Barriers to perioperative advanced care planning & The Future

In this step Dr Douglas Blackwood, an Anaesthesia and Perioperative Medicine Consultant, continues discussing the barriers to effective advanced care planning in the perioperative period and reflects on the future

Barriers to Perioperative Advance Care Planning

Despite twenty years of interest, perioperative ACP remains uncommon [1]. It has been hypothesised that there is inherent resistance to ACP within surgical culture. Doctors from surgical specialties have been shown to feel less positively towards advance directives than those from Emergency Medicine, Paediatrics, Obstetrics & Gynaecology, and Anaesthesia [2]. The temperament of a surgeon has been described as one requiring optimism and confidence [3]. Ethnographic research has found that surgeons have a different view of their relationship to patients than other doctors [4],[5],[6],[7]. Surgeons define their relationship with their patient as a promise to ‘battle death’ on their behalf [3],[4] and that this commitment is part of their identity as a surgeon [4]. Death is seen very much as a ‘failure’, often a personal failure to the patient, and therefore something that must be avoided at all cost [5]. Surgeons’ express feelings of ‘ownership’ and ‘personal responsibility’ to their patients [3],[7] and also culpability when the operation is not successful [5]. The has led to the description of ‘surgical buy-in’: a complex process by which surgeons negotiate with patients a commitment to, often burdensome, post-operative care before agreeing to undertake high-risk surgical procedures [5].

When explicitly asked about perioperative ACP some surgeons view it as contradictory to the goals and values of surgery [5]. They feel it would be a conflict of interest if a surgeon has to both advocate for aggressive surgical care and concurrently counsel the patient regarding end-of-life decisions [6]. These attitudes, whilst almost certainly not universal, are ingrained enough to be recurrent themes of qualitative research [4],[5],[6] and are supported by survey findings [1],[2],[5]. In their defence, it is a fair assumption that patients may not choose to be operated on by a pessimistic surgeon, unsure in their abilities, who did not view their death following the operation as a failure [3]. Surgeons, by assuming personal responsibility for the outcome of the operation and by conveying an expectation of success [7], likely bring comfort to their patients pre-operatively.

Shaping The Future

There is a promising opportunity ahead. In 2015 the Royal College of Anaesthetists (RCoA) launched its vision document ‘Perioperative Medicine: The pathway to better surgery’ [8]. This has been driven by an understanding of the different needs of the high-risk surgical patient and an appreciation that their number will continue to grow.

Central to this vision is the role of shared decision making prior to surgery allowing both patient and doctor to make fully informed decisions and plan future care. Currently around 80% of those undergoing planned operations are being seen at an anaesthetic pre-operative assessment clinic but often these occur only weeks or days before surgery [9]. A re-designed surgical pathway has been proposed with earlier engagement with patients, ideally, as soon as possible after the moment of contemplation of surgery [10]. High-risk patients could then be identified and siphoned to a specialised ‘high- risk clinic’ where perioperative physicians can explore beliefs, preferences, and options in a collaborative manner.

The nature of conversations around ACP in perioperative care are likely to differ from those in other medical specialties. We’ve discussed cultural barriers that may hinder the implementation of perioperative ACP, but beyond these, integrating ACP into perioperative care necessitates a tailored redesign specifically for the surgical setting. We have seen how current guidelines from the Association of Anaesthetists (AAGBI)[11] and the Faculty of Intensive Care Medicine (FICM) indicate that, in almost all instances, treatment limitations need to be either suspended or modified to facilitate surgery. This is a crucially important point as traditional ACP is often associated with treatment limitations, and this will almost always be inappropriate in the surgical context.

Perhaps these conversations could be integrated into existing shared decision-making discussions about proceeding with surgery. Topics like the patient’s acceptable quality of life and the involvement of family and friends are already important in these dialogues. More precise documentation of these aspects would offer valuable insights for health professionals when making ‘best interest’ decisions if the patient subsequently loses capacity. Specifically centring on a minimally acceptable quality of life as the primary outcome, rather than on limitations of treatment, would provide the necessary flexibility for healthcare professionals to make appropriate decisions at different points in the perioperative journey.

References

1. Redmann AJ, Brasel KJ, Alexander CG, Schwarze ML. Use of Advance Directives for High-Risk Operations. Ann Surg. 2012 Mar;255(3):418–23.
2. Periyakoil VS, Neri E, Fong A, Kraemer H. Do Unto Others: Doctors’ Personal End-of-Life Resuscitation Preferences and Their Attitudes toward Advance Directives. PLoS One. 2014 May 28;9(5):e98246.
3. Buchman TG, Cassell J, Ray SE, Wax ML. Who should manage the dying patient?: Rescue, shame, and the surgical ICU dilemma. J Am Coll Surg. 2002 May;194(5):665–73.
4. Cassell J, Buchman TG, Streat S, Stewart RM. Surgeons, intensivists, and the covenant of care: Administrative models and values affecting care at the end of life—Updated. Crit Care Med. 2003 May;31(5):1551–9.
5. Schwarze ML, Redmann AJ, Brasel KJ, Alexander GC. The Role of Surgeon Error in Withdrawal of Postoperative Life Support. Ann Surg. 2012 Jul;256(1):10–5.
6. Bradley CT, Brasel KJ, Schwarze ML. Physician attitudes regarding advance directives for high-risk surgical patients: A qualitative analysis. Surgery. 2010 Aug;148(2):209–16.
7. Pecanac KE, Kehler JM, Brasel KJ, Cooper Z, Steffens NM, McKneally MF. It’s Big Surgery. Ann Surg. 2014 Mar;259(3):458–63.
8. The Royal College of Anaesthetists. Perioperative medicine: The pathway to better surgical care. London; 2015.
9. National Confidential Enquiry into Patient Outcome and Death. Knowing the Risk [Internet]. London; 2013 p. 1–98. Available from: https://www.ncepod.org.uk/2011report2/downloads/POC_fullreport.pdf
10. Grocott MPW, Plumb JOM, Edwards M, Fecher-Jones I, Levett DZH. Re-designing the pathway to surgery: better care and added value. Perioper Med. 2017 Dec;6(1):9.
11. Implementing advance care plans in the perioperative period