Shared Decision-Making in Acute Surgical Illness: The Surgeon's Perspective

What Do We Owe Our Patients? Surgeon Obligations When Patients Are Too Sick for Surgery

As the principle of respect for patient autonomy has gained salience over the past 75 years, surgeons now struggle to resolve conflicts between autonomy and beneficence in certain clinical scenarios. One such conflict occurs when a patient desires a surgical intervention, but the surgeon concludes that the patient is "too sick for surgery" and hence would not benefit from the operation. We provide historical context for the principle of respect for patient autonomy and review recent qualitative data that demonstrate surgeons experience significant moral distress when asked to perform nonbeneficial surgery. Therefore, we sought to empower surgeons with the appropriate ethical justifications to decline to perform surgery when they believe it would be nonbeneficial or harmful to patients. We outline 4 concepts that can help surgeons engage with patients, families, and colleagues in these scenarios. First, we describe the term "futility" and explain the difficulty in precisely defining and using the term in practice. Second, we contrast patients' positive and negative rights, drawing on historical context to argue that patients have robust negative rights but limited positive rights to request nonbeneficial interventions. Third, we use the centuries-old notion of medicine as a profession to show that surgeons have a fiduciary responsibility to act in the best interests of their patients, including and especially when patients request interventions that are not beneficial. Finally, we draw on virtue ethics to give surgeons character-based resources for fulfilling their professional obligations to patients. We contend that surgeons owe their patients the ability to trust that they will always use their knowledge and skills for patients' benefit, even if surgeons must limit patients' autonomy in certain ways to do so.

Systematic review of barriers, facilitators, and tools to promote shared decision making in the emergency department

OBJECTIVE

The objective was to systematically review all studies focusing on barriers, facilitators, and tools currently available for shared decision making (SDM) in emergency departments (EDs).

BACKGROUND

Implementing SDM in EDs seems particularly challenging, considering the fast-paced environment and sometimes life-threatening situations. Over 10 years ago, a previous review revealed only a few patient decision aids (PtDAs) available for EDs.

METHODS

Literature searches were conducted in MEDLINE, Embase, and Cochrane library, up to November 2023. Observational and interventional studies were included to address barriers or facilitators for SDM or to investigate effects of PtDAs on the level of SDM for patients visiting an ED.

RESULTS

We screened 1946 studies for eligibility, of which 33 were included. PtDAs studied in EDs address chest pain, syncope, analgesics usage, lumbar puncture, ureterolithiasis, vascular access, concussion/brain bleeding, head-CT choice, coaching for elderly people, and activation of patients with appendicitis. Only the primary outcome was meta-analyzed, showing that PtDAs significantly increased the level of SDM (18.8 on the 100-point OPTION scale; 95% CI 12.5-25.0). PtDAs also tended to increase patient knowledge, decrease decisional conflict and decrease health care services usage, with no obvious effect on overall patient satisfaction. Barriers and facilitators were identified on three levels: (1) patient level-emotions, health literacy, and their own proactivity; (2) clinician level-fear of medicolegal consequences, lack of SDM skills or knowledge, and their ideas about treatment superiority; and (3) system level-time constraints, institutional guidelines, and availability of PtDAs.

CONCLUSIONS

Circumstances in EDs are generally less favorable for SDM. However, PtDAs for conditions seen in EDs are helpful in overcoming barriers to SDM and are welcomed by patients. Even in EDs, SDM is feasible and supported by an increasing number of tools for patients and physicians.

Is Everyone Beating Around the Bush?: A Qualitative Study Examining the Status of Shared Decision-Making Between Veterans Affairs Providers and Surgical Patients in the ICU

Objective

We sought to determine if and how providers use elements of shared decision-making (SDM) in the care of surgical patients in the intensive care unit (ICU).

Background

SDM is the gold standard for decision-making in the ICU. However, it is unknown if this communication style is used in caring for critically ill surgical patients.

Methods

Qualitative interviews were conducted with providers who provide ICU-level care to surgical patients in Veterans Affairs hospitals. Interviews were designed to examine end-of-life care among veterans who have undergone surgery and require ICU-level care.

