Inter-observer reliability of interpretation of numerical values of two commonly used CPET variables was good (>80%). However, inter-observer agreement regarding the presence of a reportable value was less consistent.
As a consequence of an ageing population greater numbers of elderly patients are presenting for both elective and emergency surgery. These older patients typically present with an increased burden of age-related problems and multimorbidity, which is associated with an increased risk of adverse postoperative outcomes. Traditional preoperative assessment models are adept at discerning patients' suitability for anaesthesia and surgery, but there is minimal focus on improving postoperative outcomes. Comprehensive geriatric assessment is a multidisciplinary approach used both to assess existing ‘known’ pathology and to screen for previously undiagnosed issues across medical, functional, social and/or psychological domains. This diagnostic phase then leads to the development and implementation of an individualized ‘optimization’ strategy across these domains. There is emerging evidence that comprehensive geriatric assessment and optimization in the surgical setting leads to improved outcomes, and it is reasonable to conclude that it would benefit the patient's long-term health.
As the ambitions of surgery have continued to develop, it has resulted in medical advancements that challenge the current paradigms of hospital medicine. Patients previously deemed unsuitable for surgery are now undergoing potentially lifesaving treatments, but are nonetheless still being managed within a model of care that fails to meet their individual needs. Termed 'high risk', these patients, who are frequently elderly or with multiple comorbidities, embark on a surgical journey that is often fragmented and disjointed. Such patients contribute a startlingly high mortality and morbidity rate for non-cardiac elective surgery during the perioperative period, and as a result provide an added demand on already strained hospital resources. 'Perioperative medicine' has been proposed as a possible solution to this problem as it attempts to create a bespoke patient-centric model of care from the moment the need for surgery is identified, through to patient recovery. It is envisaged that the role of a perioperative physician would be to oversee this journey, uniting varying specialties along the way to ensure the best possible patient outcomes.
The high-risk surgical patient only constitutes approximately 4% of the elective non-cardiac surgical population but contributes to the vast majority of in-hospital deaths following surgery. This, in conjunction with a high morbidity rate, can lead to a perioperative pathway fraught with challenges. It is incredibly difficult to anticipate which complications may arise and the risks involved before surgery. It is for this reason that patients need to be engaged in the decision-making processes regarding their perioperative care involved before major surgery. A combination of good medical practice, medicolegal influences and a governmental drive have begun to result in a shift away from paternalistic medicine to a shared decision-making approach. This article defines shared decision making, explores its benefits and limitations and addresses the relevant legal literature.
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