Concordance in advance care preferences among high-risk surgical patients and surrogate health care decision makers in the perioperative setting

Surgery xxx (2019) 1e8

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Concordance in advance care preferences among high-risk surgical patients and surrogate health care decision makers in the perioperative setting Brooks V. Udelsman, MD, MHSa,*, Nicolas Govea, MDb, Zara Cooper, MD, MScc,d, David C. Chang, PhD, MPH, MBAa, Angela Bader, MD, MPHd,e, Matthew J. Meyer, MDf a

Department of Surgery, Massachusetts General Hospital, Boston, MA Department of Anesthesiology, NewYork-Presbyterian-Weill Cornell Medical Center, New York, NY Department of Surgery, Brigham and Women’s Hospital, Boston, MA d Center for Surgery and Public Health, Boston, MA e Department of Anesthesiology, Brigham and Women’s Hospital, Boston, MA f Department of Anesthesiology, University of Virginia, Charlottesville, VA b c

a r t i c l e i n f o

a b s t r a c t

Article history: Accepted 17 August 2019 Available online xxx

Background: Earlier studies have demonstrated poor concordance between patients’ advance care preferences and those endorsed by their surrogate health care decision makers in a medical setting. This study aimed to determine concordance in the perioperative setting among high-risk patients and to identify areas for improvement. Methods: This was a prospective cohort study set in a preoperative clinic for high-risk patients. Patients (>55 y) and their surrogates (dyads) were eligible for participation. Dyads were surveyed on the patient’s desire for advance care preferences (cardiopulmonary resuscitation, mechanical ventilation, hemodialysis, artificial nutrition) and tolerance for physical disability, cognitive disability, and chronic pain. Concordance was defined as the surrogate correctly predicting patient preferences. Patients and surrogates were resurveyed for concordance 30 to 60 d after the index procedure. Results: A total of 100 dyads (200 subjects) completed the survey. Median patient age was 68 y. Most patients were white (87%) and had an American Society of Anesthesiologists score of III (88%). The majority of dyads (59%) reported prior conversations about advance care preferences. Concordance specifically for cardiopulmonary resuscitation was 84%. In all other domains, <60% of dyads achieved concordance. Prior conversations regarding advance care preferences did not improve concordance in univariable or multivariable analysis. In postoperative surveys, substantial improvement was found in all domains except mechanical ventilation and cardiopulmonary resuscitation. Conclusion: In all domains except cardiopulmonary resuscitation, concordance was <60% in the preoperative setting and was not improved among dyads who reported prior conversations regarding advance care preferences. Discordance may limit patient autonomy by prolonging undesired interventions or terminating desired interventions prematurely. © 2019 Elsevier Inc. All rights reserved.

Introduction Improving the delivery of goal concordant treatment especially in older adults is a point of emphasis for multiple national and international societies, including the American College of Surgeons,

Aspects of this work were presented at the 2019 Academic Surgical Congress. * Reprint requests: Brooks V. Udelsman MD, MHS, Codman Center for Clinical Effectiveness in Surgery, 165 Cambridge Street, Boston, MA 02114, USA. E-mail address: [email protected] (B.V. Udelsman). https://doi.org/10.1016/j.surg.2019.08.013 0039-6060/© 2019 Elsevier Inc. All rights reserved.

the National Quality Forum, and the Critical Care Societies Collaborative.1e5 Advance care planning allows patients and surrogate decision makers to prepare for future health care decisions.6,7 It is assumed that surrogates have an accurate understanding of a patients’ advanced care preferences (ACPs); however, this assumption has been challenged recently in several publications.8,9 In the perioperative setting, surrogate decision makers play a particularly important role because anesthesia and postoperative complications can decrease patient decision-making capacity.10e12 Although surgery is usually well tolerated, it can mark a decline

