Can Legal Witness Enhance Communication Quality? The Role of Lawyer Presence in Family Satisfaction with Surgical Risk Disclosure for Geriatric Hip Fracture

Can Legal Witness Enhance Communication Quality? The Role of Lawyer Presence in Family Satisfaction with Surgical Risk Disclosure for Geriatric Hip Fracture | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Can Legal Witness Enhance Communication Quality? The Role of Lawyer Presence in Family Satisfaction with Surgical Risk Disclosure for Geriatric Hip Fracture Heng-yan Zhang, Yi-ming Xu, Wang Wei-qing, Zhang Jia This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8659362/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The management of osteoporotic hip fractures in the elderly carries high risks. The quality of preoperative informed consent directly impacts family satisfaction and the risk of medical disputes. Conventional communication models are variable, and the introduction of a third-party lawyer witness may optimize this process by enhancing the formality and comprehensiveness of the communication. Methods This single-center retrospective cohort study consecutively enrolled elderly hip fracture patients and their guardians who underwent surgery at Peking Union Medical College Hospital between June 2022 and June 2025. Participants were divided into a Lawyer-Present Group and a Usual Care Group based on the presence of a lawyer during the preoperative consent conversation. At 3 months postoperatively, a third-party administered survey assessed guardian satisfaction, anxiety changes, and the Decision Regret Scale (DRS) measured decision-related feelings. Intergroup comparisons were performed using Chi-square tests, t-tests, and effect size analyses. Results A total of 94 patient-guardian pairs completed follow-up. The proportion of guardians who were "Very satisfied" with the preoperative conversation was significantly higher in the Lawyer-Present Group than in the Usual Care Group (79.5% vs. 12.7%, p < .001), with a large effect size (Cramér's V = 0.672). The Lawyer-Present Group also scored significantly better on the sufficiency of information regarding surgical necessity, risks, and increased decision confidence (all p < .01). However, a higher proportion of guardians in this group reported "Greatly increased anxiety" (74.4% vs. 38.2%, p < .001). While overall DRS scores showed no significant difference, within the subgroup of patients who developed postoperative complications, guardians in the Usual Care Group exhibited significantly higher regret (40.63 ± 7.29 vs. 30.00 ± 3.54, p = .012), with a very large effect size (Cohen's d = 1.72). Conclusion The introduction of a lawyer witness during preoperative conversations significantly improved communication satisfaction and perceived information quality among guardians of elderly hip fracture patients. The associated increase in anxiety may reflect a deepening of risk perception. In cases of complications, lawyer presence was associated with reduced decision regret among guardians. This suggests that procedural legal witnessing could serve as a potentially effective tool to enhance the quality of informed consent for high-risk surgery and strengthen the resilience of the doctor-patient relationship. Lawyer witnessing Informed consent Hip fracture Patient satisfaction Decision regret Doctor-patient communication Introduction With the intensification of global population aging, osteoporotic hip fractures in the elderly have become a common and high-risk condition threatening the health and lives of older adults[ 1 , 2 ]. Such fractures, due to the severe pain, significant functional loss, and consequent systemic complications, lead to consistently high rates of mortality and disability during conservative treatment[ 3 ]. Consequently, surgical intervention (e.g., internal fixation or arthroplasty) has become the primary approach to restore function and save lives[ 4 ]. However, elderly patients often present with multiple comorbidities and poor physiological reserve, leading to significantly elevated perioperative risks and a high incidence of postoperative complications, which imbues the surgery itself with substantial challenges[ 5 – 7 ]. This dilemma of "extremely high risk without surgery versus considerable risk with surgery" often places patients' families in an extremely difficult and stressful decision-making crossroads. Against this backdrop, the quality of preoperative informed consent conversations, particularly the adequate disclosure and effective communication of surgical risks, becomes paramount[ 8 ]. It is not only a legally mandated procedure but also a core element in building doctor-patient trust and reaching a therapeutic consensus. Extensive research indicates that patient and family satisfaction with the preoperative disclosure process directly influences postoperative treatment compliance, the understanding and acceptance of inevitable complications, and is ultimately significantly correlated with the risk of medical disputes[ 9 , 10 ]. Currently, a prevalent challenge in clinical practice is how surgeons, within limited time, can clearly, comprehensively, and unambiguously communicate complex and grave surgical risks while alleviating family anxiety and uncertainty. The traditional verbal disclosure model has limitations in standardization, rigor, and legal documentation, potentially leading to inconsistent communication outcomes[ 11 – 14 ]. To improve the quality and effectiveness of preoperative informed consent, balance information delivery with emotional support, and fundamentally protect the legitimate rights and interests of both patients and healthcare providers, exploring structured communication support tools or procedural interventions is particularly urgent. In recent years, alongside the development of quantitative risk assessment tools (e.g., SURPAS)[ 15 – 17 ], introducing third-party witnessing, especially formal lawyer witnessing, into major medical decision-making has begun to attract attention. This innovative practice holds theoretical dual core value: for patients and their families, the presence of a lawyer can ensure a fuller understanding of their legal rights and assist in interpreting medical documents, thereby providing more professional safeguarding of their interests procedurally; for healthcare providers, a standardized, rigorous, and documented communication process itself constitutes a form of legal protection, potentially alleviating their concerns when facing high-risk decisions and enabling them to focus more on the medical technology itself to treat patients with full effort [ 5 ]. However, whether this "legal witnessing" model truly fulfills its theoretical promise by tangibly enhancing the perceived quality of doctor-patient communication, specifically improving family satisfaction with risk disclosure, still lacks robust empirical evidence from rigorous clinical studies [ 6 ]. Therefore, this study aims to focus on the typical high-risk, high-dispute-potential scenario of elderly hip fractures. By comparatively analyzing preoperative conversations conducted with versus without a lawyer present, it empirically investigates the following core question: Can lawyer witnessing, and to what extent, enhance family satisfaction with the surgical risk disclosure process? The findings will provide critical evidence for optimizing the informed consent process for high-risk surgeries, innovating doctor-patient communication models, and fostering a more harmonious and resilient doctor-patient relationship. Methods Study Design and Setting This was a single-center, cross-sectional survey study conducted at the Orthopedic Center of Peking Union Medical College Hospital. The study protocol was approved by the Ethics Review Committee of Peking Union Medical College Hospital (Ref No: I-K10122). This study adhered to the principles of the Declaration of Helsinki. Participants The study consecutively enrolled elderly hip fracture patients and their primary decision-making guardians who underwent surgery performed by the same surgical team at Peking Union Medical College Hospital between June 2022 and