New Role for the Anesthesia Preoperative Clinic: Helping to Ensure That Surgery Is the Right Choice for Patients With Serious Illness

In his book, Being Mortal: Medicine and What Matters in the End, Gawande1 proposed 5 questions to consider when someone is dealing with a serious illness: What is your understanding of your illness and prognosis? What are your fears or worries for the future? What are your goals and priorities? What outcomes are unacceptable to you? How do you want to spend your time if your health worsens? The primary focus of anesthesiologists in the preoperative process has been to optimize patients for surgery and anesthesia. Rarely do anesthesiologists engage in difficult conversations with patients battling serious illness before scheduled elective surgery. It is often assumed that other health care providers have discussed the patient’s disease process and advance care planning before surgery. Many anesthesiologists would hesitate to ask questions like these during a preoperative clinic visit. There are, however, longer-term outcomes that may be worth considering preoperatively to avoid costly hospitalizations, prolonged durations of stay, and more intensive care unit (ICU) days that may not necessarily result in improved quality of life. Value in health care stems from the effectiveness of all of the interventions provided to a patient in a cycle of care and the resulting outcomes.2 By taking the time to engage patients in shared decision-making, ensuring that consent for surgery is truly informed, and that expected outcomes align with the patient’s goals, anesthesiologists can contribute to high-value, high-quality, patient-centered care. Herein, we propose a framework that expands the role of the preoperative clinic to serve as a “pause point”3 or a “safety net”4 in the perioperative process. The following case is considered. SCENARIO A 72-year-old man with coronary artery disease, insulin-dependent diabetes, stage 3 chronic kidney disease, and worsening back pain presented to anesthesia preoperative clinic before scheduled multilevel thoracic and lumbar decompression and fusion for metastatic prostate cancer. He was not experiencing any focal neurologic deficits or bowel or bladder dysfunction, but his worsening back pain had significantly limited his daily physical activity. This patient moved through our anesthesia preoperative assessment clinic. Indicated laboratory studies were obtained, and recent cardiac studies (electrocardiogram, echocardiogram, and nuclear stress test) were reviewed. The patient’s outpatient cardiologist “cleared” him for surgery. Although no additional tests were deemed necessary, the attending anesthesiologist responsible for overseeing the clinic had reservations about why this patient was having such an invasive surgery for symptoms that might respond to more conservative treatment options. The surgery and postoperative recovery period might be complicated or prolonged given the patient’s comorbidities and terminal cancer diagnosis. The patient’s intraoperative course was more complicated than anticipated. After multiple transfusions in response to significant acute blood loss, the patient’s increasing vasopressor requirement and the team’s concern for fluid overload prevented safe extubation at the conclusion of surgery. He was transferred to the ICU intubated. By postoperative day 5, he developed pneumonia followed by an acute on chronic kidney injury. The ICU team was unable to wean the patient from the ventilator, and 3 weeks after his surgery, his family agreed to a tracheostomy. When the ICU team gathered the patient’s family to discuss placing a feeding tube and possibly beginning dialysis in the setting of worsening renal failure, the patient’s family struggled to answer these questions. Eventually, the patient’s family declined any additional interventions, saying that they did not know if he would have wanted all of these life-sustaining efforts. They were not sure if he would have even had surgery had he known about these potential complications. They tearfully admitted that he just wanted relief from some of his pain to spend more time with his family. Just like the patient presented, many people in the United States undergo surgery in their last year of life. Kwok et al5 evaluated nearly 2 million Medicare beneficiaries who died in 2008 and found that 32% underwent surgery in the year before their death, nearly 20% had surgery in the last month of life, and 8% in their last week of life. Those who underwent surgery had more subsequent hospital admissions, longer durations of stay, and more ICU days than patients who did not have surgery.5 In a study comparing decedents and survivors at a tertiary care center, of 747 patients evaluated at the preoperative assessment center, 5% were dead 1 year later.6 It is sobering to think that 1 out of every 20 patients we meet in the preoperative clinic may not be alive in a year, a thought that would likely change the nature of our encounter. While some of the procedures taking place in the final year of life are appropriate and beneficial, others may prove futile or be judged unwanted by the patient in hindsight. Surely, there is more that can be done in the anesthesia preoperative clinic to help minimize the number of inappropriate procedures that will prove regrettable. FUTILITY VERSUS APPROPRIATENESS IN THE SETTING OF SHARED DECISION-MAKING In 1999, the Council on Ethical and Judicial Affairs of the American Medical Association published its report on Medical Futility in End-of-Life Care. It described futility as a “subjective but realistically indispensable judgment, involving a value judgment.” An objective definition of futility would result in some patients receiving interventions and others dying due to judgments with which they disagree.7 Today the emphasis has shifted to conflict resolution and negotiation as a way to resolve questions regarding futility.8 By improving the communication between physicians and patients, it may be possible to generate options that reflect the patient’s interests. The term “quantitative futility” refers to an intervention that has a very low likelihood of benefitting the patient. Compare this to the somewhat controversial term “qualitative futility,” which is used to describe a treatment likely to result in an unacceptable outcome or quality of life. Even a successful intervention as determined by health care providers may result in an inadequate outcome or unacceptable functional status as determined by the patient.9 In essence, this