Best case worst case


Many frail older adults receive burdensome treatments near the end of life that may be inconsistent with their values and goals. We believe improved communication and partnership between surgeons, patients and families can help patients make treatment decisions based on what is important to them.

Our research group at the University of Wisconsin developed the Best Case/Worst Case framework with input from surgeons, patients, and experts in education and palliative care. As part of a pilot study, we trained surgeons at our institution to use the Best Case/Worst Case framework and evaluated its use for frail, older inpatients hospitalized with an acute surgical condition.

Based on our experience training surgeons, we developed training materials to allow healthcare providers to learn how to use Best Case/Worst Case. These materials also provide guidance on how to structure a Best Case/Worst Case training session at your institution.


A free toolkit for Best Case/Worst Case is available from

This toolkit includes:


  1. An instructional video
  2. An instructor manual with learning objectives and lesson plans for teaching Best Case/Worst Case
  3. A trainee manual outlining learning objectives and core principles of Best Case/Worst Case
  4. Hypothetical case vignettes for use for practice
  5. A checklist of essential Best Case/Worst Case elements to use for practice and assessment of competency
  6. A pocket card that can serve sa quick reference for clinicians
  7. A video for instructors that demonstrates the use of Best Case/Worst Case and coaching


Download the full toolkiT

To promote shared decision making in high-stakes decisions, researchers at the University of Wisconsin – Madison developed the Best Case/Worst Case communication framework for face-to-face discussions about treatment options in the context of serious illness. This framework is designed to help physicians discuss options with frail older patients and their families to achieve treatment decisions that align with patient preferences.


How to use best case worst case

Watch this 10 minute instructional video to learn the principles of Best Case/Worst Case and to see how Best Case/Worst Case can improve your conversations with patients and their families!


For frail, older adults, acute surgical problems can have life-altering effects. The mortality rate is high and serious postoperative complications can lead to loss of independence and burdensome treatments that may be inconsistent with the values and goals of many older patients. Unfortunately, the decision to proceed with surgery can result in unwanted care and postoperative conflict between surgeons, patients, and families.

We believe that part of the problem is the way in which surgeons have typically been taught to talk to patients about high risk surgery. Surgeons commonly use the language of informed consent to disclose isolated procedural risks, for example a 25% chance of renal failure or a 30% chance of stroke. While this strategy satisfies legal requirements, it does not allow patients to consider how they might experience adverse outcomes or anticipate expected downstream consequences that can result in unwanted aggressive treatments.

BC/WC is an intervention to support decision making that builds on the conceptual model of shared decision making and uses scenarios to help patients and families imagine what life might look like if they had surgery. BC/WC combines narrative description and a hand written graphic aid to illustrate a choice between treatments and to engage patients and families in deliberation. For each treatment, the surgeon describes a range of possible outcomes in the best case, worst case, and most likely scenarios.

USe of Best Case/WORST CASE Communication framework


If you decide to use these materials, we ask that you please cite the following article, and credit the Wisconsin Surgical Outcomes Research Program (WiSOR) at the University of Wisconsin Madison. In addition, we ask that you do not modify the Best Case/Worst Case training intervention itself.

Qualitative evaluation of surgeon and patient perspectives of Best Case/Worst Case is available in the following article: Kruser JM, Nabozny MJ, Steffens NM, Brasel KJ, Campbell TC, Gaines ME, Schwarze ML. “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):1805-11.



Wisconsin Surgical Outcomes Research Program
Department of Surgery
University of Wisconsin School of Medicine and Public Health

Wisconsin Surgical Outcomes Research Program Logo



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