Limitation powers

Nearly half of U.S. surgeons who routinely perform high-risk operations do not regularly ask patients about their advance directives – also known as living wills – before proceeding with a high-risk procedure, results of a survey indicate. Perhaps more importantly, more than half of survey respondents said they would not operate if they were aware of a restrictive directive.

The findings, published online and in Annals of Surgery, were derived from a survey mailed to 2,100 randomly selected vascular, neurological, and cardiothoracic surgeons in 2010. Of these, 912 eligible responses were entered into analysis, with the three types of surgeons responding at about the same rate: 56% for vascular surgeons and neurosurgeons and 54% for cardiothoracic surgeons (Ann. Surg. 2012;255:418-23).

A majority of respondents (81%) however, reported having conversations about patients’ preferences for limiting the use of life-sustaining procedures postoperatively. The surgeons said they tend to view factors such as a patient’s predicted postoperative quality of life, age, comorbidities, and mental readiness as vastly more important in determining whether to operate than the existence of an advance directive, which 48% said they do not routinely confirm, according to the study’s authors, led by Dr. Margaret L. Schwarze of the University of Wisconsin, Madison.

Because most information about advance directives and the surgical decision-making process thus far has been anecdotal, she and her colleagues investigated how conversations about formal directives actually proceed in a surgical setting and their role in decision making.

A total of 54% of all surgeons who responded said that they would not operate if they knew a patient had an advance directive that might limit the postoperative options.

Among cardiothoracic surgeons, who routinely rely on ventilator support as part of postoperative care, 63% said they would not operate with prior knowledge of a restrictive advance directive. Multivariate analysis showed that cardiac surgeons were almost twice as likely to operate compared with their neurosurgeon counterparts (odds ratio, 1.96) and somewhat more likely than were vascular surgeons (OR, 1.35).

Younger surgeons – those with 20 or less years of experience – were less likely to discuss advance directives regularly (44%) than were those with more than 20 years of experience (69%).

Several of the survey results strongly suggest that surgeons view advance directives as "an impediment to the goals of surgical therapy" and that they interpret them as "a signal that patients with advance directives are not truly committed to the operation and the invasive postoperative therapy the operation necessarily entails," wrote the investigators. Furthermore, surgeons "often find it difficult to shift goals when surgery does not go as planned – the result of a surgical ethos which discourages moving from a curative model to a palliative mode of care."

Dr. Schwarze and her colleagues noted that their findings raise the question of whether it is ethical for surgeons to deny a patient a procedure because of a restrictive advance directive. While it may be reasonable for surgeons to want every postoperative resource available to them, they said, advance directives nonetheless protect patient autonomy in the event of a devastating complication.

However, directives are not generally designed with high-risk surgical procedures in mind, they may be vague, and they potentially can create confusion in a postoperative context. Thus, the investigators concluded that communication prior to surgery is urgently needed to "clarify patient preferences with respect to the surgical endeavor and the patient’s advance directive," and that such communication should be documented.

The investigators noted that, as with all surveys, the potential for nonresponse bias was a limitation of their study. More importantly, they stated that it was difficult to know whether the results were generalizable to other surgical subspecialties that performed high-risk surgery.

Dr. Schwarze’s research was funded under a grant from the department of surgery at the University of Wisconsin. Mr. Andrew J. Redman was supported by a grant from the University of Wisconsin, and Dr. Caleb G. Alexander received funding from the Agency for Healthcare Research and Quality

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