Best Case/Worst Case: Development of a communication tool to assist frail older adults facing acute surgical decisions Lauren Taylor, MD Lown Institute Research Day, April

The Problem Risk disclosure as discrete complications Assumes patient has bought in to postop aggressive care Alternatives appear secondary rather than a real choice Satisfies legal requirements Treatment Decision POTENTIAL OUTCOMES Less unwanted aggressive treatment Fewer symptoms of postoperative stress Value-concordant decisions POTENTIAL OUTCOMES Unwanted aggressive treatments Postoperative stress Conflict between surgeons and patients/families INFORMED CONSENT SHARED DECISION MAKING Conveys a choice between two strategies Promotes dialogue and deliberation Visualization of confined range of outcomes Allows clarification of values, preferences Treatment Decision

Our Intervention Treatment 1 Long surgery ICU 1–3 weeks Nursing home Closer to worst case ICU 2–6 weeks Death 2–3 months Long surgery Complications in ICU Die in ICU, unable to talk to family Time to say goodbye Pain controlled Go home Pain controlled Groggy Some time for family to gather Treatment 2 Time is short Death is imminent Schwarze et al, “Navigating High Risk Procedures with More than Just a Street Map” JPM 2013 Best Case Worst Case Most Likely Best Case Worst Case Most Likely

Hypothesis Teaching surgeons how to use the “best case/worst case” communication tool will improve their ability to engage older patients and their families in treatment decisions and align treatment choices with patient preferences

Our Pilot Study Pre- intervention 3 months Intervention: Surgeon training 3 months Post- intervention 8 months Goals: 1.Demonstrate surgeons can learn how to use BC/WC to discuss options with patients 2. Assess feasibility and acceptability of BC/WC in a clinical setting

How Surgeons Used BC/WC Surgeon: “Even after surgery…she’d be really debilitated for having been in the hospital, and she would likely end up in the nursing home for the rest of her life.” Family member: “That’s not something she would want.” Surgeon: “This is what I know about her…she didn’t want a lot of these interventions…and we’re gonna do a maximum amount of these things if we decide to go for surgery…so my general thought is that surgery, where she ends up in a nursing home, with complications from surgery, is not something that she ever wanted.”

What Surgeons Thought… “[BC/WC] gives me and the patient a systematic way to discuss complex high-risk illnesses and help me clarify the role of surgery for a particular patient.” “Allows me to quantify with severity scale in a visual way patient options relative to their goals.” “Made options and expected outcomes clear for the patient.”

What Patients Thought… Helps patients understand what to expect and prepare for adverse outcomes “So I think that allowing anyone to see the big picture of something, best case, worst case, no guarantees in the middle, helps people make decisions. Also prepare them in case the worst case happens.” Graphic aid helped to clarify the choice “You’re in shock when you hear any big diagnosis…and then you’re onto the whole denial thing of what’s happening…so when you have it in black and white on a piece of paper, you can reference it, when you’re more able to take in the information.” Facilitated deliberation between patient and family “We kind of passed that around too amongst everybody and just kind of looked at it while he was talking and took a picture of it and sent it to them that weren’t there.”

Next Steps Modifications to the tool Dissemination and Implementation strategy Resident training Expanded patient populations Alternative outcome measures

Acknowledgements Margaret “Gretchen” Schwarze Toby Campbell Michael Nabozny Jennifer Tucholka Karen Brasel Nicole Steffens Sara Johnson Amy Zelenski Jacky Kruser Anne Buffington Funding: Jahnigen Career Development from the AGS and Society for Vascular Surgery, NIH UL1TR000427, NIH KL2TR000428, NIH/NIA R03AG047920, Cambia Health Foundation’s Sojourns Scholars Program, NIH T32CA090217

Want to Learn More? -labs/schwarze/ -labs/schwarze/ YouTube: Schwarze ML, Kehler JM, Campbell TC. Navigating High Risk Procedures with More than Just a Street Map. J Palliat Med. 2013;16(10): Kruser JM, Nabozny MJ, Steffens NM, Brasel KJ, Campbell TC, Gaines ME, Schwarze ML. “Best Case/Worst Case”: Qualitative Evaluation of a Novel Communication Tool for Difficult in-the-moment Surgical Decisions. J Am Geriatr Soc. 2015;63(9):