Perioperative advance care planning for supporting decision-making in elderly patients: a retrospective study and questionnaire survey at a single center

Perioperative advance care planning for supporting decision-making in elderly patients: a retrospective study and questionnaire survey at a single center | 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 Perioperative advance care planning for supporting decision-making in elderly patients: a retrospective study and questionnaire survey at a single center Keisuke Shimizu, Kae Ito, Rika Iwakiri, Go Nakajima, Ayumi Hida, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7644227/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; In high-risk elderly patients with severe comorbidities, perioperative advance care planning (ACP) should go beyond informed consent/shared decision-making (SDM), and should address difficult decision-making. We examined perioperative ACP in elderly patients in an acute care hospital, including the types of decision-making support provided by healthcare professionals. Methods; Between June and October 2024, retrospective ACP data for inpatients during the perioperative period were collected and conceptually analyzed based on five dimensions: prognosis, intentions regarding operation, future goals, family-related issues, and concerns. Next, in June 2025, a scenario-based questionnaire survey regarding elderly patients with liver metastases from gastric cancer was conducted among doctors, nurses, and medical staff at our hospital. Results; Perioperative ACP was conducted in 41 cases, mainly elderly patients, females and those with cardiac disease. While 52% of ACPs patients mentioned life expectancy and 61% mentioned future goals, there was little mention of postoperative progress, long-term prognosis, or surrogate decision makers. Patients occasionally confided in their family members regarding decision makings. Nest as to questionnaire survey, among 749 participants surveyed, 575 responded (76.8% response rate: 149 physicians, 378 nurses, and 48 medical staff). Regarding their opinions about treatment preferences for patients who did not desire aggressive treatment but their family did, the proportion of respondents choosing “chemotherapy” increased, with no significant increase in preference for “operation”. Doctors respected patients' wishes, while nurses respected both patients’ and families’ wishes. Conclusions; This study examined the type of ACP implemented during the perioperative period at our hospital, an acute care hospital for elderly patients. Regarding treatment selection and long-term prognosis based on that selection was still insufficient, suggesting the need for anesthesiologists and surgeons to also implement ACP. When implementing perioperative ACP, it will be important for health care professionals to collaborate with each other and utilize their professional strengths to form multidisciplinary discussions. advance care planning do-not-attempt-resuscitation order general anesthesia shared decision making Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Perioperative shared decision-making (SDM) is a process of making collaborative decisions that are in the patient's best interests through interactive communication between the medical/care team, the patient, and their family [ 1 , 2 ]. SDM, typically conducted preoperatively, includes explanations about potential complications during and after surgery. Perioperative surgical and anesthetic procedures are basically aggressive treatments aimed at restoring health and improving the patient’s quality of life. Therefore, the shared goals of patients, their families, and healthcare professionals are successful surgery and the patient's return to normal life. However, particularly in complex surgeries, in elderly patients, and those with severe comorbidities, patients may require prolonged intubation in the intensive care unit after operation, or experience a decline in physical function, leading to life-threatening situations [ 3 ]. A key challenge in treatment selection during the perioperative and intensive care periods is blurring of the line between “life-saving” and “life-sustaining” treatments, due to rapid deterioration of the patient's condition and difficulty in predicting prognosis [ 4 ]. For elderly patients with increasing physical and mental frailty, surgery and general anesthesia pose high risks, and represent "decisions that could have life-or-death implications." In the perioperative period, beyond informed consent and SDM, there might be situations in which advance care planning (ACP), which anticipates "difficult decision-making stages," is required. ACP involves discussions between patients/ their families and medical/care teams of the patient's desired medical care and life goals in preparation for a future when communication with the patient might become difficult. Conducting ACP and preoperatively confirming the patient's wishes also protects the patient's right to self-determination of their treatment and can be useful for surviving family members and surrogate decision-makers in making decisions when recovery is unlikely. The geriatric surgery guidelines jointly compiled by the American Geriatrics Society and American College of Surgeons recommend conducting ACP preoperatively, which includes discussing the purpose of the surgery, a treatment plan including advance directives in the event of a serious condition, and selection of a surrogate decision maker in case the patient cannot be communicated with directly [ 5 ]. Japan's "Guidelines for Gastrointestinal Surgery in the Elderly" also state that ACP must be conducted during preoperative consultations, to discuss the patient's approach to life-sustaining treatment in line with their treatment and care goals and values [ 6 ]. In the field of anesthesiology, the American Society of Anesthesiologists (ASA) has established ethical guidelines on how to behave when administering anesthesia to ‘do not attempt resuscitation (DNAR)’ patients [ 7 ]. The guidelines state that surgeons and anesthesiologists should discuss the DNAR order with the patient and their family preoperatively [ 8 ]. Although similar guidelines do not exist in Japan, we previously reported on how patients with preoperative DNAR orders are managed in Japan [ 9 ]. A 2024 review noted that the ASA guidelines can be used to improve communication with patients in the multidisciplinary care of critically ill surgical patients [ 10 ]. Specifically, the goal-based approach, one method of decision-making regarding perioperative DNAR, can be considered part of ACP in the sense that it determines the patient's values, life goals, and future medical care preferences [ 11 ]. Currently, however, ACP is rarely performed preoperatively. Even in the United States, it has been reported that only 31% of patients who died within one year of high-risk surgery received preoperative ACP [ 12 ]. One reason for the lack of preoperative ACP is that discussing end-of-life care with perioperative patients is considered taboo [ 13 ]. Some patients worry that expressing end-of-life care requests to their physicians preoperatively will prevent them from receiving the necessary treatment [ 14 ]. If ACP is not implemented before surgery and the surgery ends in a disappointing outcome, the only option is to attempt to gather information about the patient's values from their family members, and evaluate them together with the surrogate decision maker [ 15 ]. In this study, we clarified the current state of perioperative ACP and examine from multiple angles the challenges in understanding the concept and its implementation. First, we investigated what kind of ACP is implemented during the perioperative period at our hospital, an acute care center for elderly patients. Based on this, we examined the elements that have and have not been realized in implementing perioperative ACP. Next, in order to verify the shortcomings revealed by the retrospective survey, we conducted a questionnaire survey of medical professionals regarding decision-making support for elderly patients during the perioperative period, tried to understand the situation of the decision-making process in hypothetical cases, and examined the extent to which the wishes of the family influence decision-making. Methods 1) Retrospective study of perioperative ACP In January 2024, a section called "ACP/Life Conference" was created within the electronic medical record system of our hospital, Tokyo Metropolitan Institute for Geriatrics and Gerontology (TMIG), a geriatric hospital in Itabashi, Tokyo, that specializes in acute care for older adults. Founded in 1972, the hospital has 550 beds and reports an average duration of hospitalization of 12.5 days. This section included data on the date, time, location, participants involved, and content of the conference, with the "content" section allowing free description. We retrospectively reviewed the electronic medical records (EMRs) of hospitalized patients who received ACP between June and October 2024. In this study, we limited ACPs to those recorded in the "ACP/Life Conference" format within the EMR. We extracted ACPs conducted in the perioperative period from among them. In this study, perioperative ACP included cases in which surgery under general anesthesia was performed during the hospitalization in which ACP was conducted, as well as cases in which surgery was not performed. Cases in which surgery was not performed were those in which surgery was indicated despite the patient's condition, but was not performed based on discussions between the attending physician and the patient and their family. Explanatory notes regarding this clinical decision were mentioned in the EMR. For perioperative ACP, as defined above, we collected information on its content, timing, frequency, participants involved, patient demographics (i.e., age, gender, and whether DNAR was ordered), and the type of surgery, if any. Next, we conducted a concept analysis of the content of perioperative ACP, based on five dimensions: prognosis, intentions regarding surgery, future goals, family-related issues, and concerns, referring to previous studies. This study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the ethics committee of our institution (approval no. R22-016; date of approval, October 2023). 