June 2025. Patient inclusion criteria were: 1) age ≥ 75 years; 2) radiographically confirmed femoral neck fracture (FNF) or intertrochanteric fracture (IFF); 3) underwent surgical treatment, including hemiarthroplasty (HA) or intramedullary nailing (IMN). Exclusion criteria were: 1) pathological fracture; 2) patients with polytrauma; 3) guardians unable to comprehend the survey content or who refused to participate in the study. Grouping and Intervention Participants were divided into two groups based on whether a practicing lawyer was present as a witness during the preoperative informed consent conversation: Lawyer-Present Group: In addition to the routine preoperative conversation, an independent practicing lawyer, separate from the medical team, was present. The lawyer's role was to witness the communication process, ensure the guardian's understanding of the discussion, and provide explanations regarding relevant legal procedures, but not to participate in the medical decision-making itself. Usual Care Group: The preoperative informed consent conversation was conducted by the surgeon following the hospital's standard protocol, without the presence of a third-party lawyer. The core content of the preoperative conversation (surgical necessity, risks, alternatives, and consequences of refusing surgery) for both groups was based on the hospital's standard Surgical Informed Consent Form, ensuring consistency in the information foundation. Data Collection and Assessment Tools Data collection took place during the patients' outpatient follow-up at 3 months postoperatively, a time when lower limb functional recovery had reached a plateau. To ensure objectivity, all questionnaire surveys were administered by a third-party lawyer who was not involved in the witness group or the medical team. Basic Information: Sociodemographic data of patients and guardians, fracture type, and surgical procedure were collected via the medical record system and questionnaires. Preoperative Communication Satisfaction: A 7-item questionnaire developed based on previously validated tools was used[ 17 – 22 ]. The questionnaire covered three dimensions: information delivery quality (surgical necessity, risks, sufficiency of time, alternatives) and communication experience (feeling respected, impact on anxiety, decision confidence). Items were scored using 4-point or 5-point Likert scales. The primary outcome measure was overall satisfaction ("Overall, how satisfied are you with the process of this preoperative conversation?"). Decision Regret Assessment: The Chinese version of the Decision Regret Scale was used to evaluate guardians' long-term feelings about the surgical decision[ 23 , 24 ]. The scale consists of 5 items, with the total score converted to a range of 0-100. A higher score indicates stronger regret, with a score > 25 considered indicative of clinically significant regret. Clinical Outcomes: Postoperative complications (e.g., intracranial hemorrhage, cerebral infarction, pulmonary embolism, myocardial infarction, surgical site infection) were recorded. At 3 months postoperatively, patient walking function was assessed using the Holden Functional Ambulation Classification (FAC). The FAC assesses walking ability across six levels: 0 (no function), 1 (requires substantial and continuous assistance), 2 (requires minimal assistance), 3 (requires supervision or verbal guidance), 4 (independent walking), and 5 (completely independent). The number of patients in each group was tallied for levels 0–1, 2–3, and 4–5. Statistical Analysis All data were analyzed using SPSS software (version 26.0). Continuous variables are presented as mean ± standard deviation, and categorical variables as frequency and percentage. For comparisons between groups, independent samples t-tests were used for continuous variables that were normally distributed; otherwise, the Mann-Whitney U test was applied. Comparisons of categorical variables were performed using the Chi-square test or Fisher's exact test. For effect size calculations, Cohen's d was reported for continuous variable comparisons, and Cramér's V or Phi coefficient for categorical variable comparisons. All statistical tests were two-sided, and a p-value < 0.05 was considered statistically significant. Results Study Population and Baseline Characteristics This study initially enrolled 132 eligible patient-guardian pairs, with 47 in the Lawyer-Present Group and 85 in the Usual Care Group. At the 3-month postoperative follow-up, complete follow-up data were obtained for 94 pairs (71.2%), which were included in the final analysis (39 in the Lawyer-Present Group and 55 in the Usual Care Group). The main reasons for loss to follow-up included inability to make contact, refusal to participate in the follow-up interview, or patient death. As shown in Tables 1 and 2 , the two groups ultimately analyzed showed no significant differences in patient age, sex, fracture/surgery type distribution, complication rates, or postoperative function (all p > 0.05). The guardians in the two groups were also comparable in terms of age, sex, and educational level distribution (all p > 0.05). This indicates that the baseline characteristics of the two groups were balanced and comparable. Table 1 Demographics of participants (n = 94). Characteristics Usual consent (n = 55) Consent with Legal Witness (n = 39) p Value* Patient Age, y, mean (SD) 83.6 (5.6) 82.7 (8.0) 0.55 Guardian Age, y, mean (SD) 57.1 (4.8) 55.5 (8.2) 0.72 Patient Sex, n (%) 0.64 Male 18(32.7) 11(28.2) Female 37(67.3) 28(71.8) Guardian Sex, n (%) 0.45 Male 24(43.6) 14(35.9) Female 31(56.4) 25(64.1) Type of Surgery, n (%) 0.70 HA for FNF 26(47.3) 20(51.3) IMN for IFF 29(52.7) 19(48.7) Guardian Education, n (%) 0.65 High school or below 13(23.6) 12(30.8) Bachelor‘s degree 32(58.2) 19(48.7) Graduate degree or above 10(18.2) 8(20.5) *Values are from χ 2 test, Fisher’s exact test or Student t-test. Table 2 Patient surgical complications and postoperative limb function (n = 94). Characteristics Usual consent (n = 55) Consent with Legal Witness (n = 39) p Value* complications , n (%) 8 (14.5) 5 (12.8) 0.531 Intracranial hemorrhage 1 (1.8) 0 (0) Cerebral infarction 1 (3.6) 2 (5.1) Pulmonary embolism 2 (3.6) 2 (5.1) Myocardial infarction 3 (5.5) 1(2.6) Surgical site infection. 1 (3.6) 0 (0) FAC , n (%) 0.900 Level 0–1 15 (27.3) 9 (23.1) Level 2–4 36 (65.5) 27 (69.2) Level 5–6 4 (7.3) 3 (7.7) *Values are from χ 2 test or Fisher’s exact test Comparison of Guardians' Satisfaction with Preoperative Communication The survey results on guardian satisfaction revealed that the Lawyer-Present Group scored significantly better than the Usual Care Group on multiple core dimensions, although a different pattern was observed for anxiety levels (Table 3 ). Table 3 Survey Responses Regarding Guardians' Satisfaction with Surgical Informed Consent Procedures (n = 94). Response Usual consent (n = 55) Consent with Legal Witness (n = 39) p Value* Cramér‘s V Assessment of Information Delivery Quality Was the doctor's explanation regarding the necessity of the surgery sufficient? n (%) <0.001 0.425 Insufficient 1 (1.8) 0 (0) Somewhat insufficient 2 (3.6) 0 (0) Sufficient 33 (60.0) 9 (23.1) Very sufficient 19 (34.5) 30 (76.9) Was the amount of time the doctor spent discussing the surgical risks sufficient? n (%) <0.001 0.466 Insufficient 1 (1.8) 0 (0) Somewhat insufficient 2 (3.6) 0 (0) Sufficient 31 (56.4) 6 (15.4) Very sufficient 21 (38.2) 33 (84.6) 3. Was the doctor's explanation of "the consequences if surgery is not performed" sufficient? n (%) <0.001 0.425 Insufficient 2 (3.6) 0 (0) Somewhat insufficient 1 (1.8) 0 (0) Sufficient 37 (67.3) 12 (30.8) Very sufficient 15 (27.3) 27 (69.2) Communication Experience and Satisfaction Did the atmosphere of the conversation make you feel respected and able to freely express your thoughts and concerns? n (%) 0.001 0.388 Disagree 1 (1.8) 0 (0) Somewhat disagree 4 (7.3) 1 (2.6) Agree 37 (67.3) 14 (35.9) Very agree 13 (23.6) 24 (61.5) Did this risk discussion affect your anxiety regarding the surgery for your family member? n (%) 0.002 0.372 Greatly increased anxiety 21 (38.2) 29 (74.4) Somewhat increased