84 year old 'pre-hab' for major surgery

[Catladyagain]

Hi all, my 84 year old father is booked for major surgery to remove a colon cancer tumour. The team just postponed it because he is weak after a year of internal bleeding and poor oxygen levels. Dad said afterwards "I thought the operation would be a bit like dealing with a bit of a cold. I had no.idea it was so serious". He also could not get his head around the fact the anaesthetist basically said life is very likely to be different / outcomes leaving him worse off than before the operation. He sees a period of recovery then he becomes his 70 year old self again. He does not have dementia but he has always been extremely good at believing what he wants to believe and disregarding any facts. That said he has very poor oxygen levels and you can see his brain is working very slowly and struggling to process everything. I have moved him into my house to 'prehab' him with more protein and trying to build up some muscles but it feels an almost impossible task as he lacks all his earlier energy. But anaesthetist says 6 weeks strengthening can offer significantly better outcomes. Likely outcomes sound horrific and I just don't know how to discuss this with dad. Has anyone else experienced anything similar? Thanks in advance.

@Catladyagain given the slow growth of the tumour and your dads fraility.....is it really worth putting him through a major operation?? It sounds like the recovery will be very hard on him. Yes the cancer can spread . It happened to my uncle many many years ago. Sending hugs and support to you all x

I’d be very weary of such invasive surgery at that age. My dad had the same surgery but he was 70 and very fit and active. It was very tough and he lost a lot of weight. He’s fine now but I work with a lot of people in their 80s and I don’t think any of them have the reserves in them to get through something like that. I am so sorry for what you are both going through.

This. I am a retired nurse.

Is he on an blood product transfusions / iron tablets for the blood loss. That will help his oxygen salts (Also make sure he's drinking plenty of water) . Likewise focusing on high iron foods (meat, leafy green vegetables.) Also eating high vitamin C foods at the same meal to increase iron absorption. Eg take iron tablet with a glass of orange juice. And avoiding caffeine and calcium at the same meal (milk, yoghurt, tea coffee) because they reduce iron absorption.

I would certainly ask to speak to the oncologist again with your dad about the operation.
It sounds like the op is intending to offer a cure for the cancer, but the op itself is the immediate risk to your dad.

Instead of pursuing a cure where the treatment has significant risks of death/disability, you could ask about radiotherapy or immunotherapy to mananage the cancer, reduce symptoms and extend life. All treatments come with side effects, which is why I didn't include old style chemo on the list, but it might be worth considering a few rounds depending on your dad's fitness at that point. We need to get out of the mindset that curing cancer at all costs is the best thing

And no the operation would not cause the cancer to spread

My FIL had this opération aged 90 and unfortunately died within hours, it was too much for his body to cope with. I had been shocked when I heard he was having such major surgery, so wasn't surprised at the sad outcome.

90 is very different to 84, though. And many 84 year olds still feel they have plenty of years left in the tank, rather than choosing to forgo treatment.

I think you and your brother need a full and frank discussion with the oncology team rather getting a 2nd opinion. If your brother thinks they weren’t keen to do the surgery when they gave him the diagnosis and they have now postponed it because your father is too weak, they may not think it is in your dad’s best interests to have it at all but are reluctant to say that.

You all need the full facts about

1. what will happen if you do nothing and how long he will have left
2. non surgical treatments eg radiotherapy - frequency of treatment, likely side effects and how much they would expect that to prolong his life
3. the surgery - risks, recovery time, future bowel functionality in the best and worst case scenario.

Then you can decide together what is the most appropriate approach and what he wants. As a daughter who loves him you want him to have the surgery and keep plodding on. He might not want that for himself. It is so hard watching our parents age.

Could you afford him to see a private physio? Even once. To prescribe some simple exercises and see him afterwards

I think there is zero evidence of the NHS "quietly saving resources for younger folk". My experience with 3 late stage elderly parents is that the doctors are likely to continue to offer invasive and extensive treatment long past the point where there is any hope of a decent recovery. The default is to do anything they can to keep people alive and to use the full range of treatment options they have available.

I’m another asking, if the team have actually said that the outcome may me much worse looking than your dad’s current functioning, with a long and harrowing recovery, when he is demonstrating very limited energy and motivation for rehab type activities now - is this the right decision?

Like a pp I think you need a much more in depth and blunt conversation with his current team, rather than paying for a private opinion. In particular I would want to know what a team who is used to rehabbing people in their 80s who already have major medical compromises and frailties thinks. A second NHS opinion is his right as well, if you do want the comparison.

It is possible of course that the ‘do nothing’ option (which should certainly be asked about) does in fact look worse than this.

