title: It's big surgery: preoperative expressions of risk, responsibility, and commitment to treatment after high-risk operations.
abstract: OBJECTIVE
  To identify the processes, surgeons use to establish patient buy-in to postoperative treatments.
  
  
  BACKGROUND
  Surgeons generally believe they confirm the patient's commitment to an operation and all ensuing postoperative care, before surgery. How surgeons get buy-in and whether patients participate in this agreement is unknown.
  
  
  METHODS
  We used purposive sampling to identify 3 surgeons from different subspecialties who routinely perform high-risk operations at each of 3 distinct medical centers (Toronto, Ontario; Boston, Massachusetts; Madison, Wisconsin). We recorded preoperative conversations with 3 to 7 patients facing high-risk surgery with each surgeon (n = 48) and used content analysis to analyze each preoperative conversation inductively.
  
  
  RESULTS
  Surgeons conveyed the gravity of high-risk operations to patients by emphasizing the operation is "big surgery" and that a decision to proceed invoked a serious commitment for both the surgeon and the patient. Surgeons were frank about the potential for serious complications and the need for intensive care. They rarely discussed the use of prolonged life-supporting treatment, and patients' questions were primarily confined to logistic or technical concerns. Surgeons regularly proceeded through the conversation in a manner that suggested they believed buy-in was achieved, but this agreement was rarely forged explicitly.
  
  
  CONCLUSIONS
  Surgeons who perform high-risk operations communicate the risks of surgery and express their commitment to the patient's survival. However, they rarely discuss prolonged life-supporting treatments explicitly and patients do not discuss their preferences. It is not possible to determine patients' desires for prolonged postoperative life support on the basis of these preoperative conversations alone.
authors.affiliation: *School of Nursing †Department of Medicine ‡Department of Surgery (Division of Vascular Surgery), and §Department of Medical History and Bioethics, University of Wisconsin, Madison, WI ¶Department of Surgery, Medical College of Wisconsin, Milwaukee, WI ∥Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA; and **Department of Surgery and ††Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Kristen E
authors.initials: KE
authors.lastname: Pecanac
authors.forename: Jacqueline M
authors.initials: JM
authors.lastname: Kehler
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Brasel
authors.forename: Zara
authors.initials: Z
authors.lastname: Cooper
authors.forename: Nicole M
authors.initials: NM
authors.lastname: Steffens
authors.forename: Martin F
authors.initials: MF
authors.lastname: McKneally
authors.forename: Margaret L
authors.initials: ML
authors.lastname: Schwarze
mesh_terms: D000328:Adult; D024362:Advance Directive Adherence / Q000941:ethics*; D016223:Advance Directives / Q000941:ethics*; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations; D011300:Preoperative Care / Q000941:ethics / Q000379:methods*