2) Questionnaire survey of medical professionals regarding perioperative decision-making This study targeted healthcare professionals working at TMIG. A cross-sectional questionnaire survey was conducted over a two-week period, from June 2 to June 16, 2025. We surveyed all professionals involved in five selected roles: physicians, nurses, targeted pharmacists, clinical psychologists, and medical social workers. A total of 749 persons working in these roles received the questionnaire, including 180 physicians and dentists, 506 nurses, 35 pharmacists, 13 psychologists, and 15 social workers. This survey was conducted to explore the actual situation, as there were many cases at our hospital where it was difficult to provide decision-making support to patients. The questionnaire presented clinical vignettes involving older patients with cognitive decline, and asked participants to reflect on medical decision-making processes, including how they weigh patient preferences, family involvement and the use of advance directives. It also inquired about respondents' prior experiences with end-of-life care, and explored how these experiences would influence their judgment. In addition, the survey included items assessing respondents' understanding of key terms frequently used in the context of end-of-life care, such as ACP, DNAR, advance directives, and SDM. The purpose of this study was not merely to quantify levels of understanding but to explore how institutional terminology intersects with ethical reasoning in clinical settings. The questionnaire and survey was developed for this study. The whole scenarios used in the questionnaire are presented in the Supplementary file. Below are summary of the scenarios and true/false questions about medical decision-making. [Scenario] An 82-year-old female patient, who was a widow. She has two sons who live separately from her. Examination led to a diagnosis of gastric cancer with multiple liver metastases, which was deemed incurable. She was anemic and required blood transfusions. Her doctor suggested chemotherapy to slow cancer progression, gastrectomy as palliative surgery, or best supportive care (BSC) treatment. The patient herself did not want aggressive treatment, stating, "Please do nothing," but her eldest son preferred aggressive treatment, stating, "Please provide all possible treatment." [True or false questions] Please read the following sentences and circle " Appropriate" if you feel the content is appropriate, or "Inappropriate" if you feel it is inappropriate or uncomfortable from the perspective of health care providers. - A 98-year-old patient is diagnosed with stomach cancer. After interviews with the patient and family, it is decided not to proceed with aggressive treatment. This process is called ACP. - An 85-year-old patient falls and suffers a femoral neck fracture. After interviews with the patient and family, it is decided that surgery will be performed. This process is called ACP. For statistical analyses, we used the chi-square test or Fisher’s exact test to examine to examine the differences between occupations in items related to decision support. Values of p < 0.05 were considered statistically significant. SPSS software (IBM, Chicago, Illinois) was used for all statistical analyses. Items with missing values were excluded from analysis. The study was approved by the ethics committee of our institution (approval no. R24-126; date of approval. March 2025). Results 1) Perioperative ACP Of the 204 ACP cases conducted during the study period, 41 were perioperative. Mean age of the 41 cases was 78.7 years, and 61% were female. ACP was provided by an internal medicine physician in one case, and by nurses in the remaining cases. Surgery was performed in 28 of the 41 cases (68%), with 15 of them receiving ACP preoperatively and 13 receiving it postoperatively. Surgery was not performed after ACP in the remaining 13 cases. Of the 28 cases in which surgery was performed, five (18%) were emergency surgeries (Fig. 1 ). The most common departments in charge were cardiovascular surgery (44%), gastroenterological surgery (24%), and orthopedic surgery (15%). ACP was conducted more than twice during hospitalization in 20 cases (48%). Among the 41 ACP conferences, 90% were attended by the patients themselves, but in 10% of cases, the patients were unable to attend due to their critical condition, and instead involved their family members. DNAR requests were received in 16 of the 41 cases (39%). 12 requests with DNAR were provided by the patients themselves, and 4 requests with DNAR by the family members of patients who were in critical condition and could not attend the conference. Regarding life expectancy, 15% of ACPs mentioned specifics such as "a 40% mortality rate within two years," while 39% were vague, with statements such as "there is a risk of sudden deterioration." In terms of intentions regarding operation, 32% patients made positive statements like "I will leave it to the surgeon," while 15% were more concerned, stating "I'm scared, so I don't want to have surgery." Regarding future goals, 27% said "I want to pursue my hobbies or work," 24% said "I want to get back to my usual life," and 10% said "I want to spend time with my family," while 17% said "none" or "I want to die soon". Regarding their families, most responses included "They worry about me" and "I don't want to be a nuisance," while some confided in nurses about discord with family, such as "My daughter seems cold, perhaps because she's my gender," and "I want to talk to my son about the surgery, I don't get along with my wife." Worries about "surgery and complications" accounted for 20%, "postoperative pain" for 20%, and "life after discharge and finances" for 42% of the patients’ concerns (Fig. 2 ). The mortality rate during the study period (June to October 2024) was 17% (seven cases). Among them, surgery was performed in six cases, three of which were emergency surgeries. Among the seven deaths, the patients themselves participated in ACP in six cases, and DNAR orders were issued in five cases. Prognosis was discussed in four cases, with statements such as "You will likely not live for more than a few months’" and "You will probably develop breathing difficulties". Regarding future goals, some stated "I have no regrets" and "I want to be relieved now," while others expressed the desire to "get better quickly and be able to do things on my own." Concerns included mental distress, such as feeling lost and anxious about their condition worsening, as well as physical distress, such as shortness of breath and pain, and in some cases, continuous sedation was considered. 2) Results of the questionnaire survey A total of 549 responses were obtained (response rate 73.3%), including from 149 physicians and dentists (response rate 82.8%, male/female = 97/48; four of them did not disclose their sex), 352 nurses (response rate 69.6%, male/female = 37/306; nine did not mention their sex), 21 pharmacists (60.0%), 12 psychologists (92.3%), and 15 social workers (100.0%) (15 male and 33 female medical staff). The average years of experience by occupation was 13.3 ± 10.0 years (range: less than 1 year − 42 years) for physicians and 11.9 ± 9.2 years (range: less than 1 year − 40 years) for nurses (Fig. 3 ). When asked what treatment they would prefer if they were suffering from advanced anemia due to incurable liver metastasis from gastric cancer, the answers were chemotherapy (physicians: 20.3%, nurses: 11.5%, medical staff: 10.2%), palliative surgery (physicians: 13.5%, nurses: 5.9%, medical staff: 2.0%), and BSC (physicians: 66.2%, nurses: 82.6%, medical staff: 87.8%). Next, when asked what treatment they would recommend if they learned that the patient did not want aggressive treatment, the answers were chemotherapy (physicians: 4.1%, nurses: 2.5%, medical staff: 6.1%), palliative surgery (physicians: 4.1%, nurses: 1.3%, medical staff: 2.0%), and BSC (physicians: 91.8%, nurses: 96.2%, medical staff: 91.9%). When asked what treatment they would choose if it was discovered that "the family wanted aggressive treatment," the answers were chemotherapy (doctors: 8.7%, nurses: 7.4%, medical staff: 4.1%), palliative surgery (doctors: 4.7%, nurses: 2.0%, medical staff: 2.1%), and BSC (doctors: 86.6%, nurses: 90.6%, medical staff: 93.8%) (Fig. 4 ). Next, we analyzed the extent to which the patient's and family's wishes influenced treatment decisions when the patient hoped for BSC and the family desired aggressive treatment. The patient's wishes carried most weight for 86.5% of doctors, 76.2% of nurses and 89.5% of medical staff. The patient's and family's wishes had equal weightage for 9.5% of doctors, 17.2% of nurses (17.2%) and 6.3% of medical staff. The family's wishes had the greatest influence for 4.1% doctors, 6.6% nurses and 4.2% of medical staff. Analyses of these results revealed a