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Prognosis

Duty of Professionals

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 judgment of the likely or expected development of a disease or of the chances of getting better.

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 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.

Knowing the 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.

In identifying the seriously ill people who are appropriate for MOLST and end-of-life thoughtful discussions, it is important that the physician and nurse practitioner estimate and communicate prognosis.

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

The question, “Would it surprise you if this person died in the next year?” has been studied and found 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.

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

Patients & Families

Studies have found that most doctors 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 managing chronic disease.  Patients receive the “best care” possible by combining chronic disease management and the key pillars of palliative care. Patients deserve honest conversations delivered with compassion.

It is critically important to understand health status and prognosis as you begin a thoughtful MOLST discussion.

 

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