Emergency abdominal surgery outcomes worse for nursing home residents

[October 02, 2019]  By Lisa Rapaport

(Reuters Health) - Older adults living in nursing homes who need emergency abdominal surgery are more likely to die or experience serious complications than counterparts living in the community, researchers say.

The study examined data on 18,326 patients who had emergency abdominal surgery from 2011 to 2015, including 905 people who lived in skilled nursing facilities.

Overall, 26% of nursing home residents died in the hospital compared with 10% of patients who didn't live in institutional settings, the study found. And 33% of nursing home residents died within 30 days of hospital admission, compared with 26% of people who didn't live in nursing homes.

It's possible that all the health issues that led people to live in nursing homes contributed to worse surgical outcomes, said Dr. Anne Mosenthal, a researcher at Rutgers New Jersey Medical School in Newark and the study's senior author.

"Frailty is a major determinate of post-operative complications and mortality," Mosenthal said by email. "Those who are not able to live independently inherently have higher risk for being frail, and this increases their risk for surgery."

As life expectancy of the U.S. population continues to rise, a growing number of older adults will face emergency surgery, Mosenthal and her colleagues note in the American Journal of Surgery. Almost one-third of older adults undergo a surgical procedure during their last year of life, most often in the last month before death, the researchers point out.

In the current study, nursing home residents were more likely than other patients to have complex chronic health issues and to be totally dependent on others for basic daily tasks like dressing, bathing and eating.

The most common reasons for surgery were gastrointestinal perforation or obstruction.

Two-thirds of nursing home residents experienced postoperative complications, compared with 42% of other people in the study.

Nursing home residents were approximately twice as likely to have pneumonia, respiratory failure, cardiac arrest, septic shock and surgical wounds that don't close properly as other patients in the study.

Failure to rescue, or the inability to prevent death after complications set in, was also 30% more common for nursing home residents than for other patients.

While advanced care planning isn't always feasible before emergency surgery, these results underscore the importance of patients and families setting up medical directives that clearly explain what life-saving measures they may want when complications occur, the study team concludes.

So-called advanced directives might make it easier for nursing home residents and other frail elderly patients to get palliative care focused on comfort rather than being put on machines to help them eat or breathe that may not ultimately be able to save their lives, Mosenthal said.

"Conversations about a patient's wishes regarding life sustaining treatment and aggressive medical therapy need to happen before they are unable to decide for themselves or worse if there is an emergent situation," Mosenthal said.

"I cannot stress enough how important it is to have these conversations early, while people are healthy, to let designated surrogate decision makers know how to proceed when that emergency situation occurs," Mosenthal added.

SOURCE: https://bit.ly/2nzsM0h American Journal of Surgery, online September 19, 2019.

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