anxiety 28 (50.9) 7 (17.9) Somewhat decreased anxiety 5 (9.1) 3 (7.7) Greatly decreased anxiety 1 (1.8) 0 (0) How did the discussion of the operation affect your confident to have the operation? n (%) <0.001 0.486 Greatly increased confident 7 (12.7) 11 (28.2) Somewhat increased confident 20 (36.4) 26 (66.7) Somewhat decreased confident 25 (45.5) 2 (5.1) Greatly decreased confident 3 (5.5) 0 (0) Overall, how satisfied are you with the process of this preoperative conversation? n (%) <0.001 0.672 Very satisfied 7 (12.7) 31 (79.5) Somewhat satisfied 45 (81.8) 8 (20.5) Somewhat dissatisfied 2 (3.6) 0 (0) Very dissatisfied 1 (1.8) 0 (0) *Values are from χ 2 test or Fisher’s exact test Primary Outcome (Overall Satisfaction): A notably high percentage of guardians in the Lawyer-Present Group (79.5%) reported being "Very satisfied" with the preoperative conversation process, compared to only 12.7% in the Usual Care Group (p < 0.001). Satisfaction in the Usual Care Group was primarily concentrated in the "Satisfied" category (81.8%). The difference between the groups was highly statistically significant, and the effect size indicated an extremely strong practical association (Cramér's V = 0.672, p < 0.001). Secondary Outcomes: Information Delivery Quality: Regarding the sufficiency of information provided on key aspects—surgical necessity, time spent discussing risks, and consequences of refusing surgery—the proportion of guardians responding "Very sufficient" was far higher in the Lawyer-Present Group (ranging from 76.9% to 84.6%) than in the Usual Care Group (ranging from 27.3% to 38.2%). All comparisons yielded p < 0.001, with effect sizes (Cramér's V) between 0.425 and 0.466, indicating a medium strength of association. Communication Experience: Significantly more guardians in the Lawyer-Present Group (61.5%) "Strongly agreed" that the conversation atmosphere made them feel respected and able to express themselves freely, compared to 23.6% in the Usual Care Group (p = 0.001, Cramér's V = 0.388). Regarding decision confidence, 94.9% of guardians in the Lawyer-Present Group reported that the discussion "increased" their confidence in proceeding with surgery, compared to 49.1% in the Usual Care Group (p < 0.001, Cramér's V = 0.486). Anxiety Level: Concerning anxiety, 74.4% of guardians in the Lawyer-Present Group reported that the discussion "greatly increased" their anxiety, compared to 38.2% in the Usual Care Group (p = 0.001, Cramér's V = 0.372). Guardians' Decision Regret Scale (DRS) Scores At 3 months postoperatively, there was no significant difference in the overall DRS scores between the two groups of guardians (Usual Care Group: 10.18 ± 1.26 vs. Lawyer-Present Group: 7.82 ± 1.21, p = 0.35), with both scores well below the threshold for clinically significant regret (25 points). However, within the subgroup of patients who developed postoperative complications (Usual Care Group: n = 8, Lawyer-Present Group: n = 5), guardians in the Usual Care Group had significantly higher DRS scores than those in the Lawyer-Present Group (40.63 ± 7.29 vs. 30.00 ± 3.54, p = 0.012). The effect size was Cohen's d = 1.72 (95% CI: [0.36, 3.08]), suggesting that in the event of an adverse outcome, lawyer presence may have a substantial practical effect on mitigating family decision regret. It should be noted that this subgroup analysis was based on a limited sample size, resulting in considerable uncertainty in the effect size estimate, which necessitates further validation in future large-sample studies. Discussion This study represents the first empirical investigation in China examining the impact of the procedural intervention of "lawyer witnessing" on the preoperative informed consent process for families of elderly patients with hip fractures. The main findings can be summarized as follows: compared to usual care, conversations with a lawyer present significantly improved overall family satisfaction and perceived information quality, but also significantly increased family anxiety levels; furthermore, when postoperative complications occurred, families in the Lawyer-Present Group exhibited significantly lower levels of decision regret. These results collectively reveal that lawyer presence, as a structural intervention, profoundly alters the dynamics of preoperative communication and the family's decision-making psychological process. First, this study found that lawyer presence greatly enhanced family satisfaction, validating the core hypothesis of procedural justice and improved communication quality. The Lawyer-Present Group demonstrated overwhelming superiority in overall satisfaction and all metrics of information delivery quality (Cramér's V > 0.65), which aligns with conclusions from similar international studies. For instance, Wiesen et al. [ 17 ] found that using a structured risk prediction tool (SURPAS) significantly improved patient satisfaction. Although the interventions differ (technical tool vs. legal procedure), both essentially function by introducing an external structured framework that guides communication toward greater formality, systematization, and completeness. The presence of a lawyer implicitly creates a more solemn and standardized communication setting. In this setting, surgeons may unconsciously provide more rigorous, point-by-point explanations of surgical necessity, risks, and alternatives, avoiding the habitual simplification that might omit critical information. Families did not reject the third-party presence; instead, they interpreted it as additional respect for their "right to know" and institutional safeguarding, thereby enhancing their trust in and satisfaction with the entire medical process. This aligns with the view in doctor-patient communication theory that "procedural justice" can effectively improve relationship satisfaction and treatment adherence[ 25 ]. Second, the significant increase in anxiety levels among families in the Lawyer-Present Group, a seemingly paradoxical phenomenon, actually reflects a deepening of risk perception and a shift in decision preparedness. This study shows that 74.4% of families in the Lawyer-Present Group reported "greatly increased anxiety," far exceeding the proportion in the Usual Care Group. This may stem from two aspects: First, families of elderly hip fracture patients generally have insufficient awareness of the condition's urgency and high rates of disability/mortality. In the formal conversation with a lawyer present, the discussion of surgical risks is more thorough and unvarnished, forcing families to confront the gravity of the decision head-on, thereby triggering intense realistic anxiety. Second, this anxiety may not be entirely negative "harmful anxiety" but rather more likely "informed anxiety" or "decisional weight anxiety" [ 26 ]. It signifies the family's transition from "vague worry" to the "deliberate stage of specific risk assessment." The lawyer's presence reinforces the authority of the information and the seriousness of the consequences, prompting more careful deliberation. Therefore, the increase in anxiety can be viewed as a psychological representation of families having a more profound understanding of risks and a more serious decision-making process, which provides better psychological preparation for subsequently facing adverse outcomes. Finally, the subgroup analysis reveals the potential protective value of lawyer presence in crisis situations. Although the overall DRS scores for both groups were low and not significantly different, among families of patients who developed complications, regret was significantly lower in the Lawyer-Present Group (d = 1.72). This has important clinical implications. A DRS score above 25 points indicates clinically significant regret[ 23 ]. When encountering adverse outcomes, families in the Lawyer-Present Group maintained relatively lower levels of regret. This may stem from: 1) A change in attribution style: Due to the extremely thorough and formal preoperative risk disclosure, families are more likely to attribute complications to known medical risks rather than medical negligence, reducing anger and regret arising from an "information surprise"; 2) Self-confirmation of decision rationality: The rigorous communication process, especially third-party witnessing, strengthens families' confidence in the procedural of their initial decision. Even with a poor outcome, they are more likely to accept it as a rational choice made under full information. This suggests that the core value of lawyer witnessing may lie not only in improving satisfaction under normal circumstances but also in building a stronger psychological buffer and legal-procedural resilience for both doctors and patients facing inevitable adverse medical events. Limitations of this study: 1) The sample size was limited, particularly for the complication subgroup analysis (n = 13). Although the effect size was large, the conclusions require further validation in larger sample studies. 