 It's my pleasure to introduce today's speaker, Dr. Zara Cooper. Dr. Cooper is an acute care surgeon, trauma surgeon, and a surgical intensivist at the Brigham and Women's Hospital in Boston. Dr. Cooper is also an associate professor of surgery at the Harvard Medical School, the associate chair of faculty development for the Department of Surgery, and deputy director of strategic planning and partnership at the Center for Surgery and Public Health at the Brigham. A graduate of Mount Sinai School of Medicine in New York, Dr. Cooper completed her general surgery residency and critical care fellowship at Brigham and Women's. She then did a trauma fellowship at Harborview Medical Center and the University of Washington in Seattle and completed training in hospice and palliative care at the Dana-Farber Institute and at the Brigham. Dr. Cooper's research aims to improve palliative and geriatric care for older, seriously ill surgical patients. A leader nationally in surgical palliative care and geriatric trauma, Dr. Cooper has authored more than 80 peer-reviewed manuscripts, as well as many chapters and abstracts, and has given many national presentations about the care of complex older patients. In 2017, Dr. Cooper published a paper on the need for a geriatric trauma coalition. Another key paper in 2017 in the journal Surgery was on surrogate decision-making in the ICU and a fascinating paper written with two of our former McLean Center fellows, Mike Nebozny and Gretchen Schwarzie, on the limitations of patient buy-in when they're facing high-risk surgery. Dr. Cooper currently has funded through the National Institutes of Aging, Paul B. Beeson Leadership and Aging Award, the Cambia Foundation Scholarship Award, and is a co-investigator on many federally supported grants. She's chair of the Prevention Committee for the American Association of the Surgery of Trauma and serves also on the Geriatric Task Force and Palliative Care Committee for the American College of Surgeons. Today, Dr. Cooper's talk is entitled, As You See Behind Me, They're Not Just Little Adults, Ethical Issues in Geriatric Trauma. Please join me in giving a warm welcome to Dr. Zara Cooper. Good. So I want to say that this is a tremendous honor. I had the opportunity to meet with the fellows today and some of the trauma faculty. And this is a huge, huge honor for me. I have been a follower of the McLean Center for decades now. A little bit about myself, I did my surgical training at Brigham's Hospital. Dr. Rogers has been a mentor of mine since I was a fourth-year medical student. And I did my critical care fellowship under him in between my third and my fourth year of my general surgery training. And to say that I had moral distress at some of the care that my patients were receiving was an understatement. And part of it was because I thought that we didn't communicate well. I really figured that there were better ways to do this and that patients were receiving treatments that weren't absolutely going to benefit them and that were actually harmful and harmful to their families. And a lot of it was because we didn't know how to communicate with them. And at first I turned to the ethics literature to help me make sense of this. And that ultimately led me to palliative care. And so I'm really indebted to the body of work that really has largely come out of this institution for helping set me on my path. And as Dr. Siegel mentioned, Gretchen Swarzy, who is a former fellow, is a very close friend, colleague, and peer mentor of mine. So again, it has influenced me in a myriad of ways. And then I was delighted when Dr. Rogers took on the Herculean task of helping to lead a trauma center here that is so important not only to this community, but to the trauma community at large. And so I really commend all of the work that is happening here. As I mentioned, I kind of came to this through the ethics literature. And as I was telling the fellows today, when I was doing my palliative care fellowship, and I will say that it's really to Dr. Rogers' credit as my division chief, when I approached him with this crazy idea that I wanted to become board certified in hospice and palliative medicine. In order to do that, I needed to spend about eight months of my time with the hospice and palliative medicine team at Data Farber, which required a junior faculty and a very busy division of trauma and critical care to take some very creative scheduling opportunities to do that. And so I am very indebted to Dr. Rogers for letting me do that. That being said, I did it. And what I noticed was when I was rounding on the oncology services, taking care of patients who had advanced cancer, I realized two things that were really startling to me. One was that the oncology patients who were near the end of life were actually younger than many of my trauma patients. And two, I recognized that these patients who had advanced illness due to their catechia, their malnutrition, had a very similar phenotype to a lot of my trauma patients. And it made me realize that, in fact, a lot of the patients that I was taking care of on the trauma service, geriatric patients in particular, were, in fact, near the end of life. And it inspired my interest in frailty and in understanding how to take care of older patients. So what I'm going to do today is really talk to you about the importance of geriatric physiology, geriatric syndromes, and caring for trauma patients. And I want to impress upon you, and the people with whom I've had the pleasure of speaking today have heard me say this, the community here is bimodally distributed. So when you open the doors to your trauma center, you will see these people. And I know that for very good reasons, and I cannot understate the importance of violence and violence prevention and violence as a systemic social disease and the amount of penetrating trauma that you're going to get and all of that stuff. And I cannot understate that, but do not forget that you're going to take care of geriatric trauma patients as well. And then, in fact, there will be increasing numbers of them as we go along. So there are two things that I want to implore upon you. One is that there is an epidemic of geriatric trauma. It is a true epidemic. And two is that these patients are different. And there are some here in my title of they're not just little adults, but they're actually not just little adults. There are some very specific changes that take place in caring for the geriatric patients that have important clinical and ethical issues that I'm looking forward to discussing with you. So when we think about trauma, I think this is the reason why many of us go into trauma. And this is also what people anticipate when they think about what a trauma center looks like. Rescuing people from the draws of death teams with blue gowns. They're doing chest compressions. They're administering blood. There's fluid. Things are rapid paced. Lots of adrenaline. People are shouting across the room. People are being whisked to the CT scanner, whisked to the operating room. It's all happening in a very rapid pace. But in fact, what we're taking care of more and more is this person in the second box. And this is actually Arnold Relman, who was a professor at Harvard Medical School who wrote about his experience as a geriatric trauma patient at the Mass General Hospital in a very detailed report a couple of years ago. And when he talked about the fact that he broke his neck and that he was in the intensive care unit for a long period of time, and then he actually died a year later of other causes. But because of that, we ended up actually doing a fair amount of palliative and end-of-life care, and I know that my very, very close friend and mentor, Ann Mosenthal, was here not too long ago. So I won't spend too much time talking about the palliative care piece of this, but I will say that they are inextricably linked and that it is an important part of the armamentarium of an acute care provider. And not just surgeon, but an acute care anesthesiologist, and acute care intensivist, and acute care internist, whoever it may be who's going to interface with these patients, it's an important skill set to have. And so just looking at trauma in older adults, as I said, this is an epidemic. There were, in 2010, there were almost 52,000 or 51,000 deaths in patients over the age of 65 related to trauma. It is the seventh leading cause of death. 55% of it is related to falls. Approximately 13% is related to motor vehicle crashes. Most of it is blunt trauma. About 15% is penetrating trauma, and what I will say is that the majority of penetrating trauma is related to suicide. The annual cost is about $7.7 billion for patients who die. Hospitalization is almost $56 billion a year, just in geriatric trauma alone. An important thing to realize is that at hospital discharge, only 22% of these patients are functionally independent. If we look at patients who are admitted to US hospitals over time, there's been a dramatic increase. And you can't see it here because of my little call out. But what I will say is that trauma is in the dark red and the line below. Trauma centers in the dark line below. And the lighter line above is for acute care hospitals. And what I want to impress upon you here is that if you look at the percentage of trauma patients who are older, who are being cared for in acute care hospitals, it's actually over 50% now. So that in total, about 35% of all trauma admissions are geriatric patients. Now I want to go back to that slide that I showed you earlier, because one of the things that we need to keep in mind is this is not the reason people go into trauma. But in fact, this is what we need to do to take care of our patients. So it's a frame shift for all of us in thinking about what trauma is. 10,000 people a day turn 65. The fastest growing segment of the population is over the age of 85. So as some of you heard me say today, I implore our residents, if you do not want to go into geriatrics, go into pediatrics because it is the only place for you. And I'm not kidding, that's the reality. So everybody needs to get good at this. So 35% of trauma admissions are at acute care hospitals. In-hospital mortality for these folks is about 11%. Mortality for older patients who have traumatic brain injury is about two times that of younger patients. 