Clinician Considerations about Surgical Decision-Making in the Context of Dementia

Abstract

Importance: Clinicians, people living with dementia (PLWD), and their caregivers face clinical, ethical, and psychosocial challenges when making surgical decisions. Objective: To explore clinician experiences with surgical decision-making when a patient has dementia Design: Qualitative case studies Setting: Interviews, Surveys, Resource Review Participants: 12 sites; 178 clinicians (64 surgeons, 100 other clinicians, 14 hospital leaders) Exposure: 1 interview Main Outcome and Measures: Themes describing clinician experiences with surgical decision-making when a patient has dementia Results: Three main themes were identified. Theme 1: Challenges with clinician identification of dementia and assessment of capacity in the surgical setting were barriers to optimal surgical decision-making. Furthermore, inconsistent documentation of cognitive impairment in electronic health records (EHR) and/or lack of EHR interoperability across health systems made it difficult to rely on medical records to identify dementia in a patient’s history. Theme 2: Caregivers and non-surgical clinicians were key contributors to surgical decision-making, but misaligned expectations, caregiver burden, and limited preparation complicated the process. Given the lack of EHR documentation for PLWD, clinicians needed to rely on caregivers to provide a sufficient picture of the PLWD’s cognitive and physical functioning, as well as their goals and values that were relevant to the surgical decision. Theme 3: Clinician appraisal of the relevance of dementia to surgical outcomes variably shaped the surgical decision-making process with PLWD and their caregivers. Clinicians commonly perceived that dementia negatively impacts surgical outcomes and recovery among PLWD, yet participants rarely referenced evidence such as published data or care guidelines supporting these views. Conclusions and Relevance: Study results suggest that surgical decision-making for PLWD is limited by failure to operationalize cognition, capacity, function, and caregiver input into clinical workflows. Clinicians face challenges including limited documentation or resources to support identification of dementia, variable caregiver involvement, and constrained access to dementia care specialists who can support the decision-making process. Addressing these challenges may include improving communication pathways with longitudinal providers, electronic health record documentation for older adults, routine and meaningful inclusion of caregivers, and access to non-surgical clinicians who can support surgical decision-making.