title: Constructing High-stakes Surgical Decisions: It's Better to Die Trying.
abstract: OBJECTIVE
  To explore high-stakes surgical decision making from the perspective of seniors and surgeons.
  
  
  BACKGROUND
  A majority of older chronically ill patients would decline a low-risk procedure if the outcome was severe functional impairment. However, 25% of Medicare beneficiaries have surgery in their last 3 months of life, which may be inconsistent with their preferences. How patients make decisions to have surgery may contribute to this problem of unwanted care.
  
  
  METHODS
  We convened 4 focus groups at senior centers and 2 groups of surgeons in Madison and Milwaukee, Wisconsin, where we showed a video about a decision regarding a choice between surgery and palliative care. We used qualitative content analysis to identify themes about communication and explanatory models for end-of-life treatment decisions.
  
  
  RESULTS
  Seniors (n = 37) and surgeons (n = 17) agreed that maximizing quality of life should guide treatment decisions for older patients. However, when faced with an acute choice between surgery and palliative care, seniors viewed this either as a choice between life and death or a decision about how to die. Although surgeons agreed that very frail patients should not have surgery, they held conflicting views about presenting treatment options.
  
  
  CONCLUSIONS
  Seniors and surgeons highly value quality of life, but this notion is difficult to incorporate in acute surgical decisions. Some seniors use these values to consider a choice between surgery and palliative care, whereas others view this as a simple choice between life and death. Surgeons acknowledge challenges framing decisions and describe a clinical momentum that promotes surgical intervention.
authors.affiliation: *Department of Surgery, University of Wisconsin-Madison, Madison, WI †Department of Medicine, Northwestern University, Chicago, IL ‡Department of Surgery, Oregon Health & Science University, Portland, OR §Department of Medicine, University of Wisconsin-Madison, Madison, WI ¶Center for Patient Partnerships, University of Wisconsin-Madison, Madison, WI ||Department of Medical History and Bioethics, University of Wisconsin-Madison, Madison, WI.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Nabozny
authors.forename: Jacqueline M
authors.initials: JM
authors.lastname: Kruser
authors.forename: Nicole M
authors.initials: NM
authors.lastname: Steffens
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Brasel
authors.forename: Toby C
authors.initials: TC
authors.lastname: Campbell
authors.forename: Martha E
authors.initials: ME
authors.lastname: Gaines
authors.forename: Margaret L
authors.initials: ML
authors.lastname: Schwarze
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000066491:Clinical Decision-Making; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010166:Palliative Care; D011788:Quality of Life; D013514:Surgical Procedures, Operative