Background: In the context of high-risk surgery, shared decision-making (SDM) can be hindered by misalignment in expectations regarding the likely surgical outcomes between patients and clinicians. This study investigates the extent of this misalignment in high-risk patients and doctors involved in perioperative care, its impact on treatment choices, and its amenability to interventions that encourage perspective taking. Methods: High-risk patients (N = 55) and doctors involved in perioperative care (N = 54) were asked to consider one of three clinical scenarios: ischaemic heart disease, colorectal cancer, or osteoarthritis of the left hip. They reported on their expectations regarding short- and long-term outcomes of different treatment options available in these scenarios. Participants were initially asked to consider the scenarios from their own perspective as a patient/clinician, and then to adopt the perspective of the other side. After stating their expectations, participants were required to choose between surgical or non-surgical treatment. Results: Systematic misalignment in expectations between high-risk patients and doctors was observed, with patients expecting better surgical outcomes compared to clinicians. Despite this misalignment, in both groups surgical treatment was strongly preferred. Willingness to consider the non-surgical option was only observed when this option offered a chance to change the undesirable status quo. Conclusion: When high-risk surgery is discussed, a non-surgical option may be viewed as doing nothing, reducing the sense of agency and control. This biases the decision-making process, regardless of the expectations doctors and patients might have about the outcomes of surgery. Thus, to improve SDM and to increase patients agency and control over decisions about their care, we advocate framing the non-surgical treatment options in a way that emphasises action, agency, and change.

RP has received research grants and/or honoraria from Edwards Lifesciences, Intersurgical and GloaxoSmithkline, and is a member of the editorial board of the British Journal of Anaesthesia. There are no other competing awards.

This study was funded by the UK National Institute of Health Research

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The study received full ethical approval from the UKHealth Research Authority London Stanmore Research Ethics Committee (19/LO/1956).

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All data produced in the present study are available upon reasonable request to the authors