EDITORIAL
Best Practices: Targeting Surgeon Communication at the End of Life Lauren J. Taylor, MD and Margaret L. Schwarze, MD, MPP y
A
s the population ages, surgeons more frequently encounter surgical emergencies in frail elderly patients with multiple comorbidities. The operative mortality for these patients is high1 and those who do survive face an arduous postoperative course as the acute surgical event precipitates a downward trajectory with loss of functional status, need for additional burdensome treatments, and after a stepwise decline, death.2,3 This new paradigm presents a serious challenge to our standard communication framework for the patient with an acute surgical problem. Preoperative discussions for acutely ill but otherwise healthy patients follow a consistent pattern4: an explanatory phase describing the disease and surgical intervention—for example, ‘‘you have a perforated ulcer that we can fix by patching it’’ followed by a deliberative phase in which the surgeon presents reasons to operate and alternative strategies, for example, ‘‘this is a life threatening problem, we need to operate or you will die.’’ For older patients with multiple comorbid conditions this communication structure is no longer satisfactory; it fails to place the immediate problem within the context of the patient’s overall health, over-states the capacity of surgery to prevent death, and omits discussion of outcomes that are valuable to patients apart from life and death. In this issue of Annals of Surgery, Cooper et al5 propose an alternative communication strategy designed to better inform patients and align surgical treatments with outcomes patients’ value. The authors convened a national advisory panel to create a comprehensive approach for these difficult conversations. The proposed structure transforms our standard conversation that previously focused on an isolated problem and its surgical treatment into a formal teachable framework with reproducible elements and touchstones. The nine-point structure may be difficult to incorporate all at once into clinical practice, however, it contains 3 critical elements that are innovative and have potential to make immediate substantive change. Perhaps the most valuable component is the need to ‘‘break bad news’’ (step #3: INFORM). Nonsurgical clinicians have the luxury of informing patients about a life threatening change in their clinical status in one conversation and returning later to discuss goals of care after they have had time to process this new reality. Given the nature of acute surgery these two elements are compressed into one conversation. As surgeons, ultimately we must decide whether to operate, so we neglect to alert the patient to the major change in health status that this acute event has created. Thus, offering a palliative strategy may feel abrasive to patients and families who are unaware of the implications of their illness. A simple ‘‘shot across the bow’’ to signal bad news is coming—for example, ‘‘I’m sorry I have bad news’’ followed by a clear statement to describe the gravity of the situation, for example, ‘‘for patients like you this is often life-ending, even with surgery’’ can orient the patient and family to the complexity of the decision at hand and the limitations of surgical intervention. The second critical component is the importance of attending to emotion (step #4: SUMMARIZE and PAUSE). Our mental model posits that these conversations are about information. If patients had the right information and understood the facts, they would realize that the value of surgical treatment is limited. But these conversations happen on two planes—a factual plane and an affective plane.6 Patients and families learning about a life-changing diagnosis are sad, anxious, and afraid. These strong emotions are difficult to process and can push patients in a direction they would not choose if they were considering the facts in an abstract and deliberative fashion.7 Attending to emotion is required so patients and their loved ones can take in the information we provide. Simple
From the Department of Surgery, University of Wisconsin-Madison, Madison, WI; and yDepartment of Medical History and Bioethics, University of Wisconsin-Madison, Madison, WI. Disclosure: L.J.T. is supported by a training award (T32CA090217) from the National Institutes of Health. M.L.S. is supported by a training award (KL2TR000428) from the Clinical and Translational Science Award (CTSA) program, through the NIH National Center for Advancing Translational Sciences (NCATS) grant (UL1 TR000427), the Grants for Early Medical/Surgical Specialists’ Transition to Aging Research Award (GEMSSTAR R03AG047920), and the American Geriatrics Society Jahnigen Career Development Award. These funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript for publication. The authors declare no conflicts of interest. Reprints: Margaret L. Schwarze, MD, MPP, Department of Medical History and Bioethics, University of Wisconsin-Madison, G5/315 CSC, 600 Highland Avenue, Madison, WI 53792. E-mail: [email protected]. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001506
Annals of Surgery Volume 263, Number 1, January 2016
www.annalsofsurgery.com | 7
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 263, Number 1, January 2016
Taylor and Schwarze