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in a patient’s health, and nearly 20% of all US deaths occur within 2 months of an operation or other invasive procedures.13,14 In older patients, complications requiring admission to the intensive care unit (ICU) are associated with substantial decreases in function and can carry up to a 32% 6-month mortality.15 The preoperative evaluation is a critical time at which patients and surrogates can and should discuss the patients’ ACPs. Preparation for elective surgery provides a natural juncture for patients and surrogates to discuss expectations, potential limitations to treatment, and unacceptable health states.10 Early engagement with their surrogate decision makers may prevent later, nonbeneficial treatment in patients admitted to the ICU who develop chronic critical illness.16,17 In this study, we aimed to determine (1) the rate of concordance between patients and surrogates in the preoperative setting, (2) the factors associated with improved concordance, and (3) the effect of the procedure and hospitalization on concordance. We hypothesized that patients and surrogates who reported prior conversations regarding ACP would have greater concordance than those who did not. Methods Design and study setting This was a longitudinal, cohort study involving patients and health surrogates termed dyads in a preoperative clinic at a tertiary academic medical center. The study was conducted between May 8, 2018, and February 20, 2019, at Brigham and Women’s Hospital, Boston, MA. Dyads were asked to complete surveys independently regarding patients’ ACP during a preoperative clinic visit. Dyads were then resurveyed between 30 and 60 d after the procedure through mailed letters. Dyads who did not respond to letters received up to 2 telephone reminders. Dyads who did not respond after 2 reminders were deemed nonresponders. This study was approved by the Partners Institutional Review Board (Boston, MA). Informed consent was implied through participation and formal written consent waived by the IRB. The deidentified data used in this study are available for review. Participants At our institution, patients are screened preoperatively, and those who are at the greatest riskdbased on the procedure and their comorbiditiesdare asked to participate in a dedicated preoperative clinic visit with an anesthesiologist. Patients who are at a lesser risk receive a phone call from nursing staff but do not have an in-person clinic visit. In this study, we focused on patients who had participated in an in-person, preoperative assessment and who were
55 y of age. We specifically used this age cutoff because this represents a vulnerable population in which surrogates play a critical role and to compare this study with earlier work in the medical literature.8,18 Patients were eligible for our study if they were accompanied by a surrogate health care decision maker. Although many of the surrogates had official power of attorney and legal documentation as a health care proxy, this criterion was not a requirement. This decision for inclusion was made, given that many times surrogates, such as spouses and adult children, are called to advocate for patients during critical illness despite a lack of official power of attorney. Dyads were excluded if either the patient and or their companion expressed discomfort with the companion acting as a surrogate decision maker. Dyads were excluded if the patient or surrogate were unable to read or complete the English surveys independently. Potential participants were approached by study staff and provided with a brief

study fact sheet. If both members of the dyad agreed to participate, they were each provided with a survey. Survey tool Patients and surrogates each completed the survey independently. Patients and surrogates were instructed to refrain from sharing answers while completing the survey but were encouraged to discuss their answers afterward. Research staff were present in the clinic to answer questions and ensure surveys were completed independently. Surveys consisted of three sections (eData Files 1 and 2). The first section contained questions about the relationship between the patient and the surrogate. This section included questions regarding how confident the surrogate was in his or her knowledge of the patient’s health care preferences and how confident the patient was in the surrogate’s understanding of his or her own health care preferences. These items were modified from interviews conducted between patients and surrogates reported by Fried et al.8,9 In the second section of the survey, patients were surveyed on seven domains of ACP. Four of these questions were based on the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) and the Physician Orders for Life-Sustaining Treatment (POLST) and included preferences regarding cardiopulmonary resuscitation (CPR), mechanical ventilation, hemodialysis, and artificial nutrition. Three additional questions that focused on physical disability, cognitive disability, and severe pain were based on a survey described by Fried et al.8,9 Physical disability was described as being unable to bathe or dress oneself. Cognitive disability was described as being unable to recognize family members or close friends. Severe pain was described as pain equivalent to a broken bone or birth labor. Patients and surrogates were asked to differentiate between health states that they would never tolerate, would tolerate for a period of time (weeks to months), or would tolerate indefinitely. For the domains of CPR, dyads were asked to differentiate between CPR with chest compressions, CPR without chest compressions, and no CPR. In the third section of the survey, dyads were asked to provide demographic information including age, sex, race/ethnicity, education level, employment status, and living situation. In addition, patients and surrogates were surveyed on their perceived state of health and quality of life. Last, patients and surrogates completed the Patient Health Questionnaire-2, a 2-question depression screen.19 These items were included because earlier work has suggested that these items may play a role in patient-surrogate concordance.20 Outcomes Surveys were reviewed to determine concordance between patients and surrogates on ACP. Concordance was dichotomized (yes/no) and defined as an agreement between ACP reported by the patient and those predicted by the surrogate. Dyads were stratified based on a reported prior conversation regarding ACP. Covariates Captured covariates included the type of surrogateepatient relationship, sociodemographics, perception of quality of life and health status, and positive screening for depression as collected in the first and third section of the survey instrument. From chart review, we included the American Society of Anesthesiologists (ASA) score. Finally, we included the type of planned operation or procedure, which was stratified into high(intrathoracic, intraperitoneal, suprainguinal vascular) or low risk based of the revised cardiac risk index.21

