One of the toughest challenges facing a heart surgeon is to explain complicated surgical procedures and obtain informed consent from patients with no medical background. It’s an art. Proficiency in the arts rarely comes from a book; it takes experience. After 22 years of practice, I have found consent discussion with the elderly to be perhaps the most challenging. Among other issues, aging reduces the capacity of the body’s organs to withstand stresses such as surgery and periods of poor blood perfusion. All we know is chronologic age (the actual amount of time a person has existed), but time doesn’t hurt everyone’s organs at the same rate. What we really need to know is biologic age, or the accumulation over time of the DNA alterations that are the underlying reason why organs are compromised and susceptible to stress. This is not (yet) a measurable concept in cardiac surgery.
Without a reliable way to appreciate organ reserve, many complications in the elderly are unforeseeable. One elderly patient struggles after a straightforward procedure while another easily tolerates a much more complicated and difficult case. This uncertainty puts the elderly patient with a severe but correctible cardiac problem in a box. They face two bad options. One is to proceed with surgical repair of the heart. However, any episode of poor perfusion around the time of surgery might lead to organ damage and result in surgical complications. The alternative to this is to manage the heart problem without surgery. That is an even worse option for the same exact reason. A heart with a severe lesion that remains uncorrected inevitably leads to worsened heart function, poor perfusion of blood to the body, and multiorgan failure. Only successful surgery gives the elderly patient any hope to alter this fate.
Given these two options, getting the elderly to sufficiently understand the information needed for informed consent can be tough. An important reason for this is that the brain is one of the organs that develops compromised reserve with age. An elderly patient may have reduced ability to comprehend complicated medical information and feel pressured (more than a younger patient) into accepting a surgeon’s recommendation. Surgeons often lack the long-standing relationship with patients that serves as a foundation for difficult conversations like this. Involving family members, when they are willing and able, is crucial. In my experience, family members of an elderly patient often voice their concerns regarding the chances of success. I always welcome this discussion—an engaged family is a strong safeguard in helping a patient feel more comfortable with their decision, particularly if they choose to turn down surgery. A questioning attitude in the patient or family is always reassuring to me; it mitigates any possible allegations that I would ever give incomplete, biased or one-sided information. Having family members be assertive during these discussions allows everyone to have a wider range of opinions and other information needed for the elderly patient to make the right decision.
There is an even higher ethical principle guiding my informed-consent process than giving the right information for a decision. That is to make sure a patient has full autonomy to choose what is most aligned with their life’s wishes. Sometimes patients have very high expectations about their lives and see it as not worth living without the ability to engage in vigorous exercise, foreign travel, or other physically demanding activities. This limits their options when they face a serious medical condition. A successful surgery is often the only reasonable avenue for returning to a full quality of life. Nonsurgical options make sense in someone willing to accept a more sedentary (albeit shortened) future, as is often the case in patients who have become accustomed to limited mobility due to dysfunctional hip or knee joints, or emphysema.
Moreover, one cannot confirm the effectiveness of informed consent based on a good surgical outcome alone. There is a far clearer metric of success: the patient has no regrets with their decision afterwards. Regret in patients after surgery is a form of preventable harm. Avoiding this is an important safety issue. One patient might make a decision that contradicts the advice of family members and that might cause discomfort, conflict or regret among the family. Another patient might end up being swayed into a decision just because the family preferred it. A decision that is voluntary, informed by an accurate understanding of risks and benefits—and not the result of undue pressure—is the one most likely to prevent regret in the patient. Elderly patients who have decision-making capacity have the right to make any decision regarding their care. Even if this means choosing an operation likely to cause suffering for only a small hope of benefit. Likewise, a patient pressured to turn down surgery might end up resenting the idea that any hope for a more active lifestyle in the future is gone. No family wants that for their loved one.
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