Only one in four U.S. seniors with chronic health problems prepare documents detailing their treatment preferences ahead of undergoing risky surgery, a study suggests. The 393 patients in the study, all 65 or older, had multiple illnesses and underwent high-risk surgery, either planned or as an emergency. 

Only about a quarter had advance care planning documents stating their preferences for treatment options, such as whether they would like to receive life support and instructions on who should make medical decisions on their behalf, in the event they become unable to decide for themselves. Among those who died within a year after their operations, only 31% had prepared such documentation, researchers reported December 5 online in JAMA Surgery.

"Advance care planning can be as little as identifying who your decision maker may be if you are not able to make your own decision," lead author Dr. Victoria Tang of the University of California, San Francisco said in an email. Advance care planning documents are not unlike wills, in that they are legal documents with variable formats.

Primary care doctors

Often, informal documents handed over to family members or primary care doctors serve as testament to a comatose patient's wishes when deciding medical treatment, said Dr. Zara Cooper, Assistant Professor of Surgery at Harvard Medical School in Boston.

Doctors can find it difficult to bring up the subject of advance directives. "There is a large cultural concern about taking away hope and discussing death and so a lot of clinicians are uncomfortable," Cooper, who was not involved in the study," said Cooper.

"Doctors are not always great at determining who is more likely to die," she added. "The other issue is that clinicians really are not well-trained to have these conversations." Certain groups were more likely to plan ahead, the study found.

For example, those aged 85 or older were more likely to have prepared advance directives than people ages 65 to 74. Those who made more frequent trips to the doctor and those diagnosed with mild cognitive impairment were also more likely to have their documents ready, researchers said.

All older adults with multiple chronic conditions undergoing high-risk surgery would benefit from having advance care directives completed and documented in medical records, the paper notes.

Dr. Lisa Gibbs, chief of geriatric medicine at the University of California, Irvine, was surprised that patients undergoing planned operations were no more likely to have documented their wishes than patients who had emergency surgeries.

"When patients do not have advance care planning documents, family members can be surprised and overwhelmed if asked to make decisions that they have not considered before," Gibbs, who was not involved in the study, said in an email. "Having prepared others for one's wishes also prevents potential family discord and disagreement during times of crisis."

"I think the vast majority of those of us who deal with acutely ill older patients have been in situations where not having guidance from advanced care planning has really created conflict in providing the most appropriate and dignified care," Cooper said.