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VA Healthcare-VISN 4


SAGE QUERI What Matters -- Surgical Pause


“What Matters:” Know and align care with older adult’s specific health outcome goals and care preferences, including, but not limited to, end-of-life care, and across settings of care.” – IHI Age-Friendly Health System

The “Surgical Pause” ascertains what matters to patients by identifying Veterans at risk for poor postoperative outcomes and triggering a structured conversation aimed at clarifying patient’s goals and expectations prior to surgical decision making.


Frailty is a powerful predictor of postoperative complications, death and disability across a broad variety of surgical procedures in all surgical specialties, yet it is not routinely assessed prior to surgical decision making. This represents a missed opportunity to discuss frailty-associated risks in the context of each individual’s personal goals and priorities. By identifying patients at greatest risk for harm, and implementing standard goal clarification conversations with patients prior to surgery, surgeons can prevent unnecessary poor clinical outcomes while providing tailored, patient-centered care.


The “Surgical Pause” identifies at-risk patients by screening for frailty with the Risk Analysis Index (RAI), a 14-item survey that takes a median 30 seconds to complete by patient or provider. Patients in the highest risk decile of RAI scores are referred for preoperative goal clarification.

Goal clarification goes beyond the recitation of risks typical of informed consent, framing the decision about surgery in the overall context of the patient’s life and goals. Although some surgeons achieve this clarity, it often requires advanced communication skills such as Best Case/Worst Case (BC/WC) scenario planning—a communication technique that frames the decision as a choice between two treatment options (e.g., surgery vs. non operative management), by using lay language to describe what life might look like for each option under the best, worst, and most likely outcomes. The shared discussion of options is further memorialized in a visual aid given to patients and can be captured in the medical record.


The Risk Analysis Index or RAI is the most thoroughly validated measure of surgical frailty prospectively tested in more than 350,000 surgical patients (including national samples of Veterans). It currently informs surgical decisions at the Omaha, Pittsburgh, Phoenix, Atlanta, and Palo Alto VAMCs, with profound effects. After implementation at the Omaha VAMC, 180-day postoperative mortality among the frail fell from 23.9% to 7.7% (p<0.001), a nearly 3-fold increase in the odds of survival in adjusted models.

Related research shows the importance of preoperative goal clarification: mortality rates were quartered when preoperative palliative care consultation was ordered by a surgeon, adjusting for age, frailty, and whether a patient had surgery.

Other national preliminary data show that Veterans who experienced perioperative mortality had superior care around the end of life with palliative care consultation, but less than 1% received this consultation.


VA centric overview to adopting a the surgical pause: 

Diffusion Marketplace (

Scenario Planning as an approach to Goal Clarification: Best Case/ Worst Case Video:

Videotaped, “Grand Rounds” style summary of the rationale for the Surgical Pause and the evidence supporting its use (45 minutes):

The contents of this website do not necessarily represent the views of the Department of Veterans Affairs or the U.S. government.


Lindsay Pelcher
Project Manager
VA SAGE Center