This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
In shared decision-making, clinicians discuss treatment and management options, patients explain their goals, and together they agree on the best course of action. Shared decision-making is encouraged in UK guidance. But little is known about how far people at high risk of poor outcomes after major surgery (older people, or those with multiple long-term conditions, for example) are involved in decisions.
Researchers observed surgical consultations between patients and their families, and clinicians, and asked people to reflect on their experience. They identified 3 different types of consultation with different opportunities for shared decision-making. These broadly asked:
- Must we act soon? These consultations typically led to consent (or not) for life-saving surgery.
- Do we need to act? The benefits and risks of surgery were evaluated for people with long-standing problems, and next steps agreed.
- How should we act? Surgical and non-surgical options, often for people with multiple other conditions and frailty, were agreed jointly.
When life-saving surgery was needed, opportunities for shared decision-making were limited. Shared decision-making was more likely in the other types of consultation.
The authors call for clinicians to take individualised approaches to shared decision-making for people in different circumstances. Even those with life-threatening conditions, who appreciate surgeons taking charge, may want more involvement in the decision to have surgery.
This Alert is intended for surgeons, but will also be of interest to people about to undergo surgery, and their families.
The issue: is decision-making before major surgery shared?
NHS England states that shared decision-making is a collaborative process in which clinicians support individuals to make decisions about their treatment that are right for them. The conversation brings together:
- the clinician’s expertise on treatment options, evidence, risks and benefits
- the patients’ preference, personal circumstances and support networks, goals, values and beliefs.
Little is known about shared decision-making when people at high risk of complications are offered major surgery (for instance heart, colorectal or orthopaedic surgery). In this group of people, 1 in 3 will develop serious medical complications after surgery, and many never recover. They can be left with reduced quality of life and a shorter life expectancy than if they had not had surgery. Some regret the surgery.
It can be difficult for both clinicians and patients to balance the risk of complications with the consequences of not addressing the problem. Shared decision-making helps patients realise they have a choice about surgery, and can prepare them for a slow recovery or weakness afterwards.
Researchers explored shared decision-making ahead of major heart, orthopaedic (involving bones, joints or muscles) and colorectal (bowel) surgery.
The study took place in 5 UK hospitals. It included 50 patients (with multiple long-term conditions or frailty) and carers, and 36 clinicians. Patients were aged 60 years and older.
Researchers video recorded consultations about major surgery and interviewed patients/carers and surgeons afterwards, and again 3 – 6 months later. They held focus groups with other patients, carers, surgeons, and anaesthetists, to explore past experiences of shared decision-making before major surgery.
All consultations that the researchers observed included discussion about the nature of the problem, the cause and likely outcome, and how it was affecting the patient. Surgeons described the procedure and what would happen afterwards.
The extent of shared decision-making was then influenced by the nature of the problem, the usual course of action (clinical pathway) and previous disease and interventions (patient trajectory). The researchers identified 3 broad types of consultation, each with a different emphasis on shared decision-making.
1. Must we act soon? In consultations for people with potentially life-threatening conditions (for instance heart problems) surgeons explained the problem, the surgery, and its risks. Decision-making was often limited to the decision to undergo surgery, and consent. Someone considering heart surgery said: ‘really I’ve got no choice… I want a better quality of life… although I don’t like it… I’ve got a problem… get it fixed’.
2. Do we need to act? These consultations were often for people with long-term conditions that were not life-threatening (arthritis, for instance) when other approaches (such as physiotherapy) had failed. Consultations evaluated the severity of all conditions, and the risks and benefits of surgery. An orthopaedic surgeon said: ‘It’s… not life-saving. It’s meant to improve things… but… it could make things worse’.
3. How should we act? People with multiple conditions (bowel cancer and diabetes, for example) and frailty had open-ended discussions about quality of life, life expectancy and other health problems. Surgeons explored multiple options, including surgery and palliation (treatment to make someone more comfortable rather than curing their condition). During a consultation, an anaesthetist said: ‘If we chose nothing [we’d]… have a chat with the palliative care doctors and see if we manage that just as comfortably as we can for you… but it’s not going to treat it…’ A collaborative discussion led to joint agreement about the next steps between the patient, family and clinician.
In focus groups, anaesthetists and colorectal surgeons stressed the value of deliberation for this group of people. But they highlighted challenges, particularly the time needed to explore options.
Why is this important?
The nature of the problem combined with patients’ circumstances prompted surgeons to take different approaches to shared decision-making.
For those with life-threatening conditions, shared decision-making was not always desirable or possible. People saw the surgeon’s role as fixing the problem and, regardless of whether they had surgery, they tended to accept the decision made. The authors urge surgeons, even in these circumstances, not to focus on the ‘fix’ in ways that close down discussions, but instead to open up opportunities for patients to reflect on the options and their implications.
Shared decision-making was more common in the other types of consultation. Options, consequences and preferences were discussed.
The findings are directly applicable to cardiac, colorectal and orthopaedic surgery. Further work is needed to confirm their relevance for other disciplines.
Have I taken all aspects of my patient’s health, and their goals and preferences, into account?
Have I outlined all my patient’s options, including those that don’t involve surgery?
Is this a shared decision, in which the patient and I have together agreed on the best course of action?
- describe choices
- assess the options and their risks
- understand patient preferences.
However, guidance often does not refer to surgical decisions, or to the impact of patients’ circumstances. The researchers suggest that their findings could be incorporated into shared decision-making models, acknowledging that the extent of shared decision-making and opportunities for it can vary. Further research is exploring how shared decision-making interventions can help with this.
The researchers propose training for clinicians to raise awareness of different consultation types, and when they are needed, alongside standardised decision support.
You may be interested to read
This Alert is based on: Shaw SE, and others. Opportunities for shared decision-making about major surgery with high-risk patients: a multi-method qualitative study. British Journal of Anaesthesia 2023; 131: 56 – 66.
The study is part of the Optimising shared decision-making for high risk major surgery (OSIRIS) research programme.
A paper from the OSIRIS programme: Change in healthcare utilisation after surgical treatment: observational study of routinely collected patient data from primary and secondary care. British Journal of Anaesthesia 2022; 129: 889 – 897.
Conflict of interest: One of the authors has received fees and funding from pharmaceutical companies. Full disclosures can be found in the original paper.
Funding: This study was funded by the NIHR Programme Grants for Applied Research.