On Prognostication
Introduction
Prognostication is one of the most important and more difficult content areas for our specialty. Historically, it an area of knowledge that clinicians spent time studying and dominated chapters in medical textbooks. Now, few clinicians know how to estimate life expectancy, although patients and families expect us to know. In many of our journals and text books, prognostication revolved around knowing the percent chance of someone living for 5 years or 10 years, or perhaps the estimate of whether someone will be able to leave the ICU alive. Prognosticating in palliative care takes on a different meaning and different skill set:
Another note: Christian Sinclair is one of the docs who has published a lot on this topic. I recommend starting with his article below and going from there.
Prognostication is one of the most important and more difficult content areas for our specialty. Historically, it an area of knowledge that clinicians spent time studying and dominated chapters in medical textbooks. Now, few clinicians know how to estimate life expectancy, although patients and families expect us to know. In many of our journals and text books, prognostication revolved around knowing the percent chance of someone living for 5 years or 10 years, or perhaps the estimate of whether someone will be able to leave the ICU alive. Prognosticating in palliative care takes on a different meaning and different skill set:
- It is needed for evaluating a patient's eligibility for hospice. Currently the rules are that the only criteria for hospice is that someone's average life expectancy is 6 months should the disease takes its natural course. Despite this, the average life expectancy on hospice is 2 weeks.
- Patients and families want to know. Despite research that tells us that most patients and families want to know their prognosis, in order to plan, in order to process, in order to gain some semblance of control, many patients are not told. Why? This is also a topic among some articles I hope to share this month. Generally, physicians often wait for patients to ask, while patients wait for physicians to offer this information. When patients do ask, physicians are often nervous to share the information fearing taking away hope and in turn, causing suffering. N. Christakis has written wonderfully about this, including a book I would recommend to anyone to read. (See his link below.) So, prognostication is about estimating and about knowing how to communicate this information.
- Knowing prognosis helps improve access to "the right care at the right time." Patients and families often return again and again to hospitals hoping that we can help make the patient better, bring them back to where they were weeks or months ago. Frustration rises as patients and families feel as though we are offering lesser than optimal care when this goal or hope is neither achieved nor its failure of achievement explained or addressed. Providing prognosis helps patients and families make choices - for example to be home, to not be rehospitalized, to avoid certain interventions that will not achieve the goal hoped for.
- It's on the boards.
Another note: Christian Sinclair is one of the docs who has published a lot on this topic. I recommend starting with his article below and going from there.
Articles
- Paul A. Glare, Christian T. Sinclair. Palliative Medicine Review: Prognostication Journal of Palliative Medicine. January 2008, 11(1): 84-103. doi:10.1089/jpm.2008.9992.*** (OPEN ACCESS)
- Lamont EB, Christakis NA. Complexities in prognostication in advanced cancer: "to help them live their lives the way they want to". JAMA. 2003 Jul 2;290(1):98-104. http://jama.ama-assn.org/cgi/content/full/290/1/98
- Solomon Liao, Robert M. Arnold. Journal of Palliative Medicine. Prognosticating: The End of a Series. January 2008, 11(1): 82-83. doi:10.1089/jpm.2008.9993. http://www.liebertonline.com/doi/abs/10.1089/jpm.2008.9993
- Moons KG, Royston P, Vergouwe Y, Grobbee DE, Altman DG. Prognosis and prognostic research: what, why, and how? BMJ 2009;338:b375 http://www.bmj.com/cgi/content/full/338/feb23_1/b375
- Prognostic Indices for Older AdultsA Systematic Review FREE Lindsey C. Yourman, MD; Sei J. Lee, MD, MAS; Mara A. Schonberg, MD, MPH; Eric W. Widera, MD; Alexander K. Smith, MD, MS, MPH JAMA. 2012;307(2):182-192. doi:10.1001/jama.2011.1966.
- For full PDFs of several key articles on prognostication by Nicholas A. Christakis, MD, PhD, MPH, visit his website and choose a few to read then discuss in the forum or write in your blog. http://christakis.med.harvard.edu/pages/publications/topic.html#prog
Prognostication tools
- ePrognosis - estimating prognosis for elders: a blog about it on Geripal
- From Pallimed Blog, a list of Prognosis Links. http://www.pallimed.org/2007/05/prognosis-links.html
- From the Medical School of Wisconsin, Prognostication in Dementia. FAST FACTS AND CONCEPTS #150.
Podcasts
- 2009 Life & Death in the USA: Medicine and Disease in Social Context. Nicholas A. Christakis, MD, PhD, MPH. The Role of Prognostication in End-of-Life Care Lecture II (mp3) AUDIO FILE
- Podcast 24: An interview with Dr. Douglas B. White on the perspectives of surrogate decision makers regarding discussions about their loved one’s prognosis. Joe Elia December 21st, 2008. http://podcasts.jwatch.org/index.php/tag/prognosis/