Doctors to use ‘Frailty Index’ to decide for or against surgery

A new test could help decide whether you should have surgery.

Doctors to use ‘Frailty Index’ to decide for or against surgery

How frail you are could be used to assess whether you’ll qualify for surgery in the future, with hospitals calling for a ‘Frailty Index’ to help them minimise ‘futile’ surgeries.

The Frailty Index, currently being developed by Melbourne hospitals, will measure how well a person, specifically older people, will recover from surgery. It is being created to help them figure out whether a person will survive surgery and how long they’ll live after an operation.

Royal Melbourne Hospital anaesthetist and intensive care specialist Dr Jai Darvall will assess 250 patients before and after surgery, to discover the factors and indicators that should provide more accurate methods of assessing a person’s suitability for surgery.

The test comes after the Australian and New Zealand College of Anaesthetists (ANZCA) urged doctors and families to be more open about the true benefits of proposed surgery.

The benchmarks will indicate who may be beyond help and who could benefit, but is not intended to deny operations.

“You could have a really fit 80-year-old who is running marathons who poses less of a surgical risk than a 60-year-old frail person,” said Dr Darvall.

“As you get older you accumulate deficits and that might be some comorbidities (such as) heart disease, lung disease, it might be problems with hearing or vision, problems with mobility, a person’s gait or arthritis, or not being able to do the stuff they used to.

“One by one, these things start to mount up and eventually they reach a threshold where you say a person is frail.

“It means that recovery is much harder and people are more likely to go on to poorer recovery, perhaps not getting back home or not getting back to functional independence.”

“In the end what we are aiming for with anaesthesia and surgery is to improve somebody’s quality of life — it is not just about quantity, it is about quality,” said ANZCA president Prof David Scott.

“And that means taking on board people’s own views and expectations and what they want to achieve.

“We are fixated on this idea that if there is a small chance of surviving then it is a success. But that may not be the case.

“It could be three months relatively pain free, highly-mobile quality of life compared to six months following a major operation with a long drawn out recovery, most likely some complications, and actually never getting back to that good quality life you expected.”

What do you think of this test? Would you welcome this type of assessment? Do you think that eliminating unnecessary procedures could, in turn, reduce the cost of health insurance?

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    COMMENTS

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    mogo51
    16th Oct 2017
    10:12am
    My mother is 94 has advanced alzimers and has little or no quality of life. Recently she developed an ulcerated cancerous wound on her leg. To my complete dismay, doctors were talking of surgery to cut out the cancer and do a skin graft.
    Both my sister and I told them in no uncertain terms that was not to happen. Rather, increase medication and keep her as pain free as possible. Eventually but begrudgingly these wishes were carried out.
    There was no way she would have survived such an operation. If I were a total cynic I would think that it was about the money rather than the patient!!! Now that would not be right surely????
    She did not have the surgery and is still going although she does not know it!. Horrible disease is dementia. This might raise a few eyebrows but I am in favour of euthanasia where loss of quality of life is final. It is about who deserves the limited health care that is currently offered, hopefully that 'operation' went to a more deserving person ie. a young child.
    Gammer
    16th Oct 2017
    11:56am
    I completely agree with you - I have told my children that, should I have some accident or illness that leaves me with no ability to comprehend my surroundings, recognise loved ones, or otherwise enjoy life then they must let me go. It is a total waste of good money that could be better spent in helping those who will recover and have fulfilling lives.

    We do not inflict unnecessary suffering on our pets so why make people endure this.
    bob
    16th Oct 2017
    10:33am
    I discussed this question of quality of life with my surgeon before I had an operation for cancer and they seemed quite amazed that I had brought it up .It was almost as though I was questioning their skills.The operation had a small effect but the following chemo and side effects stopped all normal life.And no one told me about that.
    Puglet
    16th Oct 2017
    11:19am
    I too received the same reactions from my cardiologist and cardiac surgeon when I said that IF anything went seriously wrong I didn’t want to be resuscitated. I think many people don’t realise that hospital staff will often ignore NO Resuscitation in their hospital notes. Residents of Aged Care Homes for those with Alzheimer’s etc are sometimes resuscitated if they arrest before transfer to hospital even when the wishes of the person and family are clearly documented. I too hope Euthanasia legislation will be enacted in WA. Most of us will die with Alzheimer’s so we’d better get it sorted!1
    Rosret
    16th Oct 2017
    6:30pm
    As much as people scoff at Google medicine I find that is has been incredibly useful in finding out everything the Doctor doesn't have time to tell you.
    maggie
    16th Oct 2017
    11:04am
    Quality of life should always come before quantity of life. I have seen so many patients suffer because doctors and families look at it the wrong way round. Always put the patient first.
    Dollars over Respect?
    16th Oct 2017
    11:51am
    The best decision for the patient should be a priority. However, a patient who does not have a mental deficiency/dementia surely has the right to decide whether they want a procedure done or not - why should anyone deny them the opportunity to live or to achieve a potential better quality of life? Even if the doctors do not expect the outcome to be a positive one - medical 'miracles' do happen, due to a patient's desire to overcome against all the odds. Such stories are frequently reported. I wouldn't like my decision to take on the challenge, after being fully informed of the risks, overthrown by a board of 'experts' against my will.
    Play Fairly
    16th Oct 2017
    1:00pm
    I so much agree with you. All this is becoming very scary. It is starting to look an awful lot like 'dollars over respect' to me. It seems to rest in the same category as the suggestion that Aged Pensioners should be made to reverse mortgage their family home to pay for their pensions.