statistically significant difference between professions (Chi-square = 18.24, p = 0.019) (Table 1 ). Table 1 Table showing which decision-making is influenced by the patient or the patient's family Doctors Nurses Medical staffs The patient's wishes had the greatest influence 86.5% 76.2% 89.5% The patient's and family's wishes had equal influence 9.5% 17.2% 6.3% The family's wishes had the greatest influence 4.1% 6.6% 4.2% Finally, to the question, "Is a discussion about not pursuing aggressive treatment in a 98-year-old stomach cancer patient ACP," the percentage of respondents who answered yes was 78.8% among doctors, 86.5% among nurses, and 85.1% among medical staff. In response to the question, "Is the discussion about performing surgery on an 85-year-old patient with a femoral neck fracture called ACP," 39.6% of doctors, 51.7% of nurses, and 42.6% of medical staff answered yes. Discussion This study analyzed perioperative ACP practices at our hospital, an acute care center for elderly patients, dividing them into five components. Additionally, a questionnaire survey on perioperative decision-making assessed healthcare professionals' attitudes towards aggressive and passive treatment options for terminally ill cancer patients. Previous studies on perioperative ACP have reported that the introduction of ACP reduces the rate of invasive procedures at the end of life, increases patient participation in decision-making, and reduces anxiety and difficulty regarding decision-making [ 16 – 18 ]. However, other studies have found that ACP support does not improve the quality of end-of-life care, and fails to achieve the expected benefits [ 19 ]. Other studies have also reported that the percentage of attending physicians who understand patients' values has not improved, and that ACP is not effectively utilized by treating physicians for collaborative decision-making [ 20 – 21 ]. At our hospital, approximately 200 general anesthesia cases are performed per month, and perioperative ACP is performed in approximately 10 cases per month, indicating that ACP is performed in roughly 1 in 20 cases. While the type of patients for whom ACP is performed is left to the discretion of the department, it is typically performed in elderly patients, many of whom are female, or have heart disease. Previous research has retrospectively analyzed chart entries regarding ACP, including goals of care and treatment, in patients with newly issued DNAR orders. Only 43% of ACP conferences included discussions of values and goals of care, 14% discussed prognosis, 40% discussed treatment and resuscitation options, and 29% mentioned surrogate decision makers [ 22 – 23 ]. In the ACP conducted at our hospital, life goals and personal values were relatively frequently discussed. However, surrogate decision makers, a concept unfamiliar in Japan, were rarely mentioned. Regarding matters related to surgery, out patients' were asked their thoughts about surgery, but there was little mention of postoperative progress, complications, long-term prognosis, or the extent of postoperative life-sustaining treatment. It has been suggested that patients should be asked about their goals of treatment, such as their desired postoperative outcome. If these expectations are unrealistic, the expected effects of surgery should be explained again, and the patient and surgeon should discuss whether surgery is truly necessary [ 15 ]. In Japan, previous research on the decision-making of patients with advanced cancer and their families has mainly been qualitative descriptive research on the choice of introducing artificial nutrition, such as tube feeding or enteral nutrition [ 24 – 25 ]. The questionnaire survey in this study, on the other hand, was a quantitative descriptive study, and was novel in that it also focused on aggressive treatments, such as chemotherapy and surgical therapy, in terminal cancer patients. Family members function as caregivers, sources of emotional support, and health care proxy in medical care, making their involvement essential for effective decision-making, especially during serious illnesses and end-of-life care. However, conflicts can arise between healthcare providers and family members, or between patients and their families, during end-of-life care. This is particularly prevalent in family-centered Asian cultures [ 26 ]. In a previous study, 30% of patients reported in interviews that their family members had no say in their medical decision-making [ 27 ]. Other studies have also found high rates of disagreement between patients and their families in the decision-making process regarding aggressive treatment, treatment interruption, and financial burden [ 28 ]. On the other hand, reports have shown that approximately half of patients rely on family input for important decisions regarding palliative chemotherapy [ 29 ]. When patients lack decision-making capacity, it is important for family members and surrogate decision-makers to understand the patient's treatment preferences and choices regarding life-sustaining treatment [ 30 ]. The results of our questionnaire survey showed that when it was discovered that the patient did not desire aggressive treatment but their family did, the rate of choosing chemotherapy increased, but the rate of choosing surgery did not increase significantly. Even with aggressive treatment, minimally invasive procedures, such as chemotherapy, tended to be carried out at the discretion of the family. On the other hands, more invasive procedures, such as surgery, were likely strongly influenced by the patient's wishes. Another observation of this study was that doctors tend to respect patients’ wishes, while nurses respect not only patients’ wishes, but also those of their family members. This could be because nurses have more opportunities than doctors to provide emotional support to both patients and their families. The results of the questionnaire survey showed that doctors and nurses had similar tendencies regarding treatment selection, but differences were observed in the extent to which they considered the family's wishes. When implementing perioperative ACP, it will be important for health care professionals to collaborate with each other and utilize their professional strengths to form multidisciplinary discussions. Furthermore, when discussing treatment options for patients with a surgically indicated condition, “discussions in which surgery was not selected” were considered to constitute ACP (84%), but approximately half (48%) of respondents also considered “discussions in which surgery was selected” to be ACP. The correct answer to the True or False questions in the methods section was that the decision to undergo surgery itself is informed consent, and therefore does not constitute ACP. However, the fact that about half of the respondents said that “ACP applies even when surgery is performed” might indicate that the concept of “perioperative ACP” is gradually accepted. Since surgery in high risk elderly patients involves life-or-death decisions, preoperative ACP, in addition to preoperative informed consent and SDM, might be appropriate in anticipation of the time when persistent postoperative impaired consciousness makes decision-making difficult. This study has the following limitations. First, although ACP might not have been provided in a specific format, it may have been included in the attending physician's surgical explanation or the anesthesiologist's anesthesia explanation. Since it was difficult to verify all records in this study, this could not be analyzed. Another limitation of the questionnaire survey was that the scenario presented was highly simplified, and in reality, the circumstances in each case are likely to be more complex. For example, the scenario used in this study did not mention the financial situation of the patient or their family, although treatment choices may vary depending on the patient's financial situation. Finally, this study was a single-center study in a hospital specializing in elderly patients. Even if the number of elderly patients in hospitals throughout Japan increases in the future, since we cannot consider the results of this study as being directly applicable to small hospitals or clinics in rural areas, its external validity is clearly limited. This study examined the type of ACP implemented during the perioperative period at our hospital, an acute care hospital for elderly patients. While some aspects, such as listening to patients' goals and concerns, were adequately addressed, content regarding treatment selection and long-term prognosis based on that selection was still insufficient, suggesting the need for anesthesiologists and surgeons to also implement ACP. A questionnaire survey regarding perioperative decision-making allowed us to understand the decision-making status of doctors, nurses, and medical staff regarding treatment selection in terminally ill cancer patients, and to examine the extent to which family members' wishes influence this decision. Anesthesiologists are not only skilled in life-saving and resuscitation procedures, but also in assessments of the patient’s capacity to withstand surgery and their frailty. We believe that anesthesiologists might play an important role in perioperative ACP by providing preoperative suggestions to surgeons regarding whether surgery will truly improve the patient’s postoperative activities of daily living and achieve the patient's life goals. Abbreviations SDM Shared decision-making ACP Advance care planning ASA American Society of Anesthesiologists DNAR Do-not-attempt resuscitation TMIG Tokyo