A “Best-Case/Worst-Case” Strategy for Preoperative Consent

Surgeons presumably know how to obtain informed consent: They do it before every procedure. But when surgery is considered for older patients with substantial comorbidities and limited life expectancies, decisions to operate are qualitatively different, and they often require patients and families to choose among many suboptimal care options. Can a novel approach to these difficult presurgical discussions smooth their progress?

Seventeen surgeons on the staff of a single hospital completed a 2-hour training session in a “best-case/worst-case” strategy in which the possible outcomes of both undergoing surgery and foregoing surgery were presented to patients in qualitative terms (e.g., “ICU stay,” “dialysis,” “groggy, unable to talk to family,” “death at home”) rather than specific quantitative risks. Surgeons were encouraged to construct a written diagram of care options and possible outcomes for each patient and family to review. Participants included 32 older patients (age range, 68−95; ≈70% with ≥2 comorbid conditions); surgeons conducted discussions with 12 patients before training and with remaining patients after training.

Compared with discussions conducted before the training, those conducted after the training were more likely to emphasize the partnership between patient and physician and to refer specifically to patient preferences. Median scores on transcripts of these discussions, ranked on a standard scale for shared decision-making, improved from 41% before the training to 74% afterwards.