Michael J. Nabozny

“Best Case/Worst Case”: Qualitative Evaluation of a Novel Communication Tool for Difficult in‐the‐Moment Surgical Decisions

To evaluate a communication tool called “Best Case/Worst Case” (BC/WC) based on an established conceptual model of shared decision‐making.

Constructing High-Stakes Surgical Decisions: It's Better to Die Trying

OBJECTIVE To explore high-stakes surgical decision making from the perspective of seniors and surgeons. BACKGROUND A majority of older chronically ill patients would decline a low-risk procedure if the outcome was severe functional impairment. However, 25% of Medicare beneficiaries have surgery in their last 3 months of life, which may be inconsistent with their preferences. How patients make decisions to have surgery may contribute to this problem of unwanted care. METHODS We convened 4 focus groups at senior centers and 2 groups of surgeons in Madison and Milwaukee, Wisconsin, where we showed a video about a decision regarding a choice between surgery and palliative care. We used qualitative content analysis to identify themes about communication and explanatory models for end-of-life treatment decisions. RESULTS Seniors (n = 37) and surgeons (n = 17) agreed that maximizing quality of life should guide treatment decisions for older patients. However, when faced with an acute choice between surgery and palliative care, seniors viewed this either as a choice between life and death or a decision about how to die. Although surgeons agreed that very frail patients should not have surgery, they held conflicting views about presenting treatment options. CONCLUSIONS Seniors and surgeons highly value quality of life, but this notion is difficult to incorporate in acute surgical decisions. Some seniors use these values to consider a choice between surgery and palliative care, whereas others view this as a simple choice between life and death. Surgeons acknowledge challenges framing decisions and describe a clinical momentum that promotes surgical intervention.

A framework to improve surgeon communication in high-stakes surgical decisions best case/worst case

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.

Patient-reported Limitations to Surgical Buy-in: A Qualitative Study of Patients Facing High-risk Surgery.

Objective: To characterize how patients buy-in to treatments beyond the operating room and what limits they would place on additional life-supporting treatments. Background: During a high-risk operation, surgeons generally assume that patients buy-in to life-supporting interventions that might be necessary postoperatively. How patients understand this agreement and their willingness to participate in additional treatment is unknown. Methods: We purposively sampled surgeons in Toronto, Ontario, Boston, Massachusetts, and Madison, Wisconsin, who are good communicators and routinely perform high-risk operations. We audio-recorded their conversations with patients considering high-risk surgery. For patients who were then scheduled for surgery, we performed open-ended preoperative and postoperative interviews. We used directed qualitative content analysis to analyze the interviews and surgeon visits, specifically evaluating the content about the use of postoperative life support. Results: We recorded 43 patients’ conversations with surgeons, 34 preoperative, and 27 postoperative interviews. Patients expressed trust in their surgeon to make decisions about additional treatments if a serious complication occurred, yet expressed a preference for significant treatment limitations that were not discussed with their surgeon preoperatively. Patients valued the existence or creation of an advance directive preoperatively, but they did not discuss this directive with their surgeon. Instead they assumed it would be effective if needed and that family members knew their wishes. Conclusions: Patients implicitly trust their surgeons to treat postoperative complications as they arise. Although patients may buy-in to some additional postoperative interventions, they hold a broad range of preferences for treatment limitations that were not discussed with the surgeon preoperatively.

Trajectories and Prognosis of Older Patients Who Have Prolonged Mechanical Ventilation After High-Risk Surgery.

