fast acting and can be administered
orally, intramuscularly, or intravenously.
Adverse Drug Reactions
Management of many different symptoms creates an
additional burden for clinicians who must also be vigilant for
adverse drug reactions and interactions resulting from polypharmacy. Adverse drug reactions are more frequent and
severe in the elderly population [66]. Elderly people may be
more susceptible to adverse drug reactions because of agerelated changes in body composition, metabolic rate, hepatic
mass, blood flow, and glomerular filtration rate which affect
how the body absorbs, distributes, and eliminates exogenous
chemicals. For example, antibiotics commonly cause gastrointestinal side effects including nausea and antibioticassociated diarrhea. Antibiotic-associated diarrhea has an
incidence ranging between 2 and 25%. However, in older
patients, the incidence of positive assays for Clostridium
difficle toxin can be 20–100 times more frequent than in
those 10–20 years of age [67]. Another example of the effect
of age on adverse drug reactions is with the use of nonsteroidal anti-inflammatory drugs. Perforated peptic ulcer disease
secondary to the use of nonsteroidal anti-inflammatory drugs
in patients over 65
people [68]. However, in order to avoid inadequate symptom
management, it is more important for clinicians to monitor
for the occurrence of adverse effects rather than withhold
medications to avoid these potential side effects.
years is statistically higher than in younger
Prognosis
Understanding prognosis is particularly important in older
patients because it can be the key piece of information
affecting how the individual makes decisions. In addition,
miscommunication about prognosis in older patients often
occurs [69]. Even though predictive models can result in
an accurate survival curve for a large group of people with
various conditions such as organ failure and cancer, these
models cannot accurately predict prognosis for individual
patients [83, 84]. This becomes even more complicated in
geriatric patients, who may have multiple illnesses, making it even more difficult to predict the ultimate cause and
timing of death [8].
The National Hospice and Palliative Care Organization
(NHPCO) guidelines for noncancer diagnoses were published
in 1996 [70] as an attempt to help clinicians decide when it was
appropriate to refer patients for hospice care based on a prediction of less than 6 months survival. The committee developing
the guidelines used the best medical evidence at the time to
establish clinical prognostic indicators. Hospice programs
across the country have adopted these guidelines at the time of
referral into the admission process to decide if the patient meets
reimbursement criteria under the Medicare hospice benefit.
Insurers have similarly adopted most aspects of the guidelines
as criteria to use for determining payment eligibility. However,
since 1996 many quality research projects looking at the validity
of these prognostic criteria have shown that the disease-specific
NHPCO guidelines are not accurate in determining whether a
patient with end-stage heart or lung disease or dementia will
survive more or less than 6
failure and chronic end-stage pulmonary disease have unpredictable disease trajectories. In addition, advances in medication
and device therapies have changed the prognostic factors used
in the NHPCO guidelines [70]. The palliative performance scale
(Table 16.3) is a reliable and valid tool that correlates well with
actual survival and median survival for a heterogeneous group
of palliative care patients and may present more accurate
information than individual disease prognoses [71–73].
months. For example, both heart
Advance Directives
Advance directives, referred to as living wills, are applicable
when individuals are terminally ill and unable to make their
wishes known. Advance directives authorize another individual to execute a treatment directive that specifies which lifesustaining procedures would be “offensive and unwanted”
and are based on the Congressional Uniform Rights of the
Terminally Ill [74]. Another form of advance directive is the
durable power of attorney for health care. A person can
appoint another individual to make medical decisions. This
delegation of authority over health care decisions becomes
effective when individuals are incompetent to make decisions
for themselves. Since a primary goal of palliative medicine is
patient centered care, determining the patient’s ability to make
decisions is fundamental to respecting their true wishes.
