Background: Advance directive (AD) use is uncommon in surgical patients, yet the exact reasons for this are unknown. Our aim was to identify and describe beliefs held by surgeons regarding ADs. A qualitative exploration of physicians' opinions of ADs for surgical patients was designed. This methodology is preferred to quantitative techniques, which are subject to bias when an issue's underlying themes are unknown. Methods: A purposive sample of physicians, primarily surgeons performing high-risk operations, was interviewed using a semi-structured questionnaire. Representation from several subspecialties established maximum transferability. Data collection continued until theoretical saturation was achieved. Transcribed audiotapes were first coded independently and then collaboratively using a coding scheme developed through grounded theory and deductive approaches. Modeling identified themes and trends to ensure faithful data representation. Results: Three significant themes emerged, illustrating the conflicting attitudes surgeons harbor with respect to ADs. Surgeons described a general benefit of ADs in providing a framework for discussion ("It [AD] is a useful framework to begin discussion in the end of life issues for the patient."), but they also exhibited frustration with the disconnect between reality and written ADs ("What they [patients] really mean and what the words say are totally different.") and felt conflicted between the battle for surgical cure and the treatment limitations that occur with ADs in practice ("[ADs] may tie a surgeon's hands that might influence my judgment in performing the operation."). Conclusion: Surgeons describe conflicting feelings about ADs for high-risk surgical patients. These beliefs and attitudes may be an underlying factor for the limited use of ADs by surgical patients. Methods for improving effective use of ADs in surgical practice must address these attitudes.
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