Study Suggests New Communication Tool Can Help Older Adults Who Face Difficult Decisions about Surgery
Friday, September 18, 2015
A study published in the Journal of the American Geriatrics Society offers a new tool that makes it easier for older adults and their physicians to discuss serious treatment decisions, such as surgery, that patients may face as they near the end of their lives.
Many older adults receive invasive medical treatments, despite the fact that these treatments may not be in line with their personal preferences. In fact, 32% of Americans 65-years-old and older will experience surgery during the last year of their lives. As a result, these older adults may face additional invasive procedures, making it more likely for them to spend time in the intensive care unit (ICU) and to have long hospitalizations.
Surgeons typically use “informed consent” to help people make decisions about surgery or other procedures. During these discussions, the doctors address the risks and complications that could arise, such as kidney failure or heart attack, depending on the procedure at hand and the patient’s medical history. But, say the researchers who conducted this study, informed consent discussions often don’t explain how the consequences of surgery actually impact an older person’s life. For example, the surgeon may not mention that additional treatments may be needed, or that a person’s quality of life or ability to function might change.
Up until now, say the researchers, most of the available discussion tools surgeons use to help patients make treatment choices are difficult to use for in-the-moment decisions about serious procedures like surgery.
In their study, the researchers designed a new communication tool to help support in-the-moment decision-making. The tool allows surgeons to present options and even uncertainty about potential outcomes. In turn, this helps patients express their preferences for the kind of outcomes they want. Called “best case/worst case,” the tool uses words and pictures to help patients and their caregivers organize information, visualize their options, and think about what they want.
Using this discussion tool, the surgeon offers each of the patient’s treatment options, and describes the “best case” outcome, the “worst case” outcome, and what he or she believes is the “most likely” outcome for each treatment. The goal is to present the scenario based on the surgeon’s experience and the evidence for the treatment, and to focus on how the individual patient may actually experience his or her outcome—rather than simply quoting statistics.
In this model, the surgeon also draws a diagram that clearly illustrates the range of outcomes and the rates of likelihood for “best,” “worst,” or “most likely” results.
To test this new tool, the researchers staged six focus groups—two involving surgeons and four including 37 older adults aged 60 to 80+, all of whom had made a major medical decision for themselves or a family member. Older adult participants watched a video of a 79-year-old patient dealing with several health problems and who had been diagnosed with an aneurysm. In the video, a surgeon used the best case-worst case scenario to present a choice between surgery or supportive care.
According to the researchers, the older adults who participated in the focus groups appreciated how the best case-worst case tool helped frame medical decisions. What’s more, these participants praised the way the tool clearly presented two different treatment options. They also said they liked that the tool allowed the surgeon to present “both sides of the story” rather than a single perspective. One of the older adults noted that this scenario planning method leaves room for different personalities and different perspectives on how to cope with illness at a specific point in time.
This summary is from “‘Best case/Worst case’: Qualitative evaluation of a novel communications tool for difficult in-the-moment surgical decisions.” The study authors are Jacqueline M. Kruser, MD; Michael J. Nabozny, MD; Nicole M. Steffens, MPH; Karen J. Brasel, MD, MPH; Toby C. Campbell, MD; Martha E. Gaines, JD, LLM; and Margaret L. Schwarze, MD, MPP.