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