Obligation of Physicians, Nurse Practitioners, and Physician Assistants

Prognosis is a medical term used to predict the future course of a disease, the chance for recovery and the likelihood of a person’s survival.  Typically, prognosis refers to the physician’s, nurse practitioner’s, or physician assistant’s judgment of the likely or expected development of a disease or of the chances of getting better. Prognosis varies depending on the specific advanced chronic condition, the presence of multiple advanced chronic conditions and the coexistence of frailty.

When applied to large statistical populations, prognostic estimates can be very accurate.  For example, the statement “45% of patients with severe septic shock will die within 28 days”  can” can be made with some confidence, because previous research found that this proportion of patients died.

For patients who are critically ill, particularly those in an intensive care unit, there are numerical prognostic scoring systems that are more accurate. The most famous of these is the APACHE II scale, which is most accurate when applied in the seven days prior to a patient’s predicted death.

In identifying the seriously ill patients with advanced chronic conditions who are appropriate for MOLST and end-of-life thoughtful discussions, it is important that the physician, nurse practitioner, or physician assistant estimate and communicate prognosis.

Estimating and communicating the patient’s prognosis is part of shared medical decision making. Sharing estimated prognosis helps determine whether it makes more sense to attempt certain treatments or to withhold them, including life-sustaining treatment. Thus, prognosis plays an important role in end-of-life decisions.

No one knows the precise date or time of death. However, a physician, nurse practitioner, or physician assistant can offer a range for average life expectancy:

The question, “Would it surprise you if this person died in the next year?” is helpful in identifying patients who should be offered the opportunity to have a thoughtful MOLST discussion using the 8-Step MOLST Protocol.

The surprise question, “Would it surprise you if this person died in the next 6 months?” helps to identify patients who should be offered the opportunity to receive hospice benefits.  There are specific Medicare Hospice criteria that include general decline and irreversible progression of the patient’s condition as evidenced by the patient’s clinical course, signs and symptoms.  In addition, there is measurable levels of decline in performance status and functional status associated with such as COPD, CHF, CAD, DM, Stroke, ALS, MS, Parkinson’s, CKD, Liver, Cancer, AIDS, Dementia, Immune or Autoimmune, RA, SLE.  In addition, there are disease specific criteria.

It is critically important to understand health status and prognosis as part of preparing for a thoughtful MOLST discussion.

Value to Patients & Families, Health Care Agents & Surrogates

Studies have found that most physicians are overly optimistic when making a prognosis; they tend to overstate how long a patient might live. Yet, accurate information helps patients with a serious illness and families cope and plan.

The Book of Prognostics of Hippocrates opens with the following statement: “It appears to me a most excellent thing for the physician to cultivate Prognosis; for by foreseeing and foretelling, in the presence of the sick, the present, the past, and the future, and explaining the omissions which patients have been guilty of, he will be the more readily believed to be acquainted with the circumstances of the sick; so that men will have confidence to intrust themselves to such a physician.”

Over the last several decades, the focus of efforts in Western medicine has shifted to encouraging health and wellness and managing chronic disease.  Patients receive the “best care” possible by combining chronic disease management and the key pillars of palliative care.This is especially true for patients with advanced chronic conditions. Patients with advanced chronic conditions especially those with frailty deserve honest conversations delivered with compassion.

It is critically important for a patient and family to understand health status and prognosis as a physician, nurse practitioner, or physician assistant begins a thoughtful MOLST discussion using the 8-Step MOLST Protocol.  Similarly, if a patient who does not have the ability to make MOLST decisions, the Health Care Agent (if a Health Care Proxy exists) or Surrogate must understand health status and prognosis.  For example, if the patient, family, Health Care Agent or Surrogate believe the patient has 10 years to live but the patient has a life expectancy of 6 months and is eligible for Hospice, the decisions may be not be consistent with the reality of the patient’s condition.

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