Advance Directives Don't Work for High-Risk Surgery

Madison, Wisconsin - Advance directives that limit the use of life-supporting treatments necessary for patient survival are a poor tool for helping patients express their wishes about surgery, according to a new study led by a University of Wisconsin School of Medicine and Public Health vascular surgeon.

The study finds that only 50 percent of surgeons who do high-risk operations discuss advance directives with their patients before surgery and a slightly higher proportion (54 percent) said they would decline to operate if the patient had such a directive limiting post-operative life support the surgeon thought might be necessary for patient survival.

These directives, sometimes known as a "living wills," typically limit the use of life-supporting treatments that can be necessary to achieve the goals of surgery. Instead of discussing these formal documents, a large majority of the surgeons surveyed (81 percent) have an informal conversation with patients about their preferences for limiting life-supporting therapy post-operatively.

"The study suggests that advance directives don't work for surgery," says Dr. Margaret "Gretchen" Schwarze, assistant professor of surgery at the UW School of Medicine and Public Health. Schwarze led the study.

Advance directives, sometimes called "living wills," may specify that a patient doesn't want to be kept alive by ventilator or feeding tube or to be revived if his or her heart stops beating. But these restrictions can be at odds with post-surgical care, especially for high-risk surgery such as cardiac surgery. After high-risk operations, routine and short-term use of these treatments may enable the patient to achieve the outcomes they desired from surgery.

"The goal of surgery is survival. I think that what we are seeing is that surgeons have a fierce sense of responsibility for bringing their patients out of surgery alive," she says. "Surgeons don't like advance directives because they feel the directives tie their hands behind their backs."

Schwarze and her co-authors surveyed more than 900 cardiothoracic, vascular and neurosurgeons. While all surgeons reported discussing the possibility of a poor surgical outcome and nearly all discussed the need for post-operative life-supporting therapy, the numbers fell to 52 percent when it came to asking patients specifically about whether they had written advance directives.

The study was published online ahead of its appearance in the March issue of Annals of Surgery. It will be accompanied by an editorial that calls the findings "troubling" and says they "draw attention to significant differences in how surgeons and their patients view the utility of life-sustaining therapy and they underscore the important communication gaps around this issue."

Dr. Zara Cooper, assistant professor of surgery, and her colleagues from the Harvard University Medical School, say that the study is important because, "preparation for surgery provides a unique opportunity for patients and providers to engage in advance care planning, given that a patient's hopes and expectations about the benefits of surgery are counterbalanced by anxiety about death, loss of control and unwanted treatment."

Schwarze says her study suggests that a more useful approach involves clarifying a patient's goals for high-risk operations especially in the event of an unanticipated or unwanted clinical outcome. Advance directives may not capture the true desires of a patient who is committed to having aggressive treatment such as surgery.

"I have abandoned the idea that advance directives might work for surgery," says Schwarze, who studies surgical decision-making. "It is better to have a conversation asking the patient, ‘What are your priorities in the event of a bad complication?"

Dr. Schwarze's work is supported by the Greenwall Faculty Scholars Award and the UW School of Medicine and Public Health's Department of Surgery.