A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case

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.

Interventions: A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework.

Main outcomes 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 preintervention (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.

Figure 1.. Best Case/Worst Case Graphic Aid

Example of a Best Case/Worst Case graphic aid that the surgeon would create and use during a decision-making discussion for an older patient with a serious surgical problem. The box represents the worst case scenario, the star represents the best case scenario, and the oval indicates the most likely outcome. ICU indicates intensive care unit.

Figure 2.. OPTION 5 Scores

Box plots depicting OPTION 5 scores for patients in the control and intervention arms. Dot indicates mean score within each treatment arm.

Figure 3.. Conversation Structure

Results of inductive coding analysis demonstrating the differences in communication patterns preintervention (A) and postintervention (B).