Patient-reported Limitations to Surgical Buy-in

Abstract

Objective To characterize how patients buy-in to treatments beyond the operating room and what limits they would place on additional life-supporting treatments. Background During a high-risk operation, surgeons generally assume that patients buy-in to life-supporting interventions that might be necessary postoperatively. How patients understand this agreement and their willingness to participate in additional treatment is unknown. Methods We purposively sampled surgeons in Toronto, Ontario, Boston, Massachusetts, and Madison, Wisconsin, who are good communicators and routinely perform high-risk operations. We audio-recorded their conversations with patients considering high-risk surgery. For patients who were then scheduled for surgery, we performed open-ended preoperative and postoperative interviews. We used directed qualitative content analysis to analyze the interviews and surgeon visits, specifically evaluating the content about the use of postoperative life support. Results We recorded 43 patients’ conversations with surgeons, 34 preoperative, and 27 postoperative interviews. Patients expressed trust in their surgeon to make decisions about additional treatments if a serious complication occurred, yet expressed a preference for significant treatment limitations that were not discussed with their surgeon preoperatively. Patients valued the existence or creation of an advance directive preoperatively, but they did not discuss this directive with their surgeon. Instead they assumed it would be effective if needed and that family members knew their wishes. Conclusions Patients implicitly trust their surgeons to treat postoperative complications as they arise. Although patients may buy-in to some additional postoperative interventions, they hold a broad range of preferences for treatment limitations that were not discussed with the surgeon preoperatively.

Frequency of Preoperative Advance Care Planning for Older Adults Undergoing High-risk Surgery

“…Patients trust their surgeon to make treatment decisions on their behalf yet often have strong preferences about prolonged life-sustaining treatments . This discrepancy can cause conflict among clinicians, patients, and families .…”

“…atients trust their surgeon to make treatment decisions on their behalf yet often have strong preferences about prolonged life-sustaining treatments. 1 This discrepancy can cause conflict among clinicians, patients, and families. 2,3 Routine preoperative discussion of preferences for life-sustaining treatments allows patients to discuss and document the care they would not want if they became too sick to speak for themselves.…”

Association between Do Not Resuscitate/Do Not Intubate Status and Resident Physician Decision-making. A National Survey

“…As both a bowel obstruction and septic shock secondary to Clostridium difficile infection are indications for surgery (25,26), the relative reluctance to consult surgery may indicate an assumption by residents that the scope of a DNR/DNI order may contraindicate endotracheal intubation for general anesthesia or an assumption that DNR/DNI patients would prefer not to receive aggressive interventions such as surgery. This assumption may not always be valid: a recent qualitative study found that several patients who expressed a desire to avoid CPR in the event of cardiac arrest would nonetheless accept high-risk surgical procedures (27).…”

Understanding decision making about major surgery: protocol for a qualitative study of shared decision making by high-risk patients and their clinical teams

“…30 Of the literature on shared decision making for surgery, only a small number of North American studies focus on high-risk patients. [31][32][33][34] Two have focused on how surgeons and patients discuss options in the event that postoperative complications are severe or life threatening. Analysis of audio recorded shared decision making encounters for high-risk surgery identified significant communication gaps regarding potentially severe postoperative complications.…”