It's Big Surgery

Pecanac, Kristen E.; Kehler, Jacqueline M.; Brasel, Karen J.; Cooper, Zara; Steffens, Nicole M.; McKneally, Martin F.; Schwarze, Margaret L.

doi:10.1097/sla.0000000000000314

Cited by 120 publications

(41 citation statements)

References 24 publications

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“…10,23,24 We also interviewed patients before (n=34) and after (n=27) surgery. We used an inductive coding strategy and deliberative adjudication process among researchers to support higher-level analysis whereby codes were expanded and refined to capture phenomena present in the data.…”

Section: Methodsmentioning

confidence: 99%

Engaging Patients, Health Care Professionals, and Community Members to Improve Preoperative Decision Making for Older Adults Facing High-Risk Surgery

et al. 2016

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Importance Older patients are at greater risk for postoperative complications yet they are less likely than younger patients to ask questions about surgery. Objective To design an intervention to improve preoperative decision making and manage postoperative expectations. Design We created a Patient and Family Advisory Council (PFAC) to help identify preoperative decisional needs. We met monthly for one year to examine findings from a prior qualitative study and to integrate themes with PFAC members’ lived experience. PFAC members and other stakeholders evaluated 118 publically available questions and selected 12 corresponding to identified needs to generate a question prompt list. To refine this intervention, we conducted focus groups and a clinical pilot. Setting The local library and one outpatient surgical clinic in Madison and three community centers in Madison and Milwaukee, Wisconsin. Participants Four men and women who had previous experience with high-risk surgery as either older patients or family members participated in our PFAC. Three focus groups included 31 community members from diverse backgrounds. We pilot tested the intervention with 42 patients considering surgery. Exposure(s) None Main Outcome and Measure(s) Generation of an intervention to address patients’ preoperative informational and decisional needs. Results Through exploration of qualitative data the PFAC noted three critical problems; patients and family members believed surgery “had to be done,” were surprised that postoperative recovery was difficult and lacked knowledge about the use of advance directives perioperatively. The PFAC identified a need for more information and decisional support during preoperative conversations including clarification of treatment options, setting postoperative expectations and advance care planning. Three question prompt categories arose: “Should I have surgery?”, “What should I expect if everything goes well?”, and “What happens if things go wrong?” The final list includes 11 questions within these domains, was understandable in English and Spanish, and was acceptable to patients in clinic. Conclusions and Relevance Through direct engagement of stakeholders, we created a question prompt list to address core decisional and informational needs of surgical patients. Future testing will evaluate whether this list can be used to improve patient engagement and reduce postoperative regret and conflict about postoperative treatments.

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Section: Methodsmentioning

confidence: 99%

Engaging Patients, Health Care Professionals, and Community Members to Improve Preoperative Decision Making for Older Adults Facing High-Risk Surgery

et al. 2016

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“…6-8 Furthermore, surgeons' conversations are framed by the structure of informed consent which functions poorly as a vehicle for decision making. 9 Although shared decision making holds promise for improving high-stakes clinical decision making by aligning patients' values with the appropriate treatment choice, contemporary efforts to improve shared decision making between patients and surgeons have focused on the out patient setting. 10, 11 …”

Section: Introductionmentioning

confidence: 99%

Constructing High-stakes Surgical Decisions

et al. 2016

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Objective To explore high-stakes surgical decision making from the perspective of seniors and surgeons. Background A majority of older chronically ill patients would decline a low-risk procedure if the outcome was severe functional impairment. However, 25 percent of Medicare beneficiaries have surgery in their last three months of life, which may be inconsistent with their preferences. How patients make decisions to have surgery may contribute to this problem of unwanted care. Methods We convened four focus groups at senior centers and two groups of surgeons in Madison and Milwaukee, Wisconsin, where we showed a video about a decision regarding a choice between surgery and palliative care. We used qualitative content analysis to identify themes about communication and explanatory models for end-of-life treatment decisions. Results Seniors(N = 37) and surgeons (N = 17) agreed that maximizing quality of life should guide treatment decisions for older patients. However, when faced with an acute choice between surgery and palliative care, seniors viewed this either as a choice between life and death or a decision about how to die. Although surgeons agreed that very frail patients should not have surgery they held conflicting views about presenting treatment options. Conclusions Seniors and surgeons highly value quality of life but this notion is difficult to incorporate in acute surgical decisions. Some seniors use values to consider a choice between surgery and palliative care, while others view this as a simple choice between life and death. Surgeons acknowledge challenges framing decisions and describe a clinical momentum that promotes surgical intervention.

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“…7 In a previous study of preoperative conversations, it was observed that surgeons assert a profound perception of “agency” or personal responsibility for the patient’s operative outcome, particularly survival. 8 This responsibility, embedded in surgical culture, may motivate the surgeon’s actions when patients require prolonged postoperative life-sustaining treatment.…”

Section: Introductionmentioning

confidence: 99%

Conflict in the intensive care unit: Nursing advocacy and surgical agency

Pecanac

Schwarze

2016

Nurs Ethics

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Background Nurses and surgeons may experience intra-team conflict during decision making about the use of postoperative life-sustaining treatment in the intensive care unit due to their perceptions of professional roles and responsibilities. Nurses have a sense of advocacy—a responsibility to support the patient’s best interest; surgeons have a sense of agency—a responsibility to keep the patient alive. Objectives The objectives were to (1) describe the discourse surrounding the responsibilities of nurses and surgeons, as “advocates” and “agents,” and (2) apply these findings to determine how differences in role responsibilities could foster conflict during decision making about postoperative life-sustaining treatment in the intensive care unit. Research design Articles, books, and professional documents were explored to obtain descriptions of nurses’ and surgeons’ responsibilities to their patients. Using discourse analysis, responsibilities were grouped into themes and then compared for potential for conflict. Ethical considerations No data were collected from human participants and ethical review was not required. The texts were analyzed by a surgeon and a nurse to minimize profession-centric biases. Findings Four themes in nursing discourse were identified: responsibility to support patient autonomy regarding treatment decisions, responsibility to protect the patient from the physician, responsibility to act as an intermediary between the physician and the patient, and the responsibility to support the well-being of the patient. Three themes in surgery discourse were identified personal responsibility for the patient’s outcome, commitment to patient survival, and the responsibility to prevent harm to the patient from surgery. Discussion These responsibilities may contribute to conflict because each profession is working toward different goals and each believes they know what is best for the patient. It is not clear from the existing literature that either profession understands each other’s responsibilities. Conclusion Interventions that improve understanding of each profession’s responsibilities may be helpful to reduce intra-team conflict in the intensive care unit.

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It's Big Surgery

Cited by 120 publications

References 24 publications

Engaging Patients, Health Care Professionals, and Community Members to Improve Preoperative Decision Making for Older Adults Facing High-Risk Surgery

Engaging Patients, Health Care Professionals, and Community Members to Improve Preoperative Decision Making for Older Adults Facing High-Risk Surgery

Constructing High-stakes Surgical Decisions

Conflict in the intensive care unit: Nursing advocacy and surgical agency

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