    I won't give up my determination to survive despite any of the obvious disrespect that many younger people have towards the aged in our society.
    Triss
    16th Oct 2017
    1:12pm
    I agree with you, dollars, I don't want anyone deciding on my behalf whether I should have a lifesaving operation or whether it will be too much bother.
    On the one hand we're told we're living longer and are strong enough to work longer so we can't access the age pension until 70 and on the other hand we're told to shuffle off the mortal coil because we're not strong enough for a medical procedure.
    I don't think we'll be winners here.
    Nan Norma
    16th Oct 2017
    12:20pm
    I think this already happens as I have friends that have been they wouldn't survive an operation due to other medical conditions.

    16th Oct 2017
    12:21pm
    I agree that quality of life is better than quantity. It's not clear who will make the decision and I would hope that it's not just one doctor. It may be preferable for a panel of medical specialists to make a recommendation to the patient or family rather than just the opinion of one medical person.
    Sen.Cit.90
    16th Oct 2017
    12:50pm
    At age 88, I'm unsure how to comment on this. I would hope the decision not to operate would be by a panel of doctors.
    Eventually, I would hope they would respect the wishes of my 'Advanced Health Care Directive'.
    Jennie
    16th Oct 2017
    1:02pm
    Make sure you have an ACD, Sen.Cit.88 and an advocate who you trust and who will ensure your wishes are carried out. Don't leave it to chance and trust any "panel of doctors" to be helpful - IF such a panel were to exist.
    If doctors were to ignore your ACD and advocate's acting on your behalf, then any unwanted treatment can be considered an assault and legal action threatened.
    Jennie
    16th Oct 2017
    12:56pm
    I have read the proposed Frailty Index in a book by Ken Hillman, Australian ICU specialist,
    "A Good Life to the End: Taking control of our inevitable journey through ageing and death."
    This index is extremely sensible and is aimed at preventing suffering which will occur for the aged frail especially in the ICU if there is no ACD, family disagree, the patient is not able to make a decision due to coma and/or dementia etc. Euthanasia? Yes, but do it yourself before you become "mentally incompetent" if you can... Takes courage to go before your time...
    KSS
    16th Oct 2017
    1:05pm
    I think there are a lot of factors at play here. I believe interventions often happen because not to do so lays the doctors open to lawsuits if the patient dies when there was another treatment option. At other times it's the family pushing for interventions to give them 'one more day' with the patient regardless of the quality of that extra day.
    Much money and resources are wasted on futile interventions for patients of all ages and I hope that this 'frailty index' is applied across the board not just the elderly.
    inextratime
    16th Oct 2017
    1:22pm
    A another good reason to stop smoking. One of the questions I was asked before three ops for cancer was "do you smoke". I happily declared that I didn't. 2 x 6 months of chemo had no effect on me and I wonder if the fact that I rarely take medication helped with that scenario.
    Strummer
    16th Oct 2017
    1:43pm
    A friend of mine had a problem with his foot. It didn't adversely affect his mobility but did cause him some pain. His doctor advised him that surgery could fix the problem but given his age [85] the dangers outweighed the benefits. My friend went ahead with the operation but died in hospital of a heart attack. If not for the strain he needlessly put on his heart he may have been alive today.
    Charlie
    16th Oct 2017
    2:03pm
    It's being done to a certain extent already, they are just trying to formalize it.

    I have lots of pain issues where they could do investigative surgery, but the surgery itself is a risk and there is no guarantee of success.

