Best Case/Worst Case: ICU, with special content for patients with COVID-19

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Because of the COVID-19 pandemic, critically ill patients have been hospitalized and isolated from their families and loved ones. In many hospitals, the palliative care team has been charged with maintaining communication between the critical care team and their patients’ families. The Best Case/Worst Case: ICU (COVID-19) communication toolkit is designed to assist separated families and to help them develop an understanding of their loved one’s illness, prognostic awareness and the range of possible outcomes.

Our original intervention, Best Case/Worst Case: High-Stakes Surgical Decisions, was designed specifically for face-to-face clinical interactions to support shared decision making in the context of life-limiting surgical illness. The essential elements of this tool are narrative descriptions, called scenario planning, and a hand-written graphic aid to illustrate a choice between treatments and to engage patients in deliberation. We have previously tested Best Case/Worst Case with surgeons and acutely ill surgical patients. We found that this intervention transforms the structure of the decision-making conversation and improves shared decision making on objective measures.

To expand the use of scenario planning to the ICU, where a major treatment decision does not occur each day, but evolves over time, we developed a novel version of our Best Case/Worst Case tool for use in the surgical ICU with older adults with traumatic injury. Funded by the NIA (R21 AG055856), Best Case/Worst Case: trauma ICU has been tested in Texas and Oregon (study results pending).

In March of 2020, during the COVID-19 pandemic, palliative care clinicians at the University of Wisconsin were asked to bridge the communication between patients’ families and the critical care team. We thus adapted the Best Case/Worst Case: trauma ICU intervention to suit these crisis needs. This toolkit has adapted material from the trauma ICU that now serve as training materials specific for use of the Best Case/Worst Case: ICU (COVID-19). Although it would be ideal to use this tool for all hospitalized patients during the pandemic, this has not been possible at our institution and we would not imagine others would have capacity to do this as well. We anticipate this intervention would be most beneficial for patients with COVID-19 in the ICU or with signs of impending need for the ICU.

Why use this toolkit?

The Best Case/Worst Case: ICU (COVID-19) toolkit helps palliative care clinicians and other clinicians navigate daily conversations with patients’ families. It also informs critical care clinicians about the lives of the patients they are caring for and supports families who are absent from the patient’s bedside and isolated at home. The toolkit can help critical care providers understand the patient’s overall trajectory when there is a high rate of care-team member transition.

Who should use this toolkit?

These training materials are intended for use by:

  1. Clinicians who are caring for patients who have COVID-19 and those who are tasked with communicating with families.
  2. Educators who would like to teach clinicians and clinical staff to use Best Case/Worst Case for patients with COVID-19.

What does the toolkit contain?

All materials are in either PowerPoint, PDF, or PNG formats. These materials include:

  1. Step-by-Step Instructions for using Best Case/Worst Case: ICU (COVID-19)
  2. Templates filled with hypothetical examples
  3. Blank Template: Best Case/Worst Case: ICU (COVID-19)
    • For COVID-19 patients who are in the ICU “ICU”
    • For COVID-19 patients who are not in the ICU, but are getting sicker “nonICU”
    • For COVID-19 patients, worst case scenario is left blank for clinicians to create their own
  4. De-identified photos demonstrating use of the intervention
  5. Best Case/Worst Case: ICU pocket card 

How should these tools be used?

All documents in this toolkit are available in PDF format. We include power point versions of the graphic aid template so users can tailor it to their own need. Printing is best done from the PDF version.

  1. Step-by-Step instructions for using Best Case/Worst Case: ICU (COVID-19) include detailed directions describing how to use the toolkit for individual self-education. Educators can also use these instructions to teach clinicians how to use the Best Case/Worst Case: ICU toolkit. Please note that this is not designed as an instructor’s manual.
  2. Hypothetical examples provide a visual reference to show how the tool can be used over time to support families of critically ill patients. This includes examples of both what to say and what to write in relation to the graphic aid. There are 2 trajectories – one with full recovery and one with declining health and death.
  3. Blank templates are included for Best Case/Worst Case: ICU (COVID-19). One for patients who have COVID-19 that are already in the ICU, the other is for patients with COVID-19 who are not yet in the ICU. An additional template is provided for clinicians who would prefer to fill in their own narrative for the “worst case scenario.”
  4. De-identified photos show how this tool was used at the University of Wisconsin – Madison Hospital.  These are examples of the types of photos that should be sent to families, so they can follow along and also see that the critical care team has information about what their loved one was like before they became ill.
  5. The Best Case/Worst Case: ICU pocket card is a quick reference guide. This document can be printed as a 4”x6” card.

