To cut or not to cut? When a doctor recommends surgery, the usual answer by the patient is, when? But is that the best answer for the patient?
When deciding on whether or not to have surgery, or how much surgery, a patient’s preference should become part of the decision. But too often, the patient doesn’t have a clear vision of the limits of surgery, or understand how his or her life will change after surgery, even in if all goes perfectly.
A new way of training surgeons on how to present options to patients should lead to a better understanding of what the patient wants for the doctor, the patient and the patient’s family. It can also be applied to other kinds of important medical decisions.
There are some new studies that might help us all with our medical decisions. Two recent studies reviewed how surgeons present options to their patients who were frail seniors being offered non-emergency surgery. The doctors then took a course in shared decision-making to change the focus of how they discuss surgical options. Some of the new requirements were that the doctor include in the discussion at least one non-surgical option and best case/worst case scenarios be described in terms of outcomes.
A new way of training surgeons on how to present options to patients should lead to a better understanding of what the patient wants for the doctor, the patient and the patient’s family
Both studies focused on seniors because a choice to have surgery “can initiate a cascade of invasive medical treatments that may be inconsistent with their goals.” More that 30% of seniors receive surgery during the last year of their life. Several other studies (cited within these articles) reveal that “high intensity treatment” is often not what the patient wants, but it is what the senior often gets.
To start, the studies looked at how surgeons discuss and recommend a procedure during the process of getting “informed consent.” Traditionally (before the new training), the discussion started with the doctor describing the illness or disease and surgery as a cure for that problem. Complications such as kidney failure or heart attack were noted with a percent of likelihood, rather than how that would impact future functioning for the patient.
Including the Patient in Medical Decisions
There might be some discussion of recovery time period, but seldom a discussion on whether the patient would achieve the same health enjoyed before the onset of the problem or if functioning would go downhill.
The new discussion model that the surgeons learned was based on best case/worst case. At least one alternative to surgery had to be included for comparison and the doctor was instructed to draw a simple diagram specific to that patient’s options and outcomes. Here is a sample drawing from one of the studies:
The goal of the discussion is to discover the patient’s preferences once the patient has full information on what the realistic outcomes are for treatment. The best case/worst case framework gives the doctor the ability to address probable new limitations to functioning and mortality within the context of that patient’s life. In this way, the patient might better visualize his/her changed future and also frames the limits of surgery. As noted, “it is not surprising that frail older patients who are quoted 50% surgical mortality would assume they have a 50% chance of being exactly as they were before surgery.”
Shared decision making goes beyond the estimates of surgical success (for example, 70% survival rate) to include outcomes that affect the patient’s life: Will a nursing home be involved? Will the patient walk again? Can he or she continue to live on his/her own? Even when the doctor can’t give a definite answer, it allows the patient to express an educated preference.
In the scenario diagrammed above, the patient is unlikely to live more than a few months with or without the surgery. The drawing helps the patient compare the two likely paths in front and make a clear, albeit painful, choice.
How You Can Use Best Case/Worst Case?
Consider how this can change your discussions with your doctor at your annual check-up. I’m not suggesting you impede your visit with lengthy discussions on alternatives to eating better and exercising more. But what if your doctor suggests a flu shot and you hate shots? Best case if you get the flu shot is you probably won’t get the flu at all. Worst case, you’ll get the flu, but probably a less severe case.
Alternatives if you don’t get the shot might be: Best case: You won’t get the flu anyway. Worst case is you get the flu and end up in the hospital. Second to worst case (or worst, your choice) you get the flu and pass it on to a child, an older person or other immune-compromised person for whom the flu is dire.
It’s still your choice, but visualizing the outcomes and consequences helps the patient make the decision.