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Table I Patient and surrogate characteristics Patient and surrogate characteristics

Patient (n ¼ 100)

Surrogate (n ¼ 100)

Age, y, median (IQR) Female, % Non-Hispanic white, % Married/committed relationship, % Positive depression screen* ASA, median (IQR) Surgical procedure, % Gynecologic/urologic Cardiothoracic Neurosurgery/spine Orthopedic Gastrointestinal Othery ENT Vascular Skin/soft tissue High-risk procedurez, % College degree, % Living arrangement, % With family members Alone Long-term care facility Employment status, % Full-time Part-time Retired/unemployed Self-rated health, % Excellent or very good Good Fair or poor Self-rated quality of life Best possible Good Fair/poor

68 (61e74) 48 87 86 15 3 (3e3)

65 (56e71) 58 91 89 4 NA

23 20 16 12 9 10 5 3 2 32 45

56

91 8 1

93 6 1

24 24 49

36 9 53

63 21 16

75 20 5

33 48 19

43 51 6

Surrogate is official HCP, %

81

78

Prior conversation on LST, %

75

77

72 25 3 92

74 22 4 91

Level of confidence Very confident Somewhat confident Not confident Daily contact between patient and surrogate Relationship of surrogate/patient, % Spouse/long-term partner Adult son/daughter Otherx

Dyad concordance Agree surrogate is official HCP: 73 Agree surrogate is not an official HCP: 7 Agree prior conversation on LST occurred: 59 Agree conversation on LST did not occur: 4 Both Both Both Both

patient patient patient patient

and and and and

surrogate surrogate surrogate surrogate

very confident: 59 somewhat confident: 7 not confident: 0 report daily contact: 89

78 14 8

IQR, interquartile range; ENT, ear, nose, throat; ASA, American Society of Anesthesiologists status; HCP, health care proxy; LST, life-sustaining treatment. * Depression based on Patient Health Questionnaire-2 Screen score
3. y Includes imaging, endoscopy, interventional radiology, and brachytherapy. z High-risk procedures defined by the modified cardiac risk index and includes intrathoracic, intraperitoneal, and suprailiac vascular procedures. x Includes parents, siblings, and friends.

Statistical analysis Statistical analysis was performed using Stata software, version 15.1 (StataCorp, College Station, TX). Characteristics of study participants were described with frequencies and medians with interquartile range (IQR). Characteristics of dyads who reported prior conversations regarding ACP were compared with those who did not using the Pearson c2 and the Mann-Whitney U test as appropriate to the data. An a priori power calculation was used to determine a sample size of 95 dyads (190 participants) to detect a 15% difference between dyads who had and who had not discussed ACP previously. Age, sex, self-reported prior conversations regarding ACP, and variables with an associated P value < .10 on univariable analysis were entered into a logistic regression model for the outcome of

concordance. A separate linear regression was performed for the number of domains in which concordance was achieved. Concordance in follow-up postoperative surveys was compared with that in the preoperative setting, using the McNemar exact test. Two-tailed P values < .05 were considered to be statistically significant. Results Participants The survey response rate was 66%. A total of 107 dyads agreed to participate in the study; however, 7 dyads were excluded because of incomplete surveys. Those who did not complete surveys reported that a lack of time was the primary reason.

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B.V. Udelsman et al. / Surgery xxx (2019) 1e8 Table II Concordance between patients and surrogates Domains

Overall (n ¼ 100)

Patient and surrogate reported prior conversation regarding treatment goals Yes (n ¼ 59)

No (n ¼ 41)

CPR, n (%) Intubation, n (%) Hemodialysis, n (%) Artificial nutrition, n (%) Physical disability, n (%) Cognitive disability, n (%) Severe pain, n (%) All seven domains, n (%)

84 46 51 49 57 48 42 11

46 (78) 25 (42) 30 (51) 31 (53) 37 (63) 29 (49) 27 (46) 7 (12)

38 (93) 21 (51) 21 (51) 18 (44) 20 (49) 19 (46) 15 (37) 4 (10)

(84) (46) (51) (49) (57) (48) (42) (11)

P

.05 .38 .97 .40 .17 .78 .36 .74

CPR, cardiopulmonary resuscitation.

