Daily Bulletin


The Conversation

  • Written by The Conversation Contributor
image

Predicting how long a patient will survive is critically important for them and their families to guide future planning, yet notoriously difficult for doctors to predict accurately. While many patients request this information, others do not wish to know, or are incapable of knowing due to disease progression.

Fuelling this complexity are families who prefer the patient not to be told for fear of torpedoing hope and reducing the quality of time remaining. Conversely, patients may want to know themselves, but do not want to distress their loved ones with this knowledge.

We can’t ever be sure

Central to these scenarios is whether accurate prognostication at end of life is actually possible. Providing a meaningful survival time to patients is often genuinely challenging for doctors. Accuracy declines further the longer the patient is expected to live.

A number of studies indicate clinicians tend to be over-optimistic in predicting survival times. Research from 2011 indicated surgeons’ prognosis for survival time for patients with abdominal malignancies was accurate in 27% of cases, too optimistic in 42% and too pessimistic in 31% of cases.

This is one of the reasons some doctors are reluctant to attempt to predict survival time at end of life. This has traditionally been seen as part of the doctor’s special domain of knowledge to be communicated at the doctor’s discretion (if and when it is the right time to tell the patient, so it is not going to cause harm).

This archaic and paternalistic view melds conveniently with popular positive thinking, replete with militaristic vocabulary such as “fighting to the end”, which some doctors share.

This mindset views meaningful discussions of prognosis as harmful, as it may cause the patient to lose hope and give up the fight. It underpins those not uncommon cases when a family requests the clinician not to disclose a prognosis or a diagnosis to their dying relative. Unfortunately, it may also shut down meaningful end-of-life discussion and planning and result in harm, including to the grieving who remain.

When patients do not want to know their prognosis, this should be respected. For others who ask and the outlook is poor, a relationship built on trust is important.

Author Bill, an emergency and palliative care physician, is asked to give a prognosis every day. A discussion about prognosis includes the caveat that the accuracy the patient usually seeks is elusive, if not impossible to nail down.

Much can be said, however, including an explanation of why there is no firm prognosis. If it is possible to estimate survival time (derived from a mixture of medical details about the clinical history, prior response to treatment, imaging results, pathology results, functional status of the patient and experience), this is best communicated in terms of a short number of months, (long months is very difficult), long weeks or short weeks, a week or a few days or a few hours.

The accuracy of survival time can become more obvious as time progresses, just as the doctor-patient relationship develops, enabling more explicit discussions about survival time. In emergency medicine, when there is no time for these relationships to develop and time is short, patients frequently seek honesty and are extremely good at telling if the doctor is hiding something. This may then lead to them imagining something worse than the reality.

If the doctor does get the prognosis wrong, there is surprisingly little Australian authority as to whether a doctor will be liable. Considering the general principles of medical negligence is useful here. It suggests that if a doctor provides a prognosis that is widely accepted as competent professional practice, shared by other respected clinical peers, then that prognosis is not negligent.

Even if the doctor provided a prognosis that was not widely accepted as competent professional practice, provided the incorrect prognosis did not cause additional damage to the patient, then no liability will follow.

How long have I got, doc?

Most of us are going to have to ask this one day – presuming we have not confronted it personally or through close relationships already. Despite the understandable imperative for those who want to know, the answer is rarely as crisp or accurate as the original diagnosis.

Breaking bad news to a patient is much more a process than an event, unfolding as symptoms develop and viable treatments recede. Best medical practice aims consistently for open, honest communication that is delivered sensitively.

Most doctors try to provide accurate information if able, despite clinical uncertainty. The aim is to maximise the good and minimise harm. When a prognosis appears wildly inaccurate, is not supported by a group of peer doctors and causes significant harm, Australians may be able to pursue the matter through legal action.

Authors: The Conversation Contributor

Read more http://theconversation.com/how-much-time-have-i-got-doc-the-problems-with-predicting-survival-at-end-of-life-52700

Writers Wanted

Planning a road trip in a pandemic? 11 tips for before you leave, on the road and when you arrive

arrow_forward

Biden's cabinet picks are globally respected, but one obstacle remains for the US to 'lead the world' again

arrow_forward

The Conversation
INTERWEBS DIGITAL AGENCY

Politics

Prime Minister Interview with Ben Fordham, 2GB

BEN FORDHAM: Scott Morrison, good morning to you.    PRIME MINISTER: Good morning, Ben. How are you?    FORDHAM: Good. How many days have you got to go?   PRIME MINISTER: I've got another we...

Scott Morrison - avatar Scott Morrison

Prime Minister Interview with Kieran Gilbert, Sky News

KIERAN GILBERT: Kieran Gilbert here with you and the Prime Minister joins me. Prime Minister, thanks so much for your time.  PRIME MINISTER: G'day Kieran.  GILBERT: An assumption a vaccine is ...

Daily Bulletin - avatar Daily Bulletin

Did BLM Really Change the US Police Work?

The Black Lives Matter (BLM) movement has proven that the power of the state rests in the hands of the people it governs. Following the death of 46-year-old black American George Floyd in a case of ...

a Guest Writer - avatar a Guest Writer

Business News

Nisbets’ Collab with The Lobby is Showing the Sexy Side of Hospitality Supply

Hospitality supply services might not immediately make you think ‘sexy’. But when a barkeep in a moodily lit bar holds up the perfectly formed juniper gin balloon or catches the light in the edg...

The Atticism - avatar The Atticism

Buy Instagram Followers And Likes Now

Do you like to buy followers on Instagram? Just give a simple Google search on the internet, and there will be an abounding of seeking outcomes full of businesses offering such services. But, th...

News Co - avatar News Co

Cybersecurity data means nothing to business leaders without context

Top business leaders are starting to realise the widespread impact a cyberattack can have on a business. Unfortunately, according to a study by Forrester Consulting commissioned by Tenable, some...

Scott McKinnel, ANZ Country Manager, Tenable - avatar Scott McKinnel, ANZ Country Manager, Tenable



News Co Media Group

Content & Technology Connecting Global Audiences

More Information - Less Opinion