Frequency of Preoperative Advance Care Planning for Older Adults Undergoing High-risk Surgery: A Secondary Analysis of a Randomized Clinical Trial

Abstract

Importance: For patients facing major surgery, surgeons believe preoperative advance care planning (ACP) is valuable and routinely performed. How often preoperative ACP occurs is unknown.

Objective: To quantify the frequency of preoperative ACP discussion and documentation for older adults undergoing major surgery.

Design, setting, and participants: This secondary analysis of data from a multisite randomized clinical trial testing the effects of a question prompt list intervention on preoperative communication for older adults considering major surgery was performed at 5 US academic medical centers. Participants included surgeons who routinely perform high-risk surgery and patients 60 years or older with at least 1 comorbidity and an oncological or vascular (cardiac, peripheral, or neurovascular) problem. Data were collected from June 1, 2016, to November 30, 2018.

Interventions: Patients received a question prompt list brochure with 11 questions that they might ask their surgeon.

Main outcomes and measures: For patients who had major surgery, any statement related to ACP from the surgeon, patient, or family member during the audiorecorded preoperative consultation was counted. The presence of a written advance directive (AD) in the medical record at the time of the initial consultation or added preoperatively was recorded. Open-ended interviews with patients who experienced postoperative complications and family members were conducted.

Results: Among preoperative consultations with 213 patients (122 men [57%]; mean [SD] age, 72 [7] years), only 13 conversations had any discussion of ACP. In this cohort of older patients with at least 1 comorbid condition, 141 (66%) did not have an AD on file before major surgery; there was no significant association between the presence of an AD and patient age (60-69 years, 26 [31%]; 70-79 years, 31 [33%]; ≥80 years, 15 [42%]; P = .55), number of comorbidities (1, 35 [32%]; 2, 18 [33%]; ≥3, 19 [40%]; P = .62), or type of procedure (oncological, 53 [32%]; vascular, 19 [42%]; P = .22). There was no difference in preoperative communication about ACP or documentation of an AD for patients who were mailed a question prompt list brochure (intervention, 38 [35%]; usual care, 34 [33%]; P = .77). 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.

Conclusions and relevance: Although surgeons believe that preoperative discussion of patient preferences for postoperative life-sustaining treatments is important, these preferences are infrequently explored, addressed, or documented preoperatively.

Trial registration: ClinicalTrials.gov Identifier: NCT02623335.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Brasel reported receiving grants from the Agency for Healthcare Research and Quality during the conduct of the study. Dr Finlayson reported receiving grants from the National Institute on Aging and the National Cancer Institute during the conduct of the study and founding Ooney, Inc (from which she does not receive any money), outside the submitted work. Dr Schwarze reported receiving grants from the National Institutes of Health (NIH) and Greenwall Foundation to address clinician-patient communication outside the submitted work and ownership interest by spouse in MezLight LLC, a light for the operating room. No other disclosures were reported.

Figures

Figure.. Cohort Study Design