1. Rethinking “Do Everything”: Improving communication to avoid non-beneficial treatment in seriously ill older adults Margaret (Gretchen) Schwarze Zara Cooper Dr. Schwarze is supported by : NIA: GEMSSTAR R03 Jahnigen Career Development Award (AGS & SVS) PCORI, Greenwall Foundation Dr. Cooper is supported by: Ariadne Labs, Cambia Foundation NIA: GEMSSTAR R03, Jahnigen Career Development Award (AGS & ACS)

3. Focus groups with surgeons Challenges involved with medical decisions and frail older patients 2 scenarios: 1.85 yo man with, dementia, COPD, obesity and toxic megacolon 2.79 yo woman with renal insuficiency, on home oxygen and tender thoracoabdomial aneurysm Nabozny, Kruser, Steffens et al, ”Constructing High Stakes Surgical Decisions: it’s better to die trying” Annals of Surgery, 2015.

4. Presentation of Options Choice Presentation Rationale No choice Surgery is not offered  Outcome is unacceptable  Professional duty to avoid burdensome treatment Biased choice  Surgeon has decided patient should not have surgery  Frame the decision to favor non-operative strategy Simple choice  Patient/family to decide based on options presented  Surgeon suppresses/does not present own opinion about value of surgery

5. “If you're not going to survive, you're not going to survive, and there's really no reason to take someone to surgery to do an autopsy and, you know, send the bill to Medicare.” “I mean, you, we've made our decision that probably this patient really doesn't warrant a surgery …And so you make that decision when you go see that patient, and you're going to steer the patient and the family in the direction of conservative [treatment]” “… I see my job to try and help them understand what their options are. Their job is to choose, you know.”

6. Clinical Momentum Inevitable course towards intervention Inadequate time for decision making Operating room already called Expectations of consulting docs Surgical consultation signals surgery is the appropriate treatment strategy

7. “I'll get some woman in the office who's 75, smoked all her life, on oxygen, in a wheelchair, anti-coagulated for her heart disease. Somebody gets a mammogram. They find a little spot. They biopsy the little spot. It's a little cancer. She'll show up with six family members who are just all, you know, this cancer has got to be treated, when the woman has got a life expectancy probably less than two years.”

8. “[I told him] well, the best-case scenario is I get her back to being [an] end-stage Alzheimer's patient who's completely aphasic and not ambulatory. And they go, ‘oh, we guess we never thought of that.’”

9. Conclusions Surgeons agree that very frail patients are unlikely to benefit from surgery They hold conflicting views about how to present treatment options Surgeons identify several factors beyond their control that contribute to a clinical momentum promoting intervention despite concerns that surgery is not valuable

10. The Problem

11. Key Decision-Making Elements Break Bad News Attend to emotions Describe options and outcomes of surgical and non-surgical treatment Elicit preferences Recommend treatment aligned with preferences Cooper Z, et al. Ann Surg 2016;263:1-6

13. Best case: ICU post op Nursing home Most likely: Closer to worst case Surgery Worst case: Long surgery Complications Die in ICU Palliative Care Best case: Time to say goodbye Pain controlled Go home Most likely: Pain controlled Groggy Die in hospital Worst case: Time is short Death is imminent https://www.youtube.com/watch?v=FnS3K44sbu0 Best Case/Worst Case Framework

14. https://www.youtube.com/watch?v=FnS3K44sbu0

15. Surgeon: “Even after surgery…she’d be really debilitated for having been in the hospital, and she would likely end up in the nursing home for the rest of her life.” Family member: “That’s not something she would want. I can tell you that.” Surgeon: “This is what I know about her…that she didn’t want a lot of these interventions…and we’re gonna do a maximum amount of those things if we decide to go for surgery…so my general thought is that, surgery where she ends up in a nursing home, with complications from surgery, is not something that she ever wanted.”

16. Moving forward: Objectives Develop consensus about how to assist patients making difficult decisions Move beyond informed consent to shared decision making Acquire skills: breaking bad news, managing emotion, eliciting preferences and making recommendation Recognize and address clinical momentum