Shared decision making prior to emergency laparotomy: the perspectives of healthcare professionals, patients and their family

Background

Emergency laparotomy (EmLap) is associated with high post-operative morbidity and mortality, especially in patients living with frailty. Patients who do survive can suffer a significant reduction in levels of independence and quality of life. Decision making and information exchange in this context is therefore critically important. 

Methods

Semi structured interviews with patients and healthcare professionals were undertaken to identify factors recognised as important to the decision making process in the context of EmLap. Non-participatory ethnography at three different acute NHS sites was undertaken to record normal decision making practise prior to a potential EmLap, with fieldnotes taken. Recordings underwent professional transcription and thematic analysis. Themes identified as important to patients in semi-structured interviews informed focused analysis of ethnographic transcripts. 

Results

17 patients and 22 healthcare professionals underwent semi-structured interviews. 1 week of non-participatory ethnography at each site was completed, with discussions between patients, family members and healthcare professionals recorded.  Factors affecting how patients were communicated with (choice, options, preferences, risk, uncertainty) and specific information points (stomas, mortality, recovery, post-operative independence) were identified. 

Choice, options and preferences were rarely discussed, especially in the context of low healthcare professional uncertainty about decision making. Uncertainty was discussed, though was often not sufficiently clarified when further information was available and in a way patients could understand.  Risk, stomas and mortality were discussed, but often in ways that provided limited information. Recovery and post-operative independence were referred to inconsistently.

Conclusion

There is a discrepancy between how patients want to be communicated with and what information they consider important, and how healthcare professionals currently practise. These findings are directly relevant to patients with frailty undergoing EmLap, with functional recovery and independence important in this patient cohort.