Patients may set up an advance directive (plan for end-of-life care), but according to a new study, surgeons may not abide by it, or they may even refuse to perform surgery because of restrictions outlined in an advance directive. In the study, a survey of U.S. surgeons found that most (81%) regularly talk with patients about the types of life support options a patient may want to limit after surgery, but only about half ask patients whether they have an advance directive or discuss the details, such as restricting feeding tubes or ventilators to prolong life.

The surveys were completed by a total of 912 vascular surgeons, cardiothoracic surgeons, and neurosurgeons who regularly perform high-risk operations. Among cardiothoracic surgeons, 63% said they would decline to operate if an advance directive limited the procedures that they could perform after surgery to keep the patient alive. About half of vascular surgeons and neurosurgeons might decline to operate based on an advance directive. Perhaps because neurosurgery can lead to devastating neurologic complications, neurosurgeons are more comfortable with withdrawing life support and see it as a reasonable decision.

Surgeons with more than 20 years of experience were more likely to ask about advance directives than were surgeons with less experience (69% versus 44%). And surgeons who asked patients about their preferences regarding limits on postoperative life-support therapy were five times more likely to ask about advance directives.

The results of this study suggest that some surgeons believe that advance directives send a signal that a patient isn't truly committed or is unwilling to accept the invasive therapies that come with high-risk operations.

Linda Groah, executive director and chief executive officer of the Association of periOperative Registered Nurses, points out that advance directives weren't designed to address surgical procedures but, rather, to guide lifesaving measures related to stroke, accidents, heart attacks, and related situations. "Surgery presents a different challenge, and it's important for surgeons and patients to discuss advance directives and reach an agreement on actions that could be taken during the intraoperative and postoperative phases of care," says Groah.

Nurses should make surgeons aware of patients' advance directive and then encourage and support the patients while they're discussing their desires with the surgeon. "Nurses can also make available other resources, such as a social worker, to assist in the discussion between the patient and physician," Groah says.-Carol Potera

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