Christy E Cauley1,2, Susan D Block1,3,4,5, Luca A Koritsanszky1, Jonathon D Gass1, Julia L Frydman6, Suliat M Nurudeen1,7, Rachelle E Bernacki1,3, Zara Cooper1,7,8. 1. 1 Ariadne Labs , Boston, Massachusetts. 2. 3 Department of Surgery, Massachusetts General Hospital , Boston, Massachusetts. 3. 4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts. 4. 5 Department of Psychiatry, Brigham and Women's Hospital , Boston, Massachusetts. 5. 6 Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts. 6. 7 Harvard Medical School , Boston, Massachusetts. 7. 2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts. 8. 8 Center for Surgery and Public Health, Brigham and Women's Hospital , Boston, Massachusetts.
Abstract
BACKGROUND: Clinical decisions for seriously ill older patients with surgical emergencies are highly complex. Measuring the benefits of burdensome treatments in this context is fraught with uncertainty. Little is known about how surgeons formulate treatment decisions to avoid nonbeneficial surgery, or engage in preoperative conversations about end-of-life (EOL) care. OBJECTIVE: We sought to describe how surgeons approach such discussions, and to identify modifiable factors to reduce nonbeneficial surgery near the EOL. DESIGN: Purposive and snowball sampling were used to recruit a national sample of emergency general surgeons. Semistructured interviews were conducted between February and May 2014. MEASUREMENTS: Three independent coders performed qualitative coding using NVivo software (NVivo version 10.0, QSR International). Content analysis was used to identify factors important to surgical decision making and EOL communication. RESULTS: Twenty-four surgeons were interviewed. Participants felt responsible for conducting EOL conversations with seriously ill older patients and their families before surgery to prevent nonbeneficial treatments. However, wide differences in prognostic estimates among surgeons, inadequate data about postoperative quality of life (QOL), patients and surrogates who were unprepared for EOL conversations, variation in perceptions about the role of palliative care, and time constraints are contributors to surgeons providing nonbeneficial operations. Surgeons reported performing operations they knew would not benefit the patient to give the family time to come to terms with the patient's demise. CONCLUSIONS: Emergency general surgeons feel responsible for having preoperative discussions about EOL care with seriously ill older patients to avoid nonbenefical surgery. However, surgeons identified multiple factors that undermine adequate communication and lead to nonbeneficial surgery.
BACKGROUND: Clinical decisions for seriously ill older patients with surgical emergencies are highly complex. Measuring the benefits of burdensome treatments in this context is fraught with uncertainty. Little is known about how surgeons formulate treatment decisions to avoid nonbeneficial surgery, or engage in preoperative conversations about end-of-life (EOL) care. OBJECTIVE: We sought to describe how surgeons approach such discussions, and to identify modifiable factors to reduce nonbeneficial surgery near the EOL. DESIGN: Purposive and snowball sampling were used to recruit a national sample of emergency general surgeons. Semistructured interviews were conducted between February and May 2014. MEASUREMENTS: Three independent coders performed qualitative coding using NVivo software (NVivo version 10.0, QSR International). Content analysis was used to identify factors important to surgical decision making and EOL communication. RESULTS: Twenty-four surgeons were interviewed. Participants felt responsible for conducting EOL conversations with seriously ill older patients and their families before surgery to prevent nonbeneficial treatments. However, wide differences in prognostic estimates among surgeons, inadequate data about postoperative quality of life (QOL), patients and surrogates who were unprepared for EOL conversations, variation in perceptions about the role of palliative care, and time constraints are contributors to surgeons providing nonbeneficial operations. Surgeons reported performing operations they knew would not benefit the patient to give the family time to come to terms with the patient's demise. CONCLUSIONS: Emergency general surgeons feel responsible for having preoperative discussions about EOL care with seriously ill older patients to avoid nonbenefical surgery. However, surgeons identified multiple factors that undermine adequate communication and lead to nonbeneficial surgery.
Authors: Atul A Gawande; Mary R Kwaan; Scott E Regenbogen; Stuart A Lipsitz; Michael J Zinner Journal: J Am Coll Surg Date: 2006-12-27 Impact factor: 6.113
Authors: Shukri F Khuri; William G Henderson; Ralph G DePalma; Cecilia Mosca; Nancy A Healey; Dharam J Kumbhani Journal: Ann Surg Date: 2005-09 Impact factor: 12.969
Authors: Lauren J Taylor; Michael J Nabozny; Nicole M Steffens; Jennifer L Tucholka; Karen J Brasel; Sara K Johnson; Amy Zelenski; Paul J Rathouz; Qianqian Zhao; Kristine L Kwekkeboom; Toby C Campbell; Margaret L Schwarze Journal: JAMA Surg Date: 2017-06-01 Impact factor: 14.766
Authors: Danielle R Heller; Raymond A Jean; Alexander S Chiu; Shelli I Feder; Vadim Kurbatov; Charles Cha; Sajid A Khan Journal: J Gastrointest Surg Date: 2018-09-04 Impact factor: 3.452
Authors: Holly B Cunningham; Shannon A Scielzo; Paul A Nakonezny; Brandon R Bruns; Karen J Brasel; Kenji Inaba; Scott C Brakenridge; Jeffrey D Kerby; Bellal A Joseph; M J Mohler; Joseph Cuschieri; Mary E Paulk; Akpofure P Ekeh; Tarik D Madni; Luis R Taveras; Jonathan B Imran; Steven E Wolf; Herb A Phelan Journal: J Burn Care Res Date: 2018-10-23 Impact factor: 1.845
Authors: Pasithorn A Suwanabol; Ari C Reichstein; Z Tuba Suzer-Gurtekin; Jane Forman; Maria J Silveira; Lona Mody; Arden M Morris Journal: J Palliat Med Date: 2018-03-13 Impact factor: 2.947
Authors: Claire Sokas; Irene M Yeh; Kathleen Coogan; Rachelle Bernacki; Susan Mitchell; Angela Bader; Keren Ladin; Jennifer A Palmer; James A Tulsky; Zara Cooper Journal: J Pain Symptom Manage Date: 2020-10-07 Impact factor: 3.612
Authors: Lindsay K Haines; Allyson C Cook; Justin S Hatchimonji; Vanessa P Ho; Elle L Kalbfell; Kathleen M O'Connell; Jacinta C Robenstine; Mathias Schlögl; Christine C Toevs; Christopher A Jones; Robert S Krouse; Niels D Martin Journal: J Palliat Med Date: 2021-07 Impact factor: 2.947
Authors: Blanche Blumenthal; Christina W Lee; C Ann Vitous; Alexandria J Robbins; Ana C De Roo; Mary Byrnes; Pasithorn A Suwanabol Journal: Ann Palliat Med Date: 2020-09-10