Factors Associated With Provision of Nonbeneficial Surgery

Abstract

Objective: We tested the association of systems factors with the surgeon’s likelihood of offering surgical intervention for older adults with life-limiting acute surgical conditions. Background: Use of surgical treatments in the last year of life is frequent. Improved risk prediction and clinician communication are solutions proposed to improve serious illness care, yet systems factors may also drive receipt of nonbeneficial treatment. Methods: We mailed a national survey to 5200 surgeons randomly selected from the American College of Surgeons database comprised of a clinical vignette describing a seriously ill older adult with an acute surgical condition, which utilized a 2×2 factorial design to assess patient and systems factors on receipt of surgical treatment to surgeons. Results: Two thousand one hundred sixty-one surgeons responded for a weighted response rate of 53%. For an 87-year-old patient with fulminant colitis and advanced dementia or stage IV lung cancer, 40% of surgeons were inclined to offer an operation to remove the patient’s colon while 60% were inclined to offer comfort-focused care only. Surgeons were more likely to offer surgery when an operating room was readily available (odds ratio: 4.05, P<0.001) and the family requests “do everything” (odds ratio: 2.18, P<0.001). Conclusions: Factors outside the surgeon’s control contribute to nonbeneficial surgery, consistent with our model of clinical momentum. Further characterization of the systems in which these decisions occur might expose novel strategies to improve serious illness care for older patients and their families.

Better Conversations for Better Informed Consent: Talking with Surgical Patients

“…The downsides can come in three forms: bad things that happen to everyone who has this surgery, bad things that could happen to people who have this surgery, and the surgery falls short of its goals. 20 Everyone who has surgery will need to go through it; even small incisions hurt, and minor recoveries require time and effort. Major operations hurt more, take two to three months for recovery, and can leave the patient with permanent changes, such as end ileostomy or inserted prosthetics (like mesh or intramedullary rods).…”

Innovations in Surgical Communication—Provide Your Opinion, Don’t Hide It

“…It is misleading to set them up and, without transparency, push patients and families to “make the right choice.” Furthermore, it is burdensome for families to shoulder responsibility for a “decision,” especially for a dying patient, because clinicians have concealed their thinking. When patients or family choose to pursue nonbeneficial surgery, we hold them responsible for being unreasonable, noting in conversations with other clinicians that we are operating because “they want everything.”…”