Authors: Richard D. Urman, M.D., M.B.A., CPE, FASA et al
ASA Monitor 10 2017, Vol.81, 16-17.
Recently, the Centers for Medicare & Medicaid Services (CMS) finalized a proposal to reimburse providers for end-of-life counseling as part of advanced care planning. This was in response to a push to further engage patients, families and surrogates in their medical care decisions and improve overall access to these important services. Hopefully, this will encourage more perioperative providers to have difficult conversations with some of the most medically complex surgical patients undergoing high-risk procedures. Anesthesiologists, as perioperative care physicians, have an important role in shaping the future of surgical shared decision-making (SDM) – that is, helping patients reach an optimal decision about their care that takes into consideration the latest research, available options and the patient’s own values and preferences. Better incorporation of patient preferences should lead to improved patient experience, greater levels of engagement and less decisional conflict. In fact, a high-quality decision related to the appropriateness of care takes into consideration the best clinical evidence, qualified providers, an appropriate place to perform the procedure and a well-informed patient.
While clarifying code status and goals of care are essential components of anesthesia care and quality improvement, studies have found these discussions to be often insufficient.1 One study at our institution showed that nearly 5 percent of patients seen in a preoperative clinic at a tertiary care hospital died within one year of their procedure, yet almost half of those who died did not have an advance directive by the date of surgery.2 Another study using our institutional data found that a significant number of preoperative patients showed deficits in their preoperative decision-making process.3 Specifically, we identified critical deficits such as patients unable to identify their diagnosis (8 percent) or procedure (10 percent), not knowing the risks and benefits of each treatment option (7 percent) or best choice for them (5 percent), not clear on which risks and benefits matter most to them (6 percent), and lack of support and advice to make a choice (3 percent). Deficits in advanced care planning (ACP) included not having a living will (39 percent) or a health care proxy form (54 percent) on file, not having discussed end-of-life wishes with anyone (26 percent) and wanting to talk more about ACP (29 percent).
Recently, both ASA and the American College of Surgeons reissued statements on ethical management of DNR orders, advocating discussion, documentation, and clarification of postoperative care based on a patient’s goals and values. This should also be reflected in additional training for anesthesia trainees and creation of effective educational resources.4 Currently, we are conducting a prospective, randomized, controlled study funded by the Foundation for Anesthesia Education and Research (FAER) to create a model curriculum for anesthesia residents in SDM using a simulated patient encounter. We hope that once completed, our study will demonstrate the effectiveness of a novel educational intervention.
One challenge is judging when SDM has successfully occurred. There is a need to develop a set of reliable metrics and decision outcomes that actually measure the adequacy of the SDM process. These have a potential to become recognized quality outcomes once the metrics have been tested for validity, reliability and generalizability. In fact, decision quality is an important indicator of patient-centered care and an outcome relevant for surgical decision-making. Anesthesi-ologists can also play a role in identifying risk factors for poor decision-making, such as lower socioeconomic status, limited literacy levels, personal or family values, and high frailty scores or cognitive deficits. This offers anesthesiologists a unique opportunity to participate in the appropriateness of care decisions in the era of value-based care.5 Future directions may also include designing, testing and implementing new models of high-quality SDM, creating conversation toolkits for providers and decision aids for patients, and research to better understand the patient’s and provider’s perspectives, obstacles to implementing decision-making processes, and the impact of SDM on perioperative outcomes.
Anderson WG, Chase R, Pantilat SZ, Tulsky JA, Auerbach AD . Code status discussions between attending hospitalist physicians and medical patients at hospital admission. J Gen Intern Med. 2011;26(4):359–366.
Barnet CS, Arriaga AF, Hepner DL, Correll DJ, Gawande AA, Bader AM . Surgery at the end of life: a pilot study comparing decedents and survivors at a tertiary care center. Anesthesiology. 2013;119(4):796–801.
Ankuda CK, Block SD, Cooper Z, et al. Measuring critical deficits in shared decision making before elective surgery. Patient Educ Couns. 2014;94(3):328–333.
Hickey TR, Cooper Z, Urman RD, Hepner DL, Bader AM . An agenda for improving perioperative code status discussion. AA Case Rep. 2016;6(12):411–415.
Walsh EC, Brovman EY, Bader AM, Urman RD. Do-not-resuscitate status is associated with increased mortality but not morbidity published Anesth Analg March 17, 2017.