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Original Investigation
February 1, 2017

A Framework to Improve Surgeon Communication in High-Stakes Surgical DecisionsBest Case/Worst Case

Author Affiliations
  • 1Department of Surgery, University of Wisconsin, Madison
  • 2Denver Public Health, Denver Health and Hospital Authority, Denver, Colorado
  • 3Department of Surgery, Oregon Health and Science University, Portland
  • 4Department of Medicine, University of Wisconsin, Madison
  • 5Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison
  • 6School of Nursing, University of Wisconsin, Madison
  • 7Department of Medical History and Bioethics, University of Wisconsin, Madison
JAMA Surg. Published online February 1, 2017. doi:10.1001/jamasurg.2016.5674
Key Points

Question  Does an intervention to train surgeons to use the Best Case/Worst Case framework change surgeon communication and promote shared decision making for high-stakes surgical decisions?

Findings  In this pre- and postintervention study that included 32 frail older inpatients with acute surgical problems, objective measures of shared decision making improved postintervention. Surgeons who used Best Case/Worst Case emphasized a treatment choice, described outcomes rather than discrete procedural risks, and involved patients and families in deliberation.

Meaning  Use of the Best Case/Worst Case framework can promote shared decision making, and this intervention may help surgeons structure challenging treatment conversations to support patients and families.


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.

Interventions  A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework.

Main Outcomes 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 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 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.