Objective: Evidence suggests that surgeons implicitly negotiate with their patients preoperatively about the use of life supporting treatments postoperatively as a condition for performing surgery. We sought to examine whether this surgical buy-in behavior is present among a large, nationally representative sample of surgeons who routinely perform high-risk operations.
Design: Using findings from a qualitative study, we designed a survey to determine the prevalence of surgical buy-in and its consequences. Respondents were asked to consider their response to a patient at moderate risk for prolonged mechanical ventilation or dialysis who has a preoperative request to limit postoperative life- supporting treatment. We used bivariate and multivariate analysis to identify surgeon characteristics associated with 1) preoperatively creating an informal contract with the patient defining agreed upon limitations of postoperative life support and 2) declining to operate on such patients.
Setting and Subjects: U.S. mail-based survey of 2,100 cardiothoracic, vascular, and neurosurgeons.
Measurements and Main Results: The adjusted response rate was 56%. Nearly two thirds of respondents (62%) reported they would create an informal contract with the patient describing agreed upon limitations of aggressive therapy and a similar number (60%) endorsed sometimes or always refusing to operate on a patient with preferences to limit life support. After adjusting for potentially confounding covariates, the odds of preoperatively contracting about life-supporting treatment were more than two-fold greater among surgeons who felt it was acceptable to withdraw life support on postoperative day 14 compared with those who believed it was not acceptable to withdraw life support on postoperative day 14 (odds ratio 2.1, 95% confidence intervals 1.3–3.2).
Conclusions: Many surgeons will report contracting informally with patients preoperatively about the use of postoperative life support. Recognition of this process and its limitations may help to inform postoperative decision making.
1 Department of Surgery, Division of Vascular Surgery, University of Wisconsin, Madison, WI.
2 University of Wisconsin School of Medicine and Public Health, Madison, WI.
3 Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.
4 Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD.
5 Department of Surgery, The Medical College of Wisconsin, Milwaukee, WI.
*See also p. 326.
Dr. Schwarze is supported by a Greenwall Faculty Scholars Award and the Department of Surgery at the University of Wisconsin. Mr. Redmann is supported by a Shapiro Summer Research Award from the University of Wisconsin School of Medicine and Public Health. Dr. Alexander is supported by the Agency for Healthcare Research and Quality (K08 HS15699; R01 HS0189960). These funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; and preparation, review, or approval of the article for publication.
Dr. Alexander has received funding from the National Institutes of Health. The remaining authors have not disclosed any potential conflicts of interest.
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