Results

Forty-eight providers across 14 Veterans Affairs hospitals were interviewed. These participants were diverse with respect to age, race, and sex. Participant dialogue was deductively mapped into 8 established SDM components: describing treatment options; determining roles in the decision-making process; fostering partnerships; health care professional preferences; learning about the patient; patient preferences; supporting the decision-making process; and tailoring the information. Within these components, participants shared preferred tools and tactics used to satisfy a given SDM component. Participants also noted numerous barriers to achieving SDM among surgical patients.

Conclusions

Providers use elements of SDM when caring for critically ill surgical patients. Additionally, this work identifies facilitators that can be leveraged and barriers that can be addressed to facilitate better communication and decision-making through SDM. These findings are of value for future interventions that seek to enhance SDM among surgical patients both in the ICU and in other settings.

An acute care surgeon's dilemma: Operative vs. non-operative management of emergency general surgery conditions in patients with recent colorectal cancer treatment

BACKGROUND

This comparative effectiveness study examined outcomes of operative vs. non-operative management for emergency general surgery (EGS) conditions in patients with recent cancer treatment (RT).

METHODS

Medicare beneficiaries with a history of colorectal cancer hospitalized for an EGS condition (2016-2018) were identified. RT was defined as chemotherapy/radiation within 3 months prior to admission. Instrumental variable analysis assessed the impact of management on mortality and readmissions among survivors (30d, 60d, and 90d), for patients in whom there was clinical equipoise regarding optimal management strategy.

RESULTS

Of 26,097 patients, 13% had undergone RT. In both the RT and non-RT groups, the optimal management strategy was uncertain in 14%. Operative management conferred increased risk of mortality but not readmission in patients with RT compared to those without (90d mortality:+43%, p ​= ​0.03; 90d readmission:+7.1%, p ​= ​0.776).

CONCLUSIONS

In patients with RT for whom there is clinical equipoise regarding EGS management, operative intervention increases risk of mortality.

Many patients fail to achieve MCID for PROMIS upper extremity and pain interference following nonoperative management of rotator cuff tears

Background

Efficacy of nonoperative treatment for rotator cuff tears has been debated, especially for full-thickness tears. The purpose of this study was to a) define the minimal clinically important difference (MCID) of nonoperative treatment with regard to Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) and upper extremity (UE), and b) determine the proportion of patients with both partial and full-thickness tears (PTRCT, FTRCT) who achieve this improvement following initial nonoperative treatment. We hypothesized that >75% of PTRCT and FTRTC patients would achieve MCID for PROMIS PI and UE.

Methods

We performed a retrospective cohort study evaluating nonoperatively managed patients with image-confirmed PTRCT and FTRCT. Treatment modalities and follow-up PROMIS scores at least 6 months after their initial visit were recorded. Using a distribution technique, MCID was calculated.

Results

A total of 111 FTRCT and 68 PTRCT patients were included with at least 6 months of follow-up. At 6 months from initial presentation, the MCID for PROMIS UE was 3.75 and 3.95 for FTRCT and PTRCT patients, respectively. For PROMIS PI, the MCID was 3.35 and 3.90 for FTRCT and PTRCT, respectively. In total, 41% of FTRCT and 41% of PTRCT achieved MCID for PROMIS UE. Thirty-four percent of FTRCT and 35% of PTRCT achieved MCID for PROMIS PI.

Conclusion

The majority of patients undergoing nonoperative treatment for supraspinatus/infraspinatus rotator cuff tears did not achieve MCID at 6 months for PROMIS PI (34% for FTRCT and 35% for PTRCT) or UE (41% for FTRCT and 41% for PTRCT).

Patient-Reported Symptom Burden After Cancer Surgery in Older Adults: A Population-Level Analysis

BACKGROUND

Older adults have unique needs for supportive care after surgery. We examined symptom trajectories and factors associated with high symptom burden after cancer surgery in older adults.

