Table 4 Participant quotes on risk

Increase in high-risk patients

1. … if you’ve got a patient who has got significant comorbidities, the sorts of patients we’re increasingly seeing, if you’ve got patients where the surgery is going to be particularly major, say oesophagostomy, cardiac surgery, pancreatic Whipple’s procedure, then certainly the outcomes for the patients are very, very different. [Intensivist 4]

2. I think this is one thing which has been discussed for quite some time, one, because of the ageing population and also a lot more obese people we deal with. [Surgeon 2]

3. … dilemmas of patients nowadays living well past their 80s, 90s, and we even have hundred-year-olds, so when do you stop? Do you just go on their chronological age and stop, or a patient needs - got an aneurysm, needs a complex procedure and the patient is 95, should we let them die just because they’re 95? Or should we do a complex operation to save them? [Surgeon 2]

4. Not common, but I think we’re seeing a lot more high-risk patients now because we’re all getting older and people are living longer, so we are seeing a lot more patients that are high-risk that we wouldn’t have operated on in the past, due to great medical advances and all of that. [Nurse/admin 1]

5. Back in the old days the minute you hit 80 you got this [risk assessment], whether you had no other things, but we don’t necessarily do that now because some of the 80 years olds walk in better than the 60-year olds. [Nurse/admin 1]

Recognising frailty

6. I think more and more people are realising and more and more surgeons are realising that anaesthetics is not just getting someone off to sleep and waking them up at the end of the day. It’s - it kind of seeps into the fields of perioperative medicine, which involves identifying which patients are frail and - because, yeah, some surgeons are good at identifying those. Some may not be. [Anaesthetist 2]

7. I think frailty is frailty. At the end of the day, it’s the patient. If a patient is frail, he’s not only frail for the surgeons in one aspect and then a different aspect for - as an anaesthetist or an intensivist. The frailty is going to be because of the same reasons. [Anaesthetist 2]

8. I think it says at the top there it’s about recognising frailty and it’s something that we as a profession, I’m talking medicine, not particular subgroups, have done particularly poorly. [Intensivist 4]

9. So, I guess people might look at level of function or just a list of comorbidities generally. I think frailty is often poorly recognised and poorly understood by surgeons and to some extent anaesthetists as well. [Intensivist 2]

10. Yes, and I mean often we can hear a story from [remote cities and towns], whether this patient’s this, this, this; then they turn up on your doorstep and they’re on their wheelie walker or they - and so the story completely changes. They might not have been high-risk before and then you’ve eyeballed them and go, no. [Nurse/admin 1]

Risk-benefit balance

11. … it’s the small, high-risk patients, especially if you have a procedure which might be of marginal overall benefit to the patient. It doesn’t mean that they can’t get benefit from it, and it doesn’t mean that we should necessarily deny them their opportunity if they are genuinely miserable with their current situation. [Surgeon 1]

12. I calculated the EuroSCORE, and it came to about 35% 40% mortality. ... So, I went back to the surgeon. I said, do you think you really should be operating on this patient with such a high mortality rate? He just looked at me and said, if I don’t operate this patient, her mortality is 100%. [Anaesthetist 2]

13. What’s best for the patient may not necessarily be the most that we can do. In some areas in medicine doing nothing may be the best thing. ... Think simple, aiming for comfort, palliative approach may be the best thing. [Intensivist 1]

14. I guess it comes back to the constant of futility. Yes, we can do operations, and we can do all these other things, but is it really going to benefit the patient? [Intensivist 4]

Suitability and readiness for surgery

15. I have been involved in one or instances where it was extremely clear cut that that patient would not even be fit for a haircut - let alone even a palliative non-curative surgery. [Anaesthetist 2]

16. So, when we make decisions about whether a patient is appropriate for this procedure or that procedure, when we make a decision about whether a patient should have an operation at all, when we make decisions about whether the patients should go to intensive care, should they go to intensive care for a short period of time. So when we make a decision with their treating physicians about whether now is the right time for surgery or whether that should be done in the future. [Anaesthetist 1]

17. They look at us as the primary and the initial gate, if you were to call it, as to see whether this patient is really - has that reserve to actually undergo this procedure. When I say reserve, it’s for us - predominantly, it’s physiological reserve, but I - personally I look at the patients as a whole, so it’s also the psychological, the social aspects of whether they can actually - anybody can operate and we can give them an answer, they can - yes, they’ll get better, but are they actually able to go back home? Is there enough support for them? I think in terms of looking at the whole package. [Anaesthetist 2]