Metropolitan Institute for Geriatrics and Gerontology EMRs Electronic medical records BSC Best supportive care. Declarations Clinical trial number Not applicable Ethical approval and consent to participate The protocol for this study was approved by the Institutional Review Board of the Tokyo Metropolitan Institute for Geriatrics and Gerontology (TMIG) Research Ethics Committee. Regarding the retrospective study using the EMR, in accordance with the guidelines of the Institutional Review Board of TMIG, informed and written consents were waived because of the nature of the retrospective study. Instead the details of the study and an opt-out document were posted on the hospital's website, ensuring an opportunity for participants to decline participation. Regarding the questionnaire survey, informed and written consents were obtained by asking whether or not participants agreed to participate in the study at the beginning of the questionnaire, and participants who declined were excluded from the study. Consent for publication Not applicable Competing interests The authors declare that they have no competing interest. Funding This work did not receive any grants from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution KS, KI and KK designed and conceived this study. RI, GN and AH collected data. KS, MN and RK analyzed and interpreted the results and drafted the manuscript. All authors read and approved the final manuscript. Acknowledgement We received advice from the HAIC Research and Development Unit at the Tokyo Metropolitan Institute for Geriatrics and Gerontology regarding how to proceed with the study. The authors thank FORTE Science Communications (https://www.forte-science.co.jp/) for English language editing. Data Availability The datasets generated and/or analyzed during the current study are not publicly available because the institutional rules strictly prohibit releasing the native data on the web but are available from the corresponding author on the reasonable request. References Aida K. Medical Care and Medical Care that Respect the Patient's Will: Focusing on Decision-Making Ability (in Japanese). J Japanese Geriatr Soc. 2013;50(4). Shimizu T. Supporting Patient and Family Decision-Making—From Treatment Selection to Future Planning (in Japanese). 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Additional Declarations No competing interests reported. Supplementary Files Supplementary1.docx 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-7644227","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":540502704,"identity":"7ac621e0-830d-47a8-a12d-ffc342bb382a","order_by":0,"name":"Keisuke Shimizu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBACCQbGBgYGAyBiBnErgJiZuYEULWdAWhgJaYECAxDB2AYm8WuRbD/c/OJHAYO9OTt36mbeebXR/O1ALT8qtuHUIs2T2GbZY8CQuLOZd9tt3m3Hc2ccZmxg7DlzG6cWOYbENgMeA4YEg8NgLcdyG4BamBnb8Gjhf9hm+MeAwR6iZc6x3PmEtEhLJDY/BtrCuAGspaEmdwMhLZIzHrYxyxhIJIK03Jxz7EDuRqCWg/j8InE+/fHHN39s7A3On912401NXe6884cPPvhRgVsLELBJwKKHiYfhMJhxAJ96IGD+AGMx/mCoI6B4FIyCUTAKRiIAAL6XXNV0IpaeAAAAAElFTkSuQmCC","orcid":"","institution":"Tokyo Metropolitan Institute for Geriatrics and Gerontology","correspondingAuthor":true,"prefix":"","firstName":"Keisuke","middleName":"","lastName":"Shimizu","suffix":""},{"id":540502705,"identity":"c4ecaba9-48ca-45df-989c-f813ad7002c6","order_by":1,"name":"Kae Ito","email":"","orcid":"","institution":"Tokyo Metropolitan Institute for Geriatrics and 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16:38:49","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":182220,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBar graph showing concept analysis of perioperative ACP content\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7644227/v1/dd38ae5844fdb9a19098e62b.jpeg"},{"id":95320402,"identity":"99d2ba32-4e6d-4316-9953-d7d10e8777d1","added_by":"auto","created_at":"2025-11-06 16:38:49","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":295193,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlow chart for participant inclusion in the questionnaire survey\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7644227/v1/5f06e6840a246ab6e20d1d76.jpeg"},{"id":95320410,"identity":"35f03c4e-5a88-4f73-8f57-47ca57a71759","added_by":"auto","created_at":"2025-11-06 16:38:49","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":234667,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBar graph showing the differences in perioperative decision-making by occupation\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7644227/v1/9c32411f02e2c601ef82dff3.jpeg"},{"id":100369985,"identity":"8af86c43-e678-4b33-9a4b-6eb266595fe8","added_by":"auto","created_at":"2026-01-16 07:59:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1551924,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7644227/v1/4f4963e5-18ce-4b03-95b7-9f3512db85ab.pdf"},{"id":95320407,"identity":"ad427ffc-6122-464f-ae6d-3564fdd4cf69","added_by":"auto","created_at":"2025-11-06 16:38:49","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18732,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7644227/v1/167ad042754923728dcd4202.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perioperative advance care planning for supporting decision-making in elderly patients: a retrospective study and questionnaire survey at a single center","fulltext":[{"header":"Background","content":"\u003cp\u003ePerioperative shared decision-making (SDM) is a process of making collaborative decisions that are in the patient's best interests through interactive communication between the medical/care team, the patient, and their family [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. SDM, typically conducted preoperatively, includes explanations about potential complications during and after surgery. Perioperative surgical and anesthetic procedures are basically aggressive treatments aimed at restoring health and improving the patient\u0026rsquo;s quality of life. Therefore, the shared goals of patients, their families, and healthcare professionals are successful surgery and the patient's return to normal life. However, particularly in complex surgeries, in elderly patients, and those with severe comorbidities, patients may require prolonged intubation in the intensive care unit after operation, or experience a decline in physical function, leading to life-threatening situations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A key challenge in treatment selection during the perioperative and intensive care periods is blurring of the line between \u0026ldquo;life-saving\u0026rdquo; and \u0026ldquo;life-sustaining\u0026rdquo; treatments, due to rapid deterioration of the patient's condition and difficulty in predicting prognosis [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. For elderly patients with increasing physical and mental frailty, surgery and general anesthesia pose high risks, and represent \"decisions that could have life-or-death implications.\" In the perioperative period, beyond informed consent and SDM, there might be situations in which advance care planning (ACP), which anticipates \"difficult decision-making stages,\" is required. ACP involves discussions between patients/ their families and medical/care teams of the patient's desired medical care and life goals in preparation for a future when communication with the patient might become difficult. Conducting ACP and preoperatively confirming the patient's wishes also protects the patient's right to self-determination of their treatment and can be useful for surviving family members and surrogate decision-makers in making decisions when recovery is unlikely.\u003c/p\u003e\u003cp\u003eThe geriatric surgery guidelines jointly compiled by the American Geriatrics Society and American College of Surgeons recommend conducting ACP preoperatively, which includes discussing the purpose of the surgery, a treatment plan including advance directives in the event of a serious condition, and selection of a surrogate decision maker in case the patient cannot be communicated with directly [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Japan's \"Guidelines for Gastrointestinal Surgery in the Elderly\" also state that ACP must be conducted during preoperative consultations, to discuss the patient's approach to life-sustaining treatment in line with their treatment and care goals and values [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the field of anesthesiology, the American Society of Anesthesiologists (ASA) has established ethical guidelines on how to behave when administering anesthesia to \u0026lsquo;do not attempt resuscitation (DNAR)\u0026rsquo; patients [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The guidelines state that surgeons and anesthesiologists should discuss the DNAR order with the patient and their family preoperatively [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although similar guidelines do not exist in Japan, we previously reported on how patients with preoperative DNAR orders are managed in Japan [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A 2024 review noted that the ASA guidelines can be used to improve communication with patients in the multidisciplinary care of critically ill surgical patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Specifically, the goal-based approach, one method of decision-making regarding perioperative DNAR, can be considered part of ACP in the sense that it determines the patient's values, life goals, and future medical care preferences [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCurrently, however, ACP is rarely performed preoperatively. Even