“Surgical problems often involve rapid decision-making with limited time for deliberation and require proficiency discussing interventions ranging from elective outpatient procedures to an emergency operation in the setting of life-limiting illness. For patients and families, the concept of surgery may incite strong emotions, with many discussions occurring without a previously established patient-surgeon relationship. [..]
Attend to Emotion
Receiving bad news such as a new cancer diagnosis or an unexpected postoperative complication often takes patients and families by surprise. Without warning about difficult news, they may fail to process what has happened. To anticipate and attend to their emotions, surgeons can prepare patients and families to receive the news. A “heads-up” statement can be a simple as “I have serious news” or “Things have changed.”
Next, the new information can be summarized with a clear headline. Offering a lengthy, technical explanation of clinical events can be challenging for patients and family members to understand and detract from the main message. [..] Surgeons can generate a concise headline to summarize the situation and next steps, eg, “You have a hole in your intestines. We usually treat this with surgery and several days in the hospital.”
When presented with new information, emotional response often precedes rational thinking and drives many of the behaviors of patients and their family members who may express fear, frustration, sadness, or other strong emotions through statements and questions. Surgeons fall into the cognitive trap if they fail to recognize the emotional reaction and only respond with more information. When a patient says “The other doctor told me this was nothing. Do you even talk to each other?” surgeons can first endorse the validity of these claims with empathy for the patient’s frustration. The NURSE mnemonic (naming and understanding the emotion, respecting and supporting the patient, and exploring the emotion) can prompt clinician responses that convey empathy. Empathic communication may deescalate the emotional tenor of the conversation, increase trust in the physician, and allow a rational discussion about treatments. I wish statements are particularly useful when surgery is nonbeneficial. Surgeons can answer the question “Isn’t there anything else you can do?” with “I wish things were different, but I worry that our goal of helping you to live longer is not possible with surgery,” followed by discussion of an alternative treatment such as palliative care. Rather than describing an ineffective procedure, this response allows surgeons to convey compassion while establishing that the hoped-for goal is not possible.
Use Scenario Planning to Manage Uncertainty
In the face of a new acute illness and major surgery, it may be hard to predict how events will unfold, leaving patients and families blindsided by the experience of illness and treatment. Even with accurate risk prediction, patients may falsely assume that the complications described will not happen to them or may overestimate survival in the setting of life-limiting disease. Using statistics to convey the likelihood of isolated risks does not help patients imagine what life might look like after treatment.
[..] Scenario planning permits surgeons to say “In the best-case scenario, I am hoping for… and in the worst-case scenario, I am worried about….” Surgeons can use narratives to describe short- and longer-term outcomes, including time in the hospital and the potential effect of illness and treatment on functional status. Similarly, surgeons can describe a worst-case scenario assuming complications occur, which may include death after prolonged hospitalization. Providing alternate scenarios allows surgeons to manage uncertainty by defining clinically plausible outcomes. This skill can be used to discuss prognosis after an acute clinical change or urgent operation or to facilitate shared decision-making when deliberating about high-risk operations. [..]
Describe the Goals and Downsides of Surgery to Support Deliberation
In routine discussions about surgery, surgeons commonly use a fix-it model, identifying an isolated anatomic abnormality and how surgery will repair, replace, bypass, or remove the problem. Detailed technical descriptions of surgical procedures are time-consuming and may not be useful to support patients and families who are deciding whether they want to proceed with the operation. More importantly, this model may reinforce the oversimplified narrative that surgery will fix the problem without describing the outcomes an operation can achieve.
Clearly stating the goal of surgery ensures that clinicians and patients have the same understanding of what the operation can and cannot accomplish. Surgery can help people live longer, feel better, preserve function, or obtain a diagnosis. However, a secondary analysis of 169 audio-recorded preoperative consultations between surgeons and patients discussing high-risk surgery suggests that a discussion of treatment goals rarely occurs. In this study, surgeons used the fix-it model in 92% of conversations, but the overall goal of surgery was not discussed in 80% of conversations.
Surgeons routinely list discrete potential complications of surgery; however, there are more downsides than just the technical risks. Every operation is associated with expected unpleasant experiences, such as pain and deconditioning that requires time and effort to overcome. Adverse surgical outcomes may include transient events such as urinary retention, complications such as bleeding and infection, and major changes in functional status such as loss of cognitive capacity or physical independence. Also, surgery may not achieve the patient’s goals even if complications do not occur, such as when cancer recurs after a major operation. Juxtaposing the goals and downsides allows patients to consider the trade-offs in advance and helps surgeons support patients and families in deliberation about whether surgery is the best option.”
Full article, LJ Taylor, EB Rivet and MR Kapadia, JAMA, 2025.4.16