TY - JOUR
T1 - Surgical "buy-in"
T2 - The contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy
AU - Schwarze, Margaret L.
AU - Bradley, Ciaran T.
AU - Brasel, Karen J.
N1 - Funding Information:
Dr. Schwarze is funded by the Greenwall Faculty Scholars Program; research support was partially funded by a departmental grant from the Department of Surgery at the University of Wisconsin.
PY - 2010/3
Y1 - 2010/3
N2 - Objective: There is a general consensus by intensivists and nonsurgical providers that surgeons hesitate to withdraw life-sustaining therapy on their operative patients despite a patient's or surrogate's request to do so. The Objective of this study was to examine the culture and practice of surgeons to assess attitudes and concerns regarding advance directives for their patients who have high-risk surgical procedures. Design: A qualitative investigation using one-on-one, in-person interviews with open-ended questions about the use of advance directives during perioperative planning. Consensus coding was performed using a grounded theory approach. Data accrual continued until theoretical saturation was achieved. Modeling identified themes and trends, ensuring maximal fit and faithful data representation. Setting: Surgical practices in Madison and Milwaukee, WI. Subjects: Physicians involved in the performance of high-risk surgical procedures. Interventions: None. Measurements and Main Results: We describe the concept of surgical "buy-in," a complex process by which surgeons negotiate with patients a commitment to postoperative care before undertaking high-risk surgical procedures. Surgeons describe seeking a commitment from the patient to abide by prescribed postoperative care, "This is a package deal, this is what this operation entails," or a specific number of postoperative days, "I will contract with them and say, 'look, if we are going to do this, I am going to need 30 days to get you through this operation.'" "Buy-in" is grounded in a surgeon's strong sense of responsibility for surgical outcomes and can lead to surgeon unwillingness to operate or surgeon reticence to withdraw life-sustaining therapy postoperatively. If negotiations regarding life-sustaining interventions result in treatment limitation, a surgeon may shift responsibility for unanticipated outcomes to the patient. Conclusions: A complicated relationship exists between the surgeon and patient that begins in the preoperative setting. It reflects a bidirectional contract that is assumed by the surgeon with distinct implications and consequences for surgeon behavior and patient care.
AB - Objective: There is a general consensus by intensivists and nonsurgical providers that surgeons hesitate to withdraw life-sustaining therapy on their operative patients despite a patient's or surrogate's request to do so. The Objective of this study was to examine the culture and practice of surgeons to assess attitudes and concerns regarding advance directives for their patients who have high-risk surgical procedures. Design: A qualitative investigation using one-on-one, in-person interviews with open-ended questions about the use of advance directives during perioperative planning. Consensus coding was performed using a grounded theory approach. Data accrual continued until theoretical saturation was achieved. Modeling identified themes and trends, ensuring maximal fit and faithful data representation. Setting: Surgical practices in Madison and Milwaukee, WI. Subjects: Physicians involved in the performance of high-risk surgical procedures. Interventions: None. Measurements and Main Results: We describe the concept of surgical "buy-in," a complex process by which surgeons negotiate with patients a commitment to postoperative care before undertaking high-risk surgical procedures. Surgeons describe seeking a commitment from the patient to abide by prescribed postoperative care, "This is a package deal, this is what this operation entails," or a specific number of postoperative days, "I will contract with them and say, 'look, if we are going to do this, I am going to need 30 days to get you through this operation.'" "Buy-in" is grounded in a surgeon's strong sense of responsibility for surgical outcomes and can lead to surgeon unwillingness to operate or surgeon reticence to withdraw life-sustaining therapy postoperatively. If negotiations regarding life-sustaining interventions result in treatment limitation, a surgeon may shift responsibility for unanticipated outcomes to the patient. Conclusions: A complicated relationship exists between the surgeon and patient that begins in the preoperative setting. It reflects a bidirectional contract that is assumed by the surgeon with distinct implications and consequences for surgeon behavior and patient care.
KW - Decisionmaking
KW - Ethics
KW - Informed consent
KW - Patient autonomy
KW - Surgical outcomes
UR - http://www.scopus.com/inward/record.url?scp=77249107571&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=77249107571&partnerID=8YFLogxK
U2 - 10.1097/CCM.0b013e3181cc466b
DO - 10.1097/CCM.0b013e3181cc466b
M3 - Article
C2 - 20048678
AN - SCOPUS:77249107571
SN - 0090-3493
VL - 38
SP - 843
EP - 848
JO - Critical care medicine
JF - Critical care medicine
IS - 3
ER -