Experiences of older surgical patients and care partners during <scp>COVID</scp> ‐19: Lessons for future care

The COVID-19 pandemic introduced unique challenges for patients undergoing elective major surgery, including scheduling delays, a transition to virtual care, and frequent policy changes (e.g., visitor restrictions, discharge processes).1, 2 These challenges disproportionally affected older adults (aged ≥65 years), who are more medically complex, less apt to use technology, and often involve friends and family members (i.e., care partners) in their surgical care.3, 4 The dismantling of routine care processes and support systems provided an opportunity to evaluate perceptions and values of older surgical patients and their care partners both separately and as a patient–caregiver dyad.5 Using preoperative and postoperative patient and care partner interviews, we sought to understand dyad experiences during major surgery to inform potential strategies to improve surgical care. We used convenience sampling to identify dyads undergoing elective colorectal surgery (n = 10) from July 2020 to July 2021.6 Participants were diverse across race, patient-care–partner relationship, and cognitive status as assessed using the Telephone Montreal Cognitive Assessment with scores <18 indicating possible impairment (Table 1).7 Verbal informed consent was obtained. Using Zoom, we interviewed dyad members separately before and after surgery. Interview domains centered on preparations, knowledge, and challenges. Interviews were audio recorded and transcribed. Using an inductive thematic analysis approach, two researchers independently coded transcripts without a preexisting coding schema. Following each interview, the full team met to review the codes and refine the codebook. Interviews continued until reaching data saturation. A final coding schema was then applied, and the full team analyzed the codes in segments for overarching themes. The University of Michigan Medicine Institutional Review Board approved this study. Interviews revealed four dominant themes impacting surgical experiences (Table 2). (1) Surgery was perceived as non-elective: Due to discomfort or a perceived lack of alternative options, dyads viewed the surgery as urgently needed to maintain or improve their quality of life. Uncertainty around scheduling and delays led to distress among dyads. (2) In-person meetings were valued: Meetings in-person, especially with the surgeon, were critical for establishing trust. Additionally, virtual care was sometimes perceived as an indicator of lower surgical complexity and contributed to additional distress when recovery was prolonged. (3) Importance of care partner involvement: Patients felt the emotional, physical, and informational support of their care partner contributed to the success of their surgery. Care partner involvement also improved perceived patient recall and adherence to directions from the surgical team. Without care partners present in the hospital, many patients reported remaining in bed too long after surgery, patients with cognitive impairment often underreported symptoms, and dyads felt less able to elicit responses to their inquiries. (4) Inconsistent communication: Variation in how and when surgical team members communicated with dyads reduced confidence and preparedness for surgery. Due to the pandemic, visitation policies were frequently changed and inconsistently enforced, which introduced additional challenges for care partners seeking updates on the patient's care. This was especially distressing for dyads where the patient had cognitive impairment and depended on care partner involvement for managing their health. I'm more than a little worried right now with the university canceling surgeries, that this is gonna get canceled. And I won't do well with that. Because of, it's impacting everything else I'm doing right now…You know it's, yeah, it, you know sort of an elective surgery but it's not. It's sorta one step past elective. -Patient #7 It wasn't an easy decision. It'd been recommended for quite a while, and we finally made up our mind. So now we're confident this is the way to go… we were hopin’ to get it like the next week [after surgical consultation], which we know wouldn't happen, but… if anything, to have gotten the surgery a little sooner in the month, would have been better. -Care Partner #8 When I talked to [surgeon], and we, we've only met video, so I said I would like to meet her in person before the surgery. They said she would see me in the preop area, which is fine. -Patient #7 But his follow-up surgical appointment was video. Now I found that odd—I found that odd! I mean how do you look at the surgical site and, you know? I guess just by the questions they asked they could surmise they didn't need to… I just kinda figured that was one we'd probably have to go back in person. But, you know like I say, he did, he did fine. -Care Partner #9a He's been to every one of the doctor's appointments, the only time he couldn't was when I went to the sugar doctor last week. But he got to go online, in another room. You know, he didn't want anybody in with the virus. He Is the only one that ever said no, he can't come, he can't come in. Well, then you better find; because I want him to hear everything that's being said. Cause you know four ears are better than two. -Patient #4 What things could you not provide the patient now, given the (pandemic)? The role of patient advocate. I missed all of [the plan from the medical team]. So all I had was her report, which, when you're on pain meds and you're in pain, you don't always remember exactly what was said or what the plan is. So, information was sketchy. And it was frustrating. -Care Partner #7 That's one that we do, we'll check at that time also. The way I read the… the things online is, that I can have one visitor per day. I think that, I think that means one total, not one at a time, but we need to check, ‘cause those things seem to be very… fluid and changing at the, at the moment with the COVID thing of how many… how many visitors. Other than that, uh…we'll, we just, uh… go with the flow as we go through this thing. -Patient #6a Did you have to look into the visitor policy or anything like that? “Dad was gonna check on it, um, and let me know. (Yeah) ‘Cause I mean around here… I don't even, I know some people who work at hospitals around here, and I think it's… one visitor and it's like basically for a short time… I mean without me really knowin’ what's goin’ on, I've, (Yeah) prepared the best I can” -Care Partner #1a Perspectives of patients undergoing surgery and their care partners during the COVID-19 pandemic revealed important opportunities to optimize surgical care for older adults. Participants viewed the surgery as non-elective; cited inconsistencies in communication; and placed high value on in-person meetings with their medical team and the inclusion of care partners. Other studies of older surgical patients during the pandemic have also highlighted a desire for better communication with the surgical team, the inclusion of caregivers, and a preference to meet their surgeon face-to-face before surgery as a mechanism to build trust.1, 8, 9 A strength of our study is the inclusion of care partners who are often viewed as a vital component to a successful surgery. We have four recommendations for this growing population of patients undergoing surgery: (1) Teams should consider designating “elective surgery” as “scheduled surgery” to patients and their care partners to acknowledge the importance of the surgery to dyads. (2) Virtual care practices should offer opportunities for dyads to meet the surgeon in-person and specify that virtual meetings do not signify lower surgical complexity. (3) Surgical teams should advocate for care partner involvement from initial consultation to recovery at home to better support the patient and reinforce recommendations. (4) Health systems should develop reliable methods for care partners to communicate with the surgical team (e.g., a secure portal for asynchronous two-way communication regarding patients' daily progress) during hospitalization. Such recommendations may better support dyads undergoing major surgery. All authors contributed to the study concept and design, drafting of the manuscript, and reviewing the manuscript for critical feedback and approval of the final version for publication. Blue Cross Blue Shield of Michigan Foundation (002816), VA Ann Arbor | Geriatric Research Education and Clinical Center (GRECC). No conflicts of interest declared. The sponsor had no role in the study design, data analysis, or preparation of the manuscript.