"Best Case/Worst Case": Training Surgeons to Use a Novel Communication Tool for High-Risk Acute Surgical Problems

Abstract

Context: Older adults often have surgery in the months preceding death, which can initiate postoperative 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: The objective of this study was 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 of 11 BC/WC elements with both standardized and hospitalized patients (range 5-11). 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: 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.

Keywords: Acute care surgery; communication tool; palliative care; shared decision-making.

Figure 1

Example of graphic aid component of BC/WC tool for a patient with a life-threatening surgical condition. The star represents the best case scenario, the box represents the worst case scenario, and the oval designates the most likely outcome. The location of the oval indicates whether the most likely scenario is more similar to the best case or the worst case. Adapted with permission from “Navigating High Risk Procedures with More than Just a Street Map” by ML Schwarze, JM Kehler, TC Campbell, 2013, Journal of Palliative Medicine p. 1170.

Figure 2

Enrollment and Study Completion of Surgeons and Hospitalized Patients.

Figure 3

Practitioner Opinion Survey results at 3 and 6 months. *indicates percent of surgeons who agreed or strongly agreed with statement † indicates percent of surgeons who responded “yes” There were no significant differences between surgeon responses at 3 and 6 months (p value > 0.05)