title: "Best Case/Worst Case": Training Surgeons to Use a Novel Communication Tool for High-Risk Acute Surgical Problems.
abstract: Older adults often have surgery in the months preceding death, which can initiate postoperative treatments inconsistent with end-of-life values. "Best Case/Worst Case" (BC/WC) is a communication tool designed to promote goal-concordant care during discussions about high-risk surgery.
  
  
  
  The objective of this study was to evaluate a structured training program designed to teach surgeons how to use BC/WC.
  
  
  
  Twenty-five surgeons from one tertiary care hospital completed a two-hour training session followed by individual coaching. We audio-recorded surgeons using BC/WC with standardized patients and 20 hospitalized patients. Hospitalized patients and their families participated in an open-ended interview 30 to 120 days after enrollment. We used a checklist of 11 BC/WC elements to measure tool fidelity and surgeons completed the Practitioner Opinion Survey to measure acceptability of the tool. We used qualitative analysis to evaluate variability in tool content and to characterize patient and family perceptions of the tool.
  
  
  
  Surgeons completed a median of 10 of 11 BC/WC elements with both standardized and hospitalized patients (range 5-11). We found moderate variability in presentation of treatment options and description of outcomes. Three months after training, 79% of surgeons reported BC/WC is better than their usual approach and 71% endorsed active use of BC/WC in clinical practice. Patients and families found that BC/WC established expectations, provided clarity, and facilitated deliberation.
  
  
  
  Surgeons can learn to use BC/WC with older patients considering acute high-risk surgical interventions. Surgeons, patients, and family members endorse BC/WC as a strategy to support complex decision making.
authors.affiliation: Department of Medicine and Center for Healthcare Studies, Northwestern University, Chicago, Illinois, USA.
authors.forename: Jacqueline M
authors.initials: JM
authors.lastname: Kruser
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA.
authors.forename: Lauren J
authors.initials: LJ
authors.lastname: Taylor
authors.affiliation: Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA; School of Nursing, University of Wisconsin, Madison, Wisconsin, USA.
authors.forename: Toby C
authors.initials: TC
authors.lastname: Campbell
authors.affiliation: Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA.
authors.forename: Amy
authors.initials: A
authors.lastname: Zelenski
authors.affiliation: Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA.
authors.forename: Sara K
authors.initials: SK
authors.lastname: Johnson
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Nabozny
authors.affiliation: Denver Public Health, Denver Health and Hospital Authority, Denver, Colorado, USA.
authors.forename: Nicole M
authors.initials: NM
authors.lastname: Steffens
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Tucholka
authors.affiliation: School of Nursing, University of Wisconsin, Madison, Wisconsin, USA.
authors.forename: Kris L
authors.initials: KL
authors.lastname: Kwekkeboom
authors.affiliation: Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA; Department of Medical History and Bioethics, University of Wisconsin, Madison, Wisconsin, USA. Electronic address: schwarze@surgery.wisc.edu.
authors.forename: Margaret L
authors.initials: ML
authors.lastname: Schwarze
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000066491:Clinical Decision-Making; D003142:Communication; D005260:Female; D005500:Follow-Up Studies; D006760:Hospitalization; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D010166:Palliative Care; D036301:Qualitative Research; D012306:Risk; D066231:Surgeons / Q000193:education*; D013727:Terminal Care
keywords: Acute care surgery; communication tool; palliative care; shared decision-making