Surgeon Use of Shared Decision-making for Older Adults Considering Major Surgery

Abstract

IMPORTANCEBecause major surgery carries significant risks for older adults with comorbid conditions, shared decision-making is recommended to ensure patients receive care consistent with their goals. However, it is unknown how often shared decision-making is used for these patients.OBJECTIVE To describe the use of shared decision-making during discussions about major surgery with older adults. DESIGN, SETTING, AND PARTICIPANTSThis study is a secondary analysis of conversations audio recorded during a randomized clinical trial of a question prompt list. Data were collected from June 1, 2016, to November 31, 2018, from 43 surgeons and 446 patients 60 years or older with at least 1 comorbidity at outpatient surgical clinics at 5 academic centers.INTERVENTIONS Patients received a question prompt list brochure that contained questions they could ask a surgeon. MAIN OUTCOMES AND MEASURESThe 5-domain Observing Patient Involvement in Decision-making (OPTION5) score (range, 0-100, with higher scores indicating greater shared decision-making) was used to measure shared decision-making.RESULTS A total of 378 surgical consultations were analyzed (mean [SD] patient age, 71.9 [7.2] years; 206 [55%] male; 312 [83%] White). The mean (SD) OPTION5 score was 34.7 (20.6) and was not affected by the intervention. The mean (SD) score in the group receiving the question prompt list was 36.7 (21.2); in the control group, the mean (SD) score was 32.9 (19.9) (effect estimate, 3.80; 95% CI, −0.30 to 8.00; P = .07). Individual surgeon use of shared decision-making varied greatly, with a lowest median score of 10 (IQR, 10-20) to a high of 65 (IQR,. Lower-performing surgeons had little variation in OPTION5 scores, whereas high-performing surgeons had wide variation. Use of shared decision-making increased when surgeons appeared reluctant to operate (effect estimate, 7.40; 95% CI, 2.60-12.20; P = .003). Although longer conversations were associated with slightly higher OPTION5 scores (effect estimate, 0.69; 95% CI, 0.52-0.88; P < .001), 57% of high-scoring transcripts were 26 minutes long or less. On multivariable analysis, patient age and gender, patient education, surgeon age, and surgeon gender were not significantly associated with OPTION5 scores.CONCLUSIONS AND RELEVANCE These findings suggest that although shared decision-making is important to support the preferences of older adults considering major surgery, surgeon use of shared decision-making is highly variable. Skillful shared decision-making can be done in less than 30 minutes; however, surgeons who engage in high-scoring shared decision-making are more likely to do so when surgical intervention is less obviously beneficial for the patient.

Factors Associated With Provision of Nonbeneficial Surgery

“…Offering surgery as a choice suggests the surgeon believes surgery is a reasonable, but risky, option, which is categorically different than nonbeneficial. [27][28][29] Although surgeons likely offer choices to support autonomy, it deprives patients and families of the surgeon's expertise, better expressed as "I'm worried surgery is not a good idea." [29][30][31][32] Given the fast pace of acute care and the number of clinicians involved, surgeons will need stronger communication skills to disrupt this momentum (Appendix 2, Supplemental Digital Content 2, http://links.lww.com/SLA/ E353).…”

Informed Consent and Shared Decision Making in the Perioperative Environment

“…It has been shown that surgeons more commonly employ SDM in situations in which they feel operative intervention is exceedingly risky, in hopes that patients will select nonoperative care. 12 However, in these situations it is particularly necessary for surgeons to impart their recommendation, even if it is nonoperative management, as the patient often wants to hear this opinion directly. For instance, in a study of patients diagnosed with a life-threatening illness, including a new diagnosis of cancer, >50% of patients wanted their physician to share responsibility in the decision making.…”

Identifying Patterns in Preoperative Communication about High-Risk Surgical Intervention: A Secondary Analysis of a Randomized Clinical Trial

“…Moreover, the decision support interventions designed to facilitate shared decision making, like decision aids and question prompts, focus primarily on information exchange and rarely address the clinician-patient interaction needed to elicit, refine, and apply patient preferences. 19,20 In the setting of vulnerability due to illness and an insurmountable asymmetry of information, offering choices and describing pros and cons does not mitigate the power differential between surgeons and patients, particularly in high acuity settings. 2,21 If surgeons operationalize shared decision making as the description of options and choices, it too may fall short in helping the patient consider which treatment path makes the most sense for them.…”