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

      Background

      Surgical patients increasingly have more comorbidities and are of an older age, complicating surgical decision-making in emergent situations. Little is known about surgeons' perceptions of shared decision-making in these settings.

      Study Design

      Twenty semi-structured interviews were conducted with practicing surgeons at 2 large academic medical centers. Thirteen questions and 2 case vignettes were used to assess perceptions of decision-making, considerations when deciding whether to offer to operate, and communication patterns with patients and families.

      Results

      Thematic analysis revealed 6 major themes: responsibility for the decision to operate, perceived futility, surgeon judgment, surgeon introspection, pressure to operate, and costs of the operation. Perceived futility was universally considered a contraindication to surgical intervention. However, the challenge of defining futility led participants to emphasize the importance of patients' self-determined risk-to-benefit analysis when considering surgical intervention. More experienced surgeons reported greater comfort with communicating to patients that a condition was not amenable to an operation and reserved the right to refuse to operate.

      Conclusions

      Due to external pressures and uncertainty, some providers err on the side of operative intervention, despite suspected futility. Greater experience allows surgeons to withstand external pressures, be confident in their assessments of perceived futility, and guide patients and their families away from additional interventions.
      To read this article in full you will need to make a payment
      ACS Member
      ACS Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kolata G.
        Surgery rate late in life surprises researchers.
        The New York Times. October 5, 2011;
        • Parekh A.K.
        • Barton M.B.
        The challenge of multiple comorbidity for the US health care system.
        JAMA. 2010; 303: 1303-1304
        • Wilson I.
        • Paul Barrett M.
        • Sinha A.
        • Chan S.
        Predictors of in-hospital mortality amongst octogenarians undergoing emergency general surgery: a retrospective cohort study.
        Int J Surg. 2014; 12: 1157-1161
        • Søreide K.
        • Desserud K.F.
        Emergency surgery in the elderly: the balance between function, frailty, fatality and futility.
        Scand J Trauma Resusc Emerg Med. 2015; 23: 10
        • Kilic A.
        • Arnaoutakis G.J.
        • Bavaria J.E.
        • et al.
        Outcomes of elective aortic hemiarch reconstruction for aneurysmal disease in the elderly.
        Ann Thorac Surg. 2017; 104: 1522-1530
        • Griner D.
        • Adams A.
        • Kotwall C.A.
        • et al.
        After-hours urgent and emergent surgery in the elderly: outcomes and prognostic factors.
        Am Surg. 2011; 77: 1021-1024
        • Shah K.K.
        • Tsuchiya A.
        • Wailoo A.J.
        Valuing health at the end of life: a stated preference discrete choice experiment.
        Soc Sci Med. 2015; 124: 48-56
        • Olsen J.A.
        Priority preferences: “end of life” does not matter, but total life does.
        Value Health. 2013; 16: 1063-1066
        • Kwok A.C.
        • Semel M.E.
        • Lipsitz S.R.
        • et al.
        The intensity and variation of surgical care at the end of life: a retrospective cohort study.
        Lancet. 2011; 378: 1408-1413
        • Cooper Z.
        • Courtwright A.
        • Karlage A.
        • et al.
        Pitfalls in communication that lead to nonbeneficial emergency surgery in elderly patients with serious illness: description of the problem and elements of a solution.
        Ann Surg. 2014; 260: 949-957
        • Silveira M.J.
        • Kim S.Y.
        • Langa K.M.
        Advance directives and outcomes of surrogate decision making before death.
        N Engl J Med. 2010; 362: 1211-1218
        • Yadav K.N.
        • Gabler N.B.
        • Cooney E.
        • et al.
        Approximately one in three US Adults completes any type of advance directive for end-of-life care.
        Health Aff (Millwood). 2017; 36: 1244-1251
        • Strauss A.L.
        • Corbin J.M.
        Basics of qualitative Research: Grounded Theory Procedures and Techniques.
        Sage Publications, Los Angeles, CA1998
        • Roudsari R.L.
        • Khadivzadeh T.
        • Bahrami M.
        A grounded theory approach to understand the process of decision making on fertility control methods in urban society of Mashhad, Iran.
