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Patient-Centered Surgical Decision Making

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Principles and Practice of Geriatric Surgery

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Abstract

Populations are aging, and older adults have an increasing need for high-quality surgical care. There are inherent complexities in caring for this group with altered risk and benefit profiles as well as different patient values and goals. Given higher rates of multimorbidity, frailty, and poorer overall prognosis, older patients are at greater risk of nonbeneficial or unwanted care. Surgical interventions can have unintended consequences and unwanted burdens including loss of function, reduced quality of life, multiple transitions of care, and postoperative suffering.

In this setting, standard informed consent is not enough. Decisions need to be made in the face of uncertainty with preference-sensitive choices and a need to avoid making assumptions about patients’ goals. A patient-centered approach using shared decision making integrates patient preferences, values, and goals with their underlying health status to allow patients and their surgeon to make decisions together about treatment strategies. Many barriers exist to patient-centered decision making including system factors, patient and family factors, and standard communication practices including a focus on risk disclosure.

In this chapter, we provide an approach to patient-centered decision making in geriatric surgery. This includes setting the stage to contextualize the surgical diagnosis within the patient’s overall prognosis. This requires acknowledging and addressing the uncertainty inherent in prognostic information and in the decisions that need to be made. Surgeons then identify at least two treatment alternatives and emphasize that a choice must be made together. These options may include surgery and no surgery options, medical options, or potentially time-limited trials. A multidisciplinary approach to developing and carrying out treatment options is certainly of great benefit. Information about the different treatment options and potential outcome states should be conveyed narratively to allow visualization of what the experience of various outcomes would be and what the trade-offs are rather than focusing on isolated risk disclosure. Patient’s values and preferences must be elicited with care to focus on what is possible and acceptable rather than what is wished for in unrealistic terms. Finally, a surgeon must integrate all of this information to make a treatment recommendation and should demonstrate why the recommendation is being made and that this supports the patient’s goals. Indeed, a patient-centered approach to decision making in geriatric surgery is paramount to high-quality care in this complex patient population.

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Author information

Authors and Affiliations

  1. Department of Surgery, University of Toronto, Toronto, ON, Canada

    Tyler R. Chesney

  2. Department of Surgery, University of Wisconsin–Madison, Madison, WI, USA

    Margaret L. Schwarze

  3. Department of Medical History and Bioethics, University of Wisconsin–Madison, Madison, WI, USA

    Margaret L. Schwarze

Authors
  1. Tyler R. Chesney
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  2. Margaret L. Schwarze
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Corresponding author

Correspondence to Margaret L. Schwarze .

Editor information

Editors and Affiliations

  1. Surgical Service, Yale University School of Medicine VA Connecticut Health Care System, West Haven, Connecticut, USA

    Ronnie A. Rosenthal

  2. SUNY Downstate School of Public Health, National Capital Region Johns Hopkins Medicine, Bethesda, Maryland, USA

    Michael E. Zenilman

  3. Center for Geriatric Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland, USA

    Mark R. Katlic

Section Editor information

  1. School of Medicine, Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA

    Marcia McGory Russell

  2. Ariadne Labs, Boston, MA, USA

    Zara Cooper

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Chesney, T.R., Schwarze, M.L. (2017). Patient-Centered Surgical Decision Making. In: Rosenthal, R., Zenilman, M., Katlic, M. (eds) Principles and Practice of Geriatric Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-20317-1_6-1

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  • DOI: https://doi.org/10.1007/978-3-319-20317-1_6-1

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-20317-1

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