Background for Fast Fact #486: As our population ages and the level of medical complexity continues to increase, our patients face more variables when considering surgery and other invasive medical procedures (1-3). This can elicit anxiety, distress, and indecision as patients and their families navigate whether to undergo a surgical intervention. This Fast Fact will review different tools available to clinicians to facilitate shared decision-making with their patients. While some of these tools can apply to non-surgical interventions, their application to surgical decisions will be the focus of this Fast Fact.

Informed consent: Prior to every medical procedure or surgery, an informed consent discussion takes place involving the clinician, the patient, and often the patient’s family. Ethical and legal principles call for the patient or their representative to demonstrate voluntarism, capacity, and understanding, while the clinician must disclose the risks and benefits of the procedure being considered as well as the risks and benefits of alternative treatment plans (4,5). This conversation leads to a binary decision — to pursue a surgery (or medical procedure) or not. However, for those with serious illness, such decisions are usually quite complex, weighing the interactions of patient-specific factors with demands of pre-, intra-, and post-operative (procedural) care. Prior research has shown that < 40% of patients had adequate understanding of the information provided and the risks of surgery in these clinical scenarios (6). For this reason, a decision aid may help frame the conversation and encourage more informed decision-making.  

Decision aids offer a visual or conceptual framework to start a conversation about binary treatment options (7). They have been shown to facilitate communication, increase patient knowledge, elicit patient values, and reduce internal conflict for patients in their decision-making process (8-10). Most are designed to be used in the outpatient setting when considering a specific elective operation (10). There are decision aids focused on operations for breast cancer (11), bariatric surgery (12), abdominal aortic aneurysm repair (7), and many others. Patients for whom decision aids were utilized showed less tendency to pursue major elective surgery and more likely to pursue less invasive alternatives (10). While there are several decision aids that are applicable, The National Surgical Quality Improvement Project Surgical Risk Calculator (NSRC) and Best Case/Worst Case are the best studied and most applicable. 

NSRC: Created by the National Surgical Quality Improvement Project, the NSRC incorporates data from over five million operations done at over 800 hospitals in the United States to create a calculator that provides patient-specific risk estimates (13). This tool is freely accessible to both clinicians and patients. Portal users enter the Current Procedural Terminology (CPT) code for the procedure being considered as well as information about the patient’s demographics (includes age, sex, functional status, urgency of the procedure, body mass index, and medical comorbidities). Specific metrics relevant to older patients can be included such as a history of cognitive impairment or whether the patient has been seen by a palliative care clinician in the past. These data are used to produce estimates for length of inpatient stay, mortality, postoperative complications, and likely discharge disposition (13,14). From the online portal, clinicians can print out a summary to give to patients or send to them electronically. The NSRC has been validated in different patient populations and clinical situations (15-18).  

“Best Case/Worst Case” (BCWC): BCWC has been validated as a structured communication tool which provides an individualized framework for a conversation between clinicians and patients about a specific treatment choice. This model encourages comparison by presenting the “best case,” “worst case,” and “most likely” outcomes for two possible treatment options (e.g., surgery vs no surgery/comfort care) (19,20). Rather than focusing solely on a quantified estimate of survival or complications, BCWC explores potential short- and long-term impacts of the proposed treatment options, including functional considerations. It also explores the uncertainty that is inherent to medical care and aims to align the treatment options with the patient’s values and health goals. In this way, BCWC facilitates shared decision-making as opposed to the medical team presenting information and the burden of decision being placed on the patient and family. Clinicians using this tool will draw out a visual diagram, typically on a piece of paper, during the conversation to convey the major discussion point. The diagram can then be provided as a keepsake for the patient to reference as their treatment evolves (Figure 1) (19,20). Previous work has found the BCWC to be particularly useful for older adults and for patients with significant comorbidity burdens as these discussions often involve greater medical complexity and risk (19).  BCWC can also be useful when considering non-procedural treatments like chemotherapy (21), hemodialysis (22), and COVID related treatments (22). The Patient Preferences Project has created free online tutorials and workshops to train clinicians to use this tool effectively (22). 