2) The single-center, retrospective cohort design may introduce selection bias and cannot fully control for confounding factors such as individual surgeons' communication styles. 3) The study relied primarily on subjective family reports. Future research should incorporate objective methods such as analysis of conversation recordings. 4) The study did not assess surgeons' views and feelings regarding the lawyer-present model. Conclusion and Future Directions In summary, introducing lawyer witnessing into preoperative conversations for elderly hip fractures significantly optimized families' subjective communication experience. By potentially enhancing the formality and depth of communication, it prompted more deliberate decision-making consideration and ultimately led to greater psychological resilience and lower decision regret when facing adverse outcomes. This indicates that procedural legal witnessing can serve as a valuable supplement to traditional doctor-patient communication. Future research is recommended to: 1) Conduct multicenter prospective studies incorporating long-term psychological and relational indicators for both doctors and patients; 2) Explore more cost-effective "legal witnessing" models (e.g., trained medical ethics coordinators); 3) Provide training for healthcare professionals to conduct efficient and empathetic communication effectively in the presence of a third-party witness. Declarations Funding The author(s) received no financial support for the research, authorship and/or publication of this article. Author Contribution Author ContributionsConceptualization: Zhang Heng-yan, Zhang Jia.Methodology: Zhang Heng-yan, Xu Yi-ming, Wang Wei-qing.Investigation & Data Curation: Xu Yi-ming, Wang Wei-qing.Formal Analysis: Xu Yi-ming.Writing – Original Draft Preparation: Zhang Heng-yan.Writing – Review & Editing: Zhang Heng-yan, Wang Wei-qing, Zhang Jia.Supervision: Zhang Jia.Project Administration: Zhang Jia.All authors have read and agreed to the published version of the manuscript. References Gemo V, Bini V, Macchione IG, Lucchetta L, Properzi C, Perini F, et al. Validation and Adaptation of the Nottingham Hip Fracture Score to Predict 30-Day and 1-Year Mortality Among Italian Older Adults Hospitalized Due to Hip Fractures. J Clin Med. 2025;15(1). 10.3390/jcm15010310 . Lezak BA, Mercer NP, Silberlust J, Iturrate E, Konda S, Leucht P, et al. Inpatient mortality following hip fracture in the United States: an updated analysis of over one million cases. 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Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8659362","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":579375683,"identity":"f805d536-279d-4de5-a708-cb4f153d4c46","order_by":0,"name":"Heng-yan Zhang","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Heng-yan","middleName":"","lastName":"Zhang","suffix":""},{"id":579375684,"identity":"aafbb6ee-3359-4515-a9d3-0f01492675d0","order_by":1,"name":"Yi-ming Xu","email":"","orcid":"","institution":"Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Yi-ming","middleName":"","lastName":"Xu","suffix":""},{"id":579375685,"identity":"dd79802b-da3b-4b0d-a6fa-935c9c4010d4","order_by":2,"name":"Wang Wei-qing","email":"","orcid":"","institution":"Beijing Huawei Law Firm","correspondingAuthor":false,"prefix":"","firstName":"Wang","middleName":"","lastName":"Wei-qing","suffix":""},{"id":579375687,"identity":"9b5ce0d9-0f03-48aa-9f81-99358b6265fe","order_by":3,"name":"Zhang Jia","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYBACfvbmww8+GNjw2Lc3EKlFsudYmuGMijQZA54DRGoxuJFjIM1z5rCNgUQCsS47c8bAmLftMI+55OONNxhqbKIJ6mBsbyt4OLctncdydlqxBcOxtNwGQlqYeQ5vMHjbZs3DcDvHTIKx4TBhLWwSCQYSvG3MPAw3zxCphUcixUCS54wzj8ENHiK1SPBAAplHsgfolwRi/GJ/HBKV9vzshzfe+FBjQ1gLMiAhahBaSNUxCkbBKBgFIwMAAPASQQEVtanWAAAAAElFTkSuQmCC","orcid":"","institution":"Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":true,"prefix":"","firstName":"Zhang","middleName":"","lastName":"Jia","suffix":""}],"badges":[],"createdAt":"2026-01-21 11:56:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8659362/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8659362/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101751193,"identity":"92e5c893-dea0-4de2-94be-abcf78ecf4d4","added_by":"auto","created_at":"2026-02-03 10:18:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":873194,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8659362/v1/432d3a67-3525-4c12-9067-03173f612eda.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Can Legal Witness Enhance Communication Quality? The Role of Lawyer Presence in Family Satisfaction with Surgical Risk Disclosure for Geriatric Hip Fracture","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith the intensification of global population aging, osteoporotic hip fractures in the elderly have become a common and high-risk condition threatening the health and lives of older adults[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Such fractures, due to the severe pain, significant functional loss, and consequent systemic complications, lead to consistently high rates of mortality and disability during conservative treatment[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Consequently, surgical intervention (e.g., internal fixation or arthroplasty) has become the primary approach to restore function and save lives[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, elderly patients often present with multiple comorbidities and poor physiological reserve, leading to significantly elevated perioperative risks and a high incidence of postoperative complications, which imbues the surgery itself with substantial challenges[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This dilemma of \"extremely high risk without surgery versus considerable risk with surgery\" often places patients' families in an extremely difficult and stressful decision-making crossroads.\u003c/p\u003e \u003cp\u003eAgainst this backdrop, the quality of preoperative informed consent conversations, particularly the adequate disclosure and effective communication of surgical risks, becomes paramount[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It is not only a legally mandated procedure but also a core element in building doctor-patient trust and reaching a therapeutic consensus. Extensive research indicates that patient and family satisfaction with the preoperative disclosure process directly influences postoperative treatment compliance, the understanding and acceptance of inevitable complications, and is ultimately significantly correlated with the risk of medical disputes[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Currently, a prevalent challenge in clinical practice is how surgeons, within limited time, can clearly, comprehensively, and unambiguously communicate complex and grave surgical risks while alleviating family anxiety and uncertainty. The traditional verbal disclosure model has limitations in standardization, rigor, and legal documentation, potentially leading to inconsistent communication outcomes[\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo improve the quality and effectiveness of preoperative informed consent, balance information delivery with emotional support, and fundamentally protect the legitimate rights and interests of both patients and healthcare