Abstract
Advances in anaesthetic techniques, surgical procedures and teamwork have made more and more surgical procedures possible. It is now much less common for a patient to ‘die on the table’. Instead, the morbidity and mortality of high-risk surgery is often delayed, leading to some patients spending significant amounts of time in an intensive care unit (ICU) or hospital ward before their final outcome is known.
Preoperative optimisation and planning may increase the likelihood of a desirable outcome for the patient. Objective risk assessment tools (such as NSQIP, 1 SORT, 2 frailty assessments or P-POSSUM 3 ) help frame discussions about the risks of surgery.4,5 Nonetheless, there remain many grey areas in decision-making for high-risk patients. In this issue of Anaesthesia and Intensive Care, Lee and Ashby provide a framework to set goals of care in the perioperative setting. 6 Within this, they discuss many misconceptions around performing surgery and concurrently setting limitations of treatments.
For example, for an elderly patient with end-stage lung disease, who requires palliative cancer surgery for symptom control, a multitude of scenarios need to be considered. If the surgeon and the patient decide to ‘accept the risks of surgery’, what does that actually mean? What should happen if the patient deteriorates on the table? What should happen if the patient deteriorates postoperatively?
What about that same patient who has an emergency presentation for bowel perforation? Whilst they may be unlikely to be admitted to an ICU for a deterioration of their underlying lung disease, what factors should be considered in deciding whether they should undergo an emergency laparotomy?
In answering these complex questions, we would suggest that there are some generic components to this process beyond those suggested by Lee and Ashby. The first essential component is timely involvement of key perioperative clinicians. This can be more challenging for the emergency case than for the high-risk elective case but, as a principle, should include those who are best able to explain the burdens of treatments and likely outcomes (i.e. surgeons, perioperative medicine specialists, intensivists or rehabilitation or palliative care physicians). 7 It is helpful for the team to be clear about the goals of care so that appropriate surgical and non-surgical options can be considered in an unbiased way, pooling multiple perspectives.
The next component is the need for a structured decision-making process. This includes explicitly identifying plausible complications, given the proposed technical challenges of surgery and the patient’s comorbidities and frailty status. The team then needs to identify the burdens of therapy these would require and their likely short- and long-term impacts on the patient’s life. Impacts may range from pain and prolonged hospital stay to any disability that might impact discharge disposition or need for ongoing care. A practical way of doing this is to formulate a what-if management plan between the team and the patient and their family. This involves asking ‘What if this happens?’ for each plausible potential complication, discussing the medical likelihood of reversing that complication and what that might mean in terms of the patient’s values and preferences. These plausible complications may range from the oft-discussed cardiac arrest requiring cardiopulmonary resuscitation (CPR) to varying degrees of single- or multi-organ failure. Treatments such as mechanical ventilation, return to theatre, renal replacement therapy, and provision of CPR may be withheld or recommended in the postoperative setting after due consideration.
The other key component involves a need for reflection on the part of the clinicians involved, as emphasised recently by Carlisle. 8 We are all subject to significant outcome bias in evaluating our decision-making, whereas we should really evaluate the decision-making process itself. For example, if no pre-procedure ‘goals of care’ discussion is carried out, and the patient does well, then we might congratulate ourselves. Conversely, if all the appropriate discussions and plans have been discussed, but the patient has a (potentially expected) adverse outcome, then we might believe that it didn’t go well. However, an appropriate reflection would be that in the first situation, there was inadequate preparation, while in the second, despite the adverse outcome, all appropriate preparatory steps had been taken. We should also steel ourselves against commission bias – the tendency towards action, even in the situation where not performing an action leads to an identical or better outcome. 9
Whilst the Lee and Ashby study is another important step in untangling the complexity around perioperative goals of care, more detailed decision trees are needed, as are more systemic interventions to cater for the growing need for this kind of decision-making. The intercollegiate effort to develop a diploma in perioperative medicine will drive a common knowledge and skill base for specialists involved with these decisions. 10 The increasing use of patient-related outcome measures and data linkage between registries may provide population-level outcomes that can inform bedside discussions with patients. Lastly, there is a need for hospitals to fund multidisciplinary team meetings properly for high-risk patients being considered for surgery so that patient values and preferences can be better aligned with treatment options through structured decision-making processes that minimise bias.