suggests developing a process of shared decision-making during which health care providers incorporate the patient’s goals and values to help guide treatment decisions and avoid qualitative futility. The Committee on Ethics within the American Society of Anesthesiologists composed and recently updated its Syllabus on Ethics (2016) that explains these terms in more detail, as well as the legal history surrounding the evolution of end-of-life care (https://www.asahq.org/standards-and-guidelines/resources-from-asa-committees#ethics). The concept of patient-centered care was initially presented in the Institute of Medicine 2001 Quality Chasm report that described care that is “respectful of and responsive to individual patient preferences, needs, and values while ensuring that patient values guide all clinical decisions.”10 Patient-centered care is not giving patients what they want when they want it, nor is it inundating patients with information and expecting them to comprehend it on their own. It is providing the “right care for the right person at the right time”10 to achieve optimal clinical outcomes. Clinical outcome reflects the patient’s interests in “promotion, preservation, and restoration of their health as well as mitigation of pain, suffering, and disability.”11 An option may be ethically appropriate to a patient even when significant risks exist as long as the expected benefit to the patient justifies these risks. Without clarifying with a patient which outcomes are acceptable and which are not, we may not be guiding or counseling a patient toward the “right decision” for him or her. INFORMED CONSENT Informed consent for surgery is a fundamental component of patient involvement in the shared decision-making process. Informed consent requires thorough understanding of the risks and benefits of a particular intervention as well as the potential outcomes, desirable or unplanned and alternative options. Without a doubt, it is difficult to achieve truly informed consent given the complex nature of each patient’s situation as well as time constraints frequently limiting health care providers. In a recent study looking at the efficacy of shared decision-making and informed consent before elective surgery, >1000 patients were surveyed preoperatively. Thirteen percent of these patients displayed “critical deficits” in terms of informed consent, including inability to identify their diagnosis or their procedure or being unaware of the risks and benefits for the proposed procedure. Another 13% of patients were unsure about which option was the best choice for them or which risks and benefits discussed mattered most to them. Seventeen percent of patients wanted further discussion about their surgery. In addition, the survey revealed that a significant number of patients wished to discuss advance care planning, while other patients indicated that they had not discussed their end-of-life wishes with their surrogate decision makers.4 The anesthesia preoperative clinic visit is an ideal opportunity to reflect on a patient’s goals, values, and preferences to ensure that the medical decisions respect his or her autonomy. This visit can serve as a time to ensure that the risks, benefits, and all of the potential outcomes are well understood. Engaging patients in shared decision-making may even be used as a metric of high-value patient-centered care.12 With this approach, an anesthesiologist in the preoperative clinic is not saying no to surgery or determining when surgery is futile or appropriate but is instead taking time to ask a patient: Is this what you want? Do you understand what you will go through? The goal is to ensure that everyone, patients and caregivers, is on the same page. THE FRAMEWORK While it may be difficult to discuss Gawande’s 5 questions during a preoperative clinic visit, focusing on just a few may elicit valuable information. Asking about goals, priorities, and worries for the future is a good way to understand what is truly important to a patient. Inquiring about acceptable outcomes is an alternative approach to reviewing informed consent for surgery. Gawande and his team at Ariadne Lab (Boston, MA) created the Serious Illness Conversation Guide (https://www.ariadnelabs.org/areas-of-work/serious-illness-care/), which was designed to support clinicians who engage patients in these difficult discussions. Another simple effort is to ask a patient about the presence of an advance directive. The 2 most common types of advance directives are the living will and the durable power of attorney for health care. The living will is designed to control particular future health care decisions when a person becomes unable to make or voice these decisions. It is a set of written instructions about certain things that might happen (ie, the need for dialysis if kidneys fail or mechanical ventilation if respiratory failure develops), which must be witnessed. It is more specific than a durable power of attorney for health care by which a patient designates a proxy to make all health care–related decisions when the patient is unable to do so himself or herself. This designation assumes that the patient has discussed his or her wishes with his or her proxy in advance. Both forms of advance directive are based on thoughtful discussion that hopefully aligns with a patient’s reasons for having surgery, what he or she hopes to achieve, and how to handle potential outcomes. The Stanford Letter Project (https://med.stanford.edu/letter/about.html) provides templates to help adults easily create an advance directive or simply delineate what matters most to them in an effort to begin or continue these challenging but essential conversations. In some situations, it may be beneficial to involve other health care providers preoperatively. Palliative care specialists can help manage symptoms, improve communication between providers, and assist with medical decision-making and transitions of care. Too often, palliative care is seen by patients or their surrogates as a sign of imminent death or that physicians are “giving up hope.” While palliative care is appropriate in times of hospice when patient comfort is the ultimate goal, it may be helpful at any point in the disease process, including during active treatment when the intent is to cure.9 Unfortunately, the role of palliative care for surgical patients is not well defined, and patients undergoing surgery are less likely to receive palliative care than those undergoing medical interventions only,13 despite multiple studies that have demonstrated its