Australian and New Zealand College of Anaesthetists
The Australian and New Zealand College of Anaesthetists (ANZCA) ), including the Faculty of Pain Medicine, is one of Australasia's largest specialist medical colleges and is responsible for the training, examination and specialist accreditation of anaesthetists and pain medicine specialists and for the standards of clinical practice.
Avoid initiating anaesthesia for patients with limited life expectancy, at high risk of death or severely impaired functional recovery, without discussing expected outcomes and goals of care.
The high risk of postoperative morbidity and mortality in the elderly population in particular has been well documented. Patients over 70 years of age having major surgery in Australia and New Zealand health care facilities are at high risk for postoperative events, with 20% experiencing complications within 5 days, 10% requiring critical care admission and 5% dying within 30 days.
Frailty is the state of increased vulnerability to stressors and increases the risk of adverse outcomes including falls, delirium and disability. Such stressors may include hospitalisation and surgery. Functional capacity, one aspect of frailty assessment, has been shown to be an independent predictor of mortality with each ASA class. There is currently much research into the implementation of frailty assessment as part of clinical practice and into whether preoperative measures and postoperative management can improve outcomes. Discussion with the patient and family about the risks and benefits of hospitalisation and surgery in this context are important.
Discussion must centre on patient values and preferences for care and the goals of care when there is significant risk of perioperative morbidity or mortality. This is particularly pertinent in patients with limited life expectancy due to advanced cardiac, renal or respiratory failure and / or metastatic malignancy. Discussions around expected functional recovery and treatment limitations have been demonstrated to reduce stress and anxiety in patients and their families. Many healthcare facilities now require advanced care directives or goals of care plans on or shortly after admission in the appropriate clinical setting.
For patients at highest risk, and where time allows, the discussions should be led by a multidisciplinary, consultant level team, particularly where there is a risk of futile surgery and/or futile intensive care. It is important to ensure that alternative care, focused predominantly on comfort and dignity, is offered to patients and their families.
- Story DA, Leslie K, Myles PS, et al. Complications and mortality in older surgical patients in Australia and New Zealand (the REASON study): a multicentre, prospective, observational study. Anaesthesia 2010;65:1022-30.
- Visnjevac O, Davari-Farid S, Lee J, et al. The effect of adding functional classification to ASA status for predicting 30-day mortality. Anesthesia & Analgesia 2015;121(1):110-16.
- Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010;340:c1345.
- Søreide K, Desserud KF. Emergency surgery in the elderly: the balance between function, frailty, fatality and futility. Scand J Trauma Resusc Emerg Med 2015;23:10.
ANZCA’s Safety and Quality Committee established a working group that developed a preliminary list of 10 anaesthetic-related practices that, based on clinical evidence, may have possible limited benefit, no benefit or may potentially cause harm to patients. Using an on-line survey tool, all ANZCA Fellows and trainees were invited to rank these recommendations and provide relevant comments. This engagement facilitated consensus and informed Fellows and trainees about ANZCA’s involvement with the Choosing Wisely campaign.
ANZCA’s final list of 5 Choosing Wisely recommendations deliberately supports the clinician’s judgements and emphasises the importance of considering patient and surgical factors in decision making; in particular, as regards the selection of necessary preoperative testing and appropriate facilities for all patients and the expected outcomes and goals of care for the medically frail.
- 1 Avoid routinely performing preoperative blood investigations, chest X-ray or spirometry prior to surgery, but instead order in response to patient factors, symptoms and signs, disease, or planned surgery.
- 2 Avoid ordering cardiac stress testing for asymptomatic patients prior to undergoing low to intermediate risk non-cardiac surgery.
- 3 Avoid administering packed red blood cells (blood transfusion) to a young healthy patient with a haemoglobin of ≥70g/L who does not have on-going blood loss, unless the patient is symptomatic or haemodynamically unstable.
- 4 Avoid initiating anaesthesia for patients with limited life expectancy, at high risk of death or severely impaired functional recovery, without discussing expected outcomes and goals of care.
- 5 Avoid initiating anaesthesia for patients with significant co-morbidities without adequate, timely preoperative assessment and postoperative facilities to meet their needs.