Department of Surgery, University of Wisconsin-Madison.
Department of Surgery, Georgetown University Hospital, Washington, DC.
JAMA Surg. 2021 Jul 1;156(7):e211521. doi: 10.1001/jamasurg.2021.1521. Epub 2021 Jul 14.
For patients facing major surgery, surgeons believe preoperative advance care planning (ACP) is valuable and routinely performed. How often preoperative ACP occurs is unknown.
To quantify the frequency of preoperative ACP discussion and documentation for older adults undergoing major surgery.
DESIGN, SETTING, AND PARTICIPANTS: 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.
Patients received a question prompt list brochure with 11 questions that they might ask their surgeon.
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.
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%]; P = .55), number of comorbidities (1, 35 [32%]; 2, 18 [33%]; ≥3, 19 [40%]; P = .62), or type of procedure (oncological, 53 [32%]; vascular, 19 [42%]; P = .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%]; P = .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.
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.
ClinicalTrials.gov Identifier: NCT02623335.
对于面临重大手术的患者，外科医生认为术前预先护理计划（ACP）是有价值的，并且通常会进行。目前尚不清楚术前 ACP 发生的频率。
量化老年患者接受重大手术后进行术前 ACP 讨论和记录的频率。
设计、地点和参与者：这是一项在美国 5 家学术医疗中心进行的多地点随机临床试验的二次分析，该试验测试了问题提示清单干预对考虑接受重大手术的老年患者术前沟通的影响。参与者包括经常进行高风险手术的外科医生和至少有 1 种合并症且有肿瘤或血管（心脏、外周或神经血管）问题的 60 岁或以上的患者。数据于 2016 年 6 月 1 日至 2018 年 11 月 30 日收集。
患者收到了一份问题提示清单小册子，其中包含 11 个他们可能会向外科医生提出的问题。
对于接受重大手术的患者，在录音术前咨询期间，外科医生、患者或家属与 ACP 相关的任何陈述都被记录下来。在最初咨询时或术前记录了医疗记录中预先存在的书面预先指示（AD）。对经历术后并发症的患者和家属进行了开放式访谈。
在对 213 名患者（122 名男性[57%]；平均[标准差]年龄，72[7]岁）的术前咨询中，只有 13 次对话讨论了 ACP。在这组患有至少 1 种合并症的老年患者中，141 名（66%）在接受重大手术前没有存档的 AD；AD 的存在与患者年龄之间没有显著关联（60-69 岁，26[31%]；70-79 岁，31[33%]；≥80 岁，15[42%]；P=0.55），与合并症数量（1，35[32%]；2，18[33%]；≥3，19[40%]；P=0.62）或手术类型（肿瘤学，53[32%]；血管，19[42%]；P=0.22）无关。对于接受邮寄问题提示清单小册子的患者，术前关于 ACP 的沟通或 AD 的记录没有差异（干预组，38[35%]；常规护理组，34[33%]；P=0.77）。有并发症的患者对 ACP 很感兴趣，但他们认为在术前与外科医生讨论维持生命治疗的偏好并不重要。
尽管外科医生认为术前讨论患者对术后维持生命治疗的偏好很重要，但这些偏好很少被探讨、解决或记录在术前。
ClinicalTrials.gov 标识符：NCT02623335。
