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Pitfalls in communication that lead to nonbeneficial emergency surgery in elderly patients with serious illness: description of the problem and elements of a solution

Zara Cooper, Andrew Courtwright, Ami Karlage, Atul Gawande, Susan Block
Annals of Surgery 2014, 260 (6): 949-57
24866541

OBJECTIVE: To provide a description of communication breakdowns and to identify interventions to improve surgical decision making for elderly patients with serious illness and acute, life-threatening surgical conditions.

BACKGROUND: Communication between surgeons, patients, and surrogates about goals of treatment plays an important and understudied role in determining the surgical interventions elderly patients with serious illness receive. Communication breakdowns may lead to nonbeneficial procedures in acute events near the end of life.

METHODS: We review the available literature on factors that lead to communication challenges and nonbeneficial surgery at the end of life. We use this review to identify solutions for navigating surgical decision making for seriously ill elderly patients with acute surgical conditions.

RESULTS: Surgeon, patient, surrogate, and systemic factors-including time constraints, inadequate provider communication skills and training, uncertainty about prognosis, patient and surrogate anxiety and fear of inaction, and limitations in advance care planning-contribute to communication challenges and nonbeneficial surgery at the end of life. Surgeons could accomplish more effective communication with seriously ill elderly patients if they had a structured, standardized approach to exploring patients' preferences and to integrating those preferences into surgical decisions in the acute setting.

CONCLUSIONS: Improved communication among surgeons, patients, and surrogates is necessary to ensure that patients receive the care that they want and to avoid nonbeneficial treatment. Further research is needed to learn how to best structure these conversations in the emergency surgical setting.

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