Decision-making processes in older patients that require, but do not undergo, emergency laparotomy in the UK: a multicentre observational study.

Abstract

A recent study (ELF2, 2024) showed that older adults (≥65 yr) who require, but do not undergo, emergency laparotomy (the NoLap population) are very old and living with high levels of frailty and multimorbidity. We report on the second aim of this study: to explore the decision-making process behind the decision not to operate. A prospective cohort study recruited 750 consecutive NoLap patients from 64 UK emergency surgical units (February-November 2021). Each NoLap patient had a surgical condition treatable by an emergency laparotomy as defined by the National Emergency Laparotomy Audit criteria. Shared decision-making (patient and family or both member involvement) and multispeciality decision-making (two or more specialities) factors were explored. Free text answers underwent qualitative analysis. There were 12.4% of patients with an advanced directive in NoLap cases. Patient involvement in the decision was documented in 65.9% of NoLap cases (34.4% assisted by a family member). For those not involved (33.2%), 67.5% had a family member consulted. In ≥9.0% of NoLap cases, neither the patient nor a family member was involved. Multispeciality decision-making occurred in 66.2% of cases, with the surgical team involved in almost all (99.9%-84.8% at consultant level and 73.5% in person). Medical teams were the next highest speciality to be involved (33.0%), with geriatricians present in only 8.7%. Consultant input declined over weekends and overnight. Qualitative content analysis identified a broad range of patient and clinical factors warranting further exploration. Multispeciality, shared decision-making regarding emergency laparotomy is possible in a time-pressured emergency surgical setting.