Figure 1: Included with permission from The Patient Preferences Project 

References 

1. Becher RD, Wyk BV, Leo-Summers L, et al. The Incidence and Cumulative Risk of Major Surgery in Older Persons in the United States. Ann Surg. Published online December 16, 2021. doi:10.1097/SLA.0000000000005077.
2. Richardson JD, Cocanour CS, Kern JA, et al. Perioperative risk assessment in elderly and high-risk patients1 1No competing interests declared. J Am Coll Surg. 2004;199(1):133-146. doi:10.1016/j.jamcollsurg.2004.02.023.
3. Zhang Y, Ma L, Wang T, et al. Protocol for evaluation of perioperative risk in patients aged over 75 years: Aged Patient Perioperative Longitudinal Evaluation–Multidisciplinary Trial (APPLE-MDT study). BMC Geriatr. 2021;21(1):14. doi:10.1186/s12877-020-01956-3.
4. Leclercq WKG, Keulers BJ, Scheltinga MRM, et al. A Review of Surgical Informed Consent: Past, Present, and Future. A Quest to Help Patients Make Better Decisions. World J Surg. 2010;34(7):1406-1415. doi:10.1007/s00268-010-0542-0.
5. Lidz CW. The therapeutic misconception and our models of competency and informed consent. Behav Sci Law. 2006;24(4):535-546. doi:10.1002/bsl.700.
6. Falagas ME, Korbila IP, Giannopoulou KP, et al. Informed consent: how much and what do patients understand? Am J Surg. 2009;198(3):420-435. doi:10.1016/j.amjsurg.2009.02.010.
7. Ubbink DT, Knops AM, Molenaar S, et al. Design and development of a decision aid to enhance shared decision making by patients with an asymptomatic abdominal aortic aneurysm. Patient Prefer Adherence. 2008;2:315-322. 
8. Knops AM, Legemate DA, Goossens A, et al. Decision Aids for Patients Facing a Surgical Treatment Decision: A Systematic Review and Meta-analysis. Ann Surg. 2013;257(5):860-866. doi:10.1097/SLA.0b013e3182864fd6.
9. Sepucha K, Atlas SJ, Chang Y, et al. Patient Decision Aids Improve Decision Quality and Patient Experience and Reduce Surgical Rates in Routine Orthopaedic Care: A Prospective Cohort Study. JBJS. 2017;99(15):1253-1260. doi:10.2106/JBJS.16.01045 
10. Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;2017(4). doi:10.1002/14651858.CD001431.pub5.
11. Jibaja-Weiss ML, Volk RJ, Granchi TS, et al. Entertainment education for breast cancer surgery decisions: a randomized trial among patients with low health literacy. Patient Educ Couns. 2011;84(1):41-48. doi:10.1016/j.pec.2010.06.009.
12. Arterburn DE, Westbrook EO, Bogart TA, Set al. Randomized trial of a video-based patient decision aid for bariatric surgery. Obes Silver Spring Md. 2011;19(8):1669-1675. doi:10.1038/oby.2011.65.
13. About – ACS Risk Calculator. Accessed February 28, 2024. https://riskcalculator.facs.org/RiskCalculator/about.html
14. FAQ – ACS Risk Calculator. Accessed February 28, 2024. https://riskcalculator.facs.org/RiskCalculator/faq.html
15. Bilimoria KY, Liu Y, Paruch JL, et al. Development and Evaluation of the Universal ACS NSQIP Surgical Risk Calculator: A Decision Aid and Informed Consent Tool for Patients and Surgeons. J Am Coll Surg. 2013;217(5):833-842.e3. doi:10.1016/j.jamcollsurg.2013.07.385.
16. Cohen ME, Liu Y, Ko CY, et al. An Examination of American College of Surgeons NSQIP Surgical Risk Calculator Accuracy. J Am Coll Surg. 2017;224(5):787-795.e1. doi:10.1016/j.jamcollsurg.2016.12.057.
17. Burgess JR, Smith B, Britt R, et al. Predicting Postoperative Complications for Acute Care Surgery Patients Using the ACS NSQIP Surgical Risk Calculator. Am Surg. 2017;83(7):733-738. doi:10.1177/000313481708300730.
18. Yap MKC, Ang KF, Gonzales-Porciuncula LA, et al. Validation of the American College of Surgeons Risk Calculator for preoperative risk stratification. Heart Asia. 2018;10(2):e010993. doi:10.1136/heartasia-2017-010993.
19. Kruser JM, Nabozny MJ, Steffens NM, et al. “Best Case/Worst Case”: Qualitative evaluation of a novel communication tool for difficult in-the-moment surgical decisions. J Am Geriatr Soc. 2015;63(9):1805-1811. doi:10.1111/jgs.13615.
20. Taylor LJ, Nabozny MJ, Steffens NM, et al. A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case. JAMA Surg. 2017;152(6):531-538. doi:10.1001/jamasurg.2016.5674.
21. Wong ML, Nicosia FM, Smith AK, et al. “You have to be sure that the patient has the full picture”: Adaptation of the Best Case/Worst Case communication tool for geriatric oncology. J Geriatr Oncol. 2022;13(5):606-613. doi:10.1016/j.jgo.2022.01.014.
22. The Patient Preferences Project. Accessed February 28, 2024. https://patientpreferences.org/

Authors’ Affiliations: Yale School of Medicine, New Haven, CT. 
Conflicts of Interest: None.
Version History:  originally edited by Sean Marks MD; first electronically published in June 2024.