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High Stakes Surgical Decisions to Prevent Unwanted Care

The Balfour Lecture in Surgical Ethics

Gretchen Schwarze

Gretchen Schwarze

University of Wisconsin vascular surgeon, Gretchen Schwarze, presented an excellent example of empirical ethics on April 6, 2016 at the 2nd Annual Balfour Lecture in Surgical Ethics which was co-presented by the Department of Surgery and Joint Centre for Bioethics, University of Toronto.

Dr. Schwarze gave us a tool that will enable elderly patients and their families to make well informed decisions about complex surgical care and its consequences. “We are still using a clunky model of informed consent, and have not innovated enough in communication to allow patients and families to make informed decisions about their care. The frail elderly are often rushed from the emergency room after anesthesia has been called and the operating room is ready. It’s hard to stop the clinical momentum, and the opportunity to illustrate and enrich the discussion of prognosis and alternatives is lost in the rush”, said Dr. Schwarze. “Our intervention is a simple drawing showing the range between the best case and the worst case outcomes.”

Best Case Worst Case

In this illustration, treatment 1 is extensive resection, treatment 2 is comfort care for an elderly patient with locally advanced cancer. The probable place the patient’s condition and comorbidities predict she will find herself in after surgical or supportive care can be illustrated and discussed with this tool. Using stories rather than statistics and a hand- drawn illustration, the surgeon can clearly communicate the likely outcome. This enables the patient and family to bring their values and preferences into the decision-making. A well-done whiteboard description of the “best case / worst case” technique, prepared by Gretchen’s Wisconsin team, is available on YouTube. You can also watch the archived video of Dr. Schwarze’s engaging presentation and animated Q&A session.

Dr. Schwarze is a graduate of Harvard Medical School who received her surgical training at Massachusetts General Hospital. She studied vascular surgery and bioethics at the University of Chicago. She holds many significant grants supporting research in surgical ethics, including collaborative studies with surgeons at the University of Toronto. Her seminar stimulated thoughtful questions and comments from an enthusiastic audience of bioethicists and surgeons.

Martin McKneally

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