What is the recommended approach to conducting a goals of care assessment for a patient undergoing surgery?

Goals of Care Assessment for Surgical Patients

Conduct a structured, three-stage shared decision-making conversation that includes information exchange about treatment options and risks, deliberation about the patient's values and goals, and collaborative agreement on a treatment plan—ideally initiated early in the preoperative period by the operating surgeon. 1

Core Framework: The Three-Stage Approach

The default approach to goals of care assessment should follow this algorithmic structure 1:

Stage 1: Information Exchange

• Clinician shares: Treatment options available, risks and benefits of each option (including surgery), alternatives to surgery, and the option of palliative care without life-prolonging interventions 1
• Patient/surrogate shares: The patient's values, goals, and preferences relevant to the surgical decision, including what matters most to them and their priorities 1
• Explore broadly: Even when patients haven't had explicit conversations about specific scenarios, discuss their prior actions, decisions, and overall values to inform what they might prefer in the current situation 1

Stage 2: Deliberation

• Share opinions about which option best aligns with the patient's goals 1
• Ask questions and correct misperceptions about surgical outcomes or recovery 1
• Explain perspectives on why certain options may be preferable given the patient's stated values 1
• Explore understanding of the medical situation and prognosis 1

Stage 3: Collaborative Decision

• Reach agreement on the care plan that both parties support 1
• Document clearly: Record the discussion, including benefits and risks discussed, alternatives considered, and the patient's stated goals of care 1

Timing and Setting

Initiate these conversations early—ideally during the preoperative period, not at the bedside immediately before surgery. 1, 2 The American College of Surgeons recommends structured discussions for high-risk surgical patients before the operation 3. Early timing allows:

• Patients to participate while they have decision-making capacity 1
• Adequate time for patients and families to process information 4
• Opportunity to involve appropriate family members in understanding the patient's goals 1

Critical pitfall: Most code status changes and goals of care discussions in surgical patients occur on the day of death or within 48 hours of death, suggesting these conversations happen far too late 3. This represents a failure to engage patients when they can meaningfully participate.

Who Should Lead the Discussion

The operating surgeon should conduct the preoperative assessment and goals of care discussion to formulate a surgical plan and establish a relationship with the patient before surgery 1. For high-risk patients, involve a multidisciplinary team including 1:

• Senior surgeon
• Senior anesthesiologist
• Senior intensivist
• Other specialists as appropriate (e.g., geriatricians for frail elderly patients)
• Consider surgeon-to-surgeon palliative care consultation for complex goal-setting 2

Risk Assessment Integration

Use validated risk prediction tools as part of—not a replacement for—the overall assessment to facilitate discussions about outcomes 1:

• The NELA risk prediction tool is calibrated for emergency laparotomy and performs well for high-risk patients 1
• Combine risk scores with frailty assessment and nutritional status for better mortality prediction 1
• Apply population-based risk tools cautiously to individual patients 1

For patients with severe life-limiting disease, poor quality of life, or particularly high predicted risk, multidisciplinary discussion should occur before proceeding with surgery 1.

Adapting the Approach to Patient Preferences

While shared decision-making is the default, modify the approach based on individual patient/surrogate preferences 1:

• Greater patient autonomy: When surrogates clearly understand the patient's preferences and want more control, present the range of medically appropriate options and allow them to choose 1
• Greater clinician guidance: When surrogates have strong aversion to decisional responsibility, clinicians may appropriately assume more responsibility while still ensuring alignment with patient values 1
• Reassess throughout: Decision-making preferences may change during the hospital course as trust develops or clinical circumstances evolve 1

Essential Communication Elements

Address these specific components 1:

1. Mental preparation: Anticipate patient and family emotions and questions about prognosis 1
2. Review prior documentation of any previous goals of care discussions 1
3. Ask permission before sharing difficult news or prognostic information 1
4. Provide information in small amounts using language appropriate to health literacy level, checking understanding frequently 1
5. Acknowledge emotions throughout the conversation 1
6. Define goals explicitly: Ask "What is most important to you? What are your priorities?" 1
7. Align goals with treatments: Connect the patient's stated values with the treatments and services offered 1
8. Summarize and document: Recap the conversation, establish a future plan, and document thoroughly in the medical record 1

Critical Considerations for Emergency Surgery

For emergency laparotomy and acute surgical conditions, conduct multidisciplinary discussions before surgery when feasible, particularly for high-risk patients 1. Time constraints create ethical challenges 5, but even brief structured conversations can:

• Clarify whether surgery aligns with patient goals 5
• Prevent non-beneficial surgery that occurs at the expense of patient dignity 1
• Reduce moral injury to clinicians who provide treatment they know is not beneficial 1

Document the patient's goals of care preoperatively whenever possible, as findings at surgery may dramatically alter outcomes 1. If formal assessment cannot occur before surgery, conduct it immediately postoperatively 1.

Avoiding Non-Beneficial Surgery

One-third of older patients undergo surgery in the last year of life, and 18% in the last month of life 1. To avoid non-beneficial interventions:

• Discuss alternatives to surgery explicitly 1
• Consider whether surgery can achieve the patient's stated goals given their life-limiting disease 1
• Include palliative care options in all discussions 1
• Emphasize what will be continued (comfort measures, dignity, spiritual support) not just what will be discontinued 1

Ongoing Communication

Reassure patients they will not be abandoned regardless of treatment choice 1. Throughout the surgical stay:

• Explain all care being given and why, in understandable terms 1
• Emphasize that patients and families are welcome to ask questions at any time 1
• Revisit goals of care discussions as clinical events unfold 1
• Ensure someone on the treatment team maintains continuity of communication 1