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Fast Fact and Concept #30: Prognostication

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Title: Fast Fact and Concept #30: Prognostication

Author(s): Eric Warm, MD; David E. Weissman, MD

Doctors are poor prognosticators
Physicians tend to be overly optimistic when dealing with prognosis. A recent study by Christakis illustrates this point1. He asked 343 physicians to provide survival estimates for 468 terminally ill patients at the time of hospice referral. Only 20% of predictions were accurate (as defined as within 33% of actual survival). Overall, doctors overestimated by a factor of 5.3! Every type of doctor tended to overestimate, although the more experienced physicians had less error. Inaccurate predictions were given for all types of patients, including cancer patients and those with chronic non-malignant disease. Interestingly, as the duration of the physician patient relationship increased, prognostic accuracy decreased. In other words, the longer a doctor knew his/her patient, the less likely he/she was to correctly predict prognosis.

Why does this matter?
Undue optimism may hurt patients in multiple ways. First of all, it may explain some of the findings of the SUPPORT trial. 2 This study showed that a large number of DNR orders are written in the last 2 days of life, and that physician knowledge about patient DNR preference is poor. Why review issues surrounding EOL care when the prognosis is rosy? In the same vein, undue optimism may lead to late hospice referral. Hospice care, however, is most beneficial when utilized for months, not days, as commonly happens currently. Lastly, an overestimation of prognosis may cause patients to request futile care. Learning the true prognosis of a disease very late in the course is a difficult pill to swallow, and makes for an abrupt transition from curative/life-prolonging care to palliative care.

Appropriate prognostic information is essential for informed advance planning decisions. This is often acutely true in the setting of the DNR discussion. Murphy showed that people change EOL care decisions based on their perception of prognosis.3 He asked 371 adults age 65 or older if they wanted CPR in case of arrest during an acute illness. Before learning the true probability of survival 41% wanted CPR. After learning the true probability of CPR, only 22% wanted it. If asked about a chronic disease, in which the life expectancy was less than one year, only 5% wanted CPR.

What to do?
Innumerable reasons have been put forward for why we overestimate prognosis (see Christakis' book Death Foretold4). Probably the most important step in correcting the problem is recognizing that it exists. Ask yourself, "Would I be surprised if my patient died in the next year?" Answering "no" may trigger a re-assessment of the patient's current state and immediate future. There are many scientifically derived models of patient survival probability that can be used, and there are many well recognized clinical predictors (see Fast Fact #13). Metastatic cancer has the most predictable course; assessing where a patient is along the dying trajectory is relatively easy. Other diseases such as COPD or CHF are more difficult to predict. Each exacerbation can lead to remission (and future exacerbation) or death, and knowing which will occur on any given admission can be extremely challenging. This uncertainty however, can be an excellent starting place for discussion with the patient; communicating that one of the possible outcomes of an exacerbation is death allows you both to plan accordingly.

Finally, you may want to consider a second opinion for patients you are particularly close to. Present the data objectively to a colleague and ask them to prognosticate using the information alone. Studies by Christakis and others suggest that impartial observers are more accurate than physicians well invested in the patient-physician relationship.

References:

Christakis NA, Lamont EB. Extent and Determinants of Error in Doctor's Prognoses in Terminally Ill Patients: Prospective Cohort Study. BMJ. 2000;320:pp.469-472

The SUPPORT principle investigators. JAMA 1995;2741591-1598.

Murphy DJ, et al. The Influence of the Probability of Survival on Patient's PReferences regarding CPR. NEJM. 1994;330:pp.545-49

Christakis NA. Death Foretold : Prophecy and Prognosis in Medical Care. January 2000. Univ of Chicago Pr (Trd); ISBN: 0226104702

Fast Facts and Concepts was originally developed as an end-of-life teaching tool by Eric Warm, MD, U. Cincinnati, Department of Medicine. See: Warm, E. Improving EOL care--internal medicine curriculum project. J Pall Med 1999; 2: 339-340.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman DE. Fast Facts and Concepts #30: Prognostication, December, 2000. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 12/2000

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Discussing hospice care, Hope, Negotiating treatment goals, Prognosis


The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).