A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case.
A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case.
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DOI：
10.1001/jamasurg.2016.5674
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发表时间：
2017-06-01
期刊：
影响因子：
16.9
通讯作者：
Schwarze ML
中科院分区：
文献类型：
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作者：
Taylor LJ;Nabozny MJ;Steffens NM;Tucholka JL;Brasel KJ;Johnson SK;Zelenski A;Rathouz PJ;Zhao Q;Kwekkeboom KL;Campbell TC;Schwarze ML
虽然许多老年人更愿意避免繁重的干预措施，以保持其功能状态的能力有限，积极的治疗，包括手术，是常见的接近生命的尽头。共同决策对于实现价值一致的治疗决策和最大限度地减少不必要的护理至关重要。然而，在急性住院设置的沟通是具有挑战性的。评价干预的概念验证，以指导外科医生使用最佳情况/最差情况框架作为改变外科医生沟通和促进高风险手术决策过程中共同决策的策略。我们的前瞻性前后研究于2014年6月至2015年8月进行，并使用混合方法分析数据。这些数据来自威斯康星州麦迪逊的一家三级护理医院的32名患有急性非紧急手术问题的老年住院患者、30名家庭成员和25名外科医生之间的决策对话。2小时的培训课程，教导每名入组研究的外科医生使用最佳情况/最差情况沟通框架。我们使用OPTION 5对对话记录进行评分，OPTION 5是一种共同决策的观察指标，并使用定性内容分析来表征对话结构、结果描述和对治疗方案的审议模式。研究参与者为68至95岁的患者（n=32），其中44%患有5种或以上共病;患者家属（n=30）;外科医生（n=17）。OPTION 5评分中位数从干预前的41分（四分位数范围26-66）提高到最佳情况/最差情况培训后的74分（四分位数范围60-81）。在培训之前，外科医生结合手术解决方案描述了患者的问题，指导了对选项的审议，列出了离散的手术风险，并且没有将偏好整合到治疗建议中。培训后，使用最佳情况/最差情况的外科医生明确提出了治疗之间的选择，描述了一系列术后轨迹，包括功能下降，并让患者和家属参与讨论。使用最佳情况/最差情况框架改变了外科医生的沟通，将决策对话的重点从孤立的手术问题转移到关于治疗方案和结局的讨论。这种干预可以帮助外科医生构建具有挑战性的对话，以促进急性环境中的共同决策。
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. 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. 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. A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework. 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. 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 pre-intervention (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. 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.