Communication of prognosis in palliative care
- Alexander Smith, MD
Alexander Smith, MD
- Associate Professor of Medicine
- University of California, San Francisco
Prognosis is the science of estimating the likelihood of an outcome (eg, death, disability) due to a medical condition (eg, cancer, heart failure, late-life disability). Prognosis may address many outcomes that patients care deeply about, such as the likelihood of losing the ability to care for oneself independently, of treatment leading to a cure, or of developing a debilitating condition such as dementia. This topic will focus primarily on communicating prognosis for life expectancy or survival.
Nicholas Christakis has described the “ellipsis of prognosis” in medical teaching [1,2]. In the time of Osler, textbooks focused equally on diagnosis, treatment, and prognosis. Prognosis now makes up a scant one to two lines per chapter of most medical textbooks, and medical students and residents receive little training in how to estimate or communicate prognosis. Additionally, patterns of current practice suggest that prognosis is not routinely incorporated into clinical decision-making.
The growing palliative care movement is refocusing attention on the importance of prognosis in decision making for seriously ill patients [3,4]. Prognosis reaches paramount importance at the end of life, when the risks and burdens of treatments and their alternatives must clearly be weighed in view of the patient’s life expectancy and personal goals.
This topic will discuss the science of estimating prognosis and focus on how best to communicate this information to patients and family members. Indicators of prognosis for specific medical conditions are available in disease-specific topics in UpToDate. A more general discussion about discussing serious news is provided separately. (See "Discussing serious news".)
THE IMPORTANCE OF PROGNOSIS IN CLINICAL PRACTICE
The risks and benefits of any test or treatment must be considered in light of the patient’s expected prognosis. Thus, understanding and communicating prognosis is an important element of any clinical decision-making. Determination of eligibility for hospice, where clinicians must certify a prognosis of six months or less should the disease run its usual course, is the paradigmatic example of the need to be able to determine prognosis. The importance of understanding prognosis for multiple other clinical decisions is shown in a table, organized by shortest prognosis to longest (table 1). The table includes only those decisions where a guideline, professional organization, or recognized experts have recommended a specific prognostic cutoff; these represent only a subset of decisions that are routinely made in light of prognosis.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- THE IMPORTANCE OF PROGNOSIS IN CLINICAL PRACTICE
- Patient-important factors
- RATIONALE FOR DISCUSSING PROGNOSIS
- THE SCIENCE OF ESTIMATING PROGNOSIS
- Selecting a prognostic tool and assessing limitations
- Physician errors in prognostication
- ASSESSING PATIENT AND/OR FAMILY READINESS TO DISCUSS PROGNOSIS
- DISCUSSING PROGNOSIS
- When to discuss prognosis
- How to discuss prognosis
- - Stepwise strategy for discussion