Importance Although many older adults prefer to avoid burdensome interventions with limited ability to preserve their functional status, aggressive treatments, including surgery, are common near the end of life. Shared decision making is critical to achieve value-concordant treatment decisions and minimize unwanted care. However, communication in the acute inpatient setting is challenging. Objective To evaluate the proof of concept of an intervention to teach surgeons to use the Best Case/Worst Case framework as a strategy to change surgeon communication and promote shared decision making during high-stakes surgical decisions. Design, Setting, and Participants Our prospective pre-post study was conducted from June 2014 to August 2015 and data were analyzed using a mixed methods approach. The data were drawn from decision-making conversations between 32 older inpatients with an acute nonemergent surgical problem, 30 family members, and 25 surgeons at 1 tertiary care hospital in Madison, Wisconsin. Intervention A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework. Main Outcome and Measures We scored conversation transcripts using OPTION 5, an observer measure of shared decision making, and used qualitative content analysis to characterize patterns in conversation structure, description of outcomes and deliberation over treatment alternatives. Results The study participants were patients aged 68 to 95 years (n=32), 44% of whom had 5 or more comorbid conditions; family members of patients (n=30); and surgeons (n=17). The median OPTION 5 score improved from 41 pre-intervention (interquartile range 26–66) to 74 after Best Case/Worst Case training (interquartile range 60–81). Before training, surgeons described the patient’s problem in conjunction with an operative solution, directed deliberation over options, listed discrete procedural risks and did not integrate preferences into a treatment recommendation. After training, surgeons using Best Case/Worst Case clearly presented a choice between treatments, described a range of postoperative trajectories including functional decline and involved patients and families in deliberation. Conclusions and Relevance Using the Best Case/Worst Case framework changed surgeon communication by shifting the focus of decision-making conversations from an isolated surgical problem to a discussion about treatment alternatives and outcomes. This intervention can help surgeons structure challenging conversations to promote shared decision making in the acute setting.

Context Older adults often have surgery in the months preceding death, which can initiate post-operative treatments inconsistent with end-of-life values. “Best Case/Worst Case” (BC/WC) is a communication tool designed to promote goal-concordant care during discussions about high-risk surgery. Objective To evaluate a structured training program designed to teach surgeons how to use BC/WC. Methods Twenty-five surgeons from one tertiary-care hospital completed a two-hour training session followed by individual coaching. We audio recorded surgeons using BC/WC with standardized patients and 20 hospitalized patients. Hospitalized patients and their families participated in an open-ended interview 30 to 120 days after enrollment. We used a checklist of 11 BC/WC elements to measure tool fidelity and surgeons completed the Practitioner Opinion Survey to measure acceptability of the tool. We used qualitative analysis to evaluate variability in tool content and to characterize patient and family perceptions of the tool. Results Surgeons completed a median of 10 out of 11 BC/WC elements with both standardized and hospitalized patients (range 5 to 11). We found moderate variability in presentation of treatment options and description of outcomes. Three months after training, 79% of surgeons reported BC/WC is better than their usual approach and 71% endorsed active use of BC/WC in clinical practice. Patients and families found that BC/WC established expectations, provided clarity and facilitated deliberation. Conclusions and Relevance Surgeons can learn to use BC/WC with older patients considering acute high-risk surgical interventions. Surgeons, patients, and family members endorse BC/WC as a strategy to support complex decision making.

Problem Health professionals need to learn how to relate to one another to ensure high-quality patient care and to create collaborative and supportive teams in the clinical environment. One method for addressing both of these goals is teaching empathy during professional training to foster connection and commonality across differences. The authors describe a pilot improvisational theater (improv) course and present the preliminary outcomes showing its impact on interprofessional empathy. Approach In 2016–2017, the authors piloted a 15-hour course to teach interprofessional empathy to health professions students at the University of Wisconsin–Madison using improv techniques. The authors used a convergent mixed-methods design to evaluate the course’s impact on interprofessional empathy. Students enrolled in the course (intervention group, n = 45) and a comparison group (n = 41) completed 2 validated empathy questionnaires (Interpersonal Reactivity Index [IRI], Consultative and Relational Empathy [CARE] measure) and a facial expression recognition task to measure empathy in the pre- and postintervention periods. Differences were examined using paired t tests. Semistructured interviews were conducted with 8 course participants to gain a deeper understanding of the course’s effects. Outcomes The intervention group’s mean scores on 5 CARE items improved significantly: ease, care, explain, help, and plan. On the IRI, personal distress levels decreased significantly in both the intervention and comparison groups. In the interviews, students who took the class reported a positive impact on their interprofessional relationships and on their ability to think on their feet. They also reported improv influenced other areas of their lives, including patient care and interactions with people outside their work life. Next Steps The authors have continued to offer the course. They aim to conduct a randomized controlled study with medical students and test durability by measuring empathy again 3–6 months following the intervention.