End of life decision planning in the perioperative setting: the elephant in the room?

Blackwood, Douglas H.; Santhirapala, Ramai; Mythen, Monty; Walker, D.

doi:10.1093/bja/aev209

Cited by 11 publications

(14 citation statements)

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“…15 High-quality ACP discussions will place the patient at the center of the decision-making process and help increase concordance between a patient's wishes and that of their treating team and family. 15,16 NFR Orders in the Perioperative Period Cardiopulmonary resuscitation aims to maintain cerebral and cardiac oxygenation and perfusion after a cardiac arrest and is generally administered without consent, providing all individuals with an opportunity for survival. 17 With an immediate return to circulation, the survival rate is good, but overall, the success rate remains low.…”

Section: Perioperative Advance Care Planningmentioning

confidence: 99%

“…15,17 CPR can result in incredible suffering through the extension of the dying process and was a reason for the introduction of NFR orders. One study showed that allowing such instructions led to 80% of patients dying in hospital with an NFR order in place, 16 avoiding futility through the obligation to resuscitate older or terminally ill patients and allowing them a natural death.…”

Section: Perioperative Advance Care Planningmentioning

confidence: 99%

“…29,30 This provides an opportunity for sharing prognostic information and for collaboration with palliative care in complex cases. 16,23 Establishing this culture of shared decision making for elective cases can build experience and skills within teams and be a foundation for conversations with patients and their families considering emergency or after-hours surgery.…”

Section: Considerations For Practicementioning

confidence: 99%

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The Challenge of Perioperative Advance Care Planning

Ramachenderan

Auret

2019

Journal of Pain and Symptom Management

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As our population ages, there will be an increasing number of patients with life-limiting disease who may be referred for major elective surgery and more pressingly may present acutely, requiring major emergency surgical intervention. Owing to the high risk of perioperative and postoperative complications associated this group of patients, it is paramount that specific advance care planning that encompasses a patient's goals of care and resuscitative status be clarified before undergoing surgery in this acute period. In doing so, this will lead to a better quality of life for patients with a limited trajectory and allow for more informed decisions to be made about their health care. Furthermore, it will help to prevent futile and inappropriate treatments that do not respect a patient's wishes and their clinical status. In this case discussion, we explore the key themes about the challenge of perioperative advance care planning for patients with life-limiting disease and provide a framework to help guide conversation in this crucial period.

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Section: Perioperative Advance Care Planningmentioning

confidence: 99%

Section: Perioperative Advance Care Planningmentioning

confidence: 99%

Section: Considerations For Practicementioning

confidence: 99%

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The Challenge of Perioperative Advance Care Planning

Ramachenderan

Auret

2019

Journal of Pain and Symptom Management

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“…The preoperative assessment clinic offers a timely opportunity to ensure consent is indeed informed. In addition, this window provides an opportunity to discuss end of life wishes, establishing an advance care plan (ACP) while capacity is intact (Blackwood et al 2015 ).…”

Section: Main Textmentioning

confidence: 99%

Primum Non Nocere: is shared decision-making the answer?

Santhirapala

Moonesinghe

2016

Perioper Med

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Surgical ambition is rising, with the Royal College of Surgeons reporting an increase in the number of procedures by a million over the past decade (Royal College of Surgeons. Surgery and the NHS in Numbers. Available from https://www.rcseng.ac.uk). Underpinning, this is a rapidly growing population, especially those in the over 85 age group, coupled with rising perioperative expertise; options for surgery are now present where conditions were once managed conservatively. Matching the right patient to the right procedure has never been so pertinent (Bader, Am Soc Anesthesiol 78(6), 2014).At the heart of these increasingly complex decisions, which may prove fatal or result in serious morbidity, lies the aspiration of shared decision-making (SDM) (Glance et al., N Engl J Med 370:1379–81, 2014). Shared decision-making is a patient-centred approach taking into account the beliefs, preferences and views of the patient as an expert in what is right for them, supported by clinicians who are the experts in diagnostics and valid therapeutic options (Coulter and Collins, Making shared decision-making a reality: no decision about me, without me, 2011). It has been described as the pinnacle of patient-centred care (Barry et al., N Engl J Med 366:780–1, 2012).In this commentary, we explore further the concept of shared decision-making, supported by a recent article which highlights critical deficits in current perioperative practice (Ankuda et al., Patient Educ Couns 94(3):328–33, 2014). This article was chosen for the purposes of this commentary as it is a large study across several surgical specialties investigating preoperative shared decision-making, and to our knowledge, the only of this kind.

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“…13 Given an ageing population 14 with an increasing number of co-morbidities 15 and rising levels of surgery in patients who would previously have been thought not suitable, 16 it is probable that the number of high-risk patients undergoing surgery will increase in the future. In 2015, we published an editorial 17 arguing that, given the persistence of this high-risk surgical population, it would be valuable to utilise perioperative encounters to begin the process of a voluntary patient discussion documenting a patient's hopes and aspirations for the planned treatment ahead, including, where appropriate, EOL care via ACP.…”

mentioning

confidence: 99%

Advance-care-planning and end-of-life discussions in the perioperative period: a review of healthcare professionals' knowledge, attitudes, and training

Blackwood

Vindrola‐Padros

Mythen

et al. 2018

British Journal of Anaesthesia

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Whilst the risk of dying after an operation in the UK is very small, the volume of surgery means that there are 20 000e25 000 deaths each year. For these patients and others who suffer major complications, critical illness often leads to a loss of capacity. If wishes are not discussed in advance, the patients may be excluded from meaningful involvement in decisions affecting their care. The preoperative period has been postulated as one where advance care planning could begin by engaging in voluntary conversations about an individual's wishes, priorities, and values should he/she loses capacity. There remain unanswered questions as to whether healthcare professionals are supportive of a move towards better engagement in such discussions with patients. Even if the reception to the idea is positive, it is clear that appropriate training and understanding will be required. The aims of this review were to describe the current knowledge and attitudes of healthcare professionals towards advance care planning in the perioperative setting, and to outline any educational programmes or training limitations that have been identified. Seven articles that met the inclusion criteria were identified. They indicate that healthcare professionals mostly have a positive view of advance care planning in the perioperative period, and there is little training or educational content available. Despite this, most healthcare professionals report feeling well equipped to have such discussions. Evidence was not found of advance care planning becoming a routine part of training or practice in the care of patients in the lead up to high-risk surgery.

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End of life decision planning in the perioperative setting: the elephant in the room?

Abstract: What previous generations called 'the art of dying' is undergoing a renaissance as an important aspect of healthcare delivery. In his recently published book, 'Being Mortal', 1 and accompanying Reith lectures, surgeon and author Atul Gawande has turned

Cited by 11 publications

References 10 publications

The Challenge of Perioperative Advance Care Planning

The Challenge of Perioperative Advance Care Planning

Primum Non Nocere: is shared decision-making the answer?

Advance-care-planning and end-of-life discussions in the perioperative period: a review of healthcare professionals' knowledge, attitudes, and training

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