20516 Palliative Care and Decision Making at the End of Life
https://t.me/med1917
Ta b l e 16.3 Palliative performance scale
Estimated median
Percentage Ambulation
100
90 Full Normal
80 Full Normal with effort
70 Reduced Cannot do normal
60 Reduced Cannot do hobbies
50 Mainly sit/lie Cannot do any work
40 Mainly in bed As above Mainly
30 Bed bound As above Total care Reduced As above 8 5
20 Bed bound As above As above Minimal As above 4 2 6
10 Bed bound As above As above Mouth care only Drowsy or coma 1 1
0 Death – – – –
(a) Denotes survival postadmission to an inpatient palliative unit, all diagnoses
(b) Denotes days until inpatient death following admission to an acute hospice unit, diagnoses not specified
(c) Denotes survival postadmission to an inpatient palliative unit, cancer patients only
Source: Reprinted with permission from [71]
Full Normal
Activity level
Evidence of disease Self-care Intake
Full Normal Full N/A N/A 108
No disease
Full Normal Full
Some disease
Some disease
job or work
Some disease
or housework
Significant disease
Extensive disease
Full Normal
Full As above Full 145
Occasional assistance
needed
Considerable
assistance needed
assistance
or reduced
As above Full or confusion 29 4
As above Full or confusion 30 11 41
As above Full or drowsy
Level of
consciousness
Full
or confusion
survival in days
(a) (b) (c)
18 8
The distinction between competency and decision-making
capacity is important. Competency is a legal term in which an
individual retains their legal rights; decision-making capacity
is a medical determination, made for a particular situation and
at a particular point in time [2]. Capacity determinations are
based on four key aspects: a person’s ability to understand
the relevant information and the decision at hand, appreciate
the significance of the decision and relate it to his or her own
life, reason through the options and potential outcomes of a
decision, and make and articulate a choice [18]. In the elderly
with cognitive impairment, impairment of capacity may be
temporary as a result of delirium or depression. Even people
with dementia may still participate in their decision making.
One study showed that the majority of mildly to moderately
demented patients had acceptable decision-making capacity
[75]. In another study, 92% of patients with mild-to-moderate
dementia indicated that they wanted to be involved in their
treatment decisions, and the majority of caregivers supported
this [76].
When the patient lacks decisional capacity, a surrogate is
held to these same standards. A surrogate is asked to apply
substituted judgment, that is, promote the patient’s wishes
and express the beliefs that the patient holds. The surrogate
is encouraged to act as an advocate by being a voice for the
patient. The distinction of substituted judgment is important
not only to maintain the ethic of patient autonomy, but also
to avoid the burden of the question of deciding to end the
patient’s life. Instead, the surrogate can be the advocate for
the patient’s interests in avoiding prolonged suffering [2].
For a more complete discussion of decision-making capacity,
see Chap. 14.
Hospice
Current hospice care is modeled on patients who have diseases that are characterized by rapid declines in the ability to
care for oneself shortly before death. Hospice provides a
multidisciplinary team of professionals including physicians,
nurses, home health aides, chaplains, social workers, and
volunteers working in collaboration to provide for the needs
of the patient and family during the last stage of an illness.
The benefit includes care that can be provided in the home
setting, skilled nursing facility, or inpatient hospice unit.
Hospice provides symptom control, pain management, and
emotional and spiritual support expressly tailored to the
patient’s needs and wishes. Family members also receive
206 M.F. Perkal
https://t.me/med1917
support, caregiver training, and help coping with the loss of
their loved one.
Experts agree that hospice is most beneficial when provided for at least 3 months. NHPCO reports that the
median length of service was 26 days in 2005 with 30% of
people served by hospice in the USA dying in 7 days or
less. Furthermore, while eight out of ten Americans have
indicated they would prefer to spend their final days at
home, those who received hospice for 7 days or less were
more likely to be cared for outside of their homes. Families
who felt their dying loved ones were referred “too late” to
hospice care reported more unmet needs and lower satisfaction with the quality of care provided at the end of life.
One of the ten families (11.4%) indicated that hospice
care was not provided soon enough according to the
research recently published in the Journal of Pain and
Symptom Management. Inadequate symptom management, poor care coordination, and insufficient emotional
support were some of the problems associated with late
referrals [77].
The hospice Medicare benefit was introduced in the USA
in 1982. To qualify for the Medicare hospice benefit, a patient
must have Medicare and be terminally ill; the physician must
choose to receive hospice care reimbursement instead of the
standard Medicare benefits for the illness; and the care must
be provided by a Medicare-participating hospice program
[78]. Medicare reimbursement requires careful documentation and considers the patient to be terminally ill if one of the
following conditions applies [79]:
1. “The medical documentation meets the criteria in the
NHPCO prognosticating guidelines that the patient is ter-
minally ill (i.e., there is no conflicting or inconsistent
information in the record to suggest that the patient is not
terminally ill even though the guidelines are met).
2. The medical documentation in the record supports that
the patient is terminally ill even though the NHPCO
guidelines are not met or the patient’s condition is not
covered by the NHPCO guidelines.
3. The patient dies from the illness for which he or she
elected the hospice benefit.”
The hospice medical director or attending physician provide clinical documentation to support the certification of
terminal illness. Documentation may include results of tests
or narrative descriptions of the clinical indicators or progression of disease. The patient must have a prognosis of
6 months or less for most hospice programs, including those
under Medicare [80]. Unfortunately, older people dying with
progressive frailty are poorly suited to taking advantage of
this benefit because the course of their illness can be protracted beyond the 6-month limit and there is no clear point
where a rapid decrease in functional abilities predicts imminent death [15].
