Recommendations for best communication practices to facilitate goal concordant care for seriously ill older patients with emergency surgical conditions. Cooper Z, Koritsanszky LA, Cauley CE, Frydman JL, Bernacki RE, Mosenthal AC, Gawande AA, Block SD. Ann Surg. 2016 Jan;263(1):1-6.
For seriously ill older adults with surgical emergencies, a need to improve communication with patients, family members and surrogate decision makers was identified. This need arose from the knowledge that close to one third of Medicare patients who died in the year 2008 had a surgical procedure in the year prior to their death. Additionally, 10% had a surgical procedure one week prior to their death. Patients who underwent procedures in the last year of life had less than ideal outcomes from the perspective of psychosocial well-being and physical discomfort. Their family members also have been noted to have higher rates of psychosocial distress and complicated grief. On the medical side, improved communication regarding wishes, priorities and patient’s personal goals has been associated with more favorable outcomes in these domains. Patients who have good communication regarding end-of-life care are more likely to have what is known as goal-concordant care, or care that is consistent with their personal values.
Moreover, it has been noted that physicians tend to describe the surgical outcomes, risks and benefits in isolation of the patient’s own personal context. The authors note that frailty as well as advanced age and comorbidities have a significant impact on one year mortality, healthcare utilization, functional decline and quality of life after surgery. Therefore, the authors sought to examine barriers to shared decision-making as well as examining a communication framework to assist with obtaining shared decision-making and good communication for surgeons and patients facing emergency surgical situations.
This paper discusses the results of an advisory panel set up to identify issues and form recommendations for communication surrounding emergency general surgical procedures. The panel was comprised of leaders from multiple specialties, including surgery, palliative medicine, critical care, emergency medicine, geriatrics, anesthesiology and healthcare innovation. These participants were shown a video where a resident discussed an emergency surgical procedure with a high risk, severely ill, elderly patient. They were then asked to evaluate the communication between the resident and the patient and the surrogate decision makers. Each perspective, the patient, the surrogate, and the resident surgeon was evaluated. Participants were then asked to share their relevant experiences regarding three aspects of communication: #1 information gathered from the creation of structured communication tools for oncologist, #2 novel approaches to communication surrounding high risk surgical procedures in older patients and #3 training residents to discuss DO NOT RESUSCITATE and other end-of-life topics for patients involved in emergency situations. These data were pooled to create a communication framework.
The recommendations of the advisory panel were broken down into eight different sections. They are: prognosis-understand patient’s current condition, understand chronic diagnoses, review advance directives, use prognostic tools [ePrognosis, NSQIP surgical risk calculator), connect and illicit (Introduce yourself [only done 50% of the time I prior studies], build rapport through nonverbal communication, address pain and anxiety that may distract from discussion, gauge patient and family (P/F) understanding of illness, inform (Educate P/F regarding life-threatening nature of disease, prepare P/F for bad news: “I am worried that we have hit something today that changes the course of things”. This also facilitates empathy. Avoid jargon, present information in small segments, again check P/F understanding), summarize and pause (summarize the discussion, allow time for P/F to process the information, attempt to understand emotional state of P/F), options (present both surgical and non-surgical/palliative options, discuss what is expected during the post-operative course, note that palliative care can be provided alongside surgical care, avoid terms such as “do everything” or “do nothing, his may de-value palliative options, P/F may feel abandoned, more fearful and angry with palliative option, recommended and support), goals (determine what the patient finds acceptable regarding life extending vs. comfort focused care options, examine patient’s personal milestones, i.e. going to a wedding, that may influence decisions, recommend (Discuss treatment in context of whole person, rather than only risks and benefits, support- provide verbal affirmation of P/F choices.
Finally, the advisory panel recommended that courses be designed to teach residents and surgeons these communication skills. It was also noted that more research needs to be done in the area to provide a larger evidence-base for evaluating the outcomes of emergency surgery in older patients. This would include examining morbidity and mortality further out than the usual 30-day mark. Also, evaluating quality-of-life healthcare utilization and end-of-life experiences would add to our understanding of the needs of this group of patients. Lastly, surgeons were encouraged to be familiar with the data that exists on long-term surgical outcome, including hospice outcomes, to better inform patients.
A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best case/worst-case.Taylor LJ, Nabozny MJ, Steffens NM, Tucholka JL, Brasel KJ, Johnson SK, Zelenski A, Rathouz PJ, Zhao Q, Kwekkeboom KL, Campbell TC, Schwarze ML. JAMA Surg. 2017 Jun 1;152(6):531-538.