Anaesthetist PoV….id listen a bit more to the team looking after him rather than much of the advice on here - they will be in a far better position to give a better idea of what they’re expecting - partly because they know what operation they’re planning (which does make a difference!). It sounds like they’re making some sensible decisions by not just ploughing on before optimising him. I would expect after a period of optimisation to have another conversation about the pros/cons before proceeding, but it definitely isn’t impossible to get an octogenarian through some colorectal surgery in reasonable nick if the stars align well. If prehab doesn’t go well/things deteriorate then that may equally be a sign that it’s not a great idea to operate. They (the anaesthetist probably is most likely to do this) may also think it’s helpful (or may already have done it) to punch some numbers into some helpful risk calculators to that help roughly give an idea of the softer outcomes of surgery ….things like how big an impact on mobility/cognition/ability to live at home etc surgery might have. It’s also important to have a rough idea about what not doing surgery might be like/how quickly things would progress/what that tumour might cause by way of symptoms. Of all the available options I would not be going to the private sector for this.

I agree completely with this.
OP you are still relatively young and it's your dad so I can understand your approach.
I think it's a shame you couldn't have been at the appointment as well but it sounds like your brother has picked up on the nuances.

I had cancer at 61 and the treatment was brutal. It was worth it but I lost a year in treatment. One thing I did learn was to contemplate death, it happens to us all and it's possible to come to terms with it yourself. If I was in my 80s and frail I absolutely wouldn't consider treatment for cancer.

Some valuable insights here.

OP, you don't need to go private for a second opinion! Just ask for one, that's fine 😀

You may wish to consider asking for a chat with the palliative care team, they don't just deal with imminent dying.

I think I'd be concerned that he didn't seem to fully acknowledge what the outcome would be and what recovery could look like. At that age many people go into hospital and come out in a worse condition due to deconditioning assist from anything else.

You sound a lovely daughter ❤️.

Best wishes.

Morbidity/mortality will be high for someone elderly and frail having major surgery. Look at POSSUM, SORT and ASA scoring.

the ASA won’t tell you anything about predicted mortality/morbidity. Mortality might not be as high as you think using the calculators…morbidity is more likely to be the issue and there are better scores than any those 2 for attempting to predict problems (but none of the scoring systems are perfect so they only give estimates). Best advice remains to do the prehab/optimisation and then have another chat with the people who can actually see him (and know what operation is planned).

Look up Will Harlow on YouTube.
He is a physiotherapist well worth watching.
Has many exercises that elders can do at home.

Is he of the generation that did what the doctor said? My relatives who are older
than him really struggled with being given pros and cons and being asked to make decisions and consent to medical treatment as they saw the doctor as the expert and didn’t want to engage.

It sounds like he hasn’t really engaged with the possible outcomes from the operation.

so many helpful people, thank you.
it has all hit me this evening. I'm so sad.
my mum (his ex) is already traumatised having recently been disabled by a negligent cataract operation, along with her brother and sister in law, both very ill and dying of cancer overseas. she is not the support I need, always screeching blame and urgency about everything. she has been through an unbelievably unnecessary amount of traumatised in her life. my brother js hard to talk to about this. he said "dont give me problems give me solutions!!!" when trying to explain the intricacies of the situation. Both mum and brother have been the ones obsessing about the private opinion. neither willing to look at the detail of potential risks.
dad just told me where my grandparents are buried. his entire family going way back made it to 100 or beyond. I asked if they have gravestones and he said no ive been meaning to do that. he was selfish in his youth. said he "ought to get on with it before i pop off". he's lost his energy to carry on, the low oxygen and aneamia changing him so much over last year.
I feel I want to give up work to focus on my entire family. keep dad living with me until he dies whenever that may be. I never thought it would be like this. mum always drummed it into us that we must never put her in a care home. shes been such high energy all her life and fit. her depleted vision looks set to age her 10 years. dad's mum used to cry when we left her care home "I'm so lonely". I don't remember dad responding. I've been so angry with him all mu life. the way he treated mum. but in his depleted state hes jolly and easy going and nice to have around.
ahhh life eh.

You need to take a step back and look after yourself @Catladyagain, as hard as that sounds.

You are NOT responsible for all this - your mum, your brother’s emotions or your father.

Have you got friends who can support you and/or give you unbiased, non emotional blackmail advice? 💐

You cannot be responsible for them all OP. "dont give me problems give me solutions!!!" Imagine saying that to someone in a situation like this. Be careful you don't buckle under the weight of it all.

I think the hospital team are being slightly too subtle with what they're trying to tell you about your fathers future. At 84, he's had a long life and major surgery could bring all sorts afterwards including the dreaded hospital induced delirium.
Look after yourself.