Communication and Establishing Goals
of Medical Care
One of the best ways to incorporate palliative care medicine and end-of-life issues into the care of the elderly
patient is with a systematic approach at the time of diagnosis or when planning surgical care. Formal advanced care
planning including a conversation regarding goals of treatment, living wills, power of attorney for health care decision making, surrogate decision making, and preferences
for life-support measures, such as cardiac resuscitation and
ventilator support, should be incorporated into the overall
care plan of every patient undergoing major surgery, particularly the elderly. A discussion of goals of care is a core
competency of geriatric medicine and palliative medicine,
and it should be one in surgical specialties as well. As the
burden of therapies increase, the patient’s wishes for therapy and outcome become more relevant. Patient preferences can and should be formulated into therapeutic goals,
for example, the desire to be discharged to home, surviving
to a particular event, being able to communicate and say
goodbye, or achieving a more rapid and certain death [2].
Once goals of care are established, they can be used to construct advance directives about specific care interventions,
such as cardiopulmonary resuscitation, ventilator support,
hospitalization, and appointment of a health care proxy. It
is in the initial phase of working with a patient and family
that the groundwork is laid for palliation and adherence to
a person’s goals and preferences [2]. Goodlin et al. [80]
developed a process to improve the medical care for the
very old. This involves clarifying and stating the goals of
care with the family and patient, documenting that plan on
the chart, and then carrying out that plan with careful attention to the patient’s symptoms (see Fig. 16.2). This same
process could apply to any surgeon and patient at any entry
point into the medical system.
With the increasing age of the population and more complicated treatment regimens, increased communication is
needed regarding disease trajectory, goals of care, and transitioning to an end of life setting. Patient’s families are more
likely to have overall satisfaction with their loved ones care
if they are regularly informed about the patient’s condition, if
they are provided with emotional support, if they are given
accurate information about the patient’s medical treatment,
and if they can identify one medical practioner as being in
charge of their loved one’s care [
tive care specialist, if available, could be an effective addition to the team in helping to negotiate patient-directed goals
of care and facilitate dialogue regarding the complex issues
surrounding care at the end of life. No matter who is in
charge, our goals should focus on what the Institute of
Medicine defines as a good death: “one who is free from
avoidable distress and suffering for patients, families, and
81]. The addition of a pallia-
20716 Palliative Care and Decision Making at the End of Life
All Patlents age 80 or
greater who are hospitalized,
in a nursing home, frail, or
likely to die within 1–2 years
Elicit the Patient’s Values
Review Medical status and Likely Course
Elicit the Pantient’s Preferences for Care
Clarify and make explicit the Goals of Care
(1 copy –> patient, 1 copy –> chart)
Plan Care with Patient and Others
Around: Symptoms
Functional and Self-Care Needs
Psychosocial Issues
Family Needs and Support
Spiritual/Existential lssues
Anticipatory Bereavement
Write Orders for Palliative Care
Address: Pain
Respiratory Symptoms
Food, Fluids, Mouth care
Bowel & Bladder management
Emotional & Spiritual Support
Family & Caregiver Support
Assess and Manage Symptoms:
Rate Symptoms, severity 0–4,
continually modify care plan as needed
After Death
Bereavement Support
https://t.me/med1917
Fi g u r e 16.2 A process diagram for improving care of dying patients
(from [7] Copyright © 1998 American Medical Association. All rights
reserved).
caregivers; in general accord with the patients’ and families’
wishes; and reasonably consistent with clinical, cultural, and
ethical standards” [82].
References
1. National Consensus Project for Quality Palliative Care (2009)
Clinical practice guidelines for quality palliative care, 2nd edn.
http://www.nationalconsensusproject.org2
2. Mularski RA, Osborne ML (2003) End of life in the critically ill
geriatric population. Crit Care Clin 19:789–810
3. Center for the Advancement of Palliative Care New Analysis
Shows Hospitals Continue to Implement Palliative Care Programs
at Rapid pace: New Medical Subspecialty Fills Gap for Aging
Population 2008.
