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21 Questions to Ask Before Open Heart Surgery

21 Questions to Ask Before Open Heart Surgery

Last year, my father-in-law had heart surgery that included two valve replacements, a valve repair and a single bypass. Having worked in open-heart recovery and cardiac and pulmonary rehab, I know that heart surgery is not a piece of cake, especially on anyone over 80 years of age. Cardiac surgery on octogenarians is more common now and there are specific guidelines on how to manage different types of heart conditions based on heart function and other parameters. Knowing how little time some physicians will spend at the bedside, especially before surgery, I felt the best solution was to arm ourselves with as many questions as possible, understand the risks and benefits of the procedure, the recovery process and time and anything else that would help him make a decision and prepare for his future.

What I was not prepared for was the breeziest of the initial conversations from the cardiologist and surgeon. Both doctors came in, spent some time discussing the procedure, the importance of the procedure, but honestly, did not provide much information on the negative side. We could have left the meeting with a high-five and an anticipated length of stay of five to seven days, or earlier if he did well, had we not been prepared with our list. I believe they were both surprised that our family had a list of questions for them, and we wanted numbers and statistics. When you start hearing the statistics, the decision-making process becomes more sobering.  Yes, we were at one of the best heart hospitals in the Midwest, and yes, according to the staff, “we do heart surgery on older people all the time.” What you don’t hear is what happens when you are discharged, how long recovery takes, and everything you have to do just to try to get back to a previous state of activity, if that is at all possible. As we all know, outcomes and recovery can vary, especially on older adults.
Below are the questions we asked and then some.  These questions are specific to heart failure symptoms and conditions but they can be modified to your situation. We asked these questions after all the testing was complete. The situation was not emergent. We had time to make a decision.
21 Questions to Ask Before Open Heart Surgery
  1. Which heart valves are affected?
  2. How severe is the dysfunction? (Mild, moderate, severe, etc)
  3. How is the heart dysfunction causing the congestion in the lungs?
  4. Are there non-surgical options available? (meds, oxygen, exercise, etc)
  5. What surgical options are available?
  6. What is the possibility of minimally invasive procedure(s)? (mitral “clip” or E-valve)?
  7. What is the mortality rate for valve repair or replacement in octogenarians?
  8. What is the rate of infection for your hospital in post-operative patients?
  9. What is the possibility of a stroke after surgery? We did ask this question and discovered he had a 20% chance of having a stroke). 
  10. If a stroke occurs, what is the treatment? We did not ask this question. We later found out after he had stroke after the surgery, there was a 20% chance of not surviving a stroke, and a significant chance of having paralysis or other problems.We also discovered that there is not a treatment for stroke after open-heart surgery because of the anticoagulants in the system).
  11. What are short and long-term complications and consequences of the surgery? (Neurocognitive deficits, short and long term complications, incomplete recovery, infection, leaky valves, electromechanical disorders, phlebitis, or just poor response to surgery).
  12.  Is there a way to prepare for the surgery or procedure (if indicated?)
  13. What is the one most important thing to do after surgery? (in our case, it was sitting on the side of the bed the first day of surgery).
  14.  If a valve replacement is recommended, what is the long term care/concerns we need to be aware? (anticoagulants, antibiotics, etc) or How will the medication regimen change?
  15.   What type of rehab will be needed upon discharge? (skilled nursing rehab, outpatient cardiac rehab, etc).
  16.  (For individuals living in a bi-level house or by themselves without family nearby). We live in a bi-level house with two sets of stairs. We live by ourselves. What will recovery be like and what will be needed? Will he need bathroom assistance? Physical therapy? Oxygen? Nurse visits?  Follow-up doctor visits soon after discharge?
  17.  What is the best case scenario?
  18.  What is the worst case scenario?
  19.  How can we get some idea of long-term costs?
  20.  Can you express some idea of the benefits in terms of quality of life for the procedures and associated results or consequences?
  21.  How quickly do we need to make a decision?

Some additional things to consider.

What is the real activity level of your older family member or parent?  How honest is the description of the activity given the health care providers?  For example, my father in law sounds very active when he says he plays golf three times a week, mows his grass and fishes twice a week. The doctors ate that up and thought he was a great candidate based on his personal drive, his perceived level of motivation, his seeming independence, and activity level. They failed to delve further to discover that yes, he played golf but with a cart and very little walking, he fished by driving up to the bank and walking only a few feet to the water, and he had recently outsourced his mowing to a neighbor. He was telling a good story but we as a family clarified that yes, he did a lot of activities, but it was not aerobic, his walking was very limited, he was losing balance over the last several years and so on.
If hard of hearing, is the doctor aware of the hearing impairment? Make sure the doctor is at eye level with the family member and confirming they are being understood by asking open-ended questions.
Be careful if your family member asks the doctor what he/she would do if he/she were the patient. In our case, I felt it was very inappropriate for the doctor to share that he would do the surgery if it was him.  I don’t know if it would have changed our outcome, but I have an ethical problem with a doctor telling a patient he/she would have the surgery. That is too much power and influence.
Hospitals start the discharge process now early on in the admission, sometimes even the first day. Get to know your case manager or discharge planner and make every effort to be at the daily sessions with your loved on. Things come up that need to be addressed before the day of discharge, including simple things like how to get your loved one home who lives four hours away.
Risky surgery on older adults should be discussed at length, and if at all possible, with family members present who may be providing support after discharge. Although hospitals are being held accountable for readmissions within 30 days, it is also the patient and family’s responsibility to engage in the process, gather as much information as possible, and be as truthful about self-management and resources, to help ensure a better outcome.
Fortunately, it’s been nine months and we made it through the stroke and the electromechanical problem requiring cardiac ablation. He avoided a pacemaker. He is not back to fishing independently or golfing as well as prior to surgery. That has been a disappointment. He was discharged from cardiac rehab but he is getting older and unstable on his feet. Basically, we all have a new normal that is gradually slowing down as with the general aging process.
Congestive heart failure is very difficult to manage and I know that patients with severe heart failure physically waste away over time, are severely short of breath and the majority of the end of life centers around fluid and medication management. It’s very, very difficult to watch and keeping the person comfortable is of utmost importance.
Don’t be a victim of “no one told us that.” Listen more than just for the best case, clean and glossy version. There is much to tell, so arm yourself with good questions, prepare for the worst and hope for the best. You will be the best caregiver for your loved on with the right information.
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