老年人的高风险手术：并非真正的共同决策。
High-risk surgery among older adults: Not-quite shared decision-making.
机构信息
Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI.
Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI.
出版信息
Surgery. 2021 Sep;170(3):756-763. doi: 10.1016/j.surg.2021.02.005. Epub 2021 Mar 10.
BACKGROUND
Shared decision-making is critical to optimal patient-centered care. For elective operations, when there is sufficient time for deliberate discussion, little is known about how surgeons navigate decision-making and how surgeons align care with patient preferences. In this context, we sought to explore surgeons' approaches to decision-making for adults ≥65 years at high-risk of postoperative complications or death.
METHODS
We conducted semistructured in-depth interviews with 46 practicing surgeons across Michigan. Transcripts were iteratively analyzed through steps informed by inductive thematic analysis.
RESULTS
Four major themes emerged characterizing how surgeons approach high-risk surgical decision-making for older adults: (1) risk assessment was defined as the process used by surgeons to identify and analyze factors that may negatively impact outcome; (2) expectations and goals described the process of surgeons engaging with patients and families to discuss potential outcomes and desired objectives; (3) external and internal motivating factors outlined extrinsic dynamics (eg, quality metrics, referrals) and intrinsic drivers (eg, surgeons' personal experiences) that influenced high-risk decision-making; and (4) decision-making approaches and challenges encompassed the roles of patients and surgeons and obstacles to engaging in a true shared decision-making process.
CONCLUSION
Although shared decision-making is strongly recommended, we found that surgeons who perform high-risk operations among older adults predominantly focused on assessing risk and setting expectations with patients and families rather than inviting them to actively participate in the decision-making process. Surgeons also reported influences on decision-making from quality metrics, referrals, and personal experiences. Patient involvement, however, was seldom discussed suggesting that surgeons may not be engaging in true shared decision-making when benefits should be weighed against a high likelihood of harm.
背景
共同决策对于以患者为中心的最佳护理至关重要。对于择期手术，当有足够的时间进行深思熟虑的讨论时，对于外科医生如何进行决策以及如何使护理与患者的偏好保持一致，知之甚少。在这种情况下，我们试图探讨外科医生对高风险术后并发症或死亡的 65 岁以上成年人手术决策的方法。
方法
我们对密歇根州的 46 名执业外科医生进行了半结构化深入访谈。通过归纳主题分析步骤对转录本进行了反复分析。
结果
有四个主要主题出现，描述了外科医生如何处理老年高危手术决策：（1）风险评估被定义为外科医生用于识别和分析可能对结果产生负面影响的因素的过程；（2）期望和目标描述了外科医生与患者及其家属进行沟通的过程，讨论潜在的结果和期望的目标；（3）外部和内部激励因素概述了影响高风险决策的外在动力（例如，质量指标，转介）和内在驱动力（例如，外科医生的个人经验）；（4）决策方法和挑战包括患者和外科医生的角色以及参与真正共同决策过程的障碍。
结论
尽管强烈建议进行共同决策，但我们发现，在老年高危手术中进行手术的外科医生主要侧重于评估风险和与患者及其家属设定期望，而不是邀请他们积极参与决策过程。外科医生还报告了质量指标，转介和个人经验对决策的影响。但是，很少讨论患者的参与情况，这表明当需要权衡利弊时，外科医生可能没有进行真正的共同决策，因为患者可能面临很高的风险。
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