phrases such as ‘‘I wish this were different’’ and ‘‘this is really scary’’ can help manage emotions and allow patients to consider what is important to them. Third, is the need to make a recommendation (step #8: RECOMMEND). From a genuinely noble desire to honor patient autonomy, surgeons often worry that making a recommendation, particularly for palliative care, is overbearing and paternalistic. They believe that the responsibility of the surgeon is to present options and the job of the patient is to choose.8 But respect for patients does not require this type of absolute autonomy.9 Information asymmetry is insurmountable. Without our guidance patients are abandoned to their autonomy and make value discordant decisions. Instead, we should strive for relational autonomy that requires us to understand the patient’s goals and recommend treatments that will support those goals. Recommendations should include information about how the treatment plan is linked to the patient’s reported values, for example, ‘‘given what you have told me about how much you value your independence, I would recommend palliative care as surgery is unlikely to get you back home.’’ Although these changes may seem straightforward and easy to implement, they are not. Our group has studied surgeon–patient conversations and interventions to improve them and can report that changing surgeon behavior is seriously challenging. Many will say, ‘‘I already do that’’ but in our observation, none of us do that. This is not unique to surgeons, few physicians communicate well.10 The challenges to improving communication are great; communication skills are undervalued; learning new skills takes time, practice and feedback; and there are few qualified teachers. There are other systemic barriers to goal-concordant care that improved communication alone is unlikely to overcome. Surgeons by nature and training are predisposed towards action. Our general approach focuses on an isolated critical problem and ‘‘goal directed’’ therapy (stop the bleeding, control the source of infection) that fails to adequately consider a burdensome postoperative course or the value of the best possible surgical outcome for a frail patient. To communicate a choice about treatment strategies, surgeons must first recognize a treatment choice exists. Furthermore, the fast-paced efficiency of healthcare delivery imposes a clinical momentum8,11 in which the path of least resistance is to operate, rather than explain why surgery may not be the best treatment. These systems barriers are reinforced by policy challenges. Although the benefits of nonoperative management may be more
8 | www.annalsofsurgery.com
difficult to explain and time consuming to provide, these treatments are reimbursed at a fraction of an operation, fostering the perception that nonprocedural options are inferior. New Medicare incentives for upstream end-of-life discussions are promising but the impact of this policy or how it might extend to acute decision making is unknown. To compound this problem, quality metrics such as 30-day mortality may threaten goal-concordant care by failing to accommodate patients who would benefit from palliative surgery or postoperative treatment limitations.12 The ACS NSQIP Geriatric Surgery Pilot Project is an important first step for measuring relevant outcomes. Although no adequate measure of communication quality exists presently, the nine point framework described by Cooper et al5 provides a great starting point for a prototypical measure and much needed guidance for surgeons.
REFERENCES 1. Finlayson EV, Birkmeyer JD. Operative mortality with elective surgery in older adults. Eff Clin Pract. 2001;4:172–177. 2. Finlayson E, Fan Z, Birkmeyer JD. Outcomes in octogenarians undergoing highrisk cancer operation: a national study. J Am Coll Surg. 2007;205:729–734. 3. Finlayson E, Zhao S, Boscardin WJ, et al. Functional status after colon cancer surgery in elderly nursing home residents. J Am Geriatr Soc. 2012;60:967–973. 4. Kruser JM, Pecanac KE, Brasel KJ, et al. And I think that we can fix it: mental models used in high-risk surgical decision making. Ann Surg. 2015;261: 678–684. 5. Cooper Z. Recommendations for best communication practices to facilitate goal-concordant care for seriously ill older patients with emergency surgical conditions. Ann Surg. 2016;263:1–6. 6. Arnold R. Cases: Are goals of care conversations about emotion or fact? Pallimed. Decmeber 3, 2014. Available at: http://www.pallimed.org/2014/12/ cases-are-goals-of-care-conversations.html. Accessed August 5, 2015. 7. Loewenstein GF, Weber EU, Hsee CK, et al. Risk as feelings. Psychol Bull. 2001;127:267–286. 8. Nabozny MJ, Kruser JM, Steffens NM, et al. Constructing high-stakes surgical decisions: it is better to die trying. Ann Surg. 2015 Jan 5. [Epub ahead of print]. 9. Sullivan MD. The illusion of patient choice in end-of-life decisions. Am J Geriatr Psychiatry. 2002;10:365–372. 10. Tulsky JA. Beyond advance directives: importance of communication skills at the end of life. JAMA. 2005;294:359–365. 11. Kaufman SR. And a Time To Die: How American Hospitals Shape the End of Life. New York, NY: Scribner; 2005. 12. Schwarze ML, Brasel KJ, Mosenthal AC. Beyond 30-day mortality: aligning surgical quality with outcomes that patients value. JAMA Surg. 2014;149:631–632.
ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Best Practices: Targeting Surgeon Communication at the End of Life Lauren J. Taylor, MD and Margaret L. Schwarze, MD, MPP y
A
s the population ages, surgeons more frequently encounter surgical emergencies in frail elderly patients with multiple comorbidities. The operative mortality for these patients is high1 and those who do survive face an arduous postoperative course as the acute surgical event precipitates a downward trajectory with loss of functional status, need for additional burdensome treatments, and after a stepwise decline, death.2,3 This new paradigm presents a serious challenge to our standard communication framework for the patient with an acute surgical problem. Preoperative discussions for acutely ill but otherwise healthy patients follow a consistent pattern4: an explanatory phase describing the disease and surgical intervention—for example, ‘‘you have a perforated ulcer that we can fix by patching it’’ followed by a deliberative phase in which the surgeon presents reasons to operate and alternative strategies, for example, ‘‘this is a life threatening problem, we need to operate or you will die.’’ For older patients with multiple comorbid conditions this communication structure is no longer satisfactory; it fails to place the immediate problem within the context of the patient’s overall health, over-states the capacity of surgery to prevent death, and omits discussion of outcomes that are valuable to patients apart from life and death. In this issue of Annals of Surgery, Cooper et al5 propose an alternative communication strategy designed to better inform patients and align surgical treatments with outcomes patients’ value. The authors convened a national advisory panel to create a comprehensive approach for these difficult conversations. The proposed structure transforms our standard conversation that previously focused on an isolated problem and its surgical treatment into a formal teachable framework with reproducible elements and touchstones. The nine-point structure may be difficult to incorporate all at once into clinical practice, however, it contains 3 critical elements that are innovative and have potential to make immediate substantive change. Perhaps the most valuable component is the need to ‘‘break bad news’’ (step #3: INFORM). Nonsurgical clinicians have the luxury of informing patients about a life threatening change in their clinical status in one conversation and returning later to discuss goals of care after they have had time to process this new reality. Given the nature of acute surgery these two elements are compressed into one conversation. As surgeons, ultimately we must decide whether to operate, so we neglect to alert the patient to the major change in health status that this acute event has created. Thus, offering a palliative strategy may feel abrasive to patients and families who are unaware of the implications of their illness. A simple ‘‘shot across the bow’’ to signal bad news is coming—for example, ‘‘I’m sorry I have bad news’’ followed by a clear statement to describe the gravity of the situation, for example, ‘‘for patients like you this is often life-ending, even with surgery’’ can orient the patient and family to the complexity of the decision at hand and the limitations of surgical intervention. The second critical component is the importance of attending to emotion (step #4: SUMMARIZE and PAUSE). Our mental model posits that these conversations are about information. If patients had the right information and understood the facts, they would realize that the value of surgical treatment is limited. But these conversations happen on two planes—a factual plane and an affective plane.6 Patients and families learning about a life-changing diagnosis are sad, anxious, and afraid. These strong emotions are difficult to process and can push patients in a direction they would not choose if they were considering the facts in an abstract and deliberative fashion.7 Attending to emotion is required so patients and their loved ones can take in the information we provide. Simple
From the Department of Surgery, University of Wisconsin-Madison, Madison, WI; and yDepartment of Medical History and Bioethics, University of Wisconsin-Madison, Madison, WI. Disclosure: L.J.T. is supported by a training award (T32CA090217) from the National Institutes of Health. M.L.S. is supported by a training award (KL2TR000428) from the Clinical and Translational Science Award (CTSA) program, through the NIH National Center for Advancing Translational Sciences (NCATS) grant (UL1 TR000427), the Grants for Early Medical/Surgical Specialists’ Transition to Aging Research Award (GEMSSTAR R03AG047920), and the American Geriatrics Society Jahnigen Career Development Award. These funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript for publication. The authors declare no conflicts of interest. Reprints: Margaret L. Schwarze, MD, MPP, Department of Medical History and Bioethics, University of Wisconsin-Madison, G5/315 CSC, 600 Highland Avenue, Madison, WI 53792. E-mail: [email protected]. Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/14/26105-0821 DOI: 10.1097/SLA.0000000000001506
Annals of Surgery Volume 263, Number 1, January 2016
www.annalsofsurgery.com | 7
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery Volume 263, Number 1, January 2016