providers, exploring structured communication support tools or procedural interventions is particularly urgent. In recent years, alongside the development of quantitative risk assessment tools (e.g., SURPAS)[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], introducing third-party witnessing, especially formal lawyer witnessing, into major medical decision-making has begun to attract attention. This innovative practice holds theoretical dual core value: for patients and their families, the presence of a lawyer can ensure a fuller understanding of their legal rights and assist in interpreting medical documents, thereby providing more professional safeguarding of their interests procedurally; for healthcare providers, a standardized, rigorous, and documented communication process itself constitutes a form of legal protection, potentially alleviating their concerns when facing high-risk decisions and enabling them to focus more on the medical technology itself to treat patients with full effort [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, whether this \"legal witnessing\" model truly fulfills its theoretical promise by tangibly enhancing the perceived quality of doctor-patient communication, specifically improving family satisfaction with risk disclosure, still lacks robust empirical evidence from rigorous clinical studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Therefore, this study aims to focus on the typical high-risk, high-dispute-potential scenario of elderly hip fractures. By comparatively analyzing preoperative conversations conducted with versus without a lawyer present, it empirically investigates the following core question: Can lawyer witnessing, and to what extent, enhance family satisfaction with the surgical risk disclosure process? The findings will provide critical evidence for optimizing the informed consent process for high-risk surgeries, innovating doctor-patient communication models, and fostering a more harmonious and resilient doctor-patient relationship.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis was a single-center, cross-sectional survey study conducted at the Orthopedic Center of Peking Union Medical College Hospital. The study protocol was approved by the Ethics Review Committee of Peking Union Medical College Hospital (Ref No: I-K10122). This study adhered to the principles of the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe study consecutively enrolled elderly hip fracture patients and their primary decision-making guardians who underwent surgery performed by the same surgical team at Peking Union Medical College Hospital between June 2022 and June 2025. Patient inclusion criteria were: 1) age\u0026thinsp;\u0026ge;\u0026thinsp;75 years; 2) radiographically confirmed femoral neck fracture (FNF) or intertrochanteric fracture (IFF); 3) underwent surgical treatment, including hemiarthroplasty (HA) or intramedullary nailing (IMN). Exclusion criteria were: 1) pathological fracture; 2) patients with polytrauma; 3) guardians unable to comprehend the survey content or who refused to participate in the study.\u003c/p\u003e\n\u003ch3\u003eGrouping and Intervention\u003c/h3\u003e\n\u003cp\u003e Participants were divided into two groups based on whether a practicing lawyer was present as a witness during the preoperative informed consent conversation:\u003c/p\u003e \u003cp\u003e Lawyer-Present Group: In addition to the routine preoperative conversation, an independent practicing lawyer, separate from the medical team, was present. The lawyer's role was to witness the communication process, ensure the guardian's understanding of the discussion, and provide explanations regarding relevant legal procedures, but not to participate in the medical decision-making itself.\u003c/p\u003e \u003cp\u003eUsual Care Group: The preoperative informed consent conversation was conducted by the surgeon following the hospital's standard protocol, without the presence of a third-party lawyer.\u003c/p\u003e \u003cp\u003eThe core content of the preoperative conversation (surgical necessity, risks, alternatives, and consequences of refusing surgery) for both groups was based on the hospital's standard Surgical Informed Consent Form, ensuring consistency in the information foundation.\u003c/p\u003e\n\u003ch3\u003eData Collection and Assessment Tools\u003c/h3\u003e\n\u003cp\u003eData collection took place during the patients' outpatient follow-up at 3 months postoperatively, a time when lower limb functional recovery had reached a plateau. To ensure objectivity, all questionnaire surveys were administered by a third-party lawyer who was not involved in the witness group or the medical team.\u003c/p\u003e \u003cp\u003eBasic Information: Sociodemographic data of patients and guardians, fracture type, and surgical procedure were collected via the medical record system and questionnaires.\u003c/p\u003e \u003cp\u003ePreoperative Communication Satisfaction: A 7-item questionnaire developed based on previously validated tools was used[\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The questionnaire covered three dimensions: information delivery quality (surgical necessity, risks, sufficiency of time, alternatives) and communication experience (feeling respected, impact on anxiety, decision confidence). Items were scored using 4-point or 5-point Likert scales. The primary outcome measure was overall satisfaction (\"Overall, how satisfied are you with the process of this preoperative conversation?\").\u003c/p\u003e \u003cp\u003eDecision Regret Assessment: The Chinese version of the Decision Regret Scale was used to evaluate guardians' long-term feelings about the surgical decision[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The scale consists of 5 items, with the total score converted to a range of 0-100. A higher score indicates stronger regret, with a score\u0026thinsp;\u0026gt;\u0026thinsp;25 considered indicative of clinically significant regret.\u003c/p\u003e \u003cp\u003eClinical Outcomes: Postoperative complications (e.g., intracranial hemorrhage, cerebral infarction, pulmonary embolism, myocardial infarction, surgical site infection) were recorded. At 3 months postoperatively, patient walking function was assessed using the Holden Functional Ambulation Classification (FAC). The FAC assesses walking ability across six levels: 0 (no function), 1 (requires substantial and continuous assistance), 2 (requires minimal assistance), 3 (requires supervision or verbal guidance), 4 (independent walking), and 5 (completely independent). The number of patients in each group was tallied for levels 0\u0026ndash;1, 2\u0026ndash;3, and 4\u0026ndash;5.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll data were analyzed using SPSS software (version 26.0). Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and categorical variables as frequency and percentage. For comparisons between groups, independent samples t-tests were used for continuous variables that were normally distributed; otherwise, the Mann-Whitney U test was applied. Comparisons of categorical variables were performed using the Chi-square test or Fisher's exact test. For effect size calculations, Cohen's d was reported for continuous variable comparisons, and Cram\u0026eacute;r's V or Phi coefficient for categorical variable comparisons. All statistical tests were two-sided, and a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population and Baseline Characteristics\u003c/h2\u003e \u003cp\u003eThis study initially enrolled 132 eligible patient-guardian pairs, with 47 in the Lawyer-Present Group and 85 in the Usual Care Group. At the 3-month postoperative follow-up, complete follow-up data were obtained for 94 pairs (71.2%), which were included in the final analysis (39 in the Lawyer-Present Group and 55 in the Usual Care Group). The main reasons for loss to follow-up included inability to make contact, refusal to participate in the follow-up interview, or patient death.