Of the patients, 52% were male, 87% non-Hispanic white, and the median age was 68 y (IQR 61e74; Table I). The majority were married or in a long-term relationship (86%). Most patients had an ASA score of 3 (88%). Most reported their health status to be excellent or very good (63%) and that their quality of life was at least good (82%). A total of 15% screened positive for depression on the Patient Health Questionnaire-2. The intended surgical procedures varied widely, with gynecologic/urologic being most common (23%) followed by cardiothoracic (20%) and neurosurgery/spine (16%). Most surrogates were female (58%) and non-Hispanic white (91%). Median surrogate age was 65 y (IQR 56, 71). Most surrogates reported at least a good quality of life (94%) and only 4% screened positive for depression. Patient and surrogate relationship and prior conversations of ACP Most surrogates were either spouses or long-term partners (78%), and a smaller proportion were adult children of the patient (14%; Table I). The majority of dyads agreed that the surrogate was the official health care proxy for the patient (73%) and that they had discussed the patient’s ACP (59%). Most patients (72%) were “very confident” in their surrogate’s understanding of their ACP. Correspondingly, a similar number of surrogates (74%) were “very confident” in their knowledge of the patient’s care preferences. Patient and surrogate concordance on life-sustaining treatments Patients completed closed-ended surveys of their ACP across seven domains, including four interventions (CPR, mechanical ventilation, dialysis, and artificial nutrition) and three health states (physical disability, cognitive disability, and chronic pain). Surrogates completed similar closed-ended surveys in which they predicted patient ACP across the same seven domains. Concordance was the greatest for the domain of CPR at 84% (Table II). For the 6 other domains, concordance ranged from 42% to 57%. Among the dyads, 53% were concordant on at least 4 domains, but only 11% of dyads were concordant in all 7 domains (Fig 1). In the domain of CPR, dyads in which the patient and surrogate reported prior conversations on the patients’ ACP tended to have worse concordance, but this did not achieve statistical significance. Prior conversations regarding the ACP were not associated with better or worse concordance in any domain. Overall, when discordance did occur, the surrogate tended to advocate for more invasive or prolonged treatment (Fig 2). Degree of discordance Instances of patient and surrogate discordance were related primarily to temporary versus permanent treatments/conditions.

Fig 1. Number of domains in which concordance was achieved for each dyad.

Maximal discordance occurred when one member of a dyad advocated for the most aggressive intervention, and the other member advocated for no intervention (eg, a patient desires artificial nutrition for no period of time, a surrogate advocates for it indefinitely). The percentage of dyads with maximal discordance ranged from 11% in the domain of mechanical intubation to 2% in the domain of artificial nutrition. Of note, 7% of dyads had maximal discordance in the domain of CPR. Factors associated with concordance Both unadjusted and adjusted analysis was performed to determine factors associated with concordance. Across the seven domains, no distinct factor was consistently associated with an improved concordance (eTable I). Concordance in an increasing number of domains was assessed in linear regression. In this analysis, the only factor associated with improved performance was a greater-risk procedure based on the modified cardiac risk index (Table III). Dyads who reported being very confident tended to have greater odds of concordance, but this did not achieve statistical significance on adjusted analysis. Postoperative concordance A total of 47 dyads responded to follow-up surveys. The demographics and relationships of the patients and surrogates who responded were similar to the preoperative group (eTable II). Among the respondents, there was improvement in concordance in all domains. This improvement was statistically significant in all domains except CPR and mechanical ventilation (Fig 3).

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Fig 2. Discordance among patients and surrogates regarding life-sustaining interventions. Only dyads who demonstrated discordance were included and each row totals to 100%.