Development of this toolkit

The Best Case/Worst Case: ICU (COVID-19) tool was developed by Principal Investigator: Margaret “Gretchen” Schwarze and her team of researchers, educators, and clinicians at the University of Wisconsin-Madison School of Medicine & Public Health. This project was indirectly supported by the National Institutes for Aging: 1R21AG055876-01.

To provide feedback or helpful improvements/innovations for use of this tool please contact us via email at


  1. Schwarze ML, Kehler JM, Campbell TC. Navigating high risk procedures with more than just a street map. J Palliat Med. 2013 Oct;16(10):1169-71.
  2. Kruser JM, Nabozny MJ, Steffens NM, Brasel KJ, Campbell TC, Gaines ME, Schwarze ML. “Best Case/Worst Case”: Qualitative Evaluation of a Novel Communication Tool for Difficult in-the-Moment Surgical Decisions. J Am Geriatr Soc. 2015 Sep;63(9):1805-11.
  3. Taylor LJ, Nabozny MJ, Steffens NM, Tucholka JL, Brasel KJ, Johnson SK, Zelenski A, Rathouz PJ, Zhao Q, Kwekkeboom KL, Campbell TC, Schwarze ML. A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case. JAMA Surg. 2017 Jun 1;152(6):531-538.
  4. Kruser JM, Taylor LJ, Campbell TC, Zelenski A, Johnson SK, Nabozny MJ, Steffens NM, Tucholka JL, Kwekkeboom KL, Schwarze ML. “Best Case/Worst Case”: Training Surgeons to Use a Novel Communication Tool for High-Risk Acute Surgical Problems. J Pain Symptom Manage. 2017 Apr;53(4):711-719.e5.
  5. Schwarze ML, Taylor LJ. Managing Uncertainty – Harnessing the Power of Scenario Planning. N Engl J Med. 2017 Jul 20;377(3):206-208.
  6. Taylor LJ, Adkins S, Hoel AW, Hauser J, Suwanabol P, Wood G, Anderson W, Branson C, Skube S, Johnson SK, Zelenski A, Tucholka JL, Campbell TC, Schwarze ML. Using Implementation Science to Adapt a Training Program to Assist Surgeons with High-Stakes Communication. J Surg Educ. 2019 Jan-Feb;76(1):165-173.

Toolkit Citation

Schwarze ML, Zelenski A, Baggett N, Kalbfell E, Silverman E, Campbell T. “Best Case/Worst Case: ICU (COVID-19)”. University of Wisconsin-Madison. Madison, WI; 2020. Available at


About the Developer

Margaret “Gretchen” Schwarze, MD, MPP, FACS is an Associate Professor with the University of Wisconsin – Madison Department of Surgery, Division Vascular of Surgery. Her research focuses on improving communication between older patients and their clinicians, so that patients can avoid unwanted treatment and make decisions that align with their values, preferences and goals. She is an alumna of the Greenwall Faculty Scholars program and the Cambia Sojourn Scholars Leadership Program. She and her team are currently funded by the NIH and the Greenwall Foundation to study clinician-patient communication and to test interventions to improve high-stakes decision making.

Toby Campbell, MD, MSCI, FAAHPM is a Professor (CHS) with the University of Wisconsin-Madison Department of Medicine, Division of Hematology, Oncology, and Palliative Care. He is the Ellen and Peter O Johnson Chair and the Chief of Palliative Care. He designs conversations to approach complex conversations, foster decision making and express empathy. He is a past recipient of the Cambia Sojourns Scholar Leadership Award. With Amy Zelenski he developed WeTALK and PalliTALK, communication skills teaching programs for physicians.