http://www.capc.org/news-and-events/relaeases/
news-releases-4-14-08
4. Meyers FJ, Linder J (2003) Simultaneous care: disease
treatment and palliative care throughout illness. J Clin Oncol
21(7):1412–1415
5. Dunn GP (2001) The surgeon and palliative care: an evolving perspective. Surg Oncol Clin N Am 10(1):7–24
6. Adolph MD, Dunn GP (2009) Postgraduate palliative medicine
training for the surgeon: an update on ABMS subspecialty certification. Bull Am Coll Surg 94(2):6–13
7. Goodlin SJ, Winzelberg GS, Teno JM, Whedon M, Lynn J (1998)
Death in the hospital. Arch Intern Med 158(14):1570–1572
8. Goldstein NE, Morrison RS (2005) The intersection between geriatrics and palliative care: a call for a new research agenda. J Am
Geriatr Soc 53(9):1593–1598
9. Evers MM, Meier DE, Morrison RS (2002) Assessing differences
in care needs and service utilization in geriatric palliative care
patients. J Pain Symptom Manage 23:424–432
10. Wenger NS, Rosenfeld K (2001) Quality indicators for end of life
care in vulnerable elders. Ann Intern Med 135:677–685
11. Seymour J (2001) Palliative care and geriatric medicine: shared
concerns, shared challenges. Palliat Med 15:26–270
12. American Geriatrics Society Ethics Committee (1995) The care of
dying patients: a position statement from the American Geriatrics
Society. J Am Geriatr Soc 45:577–578
13. Piccirillo JF, Vlahiotis A, Barrett LB, Flood KL, Spitznage EL,
Steyerberg EW (2008) The changing prevalence of comorbidity
across the age spectrum. Crit Rev Oncol Hematol 67(2):124–132
14. Rockwood K, Fox RA, Stolee P, Roberston D (1994) Fraility in
elderly people: an evolving concept. Can Med Assoc J
150(4):489–495
15. Covinsky KE, Eng C, Lui LY, Sands LP, Yaffe K (2003) The last 2
years of life: functional trajectories of frail older people. J Am
Geriatr Soc 51(4):492–498
16. Ellershaw J, Ward C (2003) Care of the dying patient: the last hours
of life. BMJ 326:30–34
17. Sheehan DK, Schirm V (2003) End of life care of older adults:
debunking some common misconceptions about dying in old age.
Am J Nurs 103(11):48–58
18. Kapo J, Morrison LJ, Liao S (2007) Palliative care of the older
adult. J Palliat Med 10(1):185–209
19. Gibson MC, Schroder C (2001) The many faces of pain for older,
dying adults. Am J Hosp Palliat Care 18(1):19–25
20. Ferrell B (1995) Pain evaluation and management in the nursing
home. Ann Intern Med 123:681–687
21. Helme RD, Gibson SJ (2001) The epidemiology of pain in elderly
people. Clin Geriatr Med 17:417–431
22. Moss MS, Lawton MP, Glicksman A (1991) The role of pain in the
last year of life of older persons. J Gerontol 46(2):P51–P57
23. Desbiens NA, Mueller-Rizner N, Connors AF et al (1997) Pain in
the oldest-old during hospitalization and up to one year later. J Am
Geriatr Soc 45:1167–1172
24. Cleeland CS, Gonin R, Hatfield AK (1994) Pain and its treatment in
outpatients with metastatic disease. N Engl J Med 330:592–596
25. Herr K, Bjoro K, Decker S (2006) Tools for assessment of pain in
nonverbal older adults with dementia: a state of the science review.
J Pain Symptom Manage 31(2):170–192
26. Chibnall JT, Tait RC (2001) Pain assessment in cognitively impaired
and unimpaired older adults: a comparison of four scales. Pain
92:173–186
27. Taylor LJ, Harris J, Epps CD, Herr K (2005) Psychometric evaluation of selected pain intensity scales for use with cognitively
impaired and cognitively intact older adults. Rehabil Nurs
30:55–61
28. Krulewitch H, London MR, Skakel VJ, Lundstedt GJ, Thomason H,
Brummel-Smith K (2000) Assessment of pain in cognitively
208 M.F. Perkal
https://t.me/med1917
impaired older adults: a comparison of pain assessment tools and
their use by nonprofessional caregivers. J Am Geriatr Soc
48:1607–1611
29. Pautex S, Hermann F, LeLous P, Fabjan M, Michel JP, Gold G (2005)
Feasibility and reliability of four pain self-assessment scales and
correlation with an observational rating scale in hospitalized elderly
demented patients. J Gerontol A Biol Sci Med Sci 60:524–529
30. American Geriatrics Society panel on the Pharmacological
Management of Persistent Pain in Older Persons (2009)
Pharmacological management of persistent pain in older persons. J
Am Geriatr Soc 57(8):1331–1346
31. McCarthy D (1998) Nonsteroidal anti-inflammatory drug-related
gastrointestinal toxicity: definitions and epidemiology. Am J Med
105:3S–9S
32. Greenberger NJ (1997) Update in gastroenterology. Ann Intern
Med 127:827–834
33. Cheng HF, Harris RC (2005) Renal effects of non-steroidal antiinflammatory drugs and selective cyclo-oxygenase-2 inhibitors.