\u003c/p\u003e \u003cp\u003eAs shown in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the two groups ultimately analyzed showed no significant differences in patient age, sex, fracture/surgery type distribution, complication rates, or postoperative function (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The guardians in the two groups were also comparable in terms of age, sex, and educational level distribution (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This indicates that the baseline characteristics of the two groups were balanced and comparable.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of participants (n\u0026thinsp;=\u0026thinsp;94).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUsual consent (n\u0026thinsp;=\u0026thinsp;55)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConsent with Legal Witness (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep Value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Age, y, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83.6 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82.7 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuardian Age, y, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57.1 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.5 (8.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Sex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18(32.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11(28.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37(67.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28(71.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuardian Sex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24(43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14(35.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31(56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25(64.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Surgery, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHA for FNF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26(47.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20(51.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIMN for IFF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29(52.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19(48.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuardian Education, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school or below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13(23.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12(30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor\u0026lsquo;s degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32(58.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19(48.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate degree or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10(18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8(20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Values are from χ\u003csup\u003e2\u003c/sup\u003e test, Fisher\u0026rsquo;s exact test or Student t-test.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient surgical complications and postoperative limb function (n\u0026thinsp;=\u0026thinsp;94).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUsual consent (n\u0026thinsp;=\u0026thinsp;55)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConsent with Legal Witness (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep Value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ecomplications\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.531\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracranial hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebral infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyocardial infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical site infection.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFAC\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (65.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 5\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Values are from χ\u003csup\u003e2\u003c/sup\u003e test or Fisher\u0026rsquo;s exact test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eComparison of Guardians' Satisfaction with Preoperative Communication\u003c/h3\u003e\n\u003cp\u003eThe survey results on guardian satisfaction revealed that the Lawyer-Present Group scored significantly better than the Usual Care Group on multiple core dimensions, although a different pattern was observed for anxiety levels (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurvey Responses Regarding Guardians' Satisfaction with Surgical Informed Consent Procedures (n\u0026thinsp;=\u0026thinsp;94).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUsual consent (n\u0026thinsp;=\u0026thinsp;55)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConsent with Legal Witness (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep Value*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCram\u0026eacute;r\u0026lsquo;s V\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAssessment of Information Delivery Quality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWas the doctor's explanation regarding the necessity of the surgery sufficient? n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.425\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat insufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery sufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (76.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWas the amount of time the doctor spent discussing the surgical risks sufficient? n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.466\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat insufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery sufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (38.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (84.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Was the doctor's explanation of \"the consequences if surgery is not performed\" sufficient? n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.425\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat insufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37 (67.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery sufficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommunication Experience and Satisfaction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid the atmosphere of the conversation make you feel respected and able to freely express your thoughts and concerns? n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.388\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat disagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37 (67.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (35.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (23.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid this risk discussion affect your anxiety regarding the surgery for your family member? n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreatly increased anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (38.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (74.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat increased anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (50.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat decreased anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreatly decreased anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow did the discussion of the operation affect your confident to have the operation? n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.486\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreatly increased confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (28.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat increased confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat decreased confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreatly decreased confident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverall, how satisfied are you with the process of this preoperative conversation? n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.672\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery satisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (12.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (79.