Aligning surgical decisions with older adults’ goals

Older adults with multiple chronic conditions face considerable challenges when deciding on surgical procedures due to the uncertain benefits and heightened risks involved. Varying health goals further complicate surgical decision-making. Recognizing this complexity, a Journal of the American Geriatrics Society (JAGS) research letter co-written by Yale faculty introduces a decision-making tool to align surgical interventions with what matters most to each older adult.

“Traditional decision aids typically provide information on treatment options but fail to address whether these options align with the specific health outcomes desired by the patient,” says Mary E. Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine (geriatrics), and senior author of the research letter. “This gap requires tools that promote discussions beyond merely ‘fixing’ a clinical problem.”

The new Patient Priorities-Aligned Intervention Decisions tool aims to focus patient-clinician discussions on an individual’s desired outcome goals rather than merely presenting procedural choices and expected anatomical changes.

The tool starts with four broad categories for framing procedure-related goals: feeling better, living longer, preventing disability, and obtaining a diagnosis. It then helps patients identify specific, realistic health outcome goals, highlights key symptoms or impairments they hope the procedure will address, and encourages them to voice concerns about undergoing or forgoing the procedure.

According to the JAGS publication, older adults who tested the tool reported goals such as “I want to be able to walk a mile,” or “I want to be able to bathe and dress myself.” Most patients found the tool’s questions relevant and believed it facilitated meaningful discussions with clinicians, particularly around fears and desired outcomes.

This approach aligns surgical decisions more closely with the specific goals of older adults, promoting age-friendly and patient-centered care, as required by the recent Centers for Medicare & Medicaid Services age-friendly measure.

This new tool is rooted in the principles of Patient Priorities Care, which has effectively reduced treatment burdens and improved alignment with patient priorities in managing chronic conditions.

“Beyond surgical decisions, we are working to shift these conversations at the health systems level and eventually at the level of payment and measurement of quality,” says Tinetti. “We’re gathering evidence from systems to support that moving to patient priorities-aligned care results in less unwanted care, more wanted care, and less utilization.”

Rachel Lampert, MD, FACC, Robert W. Berliner Professor of Internal Medicine (cardiology), is a co-author of the paper.