— 7 Questions Older Americans Should Ask Their Surgeon

BY Judith Graham

Larry McMahon, who turns 80 this month, is weighing whether to undergo a major surgery. Over the past five years, his back pain has intensified. Physical therapy, muscle relaxants, and injections aren’t offering relief.

“It’s a pain that leaves me hardly able to do anything,” he said.

Should McMahon, a retired Virginia state trooper who now lives in Southport, North Carolina, try spinal fusion surgery, a procedure that can take up to six hours? (Eight years ago, he had a lumbar laminectomy, another arduous back surgery.)

“Will I recover in six months — or in a couple of years? Is it safe for a man of my age with various health issues to be put to sleep for a long period of time?” McMahon asked, relaying some of his concerns to me in a phone conversation.

Older adults contemplating major surgery often aren’t sure whether to proceed. In many cases, surgery can be lifesaving or improve a senior’s quality of life. But advanced age puts people at greater risk of unwanted outcomes, including difficulty with daily activities, extended hospitalizations, problems moving around, and the loss of independence.

I wrote in November about a new study that shed light on some risks seniors face when having invasive procedures. But readers wanted to know more. How does one determine if potential benefits from major surgery are worth the risks? And what questions should older adults ask as they try to figure this out? I asked several experts for their recommendations. Here’s some of what they suggested.

What’s the goal of this surgery? Ask your surgeon, “How is this surgery going to make things better for me?” said Margaret “Gretchen” Schwarze, an associate professor of surgery at the University of Wisconsin School of Medicine and Public Health. Will it extend your life by removing a fast-growing tumor? Will your quality of life improve by making it easier to walk? Will it prevent you from becoming disabled, akin to a hip replacement?

If your surgeon says, “We need to remove this growth or clear this blockage,” ask what impact that will have on your daily life. Just because an abnormality such as a hernia has been found doesn’t mean it has to be addressed, especially if you don’t have bothersome symptoms and the procedure comes with complications, said Drs. Robert Becher and Thomas Gill of Yale University, authors of that recent paper on major surgery in older adults.

If things go well, what can I expect? Schwarze, a vascular surgeon, often cares for patients with abdominal aortic aneurysms, an enlargement in a major blood vessel that can be life-threatening if it bursts.

Here’s how she describes a “best case” surgical scenario for that condition: “Surgery will be about four to five hours. When it’s over, you’ll be in the ICU with a breathing tube overnight for a day or two. Then, you’ll be in the hospital for another week or so. Afterwards, you’ll probably have to go to rehab to get your strength back, but I think you can get back home in three to four weeks, and it’ll probably take you two to three months to feel like you did before surgery.”

Among other things people might ask their surgeon, according to a patient brochure Schwarze’s team has created: What will my daily life look like right after surgery? Three months later? One year later? Will I need help, and for how long? Will tubes or drains be inserted?

If things don’t go well, what can I expect? A “worst case” scenario might look like this, according to Schwarze: “You have surgery, and you go to the ICU, and you have serious complications. You have a heart attack. Three weeks after surgery, you’re still in the ICU with a breathing tube, and you’ve lost most of your strength, and there’s no chance of ever getting home again. Or, the surgery didn’t work, and still you’ve gone through all this.”

“People often think I’ll just die on the operating table if things go wrong,” said Dr. Emily Finlayson, director of the UCSF Center for Surgery in Older Adults in San Francisco. “But we’re very good at rescuing people, and we can keep you alive for a long time. The reality is, there can be a lot of pain and suffering and interventions like feeding tubes and ventilators if things don’t go the way we hope.”

Given my health, age, and functional status, what’s the most likely outcome? Once your surgeon has walked you through various scenarios, ask, “Do I really need to have this surgery, in your opinion?” and “What outcomes do you think are most likely for me?” Finlayson advised. Research suggests that older adults who are frail, have cognitive impairment, or other serious conditions such as heart disease have worse experiences with major surgery. Also, seniors in their 80s and 90s are at higher risk of things going wrong.

“It’s important to have family or friends in the room for these conversations with high-risk patients,” Finlayson said. Many seniors have some level of cognitive difficulties and may need assistance working through complex decisions.

What are the alternatives? Make sure your physician tells you what the nonsurgical options are, Finlayson said. Older men with prostate cancer, for instance, might want to consider “watchful waiting,” ongoing monitoring of their symptoms, rather than risk invasive surgery. Women in their 80s who develop a small breast cancer may opt to leave it alone if removing it poses a risk, given other health factors.

Because of Larry McMahon’s age and underlying medical issues (a 2021 knee replacement that hasn’t healed, arthritis, high blood pressure), his neurosurgeon suggested he explore other interventions, including more injections and physical therapy, before surgery. “He told me, ‘I make my money from surgery, but that’s a last resort,” McMahon said.

What can I do to prepare myself? “Preparing for surgery is really vital for older adults: If patients do a few things that doctors recommend — stop smoking, lose weight, walk more, eat better — they can decrease the likelihood of complications and the number of days spent in the hospital,” said Dr. Sandhya Lagoo-Deenadayalan, a leader in Duke University Medical Center’s Perioperative Optimization of Senior Health program.

