True extent of life-support buy-in revealed

Many surgeons contract informally with patients preoperatively about the use of postoperative life support, report researchers.

Recognizing this process and its limitations may help inform postoperative decision making, say Margaret Schwarze (University of Wisconsin, Madison, USA) and co-authors in Critical Care Medicine.

The authors describe a previous qualitative study, in which they examined surgeons' reluctance to withdraw postoperative life support and revealed that some surgeons and patients preoperatively form an implicit contract that necessitates the patient's participation in postoperative treatments.

Surgeons in the study noted that during this conversation, a clear understanding is reached about the potential for significant complications and the use of burdensome treatments postoperatively.

In the current study, the researchers asked 2100 surgeons the question: "Imagine that one of your patients requires nonemergency surgery and is at moderate risk for long-term postoperative ventilatory support or dialysis. If this patient had a specific request to limit life-sustaining therapy postoperatively such as ventilator support or dialysis, how often, if ever, would you decline to operate/negotiate a time period after which life support could be withdrawn/create an informal contract?"

The surgeons involved in the study were cardiothoracic, vascular, or neurosurgeons. The adjusted response rate was 56%.

Overall, 60% of respondents reported they would sometimes or always refuse to operate on a patient who preoperatively expressed a preference to limit life support postoperatively. Two-thirds (62%) of respondents also endorsed the creation of an informal contract with the patient, which described agreed upon limitations of aggressive therapy.

A small proportion of surgeons (20%) said they would formally document this contractual agreement regarding postoperative life support.

After adjusting for potentially confounding covariates, the odds for preoperatively contracting about life-supporting treatment were more than twofold greater among surgeons who felt it was acceptable to withdraw life support on postoperative day 14 than those who believed it was unacceptable, at an odds ratio of 2.1.

"Currently, a healthy skepticism about surgical buy-in as a condition to proceed with surgery is warranted," say the authors. "In the future, interventions designed to enhance preoperative communication between surgeons and patients may increase the value of these conversations in order to fully respect patients' postoperative values and goals."

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