Fit for heart surgery? Study helps older adults make decisions with their surgeons

In 2017 at the age of 77, Sally O’Brien faced a tough decision. Not only were her coronary arteries almost completely blocked, she also had emphysema and an aneurysm in her aorta.

“I was having a hard time breathing and my hands and feet were constantly cold,” recalls Sally, a resident of Timberlea, Nova Scotia. “I knew that if I didn’t have surgery, I could have a major heart attack and much bigger problems, but I was also afraid I might not survive the surgery.”

While some advised her that coronary artery bypass surgery was too risky given her age and other health problems, Dr. Greg Hirsh determined otherwise. The Halifax cardiac surgeon and his team thoroughly assessed Sally’s fitness for the surgery using sensitive tools for measuring fitness versus frailty developed at Dalhousie University and the Nova Scotia Health Authority.

“We determined Sally was a good candidate for the surgery, because she was still active in her community, mentally sharp and independent in her daily life,” says Dr. Hirsch. “Using our frailty assessment and care planning tool, called FACT, and decision aids we’ve developed to help patients understand their risk of adverse outcomes, we reached the decision with Sally to go ahead.”

Sally also opted to enroll in a study funded by the Canadian Frailty Network to examine how varying degrees of frailty prior to heart surgery can affect a patient’s well being six months after a coronary artery bypass or aortic valve replacement procedure. Dr. Hirsch is leading the Maritime-wide study in collaboration with Dr. Ansar Hassan, a cardiac surgeon in Saint John, New Brunswick.

First study of its kind

“This is a very important study because no one has ever looked at the longer-term outcomes of cardiac surgery in the over-65, possibly-frail population in Canada,” explains Dr. Hirsch. “We have found in preliminary studies that more than 50 per cent of these patients are either frail or vulnerable and face a higher risk of death, major complications or discharge to a long-term care institution soon after cardiac surgery.”

The Canadian Frailty Network study is taking the knowledge several steps further, to examine how well some 450 cardiac surgery patients aged 65 and over are doing in their day-to-day lives six months after their operations.

“We need to know if people are in their homes, doing well and able to look after themselves, or if they are still in long-term care with a lot of lost function and great need of assistance,” notes Dr. Hirsch. “By carefully assessing the patients’ frailty before surgery and comparing this to how well they are doing six months later, we can better predict longer-term outcomes for individual patients.”

Currently in Canada, frailty measures are not included in standard risk-assessment protocols for surgery. Meanwhile, the number of older adults living with frailty being referred for major cardiac procedures has grown steadily over the past decade nationwide, so that the proportion of this patient population over age 80 has nearly doubled.

What has not grown is patients’ understanding of how their older age and degree of frailty may affect their surgical outcomes.

“In talking to patients who are frail and vulnerable, we have found that most have no idea of the risks that surgery poses to them, in terms of mortality or major complications, let alone the loss of independence,” says Dr. Hirsch. “We’ve also learned that most value their independence and quality of life over simply living longer, if longevity means surgery that results in loss of independence and quality of life.”

In fact, Dr. Hirsch and his team have discovered that as many as 25 per cent of patients over 65 regret their decision to have heart surgery once they learn—the hard way—what it has cost them.

Shared decision making

“We want to ensure that people receive care that matches their values,” Dr. Hirsch says. “We also want to empower them to play a strong, well-informed role in their health care decision-making processes.”

This aligns with two of the Canadian Frailty Network’s key strategic priorities—to match care to values and to empower, engage and support patients and their family and friend caregivers in sharing decision making with clinicians.

“Older Canadians living with frailty, and their family and friend caregivers, often feel under-informed and ill-equipped when dealing with their complex health care needs. Care decisions can leave them feeling helpless and confused,” says Dr. John Muscedere, CFN’s Scientific Director and CEO. “The decision aids used in Dr. Hirsch’s research provide relevant, evidence-based information in a format that is easy for the average Canadian to understand.”

Dr. Muscedere also praises the FACT (frailty assessment and care planning tool) utilized by Dr. Hirsch and his team. “We advocate identification and assessment of frailty as standard clinical practice in all care settings across Canada,” he says. “This project is a perfect example of how this can work and why it is needed.”

As Dr. Hirsch explains, people do not always understand that the decision to go ahead with surgery—or not—is theirs to make. “We have a history of paternalism in our health care system,” he notes. “There’s the idea of ‘the doctor’s orders’ and ‘doctor knows best,’ but what we want to promote is the idea that the doctor, patient and family are both experts, the doctor in the medical alternatives and best evidence, but the patient in terms of their values and their goals and expectations. We need both inputs to make a sound decision. We need to provide patients with accurate information about their risks from surgery and have an honest discussion about what the outcomes might mean for them.”

The details matter in frailty

Unlike the most commonly used frailty assessment tools, which give a basic yes/no answer, the FACT assesses patients’ wellbeing on a scale from thriving to terminally ill, across four domains. These are mobility, social involvement, function, and cognition.

“We want to be able to tie patients’ scores in each domain to how they are likely to be doing in each of these areas six months after surgery,” explains Dr. Hirsch. “This will help us give patients a much more comprehensive picture of what their life will look like, so they have more information to guide them in the decision.”

In the case of certain domains, such as mobility, surgery may improve the patient’s ability to get around independently by improving their heart function.

That has certainly been the case for Sally O’Brien, who has no regrets about her decision to go ahead with a triple coronary artery bypass procedure. She did experience some post-surgery complications that required her to stay in hospital for 11 days but, after that, she was well enough to go back home with some follow-up home care from the VON.

“I feel great now, apart from the emphysema,” says Sally, two years after the procedure. “I have a lot more energy than I did before the surgery and it’s a relief to know my risk of heart attack is way down. I’m so grateful to Dr. Hirsch for his expertise and kindness.”

Fortunately for Sally, however, she lives with her grown children. “I don’t know how people living on their own could do it,” she says. “For the first while after the operation, I couldn’t raise my arms over my head or go up and down stairs… cooking would have been impossible. My son and daughter made my meals for me and looked after me.”

Remarkably, Sally is back at her part-time job working at a local drugstore one day a week. She enjoys getting out and talking to people… it keeps her young at heart.

“I want to be the first in my family to live to be 96,” she says. “There are some long-lived people in my family, but no one has made it to 96 before. The way I see it, your mind has a lot to do with it, and we Nova Scotians know how to be tough.”

Resilience is in fact a key quality that can help to stave off frailty and something the researchers have on their minds.

“Ultimately, we want to know if we can help to alleviate at least some aspects of frailty prior to surgery, to reduce patients’ risk of such adverse outcomes as loss of independence,” Dr. Hirsch says. “If we can help them improve their overall health and fitness, surgery can be a turning point for the better in their lives.”

A strong supporter of this “pre-habilitation” approach, the Canadian Frailty Network is also funding an Ottawa-based research team led by Dr. Daniel McIsaac to see if patients’ surgery outcomes are improved by taking part in a pre-surgery exercise program.