Curr Pharm Des 11:1795–1804
34. Abrahm JL (2003) Update in palliative medicine and end of life
care. Annu Rev Med 54:53–72
35. Indelicato RA, Portenoy RK (2002) Opioid rotation in the management of refractory cancer pain. J Clin Oncol 20:348–352
36. Gammaitoni AR, Fine P, Alvarez N, McPherson ML (2003) Clinical
applications of opioid equianalgesic data. Clin J Pain 198:286–297
37. Jacox A, Carr DB, Payne R et al (1994) Management of cancer
pain: clinical practice guideline No. 9. AHCPR pub 94-0592. US
Dept Health Hum Serv, Pub Health Serv, Rockville, MD
38. Mosenthal AC, Lee KF (2002) Management of dyspnea at the end
of life: relief for patients and surgeons. J Am Coll Surg
194(3):377–386
39. Ogle KS, Hopper K (2005) End of life care for older adults. Prim
Care 32(3):811–828
40. Thomas J, Karver S, Cooney GA, Chamberlain BH, Watt CK,
Slatkin NE, Stambler N, Kremer AB, Israel RJ (2008)
Methylnaltexone for opioid-induced constipation in advanced illness. N Engl J Med 358:2332–2343
41. Krouse RS, McCahill LE, Easson AM, Dunn GP (2002) When the
sun can set on an unoperated bowel obstruction: management of
malignant bowel obstruction. J Am Coll Surg 196(1):117–128
42. Marks WH, Perkal MF, Schwartz PE (1993) Percutaneous endoscopic gastrostomy for gastric decompression in metastatic gynecologic malignancies. Surg Gynecol Obstet 177:573–576
43. Janssens J, Peeters TL, Vantrappen G, Urbain JL, Roo MDe, Muls
E, Bouillon R (1990) Improvement of gastric emptying in diabetic
gastroparesis by erythromycin. N Engl J Med 322:1028–1031
44. Mercadente S, Caraceni A, Simonetti MJ (1993) Octreotide in
relieving gastrointestinal symptoms due to bowel obstruction.
Palliat Med 7:295–299
45. Dean A (2001) The palliative effects of octreotide in cancer patients.
Chemotherapy 47(2):54–61
46. Omram MI, Morley JE (2000) Assessment of protein energy malnutrition in older persons. Part 1: history, examination, body composition, and screening tools. Nutrition 16:131–140
47. Easson AM, Hinshaw DB, Johnson DL (2002) The role of tube
feeding and total parenteral nutrition in advanced illness. J Am Coll
Surg 194(2):225–228
48. Milne AC, Potter J, Avenell A (2002) Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane
Database Syst Rev (3): CD003288
49. MacDonald N, Easson AM, Mazurak VC, Dunn GP, Baracos VE
(2003) Understanding and managing cancer cachexia. J Am Coll
Surg 197(1):143–161
50. Onder G, Penninx BW, Balkrishnan R, Fried L, Chaves P,
Williamson J, Carter C, DiBari M, Guralnik J, Pahor M (2002)
