Many surgeons refuse to operate without patient's commitment to postoperative treatment

Patients who want to limit the amount of life support they receive after surgery might have a hard time finding a surgeon willing to do the procedure, according to a new study from the University of Wisconsin School of Medicine and Public Health.

In a nationwide survey of more than 900 vascular, cardiothoracic and neurological surgeons, 60 percent said they would either sometimes or always refuse to operate on a patient who explicitly stated a desire to limit life-supporting treatments for a life-threatening postoperative complication.

A similar number (62%) said they would preoperatively create an informal contract with patients outlining agreed-upon limits of aggressive postoperative treatments. The results of the survey were published online this month in the journal Critical Care Medicine.

"We knew that surgeons generally believe that their patients "buy in" to the use of life- supporting treatments after surgery, but we were surprised that many surgeons simply refuse to do an operation without the patient's commitment to postoperative treatment," says Dr. Margaret "Gretchen" Schwarze, assistant professor of surgery at the UW School of Medicine and Public Health. "Although we don't know exactly how this process occurs, we hope that recognition of this need for "buy-in" will help surgeons and their patients do a better job of negotiating a solution that better respects the patient's values and goals for surgery."

The survey was sent to randomly selected surgeons who are members of regional vascular societies, the Society of Thoracic Surgeons and the American Association of Neurological Surgeons. Respondents were asked to choose from options for dealing with a scenario in which a patient required a high-risk, non-emergent operation, was at moderate risk for complications and had a request to limit life support after surgery.

The survey revealed that one of the reasons surgeons may be less willing to perform operations with postoperative restrictions on life support is their concern about the negative impact on public reporting of patient outcomes and physician profiling. Of the three types of surgeons surveyed, cardiothoracic surgeons have been exposed to mandatory public reporting outcomes the longest and were significantly more likely to report they would decline to operate on patients in these scenarios.

"Surgeons obviously have a strong aversion to being 'agents of death,' and they struggle with issues that link their performance to patient outcomes, particularly when their hands are tied by postoperative restrictions," says Schwarze. "Efforts to improve quality through outcomes reporting—though well-intentioned—are likely preventing some patients from having operations they desire, mainly because they have stated their preference for limiting life-supporting treatments."

Another explanation for refusing to operate on these patients is that some surgeons may believe that patients who wish to limit the use of life support don't fully grasp the risks involved with the particular surgery. Surgeons find it contradictory, Schwarze says, that patients would be willing to consent to a burdensome treatment like surgery, yet would not accept subsequent burdensome interventions.
Other survey findings include the following:

- 72 percent of surgeons said they would negotiate a time period after which life-supporting treatment could be discontinued.

- 27 percent said they would tell the patient they could not honor the patients' specific request to limit life-support.

- 20 percent said they would create a formal contract outlining limitations on life support.