{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T15:52:19Z","timestamp":1791388339801,"version":"4.3.3"},"reference-count":41,"publisher":"American Medical Association (AMA)","issue":"10","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Surg"],"published-print":{"date-parts":[[2026,10,1]]},"abstract":"\n Importance<\/jats:title>\n Clinicians, people living with dementia (PLWD), and their caregivers face clinical, ethical, and psychosocial challenges when making surgical decisions.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To explore clinician experiences with surgical decision-making when a patient has dementia.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This qualitative study uses case studies compiled from interviews, surveys, and resource review across 12 sites and 178 clinicians. Interviews were conducted between November 2021 and May 2023, while analysis of interview data and associated survey data continued until December 2024.<\/jats:p>\n <\/jats:sec>\n \n Exposure<\/jats:title>\n One interview.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n The primary outcome was themes describing clinician experiences with surgical decision-making when a patient has dementia.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Among 178 participants (64 surgeons, 100 other clinicians, and 14 hospital leaders), mean (SD) age was 47 (10.9) years, and 92 participants (51.7%) were female. Three main themes were identified. The first theme found that challenges with clinician identification of dementia and assessment of capacity in the surgical setting were barriers to optimal surgical decision-making. Furthermore, inconsistent documentation of cognitive impairment in electronic health records (EHR) and\/or lack of EHR interoperability across health systems made it difficult to rely on medical records to identify dementia in a patient\u2019s history. Theme 2 identified that caregivers and nonsurgical clinicians were key contributors to surgical decision-making, but misaligned expectations, caregiver burden, and limited preparation complicated the process. Given the lack of EHR documentation for PLWD, clinicians needed to rely on caregivers to provide a sufficient picture of patients\u2019 cognitive and physical functioning, as well as their goals and values that were relevant to the surgical decision. The third theme found that clinician appraisal of the relevance of dementia to surgical outcomes variably shaped the surgical decision-making process with PLWD and their caregivers. Clinicians commonly perceived that dementia negatively impacts surgical outcomes and recovery among PLWD, yet participants rarely referenced evidence, such as published data or care guidelines, supporting these views.<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n Results of this qualitative study suggest that clinicians face challenges to surgical decision-making for PLWD, including limited documentation or resources to support identification of dementia, variable caregiver involvement, and constrained access to dementia care specialists who can support the decision-making process. Addressing these challenges may include improving communication pathways with longitudinal clinicians, EHR documentation for older adults, routine and meaningful inclusion of caregivers, and access to nonsurgical clinicians who can support surgical decision-making.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamasurg.2026.3729","type":"journal-article","created":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T15:30:25Z","timestamp":1787153425000},"page":"1056","source":"Crossref","is-referenced-by-count":0,"title":["Clinician Considerations Regarding Surgical Decision-Making in the Context of Dementia"],"prefix":"10.1001","volume":"161","author":[{"given":"Rachel R.","family":"Adler","sequence":"first","affiliation":[{"name":"Center for Surgery and Public Health, Brigham and Women\u2019s Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard E.","family":"Chunga","sequence":"additional","affiliation":[{"name":"Department of Gerontology, University of Massachusetts Boston"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joely A.","family":"Centracchio","sequence":"additional","affiliation":[{"name":"Department of Psychology, University of Miami, Coral Gables, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zeba N.","family":"Ahmad","sequence":"additional","affiliation":[{"name":"Harvard Medical School, Boston, Massachusetts"},{"name":"Department of Psychiatry, Massachusetts General Hospital, Boston"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karen R.","family":"Sepucha","sequence":"additional","affiliation":[{"name":"Harvard Medical School, Boston, Massachusetts"},{"name":"Health Decision Sciences Center, Massachusetts General Hospital, Boston"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christina","family":"Sheu","sequence":"additional","affiliation":[{"name":"Center for Surgery and Public Health, Brigham and