High-risk surgery among older adults: Not-quite shared decision-making

Clinical context and communication in shared decision-making about major surgery: Findings from a qualitative study with colorectal, orthopaedic and cardiac patients

Increasing numbers of older people undergo major surgery in the United Kingdom (UK), with many at high risk of complications due to age, co-morbidities or frailty. This article reports on a study of such patients and their clinicians engaged in shared decision-making. Shared decision-making is a collaborative approach that seeks to value and centre patients' preferences, potentially addressing asymmetries of knowledge and power between clinicians and patients by countering medical authority with greater patient empowerment. We studied shared decision-making practices in the context of major surgery by recruiting 16 patients contemplating either colorectal, cardiac or joint replacement surgery in the UK National Health Service (NHS). Over 18 months 2019-2020, we observed and video-recorded decision-making consultations, studied the organisational and clinical context for consultations, and interviewed patients and clinicians about their experiences of making decisions. Linguistic ethnography, the study of communication and interaction in context, guided us to analyse the interplay between interactions (during consultations between clinicians, patients and family members) and clinical and organisational features of the contexts for those interactions. We found that the framing of consultations as being about life-saving or life-enhancing procedures was important in producing three different genres of consultations focused variously on: resolving problems, deliberation of options and evaluation of benefits of surgery. We conclude that medical authority persists, but can be used to create more deliberative opportunities for decision-making through amending the context for consultations in addition to adopting appropriate communication practices during surgical consultations.

Which factors influence the approach to shared decision-making among surgeons performing complex operations?

BACKGROUND

Shared decision-making (SDM) aims to create a context in which patients and surgeons work together to explore treatment options and goals of care. The objective of the current study was to characterize demographic factors, behaviors, and perceptions of patient involvement among surgeons relative to SDM.

METHODS

Using a cross-sectional survey methodology, surgeon demographics, behaviors, and perceptions of patient involvement were assessed. Surgeon approaches to SDM were measured using a 100-point scale ranging from 'patient-led' (0) to 'surgeon-led' (100).

RESULTS

Among 241 respondents, most were male (n = 123, 67.2%) and White (n = 124, 69.3%); roughly one-half of surgeons had been in practice ≥10 years (n = 120, 52.4%). Surgeon approaches to SDM ranged from 0 to 81.0, with a median rating of 50.0 (IQR: 35.5, 62.0). Reported approaches to SDM were associated with years in practice, sharing information, and perceptions of patient involvement. Surgeons in practice 10 + years most frequently utilized a 'Shared, Patient-led' approach to SDM (27.5%), while individuals with less experience more often employed a 'Shared, Surgeon-led' approach (33.3%, p = 0.031). Surgeons with a 'Patient-led' approach perceived patient involvement as most important (M = 3.82, SD = 0.16), while respondents who had a 'Surgeon-led' approach considered this less important (M = 3.57, SD = 0.38; p < 0.001).

CONCLUSION

Surgeon factors including demographics, behaviors, and perceptions of patient involvement influenced SDM approaches. SDM between patients and surgeons should strive to be more dynamic and tailored to each specific patient's needs to promote optimal patient-centered care.

Optimization of Care for the Elderly Surgical Emergency Patient

Geriatric patients undergoing emergency surgery are at significantly higher risk for complications and death when compared with younger patients. Optimizing care for these patients requires a multidisciplinary team, special attention to physiologic changes and medication use, as well as targeted intervention to mitigate complications such as delirium, which can worsen overall outcomes. Frailty can be assessed preoperatively to identify patients at the highest risk for complications. Shared decision-making with both the family and patient during the consent process is integral to defining patient's goals of care in these high-risk situations.

Opportunities for shared decision-making about major surgery with high-risk patients: a multi-method qualitative study

BACKGROUND

Little is known about the opportunities for shared decision-making when older high-risk patients are offered major surgery. This study examines how, when, and why clinicians and patients can share decision-making about major surgery.

METHODS

This was a multi-method qualitative study, combining video recordings of preoperative consultations, interviews, and focus groups (33 patients, 19 relatives, 36 clinicians), with observations and documentary analysis in clinics in five hospitals in the UK undertaking major orthopaedic, colorectal, and/or cardiac surgery.

RESULTS

Three opportunities for shared decision-making about major surgery were identified. Resolution-focused consultations (cardiac/colorectal) resulted in a single agreed preferred option related to a potentially life-threatening problem, with limited opportunities for shared decision-making. Evaluative and deliberative consultations offered more opportunity. The former focused on assessing the likelihood of benefits of surgery for a presenting problem that was not a threat to life for the patient (e.g., orthopaedic consultations) and the latter (largely colorectal) involved discussion of a range of options while also considering significant comorbidities and patient preferences. The extent to which opportunities for shared decision-making were available, and taken up by surgeons, was influenced by the nature of the presenting problem, clinical pathway, and patient trajectory.

