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

ABSTRACT: To explore high-stakes surgical decision making from the perspective of seniors and surgeons.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.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.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.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.

SUBMITTER: Nabozny MJ

PROVIDER: S-EPMC4492901 | biostudies-literature | 2016 Jan

REPOSITORIES: biostudies-literature

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

Nabozny Michael J MJ Kruser Jacqueline M JM Steffens Nicole M NM Brasel Karen J KJ Campbell Toby C TC Gaines Martha E ME Schwarze Margaret L ML

Annals of surgery 20160101 1

<h4>Objective</h4>To explore high-stakes surgical decision making from the perspective of seniors and surgeons.<h4>Background</h4>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.<h4>Methods</h4 ...[more]

PMID: 25563878

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Project description:ImportanceAlthough 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.ObjectiveTo 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 participantsOur 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.InterventionsA 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework.Main outcomes and measuresWe 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.ResultsThe 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 relevanceUsing 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.

Project description:ObjectivesTo explore trial site staff's perceptions regarding barriers and facilitators to local recruitment.DesignQualitative semi-structured interviews with a range of trial site staff from four trial sites in the UK. Interviews were analysed thematically to identify common themes across sites, barriers that could be addressed and facilitators that could be shared with other sites.Participants11 members of staff from four trial sites: clinical grant Co-applicant (n=1); Principal Investigators (n=3); Consultant Urologist (n=1); Research Nurses (n=5); Research Assistant (n=1).SettingEmbedded within an ongoing randomised controlled trial (the TISU trial). TISU is a UK multicentre trial comparing therapeutic interventions for ureteric stones.ResultsOur study draws attention to the initial and ongoing burden of trial work that is involved throughout the duration of a clinical trial. In terms of building and sustaining a research culture, trial staff described the ongoing work of engagement that was required to ensure that clinical staff were both educated and motivated to help with the process of identifying and screening potential participants. Having adequate and sufficient organisational and staffing resources was highlighted as being a necessary prerequisite to successful recruitment both in terms of accessing potentially eligible patients and being able to maximise recruitment after patient identification. The nature of the research study design can also potentially generate challenging communicative work for recruiting staff which can prove particularly problematic.ConclusionsOur paper adds to existing research highlighting the importance of the hidden and complex work that is involved in clinical trial recruitment. Those designing and supporting the operationalisation of clinical trials must recognise and support the mitigation of this 'work'. While much of the work is likely to be contextually sensitive at the level of local sites and for individual trials, some aspects are ubiquitous issues for delivery of trials more generally.Trial registration numberISRCTN No 92289221; Pre-results.

Dataset Information

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

Publications

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

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