TY - JOUR
T1 - Frequency of Preoperative Advance Care Planning for Older Adults Undergoing High-risk Surgery
T2 - A Secondary Analysis of a Randomized Clinical Trial
AU - Kalbfell, Elle
AU - Kata, Anna
AU - Buffington, Anne S.
AU - Marka, Nicholas
AU - Brasel, Karen J.
AU - Mosenthal, Anne C.
AU - Cooper, Zara
AU - Finlayson, Emily
AU - Schwarze, Margaret L.
N1 - Publisher Copyright:
© 2021 American Medical Association. All rights reserved.
PY - 2021/7
Y1 - 2021/7
N2 - Importance: For patients facing major surgery, surgeons believe preoperative advance care planning (ACP) is valuable and routinely performed. How often preoperative ACP occurs is unknown. Objective: To quantify the frequency of preoperative ACP discussion and documentation for older adults undergoing major surgery. Design, Setting, and Participants: This secondary analysis of data from a multisite randomized clinical trial testing the effects of a question prompt list intervention on preoperative communication for older adults considering major surgery was performed at 5 US academic medical centers. Participants included surgeons who routinely perform high-risk surgery and patients 60 years or older with at least 1 comorbidity and an oncological or vascular (cardiac, peripheral, or neurovascular) problem. Data were collected from June 1, 2016, to November 30, 2018. Interventions: Patients received a question prompt list brochure with 11 questions that they might ask their surgeon. Main Outcomes and Measures: For patients who had major surgery, any statement related to ACP from the surgeon, patient, or family member during the audiorecorded preoperative consultation was counted. The presence of a written advance directive (AD) in the medical record at the time of the initial consultation or added preoperatively was recorded. Open-ended interviews with patients who experienced postoperative complications and family members were conducted. Results: Among preoperative consultations with 213 patients (122 men [57%]; mean [SD] age, 72 [7] years), only 13 conversations had any discussion of ACP. In this cohort of older patients with at least 1 comorbid condition, 141 (66%) did not have an AD on file before major surgery; there was no significant association between the presence of an AD and patient age (60-69 years, 26 [31%]; 70-79 years, 31 [33%]; ≥80 years, 15 [42%]; P =.55), number of comorbidities (1, 35 [32%]; 2, 18 [33%]; ≥3, 19 [40%]; P =.62), or type of procedure (oncological, 53 [32%]; vascular, 19 [42%]; P =.22). There was no difference in preoperative communication about ACP or documentation of an AD for patients who were mailed a question prompt list brochure (intervention, 38 [35%]; usual care, 34 [33%]; P =.77). Patients with complications were enthusiastic about ACP but did not think it was important to discuss their preferences for life-sustaining treatments with their surgeon preoperatively. Conclusions and Relevance: Although surgeons believe that preoperative discussion of patient preferences for postoperative life-sustaining treatments is important, these preferences are infrequently explored, addressed, or documented preoperatively. Trial Registration: ClinicalTrials.gov Identifier: NCT02623335.
AB - Importance: For patients facing major surgery, surgeons believe preoperative advance care planning (ACP) is valuable and routinely performed. How often preoperative ACP occurs is unknown. Objective: To quantify the frequency of preoperative ACP discussion and documentation for older adults undergoing major surgery. Design, Setting, and Participants: This secondary analysis of data from a multisite randomized clinical trial testing the effects of a question prompt list intervention on preoperative communication for older adults considering major surgery was performed at 5 US academic medical centers. Participants included surgeons who routinely perform high-risk surgery and patients 60 years or older with at least 1 comorbidity and an oncological or vascular (cardiac, peripheral, or neurovascular) problem. Data were collected from June 1, 2016, to November 30, 2018. Interventions: Patients received a question prompt list brochure with 11 questions that they might ask their surgeon. Main Outcomes and Measures: For patients who had major surgery, any statement related to ACP from the surgeon, patient, or family member during the audiorecorded preoperative consultation was counted. The presence of a written advance directive (AD) in the medical record at the time of the initial consultation or added preoperatively was recorded. Open-ended interviews with patients who experienced postoperative complications and family members were conducted. Results: Among preoperative consultations with 213 patients (122 men [57%]; mean [SD] age, 72 [7] years), only 13 conversations had any discussion of ACP. In this cohort of older patients with at least 1 comorbid condition, 141 (66%) did not have an AD on file before major surgery; there was no significant association between the presence of an AD and patient age (60-69 years, 26 [31%]; 70-79 years, 31 [33%]; ≥80 years, 15 [42%]; P =.55), number of comorbidities (1, 35 [32%]; 2, 18 [33%]; ≥3, 19 [40%]; P =.62), or type of procedure (oncological, 53 [32%]; vascular, 19 [42%]; P =.22). There was no difference in preoperative communication about ACP or documentation of an AD for patients who were mailed a question prompt list brochure (intervention, 38 [35%]; usual care, 34 [33%]; P =.77). Patients with complications were enthusiastic about ACP but did not think it was important to discuss their preferences for life-sustaining treatments with their surgeon preoperatively. Conclusions and Relevance: Although surgeons believe that preoperative discussion of patient preferences for postoperative life-sustaining treatments is important, these preferences are infrequently explored, addressed, or documented preoperatively. Trial Registration: ClinicalTrials.gov Identifier: NCT02623335.
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U2 - 10.1001/jamasurg.2021.1521
DO - 10.1001/jamasurg.2021.1521
M3 - Review article
C2 - 33978693
AN - SCOPUS:85106148269
SN - 2168-6254
VL - 156
JO - JAMA Surgery
JF - JAMA Surgery
IS - 7
ER -