PATIENTS AND METHODS

We conducted a population-level study of patients ≥ 70 years old undergoing cancer surgery (2007-2018) using prospectively collected Edmonton Symptom Assessment System (ESAS) scores. The monthly prevalence of moderate to severe symptoms (ESAS ≥ 4) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and poor wellbeing was computed over 12 months after surgery.

RESULTS

Among 48,748 patients, 234,420 ESAS scores were recorded over 12 months after surgery. Moderate to severe tiredness (57.8%), poor wellbeing (51.9%), and lack of appetite (39.3%) were most common. The proportion of patients with moderate to severe symptoms was stable over the 1 month prior to and 12 months after surgery (< 5% variation for each symptom). There was no clinically significant change (< 5%) in symptom trajectory with the initiation of adjuvant therapy.

CONCLUSIONS

Patient-reported symptom burden was stable for up to 1 year after cancer surgery among older adults. Neither surgery nor adjuvant therapy coincided with a worsening in symptom burden. However, the persistence of symptoms at 1 year may suggest gaps in supportive care for older adults. This information on symptom trajectory and predictors of high symptom burden is important to set appropriate expectations and improve patient counseling, recovery care pathways, and proactive symptom management for older adults after cancer surgery.

High risk of complications after a "low risk" procedure: A national study of nursing home residents and older adults undergoing haemorrhoid surgery

AIM

To evaluate 30-day complications and 1-year mortality for older adults undergoing haemorrhoid surgery.

METHOD

This retrospective cohort study evaluated older adults (age 66+) undergoing haemorrhoid surgery using Medicare claims and the minimum data set (MDS). Long-stay nursing home residents were identified, and propensity score matched to community-dwelling older adults. Generalized estimating equation models were created to determine the adjusted relative risk of 30-day complications, length of stay (LOS), and 1-year mortality. Among nursing home residents, functional and cognitive status were evaluated using the MDS-activities of daily living (ADL) score and the Brief Instrument of Mental Status. Faecal continence status was evaluated among a subset of nursing home residents.

RESULTS

A total of 3664 subjects underwent haemorrhoid surgery and were included in the analyses. Nursing home residents were at significantly higher risk for 30-day complications (52.3% vs. 32.9%, aRR 1.6 [95% CI: 1.5-1.7], p < 0.001), and 1-year mortality (24.9% vs. 16.1%, aRR 1.6 [95% CI: 1.3-1.8], p < 0.001). Functional and mental status showed an inflection point of decline around the time of the procedure, which did not recover to the baseline trajectory in the following year. Additionally, a subset of nursing home residents demonstrated worsening faecal incontinence.

CONCLUSION

This study demonstrated high rates of 30-day complications and 1-year mortality among all older adults (yet significantly worse among nursing home residents). Ultimately, primary care providers and surgeons should carefully weigh the potential harms of haemorrhoid surgery in older adults living in a nursing home.

Surgical mortality in patients in extremis: futility in emergency abdominal surgery

BACKGROUND

The number of older patients with multiple comorbidities in the emergency service is increasingly frequent, which implies the risk of incurring in futile surgical interventions. Some interventions generate false expectations of survival or quality of life in patients and families and represent a negligible therapeutic benefit in patients whose chances of survival are minimal. In order to address this dilemma, we describe mortality in a cohort of patients undergoing emergency laparotomy with a risk ≥ 75% per the ACS NSQIP Surgical Risk Calculator.

METHODS

A retrospective observational study was designed to analyze postoperative mortality and factors associated with postoperative mortality in a cohort of patients undergoing emergency laparotomy between January 2018 and December 2021 in a high-complexity hospital who had a mortality risk ≥ 75% per the ACS NSQIP Surgical Risk Calculator.

RESULTS

A total of 890 emergency laparotomies were performed during the study period, and 50 patients were included for the analysis. Patient median age was 82.5 (IQR: 18.25) years old and 33 (66.00%) were male. The most frequent diagnoses were mesenteric ischemia 21 (42%) and secondary peritonitis 18 (36%). Mortality in the series was 92%. Twenty-four (54.34%) died within the first 24 h of the postoperative period; 11 (23.91%) within 72 h and 10 (21.73%) within 30 days. APACHE II and SOFA scores were statistically significantly higher in patients who died.

