ADVOCACY: A FINAL WORD REGARDING FAILING TO WARN OF PND
Older adults and those who care about them are inclined to be outraged postoperatively about not having been adequately informed and warned before surgery of the possible or probable loss of neurocognitive abilities now being experienced. As previously noted, older patients most often report that they were never informed reoperatively of PND being a possible major risk to their brain function and quality of life, so postoperatively they were shocked, anxious, angry, and depressed about their condition while also experiencing the harmful stress that accompanies constant attempts to cope with the neurocognitive harm.
In addition, memories of postoperative delirium and other PND experiences can long remain as Post Traumatic Stress Disorder for patients and care partners alike. The numerous kinds of suffering by the patient’s family and friends whose lives also can be altered unfavorably or drastically, provide yet another reason to fully warn everyone involved of the estimated likelihood of PND outcomes. Those whose work life yields continuous information from families who are caring for an older adult report frequent incidents of puzzled and angry complaints that the older person has suddenly become “so difficult” or “impossible” to relate to. When asked if the problematic behavior might have started after the older person had surgery, they often answer affirmatively but had not been informed that the surgery was able to cause a PND aftermath like the family was experiencing.
All of us who are clinical healthcare professionals took an oath to do no harm that includes protecting those who are vulnerable to harm. Thankfully, some leading anesthesiologists and surgeons honor their oath by testing for and warning patients of their risks. The Joint Commission urges this through its work to accredit healthcare organizations and programs, directing them toward a zero harm to patients standard when they apply for accreditation. The Commission makes very clear that the definition of a fully informed consent process is a culturally and cognitively sensitive detailed conversation with the healthcare professional who can accurately and fully answer all questions posed by patients and those accompanying them.
Regarding candidates for surgery, full informed consent is understood to mean not just signing a long legal consent form, but is born of a respectful shared decision-making conversation in which the surgeon, anesthesiologist, and others on the team who have conducted a detailed assessment of risk are clear in communicating the details of those risks, making certain that the patient is verbalizing a correct understanding of the various forms of PND and has time to consider with family, friends, or advisors their risk versus benefits decision. Failing to obtain a truly well-informed consent prior to surgery regarding their PND risk profile is not only disrespectful and unethical but is an invitation for a potential failure to warn malpractice claim since this harm has been well documented for many years and must not be ignored in the surgical consent process.
Importantly, the notion of fully informing also would include discussing possible alternatives to the proposed procedure if the surgical candidate determines that the risks are too high to proceed with the surgery. Hopefully, such a discussion could identify alternatives to full surgery such as modifications that could cause less neuroinflammation from surgical trauma and anesthesia that is lighter or of shorter duration. It is of great importance for everyone involved to be willing to seriously consider identifying any reasonable alternative treatments to surgery or consider delaying surgery as long as possible to allow the person more time to retain their current neurocognitive abilities intact. Another alternative deserving respectful consideration is accepting the older adult’s thoughtful informed decision to decline the surgery and live with the consequences of that choice instead of the possible or probable potentially life-shattering consequences of unresolved severe PND. Surgeons who refuse to raise this option for discussion set themselves up to be seen as health professionals who choose their personal income over concordant compassionate care of the older adult patient.
The current milieu reveals insufficient caring about and performance of preoperative assessment of PND risk that includes a follow-up discussion of alternatives for the high risk surgical candidate. Just prior to the release date of this paper, the author was describing some data from it to a surgeon who was listening with interest to some of the possible causes of PND in older adults. Suddenly, the Physician’s Assistant who was standing nearby, interrupted with the all too typical denial line, saying in an arrogant and argumentative tone about PND, “It’s just a temporary setback!” She was immediately and firmly invited to read this research review paper since she clearly needed to become acquainted with facts. The conversation quickly resumed with the surgeon. Did that encounter provide a current moment of lived experience suggesting that the self-imposed deficiency of PND knowledge so harmful to older adult surgical patients also now may offer a surgeon willing to learn? Perhaps.
If a surgeon proves to be empathic and compassionate and is well able to be an excellent clinical care person regarding the standards outlined above, the potential patient and their care partners should consider themselves to be extraordinarily fortunate. Expressing deep respect and thanks to that surgeon for their unusually gifted patient care abilities is important, as is taking the time to respond if receiving a follow-up text inquiry about the quality of the visit. For most clinicians, excellence is its own reward, but appreciation from patients is also often welcome. Describing that excellent care to other healthcare professionals and offering an enthusiastic personal recommendation of that surgeon to others facing a similar decision helps everyone, since making appreciation for excellent care well-known to many others is an important part of helping elevate patient care standards to a higher level. The elevation of standards is especially needed in the arena of PND clinical care.
A few notably bright and caring women surgeons have been leading the efforts to elevate standards of PND care and must be thanked here for providing glimmers of hope that they can help surgical colleagues finally accept their share of responsibility for PND care. Dr. Ronnie Rosenthal is a geriatric surgeon with a long history of efforts to educate fellow surgeons about PND care. At the 2023 American College of Surgeons (ACS) meeting, Dr. Rosenthal, a Yale professor of geriatric surgery, lead author of the 2020 textbook on that subject, and Chair of the ACS Geriatric Surgery Taskforce led a Quality and Safety Conference. She began by noting that “the vast majority of our surgical residents and attendings have no training in how to diagnose cognitive impairment or what to do when they do diagnose it and what the impact is on the care of patients.” She announced that a grant was secured to study older adults undergoing surgery, noting that AARP had found cognitive abilities to be what matters most to older adults. For more of her breakthrough work on PND as a surgeon, use Rosenthal RA for a Pub Med search.
Dr. Rosenthal introduced Dr. Julia Berian, an assistant professor of surgery at the University of Wisconsin School of Medicine and Public Health. Dr. Berian is committed to developing kind supportive relationships and shared decision making with her patients while finding ways to enhance the surgical care of older adults. She contributed an excellent presentation about the cognitive screening that surgeons should provide preoperatively to determine the risk of PND for each potential patient. Using Berian JR for a Pub Med search retrieves much of her pioneering work.
Great thanks must also be extended to nurses who have known of and spoken about caring for patients suffering types of PND for many years. Surgical, postoperative, and geriatric nurses have been the main source of PND care for older adults. Many nurses have written about the clinical care they offer and have conducted excellent research studies that you see when you conduct your Pub Med searches for nursing care of PND.