Prognosis

Victoria Trulove

Estimating prognosis

Prognosis is estimating the likelihood of an outcome (morbidity, mortality) due to a medical condition and can help guide clinicians, patients, and families in medical decision making.

Estimating prognosis should be specific to each patient.

Factors to consider

  • Functional status: ex. ECOG is used in cancer care to evaluate ADLs and can predict a patient's ability to tolerate therapy.
  • Systemic Manifestations of Disease: cachexia, significant unintentional weight loss, lab values suggestive of inflammation (ee. Modified Glasgow Prognostic Score).
  • Frailty: ex: Clinical Frailty Scale can assess a patient’s functional reserve when faced with a stressor.
  • Comorbidities: baseline organ dysfunction (COPD, CKD, CHF, dementia) may indicate a worse prognosis.
  • While there are disease-specific prognostication tools, ePrognosisTM is a tool that estimates prognosis in any older pt.

Errors

  • Studies suggest that clinicians consistently overestimate survival.
    • 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 so that they can plan for the future.
  • “Best case” and “worst case” scenarios may be helpful in cases of prognostic uncertainty.
  • Clinicians should discuss before a patient acutely decompensates.
  • 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 they have additional questions.
  • Pairing hope and worry: “While I hope that x might happen, I worry that y is a possibility.”
  • Helpful phrasing for pts and families resistant to discussing prognosis:
    • “I am worried about how things have been going, and I would like to share my concerns, particularly about how much time you may have. Would it be okay to discuss 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.

 

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