Constructing high-stakes surgical decisions: It's better to die trying

Michael J. Nabozny, Jacqueline M. Kruser, Nicole M. Steffens, Karen J. Brasel, Toby C. Campbell, Martha E. Gaines, Margaret L. Schwarze*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

72 Scopus citations


Objective: To explore high-stakes surgical decision making from the perspective of seniors and surgeons. Background: A majority of older chronically ill patients would decline a low-risk procedure if the outcome was severe functional impairment. However, 25% of Medicare beneficiaries have surgery in their last 3 months of life, which may be inconsistent with their preferences. How patients make decisions to have surgery may contribute to this problem of unwanted care. Methods: We convened 4 focus groups at senior centers and 2 groups of surgeons in Madison and Milwaukee, Wisconsin, where we showed a video about a decision regarding a choice between surgery and palliative care. We used qualitative content analysis to identify themes about communication and explanatory models for end-of-life treatment decisions. Results: Seniors (n=37) and surgeons (n=17) agreed that maximizing quality of life should guide treatment decisions for older patients. However, when faced with an acute choice between surgery and palliative care, seniors viewed this either as a choice between life and death or a decision about how to die. Although surgeons agreed that very frail patients should not have surgery, they held conflicting views about presenting treatment options. Conclusions: Seniors and surgeons highly value quality of life, but this notion is difficult to incorporate in acute surgical decisions. Some seniors use these values to consider a choice between surgery and palliative care, whereas others view this as a simple choice between life and death. Surgeons acknowledge challenges framing decisions and describe a clinical momentum that promotes surgical intervention.

Original languageEnglish (US)
Pages (from-to)64-70
Number of pages7
JournalAnnals of surgery
Issue number1
StatePublished - 2016


  • Communication
  • End-of-life
  • Ethics
  • High-risk surgery
  • Palliative care
  • Surgical decision making

ASJC Scopus subject areas

  • Surgery


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