Objectives:Surgical patients often receive routine postoperative mechanical ventilation with excellent outcomes. However, older patients who receive prolonged mechanical ventilation may have a significantly different long-term trajectory not fully captured in 30-day postoperative metrics. The objective of this study is to describe patterns of mortality and hospitalization for Medicare beneficiaries 66 years old and older who have major surgery with and without prolonged mechanical ventilation. Design:Retrospective cohort study. Setting:Hospitals throughout the United States. Patients:Five percent random national sample of elderly Medicare beneficiaries (age ≥ 66 yr) who underwent 1 of 227 operations previously defined as high risk during an inpatient stay at an acute care hospital between January 1, 2005, and November 30, 2009. Interventions:None. Measurements and Main Results:We identified 117,917 episodes for older patients who had high-risk surgery; 4% received prolonged mechanical ventilation during the hospitalization. Patients who received prolonged mechanical ventilation had higher 1-year mortality rate than patients who did not have prolonged ventilation (64% [95% CI, 62–65%] vs 17% [95% CI, 16.4–16.9%]). Thirty-day survivors who received prolonged mechanical ventilation had a 1-year mortality rate of 47% (95% CI, 45–48%). Thirty-day survivors who did not receive prolonged ventilation were more likely to be discharged home than patients who received prolonged ventilation 71% versus 10%. Patients who received prolonged ventilation and were not discharged by postoperative day 30 had a substantially increased 1-year mortality (adjusted hazard ratio, 4.39 [95% CI, 3.29–5.85]) compared with patients discharged home by day 30. Hospitalized 30-day survivors who received prolonged mechanical ventilation and died within 6 months of their index procedure spent the majority of their remaining days hospitalized. Conclusions:Older patients who require prolonged mechanical ventilation after high-risk surgery and survive 30 days have a significant 1-year risk of mortality and high burdens of treatment. This difficult trajectory should be considered in surgical decision making and has important implications for surgeons, intensivists, and patients.

When Do Not Resuscitate Is a Nonchoice Choice: A Teachable Moment

A seventy year-old gentleman presented to our hospital for elective descending thoracic aortic aneurysm repair.

Barriers to Goal-concordant Care for Older Patients with Acute Surgical Illness

Objective: We sought to characterize patterns of communication extrinsic to a decision aid that may impede goal-concordant care. Background: Decision aids are designed to facilitate difficult clinical decisions by providing better treatment information. However, these interventions may not be sufficient to effectively reveal patient values and promote preference-aligned decisions for seriously ill, older adults. Methods: We conducted a secondary analysis of 31 decision-making conversations between surgeons and frail, older inpatients with acute surgical problems at a single tertiary care hospital. Conversations occurred before and after surgeons were trained to use a decision aid. We used directed qualitative content analysis to characterize patterns within 3 communication elements: disclosure of prognosis, elicitation of patient preferences, and integration of preferences into a treatment recommendation. Results: First, surgeons missed an opportunity to break bad news. By focusing on the acute surgical problem and need to make a treatment decision, surgeons failed to expose the life-limiting nature of the patients illness. Second, surgeons asked patients to express preference for a specific treatment without gaining knowledge about the patients priorities or exploring how patients might value specific health states or disabilities. Third, many surgeons struggled to integrate patients’ goals and values to make a treatment recommendation. Instead, they presented options and noted, “Its your decision.” Conclusions: A decision aid alone may be insufficient to facilitate a decision that is truly shared. Attention to elements beyond provision of treatment information has the potential to improve communication and promote goal-concordant care for seriously ill older patients.

