Prognosis is estimating the likelihood of an outcome (morbidity, mortality) due to a medical condition and can help guide clinicians, pts, and families in medical decision making.
Estimating prognosis should be specific to each pt’s situation (i.e. type of cancer, transplant eligibility, comorbidities). Factors to consider include a pt’s functional status, laboratory values, and their own reported symptoms.
Estimating prognosis
Examples of factors to consider
Functional status-ECOG is used in cancer care to reflect a pt’s ability to carry out daily activities at home and can predict a patient's ability to tolerate therapy
Systemic Manifestations of Disease – i.e. cachexia, significant unintentional weight loss, lab values suggestive of inflammation (ex: Modified Glasgow Prognostic Score)
Frailty – a state of diminished physiological reserve and increased vulnerability to adverse health outcomes when exposed toa stressor (ex: Clinical Frailty Scale)
Comorbidities – pts with baseline organ dysfunction (COPD, CKD, CHF, dementia) may have a worse prognosis than a pt without comorbidities
Tools
While there are disease-specific prognostication tools, ePrognosisTM is a tool that estimates prognosis in any older pt. It estimates likelihood of mortality based on comorbidities and functional status to aid in medical decision making.
Errors
Studies suggest that clinicians consistently overestimate survival
Two factors most associated with clinician error
More clinical experience correlates with less prognostic error
Longer duration of pt-clinician relationship correlates with more prognostic error
When to discuss prognosis
Several studies suggest that across age and cultural background, most pts want their physicians to discuss prognostic information with them
Clinicians should discuss before a pt acutely decompensates and can process information
Earlier prognostic discussions have been shown to decrease rates of hospitalization and highly aggressive care (chemotherapy, pressors) in terminally ill cancer pts
How to discuss prognosis
Common Four-Step approach
Confirm that the pt/family is ready to hear prognostic information
Present info using a range: hours to days, days to weeks, weeks to months, months to years
Allow silence after you provide information; respond to emotion
Use prognostic information for eliciting end-of-life goals
Ask-tell-ask
Ask the pt what type of information would be most useful for them
Provide information
Ask pt if that answers their question or if they have additional ones
Pairing hope and worry:
While I hope that x might happen, I worry that y is a possibility.”
Other
Helpful phrasing for pts and families resistant to discussing prognosis:
“In order to make this decision, it would be helpful if we talked about how much time you might have left to live. What are your thoughts on discussing this information?”
“If you knew time was short for you, what would be important to you in making this decision?”
The Palliative Care Network of Wisconsin has several helpful “Fast Facts” on determining/ communicating prognosis for specific disease states:
