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Original Investigation
May 12, 2021

Frequency of Preoperative Advance Care Planning for Older Adults Undergoing High-risk Surgery: A Secondary Analysis of a Randomized Clinical Trial

Author Affiliations
  • 1Department of Surgery, University of Wisconsin–Madison
  • 2Department of Surgery, Georgetown University Hospital, Washington, DC
  • 3Department of Surgery, Oregon Health & Science University, Portland
  • 4Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
  • 5Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
  • 6Department of Surgery, University of California, San Francisco
JAMA Surg. 2021;156(7):e211521. doi:10.1001/jamasurg.2021.1521
Key Points

Question  Do older adults undergoing high-risk surgery receive preoperative discussion or documentation of advance directives (ADs) or advance care planning?

Findings  Among 213 patients with at least 1 comorbid condition who were included in this exploratory analysis of data collected in a randomized clinical trial testing a patient-mediated intervention to improve preoperative communication, only 13 preoperative visits included discussion related to ADs, the patient’s health care proxy, or preferences for treatment limitations. One hundred forty-one patients (66%) did not have an AD on file before major surgery.

Meaning  Despite the consensus that preoperative advance care planning is important for older adults undergoing high-risk surgery, these findings suggest that it is not routinely performed.


Importance  For patients facing major surgery, surgeons believe preoperative advance care planning (ACP) is valuable and routinely performed. How often preoperative ACP occurs is unknown.

Objective  To quantify the frequency of preoperative ACP discussion and documentation for older adults undergoing major surgery.

Design, Setting, and Participants  This secondary analysis of data from a multisite randomized clinical trial testing the effects of a question prompt list intervention on preoperative communication for older adults considering major surgery was performed at 5 US academic medical centers. Participants included surgeons who routinely perform high-risk surgery and patients 60 years or older with at least 1 comorbidity and an oncological or vascular (cardiac, peripheral, or neurovascular) problem. Data were collected from June 1, 2016, to November 30, 2018.

Interventions  Patients received a question prompt list brochure with 11 questions that they might ask their surgeon.

Main Outcomes and Measures  For patients who had major surgery, any statement related to ACP from the surgeon, patient, or family member during the audiorecorded preoperative consultation was counted. The presence of a written advance directive (AD) in the medical record at the time of the initial consultation or added preoperatively was recorded. Open-ended interviews with patients who experienced postoperative complications and family members were conducted.

Results  Among preoperative consultations with 213 patients (122 men [57%]; mean [SD] age, 72 [7] years), only 13 conversations had any discussion of ACP. In this cohort of older patients with at least 1 comorbid condition, 141 (66%) did not have an AD on file before major surgery; there was no significant association between the presence of an AD and patient age (60-69 years, 26 [31%]; 70-79 years, 31 [33%]; ≥80 years, 15 [42%]; P = .55), number of comorbidities (1, 35 [32%]; 2, 18 [33%]; ≥3, 19 [40%]; P = .62), or type of procedure (oncological, 53 [32%]; vascular, 19 [42%]; P = .22). There was no difference in preoperative communication about ACP or documentation of an AD for patients who were mailed a question prompt list brochure (intervention, 38 [35%]; usual care, 34 [33%]; P = .77). Patients with complications were enthusiastic about ACP but did not think it was important to discuss their preferences for life-sustaining treatments with their surgeon preoperatively.

Conclusions and Relevance  Although surgeons believe that preoperative discussion of patient preferences for postoperative life-sustaining treatments is important, these preferences are infrequently explored, addressed, or documented preoperatively.

Trial Registration  ClinicalTrials.gov Identifier: NCT02623335

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