It may take members of our parents' generation (and our own) a long time to get over thinking of hospitals as refuges of safety and operating rooms as harbingers of better days ahead. But it's gradually becoming clearer that for the very old and frail, and for nursing home residents in particular, hospitals are places to avoid whenever possible, and surgery can become a source of danger in itself.
Even operations considered fairly routine in younger patients, like appendectomies, become high-risk for nursing home residents. "Something about undergoing anesthesia, the surgery's physiological assault on the body, impacts older people much more than we think," said Dr. Emily Finlayson, a colorectal surgeon at the University of California, San Francisco, and lead author of a recent study published in The Annals of Surgery.
In fact, the study, which compared mortality risks and subsequent interventions for four types of major abdominal surgery, found that even compared with adults of similar age who had the same number of chronic illnesses — but who weren't in institutions — nursing home residents fared sharply worse.
Bluntly put, surgery is much more likely to kill them.
Dr. Finlayson and her colleagues used national Medicare claims and nursing home surveys to identify nearly 71,000 nursing home residents who had surgery from 1999 through 2006. They compared them with more than a million elders who underwent the same four procedures but did not live in a nursing home. The researchers chose operations frequently performed on older adults: removal of an infected appendix (appendectomy), removal of an infected gallbladder (cholecystectomy), surgery for a bleeding ulcer in the upper part of the intestine, or surgery for noncancerous colon diseases like diverticulitis or colitis. These are painful conditions requiring immediate decisions, as opposed to diagnoses like breast or prostate cancer, in which a patient and his or her family can take a few days to figure out the best course.
Typically, Dr. Finlayson explained, the surgeon gets a call from the emergency room, frequently at 3 in the morning: an 85-year-old nursing home resident is being admitted with acute appendicitis. The response is almost always: Prepare the O.R.
But after an appendectomy, 12 percent of nursing home residents died, compared with 2 percent of Medicare recipients who weren't in nursing homes. Gallbladder surgery was also more dangerous: an 11 percent mortality risk for nursing home residents, versus 3 percent in elders who weren't institutionalized.
The risk of dying rose sharply for the other two operations. For colon surgery, it was nearly a third for nursing home residents, and 13 percent for others. Ulcer surgery proved the most dangerous; 42 percent of nursing home patients died, compared with 26 percent of others.
Even when the researchers matched these two groups of patients by age and by the number of other diseases they had, those in the nursing home group (and in this study that meant long-term residents, not those in temporary rehab) were significantly more likely to die in each case. Just by virtue of living in a nursing home, "they've demonstrated they don't have the strength and mobility to live independently," Dr. Finlayson said. "They don't have the energy and vitality" — in doctorspeak, they lack "physiologic reserve."
But even those who survived surgery — and they're a majority, in some cases a large majority — weren't out of the woods. Nursing home residents were far more likely to undergo "invasive interventions" afterward; they required mechanical ventilators for days to help them breathe, feeding tubes inserted in their abdomens when they couldn't eat, venous catheterization (known as a central line) to monitor their hearts. Each of these painful procedures presents additional risks, of course.
We know that a substantial proportion of older people who enter hospitals will never fully regain their physical or mental capabilities, even when the illness that brought them there is successfully treated. (More on this syndrome later.) These interventions, which typically also keep people in bed, even though getting out of bed is critical to their recovery, may help explain why.
"Surgeons are very resistant to hearing this," Dr. Finlayson said. "We're focused on 30-day mortality. If patients leave the hospital alive, that's success. We don't see what happens three months down the road."
So here's a key question family members can ask before the surgeon starts scrubbing, especially if their older relative is frail enough to require nursing home care: Is there any alternative to surgery we could try?
"We think of appendicitis as a surgical disease — you take it out," Dr. Finlayson said. "But if you get appendicitis in England, it's often treated with antibiotics, whatever age you are." Gallbladder attacks can also be treated with antibiotics, or sometimes with a drain inserted under local anesthesia. A stent inserted by a gastroenterologist can relieve a bowel obstruction.
In each case, the treatment is less of an assault than surgery with general anesthesia. And if it doesn't work — if a 24-hour course of intravenous antibiotics, which can be administered in the nursing home, avoiding hospitalization, can't overcome the infection — surgery remains an option.
It might take a confident surgeon (because invasive surgery can provide protection against lawsuits, even if it's hard on patients) and a persistent family to pull off this alternative approach.
Surgeons, like most other physicians, are trained to save lives. "But with older patients, there's less length of life to protect," Dr. Finlayson pointed out. "So the other variables become way more important: maintaining cognitive status, living independently, caring for yourself. Quality of life."