How People Die in 2014

Reflect on the innovations in surgical technology over the past 40 years: in 2014 we can treat a ruptured abdominal aortic aneurysm percutaneously, take out an esophagus or colon laparoscopically and even replace an aortic valve through 2 small incisions. Not only are the incisions smaller, patients have better outcomes. In contrast to the pace and complexity of technical innovation, innovation in communication about these and other surgical treatments has been nearly stagnant. Today, we communicate about surgery using the same process of informed consent—naming risks, identifying benefits, and stating alternatives—set by judicial mandate in the 1970s. Although disclosure of risk through informed consent is not without value, it functions poorly as a decision making tool particularly for frail elderly patients who require a complicated treatment discussion in the setting of serious illness. As Cooper and her colleagues have elegantly and comprehensively described in their review of acute surgical decision-making for frail elderly patients in the current issue of Annals of Surgery, our failure to innovate and foster skills in communication have burdened older patients at the end of life with unwanted care.1 Surgeons are often called on at off-hours to consider operations for elderly patients that have a substantial impact on their quality of life or will start them on a care trajectory—prolonged life support in the ICU or long-term care in a nursing home—that they would prefer to avoid. These conversations are challenging because surgeons typically lack a pre-existing relationship with the patient and patients’ preferences are often not clearly articulated in an advance directive or can shift in the context of a specific acute illness.2,3 Although much attention is paid in the surgical literature to precise risk prediction, little consideration is given to translation of these risks to patients in a meaningful way. When we present the overall hazards of surgery as discrete complications for isolated physiologic systems, e.g. a 50% chance of renal failure, it is difficult for patients to associate their personal values with the likely consequences of operating. To determine whether surgery is worthwhile for them, older patients need to imagine how the outcomes of surgery might be experienced within the context of their overall health. Rather than more information, patients need more interpretation about what these risks and predictors mean for them.4 When we think about risk, we tend to view it not as global construct but as a factor that can be modified.5 We turn to pre-habilitation for frail patients, pulmonary rehab for those with COPD and preoperative cardiac intervention with “risk factor modification” for patients whose comorbidities predict poor survival or a difficult postoperative course. This framing in the elective setting contributes to our own inability in many settings to see the surgical decision within the larger circumstances of the patient’s overall prognosis. Deciding to operate has always been about two things: “Can we do it?” and “Should we do it?” As our capacity to operate on the oldest-old improves we need to think more broadly when we consider the likely consequences of surgery. This requires a deliberate balance of the duty to rescue the dying patient with an advanced understanding of how older people die in the present era. With improvements in the care of chronic illness, specifically the wide use of implantable cardiac defibrillators and pacemakers, dying of “old age” peacefully during sleep is uncommon. Today, the health of older patients declines in a step-wise fashion. We aggressively treat each acute event while functional status slowly and steadily deteriorates. Frail elderly patients transfer in and out of the hospital, ratcheting up their level of dependency along the way.6 In 1990, surgeon Sherwin Nuland described pneumonia as the “old man’s friend”—a peaceful way out.7 With improvements in antibiotics and other interventions, in 2014, the “old man’s friend” is now a duodenal ulcer, toxic megacolon or some other acute surgical problem. As a result, surgeons face a special responsibility for decision making in older patients near the end of life. How we conceptualize and construct this in-the-moment decision for patients and their families has real impact. When we tell families, “If we don’t operate he will die” we fail to consider the patient’s overall trajectory and the lost opportunity for a peaceful death in the pursuit of surgical treatment. These are not “life or death decisions” but rather a choice between “death now or death later.”8 Given that 75% of chronically ill older patients would refuse aggressive treatment if the likely outcome was severe functional disability,9 a narrow-minded life-or-death framing of the treatment options for an acute surgical problem neglects consideration of the preferences of most frail elderly patients. As specialists, our discussions usually focus on the treatment of an isolated problem and say little about the patient’s overall prognosis.4 This stems in part from fear of being wrong in our predictions about survival. Of course we have all cared for patients whose positive outcome surprised us. This should not prevent us from explaining the most likely result of operating given the patient’s overall health, the burdens of treatment and carrying this prediction beyond our usual 30-day horizon. To do this we need to see more than the isolated surgical problem that distracts us with the allure that it can be “fixed” (or that it must be fixed) and consider an alternative view that accounts for the remaining duration and quality of the patient’s life. To improve communication we need to move beyond the description of risk as statistic quantifying mortality or organ system harm and focus on characterizing postoperative functional status and quality of life. More data about longer-term functional outcomes are essential. However, as a first step we can talk to patients and their family members about what they are hoping for after surgery and what they might fear, before we embark on a discussion of risks and benefits. In this way, we can use the patient’s goals and concerns to guide decision making. For patients who chose a non-operative approach, we will need to reinforce the message that we will be providing aggressive symptom management and are not simply “doing nothing” or “withdrawing support.” This will redirect hope and allow patients to control their medical care while avoiding invasive treatments that only satisfy the need to “do something.” Our myopic focus on the acute surgical illness and failure to offer and promote alternative strategies including palliative care has already prompted calls to retire the traditional model of surgical decision making and allow others to decide when to operate.10 It’s time to embrace this problem, understand its complexity, and innovate how we communicate with and care for this vulnerable group of patients. Dr. Cooper’s work is a brave and laudable step in the right direction and there is much more to do.