18% mortality after rip fractures. Rip fractures, that's not supposed to kill you, but that's what happens to these folks. They fall, they get seemingly minor injuries, and they die. And they die because they have comorbidities and geriatric syndromes that precipitate, not just proceed, that often precipitate their injury. So if we think about the physiologic impact of surgery and trauma, and for the non-clinicians in the Rimal Tri, not to bore you too much, but it's important to kind of go over this so that you can understand, I can make my case that these folks are different. If we think about trauma, we think about fluid loss, we think about blood loss, we think about hemodynamic changes, low blood pressure, hypotension, respiratory insufficiency, respiratory failure, metabolic changes, hyperglycemia that leads to increases in wound infections, functional changes. Just as a result of the injury. And the mental status changes that often come with being hospitalized, including delirium. And so if we think about how to optimize outcomes in surgery and trauma, we need patients to be able to poop, we need them to be able to pee, we need them to be able to breathe, they need to walk, they need to be able to eat, they need to be able to participate. These are kind of the minimum requirements of what we say to folks, they need to get out of the hospital. But that's a problem for a lot of our frail older patients and why is that? It's because older patients have decreased renal function, they have constipation, they have dysphagia at baseline. If you think about your Thanksgiving dinner with your old uncle Harry, who's next to you, every time he has a little bit of turkey. Right, that's because he's aspirating. Okay, he's living with aspiration. Put him in a cervical collar after a trauma and guess what, it becomes impossible for him to swallow. So asking him to eat, not so good. Functional limitations as we described and then cognitive impairment, again, these patients are at very, very high risk of delirium. And so when we look at frailty, what is the relationship between frailty and trauma? Frailty is distinct from aging. Frailty is in fact accelerated aging. Okay, and one of the things that I spoke with some of the folks about earlier today is that particularly in the population that is cared for at this hospital and will be cared for at this trauma center, frailty is accelerated aging. So that means that you, because you take care of a population that is medically disparate, right, doesn't have access to medical care in the same way that doesn't have the same social and economic services as many other patients actually are at very high risk of having even more accelerated aging. That you're gonna see 50-year-olds and 55-year-olds who are frail because of organ failure, right, because of N-sage renal disease, because of advanced heart failure, because of liver disease. These folks have the same phenotype of frailty as older patients, the one that I showed in the picture just earlier. And so if we look at this diagram here, and we look at normal aging on the solid line and we look accelerated aging as the dotted line, you can see that over time, patients who are frail have increasing disability at younger ages. And so what does that mean? That results in geriatric syndromes like falls, like delirium, functional impairment, social dependence, social isolation, right. And there's been a lot of literature recently about the impact of social isolation on older people. I mentioned as a very dramatic case, there was an article in the New York Times not too long ago about Japan, about how the social construct in Japan is leaving it so that all of these people, all of these older people are basically in housing projects, have been in housing projects since their middle age and now they're dying by themselves. That there's actually a task force, like an EMS kind of thing, to go and collect dying people's bodies because they're dying by themselves. And not only that, there's also a lot of literature saying that social isolation increased your mortality. Not a huge surprise, but it's a huge problem for older patients, particularly those who are functionally dependent and can't get out and socialize and then obviously they have increased care needs. So I wanna just kind of describe what frailty is because this was an analogy that helped me think about it because frailty, some people have described it as pornography, you know when you see it, you can't really describe it, that kind of thing, but there's been more and more science around actually what frailty is, but that being said, what I learned in medical school was the foot of the bed test, or these are people that we called poor protoplasm, disrespectfully I will say, but people that we just said, well they're not gonna make it, or somebody would walk in and say, raise your arm, they couldn't raise their arms because they were so weak and be like, no surgery for you, right? But if we think about the physiology of it, really what it is is the inability to withstand stress, right? It's the inability to withstand stress. So if you think about what trauma is, you know you say I feel like I get hit by a truck, well guess what, you got hit by a truck, you actually did get hit by a truck, right? So when you think about what trauma is, it becomes that much more difficult when you're frail. So let's say you have a 25 year old man who's in a pool and he's waiting, right? And next to him is a 75 year old man, right? Who has what we call proof frailty, and he's also waiting, right? And they're both kind of just sitting there hanging along, right? And then some kid comes up, maybe some like eight year old little punk, comes up, throws him a ball, throws a 25 year old the ball, he catches it, he waits, got this, that's good. Now do that with the 75 year old and all of a sudden, right? He's having a hard time because he's using everything that he has just to stay above water. But if you throw even the smallest ball at him, he doesn't have the physiologic reserve to stay afloat, right? And so oftentimes we forget that when we make the same demands, right? Clinical demands have the same expectations of our frail older patients as we do on our younger patients. So it's not a surprise then that if we look at the green line here, which is a minor illness in the robust elderly, and if we look at the red line here, which is minor illness in the frail elderly, that the frail elder is much more likely not only to become dependent, but to stay dependent over time. And I will say that there are a number of different ways that we can look for frailty, that we can measure frailty in research, they're cumbersome, they're often difficult to use, but I will say that the data has been really very, very uniform in all different fields of surgery that frailty has an adverse impact, not only on increased risk of complications, but increased mortality, increased risk of adverse discharge, meaning discharge to a nursing home or discharge or death after hospitalization kind of all across surgical fields, so including trauma, including emergency general surgery, including thoracic surgery, including oncology, it's really been pretty dramatic, and so what it's shown us is that actually some of the other models that we do to evaluate surgical risk, like looking at cardiac status alone, just aren't quite as robust as looking at overall physiological reserve like frailty. The other thing I wanna say is that when we look at trauma patients on the whole, because so many of them have such a high number of falls and because falling is a geriatric syndrome, somewhere between 48, it's estimated between 48 and 75% of injured older patients are in fact frail. So not only is there an epidemic of trauma, there's an epidemic of frailty within trauma. So what happens to these folks, okay? This was a study that was done by my friend Kathy Maxwell who's at Vanderbilt. She looked at over 100 older injured patients and what they did was they assessed them early on in their hospital course and said they were either frail, prefail, or robust. The frail patients are in red. The prefail patients are in yellow and the frail patients, I'm sorry, and the robust patients are in green. What you can see is if you look at their functional activity over the first year after injury, pre-injury they're down here, right? So these are the robust patients, as I said, prefail and frail, right? And this is a measure of the vulnerable elder score. A higher number is worse, right? So the higher they are, the more functionally dependent they are at baseline. You can see the frail folks, you know, they have some increased in functional dependence but pretty much they just stay, you know, they have higher functional dependence but they pretty much just stay. But if you look at these prefail folks, these are the ones who are the most vulnerable, right? They start off over here but then they kind of go up here, they become more dependent but they never quite get back down to baseline. All right, so these are a lot of the folks that you see and then for the most part the robust patients do okay. One of the things that they also looked at was a life space assessment. This is a fascinating measure where again a higher number is better but basically it says do you go outside of your city? Do you go outside of your neighborhood? Do you go outside of your home? Do you go outside of your living room? Do you go outside of your bed? Okay, and it kind of evaluates concentric circles of space for older patients. And again, when older patients get injured their life space shrinks. Their life space shrinks. So that you can see here again in green you have the robust patients, yellow is pre-frail and red is the frail. Unfortunately, if frail patients can't get much worse. Their life space is already shrunk and it's pretty shrunk here. But if you look at the free-pale patients at the pre-frail patients, I'm sorry, they have a continuous decline as do the robust patients, right? And we know this mirrors a lot of the data in the geriatric literature that tells us that when people fall they become reluctant to go outside. They become reluctant to participate in their other activities, right? So this has a huge impact on their life. But if we think outside of the patient what kind of impact does this also have on their family, right? If this was somebody who's going outside and doing stuff for themselves all of a sudden they need a caregiver, right? So these are the kinds of things that we need to think about when we're taking care of these patients. So I wanna introduce you to five of my friends. These are five of my friends. They are a composite of some of the patients that I've taken care of. None of it can go back to HIPAA. But I've tried to kind of highlight some ethical principles that I hope will be of interest to this audience and kind of the issues that we confronted taking care of them. And we'll meet them throughout the talk. But some of the topics that we're gonna cover are beneficence, non-malficence, autonomy, and justice. And I think autonomy is particularly important for this population so we're gonna talk about it twice. All right, so this is Miriam. Miriam, Miriam is my favorite because Miriam, actually, well they're all based on fact. But Miriam was an 83-year-old woman who was actually slightly cognitively impaired but still fairly functionally independent. She lived with her boyfriend and she did most of the cooking and most of the cleaning herself. He took care of the bills and they had a caregiver come into their home but she could do stuff but she was forgetful. She had reminders for her medications but she was still a little bit forgetful but she was cooking him dinner and she had this history of cervical spinal stenosis, had had it for many years, had been reluctant to have surgery despite warnings from her primary care physician as well as an orthopedic surgeon who had consulted with her because she really didn't like hospitals, didn't really want any part of it and was doing just fine, thank you. But unfortunately, she spilled some water, she slipped and she hit her chin on the countertop, head back, falls down, all right? She's immobile. Her boyfriend calls EMS. She's taken to our trauma center. On evaluation there, she has some shortness of breath. But she is able to breathe but she does have some shortness of breath. She becomes increasingly hypoxic and is ultimately intubated. She put on her breathing machine. Before we intubate her, her neurologic exam shows that she's probably got a pretty high spinal cord injury. Got a C5, C6. She's able to breathe