Author: Nathan Baggett
Dr. Atul Gawande discussed the Best Case/Worst Case framework with Dax Shepard on the Armchair Expert Podcast. Listen to the segment where they discuss BC/WC below or check out the full podcast episode at this link.
Join host Dr. Red Hoffman as she interviews Dr. Gretchen Schwarze, a vascular surgeon, medical ethicist and prolific researcher known for her work focused on surgical buy-in and the best case/worst case scenario. Gretchen is an endowed professor in the Division of Vascular Surgery, Department of Surgery, at the University of Wisconsin School of Medicine and Public Health. She completed a fellowship in medical ethics at the MacLean Center for Medical Ethics. She is a nationally recognized expert in surgical decision making, informed consent, advance directives and end-of-life care and her research focuses on improving communication between older patients and their surgeons so that patients can avoid unwanted treatment and make decisions that align with their values, preferences and goals. Gretchen defines the concept of surgical buy-in and explores how this concept manifests differently for various patients and various procedures. We discuss the ethics surrounding Do Not Resuscitate orders in the OR and the importance of clearly establishing the goals of surgery (prolonging life, improving quality of life, making a diagnosis or preventing a disability) before operating. Finally, Gretchen explains the Best Case/Worst Case decision aid and notes the importance of both eliciting preferences and making recommendations when using this aid. I learned so much from speaking with Gretchen; she helped me to articulate many of the ethical dilemmas I struggle with when taking care of many of my surgical patients.
Listen to the Podcast on your favorite podcasting app or at www.redhoffmanmd.com!
Learn more about Best Case/Worst Case!
Dr. Schwarze discussed the effects of COVID-19 on non-coronavirus patients with WORT news public affairs director Chali Pittman. Listen to the discussion using the player below or on the WORT FM Website.
Dr. Schwarze was interviewed by Caroline Chen for this ProPublica article. You can read the full article here.
The surgeons “expressed significant emotional reaction,” including “betrayal, unhappiness, disappointment,” Schwarze reported. They felt that there was an implicit contract that patients entered into when signing up for surgery. One surgeon put it this way: “There is a commitment made by both the patient and the surgeon to get through the operation, as well as all of the post-operative issues that come up.” While acknowledging that they were being “paternalistic” and contradicting the patient’s directives, several of the surgeons in the study said they would refuse to withdraw life support in Schwarze’s scenario.
Dr. Schwarze was featured in this New York Times article about the post-operative care of frail older patients. In the article, she discusses The Patient Preferences Project’s Question Prompt List Intervention that can help patients ask meaningful questions when deciding if surgery is right for them. You can read the article here.
Dr. Schwarze was a guest on the GeriPal Podcast to discuss advance care planning before major surgery. Check out the episode using the player below or on the GeriPal Website!
Dr. Schwarze was interviewed for this article in the New York Times about how surgery in older adults can lead to poor outcomes that may not be anticipated by patients and their family members.
The problem, said Dr. Schwarze, was that “the kind of language we use to explain surgery doesn’t really describe the experience.”
Hear Dr. Schwarze discuss scenario planning and her New England Journal of Medicine paper titled “Managing Uncertainty: Harnessing the power of scenario-planning” on the GeriPal Podcast. You can listen to the episode using the player below or by visiting the GeriPal website.
The idea behind scenario-planning, which is what our paper is about, is that it’s not just about showing the limits of what’s possible, but also the story that unfolds along the way. I agree with you, physicians hate this idea of uncertainty, because we don’t want to be wrong, but we’re not asking people to be certain. What we’re asking people is to tell a story that’s plausible and that shows that there are limits on what’s possible to happen.
It’s not just where you end up, but the different things that will happen along the way, because if I think about my patient in the ICU who is in respiratory failure after surgery, I don’t know how that’s gonna go. He might get better and he might not. But I have to tell you, if the respiratory failure gets better, I can tell a pretty solid story about that’s gonna look like and how things are gonna be six months from now, a year from now, based on what I know about the patient. If the respiratory failure doesn’t get better, I can tell a pretty good story about that as well.
We’re not asking people to predict the future, but rather to tell a story that allows patients to understand a series of events that are likely to happen, once you’ve identified where there’s uncertainty.
Dr. Schwarze was interviewed in this New York Times story about how the use of a 30-day mortality window in surgical report cards can lead to unacknowledged harm for patients.
