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

doi:10.1097/SLA.0000000000001081

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

Medicine, Pulmonary Division

Research output: Contribution to journal › Article › peer-review

76 Scopus citations

Abstract

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 language	English (US)
Pages (from-to)	64-70
Number of pages	7
Journal	Annals of surgery
Volume	263
Issue number	1
DOIs	https://doi.org/10.1097/SLA.0000000000001081
State	Published - 2016

Funding

Dr Schwarze is supported by a training award (KL2TR000428) from the Clinical and Translational Science Award program, through the NIH National Center for Advancing Translational Sciences grant (UL1 TR000427), and the Greenwall Foundation (Greenwall Faculty Scholars Program). The project described was also supported by the National Institute for Minority Health and Health Disparities Center of Excellence program, through the UW Collaborative Center for Health Equity grant (5P60MD003428). These funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; and preparation, review, or approval of the article for publication. No other financial support was declared for the remaining authors. The authors thank Ken Croes, PhD, from the UW Survey Center for his moderation of the focus groups, Layton "Bing" Rikkers, MD, for his role as study champion, the Collaborative Center for Health Equity (ICTR CCHE), and the Community- Academic Aging Research Network (CAARN) for their help with focus group participant recruitment, the Qualitative Research Group (ICTR QRG) and Nora Jacobson, PhD, for assistance with study design and presentation of results, and Bob Arnold, MD, for his comments on an earlier version of this article. Dr Schwarze is supported by a training award (KL2TR000428) from the Clinical and Translational Science Award program, through the NIH National Center for Advancing Translational Sciences grant (UL1 TR000427), and the Green-wall Foundation (Greenwall Faculty Scholars Program). The project described was also supported by the National Institute for Minority Health and Health Disparities Center of Excellence program, through the UW Collaborative Center for Health Equity grant (5P60MD003428). These funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; and preparation, review, or approval of the article for publication. No other financial support was declared for the remaining authors.

Keywords

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

ASJC Scopus subject areas

Surgery

Access to Document

10.1097/SLA.0000000000001081

Cite this

@article{b77b6de90ab54c9b8e44f78b144ae726,

title = "Constructing high-stakes surgical decisions: It's better to die trying",

abstract = "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.",

keywords = "Communication, End-of-life, Ethics, High-risk surgery, Palliative care, Surgical decision making",

author = "Nabozny, {Michael J.} and Kruser, {Jacqueline M.} and Steffens, {Nicole M.} and Brasel, {Karen J.} and Campbell, {Toby C.} and Gaines, {Martha E.} and Schwarze, {Margaret L.}",

note = "Funding Information: Dr Schwarze is supported by a training award (KL2TR000428) from the Clinical and Translational Science Award program, through the NIH National Center for Advancing Translational Sciences grant (UL1 TR000427), and the Greenwall Foundation (Greenwall Faculty Scholars Program). The project described was also supported by the National Institute for Minority Health and Health Disparities Center of Excellence program, through the UW Collaborative Center for Health Equity grant (5P60MD003428). These funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; and preparation, review, or approval of the article for publication. No other financial support was declared for the remaining authors. The authors thank Ken Croes, PhD, from the UW Survey Center for his moderation of the focus groups, Layton {"}Bing{"} Rikkers, MD, for his role as study champion, the Collaborative Center for Health Equity (ICTR CCHE), and the Community- Academic Aging Research Network (CAARN) for their help with focus group participant recruitment, the Qualitative Research Group (ICTR QRG) and Nora Jacobson, PhD, for assistance with study design and presentation of results, and Bob Arnold, MD, for his comments on an earlier version of this article. Funding Information: Dr Schwarze is supported by a training award (KL2TR000428) from the Clinical and Translational Science Award program, through the NIH National Center for Advancing Translational Sciences grant (UL1 TR000427), and the Green-wall Foundation (Greenwall Faculty Scholars Program). The project described was also supported by the National Institute for Minority Health and Health Disparities Center of Excellence program, through the UW Collaborative Center for Health Equity grant (5P60MD003428). These funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; and preparation, review, or approval of the article for publication. No other financial support was declared for the remaining authors. Publisher Copyright: {\textcopyright} Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.",

year = "2016",

doi = "10.1097/SLA.0000000000001081",

language = "English (US)",

volume = "263",

pages = "64--70",

journal = "Annals of surgery",

issn = "0003-4932",

publisher = "Wolters Kluwer Health",

number = "1",

}

TY - JOUR

T1 - Constructing high-stakes surgical decisions

T2 - It's better to die trying

AU - Nabozny, Michael J.

AU - Kruser, Jacqueline M.

AU - Steffens, Nicole M.

AU - Brasel, Karen J.

AU - Campbell, Toby C.

AU - Gaines, Martha E.

AU - Schwarze, Margaret L.

N1 - Funding Information: Dr Schwarze is supported by a training award (KL2TR000428) from the Clinical and Translational Science Award program, through the NIH National Center for Advancing Translational Sciences grant (UL1 TR000427), and the Greenwall Foundation (Greenwall Faculty Scholars Program). The project described was also supported by the National Institute for Minority Health and Health Disparities Center of Excellence program, through the UW Collaborative Center for Health Equity grant (5P60MD003428). These funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; and preparation, review, or approval of the article for publication. No other financial support was declared for the remaining authors. The authors thank Ken Croes, PhD, from the UW Survey Center for his moderation of the focus groups, Layton "Bing" Rikkers, MD, for his role as study champion, the Collaborative Center for Health Equity (ICTR CCHE), and the Community- Academic Aging Research Network (CAARN) for their help with focus group participant recruitment, the Qualitative Research Group (ICTR QRG) and Nora Jacobson, PhD, for assistance with study design and presentation of results, and Bob Arnold, MD, for his comments on an earlier version of this article. Funding Information: Dr Schwarze is supported by a training award (KL2TR000428) from the Clinical and Translational Science Award program, through the NIH National Center for Advancing Translational Sciences grant (UL1 TR000427), and the Green-wall Foundation (Greenwall Faculty Scholars Program). The project described was also supported by the National Institute for Minority Health and Health Disparities Center of Excellence program, through the UW Collaborative Center for Health Equity grant (5P60MD003428). These funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; and preparation, review, or approval of the article for publication. No other financial support was declared for the remaining authors. Publisher Copyright: © Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

PY - 2016

Y1 - 2016

N2 - 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.

AB - 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.

KW - Communication

KW - End-of-life

KW - Ethics

KW - High-risk surgery

KW - Palliative care

KW - Surgical decision making

UR - http://www.scopus.com/inward/record.url?scp=84953835844&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84953835844&partnerID=8YFLogxK

U2 - 10.1097/SLA.0000000000001081

DO - 10.1097/SLA.0000000000001081

M3 - Article

C2 - 25563878

AN - SCOPUS:84953835844

SN - 0003-4932

VL - 263

SP - 64

EP - 70

JO - Annals of surgery

JF - Annals of surgery

IS - 1

ER -

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

Abstract

Funding

Keywords

ASJC Scopus subject areas

Access to Document

Other files and links

Fingerprint

Cite this