To our knowledge, this is the first study to investigate the implementation of ACP support in high-risk patients using PtDAs. We found that the PtDAs implemented in this study could be used to support ACP in patients scheduled for high-risk surgery, without increasing the requirement for human resources and posing a time burden on healthcare providers.
Providing PtDAs for ACP to patients before high-risk surgery had four main effects on patients and their families. First, it helped patients to understand ACP. One outcome cited was increased knowledge of PtDAs . The provision of two PtDAs to help explain the ACP process and provide knowledge about life-prolonging treatment was an opportunity to deepen the understanding of patients and their families. Patients’ knowledge and understanding of ACP may have led them to consider long-term treatment and lifestyle rather than solely end-of-life care decisions. ACP in high-risk preoperative patients is considered in the initiation of discussion and ACP support. However, the timing of ACP support before high-risk surgery may not be appropriate for perioperative patients as it may also increase anxiety and stress regarding treatment among patients and family members. Advance life planning or ACP could be used to support early healthy stages. However, it is difficult and impractical to approach the target person as the support starts in the acute care hospital. A significant reduction in interest in ADs in postoperative patients compared with preoperative patients was previously reported .
This study showed that ACP support for patients gave patients and their families a positive feeling that they were receiving treatment in anticipation of recovery. It did not necessarily increase the participants’ anxiety but instead encouraged them to think about the treatment they wanted based on their values and life. The patients were also satisfied with the discussion process and sharing sessions with their families and researchers. By providing the patient with an opportunity to think about ACP before surgery, the patient may be able to continue to think about their life plan, including future treatment, and depending on the situation, discuss it with their family and health care provider to revise treatment goals.
The second effect is encouragement of patients to think about their values and how to think about the way they want to live and the treatment they want to receive based on those values. Most patients considered the medical treatment they wanted to receive based on their values only after being offered PtDAs. To express patients’ feelings to their families and healthcare providers, it is necessary to identify these feelings and verbalize what they value. A previous study on ACP investigated the patient’s ability to document ADs and agreement of intent with the surrogate decision-maker . The essence of an ACP is as much about the process of discussion leading to a decision, as it is about being able to make one [7–8, 27]. The ability of patients to express their desire for treatment based on their values is an essential factor.
The third point was the opportunity for the patient and the family to talk. In this study, all patients expressed their treatment thoughts to surrogate decision-makers. Only 50% of patients could initiate discussion with their family members by themselves during the period until admission; thus, it is difficult for patients to initiate ACP discussion proactively. Although family members perceived discussion with patients as important, they generally avoid edit in practice . The involvement of family members in ACP is essential , and the preferences of family members tend to be as important as respect for autonomy [30, 31]. Problems related to treatment decisions for patients undergoing perioperative or critical care often blur the line between treatment and life-prolonging treatment owing to the rapid worsening of patient status and difficulties in predicting prognosis . In addition, the patient’s ability to make decisions is likely to deteriorate, leading to surrogate decision-makers and healthcare providers . Thus, it is important for family members, including surrogate decision-makers, to understand the patient’s treatment preferences and preferences for life-prolonging treatment. When patients want to communicate their wishes for treatment or life-prolonging treatment to family members, including surrogate decision-makers, healthcare providers should consider supporting their dialogue.
This study also found that family members have as much or higher anxiety levels than patients. Family members had unchanged or higher HADS scores even when patients completed the procedure successfully. Many patients had the same need for support during their treatment as their families, suggesting the importance of family care in the comprehensive implementation of ACP support for patients undergoing high-risk surgery.
Moreover, PtDAs may promote SDM. PtDAs. They have been shown to improve physician–patient communication and patients be not passive in decision-making . This study clarified that creating opportunities for patients and their families to interact with ACP themes is a challenging task for patients. Implementation created opportunities for patients and their families to discuss ACP via PtDAs and facilitated discussions with healthcare providers. High-risk preoperative decision-making is a complex process that requires a mutual understanding between physician and patient and is important to ensure patient understanding, so patients can make decisions based on their values and preferences [34, 35].
ACP is defined as the process of understanding an individual’s values, life goals, and preferences for future health care and sharing them with family members and health care providers to support adults of all ages and stages of health  and the ability to record and confirm these as needed . An important common feature of SDM and ACP is their focus on the decision-making process and patient’s ability to make decisions based on their values and preferences. The use of PtDAs for ACP may facilitate SDM for ACPs by encouraging discussions between patients, family members, and healthcare providers.
Challenges to promoting ACP include difficulty in timing discussions and missed opportunities [36, 37] and a lack of knowledge and skills among healthcare providers [16, 38, 39]. Our findings suggest that family members also need ACP support, and that promoting family acceptance may lead to a discussion between the patient and family members and SDM involving healthcare providers.
This study had some limitations. First, this study was conducted on patients from one hospital and one department; thus, there is a limit to the generalization of our findings to patients undergoing high-risk surgery. Second, our results were affected by the fifth wave of SARS-CoV-2 infection, as the study was implemented when there was hospital restriction on the attendance of family members and a tremendous pressure on the medical system. Third, as this study was designed to assess the feasibility of implementation by combining quantitative and qualitative data, we were unable to determine effectiveness. This study evaluated the implementation by combining quantitative and qualitative data. The condition of the patient who received peripheral operation and critical care and the thought or needs of the patient/family are easily changeable. Our results indicate that it might not be able to evaluate effectiveness as an outcome of ACP based only on quantitative data. Future studies can improve the quality of data analysis by combining qualitative and quantitative evaluation when conducting outcome evaluation.
According to this study, patients undergoing high-risk surgery at acute care hospitals and their families were supported by various healthcare providers; thus, it was difficult for the same medical personnel to provide unified support to patients and their families. Therefore, in the future, it is necessary to examine the method for supporting patients and families. In particular, our results suggest that the involvement of one investigator with patients and their families in all timelines may improve the relationship between patients and their families. For example, there is usually no opportunity for a designated healthcare provider to continue interacting with the patient during the perioperative period, and there is family other than the attending physician. The fact that patients and their families were able to discuss ACP during the surgical treatment process may have been influenced by the ease of identification and judgment. For acute care hospitals, where it is difficult for specific nurses, other than the attending physician, to support patients and their families, it will be necessary to consider better methods.For instance, cross-sectoral support of patient and family care by nurses who can work across organizations, such as advanced practice nurses (e.g., clinical nurse specialist), may be effective.