        Iran J Nurs Midwifery Res. 2013; 18: 408-415
        • Burge P.
        • Jamieson M.
        Gaining balance: toward a grounded theory of the decision-making processes of applicants for adoption of children with and without disabilities.
        Qual Rep. 2009; 14: 566-603
        • Holmberg L.I.
        • Wahlberg V.
        The process of decision-making on abortion: a grounded theory study of young men in Sweden.
        J Adolesc Health. 2000; 26: 230-234
        • Thomson O.P.
        • Petty N.J.
        • Moore A.P.
        Clinical decision-making and therapeutic approaches in osteopathy 2013; a qualitative grounded theory study.
        Man Ther. 2014; 19: 44-51
        • Légaré F.
        • Thompson-Leduc P.
        Twelve myths about shared decision making.
        Patient Educ Couns. 2014; 96: 281-286
        • Dizon D.S.
        • Politi M.C.
        • Back A.L.
        The power of words: discussing decision-making and prognosis.
        Am Soc Clin Oncol Educ Book. 2013; : 442-446
        • Légaré F.
        • Witteman H.O.
        Shared decision making: examining key elements and barriers to adoption into routine clinical practice.
        Health Aff (Millwood). 2013; 32: 276-284
        • Mead E.L.
        • Doorenbos A.Z.
        • Javid S.H.
        • et al.
        Shared decision-making for cancer care among racial and ethnic minorities: a systematic review.
        Am J Public Health. 2013; 103: e15-e29
        • Kane H.L.
        • Halpern M.T.
        • Squiers L.B.
        • et al.
        Implementing and evaluating shared decision making in oncology practice.
        CA Cancer J Clin. 2014; 64: 377-388
        • Légaré F.
        • Stacey D.
        • Turcotte S.
        • et al.
        Interventions for improving the adoption of shared decision making by healthcare professionals.
        Cochrane Database Syst Rev. 2014; : CD006732
        • Politi M.C.
        • Studts J.L.
        • Hayslip J.W.
        Shared decision making in oncology practice: what do oncologists need to know?.
        Oncologist. 2012; 17: 91-100
        • Mulsow J.J.W.
        • Feeley T.M.
        • Tierney S.
        Beyond consent—improving understanding in surgical patients.
        Am J Surg. 2012; 203: 112-120
        • Larobina M.E.
        • Merry C.J.
        • Negri J.C.
        • Pick A.W.
        Is informed consent in cardiac surgery and percutaneous coronary intervention achievable?.
        ANZ J Surg. 2007; 77: 530-534
        • Hutson M.M.
        • Blaha J.D.
        Patients' recall of preoperative instruction for informed consent for an operation.
        J Bone Joint Surg Am. 1991; 73: 160-162
        • Rubin M.A.
        The collaborative autonomy model of medical decision-making.
        Neurocrit Care. 2014; 20: 311-318
        • Cai X.
        • Robinson J.
        • Muehlschlegel S.
        • et al.
        Patient preferences and surrogate decision making in neuroscience intensive care units.
        Neurocrit Care. 2015; 23: 131-141
        • Birkmeyer J.D.
        • Stukel T.A.
        • Siewers A.E.
        • et al.
        Surgeon volume and operative mortality in the United States.
        N Engl J Med. 2003; 349: 2117-2127
        • Bilimoria K.Y.
        • Phillips J.D.
        • Rock C.E.
        • et al.
        Effect of surgeon training, specialization, and experience on outcomes for cancer surgery: a systematic review of the literature.
        Ann Surg Oncol. 2009; 16: 1799-1808
        • Schwarze M.L.
        • Taylor L.J.
        Managing uncertainty—harnessing the power of scenario planning.
        N Engl J Med. 2017; 377: 206-208
        • Lauren J.
        • Taylor L.J.
        • Berlin A.
        • Brasel K.J.
        • et al.
        Navigating high-risk surgery: protocol for a multisite, stepped wedge, cluster-randomised trial of a question prompt list intervention to empower older adults to ask questions that inform treatment decisions.
        BMJ Open. 2017; 7: e014002
        • Taylor L.J.
        • Steffens N.M.
        • Tucholka J.L.
        • et al.
        A framework to improve surgeon communication in high-stakes surgical decisions: best case/worst case.
        JAMA Surg. 2017; 152: 531-538
        • Stacey D.
        • Barry M.J.
        • Col N.F.
        • et al.
        Decision aids for people facing health treatment or screening decisions.
        Cochrane Database Syst Rev. 2011; : CD001431
        • Barry M.J.
        • Edgman-Levitan S.
        Shared decision making—pinnacle of patient centered care.
        N Engl J Med. 2012; 366: 780-781
        • Pecanac K.E.
        • Schwarze M.L.
        Conflict in the intensive care unit: nursing advocacy and surgical agency.