a little bit. And so she's taken to the intensive care unit where she's given heparin for DVT prophylaxis. She's given the trauma bundle. She's on a ventilator bundle. She sees a social worker. All of these things happen for the trauma guidelines. And her children are called. They both live remotely. They're called and your mother's had a tragic accident. But, well, do we need to come? No, you don't need to come. You don't need to come. Well, it's really hard for me to come. I can't come. It's okay. I think she'll be okay. She gets the assurance from the resident. So she's assured by the resident that families are assured by the resident. Miriam's boyfriend comes to visit her. There's no discussion about what the goals of care are. There's no discussion about what will happen next. Miriam will be fine eventually. Miriam doesn't know what's happening. But she weans off the ventilator and the question is, should we try to extubate her? So we try to extubate her. She actually, we remove the breathing tube. She actually does okay for a couple of hours. We put her children on the phone. There's no discussion about her goals of care, right? And then she starts to fail. She gets tired. She's having difficulty clearing her airway. And pretty soon it's clear that she needs to be extubated again. That she needs to be intubated again. And so we have a family meeting, right? Per our IC protocol, five days, family meeting. We have a family meeting. The children are over the phone, right? They haven't come in yet. They don't have a lot of money. We've said you don't have to come in. No one's dying, right? We have the meeting, right? And at no point, again, has anybody talked about what her advanced directors are, what her goals are? And so the question is, you know, should we proceed with trach and peg? So Maryam gets a trach ostomate of peg. She gets a trach ostomate of peg. Everything's fine, right? She gets out of surgery in the next day, right? She's off the breathing machine. She's not able to, she's off the breathing machine. She's not able to talk yet. And the daughter calls and says, how is she doing? And the nurse says, fine. They're planning on sending her to a nursing home in the next day or so. My mother would never want to be in a nursing home. Ever. And the nurse says, well, you know, I don't know what to tell you, but she can't stay in the hospital. Well, she wouldn't want to be in the hospital either, right? Because nobody talked to any of them about what the end game was, right? How does this actually look, right? And so the decision is made that the daughter is gonna talk to her siblings, right? And they're gonna try and figure out what is the best thing for their mother because their mother does not want to go to a nursing home and they can't bear the thought of sending their mother to a nursing home, right? And so the question becomes, what do we do? She still needs the ventilator here and there. And so ultimately the decision is made that the ventilator should be withdrawn and that Miriam should be allowed to die a peaceful and natural death as natural as you can in the intensive care unit, right? She's DNR. Her children actually do eventually come in. One of them is able to get there. And she dies peacefully at the bedside. And so when we think about Miriam, one of the things that we didn't talk about with her family really was her prognosis, right? We didn't talk about her prognosis. And if we look at this data, this was a study that we did using Medicare data, looking at patients, older patients who had cervical spine fracture, we can see here in the solid line here is cervical spine fracture with spinal cord injury. The dotted line here is cervical fracture without spinal cord injury. And this line is cervical fracture, is a hip fracture. And what we did was we compared outcomes of patients who had hip fracture, cervical fracture. And what you can see is at every point, cervical fracture is worse, right? Why is that important? It's important because it provides context, right? Because everybody understands the implications of a hip fracture, right? Hip fracture is bad. This is the only country where if you're old and you break your neck, people think that that's okay. That's okay, but it's not okay. It's not okay. And if you have a spinal cord injury, it's really not okay. And in a year, 50% of you are gonna be dead, okay? And so this was the kind of information that we didn't share with Marion's family. The other kind of information that we didn't get from Marion was what about her goals? Who was her healthcare proxy? At no point was her healthcare proxy identified. Why didn't we tell her children to come? Why is death the only reason that people need to come, right? So there were a lot of things that we didn't do for Marion, but when we reviewed Marion's case in our performance improvement review, which is part of the trauma process. You have to have a peer review as part of, we did everything right, right? She was seen by a spine surgeon early. She received her vent bundle. She received low molecular aid heparin. And at no point did we pay attention to what was actually best for Marion, right? And so what I think about beneficence, right? It's the best possible care for the patient, right? It's not just doing good. It's providing the patient the best possible care. And when we think about the things that we put in place for our younger trauma patients, we have to think differently about our older trauma patients, right? Some of these things are much more important for patients who are nearing the end of life. I'm gonna tell you about Charlie. Charlie is an eight-year-old man who has congestive heart failure. He has coronary artery disease. He has hypertension. He has CH, I mean, he has AFib and he's on an anticoagulant. Charlie's pretty independent. He lives with his wife of 50-something years. He's got five kids and because it's Boston, and I kid you not, one of them is a doctor, three of them is a lawyer, and one of them is a nurse. That's how it is in Boston, right? These are his five kids. Charlie's very active in his community and he's driving home from the doctor and all of a sudden he passes out behind the wheel, starts driving the wrong way in the highway. EMS pulls over. He's completely unresponsive. He's brought into a trauma center. He's flighted into a trauma center. He comes in, trauma activation. He's completely uptended. He's hypotensive, right? We start pouring fluid into him. We get him intubated. He's not responding to the fluid. We're worried about a high-cord injury. We put him on vasopressors. He's getting the full-court pressure. There are 10 people around his bedside as we try to assassinate him. He is too unstable to get him to the CT scanner. His child is an intensivist and is on the phone with me, talking about coding him, okay? So Charlie gets taken up to the ICU. He's too unstable. We can't even get him to the scanner. He's taken up to the ICU. Eventually he's stabilized. We get him to the scanner. It turns out he's had a massive stroke. Massive stroke, all right? His children come in. His wife of 50-something years come in, right? And they are terrified. They're a mess. These are highly educated people. And you have a conversation with them. Well, you know, your dad has a massive stroke. This has found implications for his quality of life. What kind of treatment do you think would be in line with what he would want? Although I always hate to use the word want because nobody wants this, right? We have no idea what to do. Deer to headlight. They have absolutely no idea what to do. And one of the articles that Dr. Siegel spoke about that we just did was we actually did some qualitative interviews with surrogates of patients who are in surgical intensive care unit. There were 20 surrogates who we interviewed. You don't have to read all this. I can see a bunch of you squinting, don't worry. But we did interviews with 20 surrogates, 18 of whom actually were surrogates of trauma patients. And what we found was that there were really two archetypes who called them archetypes or phenotypes, right? The first was the preference advocate, right? So preference advocates were, it's choosing what he ultimately wants to do, right? This is what I need to do. But what was really interesting was that we also found this group that was the clinical facilitators. And for those of you who do intensive care, you know what these people are like. And in a family that has three lawyers, a nurse and a doctor, you can imagine that they were like this. My role was to get answers to my questions. My role was to do a little bit of research, right? So there's one person who said, I did a little bit of research and realized that you can live with half of your intestine. And so it's not how many feet you have, right? But I'd seen that it could be 11 feet or 20 feet. I wasn't exactly sure, but I could see that you could live with up to half of your intestine. So I figured no matter what the doctors told me, she could have a full recovery, right? It was, well, you can't wanna die when you have children. So no matter what he said, you can't wanna die when you have children. So given the information that I had, I made different decisions, right? And that's who this person's family, that's who Charlie's family were, okay? Now some of you may have heard recently that there was a story in the Washington Post about a homeless man who came in with a DNR tattooed to his chest and the medical team didn't know what to do, right? This was kind of a similar situation, right? It was really, really perplexing. And Charlie sat in our ICU for six days. His intensivist child was really, really, I mean, it was fraught. It was really, really painful to watch her distress. She really didn't know what to do. And nobody bothered to ask, does Charlie have an advanced directive? Does Charlie have a living will? Because they must know. They must know, until his son said, didn't his dad used to volunteer for a hospice? I swear. Didn't dad used to volunteer for a hospice? Yeah, you're right. You know, I think, you know, why don't we ask Judy to go and look? I bet you in his library there's something, 11 pages Charlie had written about what he wanted and what he didn't want, 11 pages. And it was very clear that this was none of it. So I think the important lesson that I learned was you can't make any assumptions and you have to ask. And you have to ask over and over and over again. And you need to continue to explore. And that people are panicked, that they are terrified. And that you can't just leave it to these families to try to kind of go through this all by themselves, even if they know the terrain. Because when it's your loved one, you don't know the terrain. And so how do you protect his autonomy, you ask. This is Francis. So Francis is, and actually in Boston, we have a lot of people named Francis. We have a lot of people named Francis, a lot of people named Megan. A lot of old Irish people. But Francis is an 82 year old man who was found unconscious at the bottom of the stairs by his wife, right? EMS was called and he was brought to a trauma center. He was still unconscious, but he was immediately intubated in the trauma bay. His head CT showed large bilateral subdurals and because they were bilateral, there was no shift. There was no need to take him to neurosurgery. He had plenty of space, but he was still completely abtunded. He was in a coma. And so he was taken to the intensive care unit. He