EVAR and goals of care

78-year-old man for EVAR, 55mm AAA

Background:

  • Nursing home resident
  • Lung nodule – mild uptake on PET, uncertain aetiology. Under surveillance by respiratory physician. Not a candidate for surgery
  • COPD. Ongoing smoker. 90PY. FEV1/FVC = 41%
  • Hypertension and high cholesterol
    • Normal sestamibi 2021
  • DHS – hip fracture, 2020. GA
  • Incarcerated hernia repair under GA 2021

Issues:

  • AAA – Incidental finding, Infra-renal. 5% annual rupture rate
  • Wheelchair-bound, Severe OA both hips
    • Assistance with all ADL’s
  • CVD, Cognitive impairment – mini cog 3

Discussion:

Clinic consultation with patient and son:

  • Patient is keen to leave nursing home but has a reasonable quality of life which he enjoys.
    • High risk for further cognitive decline
    • Risk of mortality is more than risk of rupture – both theoretical
    • Clinic anaesthetist advised against proceeding; benefits of procedure greatly outweigh potential long-term risks. Patient uncertain regarding this decision. Capacity to consent has not been formally examined.
    • NSQIP surgical risk calculator showed a 24% risk of serious complication and a 12.4% risk of death.

Benefits vs Risks

  • Consensus agreement with clinic anaesthetist.
  • Life expectancy is limited at 78 years old with significant co-morbidities
  • Patient is at risk of declining quality of life which he currently values

Where to from here?

  • Should this conversation be continued over the phone or a repeat face to face consultation?
  • Decision-making capacity uncertain – formal assessment needed.
  • GP could consider geriatrician referral
  • Daughter is NOK but was not in attendance. No POA/substitute decision maker.
  • Important to note that declining this procedure based on perioperative risk would not preclude him from further surgeries e.g., hip-fracture surgery

Plan:

  • Not for EVAR, letter to referring surgeon recommending conservative therapy
  • Further meeting with family and clear documentation in notes required

GP to assist patient and family with advanced care planning

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