Clinical Momentum: An Observational Study Identifying Latent Forces Driving Surgical Interventions for Older Adults Near the End of Life.

Abstract

OBJECTIVE We evaluated the empirical fit of our model of clinical momentum for older adults with life-limiting illness undergoing unplanned surgery. BACKGROUND Older adults often undergo surgery near the end of life, in contrast to generally stated preferences. Systems forces promoting intervention may produce nonbeneficial treatment despite advances in communication. We conducted an observational study to understand how a conceptual model of clinical momentum might apply to patients with life-limiting illnesses having surgery. METHODS We interviewed 29 interdisciplinary clinicians caring for 8 patients age 65+ with life-limiting illness who underwent unplanned surgical intervention. We evaluated physical, cognitive, and social behavioral processes related to the course of care. We used content analysis to code interview transcripts and higher-level analysis to understand the empirical fit of the conceptual model. RESULTS We found evidence of model components, including "fix it" and "recognition-primed decision-making" that related to actual clinical events and processes that occurred for patients, promoting a default of surgical intervention followed by an accumulating "cascade" of interventions that generated a perception of "sunk costs." We identified novel momentum accelerators including binary options and care fragmentation. Clinicians expressed concerns that surgery was nonbeneficial but were unable to disrupt this momentum in the moment of decision-making around surgery. We identified momentum disruption when the patient's abnormality could not be fixed and additional surgery was not considered or offered. CONCLUSIONS Clinical momentum characterizes systems forces leading to acute surgical intervention for patients with life-limiting illnesses despite surgeon concerns that the treatment does more harm than good. These forces are difficult to disrupt and may require interventions beyond improved communication to reduce nonbeneficial therapy.