76 Evaluating the frequency of advance directives obtained in patients electively undergoing high-risk operations at a public teaching hospital in Newark, New Jersey: a retrospective chart review

<h3>Background</h3> Millions of high-risk operations are performed in the United States annually. Patients undergoing these procedures without advance directives are at the highest risk for receiving unwanted care or treatment that is not aligned with their goals. Advance care planning reduces this risk and is recommended as part of the pre-operative assessment by the American College of Surgeons and the American Geriatric Society. The aim of this study is to determine the frequency of advance directives obtained prior to electively undergoing high-risk operations at a university teaching hospital in Newark, New Jersey. <h3>Methods</h3> A retrospective chart review was conducted to include all patients who electively underwent a qualifying high-risk operation over three separate 90-day time periods between 2019 and 2022. High-risk operations were selected from a previously published standardized list of procedures that met the following criteria: a procedure with greater than 1% inpatient mortality, patients with major malignancies, and patients who required post-operative ICU admission. <h3>Results</h3> A total of two hundred qualifying records were included in this analysis. In less than 1% of patients undergoing high-risk operations were advance directives documented prior to the day of surgery. Over 90% of patients had a diagnosed malignancy or terminal illness prior to surgery. Nearly 10% of patients underwent an unplanned tracheostomy and unplanned gastrostomy. One third of all patients were discharged to a skilled nursing facility, long term care facility, or rehab. <h3>Conclusion</h3> Despite compelling evidence and the legal, professional, and public endorsement for the use of advance directives, there continues to be very low utilization of these documents in this institutional study. Patients electively undergoing known high-risk major operations would benefit from pre-operative advance care planning. Targeted interventions and systems-based changes are necessary to increase the frequency of advance directive documentation in this high-risk population.