was taken to the neuro, he was given excellent care. By day three, however, he had not progressed. His GCS, his plasma coma scale was eight. At day three, it was still eight. And so the trauma surgeon and the intensivist based on current guidelines started to question whether or not we should redirect our focus of care because the current guidelines say for older patients who don't make neurologic improvement within 72 hours, we should reconsider the aggressiveness of our treatment because their prognosis is so poor. So they called him the family, the family couldn't come in, but by day four, he started to localize to pain. So there was an improvement in his neurologic exam. And so with that improvement, the team canceled the family meeting. You don't need to have a family meeting. He's had a neurologic improvement. And so now we know what to do, full court press. So instead, the intern called his wife. It's a teaching hospital, right? The intern called his wife Peter's laughing because he's like, that's exactly what happened. The intern calls his wife and says, well, you know, the team has decided that he needs a trachea and a peg. A trachea and a peg, what is a trachea and a peg? It's an exit strategy to get you to rehab, okay? Because now what else are we gonna do? He's making improvement. All of his surgical issues are resolved and we know the way forward. And so the plan is to discharge him to an LTCH in the following week, right? And so the question becomes, what is the best possible care for Francis? And it's confusing, right? Because the current East guidelines, the Eastern Association for the Surgery Trauma says exactly what I said, but it's 72 hours. If you have an older patient who's had a devastating brain injury where they make no improvement, their GCS is eight and it stays eight, that you should really consider withdrawal of life's sustaining treatment. But that's based on what happens in the hospital. Nobody knows what happens to these patients afterwards. And so the knowledge gaps that we have are regarding patient management. So what happens to these folks who die in the hospital? What is their functional status and what is their long-term survival? So we asked this question and we used our data and we had three questions. So what is the treatment intensity for patients who die? What kind of palliative care are they receiving? What kind of communication do they get? What is the function for patients who are discharged? And what is survival for patients who are discharged? So we looked at patients who are over the age of 65. They were admitted with a GCS of less than eight. Demographic data included age, gender, race and their mechanism of injury. And then we split them into three different groups. They were at 72 hours. So there were the patients who died. They were considered the early death group. There were the patients who responded, patients like Francis who got better after 72 hours and the patients who didn't respond, who had no change in their GCS at 72 hours. And what we found was that, you know, most of these patients were about 80 years old. Most of them were male and most of them were white. And their median ISS score, which is a measure of their trauma injury severity was actually quite high. But if we look at decision-making, 48 of these patients died in hospital, right? For the non-responders, there were more goals of care discussions. Fewer were focaled to death and a discharge and there was no difference in the palliative care that was delivered. One thing that I want to draw your attention to is that if we look at palliative care consults, of all of these patients, only five of them received a palliative care consult. So very low penetrance of palliative care irrespective. For the non-responders, fewer of them were full code. 46 of the 48 died after withdrawal of life-sustaining treatment, okay? Following the East guidelines, right? Following the East guidelines, withdrawal of life-sustaining treatment. But then we looked at the patients at discharge, right? Who were the patients who left the hospital? Well, most of them were actually functionally dependent when they, independent, I'm sorry, when they came into the hospital. If we look at the patients in blue who were independent at baseline and we look at patients who were independent at discharge, if we look at the responders still, the vast majority who were functionally dependent at baseline were not, had severe functional impairments at discharge. When we look at the non-responders, none of them were independent, right? So if the patients who didn't die in the hospital who were discharged, there was significant functional decline, not surprisingly. But I think equally important is that if we look at overall survival, their overall survival was actually quite poor. And as I'll show you, the non-responders are in the pink and the responders are in the blue. And if you look at discharge, you can see that the non-responders had significantly more death, right? About 60% of them die. But then here, their curves actually look the same. So if you get out of the hospital, your survival is actually pretty much the same. And it's grim all around, right? Whether you're a responder or non-responder really doesn't indicate whether you're gonna be functionally dependent, independent. And it doesn't actually signify whether or not you're gonna survive. And in fact, overall mortality at one year for this cohort was about 70%, okay? So what does that mean? That means that these people have significant palliative care needs. So how do we do no harm to Francis, right? We have to put this in context. We can't just say, on day four, you responded to pain. That's all the information that we need, right? The information that we need is Francis, what are your goals? Like, do you wanna trick? Do you wanna peg? Do you wanna be in a nursing facility? If you have a 30% chance of living the year, maybe, maybe not, right? Now when the discussion was had with his family, they determined that that was not gonna be acceptable to him, that he had been very functionally independent, that he had been very robust. Well, not very robust, but he had been very functionally independent and that that was not gonna be acceptable to him. But having those conversations would the best way to preserve his autonomy. So this is Thelma. Thelma is another patient that you are certain to meet. Thelma is a 68-year-old woman. She has grandchildren. She's very active in her church. She has a walking group that she meets with three times a week. And she has stage four ovarian cancer. She's on her second line of chemotherapy. And she's been very sick in the past. She actually had an aspiration event after an operation, had a cute lung injury, was in the intensive care unit, has a husband with fairly advanced dementia who's about 15 years older than she is. And she and her husband have been very clear about what kind of treatment they want at the end of life. Very clear about that. And they've told everybody, they've told their church group, they've told each other. And Thelma is DNR. Thelma gets into a car crash. She's a restrained passenger in motor vehicle crash. It's T-boned, going about 45 miles an hour. She sustains rib fractures and a splenic injury. Pretty significant splenic injury. She goes to the intensive care unit after her initial resuscitation. She stabilizes out. She goes to the floor a couple of days later and all of a sudden her heart rate goes up. Her blood pressure goes down. And it seems that she has delayed presentation of her splenic injury. She started to bleed again. But she's been doing so well that nobody really bothered to ask her about her code status. She's been doing so well. She looks great. She looks great. Now her decision about being DNR was made in the context of somebody who has stage four ovarian cancer. But that's not her problem today. Her problem today is that she's got an acute life-threatening injury. And so what happens to Thelma? Well, the thing is that the anesthesia resident and attending come and evaluate Thelma. The plan is to send her to interventional radiology but her blood pressure, as I said, is soft. And she's responding to fluid transiently. And so they wanna consent her for surgery just in case. And Thelma says, but I have a do not resuscitate order. You can intubate me, but I have a do not resuscitate order. And they look at each other quizzically and say, that's ridiculous. They say, that's ridiculous. You're perfectly fine. You will survive. There's no surgeon in this hospital who's gonna operate on you if you have a do not resuscitate order. That's ridiculous. Her heart rate starts to go up. Because now she's mad. Right, now she's mad. And she says, well, I don't wanna be resuscitated. I can't do that. And so the anesthesia team leaves. She's unreasonable. She's unreasonable. That's the euphemism for we can't get her to do what we want, right? They tell the intensivist, they tell the surgeon, she's unreasonable. Maybe you can find her family. Maybe you should call psych. Maybe you should call psych because we don't think that she has capacity to make her own decision, right? So what does this mean? So the first thing that I wanna impress upon you is that this will happen, right? And this is part of the reason why, again, I'm belaboring a point, but we have to figure out what these people's goals are upfront, but we also need to determine what their code status is upfront and explain to them the implications of having that code status in the hospital, right? We have to give them the opportunity to understand all of the information that we have. Now there's a real ethical dilemma which I'm sure has been discussed multiple times in this forum for providers, for clinicians who are taking care of patients who code in the operating room. Why? Because it tends to be reversible and it tends to be atrogenic. So I did it, okay? This is not you dying from your cancer, right? Now if she's in the hospital with advanced cancer, let's say she has a bowel obstruction, she becomes profoundly dehydrated, she has a code in the hospital because of her cancer, her chances of leaving the hospital are less than 5%. In this scenario, that's not true. She codes in the operating room, she has a very good chance of leaving the hospital. So if I don't provide CPR to you, am I complicit? That's the word, right? That's the Merriam-Webster word of the year. Am I complicit in your death? That's the question. And so we have to have a discussion with her, right? So the first thing is to talk to you, actually have a conversation with your patient. Now it may seem crazy, right? There actually was a survey, the Mayo Clinic did a survey, I think it was about 2013. They surveyed 500 patients and 200 physicians and what they found was that about, I think it was 33% of physicians thought that these conversations should happen, 33. That these conversations should happen, that it shouldn't be automatically reversed. And that only 57% actually had these conversations, right? So it seems obvious, but you actually have to talk, it seems like an obvious thing to say, but you actually have to talk to your patient. You have to elicit the patient's understanding. Again, does Thelma understand that it's likely reversible, right? Discuss the resuscitation alternative. So the American Association of Medicine and Zoologists says that there are three different ways to look at this, right? There's full resuscitation, there's partial resuscitation