Physicians are often faced with the challenge of deciding when it is appropriate to proceed with a surgical procedure in an older adult. In each patient, many complex factors can impact this decision. It is essential to consider the unique circumstances of each individual and the specific surgical procedure being considered prior to deciding if it is appropriate to operate. The patient’s overall medical goals and their expectations regarding the impact of the surgery should be clearly defined preoperatively. The process of explicitly setting forth these expectations can help determine if the surgical procedure is required for and would result in the desired outcome, as well as deciding if the risk/benefit profile of surgery is acceptable to the patient [5]. For example, in an older adult with multiple medical comorbidities including severe aortic stenosis and moderately advanced dementia, a transcatheter aortic valve replacement may ameliorate cardiac symptoms but may not meet expectations of the patient/family as the concurrent dementia will continue to significantly impact functionality.

Older adults experience the physiologic effects of aging at different rates. Therefore, decisions regarding the appropriateness of surgery should not be based simply on age but should take into account the risk profile of the surgery and the individual patient’s physiology, medical comorbidities, and functional status. Multicomponent preoperative geriatric assessments and measurement of frailty should be utilized to determine an individual’s operative risk. Components of the assessment should include evaluation of medical comorbidities, functional ability, cognitive ability, and frailty. Frailty is defined as a state of weakness and susceptibility to stress that originates from reduced physiological reserve resulting in diminished resiliency, loss of adaptive capacity, and increased vulnerability to stressors [6, 7]. Understanding the level of frailty of each patient can be instrumental in guiding operative decisions as well as expectations regarding the postoperative course [5, 6].

While there is currently no gold standard for assessing frailty in elderly surgical patients, several studies have demonstrated that increased frailty has a negative impact on surgical outcomes [8–11]. The two most commonly cited tools to measure frailty include the phenotypic [12] and accumulation of deficit models [13]. The frailty phenotype, described by Fried et al. [12], has five criteria: unintentional weight loss, weakness, exhaustion, slow walking speed, and a low level of activity. This definition of frailty has been studied in patients who underwent elective surgery, and increased levels of frailty were associated with an increased risk of postoperative complications, longer length of hospitalization, and a discharge disposition other than home [8]. The accumulation of deficit measure proposes that frailty is a nonspecific, age-associated vulnerability that is reflected in an accumulation of medical, social, and functional deficits which can be measured by counting an individual’s health problems or deficits [13]. In the accumulation of deficit model, a patient’s frailty index score reflects the proportion of potential deficits present in that specific individual [14]. Increasing number of deficits (i.e., anemia, low serum albumin level, history of falls, functional dependence, cognitive impairment, comorbidity, and mobility impairment) accounted for in a multidomain/accumulated deficit model of frailty has correlated with increased complications, six-month morality, and risk of institutional discharge among colorectal and cardiac surgery patients [11, 15].

A comprehensive preoperative assessment that includes clarification of goals, review of medical comorbidities, evaluation of physical and cognitive function, and frailty assessment can help to determine if a specific surgical procedure is appropriate in a given patient. In addition, the identification of factors associated with specific operative complications and a management plan to minimize these risks can be implemented. For example, a comprehensive assessment might determine that a functionally independent, cognitively intact 95-year-old could undergo surgery with a lower risk than a 65-year-old suffering from symptomatic congestive heart failure and moderate dementia. Based on the results of the comprehensive preoperative assessment, the goals for the surgery and aggressiveness of the procedure can be modified to match the actual physiologic capacity of the patient. Sometimes, a large surgery is not needed to obtain the desired outcome, and a modified or shorter procedure, with lesser surgical insult, can be undertaken to reduce the risk of adverse outcomes. In other cases, the decision may be made to forgo surgery and focus on medical management given the overall goals, medical complexity, functional impairment, or frailty of the patient. However, understanding when modifying or forgoing a surgery is appropriate can only be achieved when a clear understanding of the patient’s individual physiology and goals is achieved.

Clinical communication with patients in the form of informed consent is necessary prior to surgery. Informed consent is the process by which component adults make voluntary decisions following the disclosure of relevant information including review of the medical decision, discussion of the proposed procedure, and disclosure of risk, including any potential complications or disabilities that might occur as a result of the intervention. Additionally, the risks and benefits of not undergoing the procedure should be discussed. There are five identified benefits of informed consent: (1) protecting the patient’s right of self-determination, (2) engaging the patient in their health care, (3) enhancing the physician-patient relationship, (4) encouraging physicians to thoroughly review the patient’s therapeutic options, and (5) reducing discontent and ligation when there are complications [16].

