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It's Big Surgery: Preoperative Expressions of Risk, Responsibility, and Commitment to Treatment After High-Risk Operations

Pecanac, Kristen E. MS, RN*; Kehler, Jacqueline M. MD; Brasel, Karen J. MD, MPH; Cooper, Zara MD, MSc; Steffens, Nicole M. MPH; McKneally, Martin F. MD, PhD**,††; Schwarze, Margaret L. MD, MPP‡,§

doi: 10.1097/SLA.0000000000000314
Original Articles

Objective: To identify the processes, surgeons use to establish patient buy-in to postoperative treatments.

Background: Surgeons generally believe they confirm the patient's commitment to an operation and all ensuing postoperative care, before surgery. How surgeons get buy-in and whether patients participate in this agreement is unknown.

Methods: We used purposive sampling to identify 3 surgeons from different subspecialties who routinely perform high-risk operations at each of 3 distinct medical centers (Toronto, Ontario; Boston, Massachusetts; Madison, Wisconsin). We recorded preoperative conversations with 3 to 7 patients facing high-risk surgery with each surgeon (n = 48) and used content analysis to analyze each preoperative conversation inductively.

Results: Surgeons conveyed the gravity of high-risk operations to patients by emphasizing the operation is “big surgery” and that a decision to proceed invoked a serious commitment for both the surgeon and the patient. Surgeons were frank about the potential for serious complications and the need for intensive care. They rarely discussed the use of prolonged life-supporting treatment, and patients' questions were primarily confined to logistic or technical concerns. Surgeons regularly proceeded through the conversation in a manner that suggested they believed buy-in was achieved, but this agreement was rarely forged explicitly.

Conclusions: Surgeons who perform high-risk operations communicate the risks of surgery and express their commitment to the patient's survival. However, they rarely discuss prolonged life-supporting treatments explicitly and patients do not discuss their preferences. It is not possible to determine patients' desires for prolonged postoperative life support on the basis of these preoperative conversations alone.

We observed surgeons discussing high-risk operations to identify the processes used to establish a preoperative agreement about postoperative treatments. Although surgeons go to great lengths to describe the serious nature of high-risk operations, they do not regularly discuss the use of prolonged life support and patients do not explicitly agree to participate in prolonged aggressive treatments.

*School of Nursing

Department of Medicine

Department of Surgery (Division of Vascular Surgery), and

§Department of Medical History and Bioethics, University of Wisconsin, Madison, WI

Department of Surgery, Medical College of Wisconsin, Milwaukee, WI

Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA; and

**Department of Surgery and

††Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada.

Reprints: Margaret L. Schwarze, MD, MPP, G5/315 CSC, 600 Highland Ave, Madison, WI 53792. E-mail:

Disclosure: The project described was supported by the Clinical and Translational Science Award (CTSA) program, previously through the National Center for Research Resources (NCRR) grant 1UL1RR025011, and now by the National Center for Advancing Translational Sciences (NCATS), grant 9U54TR000021 (Dr Schwarze). This project was also supported by the Greenwall (Kornfeld) Program for Bioethics and Patient Care (Dr Schwarze), and the American Geriatrics Society Jahnigen Career Development Award, grant 1R03AG042361-01 NIH (Dr Cooper). 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 manuscript for publication. For the remaining authors no conflicts were declared.

© 2014 by Lippincott Williams & Wilkins.