Table III Linear regression for increasing concordance Patient and surrogate characteristics

Patient age, y Female patient Non-Hispanic white Married or committed relationship Positive depression screen* Living with family members Full-time employment College degree or higher ASA score High-risk procedurey Self-rated health Excellent or very good Good Fair or poor Self-rated quality of life Best possible Good Fair or poor Official designated health care proxyz Prior conversation on ACPz Patient and surrogate very confidentz Daily patient/surrogate contact

Unadjusted

Adjusted

Coefficient (95% CI)

P value

Coefficient (95%-CI)

P value

þ0.01 (e0.03 to 0.04) þ0.77 (0.03e1.51) þ0.18 (e0.94 to 1.30) þ0.15 (e0.94 to 1.23) þ0.19 (e0.86 to 1.25) e0.66 (e1.86 to 0.53) e0.35 (e1.24 to 0.52) e0.11 (e0.86 to 0.65) þ1.17 (0.09e2.25) þ0.93 (0.15e1.71)

.88 .04 .75 .79 .72 .27 .43 .78 .03 .02

þ0.01 (e0.03 to 0.05) þ0.56 (e0.18 to 1.31)

.66 .14

þ0.89 (e0.19 to 1.97) þ0.85 (0.05e1.65)

.10 .04

Ref. e0.52 (e1.45 to 0.43) e0.95 (e2.01 to 0.11)

.29 .08

e0.33 (e1.25 to 0.58) e0.88 (e1.90 to 0.14)

.47 .09

Ref. þ0.14 (e0.71 to e0.99) e0.61 (e1.69 to 0.47) þ0.60 (e0.24 to 1.44) þ0.11 (e0.66 to 0.87) þ0.68 (e0.07 to 1.44) e0.11 (e1.50 to 1.27)

.74 .27 .10 .78 .08 .87

þ0.89 (e0.10 to 1.79) e0.35 (e1.20 to 0.49) þ0.61 (e0.17 to 1.39)

.06 .41 .12

ASA, American Society of Anesthesiologists; ACP, advance care preferences. Age, Sex, prior conversation about ACP, and factors with a P value < .10 on unadjusted analysis were included in an adjusted model. * Positive screen on Patient Health Questionnaire-2. y High-risk procedures defined by the modified cardiac risk index and includes intrathoracic, intraperitoneal, and suprailiac vascular procedures. z Both patient and surrogate agreed.

Discussion In this study of patients and surrogate health care decision makers in the perioperative setting, we found concordance was up to 84% for CPR but was less than 60% for all other domains. Even for CPR, we found that 7% of dyads displayed maximal discordance, indicating that 1 member advocated for maximal resuscitative efforts, and the other member advocated for no resuscitative interventions. Surrogates tended to advocate for more aggressive treatment than that desired by patients’ ACP. We found that dyads who reported prior conversations on

ACP performed no better than those who did not. Similarly, dyads that reported that the surrogate was the legally documented health care proxy performed no better than those who did not. In postoperative surveys, concordance improved significantly. This study expands on earlier work examining patient and surrogate concordance by demonstrating that preoperative concordance is rarely greater than 70%.9,22e25 In an outpatient population of veterans
55 y of age, Fried et al8,9 reported that when patients and surrogates were asked about unacceptable health states, surrogates were only able to achieve 50% to 60%

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Fig 3. Preoperative and postoperative concordance between patients and surrogates in 47 dyads.

concordance with patient-reported preferences. Similar findings have been reported in the ICU.23 The process of making these decisions can have a substantial negative emotional effect on surrogates, especially when surrogates feel unsure about the patients’ treatment preferences.22,26 Although a modest improvement in concordance has been reported when patients and surrogates report prior conversations of the ACP, we did not observe a statistically significant improvement.8 As with earlier studies, we observed substantial disagreement within dyads on whether prior conversation about the ACP had occurred.27 Similar confusion about the completion of health care proxy forms was reported in 20% of this study’s population. This disagreement may reflect the varied and sometimes informal nature that ACP can be discussed between patients and surrogates.28 Several reasons may explain the relatively low rates of concordance. In the perioperative setting, physicians may be reluctant to engage in discussions of ACP out of concern that they may overburden patients.29,30 Furthermore, patients and surrogates may only discuss certain life-sustaining interventions, which may explain why concordance in the domain of CPR was observed in >80% of dyads, but only 11% of dyads were concordant in all 7 domains. Although concordance in all 7 domains may be difficult to expect, we would expect patients and surrogates to do fairly well if they report that they: (1) have discussed life-sustaining treatments previously, and (2) are confident in their knowledge of the patient’s wishes. That concordance is not greater indicates a potential knowledge gap. Indeed, surrogates and patients are not aware of their discordance. Efforts to improve concordance need to focus both on when and how patients and their surrogates discuss lifesustaining treatments. We included dyads in whom both the patient and surrogate expressed comfort with the surrogate acting as the health care decision maker for the patient. We did not, however, require legal documentation assigning the surrogate as a health care proxy. This decision reflects clinical practice, where only a small percentage of critically ill patients have completed a living will and less than half are admitted with an official designated health care proxy.31 Furthermore, in our analysis, we did not observe a significant difference in dyads who had and who had not designated a legal health care proxy. This study design is similar to that used in outpatient studies.8