Relation between use of angiotensin converting enzyme inhibitors
and muscle strength and physical function in older women: an
observational study. Lancet 359:926–930
51. Reuben DB, Hirsch SH, Zhou Z, Greendale GA (2005) The effects
of megestrol acetate suspension for elderly patients with reduced
appetite after hospitalization: a Phase II randomized clinical trial. J
Am Geriatr Soc 53(6):970–975
52. Oster MH, Enders SR, Samuels SJ et al (1994) Megestrol acetate in
patients with AIDS and cachexia. Ann Intern Med 121:400–408
53. Raney MS, Anding R, Fay V (2000) A pilot study to assess the use
of megestrol acetate to promote weight gain in frail elderly persons
residing in long-term care. J Am Med Dir Assoc 1:154–158
54. Amory JK, Chansky HA, Chansky KL, Camuso MR, Hoey CT,
Anawalt BD, Matsumoto AM, Brenner WJ (2002) Preopperative
supraphysiological testosterone in older men undergoing knee
replacement surgery. J Am Geriatr Soc 50:1698–1701
55. McCann RM, Hall WJ, Groth-Juncker A (1994) The appropriate
use of nutrition and hydration. JAMA 272(16):1263–1266
56. Billings JA (1985) Comfort measures for the terminally ill: is dehydration painful? J Am Geriatr Soc 33:808–810
57. Finucane TE, Christmas C, Travis K (1999) Tube feeding in patients
with advanced dementia. JAMA 282(14):1365–1370
58. Clay AS, Abernathy AP (2008) Total parenteral nutrition for
patients with advanced life-limiting cancer; decision making in the
face of conflicting evidence. Prog Palliat Care 16:69–77
59. Cole MG, Dendukuri N, McCusker J, Han L (2003) An empirical
study of different diagnostic criteria for delirium among elderly
inpatients. J Neuropsychiatry Clin Neurosci 15:200–207
60. Dyer CB, Ashton CM, Teasdale TA (1995) Postoperative delirium.
A review of 80 primary data-collection studies. Arch Intern Med
155:461–465
61. McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK
(2003) Delirium in the intensive care unit: occurrence and clinical
course in the intensive care unit. J Am Geriatr Soc 51:591–598
62. Casarett DJ, Inouye SK, American College of Physicians-American
Society of Internal Medicine End-of-Life Care Consensus Panel
(2001) Diagnosis and management of delirium near the end of life.
Ann Intern Med 135:32–40
63. Inouye SK (2006) Delirium in older persons. N Engl J Med
354:1157–1165
64. Inouye SK, van Dyck CH, Alessi CA (1990) Clarifying confusion:
the confusion assessment method: a new method for detection of
delirium. Ann Intern Med 113:941–948
65. Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L,
Acampora D, Holford TR, Cooney LM Jr (1999) A multicomponent intervention to prevent delirium in hospitalized older patients.
N Engl J Med 340:669–676
66. Tangiisuran B, Wright J, Van der Cammen T, Rajkumar C (2009)
Adverse drug reactions in the elderly: challenges in identification
and improving preventive strategies. Age Ageing 38(4):358–359
67. Bartlett JG (2002) Antibiotic-associated diarrhea. N Engl J Med
346:334–339
68. Collier DS, Pain JA (1985) Non-steroidal anti-inflammatory drugs
and peptic ulcer perforation. Gut 26:359–363
69. Fried TR, Bradley EH, O’Leary J (2003) Prognosis communication
in serious illness. Perceptions of older patients, caregivers, and clinicians. J Am Geriatr Soc 51:1398–1403
70. Standards and Accreditation Committee, Medical Guidelines Task
Force (1996) Medical guidelines for determining prognosis in
selected non-cancer diseases, 2nd edn. National Hospice and
Palliative Care Organization, Alexandria, VA
71. Wilner LS, Arnold R. The palliative performance scale (PPS). Fast
facts #125. November 2004. http://www.eperc.mcw.edu/fastfacts
72. Rickerson HJ, Carroll JT, McGrath J, Morales K, Kapo J, Casarett
D (2005) Is the palliative performance scale a useful predictor of
20916 Palliative Care and Decision Making at the End of Life
https://t.me/med1917
mortality in a heterogeneous hospice population? J Palliat Care
8(3):503–509
73. Lau F, Downing M, Lesperance M, Karlson N, Kuziemsky C, Yang
J (2009) Using the palliative performance scale to provide meaningful survival estimates. J Pain Symptom Manage 38(1):134–144
74. Congressional Research Service (1997) The right to die: constitutional and statutory analysis (97-244A). Library of Congress,
Washington, DC
75. Gabany JM (2000) Factors contributing to the quality of end of life
care. J Am Acad Nurse Pract 12(11):472–474
76. Moye J, Karel MJ, Azar AR, Gurrera RJ (2004) Capacity to
consent to treatment: empirical comparison of three instruments
in older adults with and without dementia. Gerontologist
44:166–175
77. Hirschman KB, Joyce CM, James BD, Xie SX, Karlawish JH
(2005) Do Alzheimer’s disease patients want to participate in
a treatment decision, and would their caregivers let them?
Gerontologist 45:381–388
78. Teno JM, Shu JE, Casarett D, Spence C, Rhodes R, Connor S (2007)
Timing of referral to hospice and quality of care: length of stay and
bereaved family member’s perceptions of the timing of hospice
referral. J Pain Symptom Manage 34(2):780–787
79. Marelli TM, Williams MA (2004) Hospice and palliative care handbook, 2nd edn. Mosby, FL, p 71
80. Goodlin SJ, Fisher E, Patterson JW, Wasson J (1998) End of life
care for persons age 80 years or older. J Ambul Care Manage
21(3):34–39
81. Rhodes RL, Mitchell SL, Miller SC, Connor SR, Teno JM (2008)
Bereaved family members’ evaluation of hospice care: overall satisfaction with services? J Pain Symptom Manage 35(4):365–371
82. Field MJ, Cassell CK (eds) (1997) Approaching death: improving
care at the end of life. National Academy Press, Washington, DC
83. Reisfield GM, Wilson GR. Prognostication in heart failure. Fast fact
#143. October 2005.
