The Operating Theatre Journal - Journal - Page 20
How to share decision-making about major surgery for
people at high risk of complications
In shared decision-making, clinicians discuss treatment and management
options, patients explain their goals, and together they agree on the
best course of action. Shared decision-making is encouraged in UK
guidance. But little is known about how far people at high risk of poor
outcomes after major surgery (older people, or those with multiple
long-term conditions, for example) are involved in decisions.
Researchers observed surgical consultations between patients and
their families, and clinicians, and asked people to re昀氀ect on their
experience. They identi昀椀ed 3 different types of consultation with
different opportunities for shared decision-making. These broadly
asked:
1. Must we act soon? These consultations typically led to consent (or
not) for life-saving surgery.
2. Do we need to act? The bene昀椀ts and risks of surgery were evaluated
for people with long-standing problems, and next steps agreed.
3. How should we act? Surgical and non-surgical options, often for
people with multiple other conditions and frailty, were agreed
jointly.
When life-saving surgery was needed, opportunities for shared decisionmaking were limited. Shared decision-making was more likely in the
other types of consultation.
The authors call for clinicians to take individualised approaches to
shared decision-making for people in different circumstances. Even
those with life-threatening conditions, who appreciate surgeons taking
charge, may want more involvement in the decision to have surgery.
This Alert is intended for surgeons, but will also be of interest to people
about to undergo surgery, and their families.
For more information about shared decision-making, visit the NHS
website.
The issue: is decision-making before major
surgery shared?
NHS England states that shared decision-making is a collaborative
process in which clinicians support individuals to make decisions
about their treatment that are right for them. The conversation brings
together:
• the clinician’s expertise on treatment options, evidence, risks and
bene昀椀ts
• the patients’ preference, personal circumstances and support
networks, goals, values and beliefs.
Little is known about shared decision-making when people at high
risk of complications are offered major surgery (for instance heart,
colorectal or orthopaedic surgery). In this group of people, 1 in 3 will
develop serious medical complications after surgery, and many never
recover. They can be left with reduced quality of life and a shorter life
expectancy than if they had not had surgery. Some regret the surgery.
It can be dif昀椀cult for both clinicians and patients to balance the risk of
complications with the consequences of not addressing the problem.
Shared decision-making helps patients realise they have a choice
about surgery, and can prepare them for a slow recovery or weakness
afterwards.
Researchers explored shared decision-making ahead of major heart,
orthopaedic (involving bones, joints or muscles) and colorectal (bowel)
surgery.
What’s new?
The study took place in 5 UK hospitals. It included 50 patients (with
multiple long-term conditions or frailty) and carers, and 36 clinicians.
Patients were aged 60 years and older.
20
Researchers video recorded consultations about major surgery and
interviewed patients/carers and surgeons afterwards, and again 3 –
6 months later. They held focus groups with other patients, carers,
surgeons, and anaesthetists, to explore past experiences of shared
decision-making before major surgery.
All consultations that the researchers observed included discussion
about the nature of the problem, the cause and likely outcome, and
how it was affecting the patient. Surgeons described the procedure and
what would happen afterwards.
The extent of shared decision-making was then in昀氀uenced by the
nature of the problem, the usual course of action (clinical pathway) and
previous disease and interventions (patient trajectory). The researchers
identi昀椀ed 3 broad types of consultation, each with a different emphasis
on shared decision-making.
1. Must we act soon? In consultations for people with potentially
life-threatening conditions (for instance heart problems) surgeons
explained the problem, the surgery, and its risks. Decision-making was
often limited to the decision to undergo surgery, and consent. Someone
considering heart surgery said: ‘really I’ve got no choice… I want a
better quality of life… although I don’t like it… I’ve got a problem…
get it 昀椀xed’.
2. Do we need to act? These consultations were often for people
with long-term conditions that were not life-threatening (arthritis, for
instance) when other approaches (such as physiotherapy) had failed.
Consultations evaluated the severity of all conditions, and the risks and
bene昀椀ts of surgery. An orthopaedic surgeon said: ‘It’s… not life-saving.
It’s meant to improve things… but… it could make things worse’.
3. How should we act? People with multiple conditions (bowel cancer
and diabetes, for example) and frailty had open-ended discussions about
quality of life, life expectancy and other health problems. Surgeons
explored multiple options, including surgery and palliation (treatment
to make someone more comfortable rather than curing their condition).
During a consultation, an anaesthetist said: ‘If we chose nothing [we’d]…
have a chat with the palliative care doctors and see if we manage that
just as comfortably as we can for you… but it’s not going to treat it…’
A collaborative discussion led to joint agreement about the next steps
between the patient, family and clinician.
In focus groups, anaesthetists and colorectal surgeons stressed the
value of deliberation for this group of people. But they highlighted
challenges, particularly the time needed to explore options.
Why is this important?
The nature of the problem combined with patients’ circumstances
prompted surgeons to take different approaches to shared decisionmaking.
For those with life-threatening conditions, shared decision-making
was not always desirable or possible. People saw the surgeon’s role as
昀椀xing the problem and, regardless of whether they had surgery, they
tended to accept the decision made. The authors urge surgeons, even
in these circumstances, not to focus on the ‘昀椀x’ in ways that close down
discussions, but instead to open up opportunities for patients to re昀氀ect
on the options and their implications.
Shared decision-making was more common in the other types of
consultation. Options, consequences and preferences were discussed.
The 昀椀ndings are directly applicable to cardiac, colorectal and
orthopaedic surgery. Further work is needed to con昀椀rm their relevance
for other disciplines.
For surgeons…
Have I taken all aspects of my patient’s health, and their goals and
preferences, into account?
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