    I was at the hospital today, but they won't do anything unless there is blood, urine, or CT scan to say there is something wrong and they can fix it.
    On paper everything looks great, but it doesn't feel great. One day I wont remember if it feels great or not.
    BElle
    16th Oct 2017
    2:22pm
    From my own recent family experiences I would definitely say that this should be taken into consideration. Not just for frailty but the likely hood of survival due to holistic judgement of the health of the patient. e.g. If the patient is suffering the final stages of terminal cancer, they should not then be treated for peripheral ailments such as, skin cancer, or any other cancer not immediately affected by the stage 4 cancer. I know for certain that this occurs and is futile, both from the longevity of the patient and the unnecessary additional suffering caused to the patient from unnecessary surgery or invasive treatment.

    16th Oct 2017
    2:52pm
    The more I have to do with doctors, the less impressed I get. In general, they are arrogant, ignorant, and financially rapacious.
    MD
    18th Oct 2017
    1:01pm
    Maybe so DrP however, those qualities are not confined strictly to the medical profession and could just as readily apply to mankind - in general.
    Joy Anne
    16th Oct 2017
    3:34pm
    Totally agree withmogo51 and Gammer
    KB
    16th Oct 2017
    3:34pm
    People are entitled to their opinions on both sides of the discussion, Smokers should be on the low priority list. due to the damage that smoking has caused to their bodies. If they choose to give up smoking then they are welcome to have surgery. My mother was in her eighties and had several falls and required surgery so older frail people should be entitled to surgery increase their chances of living a quality life. This article is telling me that doctors would like pick and choose who they want to operate on when it c comes to frailness. I am due for another hip operation and would not like to be told that I could not have a new hip due to mobility issues.
    Rosret
    16th Oct 2017
    6:38pm
    They already choose, KB. They don't want to steal people's precious last few years of life should not surviving be a significant risk.
    Chris B T
    18th Oct 2017
    11:52am
    Regardless of age or frailty, you do not want to hear oh oo from the "anaesthetist" while you are lying on the operating table. Just before you are about to go out.
    Nothing to do about what surgery you are about to have, the very person responsible for your life while under anaesthetic has a cavalier approach to their responsibilities .
    Name, date of birth, age etc where all ignored and gave my tailored anaesthic to a previous patient.
    Just another aspect to deal with.
    I was OK but the other patient was very ill in recovery.
    MD
    18th Oct 2017
    12:57pm
    "Quality vs quantity", what price life eh, each individual would argue they themselves (assuming faculties intact) as being fit and capable of determination.
    The small problem of cost might have something to do with this issue and given that the public health system is struggling further exacerbates the complexities.
    What might be seen as "quality of life" to the dear old soul's warmly ensconced in the TLC of a (govt subsidised) local nursing home/aged care facility and considering a surgery procedure that might lend some small degree of "quality" yet extend the "quantity" is highly questionable. To be sure, were the patient to fully fund their own procedure then no questions need be asked.
    This macabre business of 'keep em alive at any cost' sees the biggest winners being the quaks, the elderly patient's meanwhile may have scored a momentary reprieve but at what cost regards discomfort - for themselves, their family and/or the nursing staff. A few of the examples above underscore the issue.
    A cynical person might understandably suggest that 'big brother' could be prompting discussion of this nature simply as a means of putting a case for further cuts to the ailing health sector. Ours is an aging society and continues to grow exponentially meaning that if we consider all options NOW, then we might better be prepared to adopt/alter or dump ideas accordingly.
    Constancy is inconsistent, we live in a state of flux, disruption the current zeitgeist.
    patti
    23rd Jan 2018
    10:43am
    I don't believe it's only the frailty test which is applied. Following a back injury, I had some treatment and one option was surgery, which I said I didn't want. My GP told me that because of my age (72 at the time) it would probably not be covered under the public health system anyway, due to the risk. But guess what?....another friend who was 78 was able to have the surgery. The difference? she had private hospital cover. Two tiered health system, so immoral
    professori_au
    22nd Nov 2018
    6:17pm
    At first glance this seems not a bad idea. However, I would not support the notion as it is basically setting the medicaal profession as god, deciding on who will live and who should die.
    E.g. I personally know of a case many years ago when a young chapp was hit by a crane pulley and severely injured and not expected to live. He was a survival machine for 4 years in the coma and suddenly four years later suddenly woke up and started speaking quite clearly. Clearly he had to then go through some physio, etc. but he survived. My wife's operation was delayed and delayed for a couple of years as not being anemergency and suffered extreem pain until her heart failed her and she died. I cannot claim the medical professional killed her but believe as an otherwise healthy person requiring what the hospital condidered a minor operation may not have contributed to her failure. No if someone is ill and needs an operation then let them have it. They are entitled to an opportunity to live and no doctor/s should be allowed to make that decision. Are we entering a time where costs are more important than service. I know governments in australia put health, medical, dental, the disabled and education and industrial training on low priority than funding and supporting the war machine but we need to speaka up and indicate what the people wish