Pitfalls in Communication That Lead to Nonbeneficial Emergency Surgery in Elderly Patients With Serious Illness

Cooper, Zara; Courtwright, Andrew; Karlage, Ami; Gawande, Atul A.; Block, Susan D.

doi:10.1097/sla.0000000000000721

Cited by 132 publications

(111 citation statements)

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“…In contrast to other life-sustaining treatments such as mechanical ventilation, where there is a large literature on using advance care planning to help avoid nonbeneficial treatment, there were fewer "upstream" points during which a clearer conversation may have avoided disagreement about ongoing ECMO support (21). ECMO was typically initiated in a time-sensitive manner, leaving little room for a sustained conversation about "stopping conditions" or acceptable duration of a time-limited trial from the patient's perspective.…”

Section: Discussionmentioning

confidence: 99%

Ethics Committee Consultation and Extracorporeal Membrane Oxygenation

et al. 2016

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Rationale: The clinical ethics literature on extracorporeal membrane oxygenation (ECMO) has been focused primarily on identifying hypothetical ethical dilemmas that may arise with the use of this technology. Little has been written on the actual experience with ECMO-related ethical questions.Objectives: To describe the role of an ethics consultation service during the expansion of a single-center ECMO program in a cardiothoracic surgery intensive care unit (CSICU) and to identify common ethical themes surrounding the use of ECMO. Methods:We conducted a retrospective, descriptive cohort study of all ECMO ethics consultation cases in the CSICU at a large academic hospital between 2013 and 2015.Measurements and Main Results: During the study period, 113 patients were placed on ECMO in the CSICU, 45 (39.5%) of whom were seen by the ethics committee. In 2013, 10 of 46 (21.7%) patients received ethics consults. By 2015, 28 of 30 (93.3%) of patients were seen by ethics consultants. Initial consultation occurred at a median of 2 days (interquartile range, 1-6 d) following initiation of ECMO. The most common ethical issue involved disagreement about the ongoing use of ECMO, which included multiple axes: Disagreement among health care providers, disagreement among surrogates, and disagreement between health care providers and surrogates over stopping or continuing ECMO.Conclusions: In our experience with integrating ethics consultation into the routine care of ECMO patients, most of the ethical questions more closely resembled traditional concerns about the appropriate use of any life-sustaining treatment rather than the novel dilemmas imagined in the current literature.

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Section: Discussionmentioning

confidence: 99%

Ethics Committee Consultation and Extracorporeal Membrane Oxygenation

et al. 2016

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“…14,15 Work has been done recently to elucidate the unique and growing communication needs among surgeons, older patients and their families during a surgical emergency. Cooper and colleagues 16 identified pitfalls in communication that lead to nonbeneficial emergency surgery, and an interdisciplinary expert panel provided recommendations to overcome this. 17 The Best Case/Worst Case (BC/WC) framework is a decision support tool developed to improve communication between surgeons and patients with poor underlying prognosis experiencing life-threatening surgical emergencies.…”

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confidence: 99%

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

Chesney

Devon

2018

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Background:Patients with poor underlying prognosis experiencing surgical emergencies face challenging treatment decisions. The Best Case/Worst Case (BC/WC) framework has improved shared decision-making by surgeons, but it is unclear whether residents can be similarly trained. We evaluated senior general surgical residents' acceptance of the BC/WC tool and their attitudes, confidence and actions before and after training.Methods: Two-hour training included a didactic session, live demonstration, smallgroup practice and debriefing. We developed questionnaires to evaluate residents' attitudes, confidence and actions at 3 time points: before the intervention, after the intervention and 6 months after the intervention. We used the Ottawa Decision Support Framework Acceptability questionnaire to evaluate acceptability and a structured observation form to evaluate performance.Results: Eighteen (50%) of 36 invited residents participated. Most residents (83%) felt that a new communication tool would be useful. Almost all (94%) used BC/WC in practice. Residents found the tool acceptable and useful to enhance preferencesensitive communications. They felt that the training was valuable and that role play was its greatest strength but that these situations were challenging to simulate. Barriers to BC/WC use included time constraints and difficulty defining the best and worst cases precisely. Summative attitudes and confidence scores were not different before and after the intervention; however, actions scores were higher after the intervention (p = 0.04). Residents performed a median of 15 (interquartile range 13-17) of the 19 elements on the formative performance evaluation. Commonly missed items were narrating outcomes of palliative approaches, prompting deliberation and providing treatment recommendations. Conclusion:Senior residents found the BC/WC tool to be acceptable and useful, and are amenable to training in this type of communication. After training, selfreported actions scores increased, and observed performance was accurate.Contexte : La prise de décisions relatives au traitement est difficile pour les patients qui ont un pronostic sous-jacent défavorable et qui envisagent une intervention chirurgicale d'urgence. Le cadre d'évaluation de la meilleure et de la pire issue possible (Best Case/Worst Case framework [BC/WC]) a amélioré la prise de décision partagée chez les chirurgiens, mais on ignore si les médecins résidents adopteraient aussi facilement une formation sur un tel cadre. Nous avons évalué à quel point les méde-cins résidents principaux en chirurgie générale étaient prêts à accepter le cadre BC/WC, ainsi que leur attitude, leur confiance et leurs actions avant et après une formation sur celui-ci.Méthodes : La formation de 2 heures comprenait une présentation didactique, une démonstration pratique, une période d'essai en petits groupes et un débreffage. Nous avons créé un questionnaire évaluant l'attitude, la confiance et les actions des méde-cins résidents à 3 moments : avant la formation, immédiatement...

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“…The lack of outcomes information about this patient population contributes to this difficulty and is an important avenue for continued investigation [20]. We used readily available patient variables to build a risk prediction model for in-hospital mortality in the moribund surgical patient.…”

Section: Discussionmentioning

confidence: 99%