A communication tool to assist older adults facing difficult surgical decisions ABSTRACT Surgery can frequently burden older frail patients with aggressive treatments they do not want1 and often has limited ability to prolong survival or return these patients to the quality of life they had before surgery.2,3 The number of operations performed on older patients with chronic illness is significant and increasing4 such that 25 percent of older Americans undergo a surgical procedure within the last three months of life.5 Because these patients are more likely to require intensive care and prolonged hospitalization, a decision to proceed with surgery can start a frail elderly patient along a care trajectory that may be inconsistent with his or her personal preferences and goals. This proposal serves the long-term goal of improving the decision-making process for frail older adults who are considering surgery, so that their treatment choices reflect their personal preferences and goals. "A communication tool to assist older adults facing difficult surgical decisions" is a two-year R03, GEMSSTAR proposal to support a feasibility study of a decision support intervention, a communication tool, to help older patients make surgical decisions that align with their personal preferences. This project has three aims:
Aim 1, to demonstrate that surgeons can learn to use the communication tool to describe treatment choices to patients;
Aim 2, to assess acceptability of the communication tool for patients in a clinical setting;
and Aim 3, to develop recruitment and data collection standard operating procedures for a future study. This award will produce the data and the procedures necessary to submit a competitive R34 application for a larger-scale efficacy trial. The research is innovative because it tests a novel, theoretically grounded intervention in both an in vitro (with standardized patients) and an in vivo (in clinical practice) setting where surgeons would be most likely to use it. The research is significant because if it is ultimately found effective, it offers a low-cost strategy to improve surgeon engagement with older frail patients during difficult surgical decisions. The research is feasible because it has been carefully designed to fit the time frame and budget and will be guided by a team of experts in aging-related, decision-making and health services research.
Improving the care provided for people at the end of life is a public health priority because 1) it affects a large number of people, 2) it can reduce unwanted care and 3) there is public demand to address the way end-of-life care has been provided in the past.6 This project aims to address this priority by pilot testing an intervention-a nimble communication tool plus associated surgeon training in its use-designed to align the preferences of frail older adults with surgical decision making. Given trends in the number of very old patients undergoing high-risk operations,7 the intervention proposed in this study could impact approximately 400,000 Americans annually who undergo surgery in their last three months of life.