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. Intervention A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework. Main Outcome 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 pre-intervention (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.

Context Older adults often have surgery in the months preceding death, which can initiate post-operative treatments inconsistent with end-of-life values. “Best Case/Worst Case” (BC/WC) is a communication tool designed to promote goal-concordant care during discussions about high-risk surgery. Objective To evaluate a structured training program designed to teach surgeons how to use BC/WC. Methods Twenty-five surgeons from one tertiary-care hospital completed a two-hour training session followed by individual coaching. We audio recorded surgeons using BC/WC with standardized patients and 20 hospitalized patients. Hospitalized patients and their families participated in an open-ended interview 30 to 120 days after enrollment. We used a checklist of 11 BC/WC elements to measure tool fidelity and surgeons completed the Practitioner Opinion Survey to measure acceptability of the tool. We used qualitative analysis to evaluate variability in tool content and to characterize patient and family perceptions of the tool. Results Surgeons completed a median of 10 out of 11 BC/WC elements with both standardized and hospitalized patients (range 5 to 11). We found moderate variability in presentation of treatment options and description of outcomes. Three months after training, 79% of surgeons reported BC/WC is better than their usual approach and 71% endorsed active use of BC/WC in clinical practice. Patients and families found that BC/WC established expectations, provided clarity and facilitated deliberation. Conclusions and Relevance Surgeons can learn to use BC/WC with older patients considering acute high-risk surgical interventions. Surgeons, patients, and family members endorse BC/WC as a strategy to support complex decision making.

Background Breast cancer patients commonly use the internet as an information resource. Our objective was to evaluate the quality of online information available to support patients facing a decision for breast surgery. Methods Breast cancer surgery-related queries were performed (Google and Bing), and reviewed for content pertinent to breast cancer surgery. The DISCERN instrument was used to evaluate websites’ structural components that influence publication reliability and ability of information to support treatment decision-making. Scores of 4/5 were considered “good”. Results 45 unique websites were identified. Websites satisfied a median 5/9 content questions. Commonly omitted topics included: having a choice between breast conservation and mastectomy (67%) and potential for 2nd surgery to obtain negative margins after breast conservation (60%). Websites had a median DISCERN score of 2.9 (range 2.0–4.5). Websites achieved higher scores on structural criteria (median 3.6 [2.1–4.7]), with 24% rated as “good”. Scores on supporting decision-making questions were lower (2.6 [1.3–4.4]), with only 7% scoring “good”. Conclusion Although numerous breast cancer-related websites exist, most do a poor job providing women with essential information necessary to actively participate in decision-making for breast cancer surgery. Providing easily-accessible, high-quality online information has the potential to significantly improve patients’ experiences with decision-making.

Importance Older patients are at greater risk for postoperative complications yet they are less likely than younger patients to ask questions about surgery. Objective To design an intervention to improve preoperative decision making and manage postoperative expectations. Design We created a Patient and Family Advisory Council (PFAC) to help identify preoperative decisional needs. We met monthly for one year to examine findings from a prior qualitative study and to integrate themes with PFAC members’ lived experience. PFAC members and other stakeholders evaluated 118 publically available questions and selected 12 corresponding to identified needs to generate a question prompt list. To refine this intervention, we conducted focus groups and a clinical pilot. Setting The local library and one outpatient surgical clinic in Madison and three community centers in Madison and Milwaukee, Wisconsin. Participants Four men and women who had previous experience with high-risk surgery as either older patients or family members participated in our PFAC. Three focus groups included 31 community members from diverse backgrounds. We pilot tested the intervention with 42 patients considering surgery. Exposure(s) None Main Outcome and Measure(s) Generation of an intervention to address patients’ preoperative informational and decisional needs. Results Through exploration of qualitative data the PFAC noted three critical problems; patients and family members believed surgery “had to be done,” were surprised that postoperative recovery was difficult and lacked knowledge about the use of advance directives perioperatively. The PFAC identified a need for more information and decisional support during preoperative conversations including clarification of treatment options, setting postoperative expectations and advance care planning. Three question prompt categories arose: “Should I have surgery?”, “What should I expect if everything goes well?”, and “What happens if things go wrong?” The final list includes 11 questions within these domains, was understandable in English and Spanish, and was acceptable to patients in clinic. Conclusions and Relevance Through direct engagement of stakeholders, we created a question prompt list to address core decisional and informational needs of surgical patients. Future testing will evaluate whether this list can be used to improve patient engagement and reduce postoperative regret and conflict about postoperative treatments.

Poor preoperative communication can have serious consequences, including unwanted treatment and postoperative conflict.OBJECTIVE To compare the effectiveness of a question prompt list (QPL) intervention vs usual care on patient engagement and well-being among older patients considering major surgery. DESIGN, SETTING, AND PARTICIPANTSThis randomized clinical trial used a stepped-wedge design to randomly assign patients to a QPL intervention (n = 223) or usual care (n = 223) based on the timing of their visit with 1 of 40 surgeons at 5 US study sites. Patients were 60 years or older with at least 1 comorbidity and an oncologic or vascular (cardiac, neurosurgical, or peripheral vascular) problem that could be treated with major surgery. Family members were also enrolled (n = 263). The study dates were June 2016 to November 2018. Data analysis was by intent-to-treat.INTERVENTIONS A brochure of 11 questions to ask a surgeon developed by patient and family stakeholders plus an endorsement letter from the surgeon were sent to patients before their outpatient visit. MAIN OUTCOMES AND MEASURESPrimary patient engagement outcomes included the number and type of questions asked during the surgical visit and patient-reported Perceived Efficacy in Patient-Physician Interactions scale assessed after the surgical visit. Primary well-being outcomes included (1) the difference between patient's Measure Yourself Concerns and Well-being (MYCaW) scores reported after surgery and scores reported after the surgical visit and (2) treatment-associated regret at 6 to 8 weeks after surgery. RESULTSOf 1319 patients eligible for participation, 223 were randomized to the QPL intervention and 223 to usual care. Among 446 patients, the mean (SD) age was 71.8 (7.1) years, and 249 (55.8%) were male. On intent-to-treat analysis, there was no significant difference between the QPL intervention and usual care for all patient-reported primary outcomes. The difference in MYCaW scores for family members was greater in usual care (effect estimate, 1.51; 95% CI, 0.28-2.74; P = .008). When the QPL intervention group was restricted to patients with clear evidence they reviewed the QPL, a nonsignificant increase in the effect size was observed for questions about options (odds ratio, 1.88; 95% CI, 0.81-4.35; P = .16), expectations (odds ratio, 1.59; 95% CI, 0.67-3.80; P = .29), and risks (odds ratio, 2.41; 95% CI, 1.04-5.59; P = .04) (nominal α = .01). CONCLUSIONS AND RELEVANCEThe results of this study were null related to primary patient engagement and well-being outcomes. Changing patient-physician communication may be difficult without addressing clinician communication directly.