The full process of informed consent can be challenging to accomplish in the older patient population due to interactions between complex medical comorbidities, cognitive issues, and social barriers. Complications are common in older adults undergoing surgery, and possible adverse effects and future disabilities that may result should be clearly understood prior to proceeding with any procedures [17]. Surgical patients often display suboptimal understanding of the risks and benefits of their upcoming surgery. In a survey of 1,034 preoperative patients, with a mean age of 54.8 years, 13 % did not meet the standards for informed consent [18]. Additionally, this study found that socioeconomic factors including language (non-English) and educational level (lower education) place patients at higher risk for decision-making deficits [18]. Oftentimes, patients do not engage in a thorough discussion of their treatment preferences regarding advanced care planning, particularly preferences about how aggressively care should proceed in the event of significant complications [19]. Therefore, when obtaining preoperative informed consent in older adults, it is critical to ensure that patients have a clear understanding of the limitations of the procedure, complications that might occur, and possible impacts the procedure and resultant complications are anticipated to have on their function and quality of life in the future.

Ensuring that an individual has decision-making capacity is a prerequisite to obtaining legally and morally informed consent for a surgical procedure. Decision-making capacity should be evaluated based on an individual’s ability to make a specific medical decision, not their ability to make all general medical decisions. Decision-making capacity describes an individual’s ability to understand and utilize information about the proposed treatment options to make a choice that is congruent with their values and preferences. Cognitive decline, with or without meeting the diagnostic criteria for a major neurocognitive disorder, is a significant concern among elderly patients and can complicate the decision-making process [20]. In most cases, the care team can make the proper judgment regarding a patient’s decision-making capacity from conversations with the patient regarding their medical situation and possible treatment options. In cases where decision-making capacity is less clear, formal mental status testing can help determine whether a patient is capable of making this type of decision. The Mini-Cog, a brief cognitive screen that tests memory and executive function, can be helpful in determining if the patient has impaired cognitive function [21]. The Mini-Cog is highly sensitive and has advantages over many other formal tests of cognition as it is brief (3–4 min to administer), can be performed by nonphysicians, lacks a language or educational bias, evaluates for the presence of executive dysfunction, and has been used for preoperative assessment [21–23]. However, there is no gold standard for the best cognitive evaluation tool, and the score on a standard examination does not dictate a conclusion about capacity but simply serves as an important data point when making a capacity assessment.

When having informed consent discussions, it is also helpful to engage a patient’s surrogate and/or family member in the conversation. As patients may lose decision-making capacity at some point after surgery, conversations between the patient and surrogate prior to the surgery regarding preferences for medical treatment and goals of care are helpful to inform surrogates of patient preferences and improve appropriateness of care in cases where surrogates must assume the role of decision-maker.

If a patient is deemed unable to provide informed consent, then their surrogate decision-maker would be the appropriate individual to make decisions regarding any proposed surgical treatments. It is important to ensure that the surrogate decision-maker understands that decisions should be based on their best knowledge of the patient’s expressed wishes and values, not what their personal wishes would be in the same situation. If the patient’s wishes and values are not known, the surrogate decision-maker should be guided to make decisions based on what would be in the best interests of the patient. In situations where surrogates are making decisions regarding care, they should be provided with all available details regarding diagnosis, prognosis, and alternative treatments as if they were themselves the patient.

Ideally, documentation of an identified surrogate who was chosen when the patient had capacity to do so should be available. If there is not a designated surrogate, the rules regarding surrogate decision-makers for health care should be reviewed for the state in question. In many cases, family members will be able to take on the role of surrogate, or a guardian may need to be designated.

A do-not-resuscitate (DNR) order is a legal medical document that reflects an individual’s desire to decline resuscitation efforts. Older adults may choose to forgo certain resuscitative procedures because they do not want to accept the possible burdens associated with them. These burdens may be related to either the resuscitation attempt itself or a decline in cognitive and functional capacity following the resuscitation attempt. In the early 1990s, following the passage of the Patient Self-Determination Act which requires facilities receiving Medicare or Medicaid funding to inform patients about their right to refuse medical treatment and the use of advanced directives on admission [24, 25], the American Society of Anesthesiologists, the American College of Surgeons, and the Association of Operating Room Nurses published guidelines declaring that patients with DNR orders should have these reevaluated for the perioperative period. Failure to respect a patient’s wishes regarding resuscitation would constitute a violation of the moral and legal right to self-determination [26, 27]. Therefore, a clear and open conversation regarding a patient’s wishes around resuscitative efforts and expectations during the pre-, intra-, and postoperative period should occur prior to proceeding with any surgical interventions.