and there's resuscitation determined by goals of care that are agreed upon by the clinician and the patient. And that it's actually the clinicians call intraoperatively as to whether or not the patient would want that type of treatment. So this is what needs to happen. And what I implore you to do is to make sure that you have that policy in place. Now, those of you who are gonna be caring for these trauma patients may go, yeah, yeah, I'm sure the hospital has something and everybody knows what to do, but I can tell you they don't and I can tell you in the emergency setting they won't. All right, so there has to be training around this. And 30% of hospitalized older patients have some kind of advanced directive. Now, it may be on their kitchen table, but they have it, they've thought about it. These are actually easier conversations to have because these are people who have actually thought about it, right? So this is something that we need to keep in mind. And that's how we can preserve Thelma's autonomy. There's Harold. So Harold's an 84 year old man who lives at home with his daughter and his granddaughter. He walks with a walker, but otherwise he's doing okay. They tell him not to go outside alone, but Harold got to 84 because he's stubborn. Someone's looking at me because that's gonna be you. Right, right, right. And this morning, right, it's a cold Chicago day, let's say it's February and he goes outside to get his mail because nobody's gonna tell him not to get his mail. He walks down his three steps and he slips. He slips, he breaks his pelvis, he hits his head, right? A neighbor witnesses it, thank goodness, right? Neighbor witnesses, they call EMS, takes him to the hospital, right? They scan his head, he's got the head bleed. He's got a moderate size subdural. He broke his pelvis and his hip, multi-trauma. They take him away from the local hospital. They make the decision to send him to a level one trauma center, okay? They decide to send him to a level one trauma center. The social worker calls his daughter who works about five minutes away from this hospital and it's told that he's going to a level one trauma center that's about 60 minutes away from where she is now, right? And so I guess the question is what's the best care for Harold, right? Because one of the things that we have to think about is that the systems that we've put in place for older, for younger patients, right, as I was talking about today are really meant to stop bleeding, right? Trauma centers are meant to stop hemorrhage. That's really all they're set up for. That's what the resuscitation of the trauma bay is about. That's why you have to have angiography available 30 minutes away because you want to stop bleeding. That's why neurosurgery has to be here in 30 minutes. Why? Because people bleed into their head, right? That's why there has to be orthopedics all the time because people bleed, right? There are really no other orthopedic injuries that need that kind of attention, right? It's to stop bleeding. All people who die don't die because they're bleeding to death. They die because they aspirate, right? They die because they have PEs. They die because they get pneumonia. They die of congestive heart failure. They die of the medical illnesses that contributed to being there. So the systems of care that we have in place for younger patients don't necessarily apply. And so there's actually been some studies on this looking at the relationship between trauma outcomes and hospital volume. And I won't bore you with the details here too much, only to say that this was the first study that was done in Pennsylvania, a state trauma database that actually showed that if you look at in-hospital mortality, major complications and failure to rescue, that hospitals, trauma hospitals that had higher geriatric volume had better outcomes, right? Than hospitals who had higher non-geriatric volume. Now why is this important? This is important because in every other area of surgery there's been a very clear volume outcome relationship, right? And as you will see, this will be a preeminent trauma center in part because of the volume of patients that it cares for. You're gonna get good at it. You're gonna get really good at it. But in this case, what we're finding is that for those older patients, it's not just the volume of trauma. It's the volume of geriatric cure, right? And the question is why, right? So what we did was we did a study with the California state database. And we looked at different levels of trauma centers, level one, level two, and level three to five. And we looked at three different outcomes. We looked at in-hospital mortality, failure to rescue, and 30-day readmission. These were California state database, patients over the age of 65, all different levels. And what we found was that if we just looked at trauma center level on the top here, that for patients who, that in-hospital mortality was about 27% for patients, it was about 27% higher for patients that were treated at lower level hospitals. If we look at the geriatric volume, right? So the geriatric volume per 100 increase, the mortality dropped by 11% based on the geriatric volume. And if we look at the geriatric trauma proportion, right? So now we're not just looking at the volume. We're saying what proportion of your overall trauma patients are geriatric. And we find here that there's a 28% decrease for the hospitals that have a higher proportion. So what does this mean? This means that for Harold, maybe it was better to send him to the level one trauma center, but maybe he could have stayed at home because like the acute care hospitals that I mentioned earlier, 50% of their trauma patients are geriatric. As opposed to the high volume level one trauma center where only 11% of their patients are geriatric, right? And why is that? That's because there are systems of care that make this better. The same was true for failure to rescue. And so there you are. And what are the systems in place that make this better? So one of the issues is that we often overlook why these patients are so vulnerable. And for those of you who are clinicians, you take care of these patients, you know oftentimes even in the outpatient setting they come in, they put on their Sunday best, they look great, their daughter and their wife are sitting next to them, right? And every time you ask him a question, she answers for him, right? And then when you ask, well how have you been doing? He's great. He's so funny, he makes jokes, he'll make some joke, right? And they tell you that he's vigorous, he's sharp as a tack, he's a life of the party, he was great at Thanksgiving. But when you probe, well he has been having some mild memory and hearing loss, you know, he can't hear me and I don't know if it's like, it's a joke, right? But you know, when he listens then I know what he really can hear, right? I know that he's not really just paying attention to me, right? And then well he doesn't drive very, I mean, oh, we don't let him drive. We don't, we don't let him drive. Maybe we'll let him drive to his friend's house around the block, but we don't actually let him drive. It's kind of a debate in the family. My daughter wants to take away his car keys but I would never do that, right? And then messing up the bells. No, our son has been doing that for years. Our son's been doing that for years. And it's funny, you know, he just hasn't been feeling well lately. That's why we're here, right? He just hasn't been doing very well. And so you have to probe and ask some specific questions because everybody is putting on their Sunday best, right? And so one of the things that geriatric, geriatricians do is they do what's called the comprehensive geriatric assessment. And this is a much more comprehensive approach to taking care of trauma patients than we're often used to. And so it includes multiple domains, but I think the point here is that just by having a thorough history of physical, including all of these domains, right? Social circumstances, environment, advanced care planning, a Cochrane review showed that there was actually among community dwelling elders, there was actually a reduction in death, right? That this intervention, the geriatrician scalpel actually saves lives. And it actually improves function at six months. And the number needed to treat, I thought this was remarkable, was only 13 to avoid one death. I mean, that's better than almost any drug we have, right? That's huge, that's huge. But I am a trauma surgeon, right? I am a trauma surgeon. I am not, I'll be honest with you, gonna sit down for 75 minutes and do this with every patient I have. I don't have time, I'm not reimbursed for it, I'm not incentivized, I don't know how it's gonna happen. And so this is part of the question. What are the processes that are put in place at these other hospitals where they're doing it right? So this was a study that was done out at UCLA, looking at patients who had a geriatric consultation, including the comprehensive geriatric assessment and those who didn't. And you can see here, looking at functional decline over time, everybody has a decline over injury. And in fact, the patients who received the consult did worse, but then they bounced back. Whereas the control group just keeps going down. And why is that? Because just doing that geriatric assessment picks up problems that can be followed up down the road. So we, at our urban level one trauma center, 50% of our patients are 65 years and older. 50% are 65 years and older now. And so in 2014, we started a trigger, a triggered geriatric consultation model. We had a geriatrician, we hired 50% of a geriatrician for our trauma service and he saw all of our patients over the age of 70. And they were seen within 72 hours of admission. Why? Because he doesn't work weekends. And they received a comprehensive geriatrics assessment. And what we showed, this was published in the journal of the American College of Surgeons a couple of years ago. Really what we showed was that there was increased recognition of delirium. So our delirium weights went up. Why? Because people were paying attention to it. Our DNR and DNI code status also increased. And our referrals for cognitive evaluation increased by 12%. So these were processes of care that were appropriate for geriatric patients that improved with a geriatric consultation. And I will say that as was mentioned earlier, we are affiliated with Dana-Farber Cancer Institute and our trauma center now has a higher completion advanced directors on discharge than the cancer center. Okay. But if you look at our outcomes, there was actually, this study was not powered to look at mortality, but there was a 4% absolute reduction in mortality. In hospital mortality, a 5% absolute reduction in 30-day mortality and a decrease in ICU admissions. Now somebody asked me earlier, was that because they got less, they received fewer treatments or was that because they just, and this was ICU bounce backs. So there were fewer ICU bounce backs. So the problem is, is that we have these discontinuities because as I mentioned, our geriatrician is only there, is not there for, he's not there on the weekends. And so then on the weekends, everybody's receiving the same care as the 25 year old. And then we have to wait until Monday for them to get geriatric appropriate care. And so our objectives were to reduce variability, reduce delirium and to improve function. So we developed the frailty care pathway on our program. And