in the United States, it has been reported that only 31% of patients who died within one year of high-risk surgery received preoperative ACP [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. One reason for the lack of preoperative ACP is that discussing end-of-life care with perioperative patients is considered taboo [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Some patients worry that expressing end-of-life care requests to their physicians preoperatively will prevent them from receiving the necessary treatment [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. If ACP is not implemented before surgery and the surgery ends in a disappointing outcome, the only option is to attempt to gather information about the patient's values from their family members, and evaluate them together with the surrogate decision maker [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, we clarified the current state of perioperative ACP and examine from multiple angles the challenges in understanding the concept and its implementation. First, we investigated what kind of ACP is implemented during the perioperative period at our hospital, an acute care center for elderly patients. Based on this, we examined the elements that have and have not been realized in implementing perioperative ACP. Next, in order to verify the shortcomings revealed by the retrospective survey, we conducted a questionnaire survey of medical professionals regarding decision-making support for elderly patients during the perioperative period, tried to understand the situation of the decision-making process in hypothetical cases, and examined the extent to which the wishes of the family influence decision-making.\u003c/p\u003e"},{"header":"Methods","content":"\n\u003ch3\u003e1) Retrospective study of perioperative ACP\u003c/h3\u003e\n\u003cp\u003e In January 2024, a section called \"ACP/Life Conference\" was created within the electronic medical record system of our hospital, Tokyo Metropolitan Institute for Geriatrics and Gerontology (TMIG), a geriatric hospital in Itabashi, Tokyo, that specializes in acute care for older adults. Founded in 1972, the hospital has 550 beds and reports an average duration of hospitalization of 12.5 days. This section included data on the date, time, location, participants involved, and content of the conference, with the \"content\" section allowing free description.\u003c/p\u003e\u003cp\u003eWe retrospectively reviewed the electronic medical records (EMRs) of hospitalized patients who received ACP between June and October 2024. In this study, we limited ACPs to those recorded in the \"ACP/Life Conference\" format within the EMR. We extracted ACPs conducted in the perioperative period from among them. In this study, perioperative ACP included cases in which surgery under general anesthesia was performed during the hospitalization in which ACP was conducted, as well as cases in which surgery was not performed. Cases in which surgery was not performed were those in which surgery was indicated despite the patient's condition, but was not performed based on discussions between the attending physician and the patient and their family. Explanatory notes regarding this clinical decision were mentioned in the EMR. For perioperative ACP, as defined above, we collected information on its content, timing, frequency, participants involved, patient demographics (i.e., age, gender, and whether DNAR was ordered), and the type of surgery, if any. Next, we conducted a concept analysis of the content of perioperative ACP, based on five dimensions: prognosis, intentions regarding surgery, future goals, family-related issues, and concerns, referring to previous studies. This study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the ethics committee of our institution (approval no. R22-016; date of approval, October 2023).\u003c/p\u003e\n\u003ch3\u003e2) Questionnaire survey of medical professionals regarding perioperative decision-making\u003c/h3\u003e\n\u003cp\u003eThis study targeted healthcare professionals working at TMIG. A cross-sectional questionnaire survey was conducted over a two-week period, from June 2 to June 16, 2025. We surveyed all professionals involved in five selected roles: physicians, nurses, targeted pharmacists, clinical psychologists, and medical social workers. A total of 749 persons working in these roles received the questionnaire, including 180 physicians and dentists, 506 nurses, 35 pharmacists, 13 psychologists, and 15 social workers. This survey was conducted to explore the actual situation, as there were many cases at our hospital where it was difficult to provide decision-making support to patients.\u003c/p\u003e\u003cp\u003eThe questionnaire presented clinical vignettes involving older patients with cognitive decline, and asked participants to reflect on medical decision-making processes, including how they weigh patient preferences, family involvement and the use of advance directives. It also inquired about respondents' prior experiences with end-of-life care, and explored how these experiences would influence their judgment. In addition, the survey included items assessing respondents' understanding of key terms frequently used in the context of end-of-life care, such as ACP, DNAR, advance directives, and SDM. The purpose of this study was not merely to quantify levels of understanding but to explore how institutional terminology intersects with ethical reasoning in clinical settings.\u003c/p\u003e\u003cp\u003eThe questionnaire and survey was developed for this study. The whole scenarios used in the questionnaire are presented in the Supplementary file. Below are summary of the scenarios and true/false questions about medical decision-making.\u003c/p\u003e\u003cp\u003e[Scenario]\u003c/p\u003e\u003cp\u003eAn 82-year-old female patient, who was a widow. She has two sons who live separately from her. Examination led to a diagnosis of gastric cancer with multiple liver metastases, which was deemed incurable. She was anemic and required blood transfusions. Her doctor suggested chemotherapy to slow cancer progression, gastrectomy as palliative surgery, or best supportive care (BSC) treatment.\u003c/p\u003e\u003cp\u003eThe patient herself did not want aggressive treatment, stating, \"Please do nothing,\" but her eldest son preferred aggressive treatment, stating, \"Please provide all possible treatment.\"\u003c/p\u003e\u003cp\u003e[True or false questions]\u003c/p\u003e\u003cp\u003ePlease read the following sentences and circle \" Appropriate\" if you feel the content is appropriate, or \"Inappropriate\" if you feel it is inappropriate or uncomfortable from the perspective of health care providers.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e- A 98-year-old patient is diagnosed with stomach cancer. After interviews with the patient and family, it is decided not to proceed with aggressive treatment. This process is called ACP.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- An 85-year-old patient falls and suffers a femoral neck fracture. After interviews with the patient and family, it is decided that surgery will be performed. This process is called ACP.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eFor statistical analyses, we used the chi-square test or Fisher\u0026rsquo;s exact test to examine to examine the differences between occupations in items related to decision support. Values of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant. SPSS software (IBM, Chicago, Illinois) was used for all statistical analyses. Items with missing values were excluded from analysis. The study was approved by the ethics committee of our institution (approval no. R24-126; date of approval. March 2025).\u003c/p\u003e"},{"header":"Results","content":"\n\u003ch3\u003e1) Perioperative ACP\u003c/h3\u003e\n\u003cp\u003eOf the 204 ACP cases conducted during the study period, 41 were perioperative. Mean age of the 41 cases was 78.7 years, and 61% were female. ACP was provided by an internal medicine physician in one case, and by nurses in the remaining cases. Surgery was performed in 28 of the 41 cases (68%), with 15 of them receiving ACP preoperatively and 13 receiving it postoperatively. Surgery was not performed after ACP in the remaining 13 cases. Of the 28 cases in which surgery was performed, five (18%) were emergency surgeries (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The most common departments in charge were cardiovascular surgery (44%), gastroenterological surgery (24%), and orthopedic surgery (15%). ACP was conducted more than twice during hospitalization in 20 cases (48%). Among the 41 ACP conferences, 90% were attended by the patients themselves, but in 10% of cases, the patients were unable to attend due to their critical condition, and instead involved their family members. DNAR requests were received in 16 of the 41 cases (39%). 12 requests with DNAR were provided by the patients themselves, and 4 requests with DNAR by the family members of patients who were in critical condition and could not attend the conference.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eRegarding life expectancy, 15% of ACPs mentioned specifics such as \"a 40% mortality rate within two years,\" while 39% were vague, with statements such as \"there is a risk of sudden deterioration.\" In terms of intentions regarding operation, 32% patients made positive statements like \"I will leave it to the surgeon,\" while 15% were more concerned, stating \"I'm scared, so I don't want to have surgery.