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Background: Older adults with serious illness near the end-of-life often receive invasive treatments. We developed a conceptual model called clinical momentum that describes system-level forces producing a trajectory of care that is difficult to modify and contributes to overtreatment. We sought to evaluate the empirical fit of our model by examining an event with clear guidelines against intervention: permanent feeding tube placement in patients with advanced dementia. Methods: We screened three hospitals and identified patients 65 years and older with advanced dementia who received a permanent feeding tube. We interviewed 34 family members and clinicians. We coded transcripts and characterized factors that arose during the course of care and their relationships to feeding tube placement. We used abductive analysis to compare the data with theory and identify areas of discordance and alignment. Results: We found that the course of care started with a temporary tube to correct an acute problem. As problems were identified, multiple clinicians were consulted to address a specific problem without collective discussion of the patient's health trajectory. Eventually, clinicians had to address the temporary tube, which was framed to families as a decision to place a permanent feeding tube or withdraw treatment. Conclusion: Elements of the model-including recognition-primed decision-making, "fix-it," and sunk costs-contributed to placement of a feeding tube, which set in motion a path toward intervention long before a goals-of-care conversation occurs. Clinical momentum expands our understanding of overtreatment at the end-of-life and may reveal opportunities to reduce other nonbeneficial interventions.
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This Viewpoint is the last of a 4-part series discussing ways to improve communication between surgeons and patients.
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Comunicação , Cirurgiões , HumanosRESUMO
OBJECTIVE: Elderly patients with critical limb ischemia are an especially frail and vulnerable group of patients. There is little literature investigating outcomes and resource utilization in nonagenarians undergoing major lower extremity amputation (MLEA). This study aims to elucidate the outcomes of this unique set of patients for whom amputation may often be considered a "palliative" intervention. METHODS: Analyzing over 16,000 records from the Vascular Quality Initiative (VQI) database, we collected demographic, operative, and postoperative data on all patients who underwent an MLEA. We performed univariate analysis comparing nonagenarians to younger patients examining both short-term and long-term outcomes. Multimodel inference was used to analyze the effect of age on clinically meaningful outcomes: mortality and long-term living disposition. RESULTS: With 392 nonagenarians and 16,349 patients under the age of 90, we found nonagenarians were less comorbid and less likely to have a prior bypass or amputation. Despite experiencing lower rates of reoperation and individual postoperative complications, nonagenarians suffered higher long-term mortality (46% vs. 22%, P < 0.0005) and were more likely to be living in a facility at follow-up (34% vs. 15%, P < 0.0005). Incorporating important demographic and clinical factors, multimodel inference demonstrated that, the nonagenarian age group was a critical predictor of nonhome living status (Akaike Importance weight 0.99). CONCLUSIONS: Although nonagenarians were less comorbid than their younger counterparts and suffered fewer perioperative complications, MLEA leads to a poorer outcome with significant mortality and a higher likelihood of residing in a facility at long-term follow-up. These findings underscore the importance of frank goals of care discussions in nonagenarians considering major amputation.
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Amputação Cirúrgica , Nonagenários , Idoso de 80 Anos ou mais , Humanos , Idoso , Resultado do Tratamento , Fatores de Risco , Amputação Cirúrgica/efeitos adversos , Extremidade Inferior/irrigação sanguínea , Estudos Retrospectivos , Isquemia/diagnóstico , Isquemia/cirurgia , Salvamento de MembroRESUMO
OBJECTIVE: We tested the association of systems factors with the surgeon's likelihood of offering surgical intervention for older adults with life-limiting acute surgical conditions. BACKGROUND: Use of surgical treatments in the last year of life is frequent. Improved risk prediction and clinician communication are solutions proposed to improve serious illness care, yet systems factors may also drive receipt of nonbeneficial treatment. METHODS: We mailed a national survey to 5200 surgeons randomly selected from the American College of Surgeons database comprised of a clinical vignette describing a seriously ill older adult with an acute surgical condition, which utilized a 2×2 factorial design to assess patient and systems factors on receipt of surgical treatment to surgeons. RESULTS: Two thousand one hundred sixty-one surgeons responded for a weighted response rate of 53%. For an 87-year-old patient with fulminant colitis and advanced dementia or stage IV lung cancer, 40% of surgeons were inclined to offer an operation to remove the patient's colon while 60% were inclined to offer comfort-focused care only. Surgeons were more likely to offer surgery when an operating room was readily available (odds ratio: 4.05, P <0.001) and the family requests "do everything" (odds ratio: 2.18, P <0.001). CONCLUSIONS: Factors outside the surgeon's control contribute to nonbeneficial surgery, consistent with our model of clinical momentum. Further characterization of the systems in which these decisions occur might expose novel strategies to improve serious illness care for older patients and their families.
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Cirurgiões , Humanos , Idoso , Idoso de 80 Anos ou mais , Salas CirúrgicasRESUMO
BACKGROUND: It has long been debated whether it is preferable to perform conventional carotid endarterectomy (CEA) with or without patch closure. Although most contemporary surgeons patch, many still do not. Recent small studies have surfaced implying patching is unnecessary. The objective of our analysis was to determine the difference in short- and long-term outcomes according to patch use in a large modern, cross-specialty database. METHODS: Analyzing more than 118,000 records from the Vascular Quality Initiative, multimodel inference was used to evaluate the effect of patch use on important outcomes of conventional CEA. The composite short-term outcome included any ipsilateral neurological event, return to the operating room for a neurological event, and an increase in the Rankin score postoperatively. Late composite outcome incorporated restenosis as well as early and late ipsilateral neurological events. RESULTS: Patch use for conventional CEA closure was found to be a strong predictor of both early and late outcomes, as evidenced by its Akaike importance weight of 0.99. Examining predischarge events, patch closure is associated with a decrease in major negative events (odds ratio, 0.5; 95% confidence interval, 0.4-0.6). For long-term events, such closure offers a decrease in untoward outcome (odds ratio, 0.8; 95% confidence interval, 0.7-0.9). CONCLUSIONS: Analysis in a large current-day database suggests that patch closure of conventional CEA effects superior short- and long-term outcomes.
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Estenose das Carótidas , Endarterectomia das Carótidas , Acidente Vascular Cerebral , Humanos , Endarterectomia das Carótidas/efeitos adversos , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Estenose das Carótidas/complicações , Resultado do Tratamento , Bases de Dados Factuais , RecidivaRESUMO
BACKGROUND: Bacillus Calmette-Guerin (BCG) is a live, attenuated strain of Mycobacterium bovis that is used in the treatment of non-muscle invasive bladder cancer (NMIBC). Vascular complications, including mycotic aneurysms, after BCG therapy are exceedingly rare. In this patient population, the diagnosis of mycotic aneurysms can be delayed or missed due to their non-specific clinical and radiologic presentation. Literature review reveals management of mycotic aneurysms attributable to BCG therapy is widely varied.2,5-8,12,15 CASE REPORT: We report a patient who presented with mycotic aneurysm formation secondary to BCG treatment for bladder cancer that was repaired with in-line reconstruction utilizing cryoartery and buttressed with omental flap. We suggest this as an alternative treatment to in-line prosthetic graft or extra-anatomic reconstruction.