CONCLUSIONS

All available tools should be used to make decisions, with the most reliable and objective information possible, and be particularly vigilant in patients at extreme risk (mortality risk greater than 75% according to ACS NSQIP Surgical Risk Calculator) to avoid futility and its consequences. The available information should be shared with the patient, the family, or their guardians through an assertive and empathetic communication strategy. It is necessary to insist on a culture of surgical ethics based on reflection and continuous improvement in patient care and to know how to accompany them in order to have a proper death.

What Should the Surgeons Do at the Family Meeting: A Multi-Disciplinary Qualitative Description of Surgeon Participation in Palliative Care Discussions

OBJECTIVE

National guidelines have suggested that quality surgical care should incorporate effective palliative care (PC). Numerous barriers to surgeon participation remain and the domains of optimal surgeon participation are unclear.

DESIGN

Eight semi-structured and multi-professional focus groups with 34 total participants. Discussion was transcribed, and qualitative approaches were used to encode, identify, and categorize emergent themes.

SETTING

Oregon Health & Science University, Portland Oregon. A tertiary care teaching hospital.

PARTICIPANTS

34 multi-disciplinary participants in eight focus groups, identified on a volunteer basis.

RESULTS

Key themes defining domains of optimal surgeon/palliative practice include: (1) "primary/secondary PC" which detailed conflict between the surgeon's desire to be part of palliative discussions and competing clinical/time demands. (2) "role/responsibility" described the tension surgeons feel around a desire to provide honest and goal concordant care (3) "teamwork/conflict" detailed the approach to disagreement among multidisciplinary teams.

CONCLUSIONS

In this qualitative analysis, emergent themes suggest that surgeons want to be involved in the PC of their patients but are limited by available time and competing for ethical obligations. Tension between competing communication and care obligations and PC goals is common, and discord around patient goals remains an issue. This work highlights the need for a standardized curriculum to improve the PC of surgical patients.

Triage and outcomes for a whole cohort of patients presenting for major emergency abdominal surgery including the No-LAP population: a prospective single-center observational study

PURPOSE

This study aimed to characterize 252 consecutive patients with an indication for major emergency abdominal surgery including patients not proceeding to surgery (No-Lap). Patients who do not proceed to major emergency abdominal surgery and their clinical outcomes are not well characterized in the existing literature. Triage criteria may vary between centers, potentially impacting reported outcomes.

METHODS

A single-center prospective observational study in a high-volume Danish surgical center including 252 patients presenting with an indication for major emergent abdominal surgery was conducted from the 15th of October 2020 to the 15th of August 2021. The primary outcome was to estimate the prevalence of No-Lap patients.

RESULTS

Overall, 21 patients (8.3%) of our total study cohort did not proceed to surgery. These patients were significantly older, more comorbid with higher ASA scores, poorer performance status, and were more likely to have bowel ischemia. Poor functional performance and surgeons' consideration of futile intervention were the main reasons for deferring surgery in all 21 patients. Overall, 30-day mortality was 95% for the No-LAP cohort, 9% for the LAP cohort, and 16% for the whole cohort, respectively.

CONCLUSIONS

The No-LAP group selection process could be one of the main determinants of reported postoperative outcomes. Prospective international multi-center studies to characterize the entire cohort of patients eligible for emergency laparotomy including the No-LAP population are needed, as large variations in triage criteria and culture seem to exist. Trial registration Retrospectively registered.

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).

The Association Between Factors Promoting Nonbeneficial Surgery and Moral Distress: A National Survey of Surgeons

OBJECTIVE

To assess the prevalence of moral distress among surgeons and test the association between factors promoting non-beneficial surgery and surgeons' moral distress.