\" Regarding future goals, 27% said \"I want to pursue my hobbies or work,\" 24% said \"I want to get back to my usual life,\" and 10% said \"I want to spend time with my family,\" while 17% said \"none\" or \"I want to die soon\". Regarding their families, most responses included \"They worry about me\" and \"I don't want to be a nuisance,\" while some confided in nurses about discord with family, such as \"My daughter seems cold, perhaps because she's my gender,\" and \"I want to talk to my son about the surgery, I don't get along with my wife.\" Worries about \"surgery and complications\" accounted for 20%, \"postoperative pain\" for 20%, and \"life after discharge and finances\" for 42% of the patients\u0026rsquo; concerns (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe mortality rate during the study period (June to October 2024) was 17% (seven cases). Among them, surgery was performed in six cases, three of which were emergency surgeries. Among the seven deaths, the patients themselves participated in ACP in six cases, and DNAR orders were issued in five cases. Prognosis was discussed in four cases, with statements such as \"You will likely not live for more than a few months\u0026rsquo;\" and \"You will probably develop breathing difficulties\". Regarding future goals, some stated \"I have no regrets\" and \"I want to be relieved now,\" while others expressed the desire to \"get better quickly and be able to do things on my own.\" Concerns included mental distress, such as feeling lost and anxious about their condition worsening, as well as physical distress, such as shortness of breath and pain, and in some cases, continuous sedation was considered.\u003c/p\u003e\n\u003ch3\u003e2) Results of the questionnaire survey\u003c/h3\u003e\n\u003cp\u003eA total of 549 responses were obtained (response rate 73.3%), including from 149 physicians and dentists (response rate 82.8%, male/female\u0026thinsp;=\u0026thinsp;97/48; four of them did not disclose their sex), 352 nurses (response rate 69.6%, male/female\u0026thinsp;=\u0026thinsp;37/306; nine did not mention their sex), 21 pharmacists (60.0%), 12 psychologists (92.3%), and 15 social workers (100.0%) (15 male and 33 female medical staff). The average years of experience by occupation was 13.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0 years (range: less than 1 year \u0026minus;\u0026thinsp;42 years) for physicians and 11.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2 years (range: less than 1 year \u0026minus;\u0026thinsp;40 years) for nurses (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eWhen asked what treatment they would prefer if they were suffering from advanced anemia due to incurable liver metastasis from gastric cancer, the answers were chemotherapy (physicians: 20.3%, nurses: 11.5%, medical staff: 10.2%), palliative surgery (physicians: 13.5%, nurses: 5.9%, medical staff: 2.0%), and BSC (physicians: 66.2%, nurses: 82.6%, medical staff: 87.8%). Next, when asked what treatment they would recommend if they learned that the patient did not want aggressive treatment, the answers were chemotherapy (physicians: 4.1%, nurses: 2.5%, medical staff: 6.1%), palliative surgery (physicians: 4.1%, nurses: 1.3%, medical staff: 2.0%), and BSC (physicians: 91.8%, nurses: 96.2%, medical staff: 91.9%). When asked what treatment they would choose if it was discovered that \"the family wanted aggressive treatment,\" the answers were chemotherapy (doctors: 8.7%, nurses: 7.4%, medical staff: 4.1%), palliative surgery (doctors: 4.7%, nurses: 2.0%, medical staff: 2.1%), and BSC (doctors: 86.6%, nurses: 90.6%, medical staff: 93.8%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eNext, we analyzed the extent to which the patient's and family's wishes influenced treatment decisions when the patient hoped for BSC and the family desired aggressive treatment. The patient's wishes carried most weight for 86.5% of doctors, 76.2% of nurses and 89.5% of medical staff. The patient's and family's wishes had equal weightage for 9.5% of doctors, 17.2% of nurses (17.2%) and 6.3% of medical staff. The family's wishes had the greatest influence for 4.1% doctors, 6.6% nurses and 4.2% of medical staff. Analyses of these results revealed a statistically significant difference between professions (Chi-square\u0026thinsp;=\u0026thinsp;18.24, p\u0026thinsp;=\u0026thinsp;0.019) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\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\u003eTable showing which decision-making is influenced by the patient or the patient's family\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\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDoctors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurses\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedical staffs\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe patient's wishes had the greatest influence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e86.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e76.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e89.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe patient's and family's wishes had equal influence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e17.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe family's wishes had the greatest influence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFinally, to the question, \"Is a discussion about not pursuing aggressive treatment in a 98-year-old stomach cancer patient ACP,\" the percentage of respondents who answered yes was 78.8% among doctors, 86.5% among nurses, and 85.1% among medical staff. In response to the question, \"Is the discussion about performing surgery on an 85-year-old patient with a femoral neck fracture called ACP,\" 39.6% of doctors, 51.7% of nurses, and 42.6% of medical staff answered yes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study analyzed perioperative ACP practices at our hospital, an acute care center for elderly patients, dividing them into five components. Additionally, a questionnaire survey on perioperative decision-making assessed healthcare professionals' attitudes towards aggressive and passive treatment options for terminally ill cancer patients.\u003c/p\u003e\u003cp\u003ePrevious studies on perioperative ACP have reported that the introduction of ACP reduces the rate of invasive procedures at the end of life, increases patient participation in decision-making, and reduces anxiety and difficulty regarding decision-making [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, other studies have found that ACP support does not improve the quality of end-of-life care, and fails to achieve the expected benefits [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Other studies have also reported that the percentage of attending physicians who understand patients' values has not improved, and that ACP is not effectively utilized by treating physicians for collaborative decision-making [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAt our hospital, approximately 200 general anesthesia cases are performed per month, and perioperative ACP is performed in approximately 10 cases per month, indicating that ACP is performed in roughly 1 in 20 cases. While the type of patients for whom ACP is performed is left to the discretion of the department, it is typically performed in elderly patients, many of whom are female, or have heart disease.\u003c/p\u003e\u003cp\u003ePrevious research has retrospectively analyzed chart entries regarding ACP, including goals of care and treatment, in patients with newly issued DNAR orders. Only 43% of ACP conferences included discussions of values and goals of care, 14% discussed prognosis, 40% discussed treatment and resuscitation options, and 29% mentioned surrogate decision makers [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In the ACP conducted at our hospital, life goals and personal values were relatively frequently discussed. However, surrogate decision makers, a concept unfamiliar in Japan, were rarely mentioned. Regarding matters related to surgery, out patients' were asked their thoughts about surgery, but there was little mention of postoperative progress, complications, long-term prognosis, or the extent of postoperative life-sustaining treatment. It has been suggested that patients should be asked about their goals of treatment, such as their desired postoperative outcome. If these expectations are unrealistic, the expected effects of surgery should be explained again, and the patient and surgeon should discuss whether surgery is truly necessary [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Japan, previous research on the decision-making of patients with advanced cancer and their families has mainly been qualitative descriptive research on the choice of introducing artificial nutrition, such as tube feeding or enteral nutrition [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The questionnaire survey in this study, on the other hand, was a quantitative descriptive study, and was novel in that it also focused on aggressive treatments, such as chemotherapy and surgical therapy, in terminal cancer patients.