Informed decision-making in elective major vascular surgery: analysis of 145 surgeon–patient consultations

Etchells, Edward

doi:10.1503/cjs.047709

Cited by 18 publications

(19 citation statements)

References 17 publications

(18 reference statements)

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“…Although a definitive decision to proceed to surgery followed the majority of our recorded conversations, others have shown that elements of complex decision-making increase over multiple preoperative visits. 25 Additional information may have been exchanged after the conversation we audio taped (via telephone or in other settings). As such, it is possible that conversations about the use of prolonged life support and patients’ preferences were missed.…”

Section: Discussionmentioning

confidence: 99%

It's Big Surgery

Pecanac¹,

Kehler²,

Brasel

et al. 2014

Annals of Surgery

120

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Objective To identify the processes surgeons use to establish patient buy-in to postoperative treatments. Background Surgeons generally believe they confirm the patient's commitment to an operation and all ensuing postoperative care, before surgery. How surgeons get buy-in and whether patients participate in this agreement is unknown. Methods We used purposive sampling to identify three surgeons from different subspecialties who routinely perform high-risk operations at each of three distinct medical centers (Toronto, ON; Boston, MA; Madison, WI). We recorded preoperative conversations with three to seven patients facing high-risk surgery with each surgeon (n = 48) and used content analysis to analyze each preoperative conversation inductively. Results Surgeons conveyed the gravity of high-risk operations to patients by emphasizing the operation is “big surgery” and that a decision to proceed invoked a serious commitment for both the surgeon and the patient. Surgeons were frank about the potential for serious complications and the need for intensive care. They rarely discussed the use of prolonged life-supporting treatment, and patients’ questions were primarily confined to logistic or technical concerns. Surgeons regularly proceeded through the conversation in a manner that suggested they believed buy-in was achieved, but this agreement was rarely forged explicitly. Conclusions Surgeons who perform high-risk operations communicate the risks of surgery and express their commitment to the patient's survival. However, they rarely discuss prolonged life-supporting treatments explicitly and patients do not discuss their preferences. It is not possible to determine patients’ desires for prolonged postoperative life support based on these preoperative conversations alone.

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Section: Discussionmentioning

confidence: 99%

It's Big Surgery

Pecanac¹,

Kehler²,

Brasel

et al. 2014

Annals of Surgery

120

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“…15 In addition, our sample of surgeons included only those who regularly perform high-risk operations, and the patterns of decision making we describe may be limited to surgical decisions with substantial risk. For this study we selected surgeons regarded as good communicators by their peers, as such we cannot project how our findings about surgeons’ use, endorsement and rejection of the “fix-it” model works across a broad range of surgical practices and styles.…”

Section: Discussionmentioning

confidence: 99%

“And I Think That We Can Fix It”

Kruser¹,

Pecanac

Brasel

et al. 2015

Annals of Surgery

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Objective To examine how surgeons use the “fix-it” model to communicate with patients before high-risk operations. Background The “fix-it” model characterizes disease as an isolated abnormality that can be restored to normal form and function through medical intervention. This mental model is familiar to patients and physicians, but it is ineffective for chronic conditions and treatments that cannot achieve normalcy. Overuse may lead to permissive decision making favoring intervention. Efforts to improve surgical decision making will need to consider how mental models function in clinical practice, including “fix-it”. Methods We observed surgeons who routinely perform high-risk surgery during preoperative discussions with patients. We used qualitative content analysis to explore the use of “fix-it” in 48 audio-recorded conversations. Results Surgeons used the “fix-it” model for two separate purposes during preoperative conversations; 1) as an explanatory tool to facilitate patient understanding of disease and surgery and 2) as a deliberation framework to assist in decision making. Although surgeons commonly used “fix-it” as an explanatory model, surgeons explicitly discussed limitations of the “fix-it” model as an independent rationale for operating as they deliberated about the value of surgery. Conclusions While the use of “fix-it” is familiar for explaining medical information to patients, surgeons recognize that the model can be problematic for determining the value of an operation. Whether patients can transition between understanding how their disease is fixed with surgery to a subsequent deliberation about whether they should have surgery is unclear and may have broader implications for surgical decision making.

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“…Previous research makes the assumption that detailed discussions between surgeons and patients are at least a necessary, if not sufficient, condition for informed consent [1,[4][5][6]9,14,15]. By this standard, the surgeons and patients studied here are doing quite well.…”

Section: Va Author Manuscriptmentioning

confidence: 99%

“…To compare our findings to previous studies of informed consent discussions [4,5,14], we calculated the proportion of patient-provider discussions that mentioned at least one risk, benefit, alternative, indication for, and description of the procedure. Although the prevalence of each of these information categories was high (Table 4), only 50% of cholecystectomy discussions and 29% of the herniorrhaphy discussions included one item from each category.…”

Section: Basic Informed Consentmentioning

confidence: 99%

“…The culture and training of these two samples may be different. Etchells et al [14] recently published findings from a cohort of vascular surgeons, finding that 58% of the discussions in which surgery was recommended demonstrated "complex" informed decision making, discussing risks, benefits, and alternatives to the proposed surgery as well as the uncertainty of the decision. These data suggest that the informed consent practices of Etchells' vascular surgeons and our general surgeons are more detailed than Braddock's orthopedic surgeons.…”

Section: The Process Of Informed Consentmentioning

confidence: 99%

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Do surgeons and patients discuss what they document on consent forms?

Hall

Hanusa

Fine

et al. 2015

Journal of Surgical Research

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The patients and providers observed here collaborated in a detailed process of informed consent that challenges the initial reports suggesting the need to remediate surgeon's practice of informed consent. However, because the discrepancy between the information documented and discussed exposes legal and ethical liability, there is an opportunity to improve the iMed system so that it better reflects what surgeons discuss and more frequently includes all the information patients need.

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Informed decision-making in elective major vascular surgery: analysis of 145 surgeon–patient consultations

Cited by 18 publications

References 17 publications

It's Big Surgery

It's Big Surgery

“And I Think That We Can Fix It”

Do surgeons and patients discuss what they document on consent forms?

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