Our study survey included questions related both to interventions and unacceptable health states in our survey instrument. Earlier work has focused on specific interventions (eg, mechanical ventilation, artificial nutrition); however, there is a growing body of evidence supporting a shift toward a goalfocused approach.32e34 We chose to include questions derived from MOLST/POLST forms aimed at specific interventions as well as questions regarding specific health states. Although concordance was relatively high for CPR, the fact that concordance was poor throughout the other domains implies that barriers lie in the communication between patients and surrogates. These results have implications for efforts to improve perioperative communication not only between patients and their health care proxy, but also between families and their physicians. A simple inquiry into the presence of an official health care surrogate is insufficient to ensure goal-concordant treatment in the event of the development of patient incapacity. Individuals’ tolerance for health states differs and should not be assumed35 Facilitated conversations between patients, surrogates, and health care providers have demonstrated efficacy previously.36,37 Likewise, a randomized controlled trial in the ICU has shown that mandatory documentation of prognosis can help clinicians engage in goals-of-care discussions with patients,38 but these interventions can be costly and time intensive. Recently introduced Medicare reimbursement for mediated discussions of ACP may help to alleviate these costs.39 In addition, there is evidence of downstream cost savings associated with appropriate transitions to palliative and hospice care.40 Resources to help guide patients through these decisions, independent of a health care professional, are available, including the ”Five Wishes” document, but their efficacy in the perioperative setting has not been assessed formally.41 Online or computerbased interventions have been tested in a randomized clinical trial. These interventions involved providing patients with interactive, online modules focused on values for end-of-life care and were associated with increased documentation of ACP; however, whether this improved patient and surrogate concordance is unknown.42 Of note, we found improved concordance in dyads who responded to follow-up surveys. It is unclear what lead to this improvement, whether it was the preoperative clinic experience, the procedure and subsequent hospitalization, exposure to the

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survey, or the experience of answering the survey at home. Nevertheless, the results suggest that interactions with the health care system may be associated with improved understanding of ACPs between patients and surrogates. Further studies performed in a randomized fashion will be necessary to validate it as a tool to improve concordance before larger-scale implementation. Our study has a number of limitations. We included a convenience sample of patients aged 55 y and older who presented to a preoperative anesthesia clinic. This population was selected based on the ready availability of a surrogate. Patients who arrived at the clinic without a potential health care surrogate were not evaluated, and the relationship and concordance between these patients and their surrogates may be very different from those of the patients who participated in this study. Presumably, patients who arrived at the clinic with a surrogate have a close relationship with their surrogate and would be expected to have greater concordance than those that have a more distant relationship. The fact that concordance was relatively low in this study implies that the problems with patient and surrogate concordance may be even worse in patients with estranged surrogates. Although we surveyed patients and surrogates about the presence of official documentation of a health care proxy, we did not require participants to review this paperwork. Given the limitations of our electronic medical record and inability to uniformly access the paper copies of the MOLST forms and other advance directives, we do not know how this documentation compared with the responses provided in the survey. Furthermore, we were not powered to detect the association between concordance and the honoring of patient priorities in the event of a life-threatening, perioperative complication. Given the rarity of these events, future research in this area will likely require multi-institutional studies over a greater time-period. In addition, this was a single-center study in a well-educated population. Although both genders were well represented, these patients are not reflective of all surgical practices. Based on earlier research in disparities and end-of-life care, the poor concordance observed in this study would likely be similar or worse in more socioeconomically disadvantaged patients.43e45 Moreover, we only included one surrogate per patient. This situation is potentially very important to acknowledge because patients often have many surrogates, and disagreement among surrogates can also lead to considerable conflict. Studies focused on discordance among surrogates will require additional research efforts. We included the ASA score as a metric disease burden because it was collected by a board-certified anesthesiologist for every patient and is a validated marker of preoperative health status.46 Alternatives, such as the Charlson comorbidity index and the Elixhauser index, have utility, but we could not use them in this study, because the associated variables may not have been captured uniformly and may have introduced bias inadvertently to the study. Last, ACP represents only one aspect of end-of-life planning. Goals-of-care discussions are nuanced conversations, and the underlying values they represent may not be fully captured by the survey used in this study.47 In conclusion, concordance between patients and surrogates on ACP is generally <60% in the preoperative setting and, although improved for CPR, 7% still display maximal discordance. This discordance may limit patient autonomy and the reliability of substituted judgment in the perioperative period and during unexpected admission to the ICU. Self-reported conversations regarding treatment preferences did not improve concordance; however, there was improved concordance in postoperative surveys. Future work will need to evaluate the efficacy of interventions aimed at improving concordance through randomized controlled trials.

