Surgeons Expect Patients to Buy-In to Postoperative Life Support Preoperatively

Abstract

Objective Evidence suggests that surgeons implicitly negotiate with their patients preoperatively about the use of life supporting treatments postoperatively as a condition for performing surgery. We sought to examine whether this surgical buy-in behavior is present among a large, nationally representative sample of surgeons who routinely perform high risk operations. Design Using findings from a qualitative study, we designed a survey to determine the prevalence of surgical buy-in and its consequences. Respondents were asked to consider their response to a patient at moderate risk for prolonged mechanical ventilation or dialysis who has a preoperative request to limit postoperative life supporting treatment. We used bivariate and multivariate analysis to identify surgeon characteristics associated with a) preoperatively creating an informal contract with the patient defining agreed upon limitations of postoperative life support and b) declining to operate on such patients. Setting and subjects US-mail based survey of 2100 cardiothoracic, vascular and neurosurgeons. Interventions None. Measurements and Main Results The adjusted response rate was 56%. Nearly two-thirds of respondents (62%) reported they would create an informal contract with the patient describing agreed upon limitations of aggressive therapy and a similar number (60%) endorsed sometimes or always refusing to operate on a patient with preferences to limit life support. After adjusting for potentially confounding covariates, the odds of preoperatively contracting about life supporting therapy were more than twofold greater among surgeons who felt it was acceptable to withdraw life support on postoperative day 14 as compared to those who felt it was not acceptable to withdraw life support on postoperative day 14 (odds ratio 2.1, 95% confidence intervals 1.3-3.2). Conclusions Many surgeons will report contracting informally with patients preoperatively about the use of postoperative life support. Recognition of this process and its limitations may help to inform postoperative decision making.

Differences in End-of-Life Care in the ICU Across Patients Cared for by Medicine, Surgery, Neurology, and Neurosurgery Physicians

“…In addition, the primary ethical principle governing care in the surgical ICU may be different than that in a nonsurgical ICU, with more focus on a covenantal ethic rather than an ethic of scarce resources. [33][34][35] This study has several important limitations. First, there may be misclassifi cation, with patients categorized based on the specialty of the attending physician at time of death.…”

Challenges in Deactivating a Total Artificial Heart for a Patient With Capacity

“…Several authors have argued that surgeons feel personally responsible for poor operative outcomes because of the signifi cant personal investment in time and technical skill they put into their surgical cases. [25][26][27][28] This sense of personal responsibility could conceivably be greatest in situations where the patient requests to be free from a device the surgeon placed. Surgeon: "To sit down a very aggressive, optimistic surgeon, to say that you want to turn off the machine that they put in, it's hard for us to accept, simply put.…”

Overcoming Barriers to Palliative Care Consultation

“…This early involvement allowed the health care team to focus on the needs of patients and patients' families and provided patients and patients' families time for closure. 22 Patients' families clearly benefi tted from this intervention, experiencing less posttraumatic stress after the hospitalization.…”

“…The emphasis on using technology to rescue a patient each time a new complication develops is more common in surgical ICUs, where the focus may be on treating everything and, rarely, if ever, acknowledging that a patient may die. 5 In one study, 22 a majority of surgeons thought they had contracted informally with patients preoperatively, explaining to the patients that the surgeons would decline to operate if the patients wanted to limit postoperative life-supporting treatments. Routine use of triggers for palliative care consultation might result in strained relationships between health care providers in the postoperative period, especially if the surgeons do not have an accurate understanding of palliative care.…”

“…Routine use of triggers for palliative care consultation might result in strained relationships between health care providers in the postoperative period, especially if the surgeons do not have an accurate understanding of palliative care. 22 A patient and the patient's family may also have culturally based misconceptions about palliative care or they may not understand what is happening to the patient. Families may be confused and see the "small steps" the patient makes as real progress, and therefore develop false hope.…”