Palliative Medicine Review: Prognostication

Abstract

Prognostication, along with diagnosis and treatment, is a traditional core clinical skill of the physician. Many patients and families receiving palliative care want information about life expectancy to help plan realistically for their futures. Although underappreciated, prognosis is, or at least should be, part of every clinical decision. Despite this crucial role, expertise in the art and science of prognostication diminished during the twentieth century, due largely to the ascendancy of accurate diagnostic tests and effective therapies. Consequently, "Doctor, how long do I have?" is a question most physicians find unprepared to answer effectively. As we focus on palliative care in the twenty-first century, prognostication will need to be restored as a core clinical proficiency. The discipline of palliative medicine can provide leadership in this direction. This paper begins by discussing a framework for understanding prognosis and how its different domains might be applied to all patients with life limiting illness, although the main focus of the paper is predicting survival in patients with cancer. Examples of prognostic tools are provided, although the subjective assessment of prognosis remains important in the terminally ill. Other issues addressed include: the importance of prognostication in terms of clinical decision-making, discharge planning, and care planning; the impact of prognosis on hospice referrals and patient/family satisfaction; and physicians' willingness to prognosticate.

Physicians' Propensity To Discuss Prognosis Is Associated with Patients' Awareness of Prognosis for Metastatic Cancers

“…[4][5][6] Although increasingly, studies have documented that most patients want to receive prognostic information and that truthful communication is not harmful, 7,11,12 in this large, population-based study of patients with metastatic lung or colorectal cancer, we found that many had a limited prognosis awareness soon after diagnosis, even though most of them had received chemotherapy. Our findings suggest that physician communication behaviors are associated with patients' perception of prognostic information.…”

“…[1][2][3] Knowledge of prognosis is essential for terminally ill patients because prognosis awareness can influence their preferences for aggressive therapy versus supportive care. [4][5][6] Other evidence suggests that truthful communication about prognosis is not harmful. 7 Several studies have documented that patients with metastatic cancers tend to overestimate their prognosis.…”

Thinking fast and slow in pneumonia

“…The idea that a simple once a day administration regime will foster adherence is certainly beguiling, but the research evidence is more nuanced. A number of systematic reviews 1,2 and a recent meta-analysis 3 have addressed the relationship between adherence and dose frequency, and their findings do indeed suggest an inverse gradient between dose frequency and adherence. The meta-analysis by Coleman and colleagues 3 was methodologically more advanced and focused on oral dosage forms where adherence was assessed by electronic monitoring.…”

“…Glare and Sinclair demonstrated quantitatively the subservience of 'prognosis' to 'diagnosis' and 'therapy' by measuring the number of hits in a PubMed search; the number of hits for prognosis was eight to nine times less than those for the other two terms. 3 To an extent, the disappearance of 'prognosis' could be ascribed to the fact that the term is mostly associated with an answer to the question "Doc, how much time do I have? ", 4 a question only one in three physicians discusses with their patients 5 -and avoided because physicians find themselves ill-prepared for prognostication and find it stressful to make predictions.…”

Incorporating Routine Survival Prediction in a U.S. Hospital-Based Palliative Care Service

“…1 Predicting survival, in particular, is important as it may prove the deciding factor in decisions to pursue aggressive treatments, 2 to change goals of care, or decisions to leave the hospital. 3 Patients with limited predicted survival, in particular, may choose to forego disease oriented treatments and to seek care in settings other than acute care hospitals.…”