Exploring Best Communication Practices for Shared Decision Making in Older Adults Considering Major Colorectal Surgery
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The older adult population (OAs; e.g., ≥65 years old) is projected to almost double between 2012 and 2050 in the United States. This population already disproportionately utilizes surgical services and this is projected to increase with this increase in the OA population. OAs have higher rates of complications after major colorectal surgery, particularly those who are frail. In addition, pre-existing functional and cognitive decline can also amplify the consequences of surgical complications. Finally, changes to bowel, urinary or sexual function are common in OAs after major colorectal surgery and can significantly impact quality of life. Thus, surgical shared decision- making (SDM) in this population is more complex. SDM is an approach well suited to manage complex decision making, such as high risk surgery in frail OAs. However SDM is not often successfully done prior to surgery, particularly in the OA population. SDM tools have been utilized to promote and improve SDM, but there is a gap in SDM tools specific to the frail OA population considering major colorectal surgery. A scoping review of existing provider facing tools for SDM show that most are risk calculators intended for elective surgical risk assessment but few addressed patient-centered domains such as assessment of patient goals, postoperative expectations such as changes to physical or cognitive function or independence, anticipated changes to quality of life, and long-term risks. As the population of the US continues to age, it will place greater demands on surgical services and is important that the medical community meet these growing demands and ensure high quality care for OA surgical patients, particularly those who are frail and most vulnerable within this population. The American College of Surgeons Geriatric Surgery Verification Program has recognized improvement of the surgical SDM process as an important standard of care in this patient population. There is a critical need to improve the SDM process in this population that is particularly vulnerable, growing in size, and with unique needs to improve outcomes, ensure high quality care, and inform decision making with patients and their families. This proposal will help develop a user-friendly SDM tool for surgeons, specific to the needs of frail older adults considering major colorectal surgery, to improve communication in the surgical SDM process. This will be achieved through a Delphi process of clinical experts and patient representatives to adapt an existing SDM to be specific for the proposed population utilizing the RAND/UCLA Appropriateness Methodology. This tool will then be pilot tested amongst providers to examine implementation outcomes (e.g., feasibility, barriers to use, utility of the tool) using the Consolidated Framework for Implementation Research (CFIR) and explore quality of SDM among patients. This proposal will adapt an existing tool for SDM in the frail OA population considering major colorectal surgery and pilot the tool to inform larger scale testing and multi-site implementation to evaluate its effects on the quality of surgical SDM through a later R01.