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Funding/Support Brooks Udelsman was supported by the Society of University Surgeons-KARL STORZ Resident Research Award (2017e2018). Zara Cooper is supported by the Paul B. Beeson Emerging Leaders Career Development Award in Aging (1K76AG054859-01), the Cambia Foundation, PCORI (1502-27462), the American Geriatrics Society Geriatrics for Specialists Initiative, National Cancer Institute (1R35CA197730-01), and the National Institute on Aging (95R01AG044518-02), but these grants did not directly support this project. Conflict of interest/Disclosure The authors have no conflict of interest to report. Supplementary materials Supplementary material associated with this article can be found, in the online version, at https://doi.org/10.1016/j.surg.2019. 08.013. References 1. Berian JR, Rosenthal RA, Baker TL, et al. Hospital standards to promote optimal surgical care of the older adult: A report from the Coalition for Quality in Geriatric Surgery. Ann Surg. 2018;267:280e290. 2. Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: A best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215:453e466. 3. Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal perioperative management of the geriatric patient: A best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016;222:930e947. 4. Measure #0697: Risk-adjusted case-mix-adjusted elderly surgery outcome measure: National Quality Forum. Web site. http://www.qualityforum.org/QPS. Accessed January 10, 2019. 5. Critical Care Societies Collaborative - Critical care 2014. Web site. https:// www.choosingwisely.org/clinician-lists/critical-care-societies-collaborative-lifesupport-for-patients-at-high-risk-for-death-or-severely-impaired-functionalrecovery/. Accessed January 10, 2019. 6. Bernacki RE, Block SD, American College of Physicians High Value Care Task Force. Communication about serious illness care goals: A review and synthesis of best practices. JAMA Intern Med. 2014;174:1994e2003. 7. Bischoff KE, Sudore R, Miao Y, Boscardin WJ, Smith AK. Advance care planning and the quality of end-of-life care in older adults. J Am Geriatr Soc. 2013;61: 209e214. 8. Fried TR, Zenoni M, Iannone L, O'Leary J, Fenton BT. Engagement in advance care planning and surrogates’ knowledge of patients’ treatment goals. J Am Geriatr Soc. 2017;65:1712e1718. 9. Fried TR, Zenoni M, Iannone L, O'Leary JR. Assessment of surrogates’ knowledge of patients’ treatment goals and confidence in their ability to make surrogate treatment decisions. JAMA Intern Med. 2019;179:267e268. 10. Cooper ZR, Powers CL, Cobb JP. Putting the patient first: Honoring advance directives prior to surgery. Ann Surg. 2012;255:424e426. 11. Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362:1211e1218. 12. Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;158:1163e1167. 13. Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: Site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309:470e477. 14. Kwok AC, Semel ME, Lipsitz SR, et al. The intensity and variation of surgical care at the end of life: A retrospective cohort study. Lancet. 2011;378: 1408e1413. 15. Khouli H, Astua A, Dombrowski W, et al. Changes in health-related quality of life and factors predicting long-term outcomes in older adults admitted to intensive care units. Crit Care Med. 2011;39:731e737. 16. Kruser JM, Benjamin BT, Gordon EJ, et al. Patient and family engagement during treatment decisions in an ICU: A discourse analysis of the electronic health record. Crit Care Med. 2019;47:784e791. 17. Hwang DY. Engaging ICU patients and families before the certainty of treatment success or failure. Crit Care Med. 2019;47:869e871. 18. Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346:1061e1066.

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