Prognostication
Eric Widera, MD
What is Prognostication?
• The Two parts:
1. Estimating the probability of an individual
developing a particular outcome over a
specific period of time (prognosis).
2. Communicating the prognosis with the
patient and/or family.
Overview of Our Sessions
Objectives
• 2 parts
– Describe one way to teach learners how to
estimate prognosis in the clinical settings
– Name one method of communicating
prognosis…
Challenges to Prognostication in
Older Adults
• Younger patients with cancer: clearer
trajectory
– Value of disease specific prognostication
• Older adults:
– Absence of dominant terminal condition
– age + functional + cognitive + multimorbidity
Ways to Prognosticate in Elderly
Clinical Judgement
Shortcomings of Clinical Predictions
• Tend to overestimate patient survival by a
factor of between 3 and 5.
• Tend to be more accurate for very shortterm prognosis than long-term prognosis.
• Influenced by relationships
– The length of doctor patient relationships
increases the odds of making an erroneous
prediction.
Life Tables
US Life Tables
www.eprognosis.org
Great Variation in Life Expectancy
for People of Similar Ages
Life Expectancy for Women
Years
Age (years)
Walter LC. JAMA 2001;285:2750-56
Prognostic Indices
Prognostic Indices
• Physicians can use prognostic indices to lend
confidence to their judgments about prognosis
– National survey of 697 physicians: 57% felt
inadequately trained in prognostication
• Prognostic indices provide an objective measure
to support clinical intuition
• Combining clinical estimates with prognostic
indices results in more accurate estimates than
either alone.
Christakis & Iwashyna, Arch Intern Med 1998
Prognostic Information is Hard to
Find
• Generally, less than 30% of medical
textbook chapters discuss prognosis
(instead focus on etiology, diagnostic
criteria and treatment)
• Tools developed for mortality prediction in
older people may be difficult for busy
clinicians to remember or use
Communicating Prognostic
Information
Elizabeth Eckstrom, MD, MPH
Oregon Health & Science University
Do Patients Want to Know?
Those who did not have a prognosis
conversation were asked, do you want one?
Patients: 55% yes
40% no
5% I don’t know
Caregivers: 75% yes
23% no
2% I don’t know
Fried et al. JAGS 2003
Ahalt et al, JGIM
2011
SPIKES- A Tool for Communication
•
•
•
•
S—SETTING UP the Interview
P—Assessing the Patient's PERCEPTION
I—Obtaining the Patient's INVITATION
K—Giving KNOWLEDGE and Information to
the Patient
• E—Addressing the Patient's EMOTIONS with
Empathic Responses
• S—STRATEGY and SUMMARY
S—SETTING UP the Interview
• Be sure it is happening in a quiet, undistracted
environment
• Include family members whenever possible (if having
the discussion in clinic, ask if anyone else should be
present, and postpone the discussion till everyone can
be there or utilize conference calling)
– “At our next visit, I would like to talk about your health and
the ways we can go forward with your care. Is there
someone who you think should be at this meeting?”
• Connect with the patient and family first
P—Assessing the Patient's
PERCEPTION
• Ask open-ended questions to ensure you know what the
patient and family currently understands about their
medical issues and prognosis
– “It seems things are getting a little harder for you. What is your
sense of where we are going with your health?”
– “What do you understand about your current health?”
• Ask if they would like more details about “what to expect
next”
– Some people don’t want to know, or want you to speak with
their family but not themselves.
– “Some patients feel it is important to know the all the details of
their illness, prognosis, and treatment options; others don’t and
want others to make decisions for them. How do you feel?”
I—Obtaining the Patient's INVITATION
Inquire about preferences
“Some people can deal with that knowledge and some people
can’t” (AA man age 67)
Be direct, empathic, take time
“Many times the truth has to be softened. It cannot be so abrupt
because that causes harm to people”
(latino man
age 86)
Recognize uncertainty
“A good doctor would say, ‘look, I believe from all the tests and
all you’ve got about a so-and-so much to live. But then again, we
don’t know. We don’t know.”
(white
man age 76)
K—Giving KNOWLEDGE and
Information to the Patient
• Speak simply and slowly
– “If there were 100 patients in your father’s current
condition, in 5 years roughly 80 would die and 20 would
survive. I am basing this on his advanced heart failure and
his worsening functional status”
• Periodically check for understanding
• Frame conversation in light of patient goals
• Consider using a range of time
–
–
–
–
Hours to days
Days to weeks
Weeks to months
Months to years
E—Addressing the Patient's
EMOTIONS with Empathic Responses
• Consciously observe emotions
• Name the emotion to yourself- if you are not sure
what you are observing, ask
– “You seem a little surprised by this news. Is it different
from what you were expecting?”
• Express empathy with the emotion
– “I can understand that this news is a little unsettling when
you have been doing everything you can to live longer.”
– “I wish I didn’t have to tell you there isn’t much time left.
May I help communicate this news to other family
members who can’t be here today?”
S—STRATEGY and SUMMARY
• Review strategies to ensure best quality of life
possible
– “Considering how important being pain free and
remaining at home appears to be for you, I
recommend that we…”
• Solicit patient and family feedback
• Establish a future “check in” date to see how
things are going
– My patient story- Pulmonary HTN, CHF, hyponatremiaafter she outlived the prognosis I gave her (at age 95),
we started from scratch 
“ Clinicians should…offer to discuss
the overall prognosis… for patients
with a life expectancy less than 10
years or at least by…85 years of age”
NEJM
2011