Surgeons who discuss best and worst case outcomes scenarios as a part of their patient-provider communications see stronger shared decision-making with their senior patients, shows a new study published in JAMA Surgery.
Developing shared decision-making strategies with senior patients is critical, the study authors asserted, because acute surgical treatments are often high risk for this population. Twenty percent of adults over the age of 65 who undergo abdominal surgery die within 30 days, the researchers said, a startling figure considering that a third of Medicare beneficiaries undergo surgery during the last year of their life.
Additionally, the team noted that surgical treatments may not always align with patients’ end-of-life care wishes, and may not be clearly explained to them.
“Best-practice guidelines endorse shared decision making (SDM) in the context of serious illness to present options, engage patients in deliberation about treatment outcomes, and integrate patient preferences into a recommendation,” the research team explained. “However, describing a complex and often uncertain prognosis is a formidable task.”
While surgeons are required to disclose all risks associated with a surgery, it can be difficult to clearly articulate quality of life risks or portray the ramifications of a 25 percent risk of complication.
According to the researchers, surgeons need to reframe how they discuss surgical risks with their older patient populations. Testing the Best Case/Worst Case (BCWC) communication strategy, the researchers found that providers who weighed the possible outcomes of various treatment options engaged in more meaningful shared decision-making with their patients.
“Best Case/Worst Case combines narrative description and a handwritten graphic aid to illustrate choice between treatments and engage patients and families,” the researchers said. “Surgeons use stories to describe how patients might experience a range of possible outcomes in the best case, worst case, and most likely scenarios.”
The team tested BCWC using a retrospective, qualitative analysis before and after introducing the strategy to a group of 25 surgeons. The researchers scored each conversation on a 100 point scale based on five criteria: presentation of treatment options, surgeon-patient partnership, description of treatments, elicitation of preferences, and integration of preferences with a recommendation.
Prior to introducing the surgeons to the communication strategy, patient-provider interactions scored an average 41 points. Following introduction to BCWC communication, average scores rose to 74 points.
The researchers saw differences in three specific scoring criteria: presentation of treatment options, description of treatments, and deliberation over alternative treatments. Ultimately, these improvements led to conversations that compared treatment options equally, showing patients that they had a choice in their care.
“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,” the researchers said.
“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.”
BCWC offers a framework by which providers can give prognoses to patients and engage in shared-decision making. This communication strategy asks surgeons to explain both the best and worst case scenarios, as well as potential other outcomes in between.
Using this method, the surgeon offers a wide scope in potential treatment options, empowering the patient to make the choice that fits best with their wishes. Framing the conversation in this way, the researchers said surgeons and patients can consider potential outcomes in the context of their own personal care goals.
“Scenarios improve decisions by allowing people to understand the interplay between elements—an acute surgical problem and underlying frailty—and develop a new mental model,” the team said. “Within this new reality, patients can think strategically and make decisions based on what is most important to them.”
While the researchers did find that the BCWC patient-provider communication strategy was helpful for improving shared decision-making, they did not report on actual care outcomes for patients.
However, the healthcare industry is increasingly valuing patient engagement in healthcare, finding that shared decision-making is an empowering act for patients. Going forward, providers should consider communication strategies that will facilitate better shared decision-making, such as the BCWC strategy.
“This intervention helps surgeons present treatment outcomes and engage patients and families in a conversation closer to best practice guidelines,” the researchers concluded. “With this proof of concept, this intervention can be used to change surgeon behavior to support patients and families in difficult treatment decisions.”