“I’d rather die than live like this.”

Most experienced spine providers have heard this sentiment from time to time, sometimes even during an initial patient encounter. Unexpectedly, I heard this again during the question & answer portion of a recently recorded Seattle Science Foundation meeting titled, “Integration of New Technologies in Spine Surgery” featuring Sigurd Berven, MD (UCSF).1 The question was asked by Patrick Johnson, MD, (Cedars-Sinai) at the very end of the session regarding the increasing demand of elderly patients seeking surgical solutions to their complex spinal disorders. While the seminar was more about guiding thoughtful adoption of new robotics and navigation technology in spine surgery and is worth the 30-minute watch, the question about when to say “no” to the desperate patient lingered unanswered.

Berven pragmatically emphasized the need to involve the family and utilize evidence-based predictive models to help manage expectations when considering complex surgery in high-risk populations. While excellent advice, I was still left wondering what patient-centered care should look like in the situation where a frail 82-year-old patient with a degenerative spine deformity would “rather die than live like this.” I went looking in the surgical palliative care literature and found more questions than answers. Nonetheless, I wanted to share with the SpineLine readership some common themes I found useful.2-7

At the risk of grossly oversimplifying the topic, patient-centered care for a complex or high-risk spine surgical patient should include three components: measurement of outcomes that matter to patients, carrying out a deliberate “serious illness conversation” with the patient and family, and utilizing some form of a shared decision-making (SDM) tool, such as “Best Case and Worst Case” scenario communication framework.

Accepting some variability between patients, most complex spine patients are most fearful of losing independence and/or becoming a burden on family members. While reducing a pain score does still matter to many, independence is usually a larger component of quality of life. In other words, a health-related quality of life (HRQoL) measure is important, as is the durability of treatment effect, reoperation rate, and ultimate discharge location. Furthermore, a periodic review of outcomes is needed to best inform practice improvement tactics.8

A Serious Illness Conversation Guide is available for free from Ariadne Labs, which is a collaborative center for innovation between Brigham and Women’s Hospital, Harvard Public Health, and the Dana-Farber Cancer Institute.9 It provides a scripted guide to carrying out a deliberate, yet efficient, serious illness conversation. Many physicians and surgeons already do this naturally well.

For others like me, it needs to be more intentional. The guide helps keep the conversation focused on realistic goals and gives the patient space to confront some difficult uncertainties with both nonoperative and operative care choices.

SDM is distinguishable from informed consent. This becomes clear when looking at examples provided by The Patient Preferences Project from the University of Wisconsin Surgical Outcomes Research Program (WiSOR) and their associated Toolkit.10 Their framework is focused on an intentional conversation with the patient about best case, worst case, and most likely scenarios with surgical versus nonsurgical treatments and providing a visual aid to represent a realistic center-point for the most likely outcome based on the patient’s health and age. It allows for limited statistics about risk and benefit, but tailors the discussion around the most likely outcome for this patient. It also allows the patient to maintain hope for the best, while also contemplating the worst possible outcome (which may be worse than death for some patients).

This all comes back to aligning our treatments and new technologies with patients’ values and preferences. I think NASS continues to do a great job supporting this mission through the many educational offerings and extensive advocacy work to support providers and patients.

In this issue of SpineLine, the breadth of NASS is again on display, including advocacy and practice management (President’s Message), coding (spinal navigation), new technologies (2026 NASS Evidence & Technology Spine Summit), personalized spine care (individualized lumbar pseudarthrosis prevention), and practice improvement (understanding failure in cervical disc arthroplasty).

Finally, I’d like to highlight the SpineLine Literature Review feature started by Jonathan Grauer. This has been a successful journal club-style feature of SpineLine that summarizes and succinctly discusses a recent high-interest article, typically from TSJ or NASSJ. We’ve decided to build upon success and feature two articles going forward.

For this issue, please enjoy the excellent TSJ Literature Review by Junho Song, which looks at using foraminal shape to personalize cervical ACDF versus posterior cervical foraminotomy decisions. The featured article from NASSJ, reviewed by Jonathan Grauer, tries to determine if emergency medicine physicians would prefer ChatGPT over spine surgeons to answer common spine consultation questions. The results could be viewed as good or bad depending on your perspective, but I’ll let you decide for yourself. Both articles should generate more discussion among colleagues, which is what this feature is all about.