Advance care planning in the perioperative setting: a mixed methods study of anaesthetists' knowledge, attitudes and practice.

BACKGROUND

Advance care planning (ACP) allows patients to detail their wishes in case they lose capacity. Despite low mortality rates, the high volume of surgery means that thousands of people die in the weeks and months following an operation. Perioperative ACP may benefit patients at high risk of complications and death by allowing them to discuss and document their priorities.

OBJECTIVES

To assess UK anaesthetists' knowledge, attitudes and practice regarding ACP and explore perceived barriers to perioperative ACP.

DESIGN

Explanatory sequential mixed methods study, comprising a national online survey followed by qualitative interviews and observations. Data were integrated by using survey findings to shape the qualitative component, analysing both components for convergence and synthesising results into an explanatory narrative.

SETTING

The quantitative survey was distributed to anaesthetists across the UK. The qualitative component (interviews and direct observations) was conducted at a single central London teaching hospital.

PARTICIPANTS

For the survey, 534 anaesthetists were invited, with 184 (34%) responding. A minimum sample of 94 was required, determined by Cochran's formula. 14 consultant anaesthetists participated in semistructured interviews, and 40 hours of observations were conducted in preoperative assessment clinics and multidisciplinary meetings.

PRIMARY AND SECONDARY OUTCOME MEASURES

The quantitative outcome was anaesthetists' knowledge, attitudes and self-reported practice of ACP. The qualitative outcome was identification of barriers and facilitators to perioperative ACP through thematic analysis of interviews and observations.

RESULTS

Most survey respondents (92%) endorsed ACP and 54% reported having an ACP discussion at least once every 6 months. Knowledge of ACP was found to be high with eight out of 10 questions answered correctly by the majority of respondents. While 78% indicated the run-up to major surgery is an appropriate time to discuss ACP, these conversations were not routinely integrated into practice. Qualitative findings highlighted three core reasons why treatment limitations are often not enacted perioperatively: (1) relatively low perceived postoperative mortality risk; (2) reversible nature of many surgical complications; and (3) the notion that if a patient truly requires treatment limitations, surgery may be inappropriate. Additional barriers included the focus on physical optimisation in pre-assessment clinics; a lack of clarity over the anaesthetist's role in leading these discussions; and an unclear role of the anaesthetist in the surgical pathway.

CONCLUSION

This study is the first to systematically describe UK anaesthetists' ACP knowledge, attitudes and practice. Barriers include perceptions of low mortality risk, reversible complications, pre-assessment focus on physical health and cancellation avoidance, and an unclear role of the anaesthetist.