SUMMARY BACKGROUND DATA

Moral distress experienced by clinicians can lead to low-quality care and burnout. Older adults increasingly receive invasive treatments at the end of life that may contribute to surgeons' moral distress, particularly when external factors, such as pressure from colleagues, institutional norms, or social demands, push them to offer surgery they consider non-beneficial.

METHODS

We mailed surveys to 5200 surgeons randomly selected from the American College of Surgeons membership, which included questions adapted from the revised Moral Distress Scale. We then analyzed the association between factors influencing the decision to offer surgery to seriously ill older adults and surgeons' moral distress.

RESULTS

The weighted adjusted response rate was 53% (n = 2161). Respondents whose decision to offer surgery was influenced by their belief that pursuing surgery gives the patient or family time to cope with the patient's condition were more likely to have high moral distress (34% vs 22%, P < 0.001), and this persisted on multivariate analysis (odds ratio 1.44, 95% confidence interval 1.02-2.03). Time required to discuss nonoperative treatments or the consulting intensivists' endorsement of operative intervention, were not associated with high surgeon moral distress.

CONCLUSIONS

Surgeons experience moral distress when they feel pressured to perform surgery they believe provides no clear patient benefit. Strategies that empower surgeons to recommend nonsurgical treatments when they believe this is in the patient's best interest may reduce nonbeneficial surgery and surgeon moral distress.

Emergency Laparotomy

Emergency laparotomy is a high-risk surgical procedure with mortality and morbidity up to 10 times higher than for a similar procedure performed electively. An enhanced recovery approach has been shown to improve outcomes. A focus on rapid correction of underlying deranged acute physiology and proactive management of conditions associated with aging such as frailty and delirium are key. Patients are at high risk of complications and prevention and avoidance of failure to rescue are essential to improve outcomes. Other enhanced recovery components such as opioid-sparing analgesia and early postoperative mobilization are beneficial.

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.

METHODS

Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1.

RESULTS

Twelve components of preoperative care were considered. Consensus was reached after three rounds.

CONCLUSIONS

These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

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

BACKGROUND

Shared decision-making is critical to optimal patient-centered care. For elective operations, when there is sufficient time for deliberate discussion, little is known about how surgeons navigate decision-making and how surgeons align care with patient preferences. In this context, we sought to explore surgeons' approaches to decision-making for adults ≥65 years at high-risk of postoperative complications or death.

METHODS

We conducted semistructured in-depth interviews with 46 practicing surgeons across Michigan. Transcripts were iteratively analyzed through steps informed by inductive thematic analysis.

RESULTS

Four major themes emerged characterizing how surgeons approach high-risk surgical decision-making for older adults: (1) risk assessment was defined as the process used by surgeons to identify and analyze factors that may negatively impact outcome; (2) expectations and goals described the process of surgeons engaging with patients and families to discuss potential outcomes and desired objectives; (3) external and internal motivating factors outlined extrinsic dynamics (eg, quality metrics, referrals) and intrinsic drivers (eg, surgeons' personal experiences) that influenced high-risk decision-making; and (4) decision-making approaches and challenges encompassed the roles of patients and surgeons and obstacles to engaging in a true shared decision-making process.

CONCLUSION

Although shared decision-making is strongly recommended, we found that surgeons who perform high-risk operations among older adults predominantly focused on assessing risk and setting expectations with patients and families rather than inviting them to actively participate in the decision-making process. Surgeons also reported influences on decision-making from quality metrics, referrals, and personal experiences. Patient involvement, however, was seldom discussed suggesting that surgeons may not be engaging in true shared decision-making when benefits should be weighed against a high likelihood of harm.

The effect of treatment modifications by an onco-geriatric MDT on one-year mortality, days spent at home and postoperative complications

OBJECTIVES

Decision-making in older patients with cancer can be complex, as benefits of treatment should be weighed against possible side-effects and life-expectancy. A novel care pathway was set up incorporating geriatric assessment into treatment decision-making for older cancer patients. Treatment decisions could be modified following discussion in an onco-geriatric multidisciplinary team (MDT). We assessed the effect of treatment modifications on outcomes.

