"They Wanted Everything Done": Retrospective Analysis of Surrogacy Consent in Emergent Laparotomy.

INTRODUCTION

In patients with surgical emergencies, balancing time to operative intervention with goals-of-care discussions is critical. When patients lack capacity, surgeons depend on surrogate consent (SC). We aimed to understand outcomes associated with SC compared to patient consent in emergent surgery.

METHODS

We performed a single-center, retrospective review of patients undergoing emergent laparotomy within 6 h of consultation. Data were collected on demographics, clinical characteristics, outcomes, and details of consent. Univariate and multivariable analyses were performed, adjusting for demographics, comorbidities, and American Society of Anesthesiology (ASA) score, comparing SC and patient consent.

RESULTS

We included 479 patients, 26.7% with SC. Patients with SC tended to be older (median 65.2 versus 58.2 y, P < 0.001), have a higher Charlson Comorbidity Index (≥5; 46.9% versus 22.5%, overall P < 0.001), have an ASA classification of IV or V (59.3% versus 24.8%, P < 0.001), and present with a nonzero quick Sequential Organ Failure Assessment score (51.6% versus 23.4%, P < 0.001). Associated comorbidities in SC more commonly included cancer (25.0% versus 16.2%, P = 0.029) and neurodegenerative disease (8.6% versus 3.4%, P = 0.019). Patients with SC were more often discharged with mechanical ventilation (33.6% versus 5.1%, P < 0.001) and supplemental nutrition (31.3% versus 8.3%, P < 0.001). They had independently higher odds of unplanned reoperations (adjusted odds ratio [aOR] 2.8, 95% confidence interval [CI] 1.6-4.9), systemic complications (aOR 2.4, 95% CI 1.5-3.8), and death (aOR 5.4, 95% CI 2.7-11.0) when controlling for age, sex, race, insurance status, Charlson Comorbidity Index, and ASA classification.

CONCLUSIONS

Patients who underwent laparotomy with SC tended to be older, more severely ill, and with more comorbidities. They were more often discharged with life-sustaining therapy and had higher odds of inpatient complications. When obtaining SC, surgeons should discuss whether these outcomes would be goal concordant.