Taylor and Schwarze
phrases such as ‘‘I wish this were different’’ and ‘‘this is really scary’’ can help manage emotions and allow patients to consider what is important to them. Third, is the need to make a recommendation (step #8: RECOMMEND). From a genuinely noble desire to honor patient autonomy, surgeons often worry that making a recommendation, particularly for palliative care, is overbearing and paternalistic. They believe that the responsibility of the surgeon is to present options and the job of the patient is to choose.8 But respect for patients does not require this type of absolute autonomy.9 Information asymmetry is insurmountable. Without our guidance patients are abandoned to their autonomy and make value discordant decisions. Instead, we should strive for relational autonomy that requires us to understand the patient’s goals and recommend treatments that will support those goals. Recommendations should include information about how the treatment plan is linked to the patient’s reported values, for example, ‘‘given what you have told me about how much you value your independence, I would recommend palliative care as surgery is unlikely to get you back home.’’ Although these changes may seem straightforward and easy to implement, they are not. Our group has studied surgeon–patient conversations and interventions to improve them and can report that changing surgeon behavior is seriously challenging. Many will say, ‘‘I already do that’’ but in our observation, none of us do that. This is not unique to surgeons, few physicians communicate well.10 The challenges to improving communication are great; communication skills are undervalued; learning new skills takes time, practice and feedback; and there are few qualified teachers. There are other systemic barriers to goal-concordant care that improved communication alone is unlikely to overcome. Surgeons by nature and training are predisposed towards action. Our general approach focuses on an isolated critical problem and ‘‘goal directed’’ therapy (stop the bleeding, control the source of infection) that fails to adequately consider a burdensome postoperative course or the value of the best possible surgical outcome for a frail patient. To communicate a choice about treatment strategies, surgeons must first recognize a treatment choice exists. Furthermore, the fast-paced efficiency of healthcare delivery imposes a clinical momentum8,11 in which the path of least resistance is to operate, rather than explain why surgery may not be the best treatment. These systems barriers are reinforced by policy challenges. Although the benefits of nonoperative management may be more
8 | www.annalsofsurgery.com
difficult to explain and time consuming to provide, these treatments are reimbursed at a fraction of an operation, fostering the perception that nonprocedural options are inferior. New Medicare incentives for upstream end-of-life discussions are promising but the impact of this policy or how it might extend to acute decision making is unknown. To compound this problem, quality metrics such as 30-day mortality may threaten goal-concordant care by failing to accommodate patients who would benefit from palliative surgery or postoperative treatment limitations.12 The ACS NSQIP Geriatric Surgery Pilot Project is an important first step for measuring relevant outcomes. Although no adequate measure of communication quality exists presently, the nine point framework described by Cooper et al5 provides a great starting point for a prototypical measure and much needed guidance for surgeons.
REFERENCES 1. Finlayson EV, Birkmeyer JD. Operative mortality with elective surgery in older adults. Eff Clin Pract. 2001;4:172–177. 2. Finlayson E, Fan Z, Birkmeyer JD. Outcomes in octogenarians undergoing highrisk cancer operation: a national study. J Am Coll Surg. 2007;205:729–734. 3. Finlayson E, Zhao S, Boscardin WJ, et al. Functional status after colon cancer surgery in elderly nursing home residents. J Am Geriatr Soc. 2012;60:967–973. 4. Kruser JM, Pecanac KE, Brasel KJ, et al. And I think that we can fix it: mental models used in high-risk surgical decision making. Ann Surg. 2015;261: 678–684. 5. Cooper Z. Recommendations for best communication practices to facilitate goal-concordant care for seriously ill older patients with emergency surgical conditions. Ann Surg. 2016;263:1–6. 6. Arnold R. Cases: Are goals of care conversations about emotion or fact? Pallimed. Decmeber 3, 2014. Available at: http://www.pallimed.org/2014/12/ cases-are-goals-of-care-conversations.html. Accessed August 5, 2015. 7. Loewenstein GF, Weber EU, Hsee CK, et al. Risk as feelings. Psychol Bull. 2001;127:267–286. 8. Nabozny MJ, Kruser JM, Steffens NM, et al. Constructing high-stakes surgical decisions: it is better to die trying. Ann Surg. 2015 Jan 5. [Epub ahead of print]. 9. Sullivan MD. The illusion of patient choice in end-of-life decisions. Am J Geriatr Psychiatry. 2002;10:365–372. 10. Tulsky JA. Beyond advance directives: importance of communication skills at the end of life. JAMA. 2005;294:359–365. 11. Kaufman SR. And a Time To Die: How American Hospitals Shape the End of Life. New York, NY: Scribner; 2005. 12. Schwarze ML, Brasel KJ, Mosenthal AC. Beyond 30-day mortality: aligning surgical quality with outcomes that patients value. JAMA Surg. 2014;149:631–632.
ß
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
