Concordance in advance care preferences among high-risk surgical patients and surrogate health care decision makers in the perioperative setting

Background: Earlier studies have demonstrated poor concordance between patients' advance care preferences and those endorsed by their surrogate health care decision makers in a medical setting. This study aimed to determine concordance in the perioperative setting among high-risk patients and to identify areas for improvement. Methods: This was a prospective cohort study set in a preoperative clinic for high-risk patients. Patients (>55 y) and their surrogates (dyads) were eligible for participation. Dyads were surveyed on the patient's desire for advance care preferences (cardiopulmonary resuscitation, mechanical ventilation, hemodialysis, artificial nutrition) and tolerance for physical disability, cognitive disability, and chronic pain. Concordance was defined as the surrogate correctly predicting patient preferences. Patients and surrogates were resurveyed for concordance 30 to 60 d after the index procedure. Results: A total of 100 dyads (200 subjects) completed the survey. Median patient age was 68 y. Most patients were white (87%) and had an American Society of Anesthesiologists score of III (88%). The majority of dyads (59%) reported prior conversations about advance care preferences. Concordance specifically for cardiopulmonary resuscitation was 84%. In all other domains, <60% of dyads achieved concordance. Prior conversations regarding advance care preferences did not improve concordance in univariable or multivariable analysis. In postoperative surveys, substantial improvement was found in all domains except mechanical ventilation and cardiopulmonary resuscitation. Conclusion: In all domains except cardiopulmonary resuscitation, concordance was <60% in the preoperative setting and was not improved among dyads who reported prior conversations regarding advance care preferences. Discordance may limit patient autonomy by prolonging undesired interventions or terminating desired interventions prematurely. (C) 2019 Elsevier Inc. All rights reserved.