A centarian survives a complicated surgery
A geriatric patient undergoes a complex procedure for gastric outlet obstruction and causes a medical team to question their stance on geriatric surgery.
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The news that a 103-year-old female patient was being admitted to the surgical unit caused quite a stir among the nursing and physician staff, as the majority of our patients underwent major hepatobiliary and pancreas procedures. At the time, I was the nurse practitioner on the admitting service. The patient was coming from a nursing home with an admitting diagnosis of gastric outlet obstruction.
The patient arrived and did not look her stated age. She appeared younger, but what exactly is a 103-year-old lady supposed to look like? She was accompanied by her 76-year-old daughter and 56-year-old granddaughter. All of the ladies had beautiful, crystal clear, blue eyes and the resemblance to each other was apparent. The family was very involved in the care and welfare of this patient.
The patient's age was well documented. She had resided at the nursing home for a number of years, had been active, very social and with a respectable appetite until a few weeks prior. Preliminary evaluation revealed a duodenal cancer. The patient was being considered for a Whipple procedure to remove the obstruction and allow her to eat normally. The Whipple procedure is a formidable surgery for any patient to undergo even at a younger age.
This was new territory for the surgical team. The patient had an extensive preoperative medical evaluation, as well as functional status, cognition, frailty, social functioning and support, and nutritional evaluation. This petite lady was in excellent health except for poor hearing. An ethics committee consult was convened to assess the patient's physical and mental capacity to have the proposed surgery.
I was truly amazed when someone finally asked the patient if she wanted to have this complicated surgery. She was quick to reply she would like to have the surgery, so she would be able to eat again. She was deemed competent to make her own decision regarding surgery.
The day of surgery all of those involved in the surgery were anxious. Careful preoperative preparation by the surgical team was observed. The big question to be answered at the time of surgery was “What does a 103-year-old patient's pancreas look like?”
Or for that matter, any of her internal organs? I was privileged to be able to see the patient on the operating table and was amazed to see she had a normal appearing pancreas.
Surgery went smoothly and expeditiously with careful attention to delicate surgical detail, as well as the delivery of superb anesthesia. The patient progressed in her recovery as per critical pathway over a 12-day period without any complications.
During her recovery she complained of minimal pain, received almost no opioids and did not seemed phased by any manipulation or withdrawal of wound drains or tubes. Everyone was truly amazed to see her nearly flawless recovery. Ultimately, this patient challenged every healthcare provider who encountered her to reconsider their views on surgery in the older adult.
The patient was discharged and returned to the nursing home. I had the good fortune of being in the clinic the day her family accompanied the patient for a postoperative clinic visit to remove the last surgical drain and assess how she was doing. The patient had continued to do well in the nursing home for three more years when she died of causes other than cancer.
This experience helped me learn a great deal about the care of the older surgical patient. The comprehensive preoperative assessment of this older surgical patient helped the surgical team navigate a centenarian through complex surgery and postoperative recuperation.
A thorough preoperative evaluation that considered the whole person, carefully planned surgery, attention to detail by the surgeon and anesthesia, making the patient the center of care and the right of the patient to decide for herself, taught me an older patient can undergo major surgery, recuperate and continue to live their life.
This patient made a lasting impression and led me to pursue a doctoral degree in nursing practice, focusing on the preoperative assessment of the older adult. I am now the Clinical Program Coordinator for the Sinai Center for Geriatric Surgery in Baltimore -- all a result of caring for this 103-year-old patient and wondering what her pancreas looked like.
JoAnn Coleman, DNP, ACNP, AOCN, practices in Baltimore, Maryland.