Defining Surgical Shared Decision-Making for Older Adults Using the RAND/UCLA Appropriateness Method: A Consensus...

Older adults undergoing major surgery often face increased risks of functional decline, cognitive impairment, and loss of independence. While shared decision-making (SDM) is recommended, there are no standardized guidelines defining its key components for this population.

To identify valid and feasible components of surgical SDM tailored to older adults.

This qualitative consensus study used a 2-round modified Delphi process with the RAND/UCLA Appropriateness Method between June 1 and September 9, 2023. Forty-one candidate SDM components were developed from existing frameworks and stakeholder input and were rated for validity and feasibility on a scale of 1.0 to 9.0. Ratings were collected via REDCap. Components meeting a median score of 7.0 or greater with statistical agreement were considered valid and/or feasible. Data were analyzed from June 12, 2023, to January 1, 2024.

The 11 panelists included 8 clinicians (from the fields of surgery, geriatrics, palliative care, ethics, and social work) and 3 patient representatives. Seven panelists (63.6%) were female. Clinicians practiced in an urban, academic setting with a mean clinical experience of 13.8 (range, 1-35) years; the mean patient age was 67.6 (range, 52-84) years. In round 1, all 41 candidate components were rated valid; 33 (80.5%) were rated feasible and 8 (19.5%) were rated as having uncertain feasibility. After panel discussion and revisions, round 2 concluded that 39 components (95.1%) were feasible, while 2 (4.9%) were rated as unfeasible and removed. Four new components were added and rated valid and feasible for a total of 43 components. Barriers to implementation included knowledge and/or skills (55 of 164 [33.5%]), time (43 of 164 [26.2%]), and cultural factors (30 of 164 [18.3%]). Specific challenges involved assessing cognitive function and decisional capacity and counseling on long-term functional outcomes after surgery.

Through a structured consensus process, 43 components were identified as valid and feasible for surgical SDM with older adults. These components provide a framework to guide preoperative communication, inform quality measurement, and support the development of interventions to improve SDM. Addressing barriers such as time, knowledge, and cultural constraints will be essential for implementation.