Researchers improve how surgeons discuss high-stakes treatments

For frail older adults, acute health problems often have significant life-altering effects. Despite that reality, research shows that aggressive treatments, including surgery, are common near the end of life, even though the majority of older adults say they prefer to avoid burdensome interventions that could leave them with a diminished quality of life.

In a new study published online in the journal JAMA Surgery, researchers from the University of Wisconsin School of Medicine and Public Health (SMPH) describe a novel communication model that shifts the focus of decision-making conversations from a problem with a surgical solution to a discussion about treatment alternatives and outcomes.

Researchers say this framework for conversations, called "Best Case/Worst Case" (BC/WC), may allow patients and families to make treatment decisions that are better aligned with their personal goals.

The BC/WC model, developed by SMPH researchers, combines narrative description and handwritten graphic aids to illustrate choices between treatments and is designed to engage patients and families in the decision-making process. Using the BC/WC framework, surgeons use stories to describe how patients might experience a range of possible outcomes, from the best case to the worst case, and the most likely scenarios they could encounter.

"Incorporating stories that describe how surgery can impact the patient's overall quality of life can help surgeons, patients and their families avoid surgery when even the best-case surgical outcome is unacceptable," said Dr. Margaret "Gretchen" Schwarze, associate professor of surgery and principal investigator on the study. "Our study suggests that presenting and exploring a set of treatment options and plausible outcomes with patients can help patients and families think more strategically and make decisions based on what's most important to them."

For the study, 25 surgeons (cardiothoracic, vascular, and acute care) from the University Hospital in Madison, Wisconsin, completed a two-hour training session to learn the BC/WC framework using simulation with standardized patients and one-on-one instruction with coaches. Before training, the surgeons described patients' conditions in conjunction with operative solutions, directed deliberation over options, listed procedural risks and did not integrate patient/family preferences into a treatment recommendation.

After the BC/WC training, surgeons presented a clear choice between treatments, described a range of postoperative trajectories, including functional decline, and involved patients and families in the shared decision-making process and deliberation.

The study participants included a control group of nine men and three women and an intervention group of seven men and 13 women. Participants were 68 to 95 years of age and nearly half had five or more comorbid conditions.

"We believe that with this proof of concept, the Best Case/Worst Case intervention can be used to change surgeon behavior to better support patients and families who are maintaining hope for the best but who also need to be aware of and prepare for the worst," Schwarze said.

Although the study demonstrated that the BC/WC model can distinctly change the way surgeons communicate with their patients regarding high-stakes decisions, researchers were unable to identify a measurable health outcome that would allow them to test whether this intervention improves clinical outcomes beyond shared decision-making.