G. Awad Elkarim1,2, K. M. Devon1,3,4, L. Gotlib Conn2, B. Henry1,2, M. F. McKneally1, A. B. Nathens1,2 1University of Toronto,Toronto, Ontario, Canada 2Sunnybrook Health Sciences Centre,Toronto, ONTARIO, Canada 3Women’s College Hospital,Toronto, Ontario, Canada 4University Health Network,Toronto, Ontario, Canada
Introduction: Patients undergoing high-risk surgery may experience major, life-threatening complications in the intraoperative or postoperative period. Previous literature suggests that preoperative discussions of patients’ values and preferences for goals of care may prevent postoperative conflicts between surrogate decision makers and the surgical care team and ensure patients’ autonomy. Surgeons’ beliefs and attitudes towards preoperative advanced care planning (ACP) discussions are not known.
Methods: A purposive sample of surgeons who perform high-risk operations (mortality > 1%) at academic hospitals were interviewed using a semi-structured questionnaire. Representation from several surgical divisions revealed common themes and variations. We interviewed participants until theoretical saturation was achieved (n=13). Interview transcripts were initially coded independently using the grounded theory approach and constant comparison. Codes were reviewed collaboratively, a coding scheme was established, and transcripts were re-coded based on the coding scheme. Codes were analyzed for themes, trends and variations.
Results: Of the 13 surgeons interviewed, only two ask their patients preoperatively if they had expressed their values and preferences for goals of care to their family. We have identified six common challenges for having preoperative ACP conversations with high-risk surgical patients: (1) Anticipated low likelihood of prolonged stay in the intensive care unit and need for life sustaining treatments; (2) Uncertainty in predicting the course of recovery in the postoperative phase of care in complex cases; (3) Perceived psychological burden of the conversation preoperatively; (4) Providing an optimistic surgical management versus negativity of advanced care planning; (5) Patients wanting to focus on the positives; (6) Preoperative discussions overwhelm patients. We have also identified three elements that would facilitate this conversation preoperatively: (a) Patients have had an end of life discussion before or have had previous experience with high-risk surgery; (b) The higher the risk of surgery, the easier it is to segue into an ACP discussion; (c) The older the patient, the more cognizant of the concept of death. Most surgeons indicated that they rely on the family to reflect patients’ best interests and that preoperative ACP conversations may not be necessary or beneficial for all high-risk surgical patients, particularly for surgeries where the chance of mortality is < 10%.
Conclusion: Very few surgeons explicitly ask their patients if they had expressed their preferences for goals of care to family members. There are many challenges and few enablers to initiate a preoperative ACP discussion. Surgeons weigh the risks and the benefits of having this conversation preoperatively and accordingly make the decision in the best interests of their patients.