MATERIALS AND METHODS

This retrospective study was performed in the surgical department of a University Hospital. Patients of 70 years and older with a solid malignancy were included. All patients underwent a nurse-led geriatric assessment (GA) and were discussed in an onco-geriatric MDT. This could result in a modified or an unchanged treatment advice compared to the regular tumor board. Primary outcome was one-year mortality. Secondary outcomes were post-operative complications and days spent in hospital in the first year after inclusion.

RESULTS

For the 184 patients in the analyses, the median age was 77.5 years and 41.8% were female. For 46 patients (25%), the treatment advice was modified by the onco-geriatric MDT. There was no significant difference in one-year mortality between the unchanged and modified group (29.7% versus 26.1%, p = 0.7). There were, however, significantly fewer days spent in hospital (median 5 vs 8.5 days p = 0.02) and fewer grade II or higher postoperative complications (13.3% versus 35.5% p = 0.005) in the modified group.

CONCLUSION

Incorporating geriatric assessment in decision-making did not lead to excess one-year mortality, but did result in fewer complications and days spent in hospital.

Development and validation of multivariable mortality risk-prediction models in older people undergoing an interRAI home-care assessment (RiskOP)

BACKGROUND

Currently, one-year survival of older people with complex co-morbidities is unpredictable. Identifying older adults with a reduced life expectancy will lead to more targeted care and better healthcare resource allocation.

METHODS

Development and validation of one-year and three-month mortality risks in people aged ≥65 years who had completed an International Resident Assessment Instrument-Home Care (interRAI-HC) assessment between July 2012 and March 2018. Data was split into development (90%) and validation data sets (10%). A multivariable logistic regression model using data from 108 interRAI questions across multiple domains was developed and validated using discrimination metrics and calibration curves. Variables each explaining at least 1% of the model were then used to develop and validate a parsimonious model. Subgroups by sex, age, ethnicity, and comorbidities were evaluated.

FINDINGS

There were 104,436 persons (60.2% female; mean age 82.1 years) in the study cohort of whom 20,972 (20.1%) died within one year. The full multivariable model had area under the curves (AUCs) of 0.778 to 0.795 in the 5 validation datasets and was well calibrated. After variable reduction a parsimonious model consisted of 16 variables and was well calibrated and the AUC remained high: 0.773 (0.769 to 0.777). The three-month parsimonious model comprised 22 variables and was well calibrated with an AUC of 0.843 (95%CI: 0.839 to 0.848).

INTERPRETATION

These community-based risk prediction models accurately predict mortality in older people with complex co-morbidities. They may contribute to both forecasting for policy making and clinical decision making regarding an individual's needs.

FUNDING

The New Zealand Health Research Council.

Shared Decision-Making in the Context of Uncertain Care Goals and Outcomes: Dissecting a Penetrating Abdominal Trauma Case Complicated by Enterocutaneous Fistulae

Surgeons care deeply about their patients, their patient's surgical outcomes, and their fund of knowledge as it relates to disease, treatment options, and risk is remarkable. Unfortunately, surgical patients' values, hopes, fears, and unacceptable levels of suffering are rarely elicited and addressed while constructing surgical treatment plans, even when the stakes are high. How can surgeons bring all their experience, education, and expertise to bear in a patient-centered manner amidst uncertainty? Surgeons typically emulate mentors who either employed a solely informative, facilitative, or directive/paternalistic approach to decision-making. These 3 styles fail to simultaneously address: (1) what matters most to patients and (2) the surgeon's expertise. Since communication in each of these 3 approaches is unidirectional, and the decisional power locus is imbalanced, they are unshared, nonpartnering, and-perhaps surprisingly-not patient-centered. Patient-centered, collaborative shared decision-making (SDM) approaches align with palliative care principles and are rarely employed, taught, or modeled. Furthermore, nonpartnering approaches to surgical decision-making are often laden with unintended consequences, such as patient and family suffering and the suffering of surgeons. We present the high-risk case of an abdominal gunshot wound in a morbidly obese man, which was complicated by 3 enterocutaneous fistulae and a loss of abdominal wall integrity, where ongoing empathic, partnering SDM dialogue is enabling a patient-centered and value-concordant care plan. The authors invite you to virtually journey with us as this case unfolds, as the impending surgical decisions are substantial and weighty. Uncertainty and risks appear at every turn-providing additional challenges to overcome.