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat satisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45 (81.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSomewhat dissatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery dissatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Values are from χ\u003csup\u003e2\u003c/sup\u003e test or Fisher\u0026rsquo;s exact test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePrimary Outcome (Overall Satisfaction): A notably high percentage of guardians in the Lawyer-Present Group (79.5%) reported being \"Very satisfied\" with the preoperative conversation process, compared to only 12.7% in the Usual Care Group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Satisfaction in the Usual Care Group was primarily concentrated in the \"Satisfied\" category (81.8%). The difference between the groups was highly statistically significant, and the effect size indicated an extremely strong practical association (Cram\u0026eacute;r's V\u0026thinsp;=\u0026thinsp;0.672, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eSecondary Outcomes:\u003c/p\u003e \u003cp\u003eInformation Delivery Quality: Regarding the sufficiency of information provided on key aspects\u0026mdash;surgical necessity, time spent discussing risks, and consequences of refusing surgery\u0026mdash;the proportion of guardians responding \"Very sufficient\" was far higher in the Lawyer-Present Group (ranging from 76.9% to 84.6%) than in the Usual Care Group (ranging from 27.3% to 38.2%). All comparisons yielded p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, with effect sizes (Cram\u0026eacute;r's V) between 0.425 and 0.466, indicating a medium strength of association.\u003c/p\u003e \u003cp\u003e Communication Experience: Significantly more guardians in the Lawyer-Present Group (61.5%) \"Strongly agreed\" that the conversation atmosphere made them feel respected and able to express themselves freely, compared to 23.6% in the Usual Care Group (p\u0026thinsp;=\u0026thinsp;0.001, Cram\u0026eacute;r's V\u0026thinsp;=\u0026thinsp;0.388). Regarding decision confidence, 94.9% of guardians in the Lawyer-Present Group reported that the discussion \"increased\" their confidence in proceeding with surgery, compared to 49.1% in the Usual Care Group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Cram\u0026eacute;r's V\u0026thinsp;=\u0026thinsp;0.486).\u003c/p\u003e \u003cp\u003eAnxiety Level: Concerning anxiety, 74.4% of guardians in the Lawyer-Present Group reported that the discussion \"greatly increased\" their anxiety, compared to 38.2% in the Usual Care Group (p\u0026thinsp;=\u0026thinsp;0.001, Cram\u0026eacute;r's V\u0026thinsp;=\u0026thinsp;0.372).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eGuardians' Decision Regret Scale (DRS) Scores\u003c/h2\u003e \u003cp\u003eAt 3 months postoperatively, there was no significant difference in the overall DRS scores between the two groups of guardians (Usual Care Group: 10.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26 vs. Lawyer-Present Group: 7.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21, p\u0026thinsp;=\u0026thinsp;0.35), with both scores well below the threshold for clinically significant regret (25 points). However, within the subgroup of patients who developed postoperative complications (Usual Care Group: n\u0026thinsp;=\u0026thinsp;8, Lawyer-Present Group: n\u0026thinsp;=\u0026thinsp;5), guardians in the Usual Care Group had significantly higher DRS scores than those in the Lawyer-Present Group (40.63\u0026thinsp;\u0026plusmn;\u0026thinsp;7.29 vs. 30.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.54, p\u0026thinsp;=\u0026thinsp;0.012). The effect size was Cohen's d\u0026thinsp;=\u0026thinsp;1.72 (95% CI: [0.36, 3.08]), suggesting that in the event of an adverse outcome, lawyer presence may have a substantial practical effect on mitigating family decision regret. It should be noted that this subgroup analysis was based on a limited sample size, resulting in considerable uncertainty in the effect size estimate, which necessitates further validation in future large-sample studies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study represents the first empirical investigation in China examining the impact of the procedural intervention of \"lawyer witnessing\" on the preoperative informed consent process for families of elderly patients with hip fractures. The main findings can be summarized as follows: compared to usual care, conversations with a lawyer present significantly improved overall family satisfaction and perceived information quality, but also significantly increased family anxiety levels; furthermore, when postoperative complications occurred, families in the Lawyer-Present Group exhibited significantly lower levels of decision regret. These results collectively reveal that lawyer presence, as a structural intervention, profoundly alters the dynamics of preoperative communication and the family's decision-making psychological process.\u003c/p\u003e \u003cp\u003eFirst, this study found that lawyer presence greatly enhanced family satisfaction, validating the core hypothesis of procedural justice and improved communication quality. The Lawyer-Present Group demonstrated overwhelming superiority in overall satisfaction and all metrics of information delivery quality (Cramér's V \u0026gt; 0.65), which aligns with conclusions from similar international studies. For instance, Wiesen et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] found that using a structured risk prediction tool (SURPAS) significantly improved patient satisfaction. Although the interventions differ (technical tool vs. legal procedure), both essentially function by introducing an external structured framework that guides communication toward greater formality, systematization, and completeness. The presence of a lawyer implicitly creates a more solemn and standardized communication setting. In this setting, surgeons may unconsciously provide more rigorous, point-by-point explanations of surgical necessity, risks, and alternatives, avoiding the habitual simplification that might omit critical information. Families did not reject the third-party presence; instead, they interpreted it as additional respect for their \"right to know\" and institutional safeguarding, thereby enhancing their trust in and satisfaction with the entire medical process. This aligns with the view in doctor-patient communication theory that \"procedural justice\" can effectively improve relationship satisfaction and treatment adherence[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSecond, the significant increase in anxiety levels among families in the Lawyer-Present Group, a seemingly paradoxical phenomenon, actually reflects a deepening of risk perception and a shift in decision preparedness. This study shows that 74.4% of families in the Lawyer-Present Group reported \"greatly increased anxiety,\" far exceeding the proportion in the Usual Care Group. This may stem from two aspects: First, families of elderly hip fracture patients generally have insufficient awareness of the condition's urgency and high rates of disability/mortality. In the formal conversation with a lawyer present, the discussion of surgical risks is more thorough and unvarnished, forcing families to confront the gravity of the decision head-on, thereby triggering intense realistic anxiety. Second, this anxiety may not be entirely negative \"harmful anxiety\" but rather more likely \"informed anxiety\" or \"decisional weight anxiety\" [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. It signifies the family's transition from \"vague worry\" to the \"deliberate stage of specific risk assessment.\" The lawyer's presence reinforces the authority of the information and the seriousness of the consequences, prompting more careful deliberation. Therefore, the increase in anxiety can be viewed as a psychological representation of families having a more profound understanding of risks and a more serious decision-making process, which provides better psychological preparation for subsequently facing adverse outcomes.