title: Patient-reported Limitations to Surgical Buy-in: A Qualitative Study of Patients Facing High-risk Surgery.
abstract: To characterize how patients buy-in to treatments beyond the operating room and what limits they would place on additional life-supporting treatments.
  
  
  
  During a high-risk operation, surgeons generally assume that patients buy-in to life-supporting interventions that might be necessary postoperatively. How patients understand this agreement and their willingness to participate in additional treatment is unknown.
  
  
  
  We purposively sampled surgeons in Toronto, Ontario, Boston, Massachusetts, and Madison, Wisconsin, who are good communicators and routinely perform high-risk operations. We audio-recorded their conversations with patients considering high-risk surgery. For patients who were then scheduled for surgery, we performed open-ended preoperative and postoperative interviews. We used directed qualitative content analysis to analyze the interviews and surgeon visits, specifically evaluating the content about the use of postoperative life support.
  
  
  
  We recorded 43 patients' conversations with surgeons, 34 preoperative, and 27 postoperative interviews. Patients expressed trust in their surgeon to make decisions about additional treatments if a serious complication occurred, yet expressed a preference for significant treatment limitations that were not discussed with their surgeon preoperatively. Patients valued the existence or creation of an advance directive preoperatively, but they did not discuss this directive with their surgeon. Instead they assumed it would be effective if needed and that family members knew their wishes.
  
  
  
  Patients implicitly trust their surgeons to treat postoperative complications as they arise. Although patients may buy-in to some additional postoperative interventions, they hold a broad range of preferences for treatment limitations that were not discussed with the surgeon preoperatively.
authors.affiliation: *Department of Surgery, University of Wisconsin, Madison, WI †Department of Medicine, Northwestern University. Chicago, IL ‡School of Nursing, University of Wisconsin. Madison, WI §Department of Surgery, Oregon Health & Science University, Portland, OR ¶Department of Medicine, Massachusetts General Hospital. Boston, MA ||Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital. Boston, MA **Department of Surgery, University of Toronto, Toronto, Ontario, Canada ††Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada ‡‡Department of Medical History and Bioethics, University of Wisconsin, 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: Kristen E
authors.initials: KE
authors.lastname: Pecanac
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Brasel
authors.forename: Eva H
authors.initials: EH
authors.lastname: Chittenden
authors.forename: Zara
authors.initials: Z
authors.lastname: Cooper
authors.forename: Martin F
authors.initials: MF
authors.lastname: McKneally
authors.forename: Margaret L
authors.initials: ML
authors.lastname: Schwarze
mesh_terms: D016223:Advance Directives / Q000523:psychology*; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008020:Life Support Care / Q000523:psychology*; D008297:Male; D008404:Massachusetts; D008875:Middle Aged; D009864:Ontario; D010166:Palliative Care / Q000523:psychology*; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D010817:Physician-Patient Relations; D011182:Postoperative Care / Q000379:methods / Q000523:psychology*; D011183:Postoperative Complications / Q000523:psychology / Q000628:therapy*; D036301:Qualitative Research; D012306:Risk; D035502:Trust; D014922:Wisconsin