Women\u2019s Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samir K.","family":"Shah","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Florida, Gainesville"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Clancy","family":"Clark","sequence":"additional","affiliation":[{"name":"Department of Surgery, Virginia Mason Medical Center, Seattle, Washington"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dae","family":"Kim","sequence":"additional","affiliation":[{"name":"Hebrew SeniorLife, Marcus Institute for Aging Research, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan L.","family":"Mitchell","sequence":"additional","affiliation":[{"name":"Hebrew SeniorLife, Marcus Institute for Aging Research, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily","family":"Finlayson","sequence":"additional","affiliation":[{"name":"Department of Surgery, Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zara","family":"Cooper","sequence":"additional","affiliation":[{"name":"Center for Surgery and Public Health, Brigham and Women\u2019s Hospital, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Hsu","sequence":"additional","affiliation":[{"name":"Mongan Institute, Massachusetts General Hospital, Boston"},{"name":"Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kellie L.","family":"Flood","sequence":"additional","affiliation":[{"name":"Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen","family":"Ryan","sequence":"additional","affiliation":[{"name":"Geriatric Medicine and Palliative Care, University of Rochester School of Medicine, Rochester, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tamara","family":"Flys","sequence":"additional","affiliation":[{"name":"Christus St. Vincent Health System, Santa Fe, New Mexico"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"suffix":"Jr","given":"Adolph J.","family":"Yates","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah A.","family":"Wingfield","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anupama","family":"Gangavati","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joel S.","family":"Weissman","sequence":"additional","affiliation":[{"name":"Center for Surgery and Public Health, Brigham and Women\u2019s Hospital, Boston, Massachusetts"},{"name":"Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lara","family":"Traeger","sequence":"additional","affiliation":[{"name":"Department of Psychology, University of Miami, Coral Gables, Florida"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","reference":[{"issue":"10","key":"soi260055r1","doi-asserted-by":"publisher","first-page":"2838","DOI":"10.1111\/jgs.17893","article-title":"Patients living with dementia have worse outcomes when undergoing high-risk procedures.","volume":"70","author":"Shah","year":"2022","journal-title":"J Am Geriatr Soc"},{"issue":"9S1","key":"soi260055r2","doi-asserted-by":"publisher","first-page":"S308","DOI":"10.1016\/j.arth.2024.11.051","article-title":"Trends and epidemiology in revision total knee arthroplasty: a large database study.","volume":"40","author":"Jones","year":"2025","journal-title":"J Arthroplasty"},{"issue":"12","key":"soi260055r3","doi-asserted-by":"publisher","first-page":"1441","DOI":"10.1097\/01.brs.0000166503.37969.8a","article-title":"United States trends in lumbar fusion surgery for degenerative conditions.","volume":"30","author":"Deyo","year":"2005","journal-title":"Spine (Phila Pa 1976)"},{"issue":"3","key":"soi260055r4","doi-asserted-by":"publisher","first-page":"287","DOI":"10.3340\/jkns.2016.59.3.287","article-title":"The prevalence of undiagnosed presurgical cognitive impairment and its postsurgical clinical impact in older patients undergoing lumbar spine surgery.","volume":"59","author":"Lee","year":"2016","journal-title":"J Korean Neurosurg Soc"},{"issue":"1","key":"soi260055r5","doi-asserted-by":"publisher","first-page":"191","DOI":"10.1016\/j.jvs.2024.08.058","article-title":"Patients with dementia or frailty undergoing major limb amputation have poor outcomes.","volume":"81","author":"Shah","year":"2025","journal-title":"J Vasc Surg"},{"key":"soi260055r6","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.jss.2024.10.029","article-title":"Colorectal surgery outcomes and healthcare burden for Medicare beneficiaries with dementia.","volume":"305","author":"Clark","year":"2025","journal-title":"J Surg Res"},{"issue":"5","key":"soi260055r7","doi-asserted-by":"publisher","first-page":"1685","DOI":"10.1016\/j.jvs.2019.07.087","article-title":"Dementia is associated with increased mortality and poor patient-centered outcomes after vascular surgery.","volume":"71","author":"Shah","year":"2020","journal-title":"J Vasc Surg"},{"issue":"1","key":"soi260055r8","doi-asserted-by":"publisher","first-page":"108","DOI":"10.1016\/j.amjsurg.2023.03.012","article-title":"Outcomes for patients with dementia undergoing emergency and elective colorectal surgery: a large multi-institutional comparative cohort