Background: Little is known about the opportunities for shared decision-making when high-risk patients (over 60 years, with co-morbidities) are offered major surgery. This paper examines when and why clinicians and patients can share decision-making about major surgery. Methods: Multi-method qualitative study, combining video-recordings of pre-operative consultations, interviews and focus groups (with a maximum variation sample of 31 patients, 19 relatives, 37 clinicians), with observations of clinics in five UK hospitals undertaking major joint, colorectal and/or cardiac surgery. Results: Three opportunities for shared decision making about major surgery were identified. Resolution-focused consultations (cardiac/colorectal) resulted in a single agreed preferred option related to a potentially life-threatening problem, with limited opportunities for shared decision-making. Evaluative and deliberative consultations offered more opportunity. The former focused on assessing the likelihood of benefits of surgery for a presenting problem that was not a threat to life for the patient (e.g. orthopaedic consultations) and the later (largely colorectal) involving discussion of a range of options while also considering significant comorbidities and patient preferences. The extent to which opportunities for shared decision-making were available, and taken up by surgeons, was influenced by nature of the presenting problem, clinical pathway and patient trajectory. Conclusion and relevance: Decisions about major surgery are not always shared between patients and doctors. The nature of the presenting problem, comorbidities, clinical pathways and patient trajectories all inform the type of consultation and opportunities for sharing decision-making. This has implications for clinicians, with shared decision-making about major surgery most feasible when the focus is on life-enhancing rather than life saving treatment.

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.

https://bmjopen.bmj.com/content/10/5/e033703.abstract

The study was funded by the UK National Institute of Health Research [RP-PG-0217-10001].

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study received ethical approval from South Central Oxford C Research Ethics Committee (19/SC/0043) of the UK Health Research Authority in February 2019

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