Older Adults’ Perspectives 3 Months After Emergency General Surgery Highlight Opportunities to Improve Care

INTRODUCTION

Adults ≥65 years make up a significant percentage of those undergoing emergency general surgery (EGS).¹ For those who survive the index hospitalization, more than half are re-hospitalized in the year after discharge, and one in three die.¹ Although surgical quality improvement initiatives have largely focused on reducing complications and mortality in the acute peri-operative period,² patients’ long-term needs beyond this 30-day window remain understudied and the lived experience from the patient perspective poorly understood. To address this gap, we qualitatively explored factors contributing to or impeding recovery as experienced by older adults three months post-EGS.

METHODS:

Eligible patients were ≥65 years, underwent one of seven common EGS procedures, and received inpatient care at one of three Boston-area teaching hospitals between December 2018 and August 2019 with a length of stay ≥5 days. Patients were contacted three months post-discharge. Semi-structured interviews were conducted by phone by trained interviewers, audio-recorded and transcribed with verbal consent. The interview guide was designed to explore day-to-day life three months after surgery. Demographic and clinical data were collected via chart review. Data were analyzed inductively using interpretative phenomenological analysis and NVivo software.³ A codebook was developed, continuously reviewed for coding discrepancies. and refined with ongoing sampling until thematic saturation was reached.⁴

RESULTS:

Thirty-one patients were interviewed. The patients’ mean age was 73.4 years, 51.6% were men, 50% were married. Most were white (83.9%) and had a Charlson comorbidity score ≥2 (61.3%). The most common procedure was a laparotomy with bowel resection. The majority (81.6%) were discharged directly home.

Reflecting on the three months following discharge, patients shared a common recovery goal of regaining independence in activities of daily living and returning “back to normal” (Table 1). Patients noted their primary concerns regarding functional status as not being adequately addressed by their surgical team. As one patient shared, when she brought up her concern about her decreased ability to mobilize after undergoing laparotomy: “[the surgeon] told me he hadn’t operated on my legs.” Fatigue was a highly salient residual symptom. Patients identified intrinsic motivation and social support as facilitators of recovery. Most patients had in-home or local support from family that eased the transition from hospital to home. Patients noted that caregiver responsibilities caused significant changes in the day-to-day life of their family, including disruption to employment, change in living situation, and social isolation.

Table 1.

Life After Surgery

Goals and Needs During Transitions of Care
Regaining independence	“I’ve been doing everything [for the ostomy] myself. Some days are a bit hectic…but little by little I’m in a routine, I know how to take care of it and everything.” 75YF
Recovery goal: “back to normal”	“I’m not as strong as I was prior, it’s going to take some time to get that back…you know, take baby steps…the process is gonna take me four, five, six months, seven months to get back to somewhat normal.” 70YM “I was incapacitated for a week and uh but as far as the attention-medical attention I don’t have any problems…I’ve made a full recovery. I’m doing very good…I’m back to doing what I was doing before.” 80YM
Persistent fatigue	“I’m weak, still weak as we speak. It takes time, takes a little time.” 74YM
Facilitators of Recovery
Motivation	“…my attitude has always been good, you know I was never down, I always looked ahead to things are going to be better…that helps too.” 73YM
Supportive social environments	“I had my husband, my girls were all down…you know from all their places, I just relaxed, my husband cooks, my kids clean, it was all fine.” 70YF
Roles & Responsibilities of Family Caregivers
Assistance with activities of daily living	“Just getting up, you know, going to the bathroom, having someone to wash me…they did it in the hospital, so my daughter just took over here.” 67YF
Emotional Support	“…she was my shoulder to cry on when I was feeling out of it, saying “your strong mom, you can do this”…my strength during my very bad time.” 75YF
Disruption to everyday life	“[my daughter] has her own business in Jersey, she came up, it was so disruptive in that way.” 70YF
Social isolation	“[my daughter] was worried, took a couple of weeks before she would go out [with friends]…I said, “I’m fine, you don’t have to worry about me.” 73YM
Caregiver distress	“…my grown son has come back home, he’s very frightened about the illness because he’s never seen me so ill…I’m not lying in bed or that kinda thing but I’m not active.” 78YF

DISCUSSION:

This study describes the lived experience of older adults three months after undergoing EGS. During this time, patients shared a common treatment goal of “getting back to normal.” To achieve this goal, patients relied heavily on family and friends acting as informal caregivers. These findings highlight that the priorities of older adults during recovery extending beyond traditional outcomes such as 30-day morbidity or readmission and suggest that additional support is needed for both patients and caregivers.

Coordinated care at discharge for surgical patients focuses on the immediate transition from hospital to home with attention on reducing preventable 30-day readmissions, rather than functional outcomes that patients prioritize.⁵ We believe it is important for geriatricians and primary care clinicians to be aware of these potential gaps in communication and expectations, as they are likely to manage patients throughout the post-operative period. The American College of Surgeons’ Geriatric Surgery Verification Program has targeted improved documentation and communication from surgeons to primary care physicians as a standard of care for geriatric surgical patients.⁶

Although EGS patients may be community dwelling after surgery and fulfill standard surgical criteria for recovery, many still rely on informal care from family to support their everyday needs three months after discharge. This raises questions regarding whether they are receiving adequate support from the healthcare system for long-term care needs. Patients described how family members assumed new roles as caregiver, and worried about the physical, emotional, and social impact caregiving on their family. Their worries are valid: research shows that caregiving, although rewarding, may adversely affect caregiver health and well-being.⁷ Caregivers should be identified for older EGS patients prior to discharge, with a needs assessment documented in discharge paperwork and care transitions.

We recognize that our findings are not transferable to all older adults who undergo EGS. While our efforts give voice to a vulnerable group that has not previously been interviewed –patients who have survived EGS – we were unsuccessful in recruiting the sickest patients, such as those who declined to participate due to ongoing health concerns. Nonetheless, the experiences of those interviewed shed light on a previously overlooked population and reveal opportunities to improve their care in the long-term.