High Stakes Surgical Decisions to
Prevent Unwanted Care
The Balfour Lecture in Surgical Ethics
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.”
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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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