Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients With Emergency Surgical Conditions

Cooper, Zara; Koritsanszky, Luca; Cauley, Christy E.; Frydman, Julia L.; Bernacki, Rachelle; Mosenthal, Anne C.; Gawande, Atul A.; Block, Susan D.

doi:10.1097/sla.0000000000001491

Cited by 136 publications

(102 citation statements)

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“…On the formative performance evaluation, residents performed a median of 15 (79%) (interquartile range [13][14][15][16][17] of the 19 elements on the structured observation form. The 2 best-performed elements, performed by all residents, were presenting 2 explicit treatment options and avoiding medical jargon.…”

Section: Resultsmentioning

confidence: 99%

“…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. 13,15 This framework has been used to change how practising surgeons structure discussions for high-risk surgical decisions and to promote shared decisionmaking.…”

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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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Section: Resultsmentioning

confidence: 99%

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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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“…14,17,18 Furthermore, efforts to assist patients and families are hindered by the acute nature of surgical illness and lack of preexisting patient-doctor relationships. 12 …”

Section: Introductionmentioning

confidence: 99%

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

et al. 2017

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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.

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“…Difficulty with prognosticating also makes it challenging for acute care clinicians to provide goal‐concordant care to patients with emergent surgical hospitalizations. In these situations, a structured communication approach can help to personalize surgical care delivery to the individual goals of each patient . When prognosis is uncertain and the benefit of proposed interventions is unclear, offering a time‐limited trial of intensive or aggressive care may also offer clinicians, patients, and surrogates an opportunity to evaluate whether proposed therapies are aligned or discordant with the patient’s preferences .…”

Section: Ethical Considerations In Emergent Surgical Hospitalizationsmentioning

confidence: 99%

“…In these situations, a structured communication approach can help to personalize surgical care delivery to the individual goals of each patient. 17,18 When prognosis is uncertain and the benefit of proposed interventions is unclear, offering a time-limited trial of intensive or aggressive care may also offer clinicians, patients, and surrogates an opportunity to evaluate whether proposed therapies are aligned or discordant with the patient's preferences. 19 Surgery may be aligned with the patient's goals at the outset; however, the clinical course may be dynamic, and in cases where postoperative treatment is ineffective or too burdensome, a shift toward comfort-focused care may be more appropriate.…”

Section: Ethical Considerations In Emergent Surgical Hospitalizationsmentioning

confidence: 99%

Ethical considerations about emergent surgical hospitalizations in patients with advanced cancer

Lee

Cooper

2018

Cancer

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Unexpected, emergent surgical hospitalizations are common among patients with advanced cancer near end of life and pose an ethical challenge for acute care clinicians, including hospitalists, oncologists, and proceduralists. Referring to the principles of autonomy, beneficence, and nonmaleficence can guide clinicians to provide goal‐concordant care during an acute hospitalization that maximizes patient outcomes without prolonging suffering during the dying process.

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Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients With Emergency Surgical Conditions

Abstract: Communication with seriously ill patients in the acute setting is difficult. The proposed communication framework may assist surgeons in delivering goal-concordant care for high-risk patients.

Cited by 136 publications

References 39 publications

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

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

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

Ethical considerations about emergent surgical hospitalizations in patients with advanced cancer

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