so I will tell you that this pathway was a tremendous task and it was completely collaborative and totally multidisciplinary and includes physical therapy, occupational therapy, speech and language pathology, nutrition, nursing. It's all a nursing driven protocol, geriatrics and trauma. And so we worked for months to try to figure out all of the various components because I think the lesson that we have to learn is that these patients really require multidisciplinary care. And so our two areas that we wanted to prevent was delirium and loss of function. And so our pathway includes delirium prevention. And if I could make this point, the most effective non-pharmacologic approach to preventing delirium is to have some family members at the bedside. Why is that important? Because when you transfer that patient to the level one trauma center that's 75 minutes away, you increase the risk of delirium. And so if that patient is at your level one trauma center you have to figure out how to do that even with those barriers. We paid attention to the sleep wake cycle and we did CAM scores to assess for delirium. We also looking at function, a lot of these patients are osteoporidic. We did orthostatic measurements and we did a swallowing screen. And then early mobility, triggered consults and then bowel and pain regimens. And somebody brought up pain earlier. All of these patients receive regular, receive Tylenol around the clock. We have very strict guidelines around opiate use and it's really helped reduce our risk of delirium. Our risk of delirium on this pathway has decreased by 50%. Our delirium rates, I'm sorry, have decreased by 50%. So it's a very comprehensive multidisciplinary pathway. And so the patients are screened in the emergency room. We use the frail scale and I bring this up because I think this is something that you all can use. Fatigue, resistance, ambulation or inability to walk the length of a football field. Illness, five or more illnesses. All of the patients that I've described to you had them. And loss of weight of 5% or more of their body weight. And so these patients are screened in the emergency department. Patients who meet any of these criteria then fall on to the frail pathway. I'll go over this briefly. So the surgical resident who evaluates them in the emergency department sees the patient. They screen them for frailty. If they're positive, they enter the pathway and they receive an admission order set that includes all of the things that I just described. They also receive nursing care, right? And there's a nursing checklist. I know everybody loves checklist, but there's a nursing checklist that includes all of these elements. And then they also receive triggered consultations by 72 hours. Make sure that they're seen by physical therapy. They receive a social work consult if they live alone because we didn't have the resources for everybody to receive one. And then somebody asked me earlier about prevention. Everybody receives a fall prevention packet, whether they fell or not, because if they're frail, they're at risk for falling, okay? And so I bring all this up because this is kind of my attempt at looking at justice, right? What are the resources that are needed for Harold, right? Because when we look at how trauma center care is organized, it's organized around younger patients who are trying to bleed to death. But Harold is not one of those patients and he needs the same high quality trauma care as everybody else. And so these are some of the pathways and the care processes that we need to put in place to treat Harold and patients like him and there are an increasing number of them. And so we're actually working with the ACS Committee on Trauma to develop geriatric guidelines and that should be in the next version of the Optimal Resources Guide. So I wanna thank you very much for your attention and for the invitation. It's been a real pleasure and I hope that you enjoyed meeting some of my patients. I can't help but applaud the breath and depth of your work. But I think when I said yes to palliative care consult, I did not expect you to be sitting there or me to be sitting here. So much gratitude for your diligence and your passion around this arena. I very vividly remember many conversations about moral distress that you and I had when I was your faculty and you were the fellow and you were the junior faculty and I was the senior faculty. However you wanna frame that or I was learning from you. But how would you suggest that we address that dilemma about what's the right thing to do for any individual patient given the complexities that we often don't get to know our patients as well as we should get to know them. Especially in the context of how fast-paced, hectic, challenging, confusing it is to navigate that sentinel question. Who are you? So I think that's an excellent question. And so there are a number of thoughts I have on that. The first is that we need to get good at asking our patients. Too often we just don't ask them, who are you? We don't ask them who they are. We don't ask them what is important to them. We don't ask them what their goals are. We don't ask them what are the things that you're most afraid of? What are the treatments that you most wanna avoid and what are the things that make life worth living to you? And often we make presumptions that are completely off base. And we do that within our family members. I mean, surrogates are only right 50% of the time when they guess. So we need to get better at asking them. And that will take training. That will take training. We need to stop being afraid of asking them and thinking that it takes a lot of time. Because it doesn't take as much time as you think and it's often an iterative conversation. It's not necessarily a conversation that's gonna happen in a moment. And so when somebody is actively dying, it is our obligation, unless we are told otherwise, to try to rescue them. And if they cannot participate in the decision making, we are obligated to rescue them. But that doesn't mean that we shouldn't have a conversation with them when we can. And it doesn't mean that we shouldn't have a conversation with their family members when we can. And when the dust has settled after those initial hours, there's still an opportunity to reflect and recollect and make sure that what we've done is the right thing for that patient and moving forward how we can make the best decisions. So I think we need to train ourselves to be comfortable asking those questions and then understand that it's a dialogue. And too often we're waiting for the answer. I remember when I was doing my palliative care consults, I mean so often the team gets frustrated when you haven't got the code status clarified. They call the palliative care consult because they want the code status clarified and they're frustrated. They're like you didn't get the get, right? And it's like no, that's not the get. The get is to figure out what they want and it might take them a couple of hours, you know? Too often we're impatient and we want people to know and to understand but let's be clear, people don't plan for retirement. Retirement is supposed to be fun. So people aren't necessarily planning for this and we need to give them time and we need to recognize kind of how shocked they're gonna be. But I think the most important thing is we need to get comfortable asking and understand that it's okay if there isn't immediate clarity around it. Thank you so much for this wonderful talk. Obviously comes from a lot of experience. Since we are talking about ethics, I wanted to bring an issue here. That as I get older, I become more and more concerned, not only consider them, that the bias against elderly ages. Now, I used to think 70 years old was old when I was younger and often tried to, like other college, encourage him to not to have an operation, not to do this. And 10 years later I changed. Now, 70 years old to me, very young now. And so I am concerned about the bias that unconsciously, not based on evil or anything, that we have about the older age. I operated for 40 years and I see patient in a clinic, many of them older person, that I would have operated on them now, but not 20 years ago. And people have refused to operate on them because they said that person is too old. So everything you said is perfectly correct, statistically, but not about the individual. Because if we have operation on healthy adult is only 5% more complication than on a younger adult. That's exactly right, that's it. So therefore, when we put the people in the group and we statistically deal with them, we miss all those that they could have been doing fine because love to live is equal at the older age. Second, cost of death is always the same. When we have immature children, newborn with hydrocephalic intracerebral hematoma, that we know the future is actually going to be very suffering for the person. We treat them and the cost of care of them is just as much the cost of care of a younger people who have accident, trauma, the highest level. And the cost of them is equal or perhaps more than someone at the age of 75 who is dying. But we always statistically talk about cost of death at the elderly. We never talk about cost of death at any other age. And actually, elderly are the one who have paid for their chairs. The younger people have never paid for their chairs. So it is analogous to people pay for social security and when they become 70, they say, oh, you're too old to receive social security. People pay for that for their early age. And there are philosophers who say, we shouldn't treat people after age of 74. It is unfair, we should do, but when they themselves become 74, they still go to the doctor. And I wanted to see what your feeling is about. Am I correct that we have bias in every part of our society is old against young, young again? And is there is a bias against elderly for treatment? I totally agree. And it's well documented. I mean, it's well documented that there's a bias. And that's part of the reason why we can't make assumptions about what kind of treatment people want. But I think your point about a healthy elderly person is really important. That's part of the reason why I spent so much time talking about frailty. Because you cannot just judge somebody's physiologic fitness for surgery and trauma based on their age alone. You have to look at how able they are to withstand physiologic stress and you need to assess them for frailty, which is more prevalent among older patients, but not uniform. And so you're right. I mean, the data shows that frailty in and of itself is more predictive than age. And I have a friend who's actually doing some really great work in transplant, looking at frailty along with meld score and frailty is more predictive than meld score for predicting patients who are gonna do well after transplant. It's a physiologic syndrome that happens to predilect older people. But that is what makes some of this so difficult for older patients to be able to withstand. That being said, we can't assume that they can't withstand it just because they're old. I completely agree. But I think that part of what's so important in not being biased is also recognizing what is it that they find acceptable for life. And the good thing about older patients is most of them have a better sense of it than the younger patients. They have a better sense of what they find to be an acceptable quality of life. And that's part of the reason why I