More experienced surgeons are more confident in their assessments of perceived futility, according to a study recently published in the Journal of the American College of Surgeons.

Surgical patients increasingly have more comorbidities and are older, complicating surgical decision-making in emergent situations. Little is known about surgeons' perceptions of shared decision-making in these settings.

Twenty semi-structured interviews were conducted with practicing surgeons at 2 large academic medical centers. Thirteen questions and 2 case vignettes were used to assess perceptions of decision-making, considerations when deciding whether to offer to operate and communication patterns with patients and families.

Rachel S. Morris, M.D., from the Medical College of Wisconsin in Milwaukee, and colleagues conducted semi-structured interviews with 20 practicing surgeons at two large academic medical centers.

The questions and case vignettes were used to assess surgeons' perceptions of shared decision-making with older surgical patients with comorbidities. 

Through thematic analysis, the researchers identified six major themes: responsibility for the decision to operate, perceived futility, surgeon judgment, surgeon introspection, pressure to operate, and costs of the operation.

Surgical intervention

There was universal recognition that perceived futility was a contraindication to surgical intervention. Given the challenge of defining futility, participants emphasized the importance of patients' self-determined risk-to-benefit analysis when considering surgery.

Communicating to patients that a condition was not amenable to an operation and reserving the right to refuse to operate was more common among experienced surgeons.

"Due to external pressures and uncertainty, some providers err on the side of operative intervention, despite suspected futility," the authors noted.

"Greater experience allows surgeons to withstand external pressures, be confident in their assessments of perceived futility, and guide patients and their families away from additional interventions," the authors noted.

In summary, surgeons from two large academic medical centers reported that their end-of-life care decisions were influenced by external pressure from multiple sources and uncertainty about the perceived futility of treatment options.

Due to this pressure and uncertainty, some providers in our cohort erred on the side of operative intervention, even in situations where such treatment was suspected to be futile.

The surgeons in this study with greater experience and confidence in their decisions were likely to withstand external pressures, feel confident in their assessments of futility, and guide patients away from potentially futile interventions.

We must provide greater support from colleagues, institutional culture, and the literature – for surgeons performing end-of-life SDM conversations, create objective measures of futility, and work to change the culture from “do everything” to “do what is best for the patient."