INFORMED DECISION-MAKING AND UNCERTAINTY IN PATIENT-SURGEON COMMUNICATION ABOUT HIGH-RISK SURGERY

Purpose: To evaluate the quality of informed decision-making (IDM) and the degree uncertainty is acknowledged in patient-surgeon decisions about high-risk surgery.

Methods: This prospective, multi-institutional study evaluated 90 preoperative patient-surgeon discussions prior to high-risk cardiothoracic, vascular, oncologic, and neurosurgical operations in the U.S. and Canada.  Consultations were audiotaped, transcribed verbatim, and coded using Braddock's model of 9 IDM elements (see Table).  An interdisciplinary team of 5 researchers scored the transcripts (inter-rater reliability, κ=0.89). 

Results: Surgeons commonly discussed the risks and benefits of surgery (92%), nature of the decision (60%), and alternatives (46%).  Risk communication was most often numeric and narrative (33%) or numeric only (33%) and included mortality in 58%.  Surgeons uncommonly assessed patients' desire for others' input (1%), preferences (12%), or the impact of surgery on daily life (14%).  The Table lists the extent to which surgeons partially or fully discussed each IDM element.  Only 26% of discussions met Braddock's minimum criteria for IDM, which requires reviewing the patient's role or preference and the nature of the decision.  Uncertainty about the decision to have high-risk surgery or alternative treatment was fully discussed in 19% of consultations and partially discussed in 10%.  Surgeons also conveyed uncertainty about the underlying disease (33%), post-surgical outcomes (24%), and other aspects of care (28%).  If only one treatment option was offered, IDM was less extensive (mean IDM elements discussed: 7.0±3.2 vs. 5.3 ±2.9, p=0.01), and the greatest decrease was in uncertainty (49% vs. 15%, p<0.001).

   Assessment of decision-making demonstrated that patients and surgeons frequently made the decision together (68%).  Surgeons were much more likely to make recommendations (54%) than solicit patient's preferences (12%), though 20% of patients or their families offered treatment preferences without solicitation.  In 9% of consultations, patients were the primary decision maker; and IDM was more extensive than when surgeons were the dominant decision maker (7.0±3.7 vs. 4.6±2.0, p=0.06).  Without surgeon prompt, 30% of patients and/or families initiated discussion of an IDM element, and 26% asked unsolicited questions about an IDM element. 

Conclusions: In patient-surgeon decisions about high-risk surgery, IDM quality is highest in areas that overlap with informed consent—risks, benefits, and alternatives.  However, the extent to which patients' preferences, role, and uncertainty are incorporated in the decision-making process appears to need improvement.