
Frail Older Patients Struggle After Even Minor Operations - vo2maxer
https://www.nytimes.com/2019/12/13/health/frail-elderly-surgery.html
======
cameronh90
The way we care for the elderly in hospitals is not working and cannot
continue as the population ages. Issues like the one raised are just the
surface. We are spending an ever increasing fortune to keep elderly patients
alive for just weeks or months, often with poor quality of life.

What this and the article is pointing towards, is that we need to get better
at assessing when it's time to move from curative medicine to palliative care.
This is not just about advancing medicine, but about our culture and attitude
towards the (current) inevitability of death.

~~~
randycupertino
I did a rotation at a wealthy Bay Area hospital where they routinely put
stents in patients in their 80s. Thought of reporting them to medicaid for
overbilling but most of the pts were private pay. Hospital has over $4 million
dollars worth of art on the walls and a $500k koi pond in the lobby.

~~~
Ididntdothis
"Hospital has over $4 million dollars worth of art on the walls and a $500k
koi pond in the lobby."

That's one thing I ave noticed in a lot of US hospitals and doctor offices.
Everything is very shiny and new and costs a lot of money.

~~~
vkou
It's the invisible hand of the market at work. Obviously, patients are
preferring to pay premium for treatment hospitals with expensive art and
swanky facilities.

~~~
Ididntdothis
I wonder if they preferred it less if they had a way to find out how much the
hospital costs before treatment.

~~~
kube-system
That would make sense, at least for the people paying the costs themselves.

The economics change with insurance coverage. Once I hit my deductible, why do
I care how expensive it is? At that point, might as well get my money’s worth
out of my insurance company.

The last time I need non-routine care, the only thing I cared about was:

1\. Is this doctor good?

2\. Is this doctor/hospital in-network?

~~~
RugnirViking
"The economics change with insurance coverage. Once I hit my deductible, why
do I care how expensive it is? At that point, might as well get my money’s
worth out of my insurance company"

The money doesn't come from nowhere. If everybody thinks like this, your
insurance costs more money.

If you don't pay for your insurance personally, how about just straight up
being paid more by your company?

~~~
kube-system
Many people do think like that, and it is likely a significant contributing
factor to the cost of health insurance.

I do pay for my insurance personally. Health insurance law is somewhat
different than most other forms of insurance in that the premium cannot be
increased no matter my frequency or magnitude of previous claims. [0]

My marginal use is a merely a rounding error in the context of my health
insurer's outlays. Nothing I could do would personally affect my rate. The
aggregate of many thousands of people's use determines my rate, and for that,
the tragedy of the commons is fully in charge.

[0]: [https://www.healthcare.gov/how-plans-set-your-
premiums/](https://www.healthcare.gov/how-plans-set-your-premiums/)

------
craz8
2 years ago, I had major abdominal surgery. I’d had a similar one in the 80s

They really wanted me out of bed to walk a bit within 12 hours. That first
walk, I made it half way to the door of the room.

They focused on getting me out of bed and walking regularly (with a frame for
support), no matter how short, and breathing into a device to measure lung
capacity (which is almost zero with big hole in your side)

It sucked! A lot! But this was a key part of the recovery process. Being
vertical is important for many bodily functions, and the less you can be
vertical, the longer the recovery will be

I can’t imagine having to do this in another 30 years

~~~
larnmar
Hopefully in another 30 years, a machine/robot will gently raise you to a
standing position in a way that’s optimal for recovery.

------
hanoz
I once overheard a doctor say something which has always stayed with me, along
the lines that after a certain age then once you're off your feet for any
length of time, then that in itself puts you in big trouble.

~~~
27182818284
Same. I heard something from an RN like "If you break a bone after this age,
you have 6 months to live"

Every. Single. Time. since then this has been true in my anecdotal experience.
Sometimes I've really regretted mentioning it because I've mentioned it to
coworkers sort of casually and then, sure enough, their parent was dead within
6 months of the break.

After the first few came true I said it more seriously like, "Listen, you need
to prepare for their death..."

