A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions

Abstract

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.

Training surgical residents to use a framework to promote shared decision-making for patients with poor prognosis experiencing surgical emergencies

“…9,13,15,18 A graphic and detailed description of the tool is available in the initial publications. 11,18 The framework is based on a foundation of shared decision-making that is useful in situations in which uncertainty surrounds outcomes and the best choice requires an understanding of the patient's values. 24 The tool aims to help surgeons provide information about treatment options in a way that contextualizes surgical decisions into a larger personal framework for patients.…”

“…10 Often, surgeons frame discussions within the structure of informed consent, which emphasizes the risks of operative intervention and the likelihood of death without surgery. 11 This approach does not convey information in relation to a patients' values or about what it may be like to experience undesirable outcomes and how these may affect quality of life, need for additional treatment and functional status. 12 In addition, options may be framed as a choice between certain death with a nonoperative palliative approach versus a surgical intervention carrying high risk for death and complications; within this framework, many patients hope that they are within the group that survives surgical intervention.…”

“…13,15 This framework has been used to change how practising surgeons structure discussions for high-risk surgical decisions and to promote shared decisionmaking. 11,18 Several programs have been developed to educate surgical residents on geriatric topics, yet none specifically addresses the issue of communication about surgical emergencies in patients with poor underlying prognosis. [19][20][21][22][23] Although BC/WC was taught successfully to practising surgeons, it is unclear for several reasons whether surgical trainees would be amenable to training of this kind.…”

Frailty in the older person undergoing elective surgery: a trigger for enhanced multidisciplinary management – a narrative review

“…Given the increased risks of intervention in the presence of frailty, shared decision‐making must be adopted to align the person's goals with the choice of surgical interventions. The use of the Best Case/Worst Case framework can promote such shared decision‐making and help surgeons structure treatment conversations to obtain the best outcome for the person and their family …”

Communication: an enabling competency

“…Decisions related to serious acute surgical problems in elderly, frail patients need to consider their values and establish goals of management. Evaluation of a 2‐h training session for surgeons to use the best case/worst case communication framework showed that experienced surgeons could improve their communication beyond discussion about the clinical problem, the surgical procedure and its complications . Following specific training, surgeons were able to involve patients and families in deliberate dialogue about choice of treatments and likely trajectories including functional decline.…”