18. Because some people are happy with their quality of their life and they might decide at this stage I’m not ready, I don’t want to go ahead but then come back in 3 months and go, alright, I have thought about it, and now I’m ready. So, I think you’ve got to wait till they’re mentally ready. [Nurse/admin 1]

Avoiding negative outcomes

19. Hopefully, we’ll avoid unnecessary surgery, we’ll avoid unwise surgery, and we’ll avoid bad outcomes that can be avoided. So, we’ll have more advanced and sensible discussions about likely outcomes, so people will have a more realistic, potentially, expectation of what their outcomes are likely to be and make more realistic decisions about those things. [Anaesthetist 1]

20. A lot of patients think they’ll either survive the surgery and be okay or not survive the surgery and then it won’t matter. [Intensivist 3]

21. It’s pretty, very uncommon for a patient to die on the table. But someone who doesn’t have the reserves to recover from an operation, particularly if there’s complications, it’s going to be in the post-operative period that we’re struggling, and it may well be a patient’s being supported in intensive care but what treatment’s appropriate and what are the goals of treatment. If we’ve had those discussions before the operation, it’s useful. So that is something I do sometimes. [Surgeon 3]

22. … we want patients to be satisfied with what we do, and even if they don’t get an optimal result or the end of it, complication, they can at least say that, okay well we went through this process and I’m just unlucky [Surgeon 5]

Methods in use for identifying high-risk patients

23. Well, the surgeon normally flags that that they’re high-risk, and then from there we’ll get the anaesthetist and the intensivist involved. [Nurse/admin 1]

24. Well, we have some vague indicators. I think it’s just experience mainly. But then we have some indicators like for cardiac surgery there is an indicator for EuroSCORE. So, we put all the patient details, and that gives us a mortality. So, if the mortality is more than say 15%, then we know that the patient is high-risk. [Surgeon 4]

25. So, there are some validated tools, which are available. I’ve never had to use any of them. [Anaesthetist 2]

26. Well, you sort of - a lot of it will come from their history. So, if they have severe cardiac or similar problems, they’re morbidly obese and poorly mobile, so if they come in in a wheelchair because they can’t really mobilise. You see people who still manage to mobilise with fairly severely arthritic joints, for example, but it just means that - or it suggests that their reserves are not so good, if they turn up like that. So, they would probably be the ones, so someone with cardiac problems, obese and turns up in a wheelchair. [Surgeon 1]

27. Oh, we pretty know who the high-risk patient. We know from the - well it will be several things. It’s usually patient-related factors like old age, frailty, number of cardiac problems like patient needs bypass, multiple valves need to be done, patient’s heart function isn’t particularly good. Then you look at other organ functions, lungs, patients who have got emphysema or other lung disease for that matter. Kidney’s, patients on dialysis, they are always high-risk. [Surgeon 5]

28. They’re not always old. We get some really frail people in their forties, so they had rheumatic fever and other things, they look physically older than what they are. So chronologically, they don’t have to be that old. They can be quite young but have been, I guess, disadvantaged when the genes were handed out. [Intensivist 4]

29. But it’s really not an art, it’s just experience and pattern recognition and putting this - trying to see the most similar situation that you’ve been in before that might offer the patient the best outcome. [Intensivist 3]

30. You just know it. You just know. You look at - we call it an end-of-bed-o-gram. Right? So, you stand at the end of the bed, and you just get a brief idea - just looking at everything - and of course, you do need to delve into a few more specifics and details later, but you get that idea about who’s likely to make it and who’s going to struggle. [Anaesthetist 2]

31. There’s something called eyeball test in med surgery. I don’t know if you heard or not. You look at the patient from end of the bed, and it doesn’t look like 80 or 85-year-old woman. Little old woman, frail looking. [Surgeon 5]

32. Can I quote The Castle? ... It’s the vibe. [Intensivist 2]

33. I take all the patients I’m planning to do a big operation on, I walk them up three flights of stairs. So as part of coming to see me in clinic either myself or if I think - I do it personally myself if I think they really are pretty borderline, if they look fairly fit, I’ll often get the resident to do it. Basically, they need to be able to walk up three storeys and chat to me at the top. [Surgeon 3]