Ethical consultation for radical urological surgery in fragile elderly people
The care of fragile patient is an aspect still largely debated. In the past was encouraged economic assistance with low clinical content; in this context find place an evaluation also based on ethical clinic. We don’t want to discuss surgical methods or medical results, but we would like to demonstrate the way we answered an explicit (or sometimes tacit) question when we decided to perform surgery on a patient with these characteristics: “It really needs to perform surgery on him at his age?”
Materials and Methods
2) Materials and Methods
The word “fragile” identifies a condition of risk and vulnerability, with unstable equilibrium towards negative events. Elderly people, due to aging process and intercurrent diseases, become more vulnerable and many conditions can change homeostatic balance of their organism (1). It is defined essentially by two paradigms:
Biomedical: this condition is considered a physiological syndrome defined by reduction of functional reserves and weak resistance to “stressors”, resulting from cumulative decline of multiple physiological systems causing vulnerability and adverse consequences (2)
BioPsychosocial : this condition is considered like “dynamic state affecting people who experience losses in one or more functional domains (Physical, Psychic, Social) caused by multiple variables that increase risk of adverse events for health” (3,4). To evaluate fragile patients we applied the Multidimensional Oncological Geriatric Evaluation (MOGE) and the scale: Vulnerable Elders Survey (VES – 13), and screening tool (G8) (5,6). We defined three categories of patients:
FIT: absence of disability or comorbidity, standard treatment can be applied.
UNFIT/VULNERABLE: presence of many comorbidity and/or disability and /or Geriatric Syndrome; treatments conformed to general clinical conditions can be applied to improve quality of life.
UNFIT/FRAIL: cannot be included in previous two categories¸ personalized treatment to improve quality of life and survival can be applied
We scanned the caregiver. Cancer changes family architecture. Caregiver takes care of sick people in first person, is an integrated figure in the care of oncological patient with important caretaking and ethical tasks and is involved in many aspects of the care through several phases of oncological disease: drugs administration, symptoms management, nutritional assistance, treatments supervision, emotional support.
In the second half of 2016 we perform surgery on 12 patients that can be defined fragile elderly people. In 5 patients we perform radical cystectomy with ureteroileocutaneostomy (Bricker). In 3 patients we must perform radical nephrectomy (in addition to cystectomy), with monolateral ureterocutaneostomy, in 2 patients we perform radical nephrectomy and in the last 2 patients conservative renal surgery. Actually 10 patients are in follow-up. 2 patients died (one for pulmonary thromboembolism during surgery and one after 4 months for pulmonary infection).
Combining data from MOGE (VMG) and data from interview with caregiver (that we consider fundamental because relationship between caregiver and health professionals have important ethical and social implications) (7), we got to analyze the whole question according to ethical clinic using bioethical foundations, contractualism, utilitarianism, ontology based personalism (8), but in particular inspired by Bioethics of everyday life (9,10,11) that want to face daily life themes of professionals of care process so that ethics become an operative tool stimulating a change for improvement of health intervention.
Ethical consultation allows to help any health worker, patient, caregiver who need advice in facing hard or suffered decisions. In particular helps doctors to answer the initial question: “It really needs to perform surgery on him at his age?”, not only with the guidelines indications, but also in the perspective of total care so that the narrative medicine based (12) approach became always more important in health resorts
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2) Untangling the concepts of disability, frailty, and comorbidity: Implications for improved targeting and care. Journals of Gerontology. Series A: Biological and Medical Sciences; 59(3): 255-263; 2004 Fried LP et al.
3) Gobbens R.J. et al. In search of an integral conceptual definition of frailty: opinions of experts. J Am Med Dir Assoc; 11(5): 338-43; Jun 2010
4) La fragilità dell’anziano. Linea guida Regione Toscana 2013
5) Tumori dell’anziano .Linee Guida AIOM 2016
6) Gestione del paziente unfil/trail : il punto di vista dell’Urologo. A. Giacobbe Convegno renal care Verona 7-8 Marzo 2014
7) Family caregivers, patients and physicians: ethical guidance to optimize relationships. Mitnick S., Leffler C., Hood V.L. J Gen Intern Med 2010; 25: 255-260.
8) Dalla parte della vita . Itinerari di Bioetica Vol. 1 E. Larghero . Effatà Editore 2010
9) Bioetica del Quotidiano. S. Spinsanti Medico e Bambino 1/1997 pag.59-64
10) Bioetica Quotidiana. G. Berlinguer. Giunti Editore 2000
11) La Bioetica del Quotidiano. E. Sgreccia Vita e Pensiero Editore 2006
12) Bioetica e medicina narrativa: nuove prospettive di cura . E. Larghero Edizioni Camilliane 2013