think it's so important that we ask them. Oh yes, please. Your talk was excellent. The one question that didn't seem to be addressed following up on the morality issue, there's a huge controversy in the United States right now about euthanasia. Do you feel that the rules, that sufficient rules are in place for this hospital or any level one trauma center that guidelines are clear that enable people who don't want resuscitated, don't want extensive care, that rules are clearly in place, don't do anything more? Because my fear is that what you've described, however great it is, in some cases could resuscitate somebody for two days and that's it, or for two weeks. And all it means long term is vain and suffering for an older individual. So I agree with you, I agree with you. I mean the examples actually illustrate just what you're talking about. The challenge is that, again, it often was a breakdown of communication. The patient that I described who was in the ICU for six days without his 11 page advanced directive, it was a communication issue, nobody asked. We just didn't trigger anybody to think about it. And so he had untold suffering, his family had untold suffering because there was a lack of clarity about what the best thing to do was for that patient. So I think you're absolutely right. I think the other issue is when we look at the case of Thelma, the reason I brought that up is because that is going to happen. You are gonna have patients who have DNR orders and many people have the mistaken belief that we can just override that. Jacob, the American College of Surgeons, the American Society of Anesthesiology say no, you cannot just override it. You have to have a conversation with them. Now part of the problem in her case is that everybody just assumed she was doing okay and didn't have the conversations up front. Again, it was a communication breakdown. But when the time came, there was an unwillingness to discuss it. And so I definitely think that with older trauma patients in particular, there's a tremendous peril. I mean they come invulnerable, they are vulnerable when they're here and they leave vulnerable, in part because we're not providing care that is concordant with their goals, whether it's that they don't want to be resuscitated or that they absolutely do. I mean the bias is there on all sides. I mean as far as the euthanasia issue, I mean there's a complete lack of clarity around that. I don't know what it is here, but I mean even within states that have it, there's a lot of controversy around it. The right to die states. I mean there's a lot of controversy around it and there isn't necessarily clarity within institutions about what the right thing to do is. So I agree with you, I think it's a real problem. Hi, thank you so much for your talk. I'm one of the third year general surgery residents and I definitely resonated with how you're talking about, especially residents identifying and talking early about who a healthcare proxy is and what patient schools are. I think I've talked with this group about it recently. And I'm just wondering, you talk about having the frail score that your residents do in the trauma bay, how that logistically works, especially if a patient comes in more acute or critical and who they obtain that information from. And then another question I had is that a lot of this sounds like as an intern and a medical student, we had a lot of consent simulations where we talked, we learned how to obtain consent and we learned how to talk about blood consents. And I feel like this conversation almost, we're going that direction, like simulation or training. How do you train residents to ask these questions early because they are uncomfortable questions and I'm just now becoming as a third year comfortable having these conversations and a lot of times it is our interns who are the first people to see these patients prior to them deteriorating. So what I'll say is if as a third year resident you are comfortable then you are light years ahead of many of your faculty. This is an uncomfortable conversation for people to have and most of us are not good at it. It's a skill. It's a skill like any other. So as a surgeon, I'm going to look at you and say this is a skill. So practice it the same way you practice your knots. And the way that I do it with our residents is we do drills. It's the same thing. And so you're absolutely right. The simulations are really important. And I forgot your first question. I apologize. Just how the frail scoring with your residents who does that in the trauma bay and if your patients are acutely ill, like how that actual information is obtained. Most of the time we can't get the information from the patient. Sometimes we can. We get it from the medical record or we get it from a family member when we can. One of the things in there is that they have to have five or more illnesses which a lot of these patients do. So a lot of people just kind of opt in because and then we can reassess that. Our residents have overshot because patients aren't easily accessible but aren't easily accessible at the time of admission. But what I will say is, so what's the big deal if they end up on the frailty pathway? It just means that they're actually getting state of the art nursing care for geriatrics. So I think that as far as operationalizing it, our residents know it. They have it. It's posted everywhere. They're so sick. They have pocket cards. I mean, they're tired. They have like a computer module. I mean, they are tired of it. But they know it. And so they understand the criteria. It's better than the foot of the bed test because they actually have some criteria on which they can evaluate these people as opposed to, you know, you're just, you're poor for autism. And so from that standpoint, it's actually been pretty successful. I mean, it looked like the care that the people who qualified as frail got was extraordinary in terms of nursing and social service intervention. Right. And it's taken a lot of work to kind of keep, I mean, to even, I mean, on many of those measures, we're not even at 50%. I mean, we're still working. It's a work in progress. It's ongoing because it involves a lot of people. I mean, just on our trauma service, we've had to train 173 nurses. We have to change 70 surgical residents. We've had to change, train 60 anesthesia residents, eight OBGYN residents every year. I mean, the number of people that we have to train on that pathway is extraordinary. What I will say is that as they rotate the care that they're delivering on the vascular service, on the colorectal service, on the oncology service. I mean, you know, I think it's rising all tides and there's increasing interest from our faculty because they're like, what is this that these residents are doing? So, I mean, I think that it helps because, you know, this, our service kind of touches everybody in the hospital as you will soon discover. And so there really is an opportunity to kind of reach lots of different types of surgical patients in it. Hi. You know, we've started to look at what the five mile catchment area for our trauma center is gonna look like. And you know, our patients are significantly more minority, significantly less employed and significantly poorer than the rest of Chicago. You refer to the fact that in a population such as this, we could potentially expect frailty to exist in somebody younger because of the social components of their frailty. Right. How have you thought about measuring that social frailty? Right. So, you can measure the social frailty by isolation, but I think that the manifestation of that is that these folks have all the same markers that other older frail patients do, right? They still can't walk. They still have more than five medical illnesses because of that social isolation and vulnerability. So I don't think we necessarily need to use a different marker. It's the same thing. There are some places that have already started to screen patients at the age of 55 because they have a population similar to yours. So I mean, I would just say screen them and see what happens. And I think that what you will find is that you probably have more, 55 year olds on dialysis than we do, but guess what? They have physical, a lot of them are gonna have physical frailty. And so I would just think more broadly about what this means. And that goes back to this gentleman's point earlier, right? If we're looking at the physiology, then the age shouldn't matter quite as much. So my father was an academic pathologist and he well understood the futility of much of technological medicine. To talk about the technology. And when he was in his late 80s and we were talking about his advanced directives, what I basically came to understand was that what he wanted should something happen was that if there was an excellent chance that he could be returned to his previous state of being from before whatever the incident was, if he was happy with that previous state of being, then he would want to be resuscitated, et cetera, but not otherwise. How do you implement that? What do you write down? How do you implement it? When you're writing an advanced directive, what words do you use? How do you write it down? How do you communicate? So actually how do you communicate it? And what in fact does it mean? Because at any given point in time, how are you supposed to know whether he was satisfied with his status immediately before the event? Right, so there are a couple of things. I think that how do you communicate it? I think he did exactly the right thing, which is he told you. Because the problem with advanced directives, and I am embarrassed to even say it to this audience because I feel like you all know, they're too broad or they're too narrow. You can never find them in the moment. There's effective forecasting. They don't necessarily apply to exactly what you're talking about. So when you look at Thelma and she wrote her advanced directive, she's thinking, I don't want to end up like my husband and I don't want to be intubated if I'm really sick in the hospital of cancer. She's not thinking, well, what if I get hit by a car and I have a splenic injury that can easily be embolized? And so the advanced directive is almost useless. It's the thought. It's the forethought. It's the understanding of what her parameters are. So the question that your father left is was he satisfied with his previous state? So you can't write that down because nobody knows what that is. So the communication has to be dynamic. It has to be constant. And so if he writes that last week, that may be different this week. Maybe last week he was happy with it and this week he's not. So it's really important, but that's also an important piece in helping him understand. Listen, I got you, but that's pretty vague. So you need to know that if anything, should anything happen, you're gonna get resuscitated up front until we can sort out what your life would look like or you're not. But you have to clarify that. And that's what people don't understand. When a lot of people don't understand, they think that there's this magical repository with advanced directives where somebody can write their advanced directive in Alaska, I can just go, and it shows up. Or that somehow magically I'm gonna know or that their family is gonna know exactly what they want. And so I really do think that the two most important things are one, that he told you, and then two, that somebody asked you. All right, if he