It is not atypical for patients age 65 her over time have the need for emergency surgery. Understandably, their outcomes are less favorable than for younger patients. Up to 20% of patients in this age group die within 30 days of such surgery. However very few of these patients have made preparations for this scenario. It is considered best practice, when possible, to perform shared decision-making with the patient or their proxy decision maker. This type of decision making is considered the gold standard, since it is more likely to lead to surgical decisions which align with the individual’s preferences. The best case/worst-case framework was developed to provide the best avenue for shared decision-making. This framework consists of two scales. One scale is for the surgical option. The best case outcome from the surgery is discussed with the patient. Next the worst-case scenario is discussed with the patient. Finally, the most likely scenario is discussed. This format is also performed for the option of supportive care only. A graphic aid is used to facilitate patient understanding.
The study was conducted over one year at a tertiary care hospital in the Midwest. Surgeons in acute care surgery, vascular surgery and cardiothoracic surgery were paid a stipend to undergo training. The training session was a 2-hour course with standardized patients and one on one coaching with an expert in palliative care. Surgeons were later asked to use this technique in communicating with patients and family members in real-life scenarios. Patients, or their surrogate decision makers were consented. Thirty-two patients and thirty family members enrolled in the study. Exclusion criteria included deaf, non-English speaking persons and persons with emergent surgical conditions, such as ruptured AAA.
Conversations between physicians and consented patients/decision makers were recorded. The recordings were then reviewed, and the amount of shared decision-making was determined based on a validated 100 point scale. Five domains were measured. They were #1 presentation of treatment options, #2 surgeon–patient partnership, #3 description of treatments, #4 elicitation of preferences and #5 integration of preferences into the recommendation. Four investigators were involved in scoring the transcripts. Consistency among the four evaluators was also looked at. A qualitative content analysis was also performed on pre-intervention and post-intervention conversations.
In total, 25 surgeons were trained. Researchers found that there was a shift in the structure of the conversations that the surgeons had with their patients or the patient’s family members. Pre-intervention, it was noted that conversations were basically an explanation of the problem and the solution and a discussion of risk and benefits. Post-intervention more treatment decisions were made within the context of the patient’s overall health. There was more emphasis on outcomes rather than simply on the risks. The median score improved from 41 out of 100 prior to training to 74 out of 100 after the training, on the pre-validated scale. There was good intra-class correlation among the four reviewers.
The best case/worst-case framework is a format to help integrate patient preferences, including allowing them the option of no surgical management. It also allows the surgeon to elicit an understanding of what outcomes are important to the patient. And makes non-operative therapy a treatment equally as valid as the surgical therapy.
Despite some limitations, such as a challenge recruiting seriously ill older adults, the authors concluded that the training is successful in creating an environment where shared decision-making occurs.
Derivation and validation of a novel Emergency Surgery Acuity Score (ESS). Sangji NF, Bohnen JD, Ramly EP, Yeh DD, King DR. DeMoya M, Butler K, Fagenholz PJ, Velmahos GC, Chang DC, Kaafarani HMA. J. Trauma Acute Care Surg. 2016 Aug;81(2):213-20.
It has been previously reported that the overall mortality for emergency general surgery (EGS) is six times higher when compared to elective general surgery. To any surgeon performing EGS, this is not surprising, as a right hemicolectomy performed electively for cancer is expected to have different outcomes compared to the same operation performed for a perforated cecum. These differences may be explained partly by demographic factors contributing to the emergent disease process, as well as acute physiologic derangements. It is clear that quality benchmarking efforts should separate operations performed under ideal, elective conditions from those performed under sub-optimal emergent conditions. Yet, no such score specific to high-risk patients undergoing EGS currently exists. In this study, Sangji et al. describe the derivation and validation of a novel score specific to emergency general surgery: the Emergency Surgery Acuity Score (ESAS). Using the 2011 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, they identified 18,439 cases of emergency surgery. Examination of all preoperative variables and univariate analysis identified factors which were predictive of 30 day mortality. These factors were then included in regression analyses, first multiple logistic, and then subsequently stepwise logistic regression (both forward and backward). Weighted scores were assigned based on the relative size of odds ratios for mortality. For example, disseminated cancer and pre-operative ventilator requirement received 3 points each, while hypertension and thrombocytopenia received 1 point each. The final composite ESS score includes 3 demographic variables, 10 co-morbidities, and 9 laboratory variables. The C statistic (“concordance” statistic) of 0.86 for mortality indicates a strong model with high predictive ability. To validate this ESS score, the authors then applied the ESAS score to the 2012 ACS-NSQIP database and demonstrated a stepwise increase in mortality, ranging from 0 for an ESS score of 0 to 100% for an ESAS score of 22. The C statistic was identical (0.86).
In summary, this is an important study because it describes a new score specific to EGS which was derived and validated from a high quality database. Its utility is twofold: 1) It allows accurate prognostication for preoperative counseling of patients and their families, and 2) It allows for appropriate benchmarking of EGS separate from elective surgery.