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Grand Rounds / Articles

Communicating Prognosis

Nora McKee, MD
Assistant Professor
Department of Academic Family Medicine
University of Saskatchewan

Are objective tools available to aid in reaching a prognosis?
How long are palliative care benefits available?
What features suggest a shortened survival time?

Patients who are referred for palliative care support have many questions. By this stage in their illness they will know that no active curative treatment is available for them and they, and their physicians, will be meeting challenges that lie beyond the experience of diagnosis, treatment and outcome. Many physicians have less experience and feel less comfortable in these areas. This module is designed to answer some of the questions asked of physicians in this situation, and to give evidence-based support for palliative care approaches and techniques.

After completing this module the physician will be able to;

Prognosticating

Many cultures recognize impending death. In the holy city of Benares, families and priests bring dying people to end their lives in charity hospices (which do not admit cancer or infection cases). When asked how they know when to bring patients to the hospice the family members and priests answered, "when the patient no longer wanted to eat or drink". A 14-day stay is allowed but 10% died on the day of admission, 84% in the first week, and all by 17 days. Our system is very different from this, but still faces the same prognostication concerns.

Why Bother?

Are medical staff effective in prognosticating?

What tools are available to help in prognostication?

Issues concerning non-cancer palliative patients

"How long have I got?"

Barriers to clearly communicating a bad prognosis:

Patient experiences:

Advice from experience:

References

Reference for the PPS:
Anderson F, Downing GM, Hill J. Casorso L. Lerch N. Palliative Performance Scale (PPS): a new tool. J Palliat Care 1996;12(1):5-11.

Reference for the PPI:
Morita T, Tsunoda J, Inoue S, Chirara S. The Palliative Prognostic Index: a scoring system for survival prediction of terminally ill cancer patients. Support Care Cancer 1997;7:128-33.

Reference for Karnofsky's Performance Status:
Yates JW, Chalmer B, McKegney FP. Evaluation of patients with advanced cancer using the Karnofsky Performance Status. Cancer 1980;45: 2220-2224.