Frequency of Preoperative Advance Care Planning for Older Adults Undergoing High-risk Surgery

Abstract

<h3>Importance</h3> For patients facing major surgery, surgeons believe preoperative advance care planning (ACP) is valuable and routinely performed. How often preoperative ACP occurs is unknown. <h3>Objective</h3> To quantify the frequency of preoperative ACP discussion and documentation for older adults undergoing major surgery. <h3>Design, Setting, and Participants</h3> 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. <h3>Interventions</h3> Patients received a question prompt list brochure with 11 questions that they might ask their surgeon. <h3>Main Outcomes and Measures</h3> 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. <h3>Results</h3> 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%];<i>P</i>= .55), number of comorbidities (1, 35 [32%]; 2, 18 [33%]; ≥3, 19 [40%];<i>P</i>= .62), or type of procedure (oncological, 53 [32%]; vascular, 19 [42%];<i>P</i>= .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%];<i>P</i>= .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. <h3>Conclusions and Relevance</h3> 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. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT02623335