Despite its importance, advance care planning (ACP) rarely occurs before patients undergo surgery for cancer or vascular issues, according to a secondary analysis from a multisite randomized study of 40 surgeons across the U.S., reported in JAMA Surgery.
“More than two-thirds of patients 60 years and older with comorbid conditions did not have an [advanced directive (AD)] on file before undergoing high-risk surgery,” Elle Kalbfell, MD, from the Department of Surgery, University of Wisconsin-Madison, and colleagues wrote. “This makes it challenging for surgeons and families to navigate the difficult terrain around the use of postoperative life-sustaining treatments, unwanted outcomes, and goals of surgery when patients can no longer speak for themselves. Surgeons agree that patient preferences for limitations of life-sustaining treatments are important to discuss, but there is a vast disconnect between the stated value of this communication and how often it occurs. Although surgeons believe they are having these conversations preoperatively, they are not.”
Moreover, they noted that patients may be reticent to share their AD because of privacy concerns and do not see its relevance to surgical care.
Olivia A. Sacks, MD, and Teviah E. Sachs, MD, MPH, both from the Department of Surgical Oncology, Boston Medical Center, noted in an accompanying editorial that Kalbfell and colleagues study brings up important considerations:
- The barriers to ACP—most notably the time it takes to have meaningful conversations with patients about planning. Physician champions might be a way to help surgical colleagues undertake and incorporate ACP into their workflow.
- ACP, as well as AD and perioperative care preferences are not easy understood or navigate. In the surgical realm surgeons are likely focused on helping the patient understand the operation and possible consequences to quality of life and therefore the larger ACP discussions are left to primary care physicians.
In their exploratory analysis, Kalbfell and colleagues culled data from a randomized clinical trial a list of question prompts designed to improve discussions before surgery about treatment options, postoperative expectations, and potential serious complications. The original study showed that the interventions “had no effect on patients asking questions about options, expectations, or risks,” the study authors wrote. The current analysis looked at the frequency that ACPs were discussed prior to surgery as well as how postoperative complications affected patients’ and families’ views about ACP. The current intervention included a brochure with 11 question prompts that could be discussed with their surgeon.
The study took place at five sites: the University of Wisconsin Hospital and Clinics (UHWC), Madison, the University of California, San Francisco, Medical Center (UCSF), Oregon Health and Science University, (OSHU), Portland, the University Hospital of Rutgers New Jersey Medical School (Rutgers), Newark, and the Brigham and Women’s Hospital (BWH), Boston.
Patients enrolled in the study were at least 60 years old or older and had at least one comorbidity. They also had an oncological or vascular (cardiac, peripheral, or neurovascular) problem that could be treated with high-risk surgery. High risk was defined as “operations having a 30-day in-hospital mortality rate of 1% or greater.” One family member per patient was also invited to participate. Those excluded from the study were patients who were unable to make decisions or who lacked proficiency in English or Spanish. Patients from the initial study who did not have surgery were also excluded.
Most of the patients in the study were White, most of them (79%) had oncological surgery, and 98% were not Medicaid recipients.
The primary decision-making conversations between the surgeon, patient and family member was audio recorded. Also recorded were postoperative treatments and complications that occurred within six weeks of surgery. About six weeks after surgery, open-ended interviews were conducted with a subset of patients. “Interview questions focused on treatment decisions, postoperative experiences, and interpersonal relationships among patients, families, and clinicians and between clinicians. Patients and family members were specifically asked whether the patient had an AD and how they had anticipated using it postoperatively.”
Outcomes included identifying statements associated with ACP by patients, family members, and surgeons. “This includes any mention of an AD, health care power of attorney/proxy, or preference for limitations of life sustaining treatments,” Kalbfell and colleagues noted.
Among their findings:
- In preoperative consultations with 213 patients, 57% of whom were male with a mean age of 72  years, 13 conversations included items related to ACP.
- Most of the patients 141 (66%) did not have an AD on file.
- There was not a significant association between patient age and having an AD was not a significant association (60-69 years, 26 [31%]; 70-79 years, 31 [33%]; ≥80 years, 15 [42%]; P=.55)
- Number of comorbidities also was not association with having an AD (1, 35 [32%]; 2, 18 [33%]; ≥3, 19 [40%]; P=0.62),
- The type of surgery was also not a factor (oncological, 53 [32%]; vascular, 19 [42%]; P=0.22).
Of note, the study authors wrote, “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=0.77). 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.” Patients and their families also did not have a decent grasp of serious surgical complications.
“During surgical consultation, they focused on details related to their disease and treatment; the risks of surgery seemed inconsequential,” the study authors wrote. “Some anticipated the outcomes of surgery would be binary (’either you make it, or you don’t’). They did not consider that complications could affect their life or their family members. They noted that it was difficult to translate a list of discrete complications, such as bleeding or heart attack, into a vision of what their life might be like after a serious complication. Looking back at their preoperative conversations, we found wide variation in how surgeons described risks or unwanted outcomes. Patients whose surgeons described complications extensively or provided a long list of risks still reported feeling blindsided when complications occurred.”
Kalbfell and colleagues noted that ADs as they currently exist may fall short in the postsurgical setting. For example, where an AD outlines how a patient may feel about life-sustaining machines, or feeding tubes, these actually may be needed after surgery to reach the goals of the surgery. “There is little public narrative about the limits of ACP when these directives are rendered ambiguous or are contrary to surgical goals,” the study authors wrote.
Sacks and Sachs applauded the study authors for looking at this subject. “Further research should focus on facilitators and barriers to including ACP in preoperative visits and how the clinicians who are successful with ACP have integrated these conversations into their preoperative conversations,” they wrote in their commentary.
Limitations include the fact that not all touch points in conversations about ACP may have been collected and the percentage of patients with AD is limited by those that were recorded in the medical record.
More than two-thirds of older patients who have at least one comorbidity, undergoing high risk cancer or vascular surgery do not have an advance care plan.
Surgeons acknowledge the importance of having conversations about advance care planning but rarely have this conversation.
Candace Hoffmann, Managing Editor, BreakingMED™
The study was supported by a grant from the Patient-Centered Outcomes Research Institute.
Kalbfeel reported receiving a grant from the NIH.
The editorialists declared no relevant relationships.
Cat ID: 159
Topic ID: 97,159,282,494,730,192,925,159