        Nurs Ethics. 2018; 25: 69-79
        • Cauley C.E.
        • Block S.D.
        • Koritsanszky L.A.
        • et al.
        Surgeons' perspectives on avoiding nonbeneficial treatments in seriously ill older patients with surgical emergencies: a qualitative study.
        J Palliat Med. 2016; 19: 529-537
        • Limehouse W.E.
        • Ramana Feeser V.
        • Bookman K.J.
        • Derse A.
        A model for emergency department end-of-life communications after acute devastating events—part I: decision-making capacity, surrogates, and advance directives.
        Acad Emerg Med. 2012; 19: E1068-E1072
        • Nurok M.
        • Sadovnikoff N.
        Why are we doing this case? Can perioperative futile care be defined?.
        Curr Opin Anaesthesiol. 2013; 26: 176-181
        • Goede M.
        • Wheeler M.
        Advance directives, living wills, and futility in perioperative care.
        Surg Clin N Am. 2015; 95: 443-451
        • Lee K.F.
        Postoperative futile care: stopping the train when the family says “keep going”.
        Thorac Surg Clin. 2005; 15: 481-491
        • Pak L.M.
        • Gonen M.
        • Seier K.
        • et al.
        Can physician gestalt predict survival in patients with resectable pancreatic adenocarcinoma?.
        Abdom Radiol (NY). 2017 Nov 24; ([Epub ahead of print])
        • Bosslet G.T.
        • Pope T.M.
        • Rubenfeld G.D.
        • et al.
        An official ATS/AACN/ACCP/ESICM/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units.
        Am J Respir Crit Care Med. 2015; 191: 1318-1330
        • Schneiderman L.J.
        Defining medical futility and improving medical care.
        J Bioeth Inq. 2011; 8: 123-131
        • Lilley E.J.
        • Khan K.T.
        • Johnston F.M.
        • et al.
        Palliative care interventions for surgical patients: a systematic review.
        JAMA Surg. 2016; 151: 172-183
        • Pommerening M.J.
        • Goodman M.D.
        • Holcomb J.B.
        • et al.
        Clinical gestalt and the prediction of massive transfusion after trauma.
        Injury. 2015; 46: 807-813
        • Sacks G.D.
        • Dawes A.J.
        • Ettner S.L.
        • et al.
        Surgeon perception of risk and benefit in the decision to operate.
        Ann Surg. 2016; 264: 896-903
        • Steffens N.M.
        • Tucholka J.L.
        • Nabozny M.J.
        • et al.
        Engaging patients, health care professionals, and community members to improve preoperative decision making for older adults facing high-risk surgery.
        JAMA Surg. 2016; 151: 938-945
        • Lilley E.J.
        • Cooper Z.
        • Schwarze M.L.
        • Mosenthal A.C.
        Palliative care in surgery: defining the research priorities.
        J Palliat Med. 2017; 20: 702-709
      1. Medicare Access and CHIP Reauthorization Act (2015).
        (Available at:) (Accessed February 8, 2018)
        • Taylor L.J.
        • Nabozny M.J.
        • Tucholka J.L.
        • et al.
        Barriers to goal-concordant care for older patients with acute surgical illness: communication patterns extrinsic to decision aids.
        Ann Surg. 2017 Apr 26; ([Epub ahead of print])
        • Berian J.R.
        • Baker T.L.
        • Coleman J.
        • et al.
        Hospital standards to promote optimal surgical care of the older adult: a report from the coalition for quality in geriatric surgery.
        Ann Surg. 2018; 267: 280-290
        • Main B.G.
        • Huxtabe R.
        • Donovan J.L.
        • et al.
        Core information sets for informed consent to surgical interventions: baseline information of importance to patients and clinicians.
        BMC Med Ethics. 2017; 18: 29
        • Grady C.
        Enduring and emerging challenges of informed consent.
        N Engl J Med. 2015; 372: 855-862
        • Goodney P.P.
        • Lucas F.L.
        • Finlayson E.V.
        • Birkmeyer J.D.
        Hospital volume, length of stay, and readmission rates in high-risk surgery.
        Ann Surg. 2003; 238: 161-167

      Linked Article

      • Surgical Decision-Making—With Whom Is it Shared?
        Journal of the American College of SurgeonsVol. 227Issue 4
        • In Brief
          The recently published article “Shared Decision-Making in Acute Illness: The Surgeon's Perspective,” by Morris and colleagues,1 explored surgeons' perceptions of surgical decision-making related to end-of-life care. The authors found that surgeons tended to err on the side of continued care and prolonging life, even in the setting of surgeon-perceived non-beneficial treatment.
        • Full-Text
        • PDF