Use of Advance Care Plans Insufficient Among Older Patients Undergoing High-Risk Surgery

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Many older patients lack advance care plans prior to undergoing high-risk surgery.
Many older patients lack advance care plans prior to undergoing high-risk surgery.

Patients aged 65 years or older in the United States undergo more than 4 million high-risk procedures (1% or greater in-hospital mortality) per year, according to a report in JAMA Surgery. The report's authors examined the prevalence and characteristics of preoperative advance care planning (ACP) documentation in this population.

The authors evaluated preoperative ACP documentation in 393 patients within the Palo Alto Medical Foundation Health System who had undergone high-risk surgeries, were 65 years or older, and had multiple chronic conditions.

Preoperative ACP documentation existed for 25.7% of patients, and of the 55 patients (14.0% of total) who died within the year after surgery, ACP documentation existed for only 17.

Multivariate analysis revealed the following features to be most strongly associated with ACP documentation prior to surgery in this study population: age 85 years and older (adjusted odds ratio [aOR], 2.00; 95% CI, 1.03-3.90; P = .04), presence of cognitive impairment (aOR, 6.12; 95% CI, 1.54-24.31; P = .01), and, especially, history of 8 or more office visits in the year before surgery (aOR, 13.01; 95% CI, 4.07-41.64; P < .001).

In multivariate analysis, type of surgery, presence of serious illness, marital status, and race or ethnicity did not show statistically significant associations with preoperative ACP documentation.

The authors suggest that obtaining ACP documentation prior to high-risk surgery may be beneficial for older patients with comorbidities. In addition, further research to determine whether presence of ACP documentation influences surgical decisions or outcomes is needed. Other recommendations are to include a discussion of ACP documentation with elderly adults prior to surgery.


Tang VL, Dillon EC, Yang Y, et al. Advance care planning in older adults with multiple chronic conditions undergoing high-risk surgery [published online December 5, 2018]. JAMA Surg. doi: 10.1001/jamasurg.2018.4647

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