Background: High risk patients undergoing elective surgery are at increased risk of life-threatening complications. Also, most are under anesthesia, lacking capacity for at least that time. Despite this they often lack advance directives (ADs) or do not have them accessible in their medical records.
Methods: We did a retrospective chart review of 231 patients seen in perioperative clinics of 2 tertiary referral hospitals. In our health system, patients are referred to these clinics due to increased risk for perioperative complications. Chart reviews were performed by three raters. Demographic, medical, comorbidities (Charlson Index Revised), Revised Cardiac Risk Index (RCRI) and functional status information were determined based on the preoperative evaluation document. We assessed whether patients had a document appointing a surrogate decision maker (SDM), a living will or either type of AD present in the electronic medical record prior to surgery. The remainder of the admission/episode of care was also reviewed to assess complications in which ADs may be relevant. We conducted bivariate analysis of those with/without an AD in the EMR (Electronic medical record) using t-tests for continuous variables and Fisher’s exact tests for categorical variables.
Results: Patients had a mean age of 58.7 years; 52.4% were female and 12.1% were African American. We found 15.6% of patients reported they had previously completed any AD. Based on EMR review, 11.3% had an SDM and, 10.8% had a living will scanned in to the EMR at the time of surgery. Among demographic and medical variables, only patient age was associated with higher presence of ADs (mean 64.6 vs. 57.7, p=0.018). There was no association with RCRI, functional status or comorbidities. Those with ADs were more likely to be discharged to a Skilled Nursing or Rehabilitation Facility (27.8% vs. 6.7%) and less likely to be ambulatory at discharge (77.8% vs. 93.3%, p=0.0073). There was a non-significant difference in post-op complications 19.4% vs. 12.3%, p= 0.286)
Conclusions: Most patients in a preoperative clinic undergoing elective surgery lack advance directives and even fewer have them available in the medical record, despite a known risk of complications. Of variables that indicate higher risk for complications, only age was associated with higher proportion of AD’s. Medical evaluations in preoperative clinics provides an opportunity to identify high risk patients and assist with advance care planning.