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Use of Advance Directives for High-Risk Operations: A National Survey of Surgeons

Objective:To characterize surgeons' beliefs and approach to the use of an advance directive in the decision to perform high-risk operations. Background:Prior work suggests many surgeons regard advance directives as antithetical to the goals of surgical therapy, yet little is known about surgeons' approach to high-risk operations for patients with directives limiting postoperative care. Methods:We sent a self-administered survey by US mail to 2100 randomly selected vascular, neurologic, and cardiothoracic surgeons. We used stepwise logistic regression to determine the relationship between explanatory variables and: (1) how often surgeons discuss advance directives preoperatively, and (2) how advance directives limiting postoperative life-supporting therapy influence the decision to operate. Results:The adjusted response rate was 55%. All surgeons reported discussing the potential for unanticipated outcomes and nearly all (95%) discussed the need for postoperative life-supporting therapy. More than four-fifths (81%) reported discussing patient preferences to limit postoperative life-supporting therapy during informed consent. Approximately one half of respondents (52%) either sometimes or always discuss advance directives before surgery, with younger physicians less likely to do so than more experienced surgeons (odds ratio [OR] = 0.46, 95% confidence intervals [CI] = 0.06−0.85). More than one half (54%) of surgeons reported they would decline to operate on patients who have an advance directive limiting postoperative life-supporting therapy. Conclusions:Many surgeons do not routinely discuss advanced directives preoperatively and more than one half reported they would decline to operate on patients whose directives limit postoperative care. This practice may limit the expression of patient preferences during decision making for high-risk operations.