CONCLUSIONS

Decisions about major surgery were not always shared between patients and doctors. The nature of the presenting problem, comorbidities, clinical pathways, and patient trajectories all informed the type of consultation and opportunities for sharing decision-making. Our findings have implications for clinicians, with shared decision-making about major surgery most feasible when the focus is on life-enhancing treatment.

Patients' and healthcare professionals' perceived facilitators and barriers for shared decision-making for frail and elderly patients in perioperative care: a scoping review

BACKGROUND

Shared decision-making (SDM) in perioperative care, is an organizational approach to instituting sharing of information and decision-making around surgery. It aims at enabling patient autonomy and patient-centered care. Frail and elderly patients suffering from multiple health conditions and increased surgical vulnerability might particularly benefit from SDM. However, little is known about the facilitators and barriers to implementing SDM in perioperative care for the specific needs of frail and elderly patients. Our objective is twofold: First, we aim at collecting, analyzing, categorizing, and communicating facilitators and barriers. Second, we aim at collecting and mapping conceptual approaches and methods employed in determining and analyzing these facilitators and barriers.

METHODS

The search strategy focused on peer-reviewed studies. We employed a taxonomy which is based on the SPIDER framework and added the items general article information, stakeholder, barriers/facilitators, category, subcategory, and setting/contextual information. This taxonomy is based on preceding reviews. The scoping review is reported under the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews. Based on the databases MEDLINE, Embase, CINAHL, and Web of Science, we screened 984 articles, identified, and reviewed 13 original studies.

RESULTS

Within this review, two primary facilitators concerning patients' willingness to participate in SDM emerged: Patients want to be informed on their medical condition and procedures. Patients prefer sharing decisions with healthcare professionals, compared to decision-making solely by patients or decision-making solely by healthcare professionals. Communication issues and asymmetric power relationships between patients and clinical healthcare professionals are barriers to SDM. Regarding the methodological approaches, the evaluation of the conceptual approaches demonstrates that the selected articles lack employing a distinct theoretical framework. Second, the selected studies mainly used surveys and interviews, observational studies, like ethnographic or video-based studies are absent.

CONCLUSION

Diverging findings perceived by patients or clinical healthcare professionals were identified. These imply that SDM research related to elderly and frail patients should become more encompassing by employing research that incorporates theory-based qualitative analysis, and observational studies of SDM consultations for understanding practices by patients and clinical healthcare professionals. Observational studies are particularly relevant as these were not conducted.

TRIAL REGISTRATION

https://osf.io/8fjnb/.

Decisional Regret Among Patients Undergoing Colectomy

BACKGROUND

Patients undergoing colectomy may be at risk for postoperative regret, which is associated with worse quality of life, higher rates of depression, and poorer health outcomes. A better understanding of factors associated with decisional regret may allow surgeons to better tailor preoperative discussions to mitigate the risk of regret.

OBJECTIVE

This study aimed to identify factors associated with regret in patients undergoing elective and urgent/emergent colectomy.

DESIGN

A retrospective cohort study.

SETTING

The Michigan Surgical Quality Collaborative, a 73-hospital collaborative, which collects clinical data on general surgery operations.

PATIENTS

Patients aged >18 years who underwent elective or urgent/emergent colectomy between January 2017 and March 2020 and who completed a decision regret survey.

MAIN OUTCOME MEASURES

Any degree of postoperative regret.

RESULTS

Of 3638 patients, 2,530 (70%) underwent elective and 1108 (30%) underwent urgent/emergent colectomy. Overall, 381 (10.5%) patients reported regret, with higher rates among the urgent/emergent setting compared with the elective cohort (13.0% vs 9.4%; p < 0.001). In the elective cohort, regret was associated with length of stay >7 days (OR, 2.32; 95% CI, 1.06-5.07), postoperative complication (OR, 1.95; 95% CI, 1.36-2.79), and readmission (OR, 1.90; 95% CI, 1.22-2.95). Elective colectomies for cancer/adenoma/polyp were associated with lower odds of regret (OR, 0.68; 95% CI, 0.50-0.91). In the urgent/emergent cohort, regret was associated with female sex (OR, 1.69; 95% CI, 1.15-2.50) and nonhome discharge destination (OR, 1.61; 95% CI, 0.04-1.03).

LIMITATIONS

Hospitals used different sampling strategies, limiting our ability to calculate a true response rate and characterize nonresponders.

CONCLUSIONS

One in 10 patients reported regret after colectomy with higher rates in those undergoing urgent/emergent colectomy. Factors associated with regret were different between surgical settings. Efforts are needed to mitigate patients' risk of regret with individualized discussions contingent on surgical settings to better align expectations and outcomes. See Video Abstract at http://links.lww.com/DCR/C3 .

