Surgeons Often Unaware of Patients’ Views on Recovery, Life-Sustaining Treatments

NEW YORK (Reuters Health) – Surgeons may not be aware of patients’ views on recovery after surgery, and they may not address advance care planning (ACP) for older adults undergoing high-risk procedures, a pair of new studies show.

Both studies were published in the same issue of JAMA Surgery.

“I was surprised by the extent to which patients associated recovery with overcoming the mental strains imposed by surgery,” Dr. Julio Fiore Jr. of McGill University in Montreal, Canada, who worked on one of the studies, told Reuters Health by email. “Worries about the long-term postoperative outcomes and of ever reaching full recovery were very common.”

“These patients reported that they would consider themselves fully recovered only after overcoming the mental strains,” he said. “These mental strains should be taken into account by surgeons when talking to patients about recovery expectations. Anxiety-reduction strategies guided by qualified professionals should be considered in the pre- and post-operative settings.”

Dr. Fiore and colleagues conducted a qualitative study using semistructured interviews with patients recovering from abdominal surgery from 2016-2018 in tertiary hospitals in Canada, Italy, Brazil and Japan.

Thirty patients (mean age, 57; 50% women) were interviewed; 53% underwent laparoscopic surgery and the rest, open.

The interviews revealed that for the patients, recovery embodied five themes: returning to habits and routines; symptom resolution; overcoming mental strains; regaining independence; and enjoying life.

Traditional recovery parameters, such as earlier hospital discharge or absence of complications, were not mentioned.

Dr. Fiore Jr. said, “I believe that the development of a checklist, perhaps through an app, to guide discussions about recovery expectations may be beneficial to both patients and clinicians. This is a promising avenue for future research aimed at improving shared decision-making in surgery.”

Dr. Teviah Sachs of Boston Medical Center, coauthor of a linked editorial, told Reuters Health by email, “What is most important is that patients understand not just the risk of death from an operation – which is generally low and easier to accept – but how the operation itself, the recovery and the added effects of complications will impact their quality of life.”

“Most surgeons fail to communicate these issues effectively,” he said. “Unfortunately, patients and surgeons are understandably focused on the benefits, and less so on the risks. Adopting a framework for these discussions for surgeons, and promoting it as a metric within one’s department, is one way to embrace ACP.”

In the other study, Dr. Margaret L. Schwarze of the University of Wisconsin-Madison and colleagues found that among preoperative consultations with 213 patients (mean age, 72; 57% men), only 13 conversations had any discussion of advance care planning (ACP).

In this group of older patients with at least one comorbid condition, 141 (66%) did not have an advance directive (AD) on file before major surgery; there was no significant association between the presence of an AD and patient age, number of, or type of procedure.

Further, there was no difference in preoperative communication about ACP or AD documentation for patients who received a question prompt list and those who did not (35% vs. 33%).

“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,” the researchers report.

Dr. Schwarze told Reuters Health by email, “Several years ago, we surveyed a nationally representative sample of about 1,000 surgeons who perform major surgery and 55% of them reported they discussed AD with their patients preoperatively (https://bit.ly/3osxPdU). So, it’s very surprising that (in the current study), only 13 of 213 preoperative conversations had any mention of ADs or ACP, and only nine of those conversations were brought up by the surgeon.”

“The American College of Surgeons Geriatric Surgery Verification program is working to increase ACP preoperatively and documentation of ADs,” Dr. Schwarze noted.

Dr. Fiore’s study was sponsored by a grant from Merck Canada. Dr. Fiore and one coauthor have received funds from the company.

SOURCE: https://bit.ly/3tZBvoO, https://bit.ly/3owx2c8, https://bit.ly/2SaniYD and https://bit.ly/3fxO45g JAMA Surgery, online May 12, 2021.

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