Opportunities for shared decision-making about major surgery: findings from a multi-method qualitative study of decision-making about orthopaedic, colorectal and cardio thoracic surgery with high risk patients

Abstract

ABSTRACTBackgroundLittle is known about the opportunities for shared decision-making when high-risk patients (over 60 years, with co-morbidities) are offered major surgery. This paper examines when and why clinicians and patients can share decision-making about major surgery.MethodsMulti-method qualitative study, combining video-recordings of pre-operative consultations, interviews and focus groups (with a maximum variation sample of 31 patients, 19 relatives, 37 clinicians), with observations of clinics in five UK hospitals undertaking major joint, colorectal and/or cardiac surgery.ResultsThree opportunities for shared decision making about major surgery were identified. Resolution-focused consultations (cardiac/colorectal) resulted in a single agreed preferred option related to a potentially life-threatening problem, with limited opportunities for shared decision-making. Evaluative and deliberative consultations offered more opportunity. The former focused on assessing the likelihood of benefits of surgery for a presenting problem that was not a threat to life for the patient (e.g. orthopaedic consultations) and the later (largely colorectal) involving discussion of a range of options while also considering significant comorbidities and patient preferences. The extent to which opportunities for shared decision-making were available, and taken up by surgeons, was influenced by nature of the presenting problem, clinical pathway and patient trajectory.Conclusion and relevanceDecisions about major surgery are not always shared between patients and doctors. The nature of the presenting problem, comorbidities, clinical pathways and patient trajectories all inform the type of consultation and opportunities for sharing decision-making. This has implications for clinicians, with shared decision-making about major surgery most feasible when the focus is on life-enhancing rather than life-saving treatment.