How Surgeons Influence Family Decisions to Have Surgery
Surgeons influence family decisions through a structured shared decision-making process that combines their medical expertise with the family's understanding of the patient's values, goals, and preferences, while explicitly acknowledging different decision-making styles and providing balanced information about risks, benefits, and alternatives. 1
The Shared Decision-Making Framework
The American College of Critical Care Medicine and American Thoracic Society establish that surgeons should explicitly discuss decision-making preferences with families, recognizing that different families approach decisions differently. 1 Surgeons must directly ask families how they prefer to make decisions—whether they want to share responsibility, make decisions independently after receiving information, or prefer the surgeon to make recommendations based on the patient's values. 1
Three Primary Decision-Making Approaches
- Shared responsibility: Most families prefer to work collaboratively with the surgeon, combining medical knowledge with patient values 1
- Family-led decisions: Some families want complete information but prefer to decide independently 1
- Surgeon-led recommendations: Other families prefer to communicate the patient's values and have the surgeon make recommendations, with opportunity to disagree 1
Key Communication Strategies That Shape Decisions
Presenting Treatment Options Without Bias
Surgeons influence decisions by how they frame treatment alternatives. The surgeon must present each option's advantages and disadvantages in a balanced manner, explicitly stating that "different people make different choices" to avoid steering families toward a particular decision. 1 For example, when presenting surgical versus non-surgical interventions, surgeons should explain that "some people prefer" one option for specific reasons while "others prefer" the alternative for different reasons. 1
Eliciting Patient Values and Goals
Surgeons must explicitly ask families what makes the patient's life worth living and whether the patient would accept specific functional limitations (such as inability to communicate) to remain alive. 1 This values clarification directly shapes which treatment option aligns with the patient's goals. 1
Making Explicit Recommendations Based on Values
After understanding patient values, surgeons should synthesize this information into a clear recommendation that explicitly connects the patient's stated values to the proposed treatment. 1 For example: "Based on what you've told me, it sounds like your father would want to remain alive as long as possible regardless of his ability to communicate. Based on that, I would recommend we move forward with the neurosurgical option because that option has the highest chance of keeping him alive." 1
Critical Information That Must Be Disclosed
The Novel Nature and Uncertainty
When procedures are innovative or the surgeon has limited experience, this must be disclosed explicitly, as approximately 80% of patients indicate they cannot decide on surgery without knowing if it would be the surgeon's first time performing the procedure. 2 Patients place significantly more importance on volumes and outcomes data than surgeons typically recognize. 2
Comprehensive Outcome Descriptions
Surgeons influence decisions by how comprehensively they describe potential outcomes. 3, 4 Rather than simply listing discrete procedural risks, surgeons should describe a range of postoperative trajectories including functional decline and quality of life implications. 4 The Best Case/Worst Case framework shifts conversations from isolated surgical problems to discussions about treatment alternatives and realistic outcome ranges. 4
Balancing Risks of Action Versus Inaction
Surgeons must explicitly present the risks of both performing and not performing surgery, particularly when not operating carries risk of irreversible consequences such as severe osteoarthritis or death. 1 This balanced presentation allows families to weigh competing risks rather than viewing surgery as the only option with risks. 1
Common Pitfalls to Avoid
Overly Technical Explanations
Surgeons often translate informed consent into overly complicated technical disease explanations coupled with oversimplified narratives that surgery will "fix" the problem. 3 This approach fails to support deliberation and omits critical information about surgical goals and downsides. 3
Presenting Untenable Options as Patient Choice
Surgeons should not present options they believe are clearly inappropriate as matters of patient choice, as this creates false autonomy rather than genuine shared decision-making. 3 The surgeon's clinical judgment about what options are reasonable should guide which alternatives are presented. 1
Failing to Acknowledge Decision-Making Preferences
A critical error is assuming all families want the same level of involvement in decisions rather than explicitly asking about their preferred approach. 1 This assumption can lead to either overwhelming families who prefer guidance or alienating those who want autonomy. 5
Patient and Family Factors
Age and Education Influence Preferences
Elderly and less-educated patients are significantly less interested in shared medical decision-making (p=0.003 and p=0.015) and in receiving detailed information (p=0.03 and p=0.05). 5 Surgeons should assess individual preferences rather than assuming all patients want maximum information and involvement. 5
Majority Want Active Involvement
Despite individual variation, 64% of surgical patients want active roles in decisions about complications, 89% regarding resuscitation, and 73% desire detailed preoperative information. 5 The type of operation (minor versus major) and disease severity do not significantly affect these preferences. 5
Ethical and Legal Requirements
Informed Consent Standards
Informed consent requires providing sufficient information for patients to make sound judgments about whether to proceed, including the purpose of treatment, expected benefits, significant risks, and alternatives. 1 Failure to inform patients about surgical risks is unethical and legally precludes them from surgery. 1
Respecting Patient Autonomy
Competent adult patients have the right to refuse treatment even if life-saving, and the surgeon's preference or desire to gain experience should never influence treatment choice. 1 The choice of treatment belongs to the patient, not the surgeon. 1
Documentation Requirements
Information given to patients and families about medical conditions and treatment options should be recorded in clinical records, including the agreement to treatment with patient signature and the name of the clinician obtaining consent. 1