can't respond. And unfortunately too often those two things don't happen. Like that's the breakdown in communication. Nobody tells you and nobody asks you. And so we don't know. It's a black box. Hi, Dr. Cooper, thank you so much for a very interesting and engaging talk. I found your five patients to be quite interesting, but I think Thelma was for me one of the more compelling stories that you told. And as someone that's very interested in, I'm a geriatrician and I educate fellows and also work on a consult service, I'm interested to know how can we address the education of our peers, of our colleagues? Because I'm finding that some of the more complicated situations that we're having, whether they come out of the ICU or they've been having surgery, is that they get, the patients themselves are getting conflicting messages about what can be done, what should be done. And so, and I also take care of patients in skilled nursing facility. And so we have goals of care discussions there. Something happens, they go back to the hospital, they're giving completely different set of options. So how can we, I agree that we need to be talking about training and it seems like we're doing fantastic interventions with our young learners, but what can we do about our peers? Yeah, I think that's a great question. I actually, there's a lot of enthusiasm within the surgical palliative care community around resident training and I applaud it. It takes one attending to just wipe that out. You know, you can do all the ethics training you want and if you have one attending who doesn't, who doesn't, you know, kind of behave well in the sandbox so to speak, that's the only, it can just set that resident back for years, right? I'm never gonna bring this up again. I get yelled at by my attending, right? That's it. So I actually think we need to do a lot more work amongst our peers and I think it has to be overt. I mean, again, this is a skill. There has to be skills training. The American College of Surgeons is actually in the middle of setting standards for geriatric centers of excellence, of which I would presume this hospital will want to become one and part of that will be CME requirements and various processes of care around goal setting and decision making and that should help raise the floor, right? It may not raise the ceiling but it should at least help raise the floor but I do think that it's really important and so as you kind of prepare for some of these patients coming along, I think at least the immediate patients, the immediate clinicians who are gonna touch these patients should have some understanding of the importance of goal setting. I think I would say that one of the biggest challenges that you describe is they receive a lot of information that may be conflicting but what doesn't happen is that the information that they receive is not necessarily relevant to the goals that they set because nobody asks them and so the consistency should be what are your goals and that we have to recognize again that those may be dynamic, right? That those may change and then often when confronted with death people's goals change and that that's okay but we have to continue having that conversation and that everybody has to be comfortable with that and even in the patient who comes into the trauma bay and they're in the trauma center and whatever, I mean over the course of their illness their goal may be to be immediately resuscitated when they're in the ICU, their goal may be to get out of the ICU and then once they get to the floor their goal may be to never be in a nursing home, right? Because they're understanding their own trajectory and so really again I hate to be a broken record but I feel like it comes down to communication but I completely agree that we have to do more work with our peers and set some expectations and so for example I would certainly recommend that at least looking at Thelma, that the anesthesiologists, the trauma surgeons, the social workers, some of the nurses who are gonna be taking care of patients like Thelma who are gonna be sending them to the operating room have an understanding of what the procedure should be if somebody comes in with a DNR and needs a procedure at a minimum. Hi, I had a question as well. My name is Ann, I'm one of the medicine residents here. I'm not doing surgery clearly and actually going into primary care and my question for you is more along the lines of when so when you're seeing geriatric patients or trauma patients in general coming in with acute issues, what are particular questions or things you wished had been brought up or addressed like by primary care or by some physician prior regarding their acute needs? For example, I guess more so with geriatric patients. Like what role do you see like primary care serving and trying to like prepare patients for these future events to helping ease this transition and potentially their inpatient course? So I think that's an outstanding question and I'm so glad that you asked it and again tell them that this stuff happens. And that's probably, I mean nobody expects to have a sudden trauma, that's why it's sudden. I mean nobody expects to get hit by a car, right? I mean you don't expect these things to happen and so you have to prepare for them and so I think one of the things to think about when you're doing advanced care planning with your patients, which of course you will, of course you will, right? When you're doing advanced care planning with your patients to bring up this possibility to help them understand that yes, I mean a lot of people would prefer to die in their sleep but that's not always how it works, right? And then in fact what oftentimes we're most worried about is not dying, right? It's what the treatment that leads up to that. And so I would encourage them not only to think about the unexpected but also to share that information with their family and their loved one and frame it as such that it's really a kind thing to do with their family because the family suffers so much when they don't understand what to do. I mean it's terrible suffering for the family so I would really encourage them to have conversations and to bring them in, you know? If there's a significant other, if there's a daughter, if there's a son, if there's a daughter-in-law, whoever it may be, if they wanna have the conversation in your office, I mean the Medicare reimbursement isn't great but at least they reverse for it now but at least you can have that conversation but I would really try to make a dialogue and then to encourage them to revisit that over time. Really, I mean that would go a very long way. The number of patients that I've come across who are well into their 80s where nobody has any idea, I mean it is really surprising to me, not because I expect that everybody is wants to die but I mean everybody's gonna die. You know, and like we have birth plans, you know? I wonder whether, and I think about that a lot too, knowing even just the pace of my clinic and not that time should be an excuse, it should never be an excuse but if I think about the list of comorbid issues going on with the primary care patient, well I mean I get like half an hour with patients sometimes or run really late but having a conversation about potential goals of care and stuff falls down on the list compared to med wrecking them and making sure they're minimizing their risk of falls or minimizing the meds they're needing. But I mean my question is, I know that it falls up but why would this be less than the risk of falls? Because if they fall, they need to have this done. So it's the same thing. So I get it. Sometimes I try to clarify them like next time, when I see you next time, I'll put it on my list of to-dos. And as long as there's not an acute or urgent thing, I have to usually make a specific visit to have a conversation about that. Right, and so that would be one thing. And the other thing is that there is, and everybody has variable levels of literacy and understanding all that, but there's a ton on the web. There are tons of pamphlets. I mean, there are ways that you can encourage, I mean just putting, when I meet somebody in the hospital, it's terrible, I've never met them, I've never met their family members, something tragic has just happened to them. And all of a sudden, here I am sitting up here in front of the smartest people in the world and I'm saying, oh you should have a goals of care conversation. And of course that's not how it's gonna work, right? But even by just asking the question, has your mom ever thought about what kind of treatment she would want if her heart were to stop? They know everything's not okay. Just asking the question makes them realize that it's different. And so again, that communication is so important, just asking that question. You know, I realize you're getting really sick and we talked about fall prevention, but I also want you to just keep in mind, you know, if you were to fall and you were to get seriously injured, it might be worth talking to your family about, you know, what kind of treatments you might want to avoid. You know, one of the things that are most important to you so that they could help make some decisions for you if you could make it yourself. And next time, if you want to talk about it, we can talk about it more, but here's a pamphlet, here's a website. Have your daughter call me. What was that, like a minute? I mean, it's not advanced care planning, it's not great, but it's better than nothing. No, no, no, I completely agree with you. I tend to talk a lot more so it takes me a long time to get through. But that's fine, yes. And I know you and your history taking ask the question, who would you like to speak to you if you're unable to speak for yourself? Right, yeah. That's built into your encounter with the patient. Right, right. Which is very important. But it's also important to say, and what do you want them to know? Right, and like if this person is who you've said, like talk to them about what you want. Right, exactly. We can take one final question, please. Oh, I feel very privileged. And this is a response to what you just said about pamphlets, but I originally was gonna say it in response to your question about talking with your dad. I found about 10 years ago, and it's still there, I found on the web a workbook, not a pamphlet with instructions, but an actual workbook for thinking about advanced directives. And I'm sorry that I don't know the title of it or where to find it, but it was originally developed. No, I don't think so. No, no, sorry, it wasn't. It was originally developed for the army. And then the army said, no, we're not gonna use this, forget it. But it's really great because it makes you answer questions and think about things as you go along. And then you can make copies of that so people see the thinking that went into your decision making and maybe reconstruct things that you're not able to say at the point when you need it. I'm not sure how to tell you to search for it even, but maybe if you put it in terms like army and advanced directives workbook. If you want, I can find out what it is. I'm sure I bookmarked it somewhere and send it to someone. But I think it's a really terrific thing to sit down and talk with whoever your healthcare proxy is gonna be and go through that and also to give a copy to your doctor who of course will never be able to find it and time to use it, but maybe. Thank you, thank you, it's been a pleasure. Thank you.