\u003c/p\u003e\u003cp\u003eFamily members function as caregivers, sources of emotional support, and health care proxy in medical care, making their involvement essential for effective decision-making, especially during serious illnesses and end-of-life care. However, conflicts can arise between healthcare providers and family members, or between patients and their families, during end-of-life care. This is particularly prevalent in family-centered Asian cultures [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In a previous study, 30% of patients reported in interviews that their family members had no say in their medical decision-making [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Other studies have also found high rates of disagreement between patients and their families in the decision-making process regarding aggressive treatment, treatment interruption, and financial burden [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. On the other hand, reports have shown that approximately half of patients rely on family input for important decisions regarding palliative chemotherapy [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. When patients lack decision-making capacity, it is important for family members and surrogate decision-makers to understand the patient's treatment preferences and choices regarding life-sustaining treatment [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe results of our questionnaire survey showed that when it was discovered that the patient did not desire aggressive treatment but their family did, the rate of choosing chemotherapy increased, but the rate of choosing surgery did not increase significantly. Even with aggressive treatment, minimally invasive procedures, such as chemotherapy, tended to be carried out at the discretion of the family. On the other hands, more invasive procedures, such as surgery, were likely strongly influenced by the patient's wishes. Another observation of this study was that doctors tend to respect patients\u0026rsquo; wishes, while nurses respect not only patients\u0026rsquo; wishes, but also those of their family members. This could be because nurses have more opportunities than doctors to provide emotional support to both patients and their families. The results of the questionnaire survey showed that doctors and nurses had similar tendencies regarding treatment selection, but differences were observed in the extent to which they considered the family's wishes. When implementing perioperative ACP, it will be important for health care professionals to collaborate with each other and utilize their professional strengths to form multidisciplinary discussions.\u003c/p\u003e\u003cp\u003eFurthermore, when discussing treatment options for patients with a surgically indicated condition, \u0026ldquo;discussions in which surgery was not selected\u0026rdquo; were considered to constitute ACP (84%), but approximately half (48%) of respondents also considered \u0026ldquo;discussions in which surgery was selected\u0026rdquo; to be ACP. The correct answer to the True or False questions in the methods section was that the decision to undergo surgery itself is informed consent, and therefore does not constitute ACP. However, the fact that about half of the respondents said that \u0026ldquo;ACP applies even when surgery is performed\u0026rdquo; might indicate that the concept of \u0026ldquo;perioperative ACP\u0026rdquo; is gradually accepted. Since surgery in high risk elderly patients involves life-or-death decisions, preoperative ACP, in addition to preoperative informed consent and SDM, might be appropriate in anticipation of the time when persistent postoperative impaired consciousness makes decision-making difficult.\u003c/p\u003e\u003cp\u003eThis study has the following limitations. First, although ACP might not have been provided in a specific format, it may have been included in the attending physician's surgical explanation or the anesthesiologist's anesthesia explanation. Since it was difficult to verify all records in this study, this could not be analyzed. Another limitation of the questionnaire survey was that the scenario presented was highly simplified, and in reality, the circumstances in each case are likely to be more complex. For example, the scenario used in this study did not mention the financial situation of the patient or their family, although treatment choices may vary depending on the patient's financial situation. Finally, this study was a single-center study in a hospital specializing in elderly patients. Even if the number of elderly patients in hospitals throughout Japan increases in the future, since we cannot consider the results of this study as being directly applicable to small hospitals or clinics in rural areas, its external validity is clearly limited.\u003c/p\u003e\u003cp\u003eThis study examined the type of ACP implemented during the perioperative period at our hospital, an acute care hospital for elderly patients. While some aspects, such as listening to patients' goals and concerns, were adequately addressed, content regarding treatment selection and long-term prognosis based on that selection was still insufficient, suggesting the need for anesthesiologists and surgeons to also implement ACP. A questionnaire survey regarding perioperative decision-making allowed us to understand the decision-making status of doctors, nurses, and medical staff regarding treatment selection in terminally ill cancer patients, and to examine the extent to which family members' wishes influence this decision. Anesthesiologists are not only skilled in life-saving and resuscitation procedures, but also in assessments of the patient\u0026rsquo;s capacity to withstand surgery and their frailty. We believe that anesthesiologists might play an important role in perioperative ACP by providing preoperative suggestions to surgeons regarding whether surgery will truly improve the patient\u0026rsquo;s postoperative activities of daily living and achieve the patient's life goals.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSDM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eShared decision-making\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eACP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAdvance care planning\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAmerican Society of Anesthesiologists\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDNAR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDo-not-attempt resuscitation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTMIG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTokyo Metropolitan Institute for Geriatrics and Gerontology\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEMRs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eElectronic medical records\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBSC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBest supportive care.\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eClinical trial number\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003cp\u003e The protocol for this study was approved by the Institutional Review Board of the Tokyo Metropolitan Institute for Geriatrics and Gerontology (TMIG) Research Ethics Committee. Regarding the retrospective study using the EMR, in accordance with the guidelines of the Institutional Review Board of TMIG, informed and written consents were waived because of the nature of the retrospective study. Instead the details of the study and an opt-out document were posted on the hospital's website, ensuring an opportunity for participants to decline participation. Regarding the questionnaire survey, informed and written consents were obtained by asking whether or not participants agreed to participate in the study at the beginning of the questionnaire, and participants who declined were excluded from the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work did not receive any grants from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKS, KI and KK designed and conceived this study. RI, GN and AH collected data. KS, MN and RK analyzed and interpreted the results and drafted the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe received advice from the HAIC Research and Development Unit at the Tokyo Metropolitan Institute for Geriatrics and Gerontology regarding how to proceed with the study. The authors thank FORTE Science Communications (https://www.forte-science.co.jp/) for English language editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available because the institutional rules strictly prohibit releasing the native data on the web but are available from the corresponding author on the reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAida K. Medical Care and Medical Care that Respect the Patient's Will: Focusing on Decision-Making Ability (in Japanese). J Japanese Geriatr Soc. 2013;50(4).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShimizu T. Supporting Patient and Family Decision-Making\u0026mdash;From Treatment Selection to Future Planning (in Japanese). Med Soc. 2015;25(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCutuli SL, Crelli S, De Pascale G, Antonelli M. Improving the Care for Elective Surgical Patients: Post-Operative ICU Admission and Outcome. J Thorac Disease. 2018;10(9):1047\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe Heer G, Saugel B, Sensen B, Rubsteck C, Pinnschmidt HO, Kluge S. Advance Directives and Powers of Attorney in Intensive Care Patients. Dtsch Arztebl Int. 2017;114(21):363\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMohanty S. Optimal perioperative management of geriatric patients: a best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016;222:930\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGastrointestinal Surgery Practice Guidelines for the Elderly 2023 (in Japanese). Herusu-shuppan. 2023:27\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStatement on Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate Orders [online]. American Society of Anesthesiologists Committee on Ethics. 