Surgical "buy-in": The contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy

Margaret L. Schwarze, Ciaran T. Bradley, Karen Brasel

Research output: Contribution to journalArticle

116 Citations (Scopus)

Abstract

Objective: There is a general consensus by intensivists and nonsurgical providers that surgeons hesitate to withdraw life-sustaining therapy on their operative patients despite a patient's or surrogate's request to do so. The Objective of this study was to examine the culture and practice of surgeons to assess attitudes and concerns regarding advance directives for their patients who have high-risk surgical procedures. Design: A qualitative investigation using one-on-one, in-person interviews with open-ended questions about the use of advance directives during perioperative planning. Consensus coding was performed using a grounded theory approach. Data accrual continued until theoretical saturation was achieved. Modeling identified themes and trends, ensuring maximal fit and faithful data representation. Setting: Surgical practices in Madison and Milwaukee, WI. Subjects: Physicians involved in the performance of high-risk surgical procedures. Interventions: None. Measurements and Main Results: We describe the concept of surgical "buy-in," a complex process by which surgeons negotiate with patients a commitment to postoperative care before undertaking high-risk surgical procedures. Surgeons describe seeking a commitment from the patient to abide by prescribed postoperative care, "This is a package deal, this is what this operation entails," or a specific number of postoperative days, "I will contract with them and say, 'look, if we are going to do this, I am going to need 30 days to get you through this operation.'" "Buy-in" is grounded in a surgeon's strong sense of responsibility for surgical outcomes and can lead to surgeon unwillingness to operate or surgeon reticence to withdraw life-sustaining therapy postoperatively. If negotiations regarding life-sustaining interventions result in treatment limitation, a surgeon may shift responsibility for unanticipated outcomes to the patient. Conclusions: A complicated relationship exists between the surgeon and patient that begins in the preoperative setting. It reflects a bidirectional contract that is assumed by the surgeon with distinct implications and consequences for surgeon behavior and patient care.

Original languageEnglish (US)
Pages (from-to)843-848
Number of pages6
JournalCritical Care Medicine
Volume38
Issue number3
DOIs
StatePublished - Mar 2010
Externally publishedYes

Fingerprint

Therapeutics
Advance Directives
Postoperative Care
Consensus
Surgeons
Negotiating
Contracts
Patient Care
Interviews
Physicians
Grounded Theory

Keywords

  • Decisionmaking
  • Ethics
  • Informed consent
  • Patient autonomy
  • Surgical outcomes

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Surgical "buy-in" : The contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy. / Schwarze, Margaret L.; Bradley, Ciaran T.; Brasel, Karen.

In: Critical Care Medicine, Vol. 38, No. 3, 03.2010, p. 843-848.

Research output: Contribution to journalArticle

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