Risk acceptance and risk aversion: patients' perspectives on lung surgery.

Patients express risk aversion toward surgery, particularly if surgery can lead to lifelong debility and loss of independence. When faced with a guarantee of progressive lung cancer and no alternatives for cure, however, patients are willing to take extremely high risks of postoperative complications and surgery-related death. This result occurs because risk aversion toward unrelenting cancer death supersedes patients' risk attitudes toward almost all other health states. By adding conditions such as misunderstanding of prognosis, diagnostic uncertainty, a patient's denial of diagnosis, an actual alternative cure such as radiation therapy, or a perceived alternative cure such as prayer, decisions can be shifted so that risk aversion to surgery can predominate. In practical terms, the following statements can be made: 1. For patients who surely have operable stage I or stage II non small cell lung cancer, if patient risk preferences are taken seriously, the pulmonary function level and comorbidities that are acceptable for the offer of surgical care probably need to be liberalized. Patients with short life expectancies because of advanced age or comorbid illness and patients with severe preoperative functional debility (eg, bed-to-chair limitation as defined earlier) should not be candidates, however. 2. The diagnosis of cancer needs to be confirmed absolutely as often as possible before lung resection surgery. 3. Physicians or a staff member must communicate prognosis to a patient as precisely and numerically as possible and ensure the patient's understanding of the data presented. 4. This communicator also must explore a patient's trust in the diagnosis and probe for beliefs in alternative solutions. Important areas for future study include the search for methods that most accurately communicate risk information to patients, especially patients with low numeracy skills. Part of this communication effort should involve the exploration and discussion of patients' alternative beliefs and ways of using these belief systems to help them make the best possible decisions for their long-term health and quality of life. Also, clinicians must identify pulmonary and other predictors of mortality rates and the debility states that patients' cite as most important according to their risk preferences and give up the predictors of transient postoperative complications that patients find acceptable.