84. Childers JW, Arnold B, Curtis JR. Prognosis in end-stage COPD.
Fast facts #141. August 2005.
http://www.eperc.mcw.edu/fastfacts
http://www.eperc.mcw.edu/fastfacts
https://t.me/med1917
Chapter 17
https://t.me/med1917
Surgery in Centenarians
Mark R. Katlic
Ninety years is old, but 100 is news.
– Belle Boone Beard [1]
The 100th anniversary of an individual’s birth still bestows
an aura, a mystique, as the centenarian is as close to immortality as a human can be. This special prestige has been
afforded the imprimatur of scientific study by Baker [
found that centenarians represented a striking exception to
the inverted U curve of status across the life-span in Western
culture. Baker’s data, derived from factorial survey analysis,
fit the postulate that there is an “American arc of life” that
gives maximum prestige to middle age and least prestige to
young and old persons. Centenarians, however, were given
unique status nearly equal to that of middle-aged individuals
(Fig. 17.1), because “like four leaf clovers or quintuplets,
centenarians are rare.”
Even those who care for centenarians are affected.
Nishikawa [3] found that family members who care for centenarians had a lower accumulated fatigue level, despite
being older themselves and despite their subjects’ worse performance status, than those who cared for individuals aged
70–90 years. Webb and Williams described a case of acute
tenosynovitis of the right wrist and hand (centenarian hand
syndrome) resulting from the congratulatory handshakes of
many friends and relatives on a man’s 100th birthday [4].
We have an inherent curiosity about our oldest old. What
does he eat? What is her secret? Can it be bottled and sold?
Decades ago one entrepreneur, Dr. Marie Davenport, became
a professional centenarian, offering to teach her secrets of
longevity to others for a fee [
presumed oldest person when she died at 122 years, was
interviewed weekly by the foreign press who sought her out
in Arles, France [5]. In 1997, a popular magazine devoted its
cover story to “How to Live to 100” [6].
M.R. Katlic (*)
Division of Thoracic Surgery,
Director, Regional Ambulatory Campus Geisinger Wyoming Valley
Medical Center, Wilkes-Barre, PA, USA
e-mail: mrkatlic@geisinger.edu
1]. Jeanne Calment, the world’s
2], who
The mystique may wane, however, as more of us reach this
milestone. The present paucity of centenarians results from
high mortality rates and a much smaller overall
century ago. Over the past 40–50 years the number of centenarians has nearly doubled every decade, owing chiefly to
improved survival from the age of 80–100 years [7]. When
Beard began her monumental, sedulous study of centenarians
in 1940, there were 3,700 possible subjects living in the
United States; when she ended it during the late 1970s there
were at least 14,000 [8]. This number had reached 50,000 by
the year 2000 [9], and may be over 200,000 in 2020, and
500,000 to 4 million in 2050 [10]. Some authors argue that
even these projections are too conservative because they discount the possibility of future baby booms and assume slow
rates of mortality decline and low levels of immigration [11].
Vaupel and Gowan calculated that if mortality is reduced 2%
per year, by the year 2080, the number of centenarians in the
United States would approach 19 million [12].
Surgical problems do not end on a person’s centennial.
Surgeons will become increasingly familiar with these most
senior citizens.
population a
History
Surgeons have written with increasing frequency about operations in the elderly, but the definition of “elderly” has
changed. A report in 1907 listed 167 operations performed
on patients older than 50 years [13], and even 20 years later
Ochsner taught that “an elective operation for inguinal hernia in a patient older than 50 years was not justified” [14].
Brooks used a limit of 70 years as “advanced age” in his
series of 293 operations reported in 1937 [15], and over
the next few decades most authors considered patients above
age 60–70 years to be elderly. More recent studies show
that good results can be expected in octogenarians and
R.A. Rosenthal et al. (eds.), Principles and Practice of Geriatric Surgery,
DOI 10.1007/978-1-4419-6999-6_17, © Springer Science+Business Media, LLC 2011
211
212 M.R. Katlic
4.5
4.0
3.5
3.0
2.5
P
E
R
C
E
I
V
E
D
S
T
A
T
U
S
2.0
1.5
1.0
0.5
01020304050
AGE OF TARGET INDIVIDUAL
.men;Perceived status by age and sex of target individual . women). (
60 70 80 90 100 110
https://t.me/med1917
Fi g u r e 17.1 Perceived status by
age and sex of target individual.