study.","volume":"226","author":"Clark","year":"2023","journal-title":"Am J Surg"},{"issue":"1","key":"soi260055r9","doi-asserted-by":"publisher","first-page":"628","DOI":"10.1186\/s13019-024-03120-z","article-title":"National outcomes for dementia patients undergoing cardiac surgery in a pre-structural era.","volume":"19","author":"Tang","year":"2024","journal-title":"J Cardiothorac Surg"},{"issue":"6","key":"soi260055r10","doi-asserted-by":"publisher","first-page":"1132","DOI":"10.1111\/jgs.15856","article-title":"Factors considered by interprofessional team for treatment decision in hip fracture with dementia.","volume":"67","author":"Baker","year":"2019","journal-title":"J Am Geriatr Soc"},{"issue":"11","key":"soi260055r11","doi-asserted-by":"publisher","first-page":"1884","DOI":"10.1016\/j.pec.2018.06.017","article-title":"Treatment decision making involving patients with dementia in acute care: a scoping review.","volume":"101","author":"Pecanac","year":"2018","journal-title":"Patient Educ Couns"},{"issue":"3","key":"soi260055r12","doi-asserted-by":"publisher","first-page":"449","DOI":"10.1097\/SLA.0b013e3181b45598","article-title":"Redefining geriatric preoperative assessment using frailty, disability and co-morbidity.","volume":"250","author":"Robinson","year":"2009","journal-title":"Ann Surg"},{"issue":"11","key":"soi260055r13","doi-asserted-by":"publisher","first-page":"2799","DOI":"10.11124\/JBIES-21-00356","article-title":"Experiences and perceptions of health care professionals making treatment decisions for older adults with memory loss: a qualitative systematic review protocol.","volume":"20","author":"Shapkin","year":"2022","journal-title":"JBI Evid Synth"},{"issue":"1","key":"soi260055r14","doi-asserted-by":"publisher","first-page":"427","DOI":"10.1186\/s12913-016-1690-1","article-title":"The assessment and management of pain in patients with dementia in hospital settings: a multi-case exploratory study from a decision making perspective.","volume":"16","author":"Lichtner","year":"2016","journal-title":"BMC Health Serv Res"},{"key":"soi260055r15","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0000000000006936","article-title":"Patient and caregiver experiences with surgical decision-making in the context of dementia.","author":"Adler","year":"2025","journal-title":"Ann Surg"},{"issue":"9","key":"soi260055r16","doi-asserted-by":"publisher","first-page":"1245","DOI":"10.1097\/ACM.0000000000000388","article-title":"Standards for reporting qualitative research: a synthesis of recommendations.","volume":"89","author":"O\u2019Brien","year":"2014","journal-title":"Acad Med"},{"issue":"7226","key":"soi260055r18","doi-asserted-by":"publisher","first-page":"50","DOI":"10.1136\/bmj.320.7226.50","article-title":"Qualitative research in health care. assessing quality in qualitative research.","volume":"320","author":"Mays","year":"2000","journal-title":"BMJ"},{"issue":"7227","key":"soi260055r19","doi-asserted-by":"publisher","first-page":"114","DOI":"10.1136\/bmj.320.7227.114","article-title":"Qualitative research in health care. analysing qualitative data.","volume":"320","author":"Pope","year":"2000","journal-title":"BMJ"},{"issue":"3","key":"soi260055r21","doi-asserted-by":"publisher","first-page":"379","DOI":"10.1177\/0272989X20911870","article-title":"20th Anniversary Ottawa Decision Support Framework: part 3 overview of systematic reviews and updated framework.","volume":"40","author":"Stacey","year":"2020","journal-title":"Med Decis Making"},{"issue":"4","key":"soi260055r22","first-page":"476","article-title":"Supporting patients facing difficult health care decisions: use of the Ottawa Decision Support Framework.","volume":"52","author":"L\u00e9gar\u00e9","year":"2006","journal-title":"Can Fam Physician"},{"issue":"2","key":"soi260055r25","doi-asserted-by":"publisher","first-page":"141","DOI":"10.1111\/ajr.12592","article-title":"Assessing patients decision-making capacity in the hospital setting: a literature review.","volume":"28","author":"John","year":"2020","journal-title":"Aust J Rural Health"},{"issue":"6","key":"soi260055r26","doi-asserted-by":"publisher","first-page":"270","DOI":"10.1097\/HRP.0000000000000163","article-title":"Dementia, decision making, and capacity.","volume":"25","author":"Darby","year":"2017","journal-title":"Harv Rev Psychiatry"},{"issue":"1","key":"soi260055r28","doi-asserted-by":"publisher","first-page":"104","DOI":"10.1186\/s13741-025-00593-x","article-title":"The older adult surgical patient: a review of optimization and gaps in clinical practice.","volume":"14","author":"Canales","year":"2025","journal-title":"Perioper Med (Lond)"},{"issue":"8","key":"soi260055r29","doi-asserted-by":"publisher","first-page":"1125","DOI":"10.1002\/alz.12102","article-title":"Difficulty and help with activities of daily living among older adults living alone with cognitive impairment.","volume":"16","author":"Edwards","year":"2020","journal-title":"Alzheimers Dement"},{"issue":"3","key":"soi260055r30","doi-asserted-by":"publisher","first-page":"509","DOI":"10.1093\/geront\/gny008","article-title":"Care