Prioritizing Communication in the Provision of Palliative Care for the Trauma Patient

Purpose of Review

Communication skills in the ICU are an essential part of the care of trauma patients. The goal of this review is to summarize key aspects of our understanding of communication with injured patients in the ICU.

Recent Findings

The need to communicate effectively and empathetically with patients and identify primary goals of care is an essential part of trauma care in the ICU. The optimal design to support complex communication in the ICU will be dependent on institutional experience and resources. The best/worst/most likely model provides a structural model for communication.

Summary

We have an imperative to improve the communication for all patients, not just those at the end of their life. A structured approach is important as is involving family at all stages of care. Communication skills can and should be taught to trainees.

Artificial Intelligence and Surgical Decision-making

Importance

Surgeons make complex, high-stakes decisions under time constraints and uncertainty, with significant effect on patient outcomes. This review describes the weaknesses of traditional clinical decision-support systems and proposes that artificial intelligence should be used to augment surgical decision-making.

Observations

Surgical decision-making is dominated by hypothetical-deductive reasoning, individual judgment, and heuristics. These factors can lead to bias, error, and preventable harm. Traditional predictive analytics and clinical decision-support systems are intended to augment surgical decision-making, but their clinical utility is compromised by time-consuming manual data management and suboptimal accuracy. These challenges can be overcome by automated artificial intelligence models fed by livestreaming electronic health record data with mobile device outputs. This approach would require data standardization, advances in model interpretability, careful implementation and monitoring, attention to ethical challenges involving algorithm bias and accountability for errors, and preservation of bedside assessment and human intuition in the decision-making process.

Conclusions and Relevance

Integration of artificial intelligence with surgical decision-making has the potential to transform care by augmenting the decision to operate, informed consent process, identification and mitigation of modifiable risk factors, decisions regarding postoperative management, and shared decisions regarding resource use.

Predictors of elderly mortality after trauma: A novel outcome score

INTRODUCTION

Elderly trauma patients are at high risk for mortality, even when presenting with minor injuries. Previous prognostic models are poorly used because of their reliance on elements unavailable during the index hospitalization. The purpose of this study was to develop a predictive algorithm to accurately estimate in-hospital mortality using easily available metrics.

METHODS

The National Trauma Databank was used to identify patients 65 years and older. Data were split into derivation (2007-2013) and validation (2014-2015) data sets. There was no overlap between data sets. Factors included age, comorbidities, physiologic parameters, and injury types. A two-tiered scoring system to predict in-hospital mortality was developed: a quick elderly mortality after trauma (qEMAT) score for use at initial patient presentation and a full EMAT (fEMAT) score for use after radiologic evaluation. The final model (stepwise forward selection, p < 0.05) was chosen based on calibration and discrimination analysis. Calibration (Brier score) and discrimination (area under the receiving operating characteristic curve [AuROC]) were evaluated. Because National Trauma Databank did not include blood product transfusion, an element of the Geriatric Trauma Outcome Score (GTOS), a regional trauma registry was used to compare qEMAT versus GTOS. A mobile-based application is currently available for cost-free utilization.

RESULTS

A total of 840,294 patients were included in the derivation data set and 427,358 patients in the validation data set. The fEMAT score (median, 91; S.D., 82-102) included 26 factors, and the qEMAT score included eight factors. The AuROC was 0.86 for fEMAT (Brier, 0.04) and 0.84 for qEMAT. The fEMAT outperformed other trauma mortality prediction models (e.g., Trauma and Injury Severity Score-Penetrating and Trauma and Injury Severity Score-Blunt, age + Injury Severity Score). The qEMAT outperformed the GTOS (AuROC, 0.87 vs. 0.83).

