Establishing Prognosis
Most studies suggest physicians are more accurate about prognosis than even about diagnosis. However, physicians are often reluctant to acknowledge their ability to describe disease trajectory and to establish prognosis accurately. In particular, we are reluctant to share that knowledge with patients. Although motivated by the best intentions (not wanting to take away hope, fear of being wrong) this reluctance can have serious consequences:
Important Note
- Poor symptom management: for example if the emphasis is on changing the disease trajectory, symptom management is often neglected. This is a common phenomenon in cancer care.
- Misleading optimism regarding life-sustaining measures: for example the question, “do you want us to do everything?” can imply to the patient that “doing everything” will significantly change the global trajectory.
- Unexpected or unprepared for deaths: for example the ED is sometimes the first time that anyone has realistically addressed the disease trajectory with the patient and family – a common phenomenon in frailty and organ failure trajectories. How often do you hear, “But I thought Mom was doing fine!”
Emergency physicians are well-placed to make comments about prognosis. Our assessments are less affected by other more subjective overlay — for example, the oncologist focussed on treatment, the family physician with an on-going relationship with the patient, the nursing home physician and staff who have been watching the patient for years.
Establish Prognosis
Test yourself in your own ability to establish prognosis.
For each of the following patients seen in the ED, state your prognosis (probable time to death.) Express it as a range, using the units of hours, days, weeks, months, or years (eg. few hours or weeks to short months). Once you enter a response you’ll see the range of other people’s choices.
- 57 man just diagnosed with glioblastoma multiforme, still working , first seizure.
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- 74 yo woman with breast cancer, post lumpectomy, negative nodes, in third round of chemo, with vomiting.
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- 82 yo man early dementia, living at home, now with LLL pneumonia, with dyspnea.
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- 96 yo woman with advanced dementia, not drinking for five days, now drowsy.
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Helpful Questions
- How much are you able to do for yourself?
- In general how much time do you spend in bed each day?
- How far can you walk before you develop symptoms?
- How much do you eat?
- Do you need oxygen?
- How many times have you been to hospital in the past year?
Consider Also
Here are several tools that are commonly used and well validated in establishing prognosis especially in cancer and chronic organ failure:
- Palliative Performance Scale
- Karnofsky Performance Scale
- ECOG Performance Status
- Prognostic Indicator Guidance
- 10 Steps to Better Prognostication
They may help shape your thinking when asked “what’s going to happen?”
Discussion: Establishing Prognosis
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We may agree but are we correct?
prognostication is difficult
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sure
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very difficult to determine true prognosis
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good to know
good to know.
difficult to determine
bummer
challenging to determine
OK
dsfd
prognosis grading is very useful but not depended on management
sure
each case is different, family counts big
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Es difícil establecer un pronóstico pero siguiendo la trayectoria de fin de vida se puede realizar el pronóstico
where can I access some of these tools?
I often talk about the hours to days, weeks to months etc but also talk about the trajectory – how often are the family and patient noticing changes (months to months, weeks to weeks, or are things starting to change quite quickly)
Sure
good
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interesting
good
very good
Like the PPS
good
great tools
thought provoking
challenging
good review
thanks
interesting helpfull to family to have realisitic view
There wasn’t much agreement in the “other participants answered” section…
very interesting
An inaccurate prognosis can also be harmful to a patient and their family.
i need to check out these tools
Prognosis is hard to assess
Often difficult to prognosticate an acute illness on a different chronic illness, especially if PPS at baseline still quite good. must ensure treatment in line with goals of care.
PPS IS A GOOD TOOL TO USE
I’ve used PPS and its good to know other tools
these tools are not easy to use in ED setting nor are the EPs trained and have time for.There has to be something simpler!!
The Palliative Performance Scale requires five questions — ambulation, activity and evidence of disease, self-care oral intake, and level of consciousness — and there are multiple online calculators to give you a result and interpretation. If you can master PERC or Wells Scores, you can certainly add this predictive tool! https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=13380
https://eprognosis.ucsf.edu/pps-result.php
Great
great tools
exc tips
muy adecuadas recomendaciones
good tips
🙂
team approach necessary
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It is very interesting to me that despite the comments on prognosis and the comfort with its determination the range of answers to the 4 clinical scenerios. question #1 had one user state 1-2 years and another 10 years. I would be curious to see what the evidence based answers are based on the listed prognostic scoring systems… Guess I will check.
I find it very challenging giving a prognosis in the ER as we may not have the full history, the questions highlighted above provide a very helpful background.
Are the tools provided somewhere? PPS is often helpful but it’s real name is Victoria Hospice Palliative Performance Scale Ver. 2
They are all in the Related Resources section of this module.
Family meeting is impotant to discuss ongoing care.
all the helpful questions should be asked of the patient however the family and or caregivers should be asked as well
Absolutely! See the section below on Goals of Care Discussion — “What do the patient and family know?” Too often with older people in the ED we exclude the larger circle of care (probably based on conceptions of privacy and confidentiality which are more relevant to a younger population.)
too often we exclude the older person.
the questions listed are part of the scores given are easy to ask and provide useful information