B. V. Udelsman1, N. Govea3, Z. Cooper4, A. Bader5, M. Meyer2 1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Massachusetts General Hospital,Anesthesiology,Boston, MA, USA 3Harvard Medical School,Boston, MA, USA 4Brigham And Women’s Hospital,Surgery,Boston, MA, USA 5Brigham And Women’s Hospital,Anesthesiology,Boston, MA, USA
Introduction:
Under sedation patients temporarily surrender decisional capacity. Thus, the health decision surrogate can have an especially important role in the perioperative period. Prior studies of general medical and intensive care unit patients have demonstrated poor concordance between patients and their surrogates in regards to treatment priorities. The aim of this study was to determine the degree of concordance in the perioperative setting and to identify areas for improvement.
Methods:
Prospective cohort study set in the preoperative clinic. Patients (>55 years) and their surrogates (dyads) who presented to the preoperative clinic were eligible for participation. Patients who presented without a surrogate were excluded. Dyads were asked multiple choice questions about the patient’s care preferences using domains typically included in advance directives: resuscitation, intubation, hemodialysis, artificial nutrition, physical disability, cognitive disability, and chronic pain. Concordance was defined as the surrogate correctly predicting patient treatment preferences. Dyads were also surveyed on socio-demographics and quality of life.
Results:
36 pairs completed the survey. The median patient age was 68 (IQR 60, 77). Most patients were white (91%), had graduated high-school (94%), and had an ASA score of 3 or greater (86%). Surrogates were either a spouse (81%), an adult son/daughter (14%), or a sibling of the patient (5%). The majority of patients (78%) and surrogates (83%) reported having prior conversations regarding the patients’ goals of care. Most patients (86%) reported being “very confident” in their surrogates understanding of their health care preferences, while most surrogates (86%) reported similar confidence in their knowledge of the patient’s preferences. Concordance regarding major treatment domains ranged from 86% for resuscitation to 39% for artificial nutrition. Prior conversations regarding treatment preferences did not significantly effect concordance between patients and surrogates in any domain (Table 1).
Conclusions:
Concordance between patients and surrogates regarding major treatment preferences is highly variable the perioperative setting. This discordance may limit patient autonomy and result in non-beneficial treatment that is not concordant with patient goals. Conversations regarding treatment preferences did not significantly improve concordance, signifying the need for targeted conversations potentially facilitated by a health care professional.