ARREPENTIMIENTO DEL PACIENTE EN LA DECISIN DE SOMETIMIENTO A COLECTOMA

ANTECEDENTES:Los pacientes que se someten a una colectomía pueden estar en riesgo de arrepentimiento post operatorio, la cual está asociada con una peor calidad de vida, mayores tasas de depresión y peores resultados de salud. Una mejor comprensión de los factores asociados con el arrepentimiento de dicha decisión, puede permitir a los cirujanos adaptar de una mejor manera las discusiones preoperatorias y así mitigar el riesgo de arrepentimiento.OBJETIVO:Identificar factores asociados al arrepentimiento en pacientes sometidos a colectomía electiva y urgente/emergente.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:The Michigan Surgical Quality Collaborative, una colaboración de 73 hospitales.PACIENTES:Pacientes ≥18 años sometidos a colectomía electiva o urgente/emergente entre enero de 2017 y marzo de 2020, y que hayan completado una encuesta de arrepentimiento en cuanto a la decisión.PRINCIPALES MEDIDAS DE RESULTADO:Reporte de cualquier grado de arrepentimiento postoperatorio.RESULTADOS:De 3.638 pacientes, 2.530 (70%) fueron sometidos a colectomía electiva y 1.108 (30%) a colectomía urgente/emergente. En general, 381 (10,5%) pacientes informaron arrepentimiento, con tasas más altas en el grupo relacionado con el escenario urgente/emergente en comparación con la cohorte electiva (13,0% frente a 9,4%, p < 0,001). En la cohorte electiva, el arrepentimiento se asoció con una estancia hospitalaria >7 días (OR 2,32, IC 95% 1,06-5,07), complicación posoperatoria (OR 1,95, IC 95% 1,36-2,79) y reingreso (OR 1,90, IC 95% 1,22-2,95). Las colectomías electivas por cáncer/adenoma/pólipo se asociaron con una menor probabilidad de arrepentimiento (OR 0,68, IC 95%: 0,50-0,91). En la cohorte urgente/emergente, el arrepentimiento se asoció con el sexo femenino (OR 1,69, IC 95% 1,15-2,50) y el destino del alta no domiciliario (OR 1,61, IC 95% 0,04-1,03).LIMITACIONES:Los hospitales utilizaron diferentes estrategias de muestreo, lo que limita nuestra capacidad para calcular una tasa de respuesta real y caracterizar a los que no respondieron.CONCLUSIONES:Uno de cada diez pacientes reportó arrepentimiento después de la colectomía con tasas más altas en aquellos sometidos a colectomía urgente/emergente. Los factores asociados con el arrepentimiento fueron diferentes entre los entornos quirúrgicos. Se necesitan esfuerzos para mitigar el riesgo de arrepentimiento de los pacientes con discusiones individualizadas supeditadas al entorno quirúrgico para caracterizar de una mejor las expectativas y los resultados. Consulte Video Resumen en http://links.lww.com/DCR/C3 . (Traducción-Dr. Osvaldo Gauto).

Surgeons' Perspective of Decision Making in Recurrent Diverticulitis: A Qualitative Analysis

Objective

This study employs qualitative methodology to assess surgeons' perspective on decision making in management of recurrent diverticulitis to improve patient-centered decision making.

Summary Background Data

The decision to pursue colectomy for patients with recurrent diverticulitis is nuanced. Strategies to enact broad acceptance of guidelines for surgery are hindered because of a knowledge gap in understanding surgeons' current attitudes and opinions.

Methods

We performed semi-structured interviews with board-certified North American general and colorectal surgeons who manage recurrent diverticulitis. We purposely sampled specialists by both surgeon and practice factors. An iterative inductive/deductive strategy was used to code and analyze the interviews and create a conceptual framework.

Results

25 surgeons were enrolled over a nine-month period. There was diversity in surgeons' gender, age, experience, training, specialty (colorectal vs general surgery) and geography. Surgeons described the difficult process to determine who receives an operation. We identified seven major themes as well as twenty subthemes of the decision-making process. These were organized into a conceptual model. Across the spectrum of interviews, it was notable that there was a move over time from decisions based on counting episodes of diverticulitis to a focus on improving quality of life. Surgeons also felt that quality of life was more dependent on psychosocial factors than the degree of physiological dysfunction. [What about what surprised you/].

Conclusions

Surgeons mostly have discarded older dogma in recommending colectomy for recurrent diverticulitis based on number and severity of episodes. Instead, decision making in recurrent diverticulitis is complex, involving multiple surgeon and patient factors and evolving over time. Surgeons struggle with this decision and education- or communication-based interventions that focus on shared decision making warrant development.