Triangles, men; squares, women.
(Reprinted with permission from
Baker [
2]).
nonagenarians [16, 17], even in those undergoing complex
vascular [18, 19], cardiac [20], and cancer operations [21].
An occasional centenarian is included in these series,
but most papers devoted to centenarians per se are case
reports, some written 40 years ago. Welch and Whittemore
[22] in 1954 presented a 100-year-old woman who recovered well from abdominoperineal resection of the rectum
for carcinoma. The next year Maycock and Burns [23] discussed prostate surgery in two patents in this age group,
and in 1957 Childress [24] successfully treated three femoral fractures under spinal anesthesia. In 1971, isolated cases
of pacemaker placement [25] and below-knee amputation
[26] were reported. A basket-size ovarian leiomyoma was
excised from a 103-year-old woman because of bowel
obstruction in 1979, allowing her to live at least two additional years [
27]. Six patients aged 100–106 underwent
pacemaker procedures with good results in the 1989 report
of Cobler et al. [28].
During the 1990s greater numbers of patients were
reported. There were three deaths (12.5% mortality) in
McCann and Smith’s series of 24 patients undergoing a variety of operations, such as colon resection, ruptured aortic
aneurysm repair, and hip prosthesis placement [29]. Cogbill’s
1992 series of 16 patients reported perioperative mortality of
6% and a 1-year survival of 69% after a variety of small
operations [30].
In 1998, Warner [31] reported 42 procedures in 31 patients
aged 100–107 years. There was one major complication
Fi g u r e 17.2 Survival following surgery for patients ³100 years of age.
Numbers in parentheses represent number of patients alive and followed at yearly intervals during the first 3 years after surgery. (Reprinted
with permission from Warner [31]).
(3%) and no mortality within 48 h of operation; 30-day mortality was 16.1%, none directly related to the operative procedure or perioperative morbidity. Subsequent mortality of
these patients equaled that of matched peers from the general
population (Fig. 17.2). Grey [32] reported a case of revision
total hip arthroplasty. This author reported a series of major
and minor procedures in six patients aged 100–104 years, all
of whom survived (Table 17.1) [33]. The illustrative cases
below are from that series.
21317 Surgery in Centenarians
https://t.me/med1917
of CHF
Urgent Local None No Died, age 102 years
of cerebrovascular
Urgent General None No Died, age 102 years
disease
“old age”
of
“old age”
of
No Died, age 102 years
cholecystitis,
Urgent General Acute gangrenous
protruding Enders
rod pins
Elective Local Bleeding at excision site
Emergency General None
CHF
of
gastric carcinoma
of
replacement
Pacemaker generator
pacemaker, CHF, prostatec-
tomy, cataract extraction, gout,
Age
(years) Medical problems Operation Status Anesthesia Complications Death Follow-up
Ta b l e 17.1 Clinical summary of centenarians undergoing an operation
Patient no./sex
1/M 100 Old MI, sick sinus syndrome with
head, cemented Moore
prosthesis
Excision of right femoral
arthritis, chronic renal failure
2/F 100 Old MI, left radical mastectomy
Above-knee amputation Urgent General None No Died, age 101 years
(13 years), arthritis
3/M 100 Hypertension, severe peripheral
Open reduction, internal
vascular disease, prostatec-
tomy, chronic lung disease
4/F 100 Old MI, CHF, aortic stenosis,
fixation of right hip
fracture
Cholecystectomy Emergency General Pneumonia, resolved;
cataract extraction, cystocele
repair, left hip open reduction
internal fixation, arthritis,
hiatus hernia
villous adenoma
rectal polypectomy site
Removal of Enders rod pins Elective Local None
Suture ligation of bleeding
Right inguinal herniorrhaphy Elective Local None No Died, age 102 years
101 Colonoscopic resection of
5/F 101 CHF, atrial fibrillation, blind,
Gastroscopy with biopsy Emergency Local None No Died, age 105 years
33]. Copyright © American Medical Association. All rights reserved
cell carcinoma of face
basal
excised, adult-onset diabetes
excised, basal cell carcinoma
of nose excised and irradiated
6/M 104 Squamous cell carcinoma of neck
MI myocardial infarction, CHF congestive heart failure
Source: Reprinted with permission from Katlic [
Соседние файлы в папке Библиотека им академика М.И. Перельмана