R. S. Morris1, J. Ruck2, A. Conca-Cheng2, T. Smith2, T. Carver1, F. Johnston2 1Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA
Introduction: While surgical patients increasingly have more comorbid disorders and older age, surgeons face difficult decisions in emergent situations. Little is known about surgeon perceptions on the shared decision making process in these urgent settings.
Methods: Twenty semi-structured interviews were conducted with practicing surgeons at two large academic medical centers. Thirteen questions and two case vignettes were used to assess participant perceptions, considerations when deciding to offer surgery and communication patterns with patients and families.
Results:Thematic analysis revealed six major themes and numerous subthemes related to end-of-life decision-making for critically ill patients: responsibility for the decision to operate, futility, surgeon judgment, surgeon introspection, pressure to operate and costs of surgery. Futility was universally reported as a contraindication to surgical intervention. However, an inability to definitively declare futility led some participants to emphasize patient self-determined risk-benefit analysis to determine whether to proceed with surgical intervention. Other participants who felt their gestalt about futility was reliable described greater comfort communicating to a patient that their condition was not amenable to surgery and reserved the right to refuse surgical intervention. Most participants desire objective metrics to determine risk and futility in order to more clearly communicate with patients and families, and perhaps temper the pressure to operate from external sources.
Conclusion:Due to external pressures and uncertainty, some providers err on the side of continuing care despite suspected futility. Surgeons with greater experience and those who report more institutional support of their decisions are often more able to withstand external pressures, feel confident in their assessments of futility, and guide patients and their families away from futile interventions. Greater support from colleagues, institutional culture, research literature, and objective measures of futility can support surgeons in shared decision making and providing the best care for their patients.