~~~
paulcole
At some point your frankness at work is going to come back to bite you.
Honestly smarter to just stay quiet. “Your mom’s gonna croak by Christmas”
tends to not go over well with everyone.

~~~
astura
Seriously.

The only appropriate thing to see say to a co-worker in that situation is a
polite "I'm so sorry to hear about that, I hope your mom feels better soon."
Keep the prepare for death conversations for close friends and family. Even if
in was a close friend you happened to work with, the workplace is not an
appropriate place for such a conversation.

~~~
AstralStorm
Why is it not an appropriate place? What is an appropriate place? Do you get
to spend over 2/3 of waking time there?

If you do not wish to discuss it with coworkers, some of whom may or may not
be friends, it's your choice to raise them or not. Focusing the attention on
important matters could be done tactfully, which is very different from not
talking about things.

If it's by fiat, there is an ulterior motive of "think happy thoughts,
preferably shallow". There are such workspaces. There are also those that keep
grave silence by fiat or unspoken convention.

------
mirimir
Now that I'm over 70, I won't be having prostate surgery. Or surgery for
anything else that won't likely kill me within a few years.

Edit: If you would, in my circumstances, please share why.

~~~
thaumasiotes
Hm, I just looked into this after my friend's father-in-law was found to have
advanced prostate cancer. It is, in general, very slow acting.

Current standards for treatment are based on how advanced the cancer is and
what the patient's life expectancy would be in the absence of cancer.

For a small cancer, because of the slow pace of the cancer, it's common to do
nothing ("watchful waiting") or take androgen suppressants. For a cancer large
enough to be viewed as threatening in the more short-to-middle term, you'd
usually go for radiation therapy if you expect the patient to die within 10
years, and surgery if you expect the patient to last longer than that.

The reason for the radiation-surgery divide is that the very unpleasant side
effects of the radiation generally show up about 10 years after treatment.
(Whereas the side effects of surgery show up immediately and, hopefully, get
better over time.)

The father-in-law in question is in his late 60s, but would be expected to
live into his 80s if he were otherwise healthy. His father reached the age of
95. So I can understand why everyone recommended surgery in his case.

No real bottom line here, but I hope this was helpful to someone.

~~~
mirimir
Thanks, that's pretty much my perspective.

Although I'd likely opt out of androgen suppressants. In my experience, life
without testosterone was unpleasant. My arthritis was worse, and I was prone
to tendonitis. I lost muscle mass, and got fatter. I became borderline
diabetic. My acne got much worse. And I lost all interest in sex.

Testosterone supplementation reversed all of that.

~~~
thaumasiotes
Yes, I am uncomfortable with androgen suppressants for the same reasons --
they have quite far-reaching effects, including some dramatic personality
effects. However, doctors tend to view them as minimally invasive (which I
agree with) and harmless (which I don't).

------
jacquesm
There really is no such thing as a minor operation. And anything requiring
general anesthesia is a serious whack to the system. When you're older this is
a much larger factor than when you are younger. Just breaking a hip, arm or
leg, a fall or a minor infection can easily be fatal to an older person
because of the reduced efficiency of the immune system, and their general lack
of resilience.

~~~
arethuza
I remember when I was in my 20s and rather fit I had some surgery planned that
was made up of 4 separate procedures and originally the surgeon suggested
doing the work in 2 operations - for some reason I talked him round to doing
everything at the same time even though he did warn me that I would feel like
I had been "hit by a bus" (his exact words).

I did indeed feel pretty awful after - was off work for six weeks. Now I am a
good bit older I'd be pretty reluctant to undergo surgery requiring general
anaesthesia unless it was really required.

------
dr_
Ironically, some of the newer value based initiatives, such as BPCI, along
with changes to the post acute skilled nursing reimbursement, is actually
decreasing the amount of time and care some of these elderly could benefit
from post operatively to enhance their recovery. If we allowed our elderly
Medicare patients to go into a rehab unit for the amount of days they need,
without requiring a 3 night hospital stay first, I wonder the impact this
would have on morbidity and mortality, especially after minor operations.