values in dementia: patterns of perception and incongruence among family care dyads.","volume":"59","author":"Miller","year":"2019","journal-title":"Gerontologist"},{"issue":"10","key":"soi260055r31","doi-asserted-by":"publisher","first-page":"3012","DOI":"10.1111\/jgs.17892","article-title":"The current landscape of acute care for elders units in the United States.","volume":"70","author":"Rogers","year":"2022","journal-title":"J Am Geriatr Soc"},{"issue":"5","key":"soi260055r32","doi-asserted-by":"publisher","first-page":"454","DOI":"10.1001\/jamasurg.2017.5513","article-title":"Association of integrated care coordination with postsurgical outcomes in high-risk older adults: the Perioperative Optimization of Senior Health (POSH) Initiative.","volume":"153","author":"McDonald","year":"2018","journal-title":"JAMA Surg"},{"issue":"9","key":"soi260055r33","doi-asserted-by":"publisher","first-page":"2115","DOI":"10.1111\/jgs.14979","article-title":"The geriatrics 5M\u2019s: a new way of communicating what we do.","volume":"65","author":"Tinetti","year":"2017","journal-title":"J Am Geriatr Soc"},{"issue":"5","key":"soi260055r34","doi-asserted-by":"publisher","first-page":"1141","DOI":"10.1177\/1471301214555542","article-title":"Shared decision-making in dementia: a review of patient and family carer involvement.","volume":"15","author":"Miller","year":"2016","journal-title":"Dementia (London)"},{"issue":"1","key":"soi260055r36","doi-asserted-by":"publisher","first-page":"24","DOI":"10.2307\/3562720","article-title":"Wanted. single, white male for medical research.","volume":"22","author":"Dresser","year":"1992","journal-title":"Hastings Cent Rep"},{"issue":"2","key":"soi260055r37","doi-asserted-by":"publisher","first-page":"105","DOI":"10.1111\/j.1088-4963.1999.00105.x","article-title":"Respecting the margins of agency: Alzheimer\u2019s patients and the capacity to value.","volume":"28","author":"Jaworska","year":"1999","journal-title":"Philos Public Aff"},{"key":"soi260055r38","doi-asserted-by":"publisher","first-page":"2793","DOI":"10.2147\/PPA.S333923","article-title":"Priorities and preferences of people living with dementia or cognitive impairment - a systematic review.","volume":"15","author":"Wehrmann","year":"2021","journal-title":"Patient Prefer Adherence"},{"issue":"4","key":"soi260055r39","doi-asserted-by":"publisher","first-page":"875","DOI":"10.1177\/14713012231156976","article-title":"Shared decision-making in persons living with dementia: a scoping review.","volume":"22","author":"Mattos","year":"2023","journal-title":"Dementia (London)"},{"issue":"1471","key":"soi260055r40","first-page":"58","article-title":"What do doctors know about assessing decision-making capacity?","volume":"131","author":"Young","year":"2018","journal-title":"N Z Med J"},{"issue":"1","key":"soi260055r41","doi-asserted-by":"publisher","first-page":"74","DOI":"10.1186\/s13012-021-01142-y","article-title":"Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review.","volume":"16","author":"Waddell","year":"2021","journal-title":"Implement Sci"},{"key":"soi260055r17","first-page":"35","volume-title":"Qualitative Inquiry and Research Design: Choosing Among Five Approaches","author":"Creswell","year":"2013","edition":"5th ed"},{"key":"soi260055r23","volume-title":"Qualitative Research Practice: A Guide for Social Science Students and Researchers","author":"Ritchie","year":"2003"},{"key":"soi260055r35","volume-title":"Dementia Reconsidered: The Person Comes First","author":"Kitwood","year":"1997"},{"key":"soi260055r20","unstructured":"Creswell? JW, Klassen? AC, Plano Clark? VL, Clegg Smith? K. Best practices for mixed methods research in the health sciences. Office of Behavioral and Social Sciences Research. Accessed March 11, 2026. https:\/\/obssr.od.nih.gov\/sites\/g\/files\/mnhszr296\/files\/Best_Practices_for_Mixed_Methods_Research.pdf"},{"key":"soi260055r24","unstructured":"ATLAS.ti. ATLAS.ti Scientific Software Development GmbH. https:\/\/atlasti.com\/"},{"key":"soi260055r27","unstructured":"American College of Surgeons. Optimal Resources for Geriatric Surgery: 2019 Standards. Accessed May 28, 2024. https:\/\/www.facs.org\/media\/yldfbgwz\/optimal-resources-for-geriatric-surgery-2019-standards.pdf"}],"container-title":["JAMA Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/articlepdf\/2853198\/jamasurgery_adler_2026_oi_260055_1791304713.73768.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T15:00:55Z","timestamp":1791385255000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamasurgery\/fullarticle\/2853198"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,1]]},"references-count":41,"journal-issue":{"issue":"10","published-print":{"date-parts":[[2026,10,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamasurg.2026.3729","relation":{},"ISSN":["2168-6254"],"issn-type":[{"value":"2168-6254","type":"print"}],"subject":[],"published":{"date-parts":[[2026,10,1]]}}}