Expressions of conflict following postoperative complications in older adults having major surgery - 16/09/21

Doi : 10.1016/j.amjsurg.2021.06.004

Elle L. Kalbfell ^a, Anne Buffington ^a, Anna Kata ^b, Karen J. Brasel ^c, Anne C. Mosenthal ^d, Zara Cooper ^e, Emily Finlayson ^f, Margaret L. Schwarze ^a,^⁎
^a Department of Surgery, University of Wisconsin, Madison, WI, USA
^b Department of Surgery, Georgetown University Hospital, Washington D.C, USA
^c Department of Surgery, Oregon Health and Science University, Portland, OR, USA
^d Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
^e Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
^f Department of Surgery, University of California, San Francisco, San Francisco, CA, USA

^∗Corresponding author. Department of Surgery, University of Wisconsin-Madison, 600 Highland Ave, Room K6/134 Clinical Sciences Center, Madison, WI, 53792, USA.Department of SurgeryUniversity of Wisconsin-Madison600 Highland AveRoom K6/134 Clinical Sciences CenterMadisonWI53792USA

Abstract

Background

After serious postoperative complications, patients and families may experience conflict about goals of care.

Methods

We performed a multisite randomized clinical trial to test the effect of a question prompt list on postoperative conflict. We interviewed family members and patients age ≥60 who experienced serious complications. We used qualitative content analysis to analyze conflict and characterize patient experiences with complications.

Results

Fifty-six of 446 patients suffered a serious complication. Participants generally did not report conflict relating to postoperative treatments and expressed support for the care they received. We did not appreciate a difference in conflict between intervention and usual care. Respondents reported feeling unprepared for complications, witnessing heated interactions among team members, and a failure to develop trust for their surgeon preoperatively.

Conclusion

Postoperative conflict following serious complications is well described but its incidence may be low. Nonetheless, patient and family observations reveal opportunities for improvement.

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Highlights

•	Most patients experienced little conflict related to life sustaining treatments or goals of care.
•	Patients and families felt unprepared for complications and struggled to trust their surgeon following preoperative conversations.
•	Respondents often focused on minor issues (e.g., dietary restrictions) despite serious complications and life-threatening events.
•	Patients witnessed overt conflict among team members during their postoperative course.

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Keywords : Postoperative conflict, Surgical complications, High-risk surgery, Older adults, Goals of care