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