value. Improved pain and symptom management, better communication, more satisfaction with care, and improved quality of life are just some of the benefits patients have realized when palliative care physicians were involved.14 The preoperative clinic could integrate the expertise of palliative care providers into the perioperative process, thus improving a patient’s perioperative experience, potentially decreasing overall costs, while improving quality of life. With a better approach to symptom management and disease-directed care, we can work toward improved resource utilization, improved quality and patient safety, and decreased costs as we shift away from fragmented, siloed care.15Table.: Potential Challenges to ImplementationAs we realize the important roles that other specialties play in caring for these challenging patients, the need for a multidisciplinary approach is evident. It would be inappropriate for an anesthesiologist to have a difficult conversation with a patient scheduled for surgery only to have that patient change his or her mind without another discussion with the surgeon. Nevertheless, we should not be discouraged from initiating these conversations. Some surgeons may refuse to operate on a patient who wishes to limit life-sustaining treatments postoperatively.16 It has also been suggested that some surgeons may use the time between the decision for surgery and the day of surgery for additional testing and gathering input from other providers.3 At many large centers, a tumor board comprised of surgical, medical, and radiation oncology specialists, as well as other care providers, meets to discuss and create potential treatment plans for cancer patients. Gathering the surgeon, anesthesiologist, palliative care physician, and even critical care or the patient’s primary care physician, in addition to the patient, to discuss options in the context of the patient’s goals and values may be a crucial step to garner consensus among providers and provide appropriate treatment for the patient. Potential challenges to implementing a multidisciplinary strategy are outlined in the Table. NEXT STEPS While some patients in the preoperative clinic may stand out as candidates for this process, it may not be obvious which patients might benefit from some of the discussions proposed here. Computer scientists at Stanford University recently published a method to improve access to palliative care. Using deep learning and data from the electronic health record, they developed a deep neural network algorithm to determine which inpatients could benefit from a palliative care consult. Their goal is to create a proactive system that enables physicians to reach out early to patients who might benefit from palliative care involvement rather than relying on referrals from treating physicians.17 A similar tool might be useful in the perioperative setting to help identify patients who might benefit from palliative care involvement or additional multidisciplinary discussion preoperatively. Frailty assessments performed preoperatively help identify adults who are at higher risk for postoperative complications, including longer hospital stays and higher readmission rates.18 These assessments give more weight to functional status, cognitive dysfunction, and comorbidities rather than age alone. As part of their Frailty Screening Initiative, researchers developed and validated a surgical frailty tool called the Risk Analysis Index, which may be used to predict mortality 30, 180, and 365 days postoperatively. A prospective clinical questionnaire called the Risk Analysis Index-Clinical, which takes only a few minutes to complete, considers age, gender, presence of cancer, medical comorbidities, type of residence, activities of daily living, and cognitive decline to produce a composite score. In a cohort of nearly 4000 patients, perioperative plans were modified for those patients who scored above a designated cutoff, and mortality rates decreased compared to preimplementation of the Frailty Screening Initiative.18,19 If such a tool were implemented in the anesthesia preoperative clinic, we could decide within a matter of minutes which patients warrant additional discussions preoperatively. The patient in our case example scores 24 on the Risk Analysis Index-Clinical, indicating a need for additional preoperative planning. Using such a tool may also help to engage surgeons as we suggest modifications to the traditional preoperative process. One of the main limitations of the framework discussed here is the lack of financial reimbursement in our current system for the interventions that we have proposed. To ensure long-term sustainability, measures that demonstrate the value of time-intensive preoperative efforts would need to be developed. In addition to conventional metrics, such as hospital length of stay and rates of readmission or complications, other outcome metrics, such as achievement of a patient’s desired treatment goals, would need to be introduced and measured. After demonstrating the value that these efforts add to patient care, reimbursement may be warranted. SUMMARYFigure.: Proposed framework (RAI-C from Hall et al18). RAI-C indicates Risk Analysis Index-Clinical.The preoperative clinic is tasked with medically optimizing and preparing each patient for a successful surgery and postoperative recovery. Occasionally patients present and we wonder, “Why are we doing this case?” Doubting the value of surgery should be cause for concern and cause for action. The framework described in the Figure suggests a way for providers to engage in a discussion focused on patient goals, values, and preferences. It also suggests ways to identify higher-risk patients dealing with serious illness who may benefit most from multidisciplinary discussions preoperatively. Implementing a shared decision-making process may help identify patients at risk of undesirable outcomes, reduce nonbeneficial procedures, and increase the appropriateness of the medical and surgical care that we deliver to our patients. DISCLOSURES Name: Emily Goldenberg, MD. Contribution: This author helped conceive, research, draft, and revise the manuscript and approve the final version to be published. Name: Roya Saffary, MD. Contribution: This author helped draft and revise the manuscript and approve the final version to be published. Name: Cliff Schmiesing, MD. Contribution: This author helped conceive, design, and revise the manuscript and approve the final version to be published. This manuscript was handled by: Thomas R. Vetter, MD, MPH.