------
jdkee
To surgeons, surgery is the solution regardless of patient outcomes. That is
why you should always get a second opinion to hear about non-surgical options.

~~~
onetimemanytime
[https://en.wikipedia.org/wiki/Law_of_the_instrument](https://en.wikipedia.org/wiki/Law_of_the_instrument)
_" I suppose it is tempting, if the only tool you have is a hammer, to treat
everything as if it were a nail."_

Then, there's the financial side: they have bills to pay so, so, at least,
they lean on side of surgery.

------
taxicabjesus
It seems to me that there's something wrong with medicine, but I haven't quite
figured it out yet.

My recent submission [0] was about how the system defaults to expensive
treatments that are marginally effective, and that doctors frequently have no
ability to provide what patients actually need.

My one grandfather died soon after his pacemaker was replaced - the wounds
from his IVs became infected. I like to say that when he heard the doctor ask
him if wanted his pacemaker replaced, he said to himself "this is my chance":
If not for the surgery he certainly would have lived many more months while
the battery gave out...

[0]
[https://news.ycombinator.com/item?id=21728864](https://news.ycombinator.com/item?id=21728864)

~~~
trevyn
A thread to pull on: How does medicine work outside of developed countries?

~~~
hycaria
Yep I'm always astonished at how these things are taken for granted.

------
onetimemanytime
I guess it's easier said than done, but at some point we gotta understand that
we don't have "x disease or ailment," we just have old age. And accept that.
Things start to break down

------
simonsarris
> "If you want to change communications, you probably have to work on the
> surgeons" more than the patients, Dr. Schwarze concluded.

I find it harder and harder to believe that Insurance is the Bad Guy in US
healthcare, as insurance companies make fairly normal level insurance industry
margins (like, less than car insurance). The magnitude of total spend is the
real problem, and that's a provider-side problem, not a payer side problem,
but its hard to talk about doctors and pharmacy benefit managers being the
potentially evil ones. People can't stomach the thought that its not a
faceless insurance company, and that it might be doctors, in aggregate, over-
prescribing and over-practicing well beyond actual need. (And proponents of EU
style healthcare costs never mention EU style doctor salaries, and the
difference w.r.t. those and the USA).

It sure would be terrible if tons and tons of these interventions done on
frail people had no real medical use, and hundreds of them were found to be
ineffective (not budging mortality, etc), and surgeons just wanted to get
paid. Totally terrible if journals had meta-analyses of that.

[https://elifesciences.org/for-the-
press/94d42de3/almost-400-...](https://elifesciences.org/for-the-
press/94d42de3/almost-400-medical-practices-found-ineffective-in-analysis-
of-3-000-studies)

------
alleycat5000
If this article interests you, I'd highly recommend the book Being Mortal by
Atul Gawande:

[https://en.m.wikipedia.org/wiki/Being_Mortal](https://en.m.wikipedia.org/wiki/Being_Mortal)

I found it to be thought provoking, moreso as I've gotten older.

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throwaway5752
This is one of the _key_ benefits of the all the new generation of health care
sensors, particularly as they mature and hit clinical/FDA approved levels.
Obviously, you heal worse as you get older. But as noted in another comment,
just being bedbound can be deadly. But further, hospital acquired infections
are a huge problem. Getting people back into their homes and routines will
benefit patients in a number of ways beyond those described in this article.

------
alexpetralia
Non-paywalled: [http://archive.is/i9UUp](http://archive.is/i9UUp)

~~~
paulcole
This works, too:

[https://www.nytimes.com/subscription](https://www.nytimes.com/subscription)

~~~
mirimir
I bet that they don't accept Bitcoin, Monero, etc.

Or even cash by mail.

~~~
onetimemanytime
Yeah, that is stopping 99.99% of people from subscribing /supporting great
journalism.

~~~
mirimir
I subscribed once, in meatspace.

It took over a year to get rid of them, after they kept jacking up the price.

I will never again give them a card number.