2023 Oct (original approval: October 17, 2001), [Accessed August 8, 2025]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.asahq.org/standards-and-practice-parameters/statement-on-ethical-guidelines-for-the-anesthesia-care-of-patients-with-do-not-resuscitate-orders\u003c/span\u003e\u003cspan address=\"https://www.asahq.org/standards-and-practice-parameters/statement-on-ethical-guidelines-for-the-anesthesia-care-of-patients-with-do-not-resuscitate-orders\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCushman T, Waisel DB, Treggiari MM. The role of anesthesiologists in perioperative limitation of potentially life-sustaining medical treatments: a narrative review and perspective. Anesth Analg. 2021;133(3):663\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShimizu K, Komatsu K, Uchida H, Nawata M, Kubota R. Current practice and awareness of perioperative do-not-attempt-resuscitation orders: a single-center retrospective survey and complete questionnaire survey. J Anesth. 2024;39:223\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMathew BA, Shahla S, Omonele N, Catherine MK, Nicholas S, David GM, Michel JS. Reviewing ethical guidelines for the care of patients with Do-Not-Resuscitate orders after 30 years: Rethinking our approach at a time of transition. Anesthesiology. 2024;141:584\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, Matlock DD, Rietjens JAC, Korfage IJ, Ritchie CS, Kutner JS, Teno JM, Thomas J, McMahan RD, Heyland DK. Defining advance care planning for adults: A consensus definition from a multidisciplinary Delphi panel. J Pain Symptom Manage. 2017;533:821\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTang VL, Dillion EC, Yang Y. Advance care planning in older adults with multiple chronic conditions undergoing high-risk surgery. JAMA Surg. 2019;154:261\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLarobina ME, Meccy CJ, Negri JC, Pick AW. Is informed consent in cardiac surgery and percutaneous coronary intervention achievable? ANZ J Surg. 2007;77(7):530\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYamamoto K, Yonekura Y, Hayama J, Matsubara T, Misumi H, Nakayama K. Advance care planning for intensive care patients during the perioperative period: a qualitative study. SAGE Open Nurs. 2021;7:23779608211038844.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHiraoka E, Norisue Y. End-of-life discussions: From outpatient to acute care, thinking together with the field (in Japanese). Medical Science International; 2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHouben CHM, Spruit MA, Groenen MTJ, Wouters EFM, Janssen DJA. Efficacy of advance care planning: a systematic review and meta-analysis. J Am Med Dir Assoc. 2014;15:477\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYamamoto K, Nakayama K. Development and content validation of decision aids for advance care planning support for patients undergoing high-risk surgery. L Perioper Pract. 2022; 177504589221117672.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilson ME, Krupa A, Hinds RF, Litell JM, Swetz KM, Akhoundi A, Kashyap R, Gajic O, Kashaniet K. A video to improve patients and surrogate understanding of cardiopulmonary resuscitation choices in the ICU: a randomized controlled trial. Crit Care Med. 2015;43(3):621\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMorrison RS, Meier DE, Arnold RM. What\u0026rsquo;s wrong with advance care planning JAMA. 2021;326(16):1575\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmith AK. Should we still believe in advance care planning? J Am Geriatr Soc. 2022;70:1358\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHiraoka E. What is the 'Comprehensive Evaluation by a Multidisciplinary Team and Collaborative Decision-Making with the Patient' Recommended in the 2022 Guidelines for the Evaluation and Management of Cardiac Disease in Non-Cardiac Surgery? J Japanese Soc Clin Med. 2023;43(7):502\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThurston A, Wayne DB, Feinglass J. Documentation quality of inpatient code status discussions. J Pain Symptom Manage. 2014;48:632\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCooper Z, Corso K, Bernacki R, Bader A, Gawande A, Block S. Conversations about treatment preferences before high-risk surgery: a pilot study in the perioperative testing center. J Palliat Med. 2014;17:791\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNaito K, Suzuki K. Literature review of decision-making in advanced and terminally ill cancer patients and their families (in Japanese). J Nurs Res Osaka Med Coll. 2016;6:76\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKato M, Kakeda K. A Literature Review of Family Decision-Making in the End of Life for Elderly Patients (in Japanese). J Japanese Association Nurs Res. 2017;40(4):685\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJack P, James CHC, Lesile F, Ka MC. Role of Patients\u0026rsquo; Family Members in End-of-Life Communication: An Integrative Review. BMJ Open. 2023;13:e067304.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChristof S, Kurt P, Barbara D, Peter L, Thomas HL, Oliver K. Medical Decision-Making of the Patient in the Context of the Family: Results of a Survey. Support Care Cancer. 2006;14(9):952\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSiminoff LA, Rose JH, Zhang A, Zyzanski SJ. Measuring Discord in Treatment Decision-Making; Progress Toward Development of a Cancer Communication and Decision-Making Assessment Tool. Psycho-oncology. 2006;15(6):528\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrunfield EA, Maher EJ, Browne S, Ward P, Young T, Vivat B, Walker G, Wilson C, Potts HW, Westcombe AM, Richards MA, Ramirez AJ. Advanced breast cancer patients\u0026rsquo; perceptions of decision making for palliative chemotherapy. J Clin Oncol. 2006;24(7):1090\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSilvester W, Detering K. Advance directives, perioperative care and end-of\u0026ndash;life planning. Best Pract Res Clin Anaesthesiol. 2011;25(3):451\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"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":"advance care planning, do-not-attempt-resuscitation order, general anesthesia, shared decision making","lastPublishedDoi":"10.21203/rs.3.rs-7644227/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7644227/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground;\u003c/h2\u003e\u003cp\u003eIn high-risk elderly patients with severe comorbidities, perioperative advance care planning (ACP) should go beyond informed consent/shared decision-making (SDM), and should address difficult decision-making. We examined perioperative ACP in elderly patients in an acute care hospital, including the types of decision-making support provided by healthcare professionals.\u003c/p\u003e\u003ch2\u003eMethods;\u003c/h2\u003e\u003cp\u003eBetween June and October 2024, retrospective ACP data for inpatients during the perioperative period were collected and conceptually analyzed based on five dimensions: prognosis, intentions regarding operation, future goals, family-related issues, and concerns. Next, in June 2025, a scenario-based questionnaire survey regarding elderly patients with liver metastases from gastric cancer was conducted among doctors, nurses, and medical staff at our hospital.\u003c/p\u003e\u003ch2\u003eResults;\u003c/h2\u003e\u003cp\u003ePerioperative ACP was conducted in 41 cases, mainly elderly patients, females and those with cardiac disease. While 52% of ACPs patients mentioned life expectancy and 61% mentioned future goals, there was little mention of postoperative progress, long-term prognosis, or surrogate decision makers. Patients occasionally confided in their family members regarding decision makings. Nest as to questionnaire survey, among 749 participants surveyed, 575 responded (76.8% response rate: 149 physicians, 378 nurses, and 48 medical staff). Regarding their opinions about treatment preferences for patients who did not desire aggressive treatment but their family did, the proportion of respondents choosing \u0026ldquo;chemotherapy\u0026rdquo; increased, with no significant increase in preference for \u0026ldquo;operation\u0026rdquo;. Doctors respected patients' wishes, while nurses respected both patients\u0026rsquo; and families\u0026rsquo; wishes.\u003c/p\u003e\u003ch2\u003eConclusions;\u003c/h2\u003e\u003cp\u003eThis study examined the type of ACP implemented during the perioperative period at our hospital, an acute care hospital for elderly patients. Regarding treatment selection and long-term prognosis based on that selection was still insufficient, suggesting the need for anesthesiologists and surgeons to also implement ACP. When implementing perioperative ACP, it will be important for health care professionals to collaborate with each other and utilize their professional strengths to form multidisciplinary discussions.\u003c/p\u003e","manuscriptTitle":"Perioperative advance care planning for supporting decision-making in elderly patients: a retrospective study and questionnaire survey at a single center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-06 16:38:41","doi":"10.21203/rs.3.rs-7644227/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":"2456ea5d-48b1-4980-a4a5-c8663e1756b7","owner":[],"postedDate":"November 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-14T08:39:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-06 16:38:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7644227","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7644227","identity":"rs-7644227","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}