Assessing Surgeons' Professional Attitudes Toward End-of-Life Decision Making: A Standardized Simulation-Based Study...

Clinical decision-making is a nuanced skill, further complicated in end-of-life situations. Studies show there is little palliative care training regarding EOL decisions in surgery. Surgeons report performing operations that they know will not benefit the patient and have also reported being inclined towards a curative approach. We aimed to explore EOL decision-making as a potential simulatable Entrustable Professional Activity; part of nontechnical skill assessment for prospective examinations, by analyzing in a quantitative manner the ability to recognize conditions where palliative care would be in the best interest of the patient, avoiding inappropriate surgical interventions.

A standardized survey was designed and distributed among a range of experience of surgical practitioners. Their paired responses to frequently encountered acute surgical scenarios were statistically analyzed and compared among junior and senior surgeons.

About 70% respondents completed the survey. Two out of the 3 clinical vignettes found significant differences in decision-making. In terms of identifying a benign pathology as a palliative situation earlier, the consultants performed significantly better than registrars (0.03). Pair wise comparisons showed registrars scoring significantly higher than SHOs (p = 0.03) in a scenario with acute abdominal pathology on a background locally advanced malignancy. The opinion about training in this regard was split between moderately adequate (39%) and somewhat inadequate (39%), with 22% reporting it was neither adequate nor inadequate.

Assessing high end decision-making skills is achievable with meticulously structured bespoke clinical scenarios. A simulated construct determines the differences between EOL management among registrars versus consultants. Findings from the detailed study lay the foundation for development of a summative assessment tool for EOL decision-making in surgeons; a task that has not been acknowledged as an EPA.