\u003c/p\u003e \u003cp\u003eFinally, the subgroup analysis reveals the potential protective value of lawyer presence in crisis situations. Although the overall DRS scores for both groups were low and not significantly different, among families of patients who developed complications, regret was significantly lower in the Lawyer-Present Group (d = 1.72). This has important clinical implications. A DRS score above 25 points indicates clinically significant regret[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. When encountering adverse outcomes, families in the Lawyer-Present Group maintained relatively lower levels of regret. This may stem from: 1) A change in attribution style: Due to the extremely thorough and formal preoperative risk disclosure, families are more likely to attribute complications to known medical risks rather than medical negligence, reducing anger and regret arising from an \"information surprise\"; 2) Self-confirmation of decision rationality: The rigorous communication process, especially third-party witnessing, strengthens families' confidence in the procedural of their initial decision. Even with a poor outcome, they are more likely to accept it as a rational choice made under full information. This suggests that the core value of lawyer witnessing may lie not only in improving satisfaction under normal circumstances but also in building a stronger psychological buffer and legal-procedural resilience for both doctors and patients facing inevitable adverse medical events.\u003c/p\u003e \u003cp\u003eLimitations of this study: 1) The sample size was limited, particularly for the complication subgroup analysis (n = 13). Although the effect size was large, the conclusions require further validation in larger sample studies. 2) The single-center, retrospective cohort design may introduce selection bias and cannot fully control for confounding factors such as individual surgeons' communication styles. 3) The study relied primarily on subjective family reports. Future research should incorporate objective methods such as analysis of conversation recordings. 4) The study did not assess surgeons' views and feelings regarding the lawyer-present model.\u003c/p\u003e "},{"header":"Conclusion and Future Directions","content":"\u003cp\u003eIn summary, introducing lawyer witnessing into preoperative conversations for elderly hip fractures significantly optimized families' subjective communication experience. By potentially enhancing the formality and depth of communication, it prompted more deliberate decision-making consideration and ultimately led to greater psychological resilience and lower decision regret when facing adverse outcomes. This indicates that procedural legal witnessing can serve as a valuable supplement to traditional doctor-patient communication. Future research is recommended to: 1) Conduct multicenter prospective studies incorporating long-term psychological and relational indicators for both doctors and patients; 2) Explore more cost-effective \"legal witnessing\" models (e.g., trained medical ethics coordinators); 3) Provide training for healthcare professionals to conduct efficient and empathetic communication effectively in the presence of a third-party witness.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe author(s) received no financial support for the research, authorship and/or publication of this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor ContributionsConceptualization: Zhang Heng-yan, Zhang Jia.Methodology: Zhang Heng-yan, Xu Yi-ming, Wang Wei-qing.Investigation \u0026amp; Data Curation: Xu Yi-ming, Wang Wei-qing.Formal Analysis: Xu Yi-ming.Writing \u0026ndash; Original Draft Preparation: Zhang Heng-yan.Writing \u0026ndash; Review \u0026amp; Editing: Zhang Heng-yan, Wang Wei-qing, Zhang Jia.Supervision: Zhang Jia.Project Administration: Zhang Jia.All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGemo V, Bini V, Macchione IG, Lucchetta L, Properzi C, Perini F, et al. 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Med Decis Mak. 1995;15(1):25\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0272989X9501500105\u003c/span\u003e\u003cspan address=\"10.1177/0272989X9501500105\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Lawyer witnessing, Informed consent, Hip fracture, Patient satisfaction, Decision regret, Doctor-patient communication","lastPublishedDoi":"10.21203/rs.3.rs-8659362/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8659362/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe management of osteoporotic hip fractures in the elderly carries high risks. The quality of preoperative informed consent directly impacts family satisfaction and the risk of medical disputes. Conventional communication models are variable, and the introduction of a third-party lawyer witness may optimize this process by enhancing the formality and comprehensiveness of the communication.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis single-center retrospective cohort study consecutively enrolled elderly hip fracture patients and their guardians who underwent surgery at Peking Union Medical College Hospital between June 2022 and June 2025. Participants were divided into a Lawyer-Present Group and a Usual Care Group based on the presence of a lawyer during the preoperative consent conversation. At 3 months postoperatively, a third-party administered survey assessed guardian satisfaction, anxiety changes, and the Decision Regret Scale (DRS) measured decision-related feelings. Intergroup comparisons were performed using Chi-square tests, t-tests, and effect size analyses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 94 patient-guardian pairs completed follow-up. The proportion of guardians who were \"Very satisfied\" with the preoperative conversation was significantly higher in the Lawyer-Present Group than in the Usual Care Group (79.5% vs. 12.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), with a large effect size (Cram\u0026eacute;r's V\u0026thinsp;=\u0026thinsp;0.672). The Lawyer-Present Group also scored significantly better on the sufficiency of information regarding surgical necessity, risks, and increased decision confidence (all p\u0026thinsp;\u0026lt;\u0026thinsp;.01). However, a higher proportion of guardians in this group reported \"Greatly increased anxiety\" (74.4% vs. 38.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). While overall DRS scores showed no significant difference, within the subgroup of patients who developed postoperative complications, guardians in the Usual Care Group exhibited significantly higher regret (40.63\u0026thinsp;\u0026plusmn;\u0026thinsp;7.29 vs. 30.00\u0026thinsp;\u0026plusmn;\u0026thinsp;3.54, p\u0026thinsp;=\u0026thinsp;.012), with a very large effect size (Cohen's d\u0026thinsp;=\u0026thinsp;1.72).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e The introduction of a lawyer witness during preoperative conversations significantly improved communication satisfaction and perceived information quality among guardians of elderly hip fracture patients. The associated increase in anxiety may reflect a deepening of risk perception. In cases of complications, lawyer presence was associated with reduced decision regret among guardians. This suggests that procedural legal witnessing could serve as a potentially effective tool to enhance the quality of informed consent for high-risk surgery and strengthen the resilience of the doctor-patient relationship.\u003c/p\u003e","manuscriptTitle":"Can Legal Witness Enhance Communication Quality? The Role of Lawyer Presence in Family Satisfaction with Surgical Risk Disclosure for Geriatric Hip Fracture","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 06:12:42","doi":"10.21203/rs.3.rs-8659362/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3495c33d-f17b-44a3-9109-a57a4ec6b09e","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-28T06:12:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-28 06:12:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8659362","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8659362","identity":"rs-8659362","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}