CONCLUSION

The qEMAT and fEMAT accurately estimate the probability of in-hospital mortality and can be easily calculated on admission. This information could aid in deciding transfer to tertiary referral center, patient/family counseling, and palliative care utilization.

LEVEL OF EVIDENCE

Epidemiological Study, level IV.

Variability in clinicians' understanding and reported methods of identifying high-risk surgical patients: a qualitative study

Background

High-risk patients presenting for surgery require complex decision-making and perioperative management. However, given there is no gold standard for identifying high-risk patients, doing so may be challenging for clinicians in practice. Before a gold standard can be established, the state of current practice must be determined. This study aimed to understand how working clinicians define and identify high-risk surgical patients.

Methods

Clinicians involved in the care of high-risk surgical patients at a public hospital in regional Australia were interviewed as part of an ongoing study evaluating a new shared decision-making process for high-risk patients. The new process, Patient-Centred Advanced Care Planning (PC-ACP) engages patients, families, and clinicians from all relevant specialties in shared decision-making in line with the patient’s goals and values. The semi-structured interviews were conducted before the implementation of the new process and were coded using a modified form of the ‘constant comparative method’ to reveal key themes. Themes concerning patient risk, clinician’s understanding of high risk, and methods for identifying high-risk surgical patients were extricated for close examination.

Results

Thirteen staff involved in high-risk surgery at the hospital at which PC-ACP was to be implemented were interviewed. Analysis revealed six sub-themes within the major theme of factors related to patient risk: (1) increase in high-risk patients, (2) recognising frailty, (3) risk-benefit balance, (4) suitability and readiness for surgery, (5) avoiding negative outcomes, and (6) methods in use for identifying high-risk patients. There was considerable variability in clinicians’ methods of identifying high-risk patients and regarding their definition of high risk. This variability occurred even among clinicians within the same disciplines and specialties.

Conclusions

Although clinicians were confident in their own ability to identify high-risk patients, they acknowledged limitations in recognising frail, high-risk patients and predicting and articulating possible outcomes when consenting these patients. Importantly, little consistency in clinicians’ reported methods for identifying high-risk patients was found. Consensus regarding the definition of high-risk surgical patients is necessary to ensure rigorous decision-making.

Learning from regret

BACKGROUND

Death after surgery is infrequent but can be devastating for the surgeon. Surgeons may experience intense emotional reactions after a patient's death, reflecting on their part in the death and the patient's loss of life. Excessive rumination or feelings of regret may have lasting negative consequences, but these reactions may also facilitate learning for future decision-making. This qualitative study analysed surgeons' reflections on what might have been done differently before a patient's death and explored non-technical (cognitive and interpersonal) aspects of care as potential targets for improvement.

METHODS

In Australia's Queensland Audit of Surgical Mortality, surgeons reflect on factors surrounding the death of patients in their care and respond to the open-ended question: in retrospect, would you have done anything differently? Framework analysis was applied to surgeons' responses to identify themes relating to non-technical aspects of care.

RESULTS

Responses from 1214 surgeons were analysed. Two main themes were identified. Dilemmas and difficult decisions confirmed the uncertainty, complexity and situational pressures that often precede a surgical death; regret and empathy for patients featured in some responses. In the second main theme, communication matters, surgeons cited better communication, with patients, families, colleagues and at handover, as a source of reflective change to improve decision-making and reduce regret.

CONCLUSION

Surgical decision-making involves uncertainty, and regret may occur after a patient's death. Enhancing the quality of communication with patients and peers in comprehensive assessment of the surgical patient may mitigate postdecision regret among surgeons.

Goals of Care: Understanding the Outcomes that Matter Most

Advanced care planning is a critically important part of the care of seriously and critically ill patients. A responsibility of all physicians as part of primary palliative care, advanced care planning discussions are more than discussions about code status and should begin early and proceed in parallel with recovery-focused care. Strategies and best practices for advanced care planning in the elective setting and when time is short are reviewed, as are the myriad legal documents that can be used to provide a physical representation of the advanced care planning discussions.