When older patients are recommended to POSH, they receive a comprehensive evaluation of their medications, nutritional status, mobility, preexisting conditions, ability to perform daily activities, and support at home. They leave with a “to-do” list of recommended actions, usually starting several weeks before surgery.

If your hospital doesn’t have a program of this kind, ask your physician, “How can I get my body and mind ready” before having surgery, Finlayson said. Also ask: “How can I prepare my home in advance to anticipate what I’ll need during recovery?”

What will recovery look like? There are three levels to consider: What will recovery in the hospital entail? Will you be transferred to a facility for rehabilitation? And what will recovery be like at home?

Ask how long you’re likely to stay in the hospital. Will you have pain, or aftereffects from the anesthesia? Preserving cognition is a concern, and you might want to ask your anesthesiologist what you can do to maintain cognitive functioning following surgery. If you go to a rehab center, you’ll want to know what kind of therapy you’ll need and whether you can expect to return to your baseline level of functioning.

During the covid-19 pandemic, “a lot of older adults have opted to go home instead of to rehab, and it’s really important to make sure they have appropriate support,” said Dr. Rachelle Bernacki, director of care transformation and postoperative services at the Center for Geriatric Surgery at Brigham and Women’s Hospital in Boston.

For some older adults, a loss of independence after surgery may be permanent. Be sure to inquire what your options are should that occur.

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— The Reminder We All Desperately Need

“Let us prepare our minds as if we’d come to the very end of life. Let us postpone nothing. Let us balance life’s books each day. … The one who puts the finishing touches on their life each day is never short of time.” Seneca

At a Roman triumph, the majority of the public would have their eyes glued to the victorious general at the front—one of the most coveted spots during Roman times. Only a few would notice the aide in the back, right behind the commander, whispering into his ear, “Remember, thou art mortal.” What a reminder to hear at the peak of glory and victory!

It is reminders like this one that we desperately need in our own lives—a thought or an idea that we’d rather ignore, do everything to avoid and pretend is not true. Most often, our ego runs away from anything that reminds us of the reality that sits at odds with the comfortable narrative we have build for ourselves. Or, we are simply petrified to look at life’s facts as they are. And there is one simple fact that most of us are utterly scared to meditate, reflect on and face head on: We are going to die. Everyone around us is going to die.

Such reminders and exercises take part of Memento Mori—the ancient practice of reflection on mortality that goes back to Socrates, who said that the proper practice of philosophy is “about nothing else but dying and being dead.” In early Buddhist texts, a prominent term is maraṇasati, which translates as ‘remember death.’ Some Sufis have been called the “people of the graves,” because of their practice of frequenting graveyards to ponder on death and one’s mortality.

Throughout history, Memento Mori reminders have come in many forms. Some, like the aide behind the general, were there to humble. Others were invented to inspire zest for life. The essayist Michel de Montaigne, for instance, was fond of an ancient Egyptian custom where during times of festivities, a skeleton would be brought out with people cheering “Drink and be merry for when you’re dead you will look like this.”

To us moderns this sounds like an awful idea. Who wants to think about death? But what if instead of being scared and unwilling to embrace this truth we did the opposite? What if reflecting and meditating on that fact was a simple key to living life to the fullest? Or that it was the key to our freedom—as Montaigne put it, “To practice death is to practice freedom. A man who has learned how to die has unlearned how to be a slave.”

In his Meditations—essentially his own private journal—Marcus Aurelius wrote that “You could leave life right now. Let that determine what you do and say and think.” That was a personal reminder to continue living a life of virtue NOW, and not wait. The French painter Philippe de Champaigne expressed a similar sentiment in his painting Still Life with a Skull, which showed the three essentials of existence — the tulip (life), the skull (death), and the hourglass (time). The original painting is part of a genre referred to as Vanitas, a form of 17th century artwork featuring symbols of mortality which encourage reflection on the meaning and fleetingness of life.

Meditating on your mortality is only depressing if you miss the point. It is in fact a tool to create priority and meaning. It’s a tool that generations have used to create real perspective and urgency. To treat our time as a gift and not waste it on the trivial and vain. Death doesn’t make life pointless but rather purposeful. And fortunately, we don’t have to nearly die to tap into this. A simple reminder can bring us closer to living the life we want. It doesn’t matter who you are or how many things you have left to be done, a car can hit you in an intersection and drive your teeth back into your skull. That’s it. It could all be over. Today, tomorrow, someday soon.

The Stoic finds this thought invigorating and humbling. It is not surprising that one of Seneca’s biographies is titled Dying Every Day. After all, it is Seneca who urged us to tell ourselves “You may not wake up tomorrow,” when going to bed and “You may not sleep again,” when waking up as reminders of our mortality. Or as another Stoic, Epictetus, urged his students: “Keep death and exile before your eyes each day, along with everything that seems terrible— by doing so, you’ll never have a base thought nor will you have excessive desire.” Use those reminders and meditate on them daily—let them be the building blocks of living your life to the fullest